2021 Prescription Drug List - Coordinated Care Health

2021 Prescription Drug List Effective January 1 2021

AmbetterCoordinatedCareHealthcom

Formulary Introduction FORMULARY

The Ambetter from Coordinated Care Preferred Drug ListFormulary is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug beneft Generic drugs have the same active ingredients as their brand name counterparts and should be considered the frst line of treatment The FDA requires generics to be safe and work the same as brand name drugs If there is no generic available there may be more than one brand name drug to treat a condition Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate safe and cost-efective treatment options if a generic medication on the formulary is not suitable for your condition

Please note the Formulary is not meant to be a complete list of the drugs covered under your prescription beneft Not all dosage forms or strengths of a drug may be covered This list is periodically reviewed and updated and may be subject to change Drugs may be added or removed or additional requirements may be added in order to approve continued usage of a specifc drug

Specifc prescription beneft plan designs may not cover certain products or categories regardless of their appearance in this document Please check your benefts for coverage limitations and your share of cost for your drugs

Drug List Key

Brand name drugs are listed in CAPS and generic drugs are lower case Drugs are covered under diferent copay tiers depending on your beneft

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Afordable Care Act Select oral contraceptives vitamin D folic acid for women of child bearing age over-the-counter (OTC) aspirin and smoking cessation products may be covered under this tier Certain age or gender limits apply

Tier 1 - Lowest copayment for those drugs that ofer the greatest value compared to other drugs used to treat similar conditions Select over-the-counter (OTC) generic or brand name drugs may be covered under this tier

Tier 2 - Medium copayment covers brand name drugs that are generally more afordable or may be preferred compared to other drugs to treat the same conditions

Tier 3 - Highest copayment covers higher cost brand name drugs This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage

Tier 4 - Coverage for this tier is for ldquospecialtyrdquo drugs used to treat complex chronic conditions that may require special handling storage or clinical management For members who do not have a Tier 4 plan these drugs may be covered under Tier 3

Prior Authorization for Non-Formulary Drugs

To obtain prior authorization for a non-formulary drug your provider must fill out the Prior Authorization form Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgent requests and within 72 hours for non-urgent requests unless state law requires faster response If the request is disapproved the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request or if the request was incomplete the explanation will identify the missing material information that is necessary to complete the request

Formulary Abbreviations

Abbreviation Term What it means

AL Age Limit Some drugs are only covered for certain ages

QL Quantity Limit Some drugs are only covered for a certain amount

PA Prior Authorization Your doctor must ask for approval from Ambetter before

some drugs will be covered

ST Step Therapy

In some cases you must first try certain drugs before

Ambetter covers another drug for your medical condition

For example if Drug A and Drug B both treat your

medical condition Ambetter may not cover Drug B

unless you try Drug A first

NF Non-formulary

This product is not covered unless you or your provider

request an exception Alternative medications are listed

next to non-covered product

RXOTC Prescription and OTC These drugs are made in both prescription form and

Over-the-counter (OTC) form

Drug Name DrugTier

RequirementsLimits

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to TreatADHD Sleep and Eating Disorders

Amphetamines ADDERALL TABS 125 MG-125 MG-125 MG-125 MG 1875 MG-1875 MG-1875 MG-1875 MG 25 MG-25 MG-25 MG-25 MG 3125 MG-3125 MG-3125 MG-3125 MG 375 MG-375 MG-375 MG-375 MG 5 MG-5 MG-5 MG-5 MG (Use amphetamine-dextroamphetamine)

QL(3 ea daily)

ADDERALL TABS 75 MG-75 MG-75 MG-75 MG (Use amphetamine-dextroamphetamine)

QL(2 ea daily)

ADDERALL XR CP24 125 MG-125 MG-125 MG-125 MG 25 MG-25 MG-25 MG-25 MG (Use amphetamine-dextroamphetamine)

QL(1 ea daily)

ADDERALL XR CP24 375 MG-375 MG-375 MG-375 MG (Use amphetamine-dextroamphetamine)

ADDERALL XR CP24 5 MG-5 MG-5 MG-5 MG 625 MG-625 MG-625 MG-625 MG 75 MG-75 MG-75 MG-75 MG (Use amphetamine-dextroamphetamine)

QL(2 ea daily)

ADZENYS ER SUER (Use amphetamine) NF

amphetamine-dextroamphetamine cp24125 mg-125 mg-125 mg-125 mg 25 mg-25 mg-25 mg-25 mg

QL(1 ea daily)

amphetamine-dextroamphetamine cp24375 mg-375 mg-375 mg-375 mg

Drug Name DrugTier

RequirementsLimits

amphetamine-dextroamphetamine cp24 5mg-5 mg-5 mg-5 mg 625mg-625 mg-625 mg-625mg 75 mg-75 mg-75 mg-75 mg

QL(2 ea daily)

amphetamine-dextroamphetamine tabs125 mg-125 mg-125 mg-125 mg 1875 mg-1875mg-1875 mg-1875 mg25 mg-25 mg-25 mg-25mg 3125 mg-3125 mg-3125 mg-3125 mg 375mg-375 mg-375 mg-375mg 5 mg-5 mg-5 mg-5 mg

QL(3 ea daily)

amphetamine-dextroamphetamine tabs75 mg-75 mg-75 mg-75 mg

QL(2 ea daily)

DESOXYN TABS (Use methamphetamine hcl) NF

QL(5 ea daily)AL(At least 6yrs old)

DEXEDRINE CP24 10 MG 15 MG (Use dextroamphetaminesulfate)

QL(4 ea daily)

DEXEDRINE CP24 5 MG (Use dextroamphetaminesulfate)

dextroamphetamine sulfatecp24 10 mg 15 mg 1 QL(4 ea daily)

dextroamphetamine sulfatecp24 5 mg 1

dextroamphetamine sulfatetabs 10 mg 5 mg 1 QL(4 ea daily)

methamphetamine hcl tabs 3 QL(5 ea daily)AL(At least 6yrs old)

VYVANSE CAPS 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG

3 ST QL(1 eadaily)

Anorexiants Non-Amphetamine ADIPEX-P CAPS (Use phentermine hcl) NF PA

phendimetrazine tartratetabs 1 PA

Ambetter Formulary Updated December 1 2021

Drug Name DrugTier

RequirementsLimits

phentermine hcl caps 1 PA

Anti-Obesity Agents

BELVIQ TABS 3 PA QL(2 eadaily)

CONTRAVE TB12 3 PA QL(4 eadaily)

Attention-DeficitHyperactivity Disorder (ADHD)

atomoxetine hcl caps 10mg 25 mg 40 mg 18 mg 1

atomoxetine hcl caps 100mg 60 mg 80 mg 1

clonidine hcl (adhd) tb12 1

guanfacine hcl (adhd) tb24 1 QL(1 ea daily)AL(At least 6yrs old)

INTUNIV TB24 (Use guanfacine hcl (adhd)) NF

KAPVAY TB12 (Use clonidine hcl (adhd)) NF

STRATTERA CAPS 10 MG 25 MG 40 MG 18 MG (Use atomoxetine hcl)

NF QL(2 ea daily)AL(At least 6yrs old)

STRATTERA CAPS 100 MG 60 MG 80 MG (Use atomoxetine hcl)

Dopamine and Norepinephrine Reuptake

SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1

PA QL(1 eadaily) AL(Atleast 17 yrsold)

CONCERTA TBCR 18 MG 27 MG (Use methylphenidate hcl)

DAYTRANA PTCH 3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

dexmethylphenidate hclcp24 35 mg 10 mg 15 mg20 mg 25 mg 30 mg 40mg 5 mg

QL(1 ea daily)

dexmethylphenidate hcltabs 25 mg 10 mg 5 mg 1

FOCALIN TABS (Use dexmethylphenidate hcl) NF

FOCALIN XR CP24 (Use dexmethylphenidate hcl) NF QL(1 ea daily)

METHYLIN SOLN (Use methylphenidate hcl) NF

QL(30 mldaily) AL(Atleast 6 yrs old)

methylphenidate hcl cp2420 mg 40 mg 1 AL(At least 6

yrs old)

methylphenidate hcl cp2430 mg 1

methylphenidate hcl cpcr40 mg 20 mg 60 mg 10mg 30 mg 50 mg

1 QL(1 ea daily)AL(At least 6yrs old)

methylphenidate hcl soln10 mg5ml 5 mg5ml 1

methylphenidate hcl tabs10 mg 20 mg 1

methylphenidate hcl tabs 5 mg 1

methylphenidate hcl tbcr 10mg 20 mg 1

modafinil tabs 100 mg 1

Drug Name DrugTier

RequirementsLimits

NUVIGIL TABS (Use armodafinil) NF

PROVIGIL TABS 100 MG (Use modafinil) NF

RITALIN LA CP24 20 MG 40 MG (Use methylphenidate hcl)

NF AL(At least 6yrs old)

RITALIN LA CP24 30 MG (Use methylphenidate hcl) NF

RITALIN TABS 10 MG 20 MG (Use methylphenidate hcl)

RITALIN TABS 5 MG (Use methylphenidate hcl) NF

ALLERGENIC EXTRACTSBIOLOGICALS MISC

Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

amikacin sulfate soln 1

ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits

gentamicin in saline soln08 mgml-09 09 -1mgml 09 -12 mgml09 -16 mgml

gentamicin sulfate soln 40mgml 1

HUMATIN CAPS (Use paromomycin sulfate) NF

KITABIS PAK NEBU (Use tobramycin) NF PA

neomycin sulfate tabs 1

paromomycin sulfate caps 1

streptomycin sulfate solr 3

TOBI NEBU (Use tobramycin) NF PA

tobramycin nebu 300mg5ml 4 PA

tobramycin sulfate soln 10mgml 40 mgml 80mg2ml

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain Swelling Muscle and JointConditions

Anti-TNF-alpha - Monoclonal Antibodies

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

PA 1 rtl packlmt amt180 rtl pack lmtday(s)1 mailpack lmtamt180 mail pack lmtday(s)

HUMIRA PEN PNKT 40 MG04ML 40 MG08ML 4 PA QL(0143

ea daily)

HUMIRA PEN PNKT 80 MG08ML 4

HUMIRA PEN-CDUCHSSTARTER PNKT 40 MG08ML

4 PA QL(0143ea daily)

Drug Name DrugTier

RequirementsLimits

HUMIRA PEN-PEDIATRIC UC STARTER PACK PNKT

HUMIRA PEN-PSUVSTARTER PNKT 4

HUMIRA PEN-PSUVSTARTER PNKT 4 PA QL(0143

ea daily)

HUMIRA PSKT 4 PA QL(0143ea daily)

Antirheumatic - Enzyme Inhibitors

RINVOQ TB24 4 PA QL(1 eadaily)

XELJANZ TABS 10 MG 4 PA QL(2 eadaily)

XELJANZ TABS 5 MG 4 PA QL(2 eadaily) SP

XELJANZ XR TB24 4 PA QL(1 eadaily)

Antirheumatic Antimetabolites

METHOTREXATE TABS 4 PA QL(1714ea daily) SP

Gold Compounds

RIDAURA CAPS 3 QL(3 ea daily)

Interleukin-1 Blockers

ARCALYST SOLR 4 PA QL(0286ea daily) SP

Drug Name DrugTier

RequirementsLimits

Interleukin-1beta Blockers

ILARIS SOLN 4 PA QL(0072ml daily)

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ARTHROTEC 50 TBEC (Use diclofenac wmisoprostol)

ARTHROTEC 75 TBEC (Use diclofenac wmisoprostol)

CELEBREX CAPS (Use celecoxib) NF PA

celecoxib caps 1 PA

CHILDRENS ADVIL SUSP (Use ibuprofen) NF RXOTC

CHILDRENS MOTRIN SUSP (Use ibuprofen) NF RXOTC

DAYPRO TABS (Use oxaprozin) NF

diclofenac potassium tabs50 mg 1

diclofenac sodium tb24 1

diclofenac sodium tbec 1

diclofenac w misoprostoltbec 1

EC-NAPROSYN TBEC 500 MG (Use naproxen) NF

etodolac caps 200 mg 300 mg 1

etodolac tabs 400 mg 500 mg 1

FELDENE CAPS (Use piroxicam) NF

fenoprofen calcium tabs600 mg 1 ST QL(4 ea

daily)

flurbiprofen tabs 1

ibuprofen susp 100 mg5ml 1 RXOTC

ibuprofen tabs 400 mg 600mg 800 mg 1

indomethacin caps 25 mg50 mg 1

Drug Name DrugTier

RequirementsLimits

indomethacin cpcr 75 mg 1

ketoprofen caps 50 mg 75 mg 1

ketorolac tromethamine tabs or 10 mg 1 QL(0667 ea

daily) LODINE TABS (Use etodolac) NF

meclofenamate sodium caps 1

mefenamic acid caps 1 ST Must tryibuprofenQL(5 ea daily)

meloxicam tabs 15 mg 75 mg 1 QL(1 ea daily)

MOBIC TABS (Use meloxicam) NF QL(1 ea daily)

nabumetone tabs 1

NALFON TABS 600 MG (Use fenoprofen calcium) NF ST QL(4 ea

daily) NAPROSYN SUSP 125 MG5ML (Use naproxen) NF PA

NAPROSYN TABS 500 MG (Use naproxen) NF

naproxen sodium tabs 550 mg 1

naproxen susp 125 mg5ml 1 PA

naproxen tabs 250 mg 375mg 500 mg 1

naproxen tbec 500 mg 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

tolmetin sodium caps 1

tolmetin sodium tabs 1

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS 4 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4

PA 1 rtl packlmt amt180 rtl pack lmtday(s)

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use leflunomide) NF QL(1 ea daily)

leflunomide tabs 1 QL(1 ea daily)

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT 4 PA QL(015 mldaily)

ENBREL SOLN 25 MG05ML 4 PA QL(0146

ml daily)

ENBREL SOLR 25 MG 4 PA QL(0286ea daily) SP

ENBREL SOSY 25 MG05ML 4 PA QL(0146

ml daily) SP

ENBREL SOSY 50 MGML 4 PA QL(028 mldaily) SP

ENBREL SURECLICK SOAJ 4 PA QL(0143

ml daily) SP

ANALGESICS - NonNarcotic - Drugs to TreatPain Muscle and Joint Conditions

Analgesic Combinations butalbital-acetaminophentabs 50 mg-325 mg 1

butalbital-acetaminophen-caffeine caps 40 mg-50mg-300 mg 40 mg-50 mg-325 mg

butalbital-acetaminophen-caffeine tabs 40 mg-50 mg-325 mg

butalbital-aspirin-caffeine caps 1

BUTALBITALACETAMINOPHEN CAPS (Use butalbital-acetaminophen)

ESGIC TABS (Use butalbital-acetaminophen-caffeine)

FIORICET CAPS (Use butalbital-acetaminophen-caffeine)

Drug Name DrugTier

RequirementsLimits

FIORINAL CAPS (Use butalbital-aspirin-caffeine) NF

Salicylates

aspirin chew 0 AL(At least 45yrs old - Up to79 yrs old)

aspirin tabs 0 AL(At least 45yrs old - Up to79 yrs old)

aspirin tbec 0 AL(At least 45yrs old - Up to79 yrs old)

diflunisal tabs 1

salsalate tabs 1

ANALGESICS - OPIOID - Drugs to Treat PainMuscle and Joint Conditions

Opioid Agonists ACTIQ LPOP (Use fentanyl citrate) NF PA QL(4 ea

daily)

CODEINE SULFATE TABS 15 MG 60 MG 1

New starts limited to 7 daysupply

codeine sulfate tabs 30 mg 1 New starts limited to 7 daysupply

CONZIP CP24 (Use tramadol hcl) NF

DEMEROL SOLN 100 MGML 25 MGML 50MGML (Use meperidine hcl)

DILAUDID LIQD OR 1 MGML (Use hydromorphone hcl)

NF New starts limited to 7 daysupply

DILAUDID SOLN IJ 1 MGML 2 MGML (Use hydromorphone hcl)

DILAUDID TABS OR 2 MG 4 MG 8 MG (Use hydromorphone hcl)

New starts limited to 7 daysupplyQL(8 eadaily)

DURAGESIC PT72 (Use fentanyl) NF QL(034 ea

daily)

Drug Name DrugTier

RequirementsLimits

fentanyl citrate lpop bu1200 mcg 1600 mcg 200mcg 400 mcg 600 mcg800 mcg

PA QL(4 eadaily)

fentanyl pt72 td 12 mcghr100 mcghr 25 mcghr 50mcghr 75 mcghr

1 QL(034 eadaily)

FENTORA TABS (Use fentanyl citrate) NF

hydrocodone bitartratecp12 10 mg 15 mg 30 mg40 mg 50 mg

1 PA QL(2 eadaily)

HYDROCODONE BITARTRATE ER CP12 1 PA QL(2 ea

daily)

hydromorphone hcl liqd or1 mgml 1

hydromorphone hcl soln ij10 mgml 50 mg5ml 500mg50ml

hydromorphone hcl tabs or2 mg 4 mg 8 mg 1

hydromorphone hcl tb24 or12 mg 16 mg 8 mg 1 PA QL(2 ea

daily) hydromorphone hcl tb24 or32 mg 1 PA QL(1 ea

daily) HYDROMORPHONE HYDROCHLORIDE SOLN IJ 10 MGML (Use hydromorphone hcl)

KADIAN CP24 100 MG 20 MG 30 MG 50 MG 60 MG 80 MG (Use morphine sulfate)

PA QL(2 eadaily)

levorphanol tartrate tabs 2 mg 1

meperidine hcl soln ij 100mgml 25 mgml 50 mgml 1

meperidine hcl soln or 50mg5ml 1

New starts limited to 7 daysupplyQL(500ml per fill retail)

Drug Name DrugTier

RequirementsLimits

meperidine hcl tabs or 50 mg 1

methadone hcl conc or 10 mgml 1 QL(10 ml daily)

methadone hcl soln ij 10mgml 1

METHADONE HCL SOLN IJ 10 MGML (Use methadone hcl)

methadone hcl soln or 10 mg5ml 1 QL(50 ml daily)

methadone hcl soln or 5 mg5ml 1 QL(100 ml

daily) methadone hcl tabs or 10 mg 1 QL(10 ea daily)

methadone hcl tabs or 5 mg 1 QL(4 ea daily)

methadone hcl tbso or 40 mg 1 QL(2 ea daily)

METHADOSE CONC (Use methadone hcl) NF QL(10 ml daily)

METHADOSE SUGAR-FREE CONC (Use methadone hcl)

NF QL(10 ml daily)

MORPHABOND ER T12A 100 MG 30 MG 60 MG 3 PA QL(1 ea

daily) MORPHABOND ER T12A 15 MG 3 PA QL(3 ea

daily) morphine sulfate cp24 or100 mg 20 mg 30 mg 50mg 60 mg 80 mg

1 PA QL(2 eadaily)

morphine sulfate soln ij 05mgml 1 mgml 1

MORPHINE SULFATE SOLN IV 10 MGML (Use morphine sulfate)

morphine sulfate soln or 10mg5ml 1

New starts limited to 7 daysupplyQL(100ml daily)

Drug Name DrugTier

RequirementsLimits

morphine sulfate tabs or 15 mg 1

morphine sulfate tabs or 15mg 30 mg 1

morphine sulfate tbcr or100 mg 15 mg 200 mg 30mg 60 mg

1 QL(2 ea daily)

MS CONTIN TBCR (Use morphine sulfate) NF QL(2 ea daily)

NUCYNTA ER TB12 2 PA QL(2 eadaily)

NUCYNTA TABS 2 PA QL(6 eadaily)

OPANA TABS (Use oxymorphone hcl) NF PA QL(12 ea

daily)

OXAYDO TABS 5 MG 2

New starts limited to 7 daysupplyQL(12ea daily)

oxycodone hcl t12a 15 mg30 mg 60 mg 80 mg 10mg 20 mg 40 mg

3 PA QL(2 eadaily)

oxycodone hcl tabs 10 mg15 mg 20 mg 30 mg 5 mg 1

OXYCONTIN T12A 3 PA QL(2 eadaily)

oxymorphone hcl tabs 10mg 5 mg 1 PA QL(12 ea

daily) oxymorphone hcl tb12 10mg 15 mg 20 mg 30 mg5 mg 75 mg

1 PA QL(2 eadaily)

oxymorphone hcl tb12 40 mg 1 PA QL(4 ea

daily)

ROXICODONE TABS (Use oxycodone hcl) NF

SUBSYS LIQD 100 MCG 3 PA QL(3 eadaily)

SUBSYS LIQD 1200 MCG 1600 MCG 800 MCG 3 PA QL(8 ea

daily) SUBSYS LIQD 200 MCG 400 MCG 600 MCG 3 PA QL(4 ea

daily)

Drug Name DrugTier

RequirementsLimits

tramadol hcl tabs 50 mg 1

tramadol hcl tb24 100 mg200 mg 300 mg 1 QL(1 ea daily)

ULTRAM TABS (Use tramadol hcl) NF

XTAMPZA ER C12A 2 PA QL(2 eadaily)

ZOHYDRO ER CP12 1 PA QL(2 eadaily)

Opioid Combinations

acetaminophen w codeinesoln 12 mg5ml-120mg5ml

acetaminophen w codeinetabs 15 mg-300 mg 1

acetaminophen-caff-dihydrocod caps 16 mg-30mg-3205 mg

1 New starts limited to 7 daysupply

3 PA New starts limited to 7 daysupply

butalbital-acetaminophen-caffeine w codeine caps30 mg-40 mg-50 mg-300 mg

Drug Name DrugTier

RequirementsLimits

butalbital-aspirin-caffeinewcod caps 1

FIORICETCODEINECAPS (Use butalbital-acetaminophen-caffeine wcodeine)

FIORINALCODEINE 3CAPS (Use butalbital-aspirin-caffeine wcod)

hydrocodone-acetaminophen soln 10mg15ml-325 mg15ml

hydrocodone-acetaminophen soln 25mg5ml-108 mg5ml 5mg10ml-217 mg10ml 75mg15ml-325 mg15ml

hydrocodone-acetaminophen tabs 10mg-300 mg 5 mg-300 mg75 mg-300 mg

hydrocodone-ibuprofentabs 10 mg-200 mg 5 mg-200 mg

hydrocodone-ibuprofentabs 75 mg-200 mg 1

LORTAB ELIX 2

NORCO TABS (Use hydrocodone-acetaminophen)

oxycodone wacetaminophen tabs 10mg-325 mg 5 mg-325 mg75 mg-325 mg

Drug Name DrugTier

RequirementsLimits

oxycodone-ibuprofen tabs 1

PERCOCET TABS 10 MG-325 MG 5 MG-325 MG 75 MG-325 MG (Use oxycodone wacetaminophen)

tramadol-acetaminophentabs 1

TYLENOLCODEINE 3TABS (Use acetaminophenw codeine)

ULTRACET TABS (Use tramadol-acetaminophen) NF

Opioid Partial Agonists BUNAVAIL FILM 03 MG-21 MG 3 PA QL(4 ea

daily) BUNAVAIL FILM 07 MG-42 MG 3 PA QL(2 ea

daily) BUPRENEX SOLN (Use buprenorphine hcl) NF

buprenorphine hcl soln ij03 mgml 1

buprenorphine hcl subl sl 2mg 8 mg 1 QL(3 ea daily)

buprenorphine hcl-naloxone hcl dihydrate film05 mg-2 mg 1 mg-4 mg

1 QL(3 ea daily)

1 QL(2 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl05 mg-2 mg 2 mg-8 mg

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

buprenorphine ptwk td 10mcghr 15 mcghr 20mcghr 5 mcghr 75mcghr

PA QL(0143ea daily)

butorphanol tartrate soln ij1 mgml 2 mgml 1

butorphanol tartrate soln na10 mgml 1 PA

BUTRANS PTWK 10 MCGHR 15 MCGHR 20MCGHR 5 MCGHR (Use buprenorphine)

PA QL(0143ea daily)

BUTRANS PTWK 75 MCGHR (Use buprenorphine)

nalbuphine hcl soln 1 QL(8 ml daily)

pentazocine w naloxonehcl tabs 1

SUBOXONE FILM 05 MG-2 MG 1 MG-4 MG (Use buprenorphine hcl-naloxone hcl dihydrate)

QL(3 ea daily)

QL(2 ea daily)

ANDROGENS-ANABOLIC - Drugs to Regulate Hormones

Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens

ANDRODERM PT24 2 PA QL(1 eadaily)

ANDROGEL GEL 25 MG25GM 50 MG5GM(Use testosterone)

danazol caps 1

DEPO-TESTOSTERONE SOLN (Use testosterone cypionate)

Drug Name DrugTier

RequirementsLimits

METHITEST TABS 3

TESTIM GEL (Use testosterone) NF

TESTOSTERONE CYPIONATE SOLN IJ 200 MGML

testosterone cypionate solnij 200 mgml 1

testosterone cypionate solnim 100 mgml 200 mgml 1

testosterone enanthate soln 1

VOGELXO GEL (Use testosterone) NF

VOGELXO PUMP GEL (Use testosterone) NF

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (Use hydrocortisone (intrarectal)) NF

hydrocortisone (intrarectal) enem 1

UCERIS FOAM RE 2 MGACT 4 PA QL(32 gm

daily) Rectal Steroids ANUSOL-HC CREA (Use hydrocortisone (rectal)) NF

hydrocortisone (rectal) crea 1

hydrocortisone acetate(rectal) supp 1

PROCTOCORT CREA (Use hydrocortisone(rectal))

PROCTOCORT SUPP (Use hydrocortisoneacetate (rectal))

Vasodilating Agents

RECTIV OINT 3 QL(2 gm daily)

ANTHELMINTICS - Drugs to Treat Worm Infections

Anthelmintics

Drug Name DrugTier

RequirementsLimits

albendazole tabs 1 PA

ALBENZA TABS (Use albendazole) NF PA

BILTRICIDE TABS (Use praziquantel) NF PA

EMVERM CHEW 2

QL(2 ea daily6ea per fillretail6 ea perfill mail)1 rtlMAX fill60 rtl day(s) supply1mail MAX fill60 mail day(s)supply

ivermectin tabs or 3 mg 1

praziquantel tabs 1 PA

STROMECTOL TABS (Use ivermectin) NF

ANTI-INFECTIVE AGENTS - MISC - Drugs to Treat Bacterial Infections

Anti-infective Agents - Misc bacitracin solr 3

FLAGYL TABS 500 MG (Use metronidazole) NF

IMPAVIDO CAPS 3 PA QL(3 eadaily)

metronidazole tabs or 250 mg 500 mg 1

trimethoprim tabs 1

XIFAXAN TABS 3 PA AL(At least12 yrs old)

Anti-infective Misc - Combinations BACTRIM DS TABS (Use sulfamethoxazole-trimethoprim)

BACTRIM TABS (Use sulfamethoxazole-trimethoprim)

sulfamethoxazole-trimethoprim soln 1

sulfamethoxazole-trimethoprim susp 1

Drug Name DrugTier

RequirementsLimits

sulfamethoxazole-trimethoprim tabs 1

Antiprotozoal Agents ALINIA SUSR 100 MG5ML 2 PA

ALINIA TABS 500 MG (Use nitazoxanide) 2 PA

atovaquone susp 1

MEPRON SUSP (Use atovaquone) NF

nitazoxanide tabs or 1 PA

Carbapenems

ertapenem sodium solr 1

imipenem-cilastatin solr 1

INVANZ SOLR (Use ertapenem sodium) NF

meropenem solr 1

MERREM SOLR (Use meropenem) NF

PRIMAXIN IV SOLR (Use imipenem-cilastatin) NF

Chloramphenicols chloramphenicol sodiumsuccinate solr 4 PA SP

Cyclic Lipopeptides CUBICIN RF SOLR (Use daptomycin) NF

CUBICIN SOLR (Use daptomycin) NF

DAPTOMYCIN SOLR 350 MG (Use daptomycin) NF

daptomycin solr 500 mg 1

Glycopeptides

FIRVANQ SOLR 2 QL(300 ml perfill retail)

VANCOCIN CAPS (Use vancomycin hcl) NF

QL(4 eadaily40 ea perfill retail)

Drug Name DrugTier

RequirementsLimits

VANCOCIN HCL CAPS (Use vancomycin hcl) NF

vancomycin hcl caps or125 mg 250 mg 1

vancomycin hcl solr iv 500mg 1 gm 10 gm 1000 mg 1

VANCOMYCIN HYDROCHLORIDE SOLR OR 250 MG5ML

2 QL(300 ml perfill retail)

Leprostatics

dapsone tabs 1

Lincosamides CLEOCIN CAPS OR 75 MG 150 MG 300 MG (Use clindamycin hcl)

CLEOCIN PEDIATRIC GRANULES SOLR (Use clindamycin palmitatehydrochloride)

CLEOCIN PHOSPHATE SOLN IJ 600 MG4ML 900MG6ML 300 MG2ML 9GM60ML (Use clindamycin phosphate)

clindamycin hcl caps 1

clindamycin palmitatehydrochloride solr 1

clindamycin phosphate soln 1

LINCOCIN SOLN (Use lincomycin hcl) NF

lincomycin hcl soln 1

Monobactams AZACTAM SOLR (Use aztreonam) NF

aztreonam solr 1

CAYSTON SOLR 4 PA QL(3 mldaily)

Oxazolidinones

Drug Name DrugTier

RequirementsLimits

linezolid susr or 100 mg5ml 1

linezolid tabs or 600 mg 1 PA QL(2 eadaily)

SIVEXTRO TABS OR 3 PA

ZYVOX SUSR OR 100 MG5ML (Use linezolid) NF

ZYVOX TABS OR 600 MG (Use linezolid) NF PA QL(2 ea

daily) Polymyxins

polymyxin b sulfate solr 1

Urinary Anti-infectives fosfomycin tromethaminepack 1

HIPREX TABS (Use methenamine hippurate) NF

MACROBID CAPS (Use nitrofurantoin monohyd macro)

MACRODANTIN CAPS 50 MG 100 MG (Use nitrofurantoin macrocrystal)

methenamine hippuratetabs 1

MONUROL PACK (Use fosfomycin tromethamine) 3

nitrofurantoin macrocrystalcaps 50 mg 100 mg 1

nitrofurantoin monohyd macro caps 1

nitrofurantoin susp 1

ANTIANGINAL AGENTS - Drugs to Treat Chest Pain

Antianginals-Other RANEXA TB12 1000 MG (Use ranolazine) NF QL(2 ea daily)

RANEXA TB12 500 MG (Use ranolazine) NF QL(3 ea daily)

ranolazine tb12 1000 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

Nitrates ISORDIL TITRADOSE TABS 5 MG (Use isosorbide dinitrate)

isosorbide dinitrate tabs 30 mg 10 mg 20 mg 5 mg 1

isosorbide dinitrate tbcr 40 mg 1

isosorbide mononitrate tabs 1

isosorbide mononitrate tb24 1

NITRO-BID OINT 3

NITRO-DUR PT24 01 MGHR 04 MGHR 02MGHR 06 MGHR (Use nitroglycerin)

nitroglycerin cpcr or 25mg 65 mg 9 mg 1 QL(4 ea daily)

nitroglycerin pt24 td 01mghr 04 mghr 02mghr 06 mghr

NITROGLYCERIN SOLN IV 5 MGML 1

nitroglycerin subl sl 03 mg04 mg 06 mg 1

NITROSTAT SUBL (Use nitroglycerin) NF

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc buspirone hcl tabs 10 mg30 mg 75 mg 15 mg 1

buspirone hcl tabs 5 mg 1 QL(6 ea daily)

hydroxyzine hcl soln im 50mgml 1

hydroxyzine hcl syrp or 10mg5ml 1

hydroxyzine hcl tabs or 10mg 25 mg 50 mg 1

hydroxyzine pamoate caps 1

meprobamate tabs 1

Drug Name DrugTier

RequirementsLimits

VISTARIL CAPS (Use hydroxyzine pamoate) NF

Benzodiazepines alprazolam tabs 025 mg05 mg 1 mg 2 mg 1 QL(4 ea daily)

alprazolam tb24 05 mg 1mg 2 mg 3 mg 1

alprazolam tbdp 025 mg05 mg 1 mg 2 mg 1

ATIVAN TABS OR 05 MG 2 MG (Use lorazepam) NF QL(3 ea daily)

ATIVAN TABS OR 1 MG (Use lorazepam) NF QL(4 ea daily)

chlordiazepoxide hcl caps 1

clorazepate dipotassiumtabs 1

diazepam conc or 5 mgml 1

diazepam soln or 5 mg5ml 1

diazepam tabs or 10 mg 2mg 5 mg 1 QL(4 ea daily)

lorazepam conc or 2 mgml 1

lorazepam tabs or 05 mg2 mg 1 QL(3 ea daily)

lorazepam tabs or 1 mg 1 QL(4 ea daily)

oxazepam caps 10 mg 15mg 30 mg 1

TRANXENE T TABS (Use clorazepate dipotassium) NF

VALIUM TABS (Use diazepam) NF QL(4 ea daily)

XANAX TABS (Use alprazolam) NF QL(4 ea daily)

XANAX XR TB24 (Use alprazolam) NF

ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms

Antiarrhythmics Type I-A disopyramide phosphate caps 1

NORPACE CAPS (Use disopyramide phosphate) NF

Drug Name DrugTier

RequirementsLimits

procainamide hcl soln 500mgml 1

quinidine sulfate tabs 1

Antiarrhythmics Type I-B mexiletine hcl caps 250mg 150 mg 200 mg 1

Antiarrhythmics Type I-C

flecainide acetate tabs 1

propafenone hcl cp12 1

propafenone hcl tabs 1

RYTHMOL SR CP12 (Use propafenone hcl) NF

Antiarrhythmics Type III amiodarone hcl soln iv 150 mg3ml 50 mgml 1

amiodarone hcl tabs or 100 mg 200 mg 400 mg 1

dofetilide caps 1

MULTAQ TABS 3

TIKOSYN CAPS (Use dofetilide) NF

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

cromolyn sodium nebu 1 QL(8 ml daily)

Antiasthmatic - Monoclonal Antibodies

FASENRA PEN SOAJ 4 PA

FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA

XOLAIR SOLR 150 MG 4 PA SP

Drug Name DrugTier

RequirementsLimits

XOLAIR SOSY 150 MGML 75 MG05ML 4 PA

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 3 QL(044 gmdaily)

INCRUSE ELLIPTA AEPB 2 QL(1 ea daily)

ipratropium bromide soln 1 QL(15 ml daily)

SPIRIVA HANDIHALER CAPS 2 QL(1 ea daily)

SPIRIVA RESPIMAT AERS 2 QL(014 gm

daily) Leukotriene Modulators ACCOLATE TABS (Use zafirlukast) NF QL(2 ea daily)

montelukast sodium chew 4 mg 5 mg 1 QL(1 ea daily)

montelukast sodium pack 4 mg 1 PA QL(1 ea

daily) montelukast sodium tabs 10 mg 1 QL(1 ea daily)

SINGULAIR CHEW 4 MG 5 MG (Use montelukast sodium)

NF QL(1 ea daily)

SINGULAIR PACK 4 MG (Use montelukast sodium) NF PA QL(1 ea

daily) SINGULAIR TABS 10 MG (Use montelukast sodium) NF QL(1 ea daily)

zafirlukast tabs 1 QL(2 ea daily)

zileuton tb12 1 QL(4 ea daily)

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS 250 MCG 3

QL(1 eadaily)30 rtlMAX day(s)supply180 rtllmt day(s)30mail MAX day(s)supply180 maillmt day(s)

DALIRESP TABS 500 MCG 3 QL(1 ea daily)

Steroid Inhalants

Drug Name DrugTier

RequirementsLimits

ARNUITY ELLIPTA AEPB 2

budesonide (inhalation) susp 1 PA QL(4 ml

daily)

FLOVENT DISKUS AEPB 2

FLOVENT HFA AERO 2

PULMICORT FLEXHALER AEPB 2

PULMICORT SUSP (Use budesonide (inhalation)) NF PA QL(4 ml

daily)

QVAR REDIHALER AERB 2

Sympathomimetics ADVAIR DISKUS AEPB (Use fluticasone-salmeterol)

ADVAIR HFA AERO 2

AIRDUO RESPICLICK 11314 AEPB (Use fluticasone-salmeterol)

albuterol sulfate aers in 108 mcgact 1

2 rtl pack lmtamt30 rtl packlmt day(s)

Limit 2 inhalers per month1 rtlpack lmt perfill2 rtl MAX fill30 rtl day(s)supply

Limit 2 Inhalers per month1 rtlpack lmt perfill2 rtl MAX fill30 rtl day(s)supply

albuterol sulfate nebu in 05 25 mg05ml 1

Drug Name DrugTier

RequirementsLimits

albuterol sulfate nebu in 063 mg3ml 125 mg3ml0083

1 QL(15 ml daily)

albuterol sulfate syrp or 2mg5ml 1

albuterol sulfate tabs or 2 mg 4 mg 1

albuterol sulfate tb12 or 4 mg 8 mg 1

ANORO ELLIPTA AEPB 2 QL(2 ea daily)

ARCAPTA NEOHALER CAPS 2

arformoterol tartrate nebu 1 PA QL(4 mldaily)

BEVESPI AEROSPHERE AERO 2 QL(036 gm

daily)

BREO ELLIPTA AEPB 2

BROVANA NEBU (Use arformoterol tartrate) 3 PA QL(4 ml

daily) budesonide-formoterol fumarate dihydrate aero 1

fluticasone-salmeterol aepb50 mcgdose-500mcgdose 50 mcgact-100mcgact 50 mcgact-250mcgact 50 mcgdose-100mcgdose 50 mcgdose-250 mcgdose

ipratropium-albuterol soln 1 QL(18 ml daily)

levalbuterol hcl nebu 031 mg3ml 063 mg3ml 125mg3ml

1 PA QL(12 mldaily)

levalbuterol hcl nebu 125 mg05ml 1 PA

levalbuterol tartrate aero 3

PA Limit 2 inhalers permonthQL(1 gmdaily)

PROAIR HFA AERS (Use albuterol sulfate) NF

PROVENTIL HFA AERS (Use albuterol sulfate) NF

SEREVENT DISKUS AEPB 2

Drug Name DrugTier

RequirementsLimits

STRIVERDI RESPIMAT AERS 2

SYMBICORT AERO (Use budesonide-formoterol fumarate dihydrate)

terbutaline sulfate soln 1

terbutaline sulfate tabs 1

TRELEGY ELLIPTA AEPB 2 QL(2 ea daily)

UTIBRON NEOHALER CAPS 3 PA QL(2 ea

daily) VENTOLIN HFA AERS (Use albuterol sulfate) NF

XOPENEX CONCENTRATE NEBU (Use levalbuterol hcl)

XOPENEX HFA AERO (Use levalbuterol tartrate) 3

XOPENEX NEBU (Use levalbuterol hcl) NF PA QL(12 ml

daily) Xanthines

aminophylline soln 1

ELIXOPHYLLIN ELIX 1

theophylline soln 80mg15ml 1 QL(56 ml daily)

theophylline tb12 300 mg450 mg 1

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (Use warfarin sodium) 2

warfarin sodium tabs 1

Direct Factor Xa Inhibitors

BEVYXXA CAPS 3

QL(42 ea per42 daysretail42 ea per42 days mail)

Drug Name DrugTier

RequirementsLimits

ELIQUIS STARTER PACK TBPK 2 QL(247 ea

daily)

ELIQUIS TABS 2 QL(247 eadaily)

XARELTO STARTER PACK TBPK 2

1 rtl MAX fill365 rtl day(s) supply

XARELTO TABS 10 MG 20 MG 2 QL(1 ea daily)

Heparins And Heparinoid-Like Agents

ARIXTRA SOLN 10 MG08ML (Use fondaparinux sodium)

QL(72 ml per180 daysretail72 ml per180 days mail)SP

enoxaparin sodium soln ij300 mg3ml 4 QL(6 ml daily)

enoxaparin sodium soln sc100 mgml 150 mgml 4 QL(2 ml daily)

enoxaparin sodium soln sc120 mg08ml 80 mg08ml 4 QL(16 ml

daily) enoxaparin sodium soln sc30 mg03ml 4 QL(06 ml

daily) SP

enoxaparin sodium soln sc40 mg04ml 4

QL(08 mldaily30 day(s)limit) SP

Drug Name DrugTier

RequirementsLimits

fondaparinux sodium soln10 mg08ml 4

fondaparinux sodium soln 5mg04ml 4

FRAGMIN SOLN 10000 UNITML 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 2500UNIT02ML 5000UNIT02ML 7500UNIT03ML

HEPARIN LOCK FLUSH SOLN (Use heparin sodium(porcine) lock flush)

heparin sod (porcine) ind5w soln 5 -40 unitml 1

heparin sodium (porcine)soln 10000 unitml 20000unitml 5000 unitml

HEPARIN SODIUMNACL045 SOLN 045 -12500 UNIT250ML

LOVENOX SOLN IJ 300 MG3ML (Use enoxaparin sodium)

NF QL(6 ml daily)

LOVENOX SOLN SC 100 MGML 150 MGML (Use enoxaparin sodium)

NF QL(2 ml daily)

LOVENOX SOLN SC 120 MG08ML 80 MG08ML(Use enoxaparin sodium)

NF QL(16 mldaily)

Drug Name DrugTier

RequirementsLimits

LOVENOX SOLN SC 30 MG03ML (Use enoxaparin sodium)

NF QL(06 mldaily) SP

NF QL(08 mldaily30 day(s)limit) SP

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists FYCOMPA TABS 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG

Anticonvulsants - Benzodiazepines

clobazam susp 25 mgml 1 PA QL(16 mldaily)

clobazam tabs 10 mg 20 mg 1 PA QL(2 ea

daily) clonazepam tabs 05 mg 1mg 2 mg 1

DIASTAT ACUDIAL GEL (Use diazepam(anticonvulsant))

DIASTAT PEDIATRIC GEL (Use diazepam(anticonvulsant))

diazepam (anticonvulsant)gel 3

KLONOPIN TABS (Use clonazepam) NF

NAYZILAM SOLN 3 PA QL(10 eaper 30 daysretail)

ONFI SUSP 25 MGML(Use clobazam) NF PA QL(16 ml

daily) ONFI TABS 10 MG 20 MG (Use clobazam) NF PA QL(2 ea

daily)

VALTOCO LIQD 4 PA QL(10 eaper 30 daysretail)

VALTOCO LQPK 4 PA QL(10 eaper 30 daysretail)

Anticonvulsants - Misc

Drug Name DrugTier

RequirementsLimits

APTIOM TABS 3 ST QL(2 eadaily)

BANZEL SUSP 40 MGML(Use rufinamide) 2 PA QL(80 ml

daily) BANZEL TABS 200 MG (Use rufinamide) 2 PA QL(2 ea

daily) BRIVIACT SOLN OR 10 MGML 3 PA

BRIVIACT TABS OR 10 MG 100 MG 25 MG 50 MG 75 MG

carbamazepine chew 100 mg 1

carbamazepine cp12 100 mg 1

carbamazepine cp12 200 mg 1 QL(6 ea daily)

carbamazepine susp 100mg5ml 1

carbamazepine tabs 200 mg 1

carbamazepine tb12 100mg 400 mg 1 QL(4 ea daily)

carbamazepine tb12 200 mg 1 QL(6 ea daily)

CARBATROL CP12 100 MG (Use carbamazepine) NF

CARBATROL CP12 200 MG (Use carbamazepine) NF QL(6 ea daily)

DIACOMIT CAPS 250 MG 4 PA QL(12 eadaily)

DIACOMIT PACK 250 MG 4 PA QL(12 eadaily)

EPIDIOLEX SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

gabapentin caps 100 mg300 mg 400 mg 1

gabapentin soln 250mg5ml 300 mg6ml 1 QL(60 ml daily)

gabapentin tabs 600 mg800 mg 1

KEPPRA SOLN IV 500 MG5ML (Use levetiracetam)

NF QL(30 ml daily)

KEPPRA SOLN OR 100 MGML (Use levetiracetam) NF QL(30 ml daily)

KEPPRA TABS OR 1000 MG (Use levetiracetam) NF QL(3 ea daily)

KEPPRA TABS OR 250 MG 750 MG (Use levetiracetam)

NF QL(4 ea daily)

KEPPRA XR TB24 (Use levetiracetam) NF QL(4 ea daily)

LAMICTAL CHEWABLE DISPERSIBLE CHEW 25 MG (Use lamotrigine)

NF QL(20 ea daily)

NF QL(100 eadaily)

LAMICTAL ODT TBDP 100 MG 200 MG 25 MG 50 MG (Use lamotrigine)

NF QL(1 ea daily)

LAMICTAL TABS (Use lamotrigine) NF

lamotrigine chew 25 mg 1 QL(20 ea daily)

lamotrigine chew 5 mg 1 QL(100 eadaily)

lamotrigine tabs 100 mg150 mg 200 mg 25 mg 1

lamotrigine tbdp 100 mg200 mg 25 mg 50 mg 1 QL(1 ea daily)

levetiracetam soln iv 500 mg5ml 1 QL(30 ml daily)

levetiracetam soln or 100 mgml 500 mg5ml 1 QL(30 ml daily)

levetiracetam tabs or 1000 mg 1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

levetiracetam tabs or 250 mg 750 mg 1 QL(4 ea daily)

levetiracetam tb24 or 500 mg 750 mg 1 QL(4 ea daily)

LYRICA CAPS 100 MG 150 MG 200 MG 25 MG 50 MG 75 MG (Use pregabalin)

PA QL(3 eadaily)

LYRICA CAPS 225 MG 300 MG (Use pregabalin) NF PA QL(2 ea

daily) LYRICA SOLN 20 MGML(Use pregabalin) NF PA QL(30 ml

daily) MYSOLINE TABS (Use primidone) NF

NEURONTIN CAPS 100 MG 300 MG 400 MG (Use gabapentin)

NEURONTIN SOLN 250 MG5ML (Use gabapentin) NF QL(60 ml daily)

NEURONTIN TABS 600 MG 800 MG (Use gabapentin)

oxcarbazepine susp 300mg5ml 60 mgml 1 QL(40 ml daily)

oxcarbazepine tabs 150mg 300 mg 1 QL(3 ea daily)

oxcarbazepine tabs 600 mg 1 QL(4 ea daily)

pregabalin caps 100 mg150 mg 200 mg 25 mg 50mg 75 mg

1 PA QL(3 eadaily)

pregabalin caps 225 mg300 mg 1 PA QL(2 ea

daily)

pregabalin soln 20 mgml 1 PA QL(30 mldaily)

primidone tabs 1

QUDEXY XR CS24 (Use topiramate) NF

rufinamide susp 40 mgml 1 PA QL(80 mldaily)

rufinamide tabs 200 mg 1 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

TEGRETOL SUSP (Use carbamazepine) 2

TEGRETOL TABS (Use carbamazepine) 2

TEGRETOL-XR TB12 100 MG 400 MG (Use carbamazepine)

NF QL(4 ea daily)

TEGRETOL-XR TB12 200 MG (Use carbamazepine) NF QL(6 ea daily)

TOPAMAX SPRINKLE CPSP 15 MG (Use topiramate)

NF QL(6 ea daily)

NF QL(8 ea daily)

TOPAMAX TABS 100 MG 25 MG (Use topiramate) NF QL(4 ea daily)

TOPAMAX TABS 200 MG (Use topiramate) NF QL(2 ea daily)

topiramate cpsp 15 mg 1 QL(6 ea daily)

topiramate tabs 100 mg 25 mg 1 QL(4 ea daily)

topiramate tabs 200 mg 1 QL(2 ea daily)

TRILEPTAL SUSP 300 MG5ML (Use oxcarbazepine)

NF QL(40 ml daily)

TRILEPTAL TABS 150 MG 300 MG (Use oxcarbazepine)

NF QL(3 ea daily)

TRILEPTAL TABS 600 MG (Use oxcarbazepine) NF QL(4 ea daily)

VIMPAT SOLN IV 200 MG20ML 3 QL(40 ml daily)

VIMPAT SOLN OR 10 MGML 3 PA QL(40 ml

daily) VIMPAT TABS OR 100 MG 150 MG 200 MG 50 MG

3 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

ZONEGRAN CAPS (Use zonisamide) NF QL(6 ea daily)

zonisamide caps 1 QL(6 ea daily)

Carbamates

felbamate susp 600 mg5ml 1 QL(30 ml daily)

felbamate tabs 400 mg 1 QL(9 ea daily)

FELBATOL SUSP 600 MG5ML (Use felbamate) NF QL(30 ml daily)

FELBATOL TABS 400 MG (Use felbamate) NF QL(9 ea daily)

GABA Modulators GABITRIL TABS 2 MG 4 MG (Use tiagabine hcl) NF

SABRIL PACK (Use vigabatrin) NF PA QL(6 ea

daily) SP SABRIL TABS (Use vigabatrin) NF PA QL(6 ea

daily) SP tiagabine hcl tabs 2 mg 4 mg 1

vigabatrin pack 4 PA QL(6 eadaily) SP

vigabatrin tabs 4 PA QL(6 eadaily) SP

Hydantoins CEREBYX SOLN (Use fosphenytoin sodium) NF

DILANTIN CAPS 100 MG (Use phenytoin sodiumextended)

DILANTIN CAPS 30 MG 2

DILANTIN INFATABS CHEW (Use phenytoin) 2

DILANTIN-125 SUSP (Use phenytoin) 2

fosphenytoin sodium soln 1

PEGANONE TABS 3

Drug Name DrugTier

RequirementsLimits

PHENYTEK CAPS (Use phenytoin sodiumextended)

phenytoin chew 1

phenytoin sodium extended caps 1

phenytoin sodium soln 1

phenytoin susp 1

Succinimides

CELONTIN CAPS 3 QL(4 ea daily)

ethosuximide caps 250 mg 1 QL(6 ea daily)

ethosuximide soln 250 mg5ml 1 QL(30 ml daily)

ZARONTIN CAPS 250 MG (Use ethosuximide) 2 QL(6 ea daily)

ZARONTIN SOLN 250 MG5ML (Use ethosuximide)

NF QL(30 ml daily)

Valproic Acid DEPAKOTE ER TB24 (Use divalproex sodium) NF

DEPAKOTE TBEC (Use divalproex sodium) NF

divalproex sodium tb24 250mg 500 mg 1

divalproex sodium tbec 125mg 250 mg 500 mg 1

valproate sodium soln 1

valproic acid caps or 1

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 mg 1 QL(3 ea daily)

mirtazapine tabs 30 mg 1 QL(15 eadaily)

mirtazapine tabs 45 mg75 mg 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

mirtazapine tbdp 15 mg 1 QL(3 ea daily)

mirtazapine tbdp 30 mg 1 QL(15 eadaily)

REMERON SOLTAB TBDP 15 MG (Use mirtazapine) NF QL(3 ea daily)

REMERON SOLTAB TBDP 30 MG (Use mirtazapine) NF QL(15 ea

daily) REMERON SOLTAB TBDP 45 MG (Use mirtazapine) NF QL(1 ea daily)

REMERON TABS 15 MG (Use mirtazapine) NF QL(3 ea daily)

REMERON TABS 30 MG (Use mirtazapine) NF QL(15 ea

daily) Antidepressants - Misc bupropion hcl tabs 100 mg75 mg 1 QL(3 ea daily)

bupropion hcl tb12 100 mg 1 QL(4 ea daily)

FORFIVO XL TB24 (Use bupropion hcl) NF

maprotiline hcl tabs 1

WELLBUTRIN SR TB12 100 MG (Use bupropion hcl)

NF QL(4 ea daily)

NF QL(3 ea daily)

NF QL(2 ea daily)

WELLBUTRIN XL TB24 150 MG (Use bupropion hcl)

NF QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 3 QL(1 ea daily)

MARPLAN TABS 2 QL(6 ea daily)

NARDIL TABS (Use phenelzine sulfate) NF

PARNATE TABS (Use tranylcypromine sulfate) NF

phenelzine sulfate tabs 1

tranylcypromine sulfatetabs 1

N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE SOPK 4 PA

SPRAVATO 84MG DOSE SOPK 4 PA

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use citalopramhydrobromide)

NF QL(4 ea daily)

CELEXA TABS 20 MG (Use citalopramhydrobromide)

NF QL(2 ea daily)

NF QL(1 ea daily)

citalopram hydrobromidesoln 10 mg5ml 1 QL(20 ml daily)

citalopram hydrobromidetabs 10 mg 1 QL(4 ea daily)

escitalopram oxalate soln 5mg5ml 1 QL(20 ml daily)

escitalopram oxalate tabs10 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

escitalopram oxalate tabs 5 mg 1 QL(4 ea daily)

fluoxetine hcl caps 10 mg 1 QL(1 ea daily)

fluoxetine hcl cpdr 90 mg 1

fluoxetine hcl soln 20 mg5ml 1 QL(20 ml daily)

fluoxetine hcl tabs 10 mg60 mg 1 QL(1 ea daily)

fluoxetine hcl tabs 20 mg 1 QL(3 ea daily)

FLUOXETINE HYDROCHLORIDE TABS (Use fluoxetine hcl)

NF QL(1 ea daily)

fluvoxamine maleate tabs 100 mg 1 QL(3 ea daily)

fluvoxamine maleate tabs 25 mg 50 mg 1 QL(2 ea daily)

LEXAPRO TABS 10 MG (Use escitalopram oxalate) NF QL(2 ea daily)

paroxetine hcl susp 10mg5ml 3 QL(30 ml daily)

paroxetine hcl tabs 10 mg 1 QL(6 ea daily)

paroxetine hcl tb24 125 mg 1 QL(1 ea daily)

paroxetine hcl tb24 375mg 25 mg 1 QL(2 ea daily)

PAXIL CR TB24 125 MG (Use paroxetine hcl) NF QL(1 ea daily)

PAXIL CR TB24 375 MG 25 MG (Use paroxetine hcl) NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

PAXIL SUSP 10 MG5ML(Use paroxetine hcl) 3 QL(30 ml daily)

PAXIL TABS 10 MG (Use paroxetine hcl) NF QL(6 ea daily)

PROZAC CAPS 10 MG (Use fluoxetine hcl) NF QL(1 ea daily)

sertraline hcl conc 20 mgml 1 QL(10 ml daily)

sertraline hcl tabs 100 mg 1 QL(2 ea daily)

sertraline hcl tabs 25 mg50 mg 1 QL(4 ea daily)

ZOLOFT CONC 20 MGML(Use sertraline hcl) NF QL(10 ml daily)

ZOLOFT TABS 100 MG (Use sertraline hcl) NF QL(2 ea daily)

ZOLOFT TABS 25 MG 50 MG (Use sertraline hcl) NF QL(4 ea daily)

Serotonin Modulators

nefazodone hcl tabs 1

trazodone hcl tabs 1

TRINTELLIX TABS 3 PA QL(1 eadaily)

VIIBRYD STARTER PACK KIT 3

VIIBRYD TABS 3 PA QL(1 eadaily)

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use duloxetine hcl) NF QL(2 ea daily)

desvenlafaxine succinate tb24 100 mg 1 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

desvenlafaxine succinate tb24 25 mg 50 mg 1 QL(1 ea daily)

duloxetine hcl cpep or 20mg 60 mg 30 mg 1 QL(2 ea daily)

duloxetine hcl cpep or 40 mg 1

EFFEXOR XR CP24 150 MG (Use venlafaxine hcl) NF QL(2 ea daily)

FETZIMA CP24 3 PA

FETZIMA TITRATION PACK C4PK 3 PA

KHEDEZLA TB24 (Use desvenlafaxine) NF

PRISTIQ TB24 100 MG (Use desvenlafaxine succinate)

NF QL(4 ea daily)

PRISTIQ TB24 25 MG 50 MG (Use desvenlafaxine succinate)

NF QL(1 ea daily)

venlafaxine hcl cp24 150 mg 1 QL(2 ea daily)

venlafaxine hcl tabs 100 mg 25 mg 375 mg 50mg 75 mg

1 QL(3 ea daily)

venlafaxine hcl tb24 150 mg 1 QL(2 ea daily)

venlafaxine hcl tb24 225 mg 1 ST QL(1 ea

daily) venlafaxine hcl tb24 75 mg375 mg 1 QL(1 ea daily)

Tricyclic Agents

amitriptyline hcl tabs 1

amoxapine tabs 3

ANAFRANIL CAPS (Use clomipramine hcl) NF

Drug Name DrugTier

RequirementsLimits

clomipramine hcl caps 1

desipramine hcl tabs 1

doxepin hcl caps 1

doxepin hcl conc 1

imipramine hcl tabs 1

imipramine pamoate caps 1

NORPRAMIN TABS (Use desipramine hcl) NF

nortriptyline hcl caps 1

nortriptyline hcl soln 1

PAMELOR CAPS (Use nortriptyline hcl) NF

protriptyline hcl tabs 1

TOFRANIL TABS (Use imipramine hcl) NF

trimipramine maleate caps 1

ANTIDIABETICS - Drugs to Regulate Blood Sugar Alpha-Glucosidase Inhibitors

acarbose tabs 1 QL(3 ea daily)

GLYSET TABS (Use miglitol) NF

miglitol tabs 1

PRECOSE TABS (Use acarbose) NF QL(3 ea daily)

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN 2 PA QL(036 mldaily)

Antidiabetic Combinations ACTOPLUS MET TABS (Use pioglitazone hcl-metformin hcl)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

DUETACT TABS (Use pioglitazone hcl-glimepiride)

NF QL(1 ea daily)

glipizide-metformin hcl tabs25 mg-250 mg 25 mg-500 mg

1 QL(2 ea daily)

glipizide-metformin hcl tabs5 mg-500 mg 1 QL(4 ea daily)

glyburide-metformin tabs125 mg-250 mg 1 QL(2 ea daily)

glyburide-metformin tabs25 mg-500 mg 5 mg-500 mg

1 QL(4 ea daily)

GLYXAMBI TABS 2

JANUMET TABS 2 QL(2 ea daily)

JANUMET XR TB24 100 MG-1000 MG 2 QL(1 ea daily)

JANUMET XR TB24 50 MG-1000 MG 50 MG-500 MG

2 QL(2 ea daily)

KAZANO TABS (Use alogliptin-metformin hcl) NF

OSENI TABS (Use alogliptin-pioglitazone) NF

pioglitazone hcl-glimepiridetabs 1 QL(1 ea daily)

pioglitazone hcl-metforminhcl tabs 1 QL(2 ea daily)

repaglinide-metformin hcltabs 1 QL(2 ea daily)

SEGLUROMET TABS 2 QL(2 ea daily)

SYNJARDY TABS 2 QL(2 ea daily)

SYNJARDY XR TB24 10 MG-1000 MG 125 MG-1000 MG 5 MG-1000 MG

2 QL(2 ea daily)

SYNJARDY XR TB24 25 MG-1000 MG 2 QL(1 ea daily)

TRIJARDY XR TB24 2

XIGDUO XR TB24 10 MG-1000 MG 10 MG-500 MG 5 MG-500 MG

3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

XIGDUO XR TB24 25 MG-1000 MG 3 QL(2 ea daily)

XIGDUO XR TB24 5 MG-1000 MG 3 PA QL(2 ea

daily)

XULTOPHY 10036 SOPN 2 PA QL(05 mldaily)

Biguanides metformin hcl tabs 1000 mg 1 QL(25 ea

daily)

metformin hcl tabs 500 mg 1 QL(5 ea daily)

metformin hcl tb24 500 mg 1 QL(4 ea daily)

Diabetic Other BAQSIMI ONE PACK POWD 3 QL(0069 ea

daily) BAQSIMI TWO PACK POWD 3 QL(0069 ea

daily)

diazoxide susp 1

GLUCAGEN HYPOKIT SOLR 3 QL(0035 ea

daily)

glucagon (rdna) kit 1 QL(0035 eadaily)

GLUCAGON EMERGENCY KIT KIT (Use glucagon (rdna))

3 QL(0035 eadaily)

GVOKE PFS SOSY 3 QL(002 mldaily)

PROGLYCEM SUSP (Use diazoxide) NF

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin benzoate tabs 1 QL(1 ea daily)

JANUVIA TABS 2 QL(1 ea daily)

NESINA TABS (Use alogliptin benzoate) NF

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS 3 QL(6 ea daily)

Incretin Mimetic Agents (GLP-1 Receptor

Drug Name DrugTier

RequirementsLimits

OZEMPIC SOPN 2 MG15ML 2 PA QL(0054

ml daily) OZEMPIC SOPN 2 MG15ML 4 MG3ML 2 PA QL(0108

ml daily)

TRULICITY SOPN 2 PA QL(0143ml daily)

VICTOZA SOPN 2 PA QL(03 mldaily)

Insulin Sensitizing Agents ACTOS TABS (Use pioglitazone hcl) NF QL(1 ea daily)

AVANDIA TABS 3 QL(1 ea daily)

pioglitazone hcl tabs 1 QL(1 ea daily)

Insulin

APIDRA SOLN 3 PA

APIDRA SOLOSTAR SOPN 3 PA

BASAGLAR KWIKPEN SOPN 2

FIASP FLEXTOUCH SOPN 2

FIASP PENFILL SOCT 2

FIASP SOLN 2

HUMULIN R U-500 (CONCENTRATED) SOLN 2

HUMULIN R U-500 KWIKPEN SOPN 2

LEVEMIR FLEXTOUCH SOPN 2

LEVEMIR SOLN 2

NOVOLIN 7030 FLEXPENRELION SUPN 2

NOVOLIN 7030 FLEXPENSUPN 2

NOVOLIN 7030 RELIONSUSP 2

NOVOLIN 7030 SUSP 2

NOVOLIN N RELION SUSP 2

Drug Name DrugTier

RequirementsLimits

NOVOLIN N SUSP 2

NOVOLIN R RELION SOLN 2

NOVOLIN R SOLN 2

NOVOLOG FLEXPEN SOPN 2

NOVOLOG MIX 7030PREFILLED FLEXPEN SUPN

NOVOLOG MIX 7030SUSP 2

NOVOLOG PENFILL SOCT 2

NOVOLOG SOLN 2

TRESIBA FLEXTOUCH SOPN 2

TRESIBA SOLN 2

Meglitinide Analogues

nateglinide tabs 1 QL(3 ea daily)

repaglinide tabs 05 mg 1 mg 1 QL(4 ea daily)

repaglinide tabs 2 mg 1 QL(8 ea daily)

STARLIX TABS (Use nateglinide) NF QL(3 ea daily)

Sodium-Glucose Co-Transporter 2 (SGLT2)

FARXIGA TABS 3 PA QL(1 eadaily)

JARDIANCE TABS 2 QL(1 ea daily)

STEGLATRO TABS 2 QL(1 ea daily)

Sulfonylureas AMARYL TABS 1 MG 2 MG (Use glimepiride) NF QL(4 ea daily)

AMARYL TABS 4 MG (Use glimepiride) NF QL(2 ea daily)

glimepiride tabs 1 mg 2 mg 1 QL(4 ea daily)

glimepiride tabs 4 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

glipizide tabs 10 mg 5 mg 1 QL(4 ea daily)

glipizide tb24 10 mg 25mg 5 mg 1 QL(2 ea daily)

GLUCOTROL TABS (Use glipizide) NF QL(4 ea daily)

GLUCOTROL XL TB24 (Use glipizide) NF QL(2 ea daily)

glyburide micronized tabs 1 QL(4 ea daily)

glyburide tabs 1 QL(4 ea daily)

GLYNASE TABS (Use glyburide micronized) NF QL(4 ea daily)

tolbutamide tabs 1 QL(6 ea daily)

ANTIDIARRHEALPROBIOTIC AGENTS - Drugs to Treat Diarrhea

Antiperistaltic Agents diphenoxylate w atropineliqd 1

diphenoxylate w atropinetabs 1

IMODIUM A-D CAPS (Use loperamide hcl) NF RXOTC

LOMOTIL TABS (Use diphenoxylate w atropine) NF

loperamide hcl caps 2 mg 1 RXOTC

MOTOFEN TABS 3

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

CHEMET CAPS 3

deferasirox pack 180 mg360 mg 90 mg 4 PA

deferasirox tabs 180 mg360 mg 90 mg 4 PA SP

deferasirox tbso 125 mg250 mg 500 mg 4 PA SP

deferiprone tabs 1

EXJADE TBSO (Use deferasirox) NF PA SP

Drug Name DrugTier

RequirementsLimits

FERRIPROX TABS 500 MG (Use deferiprone) 3

JADENU SPRINKLE PACK (Use deferasirox) NF PA

JADENU TABS (Use deferasirox) NF PA SP

Antidotes and Specific Antagonists

VISTOGARD PACK 4 PA

Opioid Antagonists naloxone hcl soln 04 mgml 4 mg10ml 1

naltrexone hcl tabs 1

NARCAN LIQD 3

QL(2 ea per fillretail)2 rtl MAXfill30 rtl day(s)supply

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists ALOXI SOLN (Use palonosetron hcl) NF

ANZEMET TABS 3 PA QL(0167ea daily)

granisetron hcl soln iv 1mgml 1

granisetron hcl tabs or 1 mg 1 QL(034 ea

daily) ondansetron hcl soln ij 4mg2ml 1

ondansetron hcl soln or 4 mg5ml 1 QL(334 ml

daily) ondansetron hcl tabs or 24 mg 1 QL(0143 ea

daily)

ondansetron hcl tabs or 4 mg 1

QL(4 eadaily60 ea perfill retail60 ea per fill mail)

ondansetron tbdp 4 mg 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

ondansetron tbdp 8 mg 1

palonosetron hcl soln 1

ZOFRAN TABS 4 MG (Use ondansetron hcl) NF

Antiemetics - Anticholinergic

meclizine hcl tabs 1 RXOTC

scopolamine pt72 1 QL(034 eadaily)

TIGAN CAPS OR 300 MG (Use trimethobenzamide hcl)

TRANSDERM SCOP PT72 (Use scopolamine) 2 QL(034 ea

daily) TRANSDERM-SCOP PT72 (Use scopolamine) 2 QL(034 ea

daily) trimethobenzamide hcl caps 1

Antiemetics - Miscellaneous AKYNZEO CAPS OR 05 MG-300 MG 3 PA

DICLEGIS TBEC (Use doxylamine-pyridoxine) NF

PA QL(4 eadaily)3 rtl MAXfill365 rtl day(s) supply3mail MAX fill365 mail day(s) supply

doxylamine-pyridoxine tbec 1

dronabinol caps 1

MARINOL CAPS (Use dronabinol) NF

Drug Name DrugTier

RequirementsLimits

Substance PNeurokinin 1 (NK1) Receptor aprepitant caps 1 PA

aprepitant caps 125 mg 40 mg 1 PA QL(0067

ea daily)

aprepitant caps 80 mg 1 PA QL(0134ea daily)

aprepitant misc 1 PA

EMEND CAPS OR 40 MG (Use aprepitant) NF PA QL(0067

ea daily) EMEND CAPS OR 80 MG (Use aprepitant) NF PA QL(0134

ea daily) EMEND SOLR IV 150 MG (Use fosaprepitantdimeglumine)

EMEND TRIPACK CAPS (Use aprepitant) NF PA

VARUBI TBPK 3 PA

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors CANCIDAS SOLR (Use caspofungin acetate) NF

caspofungin acetate solr 50mg 70 mg 1

ERAXIS SOLR 3

micafungin sodium solr 100mg 50 mg 1

MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3

amphotericin b solr 3

ANCOBON CAPS (Use flucytosine) NF

flucytosine caps 1

griseofulvin microsize susp125 mg5ml 1 AL(At least 2

yrs old)

Drug Name DrugTier

RequirementsLimits

griseofulvin microsize tabs500 mg 1

griseofulvin ultramicrosizetabs 1

nystatin tabs 1

terbinafine hcl tabs 1 QL(1 ea daily)

Imidazole-Related Antifungals CRESEMBA CAPS OR 186 MG 3 PA

DIFLUCAN SUSR (Use fluconazole) NF

DIFLUCAN TABS (Use fluconazole) NF

fluconazole susr 1

fluconazole tabs 1

itraconazole caps 100 mg 1 PA QL(4 eadaily)

itraconazole soln 10 mgml 1 PA QL(20 mldaily)

ketoconazole tabs 1

NOXAFIL SUSP OR 40 MGML 3 QL(20 ml daily)

SPORANOX CAPS 100 MG (Use itraconazole) NF PA QL(4 ea

daily) SPORANOX PULSEPAK CAPS (Use itraconazole) NF PA QL(4 ea

daily) SPORANOX SOLN 10 MGML (Use itraconazole) NF PA QL(20 ml

daily)

TOLSURA CAPS 4 PA

VFEND TABS 200 MG 50 MG (Use voriconazole) NF QL(4 ea daily)

voriconazole tabs or 200 mg 50 mg 1 QL(4 ea daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines dexchlorpheniraminemaleate soln 1

Antihistamines - Ethanolamines

Drug Name DrugTier

RequirementsLimits

carbinoxamine maleate soln 4 mg5ml 1

carbinoxamine maleate tabs 4 mg 1

CLEMASTINE FUMARATE SYRP 067 MG5ML 1

clemastine fumarate tabs 268 mg 1

diphenhydramine hcl capsor 50 mg 1

diphenhydramine hcl elix or125 mg5ml 1

diphenhydramine hcl liqd or125 mg5ml 1

diphenhydramine hcl soln ij50 mgml 1

Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG5ML (Use fexofenadine hcl)

QL(30 ml daily)

ALLEGRA ALLERGY CHILDRENS TBDP 30 MG 1 QL(2 ea daily)

ALLEGRA ALLERGY TABS 180 MG (Use fexofenadine hcl)

1 QL(1 ea daily)

1 QL(2 ea daily)

cetirizine hcl caps 10 mg 1 QL(1 ea daily)

cetirizine hcl chew 5 mg10 mg 1 QL(1 ea daily)

cetirizine hcl soln 1 mgml5 mg5ml 1 QL(10 ml

daily) RXOTC cetirizine hcl syrp 1 mgml5 mg5ml 1 QL(10 ml

daily) RXOTC cetirizine hcl tabs 5 mg 10 mg 1 QL(1 ea daily)

CLARINEX TABS (Use desloratadine) NF QL(1 ea daily)

CLARITIN ALLERGY CHILDRENS SYRP (Use loratadine)

CLARITIN CAPS (Use loratadine) 1

Drug Name DrugTier

RequirementsLimits

CLARITIN CHEW (Use loratadine) 1

CLARITIN CHILDRENS CHEW (Use loratadine) 1

CLARITIN REDITABS TBDP 10 MG (Use loratadine)

CLARITIN REDITABS TBDP 5 MG 1

CLARITIN SYRP (Use loratadine) 1

CLARITIN TABS (Use loratadine) 1

desloratadine tabs 5 mg 1 QL(1 ea daily)

desloratadine tbdp 25 mg 1 QL(1 ea daily)

fexofenadine hcl susp 30mg5ml 1 QL(30 ml daily)

fexofenadine hcl tabs 180 mg 1 QL(1 ea daily)

levocetirizine dihydrochloride soln 25mg5ml

1 QL(10 mldaily) RXOTC

levocetirizine dihydrochloride tabs 5 mg 1 QL(1 ea daily)

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1

XYZAL ALLERGY 24HR CHILDRENS SOLN (Use levocetirizine dihydrochloride)

QL(10 mldaily) RXOTC

XYZAL ALLERGY 24HR TABS (Use levocetirizine dihydrochloride)

NF QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

ZYRTEC ALLERGY CAPS (Use cetirizine hcl) 1 QL(1 ea daily)

ZYRTEC ALLERGY TABS (Use cetirizine hcl) 1 QL(1 ea daily)

ZYRTEC CHILDRENS ALLERGY SOLN (Use cetirizine hcl)

Antihistamines - Phenothiazines PHENERGAN SOLN (Use promethazine hcl) NF

promethazine hcl soln 1

promethazine hcl supp 1

promethazine hcl syrp 1

promethazine hcl tabs 1

Antihistamines - Piperidines

cyproheptadine hcl syrp 1

cyproheptadine hcl tabs 1

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations

ezetimibe-simvastatin tabs 1 QL(1 ea daily)

VYTORIN TABS (Use ezetimibe-simvastatin) NF QL(1 ea daily)

Antihyperlipidemics - Misc

icosapent ethyl caps 1 PA QL(4 eadaily)

LOVAZA CAPS (Use omega-3-acid ethyl esters) NF QL(4 ea daily)

omega-3-acid ethyl esters caps 1 QL(4 ea daily)

VASCEPA CAPS 05 GM 3 PA

VASCEPA CAPS 1 GM 3 PA QL(4 eadaily)

Bile Acid Sequestrants cholestyramine light pack 4 gm 1 QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

cholestyramine light powd4 gmdose 1 QL(24 gm

daily)

cholestyramine pack 4 gm 1 QL(6 ea daily)

cholestyramine powd 4gmdose 1 QL(252 gm

daily) colesevelam hcl pack 375 gm 1 PA QL(1 ea

daily) colesevelam hcl tabs 625 mg 1 QL(7 ea daily)

COLESTID FLAVORED GRAN 5 GM (Use colestipol hcl)

NF QL(6 gm daily)

COLESTID FLAVORED PACK 5 GM75GM (Use colestipol hcl)

NF QL(6 ea daily)

COLESTID GRAN 5 GM (Use colestipol hcl) NF QL(6 gm daily)

COLESTID PACK 5 GM (Use colestipol hcl) NF QL(6 ea daily)

COLESTID TABS 1 GM (Use colestipol hcl) NF QL(16 ea daily)

colestipol hcl gran 5 gm 1 QL(6 gm daily)

colestipol hcl pack 5 gm 1 QL(6 ea daily)

colestipol hcl tabs 1 gm 1 QL(16 ea daily)

QUESTRAN LIGHT POWD (Use cholestyramine light) NF QL(24 gm

daily) QUESTRAN PACK 4 GM (Use cholestyramine) NF QL(6 ea daily)

QUESTRAN POWD 4 GMDOSE (Use cholestyramine)

NF QL(252 gmdaily)

WELCHOL PACK 375 GM (Use colesevelam hcl) NF PA QL(1 ea

daily) WELCHOL TABS 625 MG (Use colesevelam hcl) NF QL(7 ea daily)

Fibric Acid Derivatives

choline fenofibrate cpdr 1 QL(1 ea daily)

fenofibrate micronized caps134 mg 200 mg 67 mg 1 QL(1 ea daily)

fenofibrate tabs 145 mg 48mg 54 mg 160 mg 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

FIBRICOR TABS (Use fenofibric acid) NF

gemfibrozil tabs 1 QL(2 ea daily)

LIPOFEN CAPS (Use fenofibrate) NF

LOPID TABS (Use gemfibrozil) NF QL(2 ea daily)

TRICOR TABS (Use fenofibrate) NF QL(1 ea daily)

TRILIPIX CPDR (Use choline fenofibrate) NF QL(1 ea daily)

HMG CoA Reductase Inhibitors

ALTOPREV TB24 3 ST QL(1 eadaily)

atorvastatin calcium tabs 1 QL(1 ea daily)

CRESTOR TABS (Use rosuvastatin calcium) NF QL(1 ea daily)

fluvastatin sodium caps 20 mg 1 QL(1 ea daily)

LIPITOR TABS (Use atorvastatin calcium) NF QL(1 ea daily)

LIVALO TABS 3 ST QL(1 eadaily)

lovastatin tabs 20 mg 10 mg 1

$0 copay forgeneric onlyage 40 to76QL(1 eadaily) PV

lovastatin tabs 40 mg 1

PRAVACHOL TABS (Use pravastatin sodium) NF QL(1 ea daily)

pravastatin sodium tabs 1 QL(1 ea daily)

rosuvastatin calcium tabs 3 QL(1 ea daily)

simvastatin tabs 5 mg 80mg 10 mg 20 mg 40 mg 1 QL(1 ea daily)

ZOCOR TABS (Use simvastatin) NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 1 QL(1 ea daily)

ZETIA TABS (Use ezetimibe) NF QL(1 ea daily)

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1000 mg 500 mg 750 mg

1 QL(2 ea daily)

NIASPAN TBCR (Use niacin (antihyperlipidemic)) NF QL(2 ea daily)

Proprotein Convertase SubtilisinKexin Type 9 REPATHA PUSHTRONEX SYSTEM SOCT 4 PA QL(025 ml

daily)

REPATHA SOSY 4 PA QL(00714ml daily)

REPATHA SURECLICK SOAJ 4 PA QL(00714

ml daily) ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors ACCUPRIL TABS (Use quinapril hcl) NF

ALTACE CAPS (Use ramipril) NF

benazepril hcl tabs 1

captopril tabs 1

enalapril maleate tabs 10mg 25 mg 20 mg 5 mg 1

fosinopril sodium tabs 1

lisinopril tabs 1

LOTENSIN TABS (Use benazepril hcl) NF

moexipril hcl tabs 1

perindopril erbumine tabs 1

PRINIVIL TABS (Use lisinopril) NF

quinapril hcl tabs 1

Drug Name DrugTier

RequirementsLimits

ramipril caps 1

trandolapril tabs 1

VASOTEC TABS (Use enalapril maleate) NF

ZESTRIL TABS (Use lisinopril) NF

Agents for Pheochromocytoma DIBENZYLINE CAPS (Use phenoxybenzamine hcl) NF PA

phenoxybenzamine hcl caps 3 PA

Angiotensin II Receptor Antagonists ATACAND TABS (Use candesartan cilexetil) NF QL(1 ea daily)

AVAPRO TABS (Use irbesartan) NF QL(1 ea daily)

BENICAR TABS (Use olmesartan medoxomil) NF QL(1 ea daily)

candesartan cilexetil tabs 1 QL(1 ea daily)

COZAAR TABS (Use losartan potassium) NF QL(1 ea daily)

DIOVAN TABS (Use valsartan) NF QL(1 ea daily)

EDARBI TABS 3 ST QL(1 eadaily)

eprosartan mesylate tabs 1 QL(1 ea daily)

irbesartan tabs 1 QL(1 ea daily)

losartan potassium tabs or100 mg 25 mg 50 mg 1 QL(1 ea daily)

MICARDIS TABS (Use telmisartan) NF QL(1 ea daily)

olmesartan medoxomil tabs 1 QL(1 ea daily)

telmisartan tabs 1 QL(1 ea daily)

valsartan tabs 1 QL(1 ea daily)

Antiadrenergic Antihypertensives CARDURA TABS (Use doxazosin mesylate) NF

Drug Name DrugTier

RequirementsLimits

CATAPRES TABS (Use clonidine hcl) NF QL(8 ea daily)

CATAPRES-TTS-1 PTWK (Use clonidine) NF QL(015 ea

daily) CATAPRES-TTS-2 PTWK (Use clonidine) NF QL(015 ea

daily)

clonidine hcl tabs 1 QL(8 ea daily)

clonidine ptwk 3 QL(015 eadaily)

doxazosin mesylate tabs 1

guanfacine hcl tabs 1

MINIPRESS CAPS (Use prazosin hcl) NF QL(4 ea daily)

prazosin hcl caps 1 QL(4 ea daily)

terazosin hcl caps 1

Antihypertensive Combinations ACCURETIC TABS 10 MG-125 MG (Use quinapril-hydrochlorothiazide)

QL(3 ea daily)

ACCURETIC TABS 125 MG-20 MG (Use quinapril-hydrochlorothiazide)

NF QL(4 ea daily)

NF QL(2 ea daily)

amlodipine besylate-benazepril hcl caps 1

amlodipine besylate-olmesartan medoxomil tabs 1 ST

amlodipine besylate-valsartan tabs 1

amlodipine-valsartan-hydrochlorothiazide tabs 1

ATACAND HCT TABS (Use candesartan cilexetil-hydrochlorothiazide)

atenolol amp chlorthalidone tabs 1

Drug Name DrugTier

RequirementsLimits

AVALIDE TABS (Use irbesartan-hydrochlorothiazide)

AZOR TABS (Use amlodipine besylate-olmesartan medoxomil)

benazepril amphydrochlorothiazide tabs 1

BENICAR HCT TABS (Use olmesartan medoxomil-hydrochlorothiazide)

bisoprolol amphydrochlorothiazide tabs 1 QL(2 ea daily)

candesartan cilexetil-hydrochlorothiazide tabs 1

DIOVAN HCT TABS (Use valsartan-hydrochlorothiazide)

enalapril maleate amphydrochlorothiazide tabs 1

EXFORGE HCT TABS 2

EXFORGE TABS (Use amlodipine besylate-valsartan)

fosinopril sodium amphydrochlorothiazide tabs 1

HYZAAR TABS 125 MG-100 MG 25 MG-100 MG (Use losartan potassium amphydrochlorothiazide)

QL(1 ea daily)

HYZAAR TABS 125 MG-50 MG (Use losartan potassium amphydrochlorothiazide)

QL(2 ea daily)

irbesartan-hydrochlorothiazide tabs 1

lisinopril amphydrochlorothiazide tabs 1

LOPRESSOR HCT TABS (Use metoprolol amphydrochlorothiazide)

losartan potassium amphydrochlorothiazide tabs125 mg-100 mg 25 mg-100 mg

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

losartan potassium amphydrochlorothiazide tabs125 mg-50 mg

1 QL(2 ea daily)

LOTENSIN HCT TABS (Use benazepril amphydrochlorothiazide)

LOTREL CAPS (Use amlodipine besylate-benazepril hcl)

metoprolol amphydrochlorothiazide tabs 1

MICARDIS HCT TABS (Use telmisartan-hydrochlorothiazide)

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

olmesartan medoxomil-hydrochlorothiazide tabs 1

quinapril-hydrochlorothiazide tabs 10mg-125 mg

1 QL(3 ea daily)

quinapril-hydrochlorothiazide tabs125 mg-20 mg

1 QL(4 ea daily)

1 QL(2 ea daily)

TARKA TBCR (Use trandolapril-verapamil hcl) NF

telmisartan-amlodipine tabs 1

telmisartan-hydrochlorothiazide tabs 1

TENORETIC 100 TABS (Use atenolol amp chlorthalidone)

trandolapril-verapamil hcltbcr 1

TRANDOLAPRILVERAPAMIL HCL ER TBCR 2

Drug Name DrugTier

RequirementsLimits

TRIBENZOR TABS (Use olmesartan medoxomil-amlodipine-hydrochlorothiazide)

TWYNSTA TABS (Use telmisartan-amlodipine) NF

valsartan-hydrochlorothiazide tabs 1

VASERETIC TABS (Use enalapril maleate amphydrochlorothiazide)

ZESTORETIC TABS (Use lisinopril amphydrochlorothiazide)

ZIAC TABS (Use bisoprololamp hydrochlorothiazide) NF QL(2 ea daily)

Antihypertensives - Misc VECAMYL TABS 3 PA

Direct Renin Inhibitors

aliskiren fumarate tabs 1 QL(1 ea daily)

TEKTURNA TABS (Use aliskiren fumarate) NF QL(1 ea daily)

Selective Aldosterone Receptor Antagonists

eplerenone tabs 1

INSPRA TABS (Use eplerenone) NF

Vasodilators

hydralazine hcl soln 1

hydralazine hcl tabs 1

minoxidil tabs 1

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations

Drug Name DrugTier

RequirementsLimits

atovaquone-proguanil hcltabs 1

Covered for malaria treatment onlyLimit 1 fill every180 daysQL(12 eaper fill retail12ea per fillmail)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

COARTEM TABS 2

MALARONE TABS (Use atovaquone-proguanil hcl) NF

Antimalarials

chloroquine phosphate tabs 1

DARAPRIM TABS 3 PA QL(3 eadaily)

hydroxychloroquine sulfatetabs 200 mg 1

Drug Name DrugTier

RequirementsLimits

KRINTAFEL TABS 3 QL(2 ea per 30days retail)

mefloquine hcl tabs 1

Covered for malaria treatment onlyLimit 1 fill every180 daysQL(5ea daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PLAQUENIL TABS (Use hydroxychloroquine sulfate) NF

primaquine phosphate tabs 3

PRIMAQUINE PHOSPHATE TABS (Use primaquine phosphate)

pyrimethamine tabs 1 PA QL(3 eadaily)

QUALAQUIN CAPS (Use quinine sulfate) NF PA

quinine sulfate caps 1 PA

ANTIMYASTHENICCHOLINERGIC AGENTS

AntimyasthenicCholinergic Agents

FIRDAPSE TABS 4 PA

GUANIDINE HCL TABS 2

MESTINON SOLN (Use pyridostigmine bromide) NF

MESTINON TABS (Use pyridostigmine bromide) NF

MESTINON TIMESPAN TBCR (Use pyridostigminebromide)

NEOSTIGMINE METHYLSULFATE SOSY 3 MG3ML

pyridostigmine bromidesoln 60 mg5ml 1

pyridostigmine bromidetabs 60 mg 1

Drug Name DrugTier

RequirementsLimits

pyridostigmine bromide tbcr180 mg 1

RUZURGI TABS 4 PA QL(10 eadaily)

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Anti TB Combinations

RIFAMATE CAPS 3

RIFATER TABS 3 QL(6 ea daily)

Antimycobacterial Agents CAPASTAT SULFATE SOLR 3

cycloserine caps 1 QL(4 ea daily)

ethambutol hcl tabs 1

isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1

MYAMBUTOL TABS (Use ethambutol hcl) NF

MYCOBUTIN CAPS (Use rifabutin) NF PA

PASER PACK 3 QL(3 ea daily)

PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA

RIFADIN CAPS (Use rifampin) NF

RIFADIN SOLR (Use rifampin) NF

rifampin caps 1

rifampin solr 1

SIRTURO TABS 100 MG 3 PA

Drug Name DrugTier

RequirementsLimits

TRECATOR TABS 3 QL(4 ea daily)

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN SOLR (Use melphalan hcl) NF

ALKERAN TABS (Use melphalan) NF

BICNU SOLR (Use carmustine) NF PA SP

busulfan soln 4 PA SP

BUSULFEX SOLN (Use busulfan) NF PA SP

carboplatin soln 50 mg5ml 4 PA SP

carmustine solr 4 PA SP

cisplatin soln 100mg100ml 4 PA SP

cyclophosphamide caps or25 mg 50 mg 1 PA

cyclophosphamide solr ij 1gm 2 gm 500 mg 4

GLEOSTINE CAPS 10 MG 4 PA SP

GLEOSTINE CAPS 100 MG 40 MG 4 PA

IFEX SOLR 1 GM (Use ifosfamide) NF PA SP

ifosfamide soln 1 gm20ml 4 PA SP

ifosfamide solr 1 gm 4 PA SP

LEUKERAN TABS 4 PA SP

melphalan hcl solr 1

melphalan tabs 1

MYLERAN TABS 4 PA SP

oxaliplatin soln 100mg20ml 50 mg10ml 4 PA SP

Drug Name DrugTier

RequirementsLimits

TEMODAR CAPS OR 100 MG 140 MG 180 MG 20 MG 250 MG 5 MG (Use temozolomide)

TEMODAR SOLR IV 100 MG 4

temozolomide caps 4 PA SP

TEPADINA SOLR 100 MG (Use thiotepa) NF

TEPADINA SOLR 15 MG (Use thiotepa) NF PA SP

thiotepa solr 15 mg 4 PA SP

TREANDA SOLR 4 PA SP

ZANOSAR SOLR 4 PA SP

Antimetabolites

ALIMTA SOLR 500 MG 4 PA SP

ARRANON SOLN (Use nelarabine) 4 PA SP

azacitidine susr 4 PA SP

capecitabine tabs 4 PA SP

clofarabine soln 4 PA SP

CLOLAR SOLN (Use clofarabine) NF PA SP

cytarabine soln 100 mgml20 mgml 4 PA SP

DACOGEN SOLR (Use decitabine) NF PA SP

decitabine solr 4 PA SP

floxuridine solr 4 PA SP

fludarabine phosphate soln 4 PA SP

fludarabine phosphate solr 4 PA SP

fluorouracil soln 500 mg10ml 4 PA SP

FOLOTYN SOLN 20 MGML 4 PA SP

Drug Name DrugTier

RequirementsLimits

gemcitabine hcl solr 2 gm200 mg 4 PA SP

GEMCITABINE HYDROCHLORIDE SOLN 1 GM10ML 2 GM20ML200 MG2ML (Use gemcitabine hcl)

mercaptopurine tabs 1

methotrexate sodium soln ij250 mg10ml 50 mg2ml 1

methotrexate sodium solr ij1 gm 1 SP

methotrexate sodium tabs or 25 mg 1 SP

nelarabine soln 4 PA SP

TABLOID TABS 4 PA SP

TREXALL TABS 4 PA SP

VIDAZA SUSR (Use azacitidine) NF PA SP

XELODA TABS (Use capecitabine) NF PA SP

Antineoplastic - Angiogenesis Inhibitors

INLYTA TABS 4 PA QL(2 eadaily) SP

LENVIMA 10 MG DAILY DOSE CPPK 4 PA QL(1 ea

daily) LENVIMA 12MG DAILY DOSE CPPK 4 PA QL(3 ea

daily) LENVIMA 14 MG DAILY DOSE CPPK 4 PA QL(2 ea

daily)

MVASI SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

ZALTRAP SOLN 100 MG4ML 4 PA SP

ZIRABEV SOLN 4 PA

Antineoplastic - Anti-HER2 Agents

HERCEPTIN SOLR 4 PA SP

PERJETA SOLN 4 PA SP

TUKYSA TABS 4 PA

Antineoplastic - Antibodies

ADCETRIS SOLR 4 PA SP

ARZERRA CONC 4 PA SP

RITUXAN SOLN 4 PA SP

RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP

Antineoplastic - EGFR Inhibitors

ERBITUX SOLN 4 PA SP

erlotinib hcl tabs 4 PA QL(1 eadaily) SP

GILOTRIF TABS 4 PA QL(1 eadaily)

TARCEVA TABS (Use erlotinib hcl) NF PA QL(1 ea

daily) SP VECTIBIX SOLN 100 MG5ML 4 PA SP

VIZIMPRO TABS 4 PA

Antineoplastic - Hedgehog Pathway Inhibitors

DAURISMO TABS 4 PA

ERIVEDGE CAPS 4 PA QL(1 eadaily) SP

ODOMZO CAPS 4 PA QL(1 eadaily)

Antineoplastic - Hormonal and Related Agents abiraterone acetate tabs 250 mg 4 PA QL(4 ea

daily) SP

Drug Name DrugTier

RequirementsLimits

abiraterone acetate tabs 500 mg 4 PA QL(2 ea

daily)

anastrozole tabs 1 QL(1 ea daily)

ARIMIDEX TABS (Use anastrozole) NF QL(1 ea daily)

AROMASIN TABS (Use exemestane) NF QL(1 ea daily)

bicalutamide tabs 4 PA QL(1 eadaily) SP

CASODEX TABS (Use bicalutamide) NF PA QL(1 ea

daily) SP

ELIGARD KIT 225 MG 4 PA SP

ELIGARD KIT 75 MG 4 PA QL(00089ea daily) SP

EMCYT CAPS 4 PA SP

exemestane tabs 4 QL(1 ea daily)SP

FARESTON TABS (Use toremifene citrate) NF

FASLODEX SOLN (Use fulvestrant) NF PA QL(0357

ml daily) SP FEMARA TABS (Use letrozole) NF

FIRMAGON SOLR 4 PA QL(0143ea daily) SP

flutamide caps 4 PA QL(6 eadaily) SP

fulvestrant soln 4 PA QL(0357ml daily) SP

letrozole tabs 1

leuprolide acetate kit 4 PA SP

LUPRON DEPOT (1-MONTH) KIT 4 PA QL(00357

ea daily) SP LUPRON DEPOT (3-MONTH) KIT 4 PA SP

ea daily) SP

Drug Name DrugTier

RequirementsLimits

ea daily) SP

LYSODREN TABS 4 PA SP

megestrol acetate susp 1

megestrol acetate tabs 1

NILANDRON TABS (Use nilutamide) NF QL(2 ea daily)

nilutamide tabs 1 QL(2 ea daily)

NUBEQA TABS 4 PA

tamoxifen citrate tabs 0

toremifene citrate tabs 1

TRELSTAR MIXJECT SUSR 4 PA SP

XTANDI CAPS 40 MG 4 PA QL(4 eadaily) SP

YONSA TABS 4 PA

ZOLADEX IMPL 108 MG 4 PA QL(00119ea daily) SP

ZYTIGA TABS 250 MG (Use abiraterone acetate) NF PA QL(4 ea

daily) SP ZYTIGA TABS 500 MG (Use abiraterone acetate) 4 PA QL(2 ea

daily) Antineoplastic - Immunomodulators

POMALYST CAPS 4 PA QL(1 eadaily)

Antineoplastic - PDGFR-alpha Inhibitors AYVAKIT TABS 100 MG 200 MG 300 MG 4 PA SL(1 ea

daily) Antineoplastic - XPO1 Inhibitors XPOVIO 100 MG ONCE WEEKLY TBPK 4 PA

XPOVIO 60 MG ONCE WEEKLY TBPK 4 PA

Drug Name DrugTier

RequirementsLimits

XPOVIO 80 MG TWICE WEEKLY TBPK 4 PA

Antineoplastic Antibiotics bleomycin sulfate solr 15unit 4 PA SP

COSMEGEN SOLR (Use dactinomycin) NF PA SP

dactinomycin solr 4 PA SP

DAUNORUBICIN HYDROCHLORIDE SOLN 20 MG4ML (Use daunorubicin hcl)

DOXIL INJ (Use doxorubicin hcl liposomal) NF PA SP

doxorubicin hcl liposomalinj 4 PA SP

doxorubicin hcl soln 2 mgml 200 mg100ml 4 PA SP

doxorubicin hcl solr 50 mg10 mg 4 PA SP

ELLENCE SOLN 50 MG25ML (Use epirubicin hcl)

NF PA SP

epirubicin hcl soln 50mg25ml 4 PA SP

IDAMYCIN PFS SOLN 10 MG10ML 5 MG5ML (Use idarubicin hcl)

NF PA SP

IDAMYCIN PFS SOLN 20 MG20ML (Use idarubicin hcl)

idarubicin hcl soln 10 mg10ml 5 mg5ml 4 PA SP

idarubicin hcl soln 20 mg20ml 4 PA

mitomycin solr iv 20 mg 4 PA SP

mitoxantrone hcl conc 4 PA SP

valrubicin soln 4 PA SP

VALSTAR SOLN (Use valrubicin) NF PA SP

Antineoplastic Combinations

Drug Name DrugTier

RequirementsLimits

KISQALI FEMARA 200 DOSE TBPK 3 PA

Antineoplastic Enzyme Inhibitors AFINITOR TABS (Use everolimus) NF PA QL(1 ea

daily) SP

ALECENSA CAPS 4 PA QL(4 eadaily)

ALUNBRIG TABS 4 PA QL(1 eadaily)

ALUNBRIG TBPK 4 PA QL(1 eadaily)

BALVERSA TABS 4 PA

BORTEZOMIB SOLR 4 PA

BOSULIF TABS 100 MG 500 MG 4 PA QL(1 ea

daily) SP

BOSULIF TABS 400 MG 4 PA

BRAFTOVI CAPS 4 PA SP

BRUKINSA CAPS 4 PA

CAPRELSA TABS 4 PA QL(1 eadaily) SP

COMETRIQ KIT 4 PA QL(2 eadaily) SP

COPIKTRA CAPS 4 PA

everolimus tabs 10 mg 5mg 75 mg 25 mg 4 PA QL(1 ea

daily) SP GLEEVEC TABS (Use imatinib mesylate) NF PA QL(2 ea

daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

ICLUSIG TABS 10 MG 30 MG 45 MG 4 PA QL(1 ea

daily)

Drug Name DrugTier

RequirementsLimits

ICLUSIG TABS 15 MG 4 PA QL(2 eadaily)

imatinib mesylate tabs 4 PA QL(2 eadaily) SP

IMBRUVICA CAPS 140 MG 4 PA QL(3 ea

daily)

IMBRUVICA CAPS 70 MG 4 PA QL(1 eadaily)

IMBRUVICA TABS 140 MG 280 MG 420 MG 560 MG

4 PA QL(1 eadaily)

INREBIC CAPS 4 PA

ISTODAX (OVERFILL) SOLR 4 PA SP

JAKAFI TABS 10 MG 20 MG 4 PA SP

JAKAFI TABS 15 MG 25 MG 5 MG 4 PA QL(2 ea

daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA

lapatinib ditosylate tabs 4 PA QL(6 eadaily) SP

LORBRENA TABS 4 PA

LYNPARZA TABS 4 PA QL(16 eadaily)

MEKINIST TABS 05 MG 4 PA QL(3 eadaily)

MEKTOVI TABS 4 PA SP

NEXAVAR TABS 4 PA QL(4 eadaily) SP

NINLARO CAPS 4 PA QL(0143ea daily)

PEMAZYRE TABS 4 PA QL(1 eadaily)

PIQRAY 200MG DAILY DOSE TBPK 4 PA

Drug Name DrugTier

RequirementsLimits

QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA

ROMIDEPSIN SOLR 10 MG 4 PA SP

ROZLYTREK CAPS 4 PA

RUBRACA TABS 4 PA QL(4 eadaily)

SPRYCEL TABS 4 PA QL(1 eadaily) SP

STIVARGA TABS 4 PA QL(4 eadaily) SP

sunitinib malate caps 125mg 25 mg 50 mg 4 PA QL(1 ea

daily) SP SUTENT CAPS 125 MG 25 MG 50 MG (Use sunitinib malate)

4 PA QL(1 eadaily) SP

TABRECTA TABS 4 PA

TAFINLAR CAPS 4 PA QL(4 eadaily)

TALZENNA CAPS 4 PA

TASIGNA CAPS 150 MG 200 MG 4 PA QL(4 ea

daily) SP

TASIGNA CAPS 50 MG 4 PA QL(4 eadaily)

TAZVERIK TABS 4 PA

temsirolimus soln 4 PA QL(0143ml daily) SP

TIBSOVO TABS 4 PA

TORISEL SOLN (Use temsirolimus) NF PA QL(0143

ml daily) SP

TURALIO CAPS 4 PA

TYKERB TABS (Use lapatinib ditosylate) 4 PA QL(6 ea

daily) SP

VELCADE SOLR 4 PA SP

VERZENIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

VOTRIENT TABS 4 PA QL(4 eadaily) SP

XALKORI CAPS 4 PA QL(2 eadaily) SP

XOSPATA TABS 4 PA

ZEJULA CAPS 4 PA QL(3 eadaily)

ZELBORAF TABS 4 PA SP

ZOLINZA CAPS 4 PA QL(4 eadaily) SP

ZYDELIG TABS 4 PA QL(2 eadaily)

Antineoplastic Enzymes

ERWINASE SOLR 4 PA SP

ERWINAZE SOLR 4 PA SP

ONCASPAR SOLN 4 PA SP

Antineoplastics Misc ACTIMMUNE SOLN 4 PA SP

arsenic trioxide soln 10 mg10ml 4 PA SP

bexarotene caps 4 PA SP

dacarbazine solr 200 mg 4 PA SP

HYDREA CAPS (Use hydroxyurea) NF

hydroxyurea caps 1

INTRON A SOLR 18 MU 4 PA SP

MATULANE CAPS 4 PA SP

NIPENT SOLR 4 PA SP

PHOTOFRIN SOLR 4 PA SP

PROLEUKIN SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

SYNRIBO SOLR 4 PA SP

TARGRETIN CAPS OR 75 MG (Use bexarotene) NF PA SP

tretinoin (chemotherapy) caps 1

UVADEX SOLN 4 PA SP

Chemotherapy Adjuncts

KEPIVANCE SOLR 4 PA SP

Chemotherapy RescueAntidoteProtective Agents leucovorin calcium solr ij500 mg 100 mg 200 mg350 mg 50 mg

leucovorin calcium tabs or 25 mg 5 mg 10 mg 15 mg 1

VORAXAZE SOLR 4 PA SP

Mitotic Inhibitors

ABRAXANE SUSR 4 PA SP

docetaxel conc 20 mgml 4 PA SP

DOCETAXEL CONC 20 MGML (Use docetaxel) NF PA SP

DOCETAXEL CONC 80 MG4ML (Use docetaxel) NF

DOCETAXEL SOLN 20 MG2ML 4 PA SP

docetaxel soln 20 mg2ml 4 PA SP

DOCETAXEL SOLN 20 MG2ML (Use docetaxel) 4 PA SP

ETOPOPHOS SOLR 4 PA SP

etoposide caps or 50 mg 4 PA SP

etoposide soln iv 1gm50ml 500 mg25ml100 mg5ml

HALAVEN SOLN 4 PA SP

IXEMPRA KIT SOLR 15 MG 4 PA SP

JEVTANA SOLN 4 PA SP

Drug Name DrugTier

RequirementsLimits

NAVELBINE SOLN 10 MGML (Use vinorelbine tartrate)

NF PA SP

paclitaxel conc 150mg25ml 100 mg167ml 6mgml

4 PA SP

TAXOTERE CONC (Use docetaxel) NF PA SP

TENIPOSIDE SOLN 4 PA SP

vincristine sulfate soln 4 PA SP

vinorelbine tartrate soln 10 mgml 4 PA SP

Topoisomerase I Inhibitors CAMPTOSAR SOLN 100 MG5ML 40 MG2ML (Use irinotecan hcl)

NF PA SP

HYCAMTIN CAPS OR 025 MG 1 MG 4 PA SP

HYCAMTIN SOLR IV 4 MG (Use topotecan hcl) NF

irinotecan hcl soln 100 mg5ml 40 mg2ml 4 PA SP

topotecan hcl soln 4mg4ml 4

TOPOTECAN HCL SOLN 4 MG4ML (Use topotecan hcl)

topotecan hcl solr 4 mg 4

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease

Antiparkinson Adjunctive Therapy

carbidopa tabs 1

LODOSYN TABS (Use carbidopa) NF

Antiparkinson Anticholinergics

benztropine mesylate soln 1

benztropine mesylate tabs 1

COGENTIN SOLN (Use benztropine mesylate) NF

Drug Name DrugTier

RequirementsLimits

trihexyphenidyl hcl soln 1

trihexyphenidyl hcl tabs 1

Antiparkinson COMT Inhibitors COMTAN TABS (Use entacapone) NF QL(8 ea daily)

entacapone tabs 1 QL(8 ea daily)

TASMAR TABS (Use tolcapone) NF

tolcapone tabs 1

Antiparkinson Dopaminergics

amantadine hcl caps 1

amantadine hcl tabs 1

APOKYN SOCT 4 PA

bromocriptine mesylate caps 1

bromocriptine mesylatetabs 1

carbidopa-levodopa tabs 1

carbidopa-levodopa tbcr 1

carbidopa-levodopa tbdp 1

carbidopa-levodopa-entacapone tabs 1

CARBIDOPALEVODOPAODT TBDP 1

MIRAPEX TABS 0125 MG (Use pramipexoledihydrochloride)

NF QL(4 ea daily)

MIRAPEX TABS 025 MG 05 MG 075 MG 1 MG 15 MG (Use pramipexoledihydrochloride)

NEUPRO PT24 2

PARLODEL CAPS (Use bromocriptine mesylate) NF

PARLODEL TABS (Use bromocriptine mesylate) NF

Drug Name DrugTier

RequirementsLimits

pramipexoledihydrochloride tabs 0125 mg

1 QL(4 ea daily)

pramipexoledihydrochloride tabs 025mg 05 mg 075 mg 1 mg15 mg

REQUIP XL TB24 12 MG 8 MG (Use ropinirolehydrochloride)

NF ST QL(2 eadaily)

REQUIP XL TB24 6 MG (Use ropinirolehydrochloride)

NF ST QL(1 eadaily)

ropinirole hydrochloridetabs 025 mg 3 mg 1 mg2 mg 4 mg 5 mg 05 mg

ropinirole hydrochloridetb24 12 mg 8 mg 1 ST QL(2 ea

daily) ropinirole hydrochloridetb24 2 mg 4 mg 6 mg 1 ST QL(1 ea

daily) SINEMET CR TBCR (Use carbidopa-levodopa) NF

SINEMET TABS (Use carbidopa-levodopa) NF

STALEVO 100 TABS (Use carbidopa-levodopa-entacapone)

Drug Name DrugTier

RequirementsLimits

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Use rasagiline mesylate) NF PA QL(1 ea

daily)

rasagiline mesylate tabs 1 PA QL(1 eadaily)

selegiline hcl caps 1

selegiline hcl tabs 1

ANTIPSYCHOTICSANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents

lithium carbonate caps 1

lithium carbonate tabs 1

lithium carbonate tbcr 1

LITHIUM SOLN 1

LITHOBID TBCR (Use lithium carbonate) NF

Antipsychotics - Misc

EQUETRO CP12 100 MG 3 ST QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

GEODON CAPS OR 20 MG 40 MG 60 MG 80 MG (Use ziprasidone hcl)

LATUDA TABS 120 MG 20 MG 40 MG 60 MG 3 PA QL(1 ea

daily)

LATUDA TABS 80 MG 3 PA QL(2 eadaily)

ziprasidone hcl caps 1 QL(2 ea daily)AL(At least 18yrs old)

Benzisoxazoles

FANAPT TABS 2 PA QL(2 eadaily)

FANAPT TITRATION PACK TABS 2 PA

INVEGA TB24 15 MG 3 MG 9 MG (Use paliperidone)

NF QL(1 ea daily)

INVEGA TB24 6 MG (Use paliperidone) NF QL(2 ea daily)

paliperidone tb24 15 mg 3mg 9 mg 1 QL(1 ea daily)

paliperidone tb24 6 mg 1 QL(2 ea daily)

PERSERIS PRSY 2 PA QL(0072ea daily)

RISPERDAL CONSTA SRER 2 PA QL(0072

ea daily) RISPERDAL SOLN 1 MGML (Use risperidone) NF QL(8 ml daily)

RISPERDAL TABS 05 MG 1 MG 2 MG 3 MG 4 MG (Use risperidone)

NF QL(4 ea daily)

risperidone soln 1 mgml 1 QL(8 ml daily)

risperidone tabs 025 mg05 mg 1 mg 2 mg 3 mg4 mg

1 QL(4 ea daily)

risperidone tbdp 025 mg05 mg 1 mg 2 mg 3 mg4 mg

1 QL(2 ea daily)

Butyrophenones HALDOL DECANOATE 100 SOLN (Use haloperidol decanoate)

NF QL(0036 mldaily)

Drug Name DrugTier

RequirementsLimits

HALDOL DECANOATE 50 SOLN (Use haloperidoldecanoate)

NF QL(0036 mldaily)

HALDOL SOLN (Use haloperidol lactate) NF

haloperidol decanoate soln 1 QL(0036 mldaily)

haloperidol lactate conc 1

haloperidol lactate soln 1

haloperidol tabs 1

Dibenzapines asenapine maleate subl 10mg 5 mg 1 PA QL(2 ea

daily) asenapine maleate subl 25 mg 1 PA QL(4 ea

daily) clozapine tabs 200 mg 50mg 100 mg 25 mg 1

clozapine tbdp 100 mg 1 QL(9 ea daily)

clozapine tbdp 125 mg150 mg 1 QL(6 ea daily)

CLOZARIL TABS (Use clozapine) NF

FAZACLO TBDP 100 MG (Use clozapine) NF QL(9 ea daily)

FAZACLO TBDP 150 MG (Use clozapine) 1 QL(6 ea daily)

loxapine succinate caps 1

olanzapine solr im 10 mg 1 QL(0215 eadaily)

olanzapine tabs or 10 mg15 mg 20 mg 75 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

olanzapine tabs or 25 mg5 mg 1 QL(4 ea daily)

olanzapine tbdp or 10 mg15 mg 5 mg 1 QL(2 ea daily)

olanzapine tbdp or 20 mg 1 QL(1 ea daily)

quetiapine fumarate tabs100 mg 200 mg 25 mg 50 mg

quetiapine fumarate tabs300 mg 400 mg 1

quetiapine fumarate tb24150 mg 200 mg 50 mg 1 PA QL(1 ea

daily) quetiapine fumarate tb24300 mg 400 mg 1 PA QL(2 ea

daily) SAPHRIS SUBL 10 MG 5 MG (Use asenapinemaleate)

3 PA QL(2 eadaily)

SAPHRIS SUBL 25 MG (Use asenapine maleate) 3 PA QL(4 ea

daily)

SAPHRIS SUBL 5 MG 3 PA QL(2 eadaily)

SEROQUEL TABS 100 MG 200 MG 25 MG 50 MG (Use quetiapinefumarate)

SEROQUEL TABS 300 MG 400 MG (Use quetiapine fumarate)

SEROQUEL XR TB24 150 MG 200 MG 50 MG (Use quetiapine fumarate)

NF PA QL(1 eadaily)

SEROQUEL XR TB24 300 MG 400 MG (Use quetiapine fumarate)

NF PA QL(2 eadaily)

ZYPREXA SOLR IM 10 MG (Use olanzapine) NF QL(0215 ea

daily) ZYPREXA TABS OR 10 MG 15 MG 20 MG 75 MG (Use olanzapine)

NF QL(2 ea daily)

ZYPREXA TABS OR 25 MG 5 MG (Use olanzapine)

NF QL(4 ea daily)

ZYPREXA ZYDIS TBDP 10 MG 15 MG 5 MG (Use olanzapine)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

ZYPREXA ZYDIS TBDP 20 MG (Use olanzapine) NF QL(1 ea daily)

Phenothiazines chlorpromazine hcl soln ij25 mgml 50 mg2ml 3

chlorpromazine hcl tabs or10 mg 100 mg 200 mg 25mg 50 mg

fluphenazine hcl conc or 5mgml 1

fluphenazine hcl elix or 25mg5ml 1

fluphenazine hcl soln ij 25mgml 1

fluphenazine hcl tabs or 1mg 10 mg 25 mg 5 mg 1

perphenazine tabs 1

prochlorperazine maleatetabs 1

prochlorperazine supp 1

thioridazine hcl tabs 1

trifluoperazine hcl tabs 1

Quinolinone Derivatives

ABILIFY TABS (Use aripiprazole) NF

aripiprazole soln 1 mgml 3 QL(30 mldaily) AL(Atleast 6 yrs old)

aripiprazole tabs 10 mg 15mg 2 mg 20 mg 30 mg 5 mg

REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 20 mgml 1 QL(32 ml daily)

Drug Name DrugTier

RequirementsLimits

abacavir sulfate tabs 300 mg 1 QL(2 ea daily)

abacavir sulfate-lamivudine tabs 1 QL(1 ea daily)

abacavir sulfate-lamivudine-zidovudine tabs 1 QL(2 ea daily)

APTIVUS CAPS 250 MG 2 QL(4 ea daily)

APTIVUS SOLN 100 MGML 2 QL(10 ml daily)

atazanavir sulfate caps 150mg 300 mg 1 QL(1 ea daily)

atazanavir sulfate caps 200 mg 1 QL(2 ea daily)

ATRIPLA TABS (Use efavirenz-emtricitabine-tenofovir disoproxilfumarate)

QL(1 ea daily)

BIKTARVY TABS 2 QL(1 ea daily)

CIMDUO TABS 2 ST QL(1 eadaily)

COMBIVIR TABS (Use lamivudine-zidovudine) NF QL(2 ea daily)

COMPLERA TABS 3 QL(1 ea daily)

CRIXIVAN CAPS 200 MG 2 QL(9 ea daily)

DELSTRIGO TABS 3 QL(1 ea daily)

DESCOVY TABS 2 PA QL(1 eadaily)

didanosine cpdr 200 mg 1 QL(2 ea daily)

didanosine cpdr 250 mg400 mg 1 QL(1 ea daily)

DOVATO TABS 2 QL(1 ea daily)

EDURANT TABS 2 QL(1 ea daily)

efavirenz caps 200 mg 1 QL(2 ea daily)

efavirenz tabs 600 mg 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

efavirenz-emtricitabine-tenofovir disoproxilfumarate tabs

1 QL(1 ea daily)

efavirenz-lamivudine-tenofovir disoproxilfumarate tabs

1 QL(1 ea daily)

emtricitabine caps 1 QL(1 ea daily)

emtricitabine-tenofovir disoproxil fumarate tabs100 mg-150 mg 133 mg-200 mg 167 mg-250 mg

QL(1 eadaily30 day(s)limit)

emtricitabine-tenofovir disoproxil fumarate tabs200 mg-300 mg

0 QL(1 ea daily)

0 QL(1 eadaily30 day(s)limit)

EMTRIVA CAPS 200 MG (Use emtricitabine) 2 QL(1 ea daily)

EMTRIVA SOLN 10 MGML 2 QL(24 ml daily)

EPIVIR SOLN 10 MGML(Use lamivudine) NF QL(30 ml daily)

EPIVIR TABS 150 MG (Use lamivudine) NF QL(2 ea daily)

EPZICOM TABS (Use abacavir sulfate-lamivudine)

NF QL(1 ea daily)

etravirine tabs 100 mg 1 QL(4 ea daily)

fosamprenavir calcium tabs 1 QL(4 ea daily)

FUZEON SOLR 4 PA SP

GENVOYA TABS 2 QL(1 ea daily)

INTELENCE TABS 100 MG (Use etravirine) 2 QL(4 ea daily)

INTELENCE TABS 25 MG 2 QL(8 ea daily)

Drug Name DrugTier

RequirementsLimits

INVIRASE TABS 2 QL(4 ea daily)

ISENTRESS CHEW 100 MG 25 MG 2 QL(6 ea daily)

ISENTRESS HD TABS 2 QL(2 ea daily)

ISENTRESS TABS 400 MG 2 QL(2 ea daily)

JULUCA TABS 3 QL(1 ea daily)

KALETRA SOLN 100 MG5ML-400 MG5ML(Use lopinavir-ritonavir)

NF QL(125 mldaily)

KALETRA TABS 25 MG-100 MG 50 MG-200 MG (Use lopinavir-ritonavir)

2 QL(4 ea daily)

lamivudine soln 10 mgml 1 QL(30 ml daily)

lamivudine tabs 150 mg 1 QL(2 ea daily)

lamivudine-zidovudine tabs 1 QL(2 ea daily)

LEXIVA SUSP 50 MGML 2 QL(56 ml daily)

LEXIVA TABS 700 MG (Use fosamprenavircalcium)

NF QL(4 ea daily)

lopinavir-ritonavir soln 100mg5ml-400 mg5ml 1 QL(125 ml

daily) lopinavir-ritonavir tabs 25mg-100 mg 50 mg-200 mg 1 QL(4 ea daily)

nevirapine tabs 200 mg 1 QL(2 ea daily)

nevirapine tb24 100 mg 1 QL(3 ea daily)

NORVIR PACK 100 MG 2

QL(12 eadaily)30 rtl lmtday(s)30 maillmt day(s)

NORVIR SOLN 80 MGML 2 QL(15 ml daily)

NORVIR TABS 100 MG (Use ritonavir) NF QL(12 ea daily)

Drug Name DrugTier

RequirementsLimits

ODEFSEY TABS 2 QL(1 ea daily)

PIFELTRO TABS 2 QL(1 ea daily)

PREZCOBIX TABS 2 QL(1 ea daily)

PREZISTA SUSP 100 MGML 2 QL(12 ml daily)

PREZISTA TABS 150 MG 600 MG 75 MG 2 QL(2 ea daily)

PREZISTA TABS 800 MG 2 QL(1 ea daily)

RESCRIPTOR TABS 2 QL(6 ea daily)

RETROVIR CAPS 100 MG (Use zidovudine) NF QL(6 ea daily)

RETROVIR IV INFUSION SOLN 1

RETROVIR SYRP 50 MG5ML (Use zidovudine) NF QL(60 ml daily)

REYATAZ CAPS 150 MG 300 MG (Use atazanavir sulfate)

NF QL(1 ea daily)

REYATAZ CAPS 200 MG (Use atazanavir sulfate) NF QL(2 ea daily)

ritonavir tabs 1 QL(12 ea daily)

RUKOBIA TB12 4 PA

SELZENTRY SOLN 20 MGML 2 QL(30 ml daily)

SELZENTRY TABS 150 MG 25 MG 75 MG 2 QL(2 ea daily)

SELZENTRY TABS 300 MG 2 QL(4 ea daily)

stavudine caps 15 mg 20mg 30 mg 40 mg 1 QL(2 ea daily)

STAVUDINE CAPS 15 MG 30 MG 2 QL(2 ea daily)

STRIBILD TABS 3 QL(1 ea daily)

SUSTIVA CAPS 200 MG (Use efavirenz) NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

SUSTIVA TABS 600 MG (Use efavirenz) NF QL(1 ea daily)

SYMFI LO TABS (Use efavirenz-lamivudine-tenofovir disoproxilfumarate)

QL(1 ea daily)

SYMFI TABS (Use efavirenz-lamivudine-tenofovir disoproxilfumarate)

QL(1 ea daily)

SYMTUZA TABS 3 ST QL(1 eadaily)

TEMIXYS TABS 2 ST QL(1 eadaily)

tenofovir disoproxilfumarate tabs 1

TIVICAY TABS 3 QL(2 ea daily)

TRIUMEQ TABS 2 QL(1 ea daily)

TRIZIVIR TABS (Use abacavir sulfate-lamivudine-zidovudine)

NF QL(2 ea daily)

TRUVADA TABS (Use emtricitabine-tenofovir disoproxil fumarate)

TYBOST TABS 2 QL(1 ea daily)

VIDEX EC CPDR 125 MG 2 QL(2 ea daily)

VIDEX EC CPDR 200 MG (Use didanosine) NF QL(2 ea daily)

VIDEXPEDIATRIC SOLR 2

VIRACEPT TABS 250 MG 2 QL(10 ea daily)

VIRAMUNE SUSP 50 MG5ML NF QL(40 ml daily)

VIRAMUNE TABS 200 MG (Use nevirapine) NF QL(2 ea daily)

VIRAMUNE XR TB24 (Use nevirapine) NF QL(1 ea daily)

VIREAD POWD 40 MGGM 2

Drug Name DrugTier

RequirementsLimits

VIREAD TABS 150 MG 200 MG 250 MG 2 QL(1 ea daily)

VIREAD TABS 300 MG (Use tenofovir disoproxilfumarate)

ZIAGEN SOLN 20 MGML(Use abacavir sulfate) NF QL(32 ml daily)

ZIAGEN TABS 300 MG (Use abacavir sulfate) NF QL(2 ea daily)

zidovudine caps 100 mg 1 QL(6 ea daily)

zidovudine syrp 50 mg5ml 1 QL(60 ml daily)

zidovudine tabs 300 mg 1 QL(2 ea daily)

CMV Agents

cidofovir soln 3

CYTOVENE SOLR (Use ganciclovir sodium) NF

ganciclovir sodium solr 1

VALCYTE TABS 450 MG (Use valganciclovir hcl) NF PA QL(4 ea

daily) valganciclovir hcl tabs 450 mg 1 PA QL(4 ea

daily) Hepatitis Agents

adefovir dipivoxil tabs 4 PA QL(1 eadaily) SP

BARACLUDE SOLN 005 MGML 4 PA QL(20 ml

daily) SP BARACLUDE TABS 05 MG 1 MG (Use entecavir) NF PA QL(1 ea

daily) SP

entecavir tabs 4 PA QL(1 eadaily) SP

EPCLUSA TABS 100 MG-400 MG 50 MG-200 MG 4 PA QL(1 ea

daily) EPIVIR HBV SOLN 5 MGML 4 PA QL(60 ml

daily) SP EPIVIR HBV TABS 100 MG (Use lamivudine (hbv)) NF QL(3 ea daily)

SP HEPSERA TABS (Use adefovir dipivoxil) NF PA QL(1 ea

daily) SP

lamivudine (hbv) tabs 1 QL(3 ea daily)SP

Drug Name DrugTier

RequirementsLimits

MAVYRET TABS 40 MG-100 MG 4 PA QL(3 ea

daily)

PEGASYS SOLN 4 PA QL(00714ml daily) SP

PEGINTRON KIT 4 PA QL(0143ea daily) SP

ribavirin (hepatitis c) caps 1 QL(7 ea daily)

ribavirin (hepatitis c) tabs 1 PA QL(7 eadaily)

SOFOSBUVIRVELPATASVIR TABS 4 PA QL(1 ea

daily)

VEMLIDY TABS 4 PA QL(1 eadaily) SP

VOSEVI TABS 4 PA QL(1 eadaily)

ZEPATIER TABS 4 PA

Herpes Agents

acyclovir caps 200 mg 1

acyclovir susp 200 mg5ml 1 QL(1334 mldaily)

acyclovir tabs 400 mg 800 mg 1 QL(5 ea daily)

famciclovir tabs 125 mg250 mg 1 QL(3 ea daily)

famciclovir tabs 500 mg 1 QL(4 ea daily)

valacyclovir hcl tabs 1 gm1000 mg 1 QL(4 ea daily)

valacyclovir hcl tabs 500 mg 1 QL(2 ea daily)

VALTREX TABS 1 GM (Use valacyclovir hcl) NF QL(4 ea daily)

VALTREX TABS 500 MG (Use valacyclovir hcl) NF QL(2 ea daily)

ZOVIRAX CAPS OR 200 MG (Use acyclovir) NF

ZOVIRAX SUSP OR 200 MG5ML (Use acyclovir) NF QL(1334 ml

daily)

Drug Name DrugTier

RequirementsLimits

ZOVIRAX TABS OR 400 MG 800 MG (Use acyclovir)

NF QL(5 ea daily)

Influenza Agents FLUMADINE TABS (Use rimantadine hydrochloride) NF QL(2 ea daily)

oseltamivir phosphate capsor 30 mg 45 mg 75 mg 1

Limit 1 fill every90 daysQL(10ea per fillretail10 ea perfill mail)1 rtlMAX fill90 rtl day(s) supply1mail MAX fill90 mail day(s)supply

oseltamivir phosphate susror 6 mgml 1

Limit 1 fill every90 daysQL(125ml per fillretail)1 rtl MAXfill90 rtl day(s)supply

RELENZA DISKHALER AEPB 2

rimantadine hydrochloridetabs 1 QL(2 ea daily)

TAMIFLU CAPS 30 MG 45 MG 75 MG (Use oseltamivir phosphate)

TAMIFLU SUSR 6 MGML(Use oseltamivir phosphate)

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

Drug Name DrugTier

RequirementsLimits

carvedilol tabs 1

COREG TABS (Use carvedilol) NF

labetalol hcl soln iv 5 mgml 1

labetalol hcl tabs or 100 mg 200 mg 300 mg 1

Beta Blockers Cardio-Selective

acebutolol hcl caps 1

atenolol tabs 1

betaxolol hcl tabs 1

bisoprolol fumarate tabs or10 mg 5 mg 1

BYSTOLIC TABS 25 MG 10 MG 5 MG (Use nebivolol hcl)

2 PA QL(1 eadaily)

BYSTOLIC TABS 20 MG (Use nebivolol hcl) 2 PA QL(2 ea

daily) LOPRESSOR TABS (Use metoprolol tartrate) NF

metoprolol succinate tb24 1

metoprolol tartrate soln iv 5mg5ml 1

metoprolol tartrate tabs or100 mg 25 mg 50 mg 1

nebivolol hcl tabs 25 mg10 mg 5 mg 1 PA QL(1 ea

daily)

nebivolol hcl tabs 20 mg 1 PA QL(2 eadaily)

TENORMIN TABS (Use atenolol) NF

TOPROL XL TB24 (Use metoprolol succinate) NF

Beta Blockers Non-Selective BETAPACE AF TABS (Use sotalol hcl (afibafl)) NF

BETAPACE TABS (Use sotalol hcl) NF QL(2 ea daily)

CORGARD TABS (Use nadolol) NF

Drug Name DrugTier

RequirementsLimits

HEMANGEOL SOLN 4 PA QL(75 mldaily)

INDERAL LA CP24 (Use propranolol hcl) NF

nadolol tabs 1

pindolol tabs 1

propranolol hcl cp24 or 60mg 80 mg 120 mg 160 mg

propranolol hcl soln iv 1mgml 1

propranolol hcl soln or 40mg5ml 20 mg5ml 1

propranolol hcl tabs or 10mg 20 mg 80 mg 40 mg60 mg

sotalol hcl (afibafl) tabs 1

sotalol hcl tabs 120 mg160 mg 80 mg 1 QL(2 ea daily)

sotalol hcl tabs 240 mg 1

timolol maleate tabs 1

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers ADALAT CC TB24 (Use nifedipine) NF

amlodipine besylate tabs 1

CALAN SR TBCR (Use verapamil hcl) NF

CARDIZEM CD CP24 (Use diltiazem hcl coated beads) NF

CARDIZEM LA TB24 180 MG 240 MG 300 MG 360 MG 420 MG (Use diltiazem hcl coated beads)

CARDIZEM TABS (Use diltiazem hcl) NF

diltiazem hcl coated beads cp24 1

diltiazem hcl coated beads tb24 1

Drug Name DrugTier

RequirementsLimits

diltiazem hcl cp12 or 120mg 60 mg 90 mg 1

diltiazem hcl extended release beads cp24 120mg 180 mg 240 mg 300mg 360 mg

diltiazem hcl soln iv 50 mg10ml 1

DILTIAZEM HCL SOLR IV 100 MG 1

diltiazem hcl tabs or 120 mg 30 mg 60 mg 90 mg 1

felodipine tb24 1

isradipine caps 1

nicardipine hcl caps 1

nicardipine hcl soln 1

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1

nisoldipine tb24 17 mg 20mg 30 mg 34 mg 40 mg85 mg

NORVASC TABS (Use amlodipine besylate) NF

PROCARDIA CAPS (Use nifedipine) NF

PROCARDIA XL TB24 (Use nifedipine) NF

SULAR TB24 (Use nisoldipine) NF

TIAZAC CP24 120 MG 180 MG 240 MG 300 MG 360 MG (Use diltiazem hcl extended release beads)

verapamil hcl cp24 1

verapamil hcl soln 1

Drug Name DrugTier

RequirementsLimits

verapamil hcl tabs 1

verapamil hcl tbcr 1

VERELAN CP24 120 MG 180 MG 240 MG (Use verapamil hcl)

VERELAN CP24 360 MG (Use verapamil hcl) 1

VERELAN PM CP24 100 MG 200 MG (Use verapamil hcl)

VERELAN PM CP24 300 MG (Use verapamil hcl) 1

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

digoxin soln 1

digoxin tabs 1

LANOXIN SOLN IJ 025 MGML (Use digoxin) 2

LANOXIN TABS OR 250 MCG 125 MCG (Use digoxin)

LANOXIN TABS OR 625 MCG 2

CARDIOVASCULAR AGENTS - MISC - Drugs toTreat Heart and Circulation Conditions

Cardioplegic Solutions PLEGISOL SOLN (Use cardioplegic soln) NF

Cardiovascular Agents Misc - Combinations amlodipine besylate-atorvastatin calcium tabs 1 QL(1 ea daily)

BIDIL TABS 2

CADUET TABS (Use amlodipine besylate-atorvastatin calcium)

NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents

Drug Name DrugTier

RequirementsLimits

CIALIS TABS 5 MG (Use tadalafil) NF

PA BPH OnlyQL(1 eadaily)

sildenafil citrate tabs 1 PA QL(01334ea daily)

STENDRA TABS 3 QL(0134 eadaily)

tadalafil tabs 5 mg 1 PA BPH OnlyQL(1 eadaily)

VIAGRA TABS (Use sildenafil citrate) NF PA QL(01334

ea daily) Prostaglandin Vasodilators

epoprostenol sodium solr 4 PA

FLOLAN SOLR (Use epoprostenol sodium) NF PA

ORENITRAM TBCR 0125 MG 025 MG 1 MG 25 MG

treprostinil soln 4 PA SP

VELETRI SOLR (Use epoprostenol sodium) NF PA

VENTAVIS SOLN 4 PA SP

Pulmonary Hypertension - Endothelin Receptor

ambrisentan tabs 4 PA QL(1 eadaily) SP

bosentan tabs 125 mg 4 PA QL(2 eadaily) SP

bosentan tabs 625 mg 4 PA QL(2 eadaily)

LETAIRIS TABS (Use ambrisentan) NF PA QL(1 ea

daily) SP

OPSUMIT TABS 4 PA QL(1 eadaily)

TRACLEER TABS 125 MG (Use bosentan) NF PA QL(2 ea

daily) SP TRACLEER TABS 625 MG (Use bosentan) NF PA QL(2 ea

daily)

TRACLEER TBSO 32 MG 4 PA QL(2 eadaily) SP

Pulmonary Hypertension - Phosphodiesterase

Drug Name DrugTier

RequirementsLimits

ADCIRCA TABS (Use tadalafil (pulmonaryhypertension))

NF PA QL(2 eadaily) SP

REVATIO SOLN IV 10 MG125ML (Use sildenafil citrate (pulmonaryhypertension))

PA QL(375 mldaily) SP

REVATIO SUSR OR 10 MGML (Use sildenafil citrate (pulmonaryhypertension))

PA QL(6 mldaily)

REVATIO TABS OR 20 MG (Use sildenafil citrate (pulmonary hypertension))

sildenafil citrate (pulmonaryhypertension) soln iv 10mg125ml

4 PA QL(375 mldaily) SP

sildenafil citrate (pulmonaryhypertension) susr or 10mgml

4 PA QL(6 mldaily)

sildenafil citrate (pulmonaryhypertension) tabs or 20 mg

tadalafil (pulmonaryhypertension) tabs 4 PA QL(2 ea

daily) SP

Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 05 MG 15 MG 2 MG 25 MG 4 PA QL(3 ea

daily) Sinus Node Inhibitors CORLANOR SOLN 5 MG5ML 3 PA QL(15 ml

daily) CORLANOR TABS 5 MG 75 MG 3 PA QL(2 ea

daily) Transthyretin Stabilizers

VYNDAMAX CAPS 4 PA QL(1 eadaily)

VYNDAQEL CAPS 4 PA QL(4 eadaily)

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps 1

cefadroxil susr 1

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

cefazolin sodium solr ij 500mg 1 gm 10 gm 1

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1

KEFLEX CAPS (Use cephalexin) NF

Cephalosporins - 2nd Generation

cefaclor caps 1

cefaclor susr 1

CEFOTAN SOLR (Use cefotetan disodium) NF

cefotetan disodium solr 1

cefoxitin sodium solr 1 gm2 gm 1

cefprozil susr 1

cefprozil tabs 1

cefuroxime axetil tabs 1

cefuroxime sodium solr ij750 mg 1

Cephalosporins - 3rd Generation

cefdinir caps 1

cefdinir susr 1

cefditoren pivoxil tabs 200 mg 3

cefixime susr 100 mg5ml200 mg5ml 1 ST

cefotaxime sodium solr 1

cefpodoxime proxetil susr 1

cefpodoxime proxetil tabs 1

Drug Name DrugTier

RequirementsLimits

ceftazidime solr ij 6 gm 1 gm 1

ceftriaxone sodium solr ij250 mg 500 mg 1 gm 2 gm

FORTAZ SOLR IJ 1 GM (Use ceftazidime) NF

FORTAZ SOLR IV 2 GM (Use ceftazidime) NF

SUPRAX SUSR 100 MG5ML 200 MG5ML(Use cefixime)

Cephalosporins - 4th Generation

cefepime hcl solr 1

MAXIPIME SOLR IJ 1 GM 2 GM (Use cefepime hcl) NF

TEFLARO SOLR 3

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral BALCOLTRA TABS 0

BEYAZ TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

desogestrel amp ethinylestradiol tabs 0

desogestrel-ethinylestradiol (biphasic) tabs 0

desogestrel-ethinylestradiol (triphasic) tabs 0

drospirenone-ethinylestradiol tabs 0

drospirenone-ethinylestradiol-levomefolate calcium tabs

ESTROSTEP FE TABS (Use norethindrone acetate-ethinyl estradiol-fe)

ethynodiol diacet amp ethestrad tabs 0

Drug Name DrugTier

RequirementsLimits

FALESSA KIT 0

GENERESS FE CHEW (Use norethindrone amp ethinyl estradiol-fe)

levonorgestrel amp ethestradiol tabs 0

levonorgestrel-eth estradiol(triphasic) tabs 0

levonorgestrel-ethinylestradiol (91-day) tabs 0

levonorgestrel-ethinylestradiol (continuous) tabs 0

LO LOESTRIN FE TABS 0

LOSEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

MINASTRIN 24 FE CHEW (Use norethin acet amp estrad-fe)

MIRCETTE TABS (Use desogestrel-ethinylestradiol (biphasic))

NATAZIA TABS 0

norethin acet amp estrad-fe caps 0

norethin acet amp estrad-fe chew 0

norethin acet amp estrad-fe tabs 0

norethindrone amp eth estradiol tabs 0

norethindrone amp ethinylestradiol-fe chew 0

norethindrone acet amp eth estra tabs 0

norethindrone acetate-ethinyl estradiol-fe tabs 0

norethindrone-eth estradiol (triphasic) tabs 0

norgestimate-ethinylestradiol (triphasic) tabs 0

norgestimate-ethinylestradiol tabs 0

Drug Name DrugTier

RequirementsLimits

norgestrel amp ethinylestradiol tabs 0

ORTHO TRI-CYCLEN LO TABS (Use norgestimate-ethinyl estradiol (triphasic))

ORTHO-NOVUM 135TABS (Use norethindrone amp eth estradiol)

ORTHO-NOVUM 777TABS (Use norethindrone-eth estradiol (triphasic))

QUARTETTE TABS (Use levonorgestrel-ethinylestradiol (91-day))

SAFYRAL TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

SEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

TAYTULLA CAPS (Use norethin acet amp estrad-fe) 0

TYBLUME CHEW 0

YASMIN 28 TABS (Use drospirenone-ethinylestradiol)

YAZ TABS (Use drospirenone-ethinylestradiol)

Combination Contraceptives - Transdermal norelgestromin-ethinylestradiol ptwk 0

TWIRLA PTWK 0 QL(3 ea per 28days retail)

Combination Contraceptives - Vaginal ANNOVERA RING 0 PA

etonogestrel-ethinylestradiol ring 0

NUVARING RING (Use etonogestrel-ethinylestradiol)

Copper Contraceptives - IUD

Drug Name DrugTier

RequirementsLimits

PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A IUD

Emergency Contraceptives

ELLA TABS 0

levonorgestrel (emergencyoc) tabs 0

PLAN B ONE-STEP TABS (Use levonorgestrel(emergency oc))

Progestin Contraceptives - IUD

KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0

Progestin Contraceptives - Implants

NEXPLANON IMPL 0

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (Use medroxyprogesteroneacetate (contraceptive))

QL(1 ml per 90days retail)

DEPO-PROVERA CONTRACEPTIVE SUSY (Use medroxyprogesteroneacetate (contraceptive))

QL(90 day(s)limit1 ml per90 days retail)

DEPO-SUBQ PROVERA 104 SUSY 0

medroxyprogesteroneacetate (contraceptive) susp

0 QL(1 ml per 90days retail)

medroxyprogesteroneacetate (contraceptive) susy

0 QL(90 day(s)limit1 ml per90 days retail)

Progestin Contraceptives - Oral norethindrone (contraceptive) tabs 0

Drug Name DrugTier

RequirementsLimits

ORTHO MICRONOR TABS (Use norethindrone (contraceptive))

SLYND TABS 0 QL(1 ea daily)

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids

budesonide cpep 3 mg 1 QL(3 ea daily)

CELESTONE SOLUSPAN SUSP (Use betamethasone sod phosphate amp acetate)

CELESTONE-SOLUSPAN SUSP (Use betamethasone sod phosphate amp acetate)

CORTEF TABS (Use hydrocortisone) NF

cortisone acetate tabs 1

DEPO-MEDROL SUSP 20 MGML 3

DEPO-MEDROL SUSP 80 MGML 40 MGML (Use methylprednisolone acetate)

dexamethasone elix 05 mg5ml 1

DEXAMETHASONE INTENSOL CONC 1

dexamethasone sodium phosphate soln ij 120mg30ml 20 mg5ml 4mgml

dexamethasone soln 05 mg5ml 1

dexamethasone tabs 1 mg15 mg 2 mg 4 mg 05mg 075 mg 6 mg

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA

ENTOCORT EC CPEP (Use budesonide) NF QL(3 ea daily)

hydrocortisone tabs 1

Drug Name DrugTier

RequirementsLimits

KENALOG-40 SUSP (Use triamcinolone acetonide) NF

MEDROL DOSEPAK TBPK (Use methylprednisolone) NF

MEDROL TABS 16 MG 32 MG 4 MG 8 MG (Use methylprednisolone)

MEDROL TABS 2 MG 3

methylprednisolone acetatesusp 80 mgml 40 mgml 1

methylprednisolone sodsucc solr 1

methylprednisolone tabs 1

methylprednisolone tbpk 1

MILLIPRED DP TBPK 3

MILLIPRED TABS 3

ORAPRED ODT TBDP (Use prednisolone sodiumphosphate)

PEDIAPRED SOLN (Use prednisolone sodiumphosphate)

prednisolone sodiumphosphate soln or 10mg5ml 15 mg5ml 25mg5ml 20 mg5ml 5mg5ml 67 mg5ml

prednisolone sodiumphosphate tbdp or 10 mg15 mg 30 mg

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1

SOLU-CORTEF SOLR 100 MG 1000 MG 500 MG 3

2 rtl MAX fill30 rtl day(s)supply

SOLU-CORTEF SOLR 250 MG 3

Drug Name DrugTier

RequirementsLimits

SOLU-MEDROL SOLR 2 GM 3

SOLU-MEDROL SOLR 500 MG 1000 MG 125 MG 40 MG (Use methylprednisolone sod succ)

triamcinolone acetonide susp 40 mgml 1

Mineralocorticoids

fludrocortisone acetate tabs 1

COUGHCOLDALLERGY - Drugs to TreatCough Cold and Allergy Symptoms

Antitussives

benzonatate caps 100 mg 1 QL(6 ea daily)

TESSALON PERLES CAPS (Use benzonatate) NF QL(6 ea daily)

CoughColdAllergy Combinations ALLEGRA-D 12 HOUR ALLERGY amp CONGESTION TB12 (Use fexofenadine-pseudoephedrine)

QL(2 ea daily)

ALLEGRA-D 24 HOUR ALLERGY amp CONGESTION TB24 (Use fexofenadine-pseudoephedrine)

QL(1 ea daily)

cetirizine-pseudoephedrinetb12 1 QL(2 ea daily)

CLARITIN-D 12 HOUR TB12 (Use loratadine amp pseudoephedrine)

1 QL(2 ea daily)

1 QL(1 ea daily)

fexofenadine-pseudoephedrine tb12 60mg-120 mg

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

hydrocodone polistirex-chlorpheniramine polistirex suer

loratadine amp pseudoephedrine tb12 5mg-120 mg

1 QL(2 ea daily)

loratadine amp pseudoephedrine tb24 10mg-10 mg-240 mg-240 mg

1 QL(1 ea daily)

TUZISTRA XR SUER 2 PA

ZYRTEC-D ALLERGYCONGESTIONTB12 (Use cetirizine-pseudoephedrine)

QL(2 ea daily)

Misc Respiratory Inhalants HYPER-SAL NEBU (Use sodium chloride (inhalant)) NF

HYPERSAL NEBU 35 1

HYPERSAL NEBU 7 (Use sodium chloride (inhalant))

NEBUSAL NEBU 1

sodium chloride (inhalant)nebu 7 1

Mucolytics

acetylcysteine soln 1

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products ABSORICA CAPS 30 MG 10 MG 20 MG 40 MG (Use isotretinoin)

NF PA AL(At least12 yrs old)

adapalene crea 01 1 PA AL(At least12 yrs old)

adapalene gel 01 1 PA AL(At least12 yrs old)RXOTC

adapalene gel 03 1 ST AL(At least12 yrs old)

Drug Name DrugTier

RequirementsLimits

adapalene-benzoylperoxide gel 1 ST AL(At least

12 yrs old)

AZELEX CREA 3 ST AL(At least12 yrs old)

BENZACLIN GEL (Use clindamycin phosphate-benzoyl peroxide)

BENZACLIN WITH PUMP GEL (Use clindamycinphosphate-benzoylperoxide)

PA AL(At least12 yrs old)

BENZAMYCIN GEL (Use benzoyl peroxide-erythromycin)

BENZOYL PEROXIDE CLEANSER LIQD 2 AL(At least 12

yrs old)

benzoyl peroxide foam 53 1

AL(At least 12yrs old)RXOTC

benzoyl peroxide foam 98 1 AL(At least 12

yrs old) benzoyl peroxide gel 5 10 1 AL(At least 12

yrs old) benzoyl peroxide liqd 4 7 10 1 AL(At least 12

yrs old) benzoyl peroxide-erythromycin gel 1 PA AL(At least

12 yrs old) CLEOCIN-T GEL (Use clindamycin phosphate(topical))

CLEOCIN-T LOTN (Use clindamycin phosphate(topical))

CLINDAGEL GEL (Use clindamycin phosphate(topical))

clindamycin phosphate(topical) foam 1 PA AL(At least

12 yrs old) clindamycin phosphate(topical) gel 1 AL(At least 12

yrs old) clindamycin phosphate(topical) lotn 1 AL(At least 12

yrs old)

clindamycin phosphate(topical) soln 1

QL(4 ml daily)AL(At least 12yrs old)

clindamycin phosphate(topical) swab 1 AL(At least 12

yrs old)

Drug Name DrugTier

RequirementsLimits

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

1 PA AL(At least12 yrs old)

clindamycin phosphate-benzoyl peroxide gel 1 -5

clindamycin phosphate-tretinoin gel 1 ST AL(At least

12 yrs old) DIFFERIN CREA 01 (Use adapalene) NF PA AL(At least

12 yrs old)

DIFFERIN GEL 01 (Use adapalene) NF

PA AL(At least12 yrs old)RXOTC

DIFFERIN GEL 03 (Use adapalene) NF ST AL(At least

12 yrs old)

DIFFERIN LOTN 01 1 ST AL(At least12 yrs old)

DUAC GEL (Use clindamycin phosphate-benzoyl peroxide(refrigerate))

EPIDUO GEL (Use adapalene-benzoylperoxide)

NF ST AL(At least12 yrs old)

erythromycin (acne aid)pads 1 AL(At least 12

yrs old) erythromycin (acne aid)soln 1 AL(At least 12

yrs old) EVOCLIN FOAM (Use clindamycin phosphate(topical))

isotretinoin caps 30 mg 10mg 20 mg 40 mg 3 PA AL(At least

12 yrs old) KLARON LOTN (Use sulfacetamide sodium (acne))

RETIN-A CREA (Use tretinoin) NF

AL(At least 12yrs old - Up to30 yrs old)

RETIN-A GEL (Use tretinoin) NF

RETIN-A MICRO GEL 01 (Use tretinoin microsphere)

NF PA AL(At least12 yrs old - Upto 30 yrs old)

Drug Name DrugTier

RequirementsLimits

RETIN-A MICRO PUMP GEL 01 (Use tretinoin microsphere)

sulfacetamide sodium (acne) lotn 1 AL(At least 12

yrs old) sulfacetamide sodium wsulfur crea 5 -10 1 AL(At least 12

yrs old) sulfacetamide sodium wsulfur liqd 45 -9 1 ST AL(At least

12 yrs old) sulfacetamide sodium-sulfur in urea vehicle emul 1 AL(At least 12

yrs old) SUMADAN WASH LIQD (Use sulfacetamide sodium w sulfur)

tretinoin crea 005 01 0025 1

tretinoin gel 001 0025 1

tretinoin microsphere gel01 1

PA AL(At least12 yrs old - Upto 30 yrs old)

VELTIN GEL (Use clindamycin phosphate-tretinoin)

ZIANA GEL (Use clindamycin phosphate-tretinoin)

Agents for External Genital and Perianal Warts

VEREGEN OINT 3

Anti-inflammatory Agents - Topical

diclofenac epolamine ptch 1 PA QL(2 eadaily)

diclofenac sodium (topical)gel 1 1 QL(334 gm

daily) RXOTC FLECTOR PTCH (Use diclofenac epolamine) 3 PA QL(2 ea

daily) VOLTAREN GEL (Use diclofenac sodium (topical)) NF QL(334 gm

daily) RXOTC

Antibiotics - Topical ALTABAX OINT 2

gentamicin sulfate (topical) crea 1 QL(1 gm daily)

Drug Name DrugTier

RequirementsLimits

gentamicin sulfate (topical)oint 1

mupirocin oint 1

NEO-SYNALAR CREA 3 PA

Antifungals - Topical butenafine hcl crea 1 RXOTC

ciclopirox gel ex 077 1

ciclopirox olamine crea 1

QL(90 gm perfill retail)1 rtlMAX fill30 rtl day(s) supply

ciclopirox olamine susp 1

ciclopirox sham ex 1 1

ciclopirox soln ex 8 1

clotrimazole (topical) crea 1 RXOTC

clotrimazole (topical) soln 1 RXOTC

clotrimazole wbetamethasone crea 1

clotrimazole wbetamethasone lotn 1

econazole nitrate crea 1 QL(85 gm perfill retail85 gmper fill mail)

ERTACZO CREA 3

EXELDERM CREA (Use sulconazole nitrate) 3

EXELDERM SOLN 3

EXELDERM SOLN (Use sulconazole nitrate) 3

JUBLIA SOLN 3 PA

KERYDIN SOLN (Use tavaborole) 3 PA

ketoconazole (topical) crea2 1

ketoconazole (topical)sham 2 1

Drug Name DrugTier

RequirementsLimits

LOPROX CREA (Use ciclopirox olamine) NF

LOPROX SHAMPOO SHAM (Use ciclopirox) NF

LOPROX SUSP (Use ciclopirox olamine) NF

LOTRIMIN AF CREA (Use clotrimazole (topical)) NF RXOTC

LOTRIMIN AF JOCK ITCH CREA (Use clotrimazole (topical))

NF RXOTC

LOTRIMIN ULTRA CREA (Use butenafine hcl) 1 RXOTC

LOTRISONE CREA (Use clotrimazole wbetamethasone)

luliconazole crea 1 PA

LUZU CREA (Use luliconazole) 3 PA

naftifine hcl crea 1 1

QL(3 gmdaily)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

naftifine hcl gel 1 1

Drug Name DrugTier

RequirementsLimits

NAFTIFINE HYDROCHLORIDE CREA (Use naftifine hcl)

NAFTIN CREA 2 (Use naftifine hcl) NF

NAFTIN GEL 1 (Use naftifine hcl) NF

NIZORAL SHAM (Use ketoconazole (topical)) NF

nystatin (topical) crea 1

nystatin (topical) oint 1

nystatin (topical) powd 1

nystatin-triamcinolone crea 1

nystatin-triamcinolone oint 1

oxiconazole nitrate crea 1

Limit 1 Fill per180 daysQL(3gm daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

OXISTAT CREA (Use oxiconazole nitrate) NF

Drug Name DrugTier

RequirementsLimits

OXISTAT LOTN 2

Limit 1 Fill per180 daysQL(2ml daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PENLAC NAIL LACQUER SOLN (Use ciclopirox) NF

sulconazole nitrate crea 1

sulconazole nitrate soln 1

tavaborole soln 1 PA

VUSION OINT (Use miconazole-zinc oxide-white petrolatum)

Antineoplastic or Premalignant Lesion Agents -CARAC CREA (Use fluorouracil (topical)) NF

diclofenac sodium (actinickeratoses) gel 1 PA QL(334

gm daily) EFUDEX CREA (Use fluorouracil (topical)) NF

fluorouracil (topical) crea 5 1

fluorouracil (topical) soln 2 5 1

PANRETIN GEL 3

PICATO GEL 0015 2

QL(3 ea per fillretail3 ea perfill mail)1 rtlMAX fill60 rtl day(s) supply1mail MAX fill60 mail day(s)supply

PICATO GEL 005 2

Drug Name DrugTier

RequirementsLimits

TARGRETIN GEL EX 1 4 PA SP

Antipruritics - Topical

doxepin hcl (antipruritic) crea 3

PA Limit 1 fill every 180daysQL(45 gmper fill retail45gm per fillmail)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PRUDOXIN CREA (Use doxepin hcl (antipruritic)) 3

ZONALON CREA (Use doxepin hcl (antipruritic)) 3

Antipsoriatics acitretin caps 175 mg 10 mg 1 QL(1 ea daily)

acitretin caps 25 mg 1 QL(2 ea daily)

calcipotriene crea 1 PA QL(4 gmdaily)

calcipotriene oint 1 PA QL(4 gmdaily)

calcipotriene soln 1 PA QL(4 mldaily)

calcitriol (topical) oint 1 QL(334 gmdaily)

Drug Name DrugTier

RequirementsLimits

COSENTYX SENSOREADY PEN SOAJ 4 PA QL(0072

ml daily) COSENTYX SOSY 150 MGML 4 PA QL(0072

ml daily) DOVONEX CREA (Use calcipotriene) NF PA QL(4 gm

daily)

methoxsalen rapid caps 1 QL(4 ea daily)

OXSORALEN ULTRA CAPS (Use methoxsalen rapid)

NF QL(4 ea daily)

SKYRIZI PEN SOAJ 4 PA QL(0025ml daily)

SKYRIZI PSKT 75 MG083ML 4 PA QL(0025

ea daily) SKYRIZI SOSY 150 MGML 4 PA QL(0025

ml daily) SORIATANE CAPS 10 MG (Use acitretin) NF QL(1 ea daily)

SORIATANE CAPS 25 MG (Use acitretin) NF QL(2 ea daily)

STELARA SOLN SC 45 MG05ML 4 PA QL(0012

ml daily) STELARA SOSY SC 45 MG05ML 4 PA QL(0012

ml daily) STELARA SOSY SC 90 MGML 4 PA QL(0018

ml daily) SP

tazarotene crea 1 PA

TAZORAC CREA 005 2

TAZORAC CREA 01 (Use tazarotene) NF PA

TAZORAC GEL 005 01 2

TREMFYA SOPN 4 PA QL(0018ml daily)

TREMFYA SOSY 4 PA QL(0018ml daily)

VECTICAL OINT (Use calcitriol (topical)) 1 QL(334 gm

daily) Antiseborrheic Products

selenium sulfide lotn 1

Drug Name DrugTier

RequirementsLimits

Antivirals - Topical acyclovir topical crea 1

acyclovir topical oint 1

DENAVIR CREA 3 QL(018 gmdaily)

ZOVIRAX CREA EX 5 (Use acyclovir topical) NF

ZOVIRAX OINT EX 5 (Use acyclovir topical) NF

Burn Products

mafenide acetate pack 3

SILVADENE CREA (Use silver sulfadiazine) NF

silver sulfadiazine crea 1

SULFAMYLON CREA 85 MGGM 3

SULFAMYLON PACK 5 (Use mafenide acetate) NF

Corticosteroids - Topical alclometasone dipropionate crea 1

alclometasone dipropionateoint 1

amcinonide crea 1

QL(60 gm perfill retail60 gmper fill mail)1 rtlMAX fill30 rtl day(s) supply1mail MAX fill30 mail day(s)supply

amcinonide lotn 3

AMCINONIDE OINT 3

betamethasone dipropionate (topical) crea 1

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint 1

Drug Name DrugTier

RequirementsLimits

betamethasone dipropionate augmented crea

betamethasone dipropionate augmentedlotn

betamethasone dipropionate augmentedoint

betamethasone valerate crea 01 1

betamethasone valerate foam 012 1 QL(167 gm

daily) betamethasone valerate lotn 01 1

betamethasone valerate oint 01 1

calcipotriene-betamethasone dipropionate oint

calcipotriene-betamethasone dipropionate susp

clobetasol propionate crea 1 PA QL(3 gmdaily)

clobetasol propionateemollient base crea 1 PA QL(1 gm

daily)

clobetasol propionate foam 1 ST QL(3 gmdaily)

clobetasol propionate gel 1 ST QL(2 gmdaily)

clobetasol propionate oint 1 PA QL(1 gmdaily)

clobetasol propionate soln 1 PA QL(334 mldaily)

clocortolone pivalate crea 3

CLODERM CREA (Use clocortolone pivalate) 3

CORDRAN CREA 005 (Use flurandrenolide) NF

CORDRAN LOTN 005 (Use flurandrenolide) NF

CORDRAN TAPE 4 MCGSQCM 3

Drug Name DrugTier

RequirementsLimits

CUTIVATE LOTN (Use fluticasone propionate) NF QL(6 ml daily)

DERMA-SMOOTHEFSBODY OIL (Use fluocinolone acetonide)

QL(11828 mlper fill retail)1rtl MAX fill30 rtl day(s) supply

DERMA-SMOOTHEFSSCALP OIL (Use fluocinolone acetonide)

desonide crea 1 QL(4 gm daily)

desonide lotn 1 QL(4 ml daily)

desonide oint 1 QL(3 gm daily)

DESOWEN CREA (Use desonide) NF QL(4 gm daily)

desoximetasone crea 025 1

desoximetasone gel 005 1

desoximetasone oint 025 1

diflorasone diacetate crea 1 PA

diflorasone diacetate oint 1 PA

DIPROLENE AF CREA (Use betamethasone dipropionate augmented)

DIPROLENE OINT (Use betamethasone dipropionate augmented)

ELOCON CREA (Use mometasone furoate) NF

fluocinolone acetonide crea 001 0025 1

fluocinolone acetonide oil 001 1

fluocinolone acetonide oint 0025 1

fluocinolone acetonide soln 001 1

Drug Name DrugTier

RequirementsLimits

fluocinonide crea 005 1 QL(2 gm daily)

fluocinonide emulsified base crea 1 QL(2 gm daily)

fluocinonide gel 005 1

fluocinonide oint 005 1 QL(2 gm daily)

fluocinonide soln 005 1 QL(2 ml daily)

flurandrenolide crea 2 QL(2 gm daily)

flurandrenolide lotn 2 QL(2 ml daily)

fluticasone propionate crea005 1

fluticasone propionate lotn005 1 QL(6 ml daily)

fluticasone propionate oint0005 1

halcinonide crea 1 PA

halobetasol propionate crea 1

halobetasol propionate oint 1

HALOG CREA (Use halcinonide) NF PA

HALOG OINT 3 PA

hydrocortisone (topical)crea 1 1 RXOTC

hydrocortisone (topical)crea 25 1

hydrocortisone (topical) lotn25 1

hydrocortisone (topical) oint1 1 RXOTC

hydrocortisone (topical) oint25 1

hydrocortisone butyrate crea 1

hydrocortisone butyrateoint 1

hydrocortisone butyratesoln 1

Drug Name DrugTier

RequirementsLimits

hydrocortisone valerate crea 1

hydrocortisone valerateoint 1

LOCOID CREA (Use hydrocortisone butyrate) NF

LOCOID SOLN (Use hydrocortisone butyrate) NF

LUXIQ FOAM (Use betamethasone valerate) NF QL(167 gm

daily)

mometasone furoate crea 1

mometasone furoate oint 1

mometasone furoate soln 1

MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use hydrocortisone(topical))

OLUX FOAM (Use clobetasol propionate) NF ST QL(3 gm

daily)

prednicarbate crea 1

prednicarbate oint 1

PSORCON CREA 2 PA

SYNALAR CREA (Use fluocinolone acetonide) NF

SYNALAR OINT (Use fluocinolone acetonide) NF

SYNALAR SOLN (Use fluocinolone acetonide) NF

TACLONEX OINT (Use calcipotriene-betamethasone dipropionate)

TACLONEX SUSP (Use calcipotriene-betamethasone dipropionate)

TEMOVATE CREA (Use clobetasol propionate) NF PA QL(3 gm

daily) TEMOVATE OINT (Use clobetasol propionate) NF PA QL(1 gm

daily)

Drug Name DrugTier

RequirementsLimits

TOPICORT CREA 025 (Use desoximetasone) NF

TOPICORT GEL 005 (Use desoximetasone) NF

TOPICORT OINT 025 (Use desoximetasone) NF

triamcinolone acetonide (topical) crea 0025 05

triamcinolone acetonide (topical) crea 01 1 QL(334 gm

daily) triamcinolone acetonide (topical) lotn 0025 01

triamcinolone acetonide (topical) oint 0025 01 05

triamcinolone acetonide-dimethicone-silicone kit 1 PA

TRIDESILON CREA (Use desonide) NF QL(4 gm daily)

Eczema Agents DUPIXENT SOPN 300 MG2ML 4 PA

DUPIXENT SOSY 200 MG114ML 300 MG2ML 4 PA

EmollientKeratolytic Agents HYDRO 35 FOAM (Use urea in lactic acid vehicle) NF

Emollients LAC-HYDRIN CREA (Use lactic acid (ammoniumlactate))

NF RXOTC

LAC-HYDRIN TWELVE LOTN (Use lactic acid (ammonium lactate))

NF RXOTC

lactic acid (ammoniumlactate) crea 1 RXOTC

lactic acid (ammoniumlactate) lotn 1 RXOTC

Enzymes - Topical SANTYL OINT 3 PA

Immunomodulating Agents - Topical

Drug Name DrugTier

RequirementsLimits

ALDARA CREA (Use imiquimod) NF

QL(12 ea perfill retail12 ea per fill mail)

imiquimod crea 5 1 QL(12 ea perfill retail12 ea per fill mail)

ZYCLARA CREA (Use imiquimod) NF

ZYCLARA PUMP CREA 375 (Use imiquimod) NF

Immunosuppressive Agents - Topical ELIDEL CREA (Use pimecrolimus) NF PA AL(At least

2 yrs old)

pimecrolimus crea 1 PA AL(At least2 yrs old)

PROTOPIC OINT (Use tacrolimus (topical)) NF PA AL(At least

2 yrs old)

tacrolimus (topical) oint 1 PA AL(At least2 yrs old)

KeratolyticAntimitotic Agents

podofilox soln 1

Local Anesthetics - Topical lidocaine hcl gel ex 2 1 QL(4 ml daily)

lidocaine hcl gel ex 2 1 QL(4 ml daily)RXOTC

lidocaine hcl prsy ex 2 1 QL(4 ml daily)

lidocaine hcl soln ex 4 1

lidocaine ptch ex 5 1 PA

lidocaine-prilocaine crea 1 QL(1 gm daily)

LIDODERM PTCH (Use lidocaine) NF PA

SYNERA PTCH 3

QL(10 ea perfill retail10 ea per fill mail)1 rtlMAX fill30 rtl day(s) supply1mail MAX fill30 mail day(s)supply

Phosphodiesterase 4 (PDE4) Inhibitors - Topical

Drug Name DrugTier

RequirementsLimits

EUCRISA OINT 3 PA QL(2 gmdaily)

Rosacea Agents

azelaic acid gel 1 PA

FINACEA GEL (Use azelaic acid) NF PA

METROCREAM CREA (Use metronidazole (topical))

METROGEL GEL (Use metronidazole (topical)) NF

METROLOTION LOTN (Use metronidazole (topical))

metronidazole (topical) crea 1

metronidazole (topical) gel 1

metronidazole (topical) lotn 1

MIRVASO GEL 3 PA QL(1 gmdaily)

ORACEA CPDR (Use doxycycline (rosacea)) NF

SOOLANTRA CREA (Use ivermectin (rosacea)) NF

Scabicides amp Pediculicides

crotamiton lotn 1 PA

ELIMITE CREA (Use permethrin) NF

EURAX CREA 3

EURAX LOTN (Use crotamiton) NF PA

ivermectin (pediculicide)lotn 1 PA RXOTC

IVERMECTIN LOTN EX 05 3 PA RXOTC

lindane sham 1

malathion lotn 1

NATROBA SUSP (Use spinosad) 1 PA

Drug Name DrugTier

RequirementsLimits

NIX CREME RINSE LIQD (Use permethrin) NF

OVIDE LOTN (Use malathion) NF

permethrin crea 1

permethrin liqd 1

SKLICE LOTN (Use ivermectin (pediculicide)) 3 PA RXOTC

spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS

Diagnostic Drugs GLUCAGEN DIAGNOSTIC SOLR 3 QL(0035 ea

daily) Diagnostic Tests

CHEMSTRIP-K STRP 1

FORA GTEL BLOOD KETONE TEST STRIPS STRP

GOJJI BLOOD KETONE TEST STRIPS STRP 1

KETONE STRP 1

KETONE TEST STRIPS STRP 1

KETOSTIX STRP 1

NOVA MAX PLUS KETONE TESTSTRIPS STRP

PRECISION XTRA STRP VI 1

PTS PANELS KETONE TEST STRP 1

RELION KETONE TEST STRIPS STRP 1

Drug Name DrugTier

RequirementsLimits

RELION TRUE METRIX BLOODGLUCOSE TEST STRIPS STRP

1 QL(334 eadaily) RXOTC

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

Limit 100 permonthQL(334ea daily)RXOTC

TRUETRACK TEST STRP 1

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

DIURETICS - Drugs to Treat Heart CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors acetazolamide cp12 500 mg 1 QL(2 ea daily)

acetazolamide sodium solr 1

acetazolamide tabs 125 mg 1 QL(8 ea daily)

KEVEYIS TABS 4 PA QL(4 eadaily)

methazolamide tabs 1 QL(6 ea daily)

Diuretic Combinations ALDACTAZIDE TABS 25 MG-25 MG (Use spironolactone amphydrochlorothiazide)

amiloride amp hydrochlorothiazide tabs 1

DYAZIDE CAPS (Use triamterene amp hydrochlorothiazide)

Drug Name DrugTier

RequirementsLimits

MAXZIDE TABS (Use triamterene amp hydrochlorothiazide)

MAXZIDE-25 TABS (Use triamterene amp hydrochlorothiazide)

spironolactone amphydrochlorothiazide tabs 1

triamterene amp hydrochlorothiazide caps 1

triamterene amp hydrochlorothiazide tabs 1

Loop Diuretics bumetanide soln ij 025mgml 1

bumetanide tabs or 05 mg1 mg 2 mg 1 QL(5 ea daily)

BUMEX TABS (Use bumetanide) NF QL(5 ea daily)

EDECRIN TABS (Use ethacrynic acid) NF QL(16 ea daily)

ethacrynic acid tabs 1 QL(16 ea daily)

furosemide soln 1

furosemide tabs 1

LASIX TABS (Use furosemide) NF

torsemide tabs 1

Potassium Sparing Diuretics ALDACTONE TABS (Use spironolactone) NF

amiloride hcl tabs 1

DYRENIUM CAPS (Use triamterene) NF QL(3 ea daily)

spironolactone tabs 1

triamterene caps 1 QL(3 ea daily)

Thiazides and Thiazide-Like Diuretics

chlorthalidone tabs 1

Drug Name DrugTier

RequirementsLimits

DIURIL SUSP 2 QL(20 ml daily)

hydrochlorothiazide caps 1 QL(2 ea daily)

hydrochlorothiazide tabs 1 QL(2 ea daily)

indapamide tabs 125 mg 1 QL(1 ea daily)

metolazone tabs 1 QL(2 ea daily)

ENDOCRINE AND METABOLIC AGENTS -MISC - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators ACTONEL TABS 150 MG (Use risedronate sodium) NF PA QL(0036

ea daily) ACTONEL TABS 35 MG (Use risedronate sodium) NF PA QL(0143

ea daily) alendronate sodium tabs 35 mg 70 mg 1 QL(0143 ea

daily) alendronate sodium tabs 5 mg 10 mg 1 QL(1 ea daily)

ATELVIA TBEC (Use risedronate sodium) NF PA

BONIVA SOLN IV 3 MG3ML (Use ibandronate sodium)

NF PA SP

BONIVA TABS OR 150 MG (Use ibandronate sodium) NF QL(0036 ea

daily) calcitonin (salmon) soln na200 unitact 1

etidronate disodium tabs 1

FOSAMAX PLUS D TABS 3 PA QL(0143ea daily)

FOSAMAX TABS (Use alendronate sodium) NF QL(0143 ea

daily) ibandronate sodium soln iv 3 mg3ml 4 PA SP

ibandronate sodium tabs or 150 mg 1 QL(0036 ea

daily) pamidronate disodium soln30 mg10ml 90 mg10ml 4 PA SP

Drug Name DrugTier

RequirementsLimits

PAMIDRONATE DISODIUM SOLN 6 MGML

4 PA SP

pamidronate disodium solr30 mg 90 mg 4 PA SP

PROLIA SOSY 4

PA 1 rtl MAX fill180 rtl day(s) supplySP

RECLAST SOLN (Use zoledronic acid) NF PA SP

risedronate sodium tabs 150 mg 1 PA QL(0036

ea daily) risedronate sodium tabs 30 mg 5 mg 1 PA QL(1 ea

daily) risedronate sodium tabs 35 mg 1 PA QL(0143

ea daily) risedronate sodium tbec 35 mg 1 PA

TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP

zoledronic acid conc 4 mg5ml 4 PA SP

ZOLEDRONIC ACID SOLN 4 MG100ML 4 PA SP

zoledronic acid soln 4 mg100ml 5 mg100ml 4 PA SP

Corticotropin

ACTHAR GEL 4 PA

Fertility Regulators CHORIONIC GONADOTROPIN SOLR 4 PA SP

NOVAREL SOLR 10000 UNIT 4 PA SP

PREGNYL WDILUENTBENZYLALCOHOLNACLSOLR

4 PA SP

GnRHLHRH Antagonists

CETROTIDE KIT 4 PA

ganirelix acetate sosy 4 PA

Drug Name DrugTier

RequirementsLimits

GANIRELIX ACETATE SOSY (Use ganirelix acetate)

Growth Hormone Receptor Antagonists SOMAVERT SOLR 10 MG 15 MG 20 MG 4 PA SP

Growth Hormone Releasing Hormones (GHRH) EGRIFTA SOLR 4 PA

EGRIFTA SV SOLR 4 PA

Growth Hormones GENOTROPIN MINIQUICK SOLR 02 MG 4 PA SP

GENOTROPIN SOLR 5 MG 4 PA SP

HUMATROPE COMBO PACK SOLR 4 PA SP

HUMATROPE SOLR 4 PA SP

NORDITROPIN FLEXPRO SOPN 10 MG15ML 15MG15ML 5 MG15ML

4 PA SP

NORDITROPIN FLEXPRO SOPN 30 MG3ML 4 PA

NUTROPIN AQ NUSPIN 10 SOPN 4 PA SP

OMNITROPE SOCT 10 MG15ML 5 MG15ML 4 PA SP

SAIZEN SOLR 4 PA SP

SAIZENPREP RECONSTITUTIONKIT SOLR

4 PA SP

SEROSTIM SOLR 4 PA SP

ZOMACTON SOLR 4 PA SP

ZORBTIVE SOLR 4 PA SP

Hormone Receptor Modulators EVISTA TABS (Use raloxifene hcl) NF QL(1 ea daily)

OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits

raloxifene hcl tabs 0 QL(1 ea daily)

Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN 4 PA SP

LHRHGnRH Agonist Analog Pituitary

FENSOLVI KIT 4 PA SP

LUPANETA PACK KIT 4 PA

LUPRON DEPOT-PED (1-MONTH) KIT 4 PA SP

LUPRON DEPOT-PED (3-MONTH) KIT 30 MG 4 PA SP

SYNAREL SOLN 4 PA SP

Metabolic Modifiers

ALDURAZYME SOLN 4 PA SP

BUPHENYL POWD (Use sodium phenylbutyrate) NF PA

BUPHENYL TABS (Use sodium phenylbutyrate) NF PA

calcitriol caps 1

calcitriol soln 1

CARBAGLU TABS 4 PA SP

cinacalcet hcl tabs 4 PA QL(4 eadaily) SP

CYSTADANE POWD 4 PA SP

doxercalciferol caps 1

doxercalciferol soln 1

ELAPRASE SOLN 4 PA SP

FABRAZYME SOLR 35 MG 4 PA SP

GALAFOLD CAPS 4 PA QL(05 eadaily)

HECTOROL SOLN 4 MCG2ML (Use doxercalciferol)

Drug Name DrugTier

RequirementsLimits

KUVAN PACK (Use sapropterindihydrochloride)

KUVAN TABS (Use sapropterindihydrochloride)

LUMIZYME SOLR 4 PA SP

MYALEPT SOLR 4 PA

NAGLAZYME SOLN 4 PA SP

nitisinone caps 4 PA SP

ORFADIN CAPS 10 MG 2 MG 5 MG (Use nitisinone) NF PA SP

PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1

ROCALTROL CAPS (Use calcitriol) NF

ROCALTROL SOLN (Use calcitriol) NF

sapropterin dihydrochloridepack 4 PA

sapropterin dihydrochloridetabs 4 PA

SENSIPAR TABS (Use cinacalcet hcl) NF PA QL(4 ea

daily) SP sodium phenylbutyratepowd 1 PA

sodium phenylbutyrate tabs 1 PA

ZEMPLAR CAPS (Use paricalcitol) NF

ZEMPLAR SOLN (Use paricalcitol) NF

Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCGML (Use desmopressin acetate)

DDAVP SOLN NA 001 (Use desmopressin acetate spray)

Drug Name DrugTier

RequirementsLimits

DDAVP TABS OR 01 MG (Use desmopressin acetate)

NF QL(6 ea daily)

NF QL(8 ea daily)

desmopressin acetate solnij 4 mcgml 1 PA

DESMOPRESSIN ACETATE SOLN NA 15 MGML

4 PA SP

desmopressin acetatespray refrigerated soln 1

desmopressin acetatespray soln 1

desmopressin acetate tabsor 01 mg 1 QL(6 ea daily)

STIMATE SOLN 4 PA SP

Prolactin Inhibitors

cabergoline tabs 1

Somatostatic Agents

octreotide acetate soln 4 PA SP

SANDOSTATIN SOLN (Use octreotide acetate) NF PA SP

SIGNIFOR SOLN 4 PA

SOMATULINE DEPOT SOLN 120 MG05ML 4 PA QL(00179

ml daily) SP SOMATULINE DEPOT SOLN 60 MG02ML 4 PA QL(00075

ml daily) SP

Vasopressin Receptor Antagonists JYNARQUE TABS 15 MG 30 MG 4 PA QL(2 ea

daily) SP

JYNARQUE TBPK 4 PA SP

SAMSCA TABS (Use tolvaptan) 4 PA QL(2 ea

daily) SP

tolvaptan tabs 4 PA QL(2 eadaily) SP

Drug Name DrugTier

RequirementsLimits

ESTROGENS - Hormone ReplacementModifyingDrugs

Estrogen Combinations

CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA

FEMHRT TABS (Use norethindrone acetate-ethinyl estradiol)

norethindrone acetate-ethinyl estradiol tabs 1

PREMPHASE TABS 2

PREMPRO TABS 2

Estrogens CLIMARA PTWK (Use estradiol) NF

DELESTROGEN OIL 10 MGML 1

DELESTROGEN OIL 20 MGML 40 MGML (Use estradiol valerate)

DEPO-ESTRADIOL OIL 3

DIVIGEL GEL 025 MG025GM 05MG05GM 1 MGGM

ELESTRIN GEL 3

ESTRACE TABS (Use estradiol) NF

estradiol pttw td 0025mg24hr 00375 mg24hr005 mg24hr 0075mg24hr 01 mg24hr

QL(0286 eadaily)

estradiol ptwk td 0025mg24hr 0075 mg24hr01 mg24hr 005 mg24hr006 mg24hr 375mcg24hr

estradiol tabs or 05 mg 1mg 2 mg 1

estradiol valerate oil 1

Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3

MINIVELLE PTTW (Use estradiol) NF QL(0286 ea

daily)

PREMARIN SOLR 2

PREMARIN TABS 2

VIVELLE-DOT PTTW (Use estradiol) NF QL(0286 ea

daily) FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones AVELOX SOLN (Use moxifloxacin hcl in sodium chloride)

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA

CIPRO SUSR 5 GM100ML 500 MG5ML 2

CIPRO TABS 250 MG 500 MG (Use ciprofloxacin hcl) NF

ciprofloxacin hcl tabs 1

ciprofloxacin in d5w soln 5-200 mg100ml 3

ciprofloxacin susr 1 2 rtl MAX fill30 rtl day(s)supply

LEVAQUIN TABS (Use levofloxacin) NF

levofloxacin in d5w soln 5 -500 mg100ml 1

levofloxacin soln 1

levofloxacin tabs 1

Drug Name DrugTier

RequirementsLimits

moxifloxacin hcl in sodium chloride soln 1

moxifloxacin hcl tabs 1

ofloxacin tabs 1

GASTROINTESTINAL AGENTS - MISC -Miscellaneous Gastrointestinal Drugs

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS 4 PA SP

Gallstone Solubilizing Agents ACTIGALL CAPS (Use ursodiol) NF

URSO 250 TABS (Use ursodiol) NF

URSO FORTE TABS (Use ursodiol) NF

ursodiol caps 300 mg 1

ursodiol tabs 250 mg 500 mg 1

Gastrointestinal Chloride Channel Activators AMITIZA CAPS (Use lubiprostone) 2 PA QL(2 ea

daily)

lubiprostone caps 1 PA QL(2 eadaily)

Gastrointestinal Stimulants metoclopramide hcl soln ij5 mgml 1

metoclopramide hcl soln or10 mg10ml 5 mg5ml 1 QL(60 ml daily)

metoclopramide hcl tabs or10 mg 5 mg 1 QL(6 ea daily)

REGLAN TABS (Use metoclopramide hcl) NF QL(6 ea daily)

Inflammatory Bowel Agents APRISO CP24 (Use mesalamine) NF

ASACOL HD TBEC (Use mesalamine) NF QL(6 ea daily)

AVSOLA SOLR 4 PA

AZULFIDINE EN-TABS TBEC (Use sulfasalazine) NF

Drug Name DrugTier

RequirementsLimits

AZULFIDINE TABS (Use sulfasalazine) NF

balsalazide disodium caps 1

CANASA SUPP (Use mesalamine) NF

COLAZAL CAPS (Use balsalazide disodium) NF

DELZICOL CPDR (Use mesalamine) NF

DIPENTUM CAPS 2

INFLECTRA SOLR 4 PA 30 rtl lmt day(s)30 maillmt day(s)

LIALDA TBEC (Use mesalamine) NF

mesalamine cp24 or 0375 gm 1

mesalamine cpdr or 400 mg 1

mesalamine enem re 4 gm 1

mesalamine supp re 1000 mg 1

mesalamine tbec or 12 gm 1

mesalamine tbec or 800 mg 1 QL(6 ea daily)

RENFLEXIS SOLR 4 PA 30 rtl lmt day(s)30 maillmt day(s)

STELARA SOLN IV 130 MG26ML 4 PA

sulfasalazine tabs 1

sulfasalazine tbec 1

Intestinal Acidifiers lactulose (encephalopathy)soln 1

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs 1 QL(2 ea daily)

LINZESS CAPS 2 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

LOTRONEX TABS (Use alosetron hcl) NF QL(2 ea daily)

Peripheral Opioid Receptor Antagonists

alvimopan caps 1

ENTEREG CAPS (Use alvimopan) 3

RELISTOR SOLN SC 12 MG06ML 8 MG04ML 3 PA

Phosphate Binder Agents calcium acetate (phosphatebinder) caps 1

calcium acetate (phosphatebinder) tabs 1 RXOTC

FOSRENOL CHEW 1000 MG 500 MG 750 MG (Use lanthanum carbonate)

lanthanum carbonate chew 1

PHOSLYRA SOLN 2

RENVELA PACK (Use sevelamer carbonate) NF

RENVELA TABS (Use sevelamer carbonate) NF

sevelamer carbonate pack 1

sevelamer carbonate tabs 1

VELPHORO CHEW 3 PA

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System

Alkalinizers potassium citrate(alkalinizer) tbcr 10 meq1080 mg

sodium citrate amp citric acid soln 1 RXOTC

UROCIT-K 10 TBCR (Use potassium citrate(alkalinizer))

Cystinosis Agents

CYSTAGON CAPS 3 PA

Drug Name DrugTier

RequirementsLimits

Genitourinary Irrigants

acetic acid soln 1

glycine (gu irrigant) soln 1

RESECTISOL SOLN 1

sodium chloride (guirrigant) soln 1

SORBITOL SOLN 1

SORBITOL-MANNITOL SOLN 1

SORBITOLMANNITOLIRRIGATION SOLN 1

Interstitial Cystitis Agents

ELMIRON CAPS 2

Prostatic Hypertrophy Agents

alfuzosin hcl tb24 1 QL(1 ea daily)

AVODART CAPS (Use dutasteride) NF QL(1 ea daily)

dutasteride caps 1 QL(1 ea daily)

finasteride tabs 1 5 mg only

FLOMAX CAPS (Use tamsulosin hcl) NF

PROSCAR TABS (Use finasteride) NF 5 mg only

RAPAFLO CAPS (Use silodosin) NF

silodosin caps 8 mg 4 mg 1

tamsulosin hcl caps 1

UROXATRAL TB24 (Use alfuzosin hcl) NF QL(1 ea daily)

Urinary Analgesics

phenazopyridine hcl tabs 1

PYRIDIUM TABS (Use phenazopyridine hcl) NF

GOUT AGENTS - Drugs to Treat Gout

Drug Name DrugTier

RequirementsLimits

Gout Agent Combinations colchicine w probenecidtabs 1

Gout Agents

allopurinol tabs 1

colchicine tabs 1 QL(1 ea daily)

COLCRYS TABS (Use colchicine) NF QL(1 ea daily)

febuxostat tabs 1 PA QL(1 eadaily)

KRYSTEXXA SOLN 4 PA

MITIGARE CAPS (Use colchicine) NF

ULORIC TABS (Use febuxostat) NF PA QL(1 ea

daily) ZYLOPRIM TABS (Use allopurinol) NF

Uricosurics

probenecid tabs 1

HEMATOLOGICAL AGENTS - MISC - Drugs toTreat Blood Disorders

Bradykinin B2 Receptor Antagonists FIRAZYR SOLN (Use icatibant acetate) NF PA QL(9 ml

daily)

icatibant acetate soln 4 PA QL(9 mldaily)

Complement Inhibitors

CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA

RUCONEST SOLR 4 PA QL(0143ea daily)

SOLIRIS SOLN 4 PA

Hematorheologic Agents

pentoxifylline tbcr 1 QL(3 ea daily)

Plasma Kallikrein Inhibitors

TAKHZYRO SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

Platelet Aggregation Inhibitors AGGRENOX CP12 (Use aspirin-dipyridamole) NF PA QL(2 ea

daily) AGRYLIN CAPS (Use anagrelide hcl) NF

anagrelide hcl caps 1

aspirin-dipyridamole cp12 1 PA QL(2 eadaily)

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1

clopidogrel bisulfate tabs300 mg 1

clopidogrel bisulfate tabs75 mg 1 QL(1 ea daily)

dipyridamole tabs 1

EFFIENT TABS (Use prasugrel hcl) NF QL(1 ea daily)

PLAVIX TABS (Use clopidogrel bisulfate) NF QL(1 ea daily)

prasugrel hcl tabs 1 QL(1 ea daily)

ZONTIVITY TABS 3 PA

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Gaucher Disease

CERDELGA CAPS 4 PA QL(2 eadaily)

CEREZYME SOLR 4 PA SP

ELELYSO SOLR 4 PA SP

miglustat caps 4 PA QL(3 eadaily) SP

VPRIV SOLR 4 PA SP

ZAVESCA CAPS (Use miglustat) NF PA QL(3 ea

daily) SP

Agents for Sickle Cell Disease

Drug Name DrugTier

RequirementsLimits

DROXIA CAPS 3

OXBRYTA TABS 4 PA

Cobalamins cyanocobalamin soln ij1000 mcgml 1 QL(1 ml daily)

Folic AcidFolates

folic acid tabs or 1 mg 0 RXOTC

folic acid tabs or 400 mcg 0

Hematopoietic Growth Factors ARANESP ALBUMIN FREE SOLN 100 MCGML40 MCGML 60 MCGML

4 PA SP

ARANESP ALBUMIN FREE SOLN 25 MCGML 4 SP

ARANESP ALBUMIN FREE SOSY 150 MCG03ML 200MCG04ML 300MCG06ML 500 MCGML

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA

LEUKINE SOLR 4 PA SP

MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA

NEULASTA ONPRO KIT PSKT 4 PA SP

NEULASTA SOSY 4 PA SP

NEUPOGEN SOLN 4 PA SP

NEUPOGEN SOSY 4 PA SP

NIVESTYM SOSY 300 MCG05ML 480MCG08ML

Drug Name DrugTier

RequirementsLimits

NPLATE SOLR 250 MCG 500 MCG 4 PA SP

PROCRIT SOLN 10000 UNITML 2000 UNITML20000 UNITML 3000UNITML 4000 UNITML

PROCRIT SOLN 40000 UNITML 4 PA SP

PROMACTA PACK 125 MG 4 PA QL(1 ea

daily) PROMACTA TABS 125 MG 25 MG 50 MG 75 MG 4 PA SP

RETACRIT SOLN 10000 UNITML 2000 UNITML20000 UNIT2ML 3000UNITML 4000 UNITML40000 UNITML

UDENYCA SOSY 4 PA

ZARXIO SOSY 4 PA 30 rtl lmt day(s)30 maillmt day(s)

ZIEXTENZO SOSY 4 PA

Hematopoietic Mixtures ferrous fumarate-folic acid tabs 1 QL(1 ea daily)

Iron FER-IN-SOL SOLN (Use ferrous sulfate) 0 AL(Up to 1 yrs

old ) ferrous sulfate soln or 15 mgml 0 AL(Up to 1 yrs

old ) ferrous sulfate tabs or 325 mg 65 mg 0

ferrous sulfate tbec or 325 mg 0

Stem Cell Mobilizers

MOZOBIL SOLN 4 PA SP

HEMOSTATICS - Drugs to Stop BleedingTreatBlood Disorders

Hemostatics - Systemic AMICAR TABS 1000 MG 500 MG (Use aminocaproic acid)

Drug Name DrugTier

RequirementsLimits

aminocaproic acid tabs or1000 mg 500 mg 1 PA

CYKLOKAPRON SOLN (Use tranexamic acid) NF

LYSTEDA TABS (Use tranexamic acid) NF

tranexamic acid soln 1

tranexamic acid tabs 1

HYPNOTICSSEDATIVESSLEEP DISORDERAGENTS

Barbiturate Hypnotics phenobarbital elix 20mg5ml 1

phenobarbital soln 20mg5ml 1

phenobarbital tabs 100 mg162 mg 324 mg 648 mg972 mg 15 mg 30 mg

Hypnotics - Tricyclic Agents

doxepin hcl (sleep) tabs 1 PA QL(1 eadaily)

SILENOR TABS (Use doxepin hcl (sleep)) NF PA QL(1 ea

daily) Non-Barbiturate Hypnotics

AMBIEN CR TBCR (Use zolpidem tartrate) NF

ST Must tryimmediate release zolpidemQL(1ea daily)

AMBIEN TABS (Use zolpidem tartrate) NF

DORAL TABS (Use quazepam) NF

estazolam tabs 1

eszopiclone tabs 1

ST QL(1 eadaily) AL(Atleast 18 yrsold)

HALCION TABS (Use triazolam) NF

Drug Name DrugTier

RequirementsLimits

LUNESTA TABS (Use eszopiclone) NF

RESTORIL CAPS (Use temazepam) NF QL(1 ea daily)

temazepam caps 1 QL(1 ea daily)

triazolam tabs 1

zaleplon caps 10 mg 1 QL(2 ea daily)AL(At least 18yrs old)

zolpidem tartrate tabs or 10mg 5 mg 1

zolpidem tartrate tbcr or625 mg 125 mg 1

Orexin Receptor Antagonists

BELSOMRA TABS 3 PA

Selective Melatonin Receptor Agonists

HETLIOZ CAPS 3 PA QL(1 eadaily)

ramelteon tabs 1

ROZEREM TABS (Use ramelteon) NF

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs 1

FIBERCON TABS (Use calcium polycarbophil) NF

Laxative Combinations

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 3 PA

COLYTE-FLAVOR PACKS SOLR (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

GOLYTELY SOLR (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

MOVIPREP SOLR (Use peg 3350-kcl-nacl-nasulfate-na ascorbate-ascorbic acid)

peg 3350-kcl-nacl-nasulfate-na ascorbate-ascorbic acid solr

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr 297 gm-586 gm-674gm-2274 gm-236 gm

PREPOPIK PACK 3 PA

SUPREP BOWEL PREP KIT SOLN 0

Laxatives - Miscellaneous lactulose soln 10 gm15ml20 gm30ml 1

Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1

DULCOLAX TBEC (Use bisacodyl) NF

Surfactant Laxatives COLACE CAPS (Use docusate sodium) NF

docusate calcium caps 1

docusate sodium caps 1

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing

Local Anesthetics - Amides

Drug Name DrugTier

RequirementsLimits

lidocaine hcl (local anesth)soln 05 1 2 1

MARCAINE SOLN 05 (Use bupivacaine hcl) NF

NAROPIN SOLN 5 MGML2 MGML (Use ropivacaine hcl)

XYLOCAINE SOLN 05 1 (Use lidocaine hcl (local anesth))

XYLOCAINE-MPF SOLN 05 1 2 (Use lidocaine hcl (localanesth))

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin

azithromycin pack or 1 gm 1

azithromycin solr iv 500 mg 1

azithromycin susr or 100mg5ml 200 mg5ml 1

azithromycin tabs or 250 mg 1

QL(6 ea per fillretail6 ea perfill mail)

azithromycin tabs or 600 mg 1 QL(0286 ea

daily) ZITHROMAX PACK OR 1 GM (Use azithromycin) NF

ZITHROMAX SOLR IV 500 MG (Use azithromycin) NF

ZITHROMAX SUSR OR 100 MG5ML 200 MG5ML(Use azithromycin)

ZITHROMAX TABS OR 250 MG (Use azithromycin) NF

ZITHROMAX TABS OR 600 MG (Use azithromycin) NF QL(0286 ea

daily)

Drug Name DrugTier

RequirementsLimits

ZITHROMAX TRI-PAK TABS (Use azithromycin) NF

ZITHROMAX Z-PAK TABS (Use azithromycin) NF

Clarithromycin

clarithromycin susr 1

clarithromycin tabs 1

clarithromycin tb24 1

Erythromycins EES GRANULES SUSR (Use erythromycinethylsuccinate)

ERYPED 200 SUSR (Use erythromycinethylsuccinate)

erythromycin base cpep250 mg 3

erythromycin base tabs 250mg 500 mg 3

erythromycin base tbec 333mg 500 mg 250 mg 1

erythromycinethylsuccinate susr 200mg5ml 400 mg5ml

erythromycinethylsuccinate tabs 400 mg 3

Fidaxomicin

DIFICID TABS 200 MG 2

MEDICAL DEVICES AND SUPPLIES

Contraceptives AIMSCO LUBRICATED MISC 0 QL(2 ea daily)

CAYA DPRH 0

DUREX EXTRA SENSITIVE DEVI 0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

FANTASY LUBRICATED MISC 0 QL(2 ea daily)

FANTASY LUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

FC FEMALE CONDOM MISC 0 QL(1 ea daily)

FEMCAP DEVI 0

K-Y ME amp YOU EXTRA LUBRICATED DEVI 0 QL(2 ea daily)

K-Y ME amp YOU INTENSE DEVI 0 QL(2 ea daily)

KAMELEON LUBRICATED MISC 0 QL(2 ea daily)

KIMONO COLORS DEVI 0 QL(2 ea daily)

KIMONO LUBRICATED MISC 0 QL(2 ea daily)

KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO PLUS SPERMICIDELUBRICATED MISC

0 QL(2 ea daily)

KIMONO PS LUBRICATED MISC 0 QL(2 ea daily)

KIMONO PS PLUS SPERMICIDELUBRICATED MISC

0 QL(2 ea daily)

KIMONO SENSATION LUBRICATED MISC 0 QL(2 ea daily)

KIMONO SENSATION PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO SPECIAL DEVI 0 QL(2 ea daily)

MAXX LUBRICATED MISC 0 QL(2 ea daily)

MAXX PLUS SPERMICIDE LUBRICATED MISC 0 QL(2 ea daily)

OMNIFLEX DIAPHRAGM DPRH 0

Drug Name DrugTier

RequirementsLimits

PREMIUM CONDOMS LUBRICATED MISC 0 QL(2 ea daily)

REALITY LATEX CONDOMSLUBRICATEDMISC

0 QL(2 ea daily)

REALITY LATEXULTRATEXTURED DEVI 0 QL(2 ea daily)

REALITY LATEXULTRATHIN DEVI 0 QL(2 ea daily)

TRUSTEX COLOR CONDOMS + LUBE MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED EXTRALARGE MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED EXTRASTRENGTH MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATEDRIBBEDSTUDDED MISC

0 QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE EXTRA LARGE MISC

0 QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE EXTRA STRENGTH MISC

QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

TRUSTEX NATURAL CONDOMS +LUBELUBRICATEDMISC

QL(2 ea daily)

TRUSTEX WITH NONOXYNOL-9RIBBEDSTUDDEDMISC

QL(2 ea daily)

TRUSTEXRIALUBRICATED MISC 0 QL(2 ea daily)

TRUSTEXRIALUBRICATED SPERMICIDE MISC

0 QL(2 ea daily)

TRUSTEXRIALUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

WIDE-SEAL SILICONE DIAPHRAGM KIT 60 DPRH

Diabetic Supplies 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

1 QL(66667 eadaily)

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC

1 QL(66667 eadaily)

ACCU-CHEK FASTCLIX LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK MULTICLIX LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SAFE-T-PRO LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SAFE-T-PRO PLUSLANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SOFTCLIX LANCETS MISC 1 QL(66667 ea

daily) ACTI-LANCE LANCETS 28G MISC 1 QL(66667 ea

daily) ACTI-LANCE LITE SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

ACTI-LANCE SPECIAL SAFETY LANCETS 17G MISC

1 QL(66667 eadaily)

ACTI-LANCE SPECIAL SAFETYLANCETS 17G MISC

1 QL(66667 eadaily)

ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G MISC

1 QL(66667 eadaily)

ADJUSTABLE LANCING DEVICE MISC 1

ADVANCED MOBILE LANCET 30G MISC 1 QL(66667 ea

daily) ADVOCATE LANCETS 30G MISC 1 QL(66667 ea

daily) ADVOCATE LANCETS MISC 1 QL(66667 ea

daily) ADVOCATE LANCING DEVICE MISC 1

ADVOCATE RAPID-SAFE LANCING DEVICE MISC 1

ADVOCATE SAFETY LANCETS 26G MISC 1 QL(66667 ea

daily) ADVOCATE SAFETY LANCETS MISC 1 QL(66667 ea

daily) AGAMATRIX ULTRA-THIN LANCETS 33G MISC 1 QL(66667 ea

daily) AIMSCO TWIST LANCETS 32G MISC 1 QL(66667 ea

daily) ALTERNATE SITE LANCING DEVICE MISC 1

AQUA LANCE ADJUSTABLE LANCING DEVICE DEVI

ASSURE HAEMOLANCE PLUS HIGH FLOW 18G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS LOW FLOW 25G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS MICRO FLOW 28G MISC

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE MISC

1 QL(66667 eadaily)

ASSURE LANCE LANCETS 21G MISC 1 QL(66667 ea

daily) ASSURE LANCE LANCETS MISC 1 QL(66667 ea

daily) ASSURE LANCE PLUS SAFETYLANCETS 25G MISC

1 QL(66667 eadaily)

ASSURE LANCE PLUS SAFETYLANCETS 30G MISC

1 QL(66667 eadaily)

ASSURE LANCE SAFETY LANCET 28G MISC 1 QL(66667 ea

daily)

ASSURE LANCETS MISC 1 QL(66667 eadaily)

AURORA LANCET SUPER THIN30G MISC 1 QL(66667 ea

daily) AURORA LANCET THIN 23G MISC 1 QL(66667 ea

daily)

AUTO-LANCET MINI MISC 1

AUTO-LANCET MISC 1

AUTOLET IMPRESSION LANCING DEVICE MISC 1

AUTOLET LANCING DEVICE MISC 1

AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1

BD LANCET ULTRAFINE 30G MISC 1 QL(66667 ea

daily) BD LANCET ULTRAFINE 33G MISC 1 QL(66667 ea

daily) BD MICROTAINER LANCETS MISC 1 QL(66667 ea

daily) BULLSEYE MINI SAFETY LANCETS MISC 1 QL(66667 ea

daily) BULLSEYE SAFETY LANCETS MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

CARDIOCOM LANCING DEVICE MISC 1

CAREONE ADVANCED LANCINGDEVICE MISC 1

CAREONE LANCET SUPER THIN30G MISC 1 QL(66667 ea

daily) CAREONE LANCET THIN MISC 1 QL(66667 ea

daily) CARESENS LANCETS MISC 1 QL(66667 ea

daily) CARETOUCH LANCING DEVICEWITH EJECTOR MISC

CARETOUCH SAFETY LANCETS26G MISC 1 QL(66667 ea

daily) CARETOUCH SAFETY LANCETS28G MISC 1 QL(66667 ea

daily) CARETOUCH TWIST LANCETS 28G MISC 1 QL(66667 ea

daily) CLEANLET LANCETS 28G MISC 1 QL(66667 ea

daily) COAGUCHEK LANCETS MISC 1 QL(66667 ea

daily) COMFORT ASSURED LANCETS MICRO THIN 33G MISC

1 QL(66667 eadaily)

COMFORT ASSURED LANCETS SUPER THIN 28G MISC

1 QL(66667 eadaily)

COMFORT LANCETS MISC 1 QL(66667 ea

daily)

CVS LANCETS 21G MISC 1 QL(66667 eadaily)

CVS LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) CVS LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) CVS LANCETS ORIGINAL MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

CVS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) CVS LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) CVS LANCETS ULTRA-THIN 30G MISC 1 QL(66667 ea

daily) CVS LANCING DEVICE MISC 1

CVS ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily) DIATHRIVE LANCETS MISC 1 QL(66667 ea

daily) DIATHRIVE LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) DIATHRIVE LANCING DEVICE MISC 1

DROPLET GENTEEL LANCING DEVICE MISC 1

DROPLET LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) DROPLET LANCING DEVICE MISC 1

DROPLET PERSONAL LANCETS30G MISC 1 QL(66667 ea

daily) DRUG MART ADJUSTABLE LANCING DEVICE MISC

DRUG MART LANCETS THIN MISC 1 QL(66667 ea

daily) DRUG MART ON-THE-GO LANCETS GENTLE 30G MISC

1 QL(66667 eadaily)

DRUG MART UNILET LANCETSSUPER THIN 30G MISC

1 QL(66667 eadaily)

DRUG MART UNILET LANCETSULTRA THIN 28G MISC

1 QL(66667 eadaily)

DRUG MART UNILET MICRO THIN LANCETS 33G MISC

1 QL(66667 eadaily)

E-Z JECT LANCETS 21G MISC 1 QL(66667 ea

daily) E-Z JECT LANCETS COLOR MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

E-Z JECT LANCETS MISC 1 QL(66667 eadaily)

E-Z JECT LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) E-Z JECT LANCETS THIN 26G MISC 1 QL(66667 ea

daily) E-ZJECT LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) EASY MINI EJECT LANCING DEVICE MISC 1

EASY MINI LANCING DEVICE MISC 1

EASY TOUCH LANCETS 21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)

EASY TOUCH LANCETS 26GPULL-TOP MISC 1 QL(66667 ea

daily) EASY TOUCH LANCETS 28GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)

daily) EASY TOUCH LANCETS 28GTWIST MISC 1 QL(66667 ea

daily) EASY TOUCH LANCETS 30GBUTTON-ACTIVATEDMISC

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

EASY TOUCH LANCETS 33GTWIST MISC 1 QL(66667 ea

daily) EASY TOUCH LANCING DEVICEEJECTOR MISC 1

EASY TOUCH SAFETY LANCETS21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)

EASY TOUCH SAFETY LANCETS26GBUTTONACTIVATED MISC

1 QL(66667 eadaily)

EASY TWIST amp CAP LANCETS MISC 1 QL(66667 ea

daily) EMBRACE LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) EMBRACE LANCING DEVICE WITH EJECTOR MISC

EQL COLOR LANCETS 21G MISC 1 QL(66667 ea

daily) EQL COLOR LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) EQL SUPER THIN LANCETS 30G MISC 1 QL(66667 ea

daily) EQL THIN LANCETS 26G MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 21G MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 26G SUPER-SOFT MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 28G ULTRA-SOFT MISC 1 QL(66667 ea

daily) FIFTY50 SAFETY SEAL LANCETS 30G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

FIFTY50 SAFETY SEAL LANCETS 32G MISC 1 QL(66667 ea

daily) FIFTY50 UNILET LANCETS 33G MISC 1 QL(66667 ea

daily)

FINE 30 MISC 1 QL(66667 eadaily)

FINGERSTIX LANCETS MISC 1 QL(66667 ea

daily)

FORA LANCETS MISC 1 QL(66667 eadaily)

FORA LANCING DEVICE MISC 1

FORA LANCING DEVICECLEARCAP MISC 1

FREDS PHARMACY AUTOLET LANCING DEVICE MISC

FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

FREESTYLE LANCETS MISC 1 QL(66667 ea

daily) FREESTYLE UNISTICK II LANCETS MISC 1 QL(66667 ea

daily) GENTEEL BUTTERFLY TOUCH LANCETS MISC 1 QL(66667 ea

daily) GENTEEL LANCING DEVICEGLORIOUSGOLD MISC

GENTEEL LANCING DEVICEPRECIOUSPLATINUM MISC

GENTEEL LANCING DEVICESTATELY SILVERMISC

GENTEEL PLUS LANCING DEVICEBUFF BLACKMISC

GENTEEL PLUS LANCING DEVICEBUTTERFLYBLUE MISC

GENTEEL PLUS LANCING DEVICEPLAYFULPURPLE MISC

Drug Name DrugTier

RequirementsLimits

GENTEEL PLUS LANCING DEVICEPRINCESS PINKMISC

GENTEEL PLUS LANCING DEVICEWILLOWY WHITEMISC

GENTLE-LET GP LANCETS MISC 1 QL(66667 ea

daily) GENTLE-LET LANCETS GENERAL PURPOSE STYLEFINE POINT MISC

1 QL(66667 eadaily)

GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINTMISC

QL(66667 eadaily)

GENTLE-LET LANCETS SAFETY STYLEFINEPOINT MISC

1 QL(66667 eadaily)

GENTLE-LET LANCETS SAFETY STYLEMEDIUMPOINT MISC

1 QL(66667 eadaily)

GLOBAL LANCING DEVICE MISC 1

GLUCOCOM LANCETS 28G MISC 1 QL(66667 ea

daily) GLUCOCOM LANCETS 30G MISC 1 QL(66667 ea

daily)

GNP LANCETS 21G MISC 1 QL(66667 eadaily)

GNP LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) GNP LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) GNP LANCETS THIN 26G MISC 1 QL(66667 ea

daily) GNP LANCETS THIN MISC 1 QL(66667 ea

daily) GNP LANCING SYSTEM DEVICE MISC 1

GOJJI LANCING DEVICECLEAR CAPMISC

GOJJI STERILE LANCETS 30G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS ULTRA-THIN 30G MISC 1 QL(66667 ea

daily) GOODSENSE LANCETS ULTRA-THIN 30G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCING DEVICE MISC 1

H-E-B INCONTROL ADVANCEDLANCING DEVICE MISC

H-E-B INCONTROL LANCETS MICRO THIN 33G MISC

1 QL(66667 eadaily)

H-E-B INCONTROL LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

HAEMOLANCE LOW FLOW LANCETS MISC 1 QL(66667 ea

daily)

HAEMOLANCE MISC 1 QL(66667 eadaily)

HAEMOLANCE PLUS HIGH FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS LOW FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS MAX FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS PEDIATRIC FLOW MISC 1 QL(66667 ea

daily) HEALTH CARE LANCING DEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MISC

HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

HY-VEE LANCETS MISC 1 QL(66667 eadaily)

HY-VEE THIN LANCETS MISC 1 QL(66667 ea

daily) IN TOUCH LANCING DEVICE MISC 1

IN TOUCH STERILE LANCETS30G MISC 1 QL(66667 ea

daily)

KINNEY LANCETS MISC 1 QL(66667 eadaily)

KINNEY THIN LANCETS MISC 1 QL(66667 ea

daily) KROGER AUTOLET LANCING DEVICE MISC 1

KROGER HEALTHPRO TWIST LANCETS26GMISC

1 QL(66667 eadaily)

KROGER LANCETS 21G MISC 1 QL(66667 ea

daily) KROGER LANCETS MICRO THIN33G MISC 1 QL(66667 ea

daily)

KROGER LANCETS MISC 1 QL(66667 eadaily)

KROGER LANCETS SUPER THIN MISC 1 QL(66667 ea

daily) KROGER LANCETS THIN 26G MISC 1 QL(66667 ea

daily) KROGER LANCETS THIN MISC 1 QL(66667 ea

daily) KROGER LANCETS ULTRATHIN30G MISC 1 QL(66667 ea

daily) KROGER LANCING DEVICE MISC 1

LANCET DEVICE ADJUSTABLE MISC 1

LANCET DEVICE WITH EJECTOR MISC 1

LANCETS 26G TWIST TOP MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

LANCETS 30G MISC 1 QL(66667 eadaily)

daily) LANCETS 30GTWISTTOP MISC 1 QL(66667 ea

daily) LANCETS 31G TWIST TOP MISC 1 QL(66667 ea

daily) LANCETS 33G EXTRA FINE MISC 1 QL(66667 ea

daily) LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily)

LANCETS MISC 1 QL(66667 eadaily)

LANCETS SAFETY SEAL 21G MISC 1 QL(66667 ea

daily) LANCETS SAFETY SEAL 26G MISC 1 QL(66667 ea

daily) LANCETS SUPER THIN 28G MISC 1 QL(66667 ea

daily)

LANCETS THIN MISC 1 QL(66667 eadaily)

LANCETS TWIST TOP MISC 1 QL(66667 ea

daily) LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) LANCETSBULLSEYE SAFETY MISC 1 QL(66667 ea

daily) LANCING DEVICE ADJUSTABLE MISC 1

LANCING DEVICE MISC 1

LANZO MISC 1

LEADER ADVANCED LANCING DEVICE MISC 1

LIBERTY MEDICAL LANCETS 30G MISC 1 QL(66667 ea

daily) LIBERTY MINI LANCING DEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

LIFESCAN UNISTIK 2 DEEP PENETRATION MISC

1 QL(66667 eadaily)

LIFESCAN UNISTIK II LANCETS MISC 1 QL(66667 ea

daily) LITE TOUCH LANCETS MISC 1 QL(66667 ea

daily) LITE TOUCH LANCING PEN MISC 1

LITETOUCH LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) LIVE BETTER ADVANCED LANCING DEVICE MISC 1

LIVE BETTER LANCET SUPERTHIN 30G MISC 1 QL(66667 ea

daily) LIVE BETTER LANCET ULTRATHIN 28G MISC 1 QL(66667 ea

daily) LONGS LANCETS STANDARD MISC 1 QL(66667 ea

daily) LONGS LANCETS THIN MISC 1 QL(66667 ea

daily) LONGS LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) MEDICHOICE PRE-SET SAFETY LANCET DUAL USE MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE SAFETY LANCETEXTRA MISC 1 QL(66667 ea

daily) MEDICHOICE SAFETY LANCETNORMAL MISC 1 QL(66667 ea

daily) MEDISENSE THIN LANCETS MISC 1 QL(66667 ea

daily) MEDLANCE PLUS EXTRA LANCETS 21G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS LANCETS LITE 25G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

MEDLANCE PLUS LANCETS MISC 1 QL(66667 ea

daily) MEDLANCE PLUS LITE LANCETS 25G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS SPECIAL LANCETS 08MM MISC

1 QL(66667 eadaily)

MEDLANCE PLUS SUPERLITE 30G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS SUPERLITE 30GCOMFORT MAXMISC

QL(66667 eadaily)

MEDLANCE PLUS UNIVERSAL LANCETS 21G MISC

1 QL(66667 eadaily)

MEDLANCE PLUSLITE25G MISC 1 QL(66667 ea

daily)

MEDLANCEEXTRA MISC 1 QL(66667 eadaily)

MEDLANCELITE MISC 1 QL(66667 eadaily)

MEDLANCEUNIVERSALMISC 1 QL(66667 ea

daily) MEIJER COLOR LANCETS UNIVERSAL 33G MISC

1 QL(66667 eadaily)

MEIJER LANCETS MISC 1 QL(66667 eadaily)

MEIJER LANCETS THIN MISC 1 QL(66667 ea

daily) MEIJER LANCETS UNIVERSAL21G MISC 1 QL(66667 ea

daily) MEIJER SUPER THIN LANCETS MISC 1 QL(66667 ea

daily) MICROLET LANCETS MISC 1 QL(66667 ea

daily)

MICROLET NEXT MISC 1

MINI LANCING DEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

MM LANCING DEVICE MISC 1

MM TWIST LANCETS MISC 1 QL(66667 ea

daily) MONOLET LANCETS MISC 1 QL(66667 ea

daily) MONOLET OPD LANCETS MISC 1 QL(66667 ea

daily) MONOLETTOR SAFETY LANCETS MISC 1 QL(66667 ea

daily) MPD SAFETY LANCET 21G18MM MISC 1 QL(66667 ea

daily) MPD SAFETY LANCETS 23G18MM MISC 1 QL(66667 ea

daily) MULTI-LANCET DEVICE MISC 1

MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G MISC

1 QL(66667 eadaily)

NOVA SAFETY LANCETS 23G MISC 1 QL(66667 ea

daily) NOVA SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) NOVA SUREFLEX LANCETS MISC 1 QL(66667 ea

daily) NOVA SUREFLEX LANCING DEVICE MISC 1

ON CALL LANCING DEVICE MISC 1

ON CALL PLUS LANCING DEVICE MISC 1

ONETOUCH CLUB LANCETS FINE POINT MISC

1 QL(66667 eadaily)

ONETOUCH DELICA LANCETS EXTRA FINE 33G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA LANCETS FINE 30G MISC 1 QL(66667 ea

daily) ONETOUCH DELICA LANCING DEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA PLUS LANCETS FINE 30G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA PLUS LANCING DEVICE MISC

ONETOUCH DELICA SAFETY LANCING DEVICE MISC

ONETOUCH FINEPOINT LANCETS MISC 1 QL(66667 ea

daily) ONETOUCH ULTRASOFT LANCETS MISC 1 QL(66667 ea

daily) PC LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) PERFECT LANCETS 30G MISC 1 QL(66667 ea

daily) PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

PHARMACY COUNTER LANCETS MISC 1 QL(66667 ea

daily)

PIP LANCETS28G MISC 1 QL(66667 eadaily)

PRECISION THINS GP LANCET MISC 1 QL(66667 ea

daily) PREFERRED PLUS LANCETS COLORED 21G MISC

1 QL(66667 eadaily)

PREFERRED PLUS LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

PREFERRED PLUS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) PRESSURE ACTIVATED SAFETYLANCET 21G MISC

1 QL(66667 eadaily)

PRODIGY LANCING DEVICE MISC 1

PRODIGY PRESSURE ACTIVATED SAFETY LANCETS MISC

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

PRODIGY SAFETY LANCETS MISC 1 QL(66667 ea

daily) PRODIGY TWIST TOP LANCETS MISC 1 QL(66667 ea

daily) PSS SELECT GP LANCETS MISC 1 QL(66667 ea

daily) PSS SELECT SAFETY LANCETS MISC 1 QL(66667 ea

daily) PUSH BUTTON SAFETY LANCETS 21G MISC 1 QL(66667 ea

daily) PX ADVANCED LANCING DEVICE MISC 1

PX LANCET AUTO INJECTOR MISC 1

PX LANCETS ULTRA THIN 28G MISC 1 QL(66667 ea

daily) PX LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) QC ADVANCED LANCING DEVICE MISC 1

QC LANCETS SUPER THIN MISC 1 QL(66667 ea

daily) QC LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) QC UNILET LANCETS 28GULTRA THIN MISC 1 QL(66667 ea

daily) QC UNILET LANCETS 33GMICRO THIN MISC 1 QL(66667 ea

daily) RA E-ZJECT LANCETS 28G MISC 1 QL(66667 ea

daily) RA E-ZJECT LANCETS THIN 26G MISC 1 QL(66667 ea

daily) RA E-ZJECT LANCETS ULTRATHIN 30G MISC 1 QL(66667 ea

daily) READYLANCE SAFETY LANCETS21G22MMMISC

1 QL(66667 eadaily)

READYLANCE SAFETY LANCETS23G18MMMISC

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

REALITY LANCETS MISC 1 QL(66667 eadaily)

REALITY TRIGGER LANCETS MISC 1 QL(66667 ea

daily) RELION 2-IN-1 LANCET DEVICES 30G MISC 1

RELION 2-IN-1 LANCING DEVICE 25G MISC 1

RELION LANCETS MICRO-THIN33G MISC 1 QL(66667 ea

daily) RELION LANCETS THIN 26G MISC 1 QL(66667 ea

daily) RELION LANCETS ULTRA-THIN30G MISC 1 QL(66667 ea

daily) RELION LANCING DEVICE MISC 1

RELION ULTRA THIN LANCETS30G MISC 1 QL(66667 ea

daily) RELION ULTRA THIN LANCETS30G MISC 1 QL(66667 ea

daily) RELION ULTRA THIN PLUS LANCETS 32G MISC

1 QL(66667 eadaily)

RELION ULTRA THIN PLUS LANCETS 33G MISC

1 QL(66667 eadaily)

REXALL LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) RIGHTEST GD500 LANCING DEVICE MISC 1

RIGHTEST GL300 LANCETS MISC 1 QL(66667 ea

daily) SAFE-T-LANCE LOW FLOW 25G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

SAFE-T-LANCE NORMAL FLOW21G MISC 1 QL(66667 ea

daily) SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW MISC

1 QL(66667 eadaily)

SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW MISC

1 QL(66667 eadaily)

SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW MISC

1 QL(66667 eadaily)

SAFETY LANCET 21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)

SAFETY LANCETS 21G MISC 1 QL(66667 ea

daily) SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) SAFETY LET LANCETS MISC 1 QL(66667 ea

daily)

SB LANCETS THIN MISC 1 QL(66667 eadaily)

SB LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) SELECT-LITE LANCING DEVICE MISC 1

SHOPKO AUTOLET LANCING DEVICE MISC 1

SHOPKO ON-THE-GO COMFORTLANCETS 30G MISC

1 QL(66667 eadaily)

SHOPKO UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

SHOPKO UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

SIDE BUTTON SAFETY LANCET21G MISC 1 QL(66667 ea

daily) SIMPLE DIAGNOSTICS LANCING DEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

SINGLE-LET MISC 1 QL(66667 eadaily)

SM MICRO THIN LANCETS 33G MISC 1 QL(66667 ea

daily) SM TRUEDRAW LANCING DEVICE MISC 1

SMART DIABETES VANTAGE LANCING DEVICE MISC

SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC

1 QL(66667 eadaily)

SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC

1 QL(66667 eadaily)

SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC

1 QL(66667 eadaily)

SMART SENSE THIN LANCETSUNIVERSAL 26G MISC

1 QL(66667 eadaily)

SMARTEST LANCETS 28G MISC 1 QL(66667 ea

daily) SOLUS V2 LANCING DEVICE MISC 1

SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

SOLUS V2 TWIST LANCETS 30G MISC 1 QL(66667 ea

daily)

STERILANCE TL MISC 1 QL(66667 eadaily)

SUPER THIN LANCETS MISC 1 QL(66667 ea

daily) SURE COMFORT LANCETS 18G MISC 1 QL(66667 ea

daily) SURE COMFORT LANCING PEN MISC 1

Drug Name DrugTier

RequirementsLimits

SURE-LANCE FLAT LANCETS MISC 1 QL(66667 ea

daily) SURE-LANCE LANCETS 26G MISC 1 QL(66667 ea

daily) SURE-LANCE THIN LANCETS 28G MISC 1 QL(66667 ea

daily) SURE-LANCE ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily)

SURE-PEN MISC 1

SURE-TOUCH LANCETS UNIVERSAL MISC 1 QL(66667 ea

daily) SURELITE LANCETS MISC 1 QL(66667 ea

daily) TECHLITE AST LANCETS MISC 1 QL(66667 ea

daily) TECHLITE LANCETS 30G MISC 1 QL(66667 ea

daily) TECHLITE LANCETS MISC 1 QL(66667 ea

daily) TGT LANCET MICRO THIN 33G MISC 1 QL(66667 ea

daily) TGT LANCET THIN 26G MISC 1 QL(66667 ea

daily) TGT LANCET ULTRA THIN 30G MISC 1 QL(66667 ea

daily) TGT LANCING DEVICE MISC 1

THINLETS GP LANCETS MISC 1 QL(66667 ea

daily) TODAYS HEALTH ADVANCED LANCING DEVICE MISC

TODAYS HEALTH SUPER THINLANCETS 30G MISC 1 QL(66667 ea

daily) TODAYS HEALTH ULTRA THINLANCETS 28G MISC 1 QL(66667 ea

daily) TOPCARE LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) TRAVEL LANCETS 30G MISC 1 QL(66667 ea

daily) TRAVEL LANCETS ADVANCED 28G MISC 1 QL(66667 ea

daily) TRUE METRIX CONTROL SOLUTION LEVEL 3 SOLN

Drug Name DrugTier

RequirementsLimits

TRUEDRAW LANCING DEVICE MISC 1

TRUEPLUS LANCETS 26G MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 28G MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 28G SUPER THIN MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 30G ULTRA THIN MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 33G MICRO THIN MISC 1 QL(66667 ea

daily) TRUEPLUS SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) ULTI-LANCE AUTOMATICCLEAR TIP MISC 1

ULTILET CLASSIC LANCETS MISC 1 QL(66667 ea

daily) ULTILET LANCETS 33G MISC 1 QL(66667 ea

daily)

ULTILET LANCETS MISC 1 QL(66667 eadaily)

ULTILET SAFETY LANCETS 21G X 22MM MISC

1 QL(66667 eadaily)

ULTILET SAFETY LANCETS 23G MISC 1 QL(66667 ea

daily) ULTRA THIN LANCETS 31G MISC 1 QL(66667 ea

daily) ULTRA-THIN II AUTO LANCET MISC 1 QL(66667 ea

daily) ULTRA-THIN II LANCETS 28G MISC 1 QL(66667 ea

daily) UNILET COMFORTOUCH LANCET MISC 1 QL(66667 ea

daily)

UNILET EXCELITE II MISC 1 QL(66667 eadaily)

UNILET EXCELITE MISC 1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

UNILET GP LANCET MISC 1 QL(66667 ea

daily) UNILET GP SUPERLITE LANCET MISC 1 QL(66667 ea

daily) UNILET GP 28 ULTRA THIN MISC 1 QL(66667 ea

daily)

UNILET LANCET MISC 1 QL(66667 eadaily)

UNILET LANCETS MICRO-THIN33G MISC 1 QL(66667 ea

daily) UNILET LANCETS SUPER-THIN30G MISC 1 QL(66667 ea

daily) UNILET LANCETS ULTRA-THIN 28G MISC 1 QL(66667 ea

daily) UNILET SUPERLITE LANCET MISC 1 QL(66667 ea

daily)

UNISTIK 3 GENTLE MISC 1 QL(66667 eadaily)

UNISTIK PRO SAFETY LANCET 21G MISC 1 QL(66667 ea

daily) UNISTIK PRO SAFETY LANCET 25G MISC 1 QL(66667 ea

daily) UNISTIK SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) UNISTIK TOUCH SAFETY LANCETS 21G MISC 1 QL(66667 ea

daily) UNIVERSAL 1 LANCETS THIN26G MISC 1 QL(66667 ea

daily) UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) UNIVERSAL 1 LANCETS33GMICRO-THIN MISC

1 QL(66667 eadaily)

VALUE PLUS LANCETS STANDARD 21G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

VALUE PLUS LANCETS SUPERTHIN 30G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCING DEVICE MISC 1

VALUMARK LANCET SUPER THIN 30G MISC 1 QL(66667 ea

daily) VALUMARK LANCET ULTRA THIN 28G MISC 1 QL(66667 ea

daily) VIDA MIA AUTOLET LANCINGDEVICE MISC 1

VIDA MIA UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

VIVAGUARD LANCETS MISC 1 QL(66667 ea

daily) VIVAGUARD LANCING DEVICE MISC 1

WALGREENS ADVANCED TRAVELLANCETS 28G MISC

1 QL(66667 eadaily)

WALGREENS COMFORT ASSUREDLANCETS MICRO THIN33G MISC

1 QL(66667 eadaily)

WALGREENS COMFORT ASSUREDLANCETS SUPER THIN28G MISC

1 QL(66667 eadaily)

WALGREENS LANCETS MISC 1 QL(66667 ea

daily) WALGREENS THIN LANCETS MISC 1 QL(66667 ea

daily) WALGREENS ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily) Parenteral Therapy Supplies ADVOCATE INSULIN SYRINGEU-10003ML29GX12 MISC

1 QL(5 ea daily)RXOTC

ADVOCATE INSULIN SYRINGEU-10003ML30GX516MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

ADVOCATE INSULIN SYRINGEU-10005ML29GX12 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

ASSURE ID INSULIN SAFETYSYRINGEU-10005ML29G X 12MISC

QL(5 ea daily)RXOTC

ASSURE ID INSULIN SAFETYSYRINGEU-1001ML29G X 12 MISC

B-D INSULIN SYRINGE ULTRAFINE II03ML31GX 516 MISC

1 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II1ML31G X516 MISC

1 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE03ML30G X12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

BD LO-DOSE INSULIN SYRINGE MICROFINE IV05ML28G X 12 MISC

BD AUTOSHIELD 29G X 316 MISC 1 QL(5 ea daily)

BD AUTOSHIELD DUO 30G X 5MM MISC 1 QL(5 ea daily)

BD INSULIN SYRINGE LUER-LOKU-1001MLMISC

BD INSULIN SYRINGE MICROFINE IVU-10005ML28G X 12MISC

QL(5 ea daily)RXOTC

BD INSULIN SYRINGE MICROFINE IVU-1001ML27G X 58 MISC

1 QL(5 ea daily)

BD INSULIN SYRINGE MICROFINEU-1001ML27G X 58 MISC

1 QL(5 ea daily)

BD INSULIN SYRINGE SAFETYGLIDE1ML29G X12 MISC

BD INSULIN SYRINGE SLIP TIPU-1001ML MISC 1 QL(5 ea daily)

RXOTC BD INSULIN SYRINGE ULTRA-FINE03ML30G X127MM MISC

1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE03ML31G X8MM MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

BD INSULIN SYRINGE ULTRA-FINE12UNIT03ML31G X 8MMMISC

QL(5 ea daily)

1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE HALF-UNIT03ML31G X 516MISC

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE03ML30G X12 MISC

1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

BD INSULIN SYRINGE ULTRAFINEU-1001ML29G X 12 MISC

QL(5 ea daily)

BD INSULIN SYRINGE03ML29G X127MM MISC

Drug Name DrugTier

RequirementsLimits

BD INSULIN SYRINGEDETACHABLENEEDLEU-1001ML25GX 1 MISC

QL(5 ea daily)

BD INSULIN SYRINGEU-1001ML27G X 12 MISC 1 QL(5 ea daily)

RXOTC BD PEN NEEDLEMICROULTRA-FINE32G X 6MM MISC

1 QL(5 ea daily)

BD PEN NEEDLEMINIULTRA-FINE31G X 5MM MISC

BD PEN NEEDLENANO2ND GEN32G X 532MISC

BD PEN NEEDLENANOULTRA-FINE32G X 4MM MISC

BD PEN NEEDLEORIGINALULTRA-FINE29G X 127MMMISC

QL(5 ea daily)

BD PEN NEEDLESHORTULTRA-FINE31G X 8MM MISC

BD SAFETY-GLIDE INSULIN SYRINGE05ML29G X12 MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

BD SAFETY-LOK INSULIN SYRINGEPERMNEEDLEUF1ML29G X12 MISC

QL(5 ea daily)RXOTC

BD SAFETYGLIDE INSULIN SYRINGE03ML29G X12 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

BD SAFETYGLIDE INSULIN SYSYRINGE05ML30G X516 MISC

QL(5 ea daily)RXOTC

BD VEO INSULIN SYRINGE ULTRA-FINE1ML31G X 6MMMISC

QL(5 ea daily)

BD VEO INSULIN SYRINGE ULTRA-FINEU-1001ML31G X 1564MISC

QL(5 ea daily)

CAREONE INSULIN SYRINGES03ML30G X12 MISC

1 QL(5 ea daily)

CAREONE INSULIN SYRINGES1ML31GX516 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

CARETOUCH INSULIN SYRINGE03ML31GX516 MISC

1 QL(5 ea daily)

CARETOUCH INSULIN SYRINGE1ML30GX516MISC

1 QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML29G X12 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML28G X 12MISC

QL(5 ea daily)RXOTC

CLEVER CHOICE COMFORT EZINSULIN SYRINGEU-1001ML31GX516 MISC

QL(5 ea daily)

COMFORT ASSIST INSULIN SYRINGE 03ML29G X 12 MISC

COMFORT ASSIST INSULIN SYRINGE03ML30G X516 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

COMFORT ASSIST INSULIN SYRINGE1ML29G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGEU-10005ML31G X 516MISC

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGEU-1001ML31GX 516 MISC

1 QL(5 ea daily)

DROPLET INSULIN SYRINGE 03ML29G X12 MISC

DROPLET INSULIN SYRINGE 1ML29G X 12MISC

DROPLET INSULIN SYRINGE U-1000331G X516 MISC

1 QL(5 ea daily)

DROPLET INSULIN SYRINGE U-10003ML30G X 12MISC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

DROPLET INSULIN SYRINGE U-1001ML30GX 12 MISC

1 QL(5 ea daily)

DROPLET INSULIN SYRINGEU-10003ML31G X 516MISC

QL(5 ea daily)

DROPLET INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE05ML30G X516 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGEU-10005ML30G X 12MISC

QL(5 ea daily)

EASY COMFORT INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML29GX12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE03ML30G X516 MISC

1 QL(5 ea daily)

EASY TOUCH INSULIN SYRINGESAFETYU-10005ML29G X 12MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

EASY TOUCH INSULIN SYRINGESAFETYU-1001ML29G X 12 MISC

1 QL(5 ea daily)

EASY TOUCH INSULIN SYRINGEU-10003ML30G X 12MISC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGEU-1001ML27GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML29GX12 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML30GX12MISC

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE03ML31G X516 MISC

1 QL(5 ea daily)

ELITE-THIN INSULIN SYRINGEU-10005ML28G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGEU-1001ML28GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

EQL INSULIN SYRINGE03ML29G X12 MISC

1 QL(5 ea daily)

EQL INSULIN SYRINGE1ML29G X 12MISC

1 QL(5 ea daily)

EXEL COMFORT POINT INSULIN SYRINGE03ML29G X12 MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

EXEL COMFORT POINT INSULIN SYRINGE1ML28G X 12MISC

QL(5 ea daily)RXOTC

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE03ML31G X516 MISC

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGEU-10005ML30G X 516MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGESU-1001ML30G X 516MISC

QL(5 ea daily)RXOTC

GLOBAL EASY GLIDE INSULIN SYRINGE1ML31G X1564 MISC

QL(5 ea daily)

GLOBAL EASY GLIDE INSULINSYRINGEU-10003ML31G X 516MISC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML28G X 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

GLOBAL INSULIN SYRINGEU-10003ML30G X 12MISC

QL(5 ea daily)

GLOBAL INSULIN SYRINGESU-10003ML30GX516MISC

QL(5 ea daily)RXOTC

GLUCOPRO INSULIN SYRINGEU-10003ML30G X 12MISC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

GLUCOPRO INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

GNP INSULIN SYRINGE03ML29G X12 MISC

1 QL(5 ea daily)

GNP INSULIN SYRINGE1ML28G X 12MISC

1 QL(5 ea daily)

GNP INSULIN SYRINGES03ML30GX516 MISC

GNP INSULIN SYRINGES1ML28GX12MISC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE03ML29G X12 MISC

QL(5 ea daily)RXOTC

GNP ULTRA COMFORT INSULIN SYRINGE03ML30G X516 SHORT MISC

QL(5 ea daily)RXOTC

GNP ULTRA COMFORT INSULIN SYRINGE1ML28G X 12MISC

QL(5 ea daily)RXOTC

HEALTHWISE INSULIN SYRINGEU-10003ML30G X 516MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

HEALTHWISE INSULIN SYRINGEU-1001ML30GX 516 MISC

1 QL(5 ea daily)

HM ULTICARE INSULIN SYRINGE1ML30G X 12MISC

1 QL(5 ea daily)

HM ULTICARE INSULIN SYRINGEU-10003ML31G X 516MISC

QL(5 ea daily)

INSULIN SYRINGE03ML29G X 1MISC

1 QL(5 ea daily)

INSULIN SYRINGE03ML29G X12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

INSULIN SYRINGENEEDLE03ML30G X 516 MISC

1 QL(5 ea daily)

INSULIN SYRINGEU-10003ML29G X 12MISC

INSULIN SYRINGEU-1001ML29G X 12 MISC 1 QL(5 ea daily)

RXOTC INSULIN SYRINGEU-1001ML30G X 516MISC

1 QL(5 ea daily)

INSULIN SYRINGES05ML27GX12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

INSULIN SYRINGES1ML27GX12MISC

1 QL(5 ea daily)

KINRAY INSULIN SYRINGE PREFERRED PLUS03ML31G X 516MISC

QL(5 ea daily)

KINRAY INSULIN SYRINGE05ML29G X12 MISC

Drug Name DrugTier

RequirementsLimits

KMART VALU PLUS INSULIN SYRINGE1ML29G MISC

KROGER INSULIN SYRINGE03ML29G X12 MISC

1 QL(5 ea daily)

KROGER INSULIN SYRINGE1ML29G X 12MISC

1 QL(5 ea daily)

LEADER INSULIN SYRINGE03ML29G X12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

LEADER INSULIN SYRINGE1ML28G X 12MISC

1 QL(5 ea daily)

LITETOUCH INSULIN SYRINGE03ML29G X12 MISC

1 QL(5 ea daily)

LITETOUCH INSULIN SYRINGEU-10003ML30G X 516MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

LITETOUCH INSULIN SYRINGEU-1001ML28GX 12 MISC

1 QL(5 ea daily)

LONGS INSULIN SYRINGE05ML31G X516 MISC

1 QL(5 ea daily)

MAGELLAN INSULIN SAFETY SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

MAGELLAN INSULIN SAFETY SYRINGEU-1001ML29G X 12 MISC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

MAXI-COMFORT INSULIN SYRINGEU-10005ML28GX12 MISC

MAXICOMFORT INSULIN SYRINGES 27G X 12MISC

1 QL(5 ea daily)

MEDIC INSULIN SYRINGE03ML30G X516 MISC

MM INSULIN SYRINGEU-10003ML30G X 516MISC

1 QL(5 ea daily)

MONOJECT INSULIN SYRINGE1ML MISC 1 QL(5 ea daily)

RXOTC MONOJECT INSULIN SYRINGE1ML31G X516 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

MONOJECT INSULIN SYRINGEDETACHNEEDLE1ML25G X 58MISC

QL(5 ea daily)

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEPERMNEEDLE1ML28G X 12MISC

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEPERMNEEDLEU-10005ML28GX 12 MISC

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29G X 12MISC

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29GX12MISC

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESOFTPACK1ML27G X 12 MISC

MONOJECT INSULIN SYRINGESOFTPACKU-10005ML28G X 12MISC

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEU-10003ML30G X 516MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

MONOJECT INSULIN SYRINGEU-1001ML28GX 12 MISC

MONOJECT INSULIN SYRINGEREGULAR LUER TIPSOFTPACK1ML MISC

MONOJECT ULTRA COMFORT INSULIN SYRINGE03ML29G X12 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

MONOJECT ULTRA COMFORT INSULIN SYRINGE1ML28G X 12MISC

QL(5 ea daily)RXOTC

MS INSULIN SYRINGE03ML31G X516 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE03ML30G X516 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE1ML28G X 12MISC

QL(5 ea daily)RXOTC

PRECISION SURE-DOSE PLUSINSULIN SYRINGE03ML29G X12 MISC

QL(5 ea daily)RXOTC

PRECISION SURE-DOSE PLUSINSULIN SYRINGE1ML29G X 12MISC

QL(5 ea daily)RXOTC

PREFERRED PLUS INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

PREFERRED PLUS INSULIN SYRINGEU-1001ML28G X 12 MISC

QL(5 ea daily)RXOTC

PRO COMFORT INSULIN SYRINGES05ML30G X12 MISC

1 QL(5 ea daily)

PRODIGY INSULIN SYRINGU-10003ML31GX 516 MISC

1 QL(5 ea daily)

PRODIGY INSULIN SYRINGE12ML31G X516 MISC

1 QL(5 ea daily)

PRODIGY INSULIN SYRINGE1ML28G X 12MISC

PX INSULIN SYRINGEU-10005ML30G X 12MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

RA INSULIN SYRINGE05ML29G X12 MISC

RA INSULIN SYRINGE1ML29G X 12MISC

RA INSULIN SYRINGEU-10005ML30G X 516MISC

RA INSULIN SYRINGEU-1001 ML30G X 516MISC

REALITY INSULIN SYRINGEU-10005ML28G X 12MISC

QL(5 ea daily)RXOTC

REALITY INSULIN SYRINGEU-1001ML28GX 12 MISC

RELION INSULIN SYRINGE 1ML31GX1564 MISC

1 QL(5 ea daily)

RELION INSULIN SYRINGEU-10003ML31G X 516MISC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

RELION INSULIN SYRINGEU-1001ML31GX 1564 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

SAFESNAP INSULIN SYRINGE03ML30G X516 MISC

SAFESNAP INSULIN SYRINGE1ML28G X 12MISC

SAFETY INSULIN SYRINGES 05ML29GX12 MISC

SAFETY INSULIN SYRINGES 1ML27GX12MISC

1 QL(5 ea daily)

SB INSULIN SYRINGEU-10005ML29G X 12MISC

SB INSULIN SYRINGEU-1001ML29G X 12 MISC 1 QL(5 ea daily)

RXOTC SB INSULIN SYRINGEU-1001ML30G X 516MISC

1 QL(5 ea daily)

SECURESAFE SAFETY INSULIN SYRINGESU-10005ML29GX12 MISC

Drug Name DrugTier

RequirementsLimits

SURE COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

SURE COMFORT INSULIN SYRINGEU-1001ML28G X 12 MISC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

SURE-JECT INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

SURE-JECT INSULIN SYRINGEU-1001ML28GX 12 MISC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-1001ML29GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE03ML30G X516 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

TOPCARE ULTRA COMFORT INSULIN SYRINGEU-1001ML29GX 12 MISC

QL(5 ea daily)RXOTC

TRUE COMFORT INSULIN SYRINGE05ML31G X516 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGE05ML30G X 516 MISC

1 QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGEU-10005ML30G X 12MISC

QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGEU-1001ML30G X 12 MISC

1 QL(5 ea daily)

TRUEPLUS INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

TRUEPLUS INSULIN SYRINGEU-1001ML28GX 12 MISC

1 QL(5 ea daily)

ULTICARE INSULIN SAFETY SYRINGE05ML29G X12 MISC

QL(5 ea daily)RXOTC

ULTICARE INSULIN SAFETY SYRINGE1ML29G X 12MISC

QL(5 ea daily)RXOTC

ULTICARE INSULIN SYRINGE03ML29G X12 MISC

1 QL(5 ea daily)

ULTICARE INSULIN SYRINGE1ML28G X 12MISC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

ULTICARE INSULIN SYRINGESHORT03ML30G X 516 MISC

1 QL(5 ea daily)

ULTICARE INSULIN SYRINGEU-10003ML30G X 12MISC

QL(5 ea daily)

ULTICARE INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-10003ML31G X 516MISC

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 03ML30G X12SHARPS C MISC

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 12ML30G X 12SHARPS CMISC

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 30G X 12SHARPS CONMISC

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 31G X 516SHARPS COMISC

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE03ML30G X12SHARPS C MISC

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE03ML31G X516SHARPS MISC

QL(5 ea daily)

ULTIGUARD SAFEPACKSYRINGENEEDLE31G X516SHARPS CONTAINMISC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

ULTILET INSULIN SYRINGE03ML30G X8MM MISC

1 QL(5 ea daily)

ULTILET INSULIN SYRINGESHORT03ML30G X 127MM MISC

1 QL(5 ea daily)

ULTILET INSULIN SYRINGESHORT03ML30G X 516 MISC

1 QL(5 ea daily)

ULTILET INSULIN SYRINGEU-10005ML30G X 12MISC

QL(5 ea daily)

ULTILET INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

ULTRA COMFORT INSULIN SYRINGEU-10003ML30G X 516MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

ULTRA FLO INSULIN SYRINGE 03ML29G X12 MISC

ULTRA FLO INSULIN SYRINGE 03ML30GX12MISC

1 QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 03ML30GX516 MISC

1 QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 12UNIT03ML30GX12MISC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 1M29GX12MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

ULTRA-COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

ULTRA-COMFORT INSULIN SYRINGEU-1001ML28G X 12 MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML30GX516MISC

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML30GX516 MISC

1 QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGEU-10005ML29GX12 MISC

ULTRACARE INSULIN SYRINGEU-10003ML30G X 516MISC

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

ULTRACARE INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

VALUE HEALTH INSULIN SYRINGEU-10005ML29G X 12MISC

QL(5 ea daily)RXOTC

VALUE HEALTH INSULIN SYRINGEU-1001ML29GX 12 MISC

VANISHPOINT INSULIN SYRINGE05ML30G X12 MISC

1 QL(5 ea daily)

VANISHPOINT INSULIN SYRINGE1ML29G X 12MISC

VP INSULIN SYRINGEU-10003ML29G X 12MISC

ZEVRX INSULIN SYRINGE05ML30G X12 MISC

1 QL(5 ea daily)

ZEVRX INSULIN SYRINGE1ML30G X 12MISC

1 QL(5 ea daily)

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Calcitonin Gene-Related Peptide (CGRP)

AIMOVIG SOAJ 2 PA QL(004 mldaily)

EMGALITY SOAJ 120 MGML 2 PA QL(007 ml

daily)

Drug Name DrugTier

RequirementsLimits

EMGALITY SOSY 100 MGML 3 PA QL(01 ml

daily) EMGALITY SOSY 120 MGML 2 PA QL(007 ml

daily) Migraine Combinations CAFERGOT TABS (Use ergotamine w caffeine) NF

ergotamine w caffeine tabsor 1 mg-100 mg 1

sumatriptan-naproxensodium tabs 3

TREXIMET TABS (Use sumatriptan-naproxensodium)

Migraine Products DHE 45 SOLN (Use dihydroergotaminemesylate)

dihydroergotaminemesylate soln ij 1 mgml 1

dihydroergotaminemesylate soln na 4 mgml 1 PA QL(0267

ml daily) dihydroergotaminemesylate soln na 4 mgml 1 QL(0267 ml

daily)

ERGOMAR SUBL 3 QL(0667 eadaily)

MIGRANAL SOLN (Use dihydroergotaminemesylate)

NF ST QL(0267ml daily)

Serotonin Agonists

almotriptan malate tabs125 mg 1

AMERGE TABS (Use naratriptan hcl) NF

QL(03 eadaily) AL(Atleast 18 yrsold)

Drug Name DrugTier

RequirementsLimits

eletriptan hydrobromidetabs 1

FROVA TABS (Use frovatriptan succinate) NF

frovatriptan succinate tabs 1

IMITREX SOLN NA 20 MGACT 5 MGACT (Use sumatriptan)

IMITREX SOLN SC 6 MG05ML (Use sumatriptan succinate)

QL(0134 mldaily) AL(Atleast 18 yrsold)

IMITREX STATDOSE REFILL SOCT (Use sumatriptan succinate)

IMITREX STATDOSE SYSTEM SOAJ (Use sumatriptan succinate)

IMITREX TABS OR 100 MG 25 MG 50 MG (Use sumatriptan succinate)

MAXALT TABS (Use rizatriptan benzoate) NF

QL(06 eadaily) AL(Atleast 6 yrs old)

MAXALT-MLT TBDP (Use rizatriptan benzoate) NF

naratriptan hcl tabs 1

RELPAX TABS (Use eletriptan hydrobromide) NF

Drug Name DrugTier

RequirementsLimits

rizatriptan benzoate tabs10 mg 1

rizatriptan benzoate tabs 5 mg 1

rizatriptan benzoate tbdp10 mg 1

rizatriptan benzoate tbdp 5 mg 1

sumatriptan soln 1

sumatriptan succinate soajsc 6 mg05ml 4 mg05ml 1

sumatriptan succinate soctsc 6 mg05ml 4 mg05ml 1

sumatriptan succinate solnsc 6 mg05ml 1

sumatriptan succinate sosysc 6 mg05ml 1

sumatriptan succinate tabsor 100 mg 25 mg 50 mg 1

zolmitriptan soln na 25 mg5 mg 1

zolmitriptan tabs or 25 mg5 mg 1

zolmitriptan tbdp or 25 mg5 mg 1

Drug Name DrugTier

RequirementsLimits

ZOMIG SOLN NA 25 MG 5 MG (Use zolmitriptan) 3

ZOMIG TABS OR 25 MG 5 MG (Use zolmitriptan) NF

ZOMIG ZMT TBDP (Use zolmitriptan) NF

MINERALS amp ELECTROLYTES

Bicarbonates SODIUM ACETATE SOLN 2 MEQML (Use sodium acetate)

sodium acetate soln 2 meqml 4 meqml 1

Calcium calcium chloride (dihydrate)soln 1

CALCIUM GLUCONATE SOLN 1

calcium gluconate soln 1

Electrolyte Mixtures DEXTROSE 5NACL03 SOLN (Use dextrose w sodium chloride)

dextrose in lactated ringerssoln 1

DEXTROSESODIUMCHLORIDE SOLN (Use dextrose w sodiumchloride)

IONOSOL-MBDEXTROSE5 SOLN 3 MEQL-3MEQL-5 -20 MEQL-22MEQL-23 MEQL-25MEQL 3 MEQL-3MMOLEL-5 -20 MEQL-22 MEQL-23 MEQL-25MEQL

ISOLYTE-PDEXTROSE5 SOLN 1

Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1

KCL 03D5WNACL09 SOLN 1

lactated ringers soln 20mg100ml-30 mg100ml-310 mg100ml-600mg100ml 3 meql-4 meql-28 meql-109 meql-130meql

NORMOSOL-M IN D5W SOLN 1

NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1

parenteral electrolytes conc 1

PLASMA-LYTE A SOLN 1

PLASMA-LYTE-148 SOLN 1

potassium chloride indextrose amp sodium chloride soln

potassium chloride indextrose soln 1

potassium chloride in naclsoln 015 -09 045 -20 meql 09 -40 meql

POTASSIUM CHLORIDEDEXTROSELACTATED RINGERS SOLN 27 MEQL-5 -24MEQL-28 MEQL-129MEQL-130 MEQL 3MEQL-5 -24 MEQL-28MEQL-130 MEQL-149MEQL

POTASSIUM CHLORIDESODIUMCHLORIDE SOLN 045 -20 MEQL (Use potassiumchloride in nacl)

ringers soln 1

Fluoride

Drug Name DrugTier

RequirementsLimits

sodium fluoride chew 025 mg 05 mg 1 mg 22 mg 0 QL(1 ea daily)

Magnesium magnesium sulfate soln ij50 1

Phosphate potassium phosphates soln224 mgml-236 mgml 1

Potassium K-TAB TBCR 10 MEQ (Use potassium chloride) NF

K-TAB TBCR 8 MEQ (Use potassium chloride) 1

potassium acetate soln 1

potassium bicarbonate tbef 1

potassium chloride cpcr or10 meq 8 meq 1

potassium chloridemicroencapsulated crystalser tbcr 15 meq 20 meq 10 meq

potassium chloride pack or20 meq 1 PA

POTASSIUM CHLORIDE SOLN IV 10 MEQ100ML10 MEQ50ML

POTASSIUM CHLORIDE SOLN IV 10 MEQ100ML10 MEQ50ML (Use potassium chloride)

potassium chloride soln iv10 meq50ml 20meq50ml 2 meqml

potassium chloride soln or10 1

potassium chloride tbcr or10 meq 8 meq 1

Sodium sodium chloride soln ij 25meqml 1

Drug Name DrugTier

RequirementsLimits

sodium chloride soln iv 3 5 4 meqml 045 09

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS (Use penicillamine) NF PA

DEPEN TITRATABS TABS (Use penicillamine) NF QL(8 ea daily)

penicillamine caps 1 PA

penicillamine tabs 1 QL(8 ea daily)

SYPRINE CAPS (Use trientine hcl) NF PA QL(8 ea

daily) SP

trientine hcl caps 4 PA QL(8 eadaily) SP

Immunomodulators REVLIMID CAPS 10 MG 15 MG 25 MG 25 MG 5 MG

REVLIMID CAPS 20 MG 4 PA

THALOMID CAPS 4 PA QL(3 eadaily) SP

Immunosuppressive Agents

ATGAM INJ 4 PA SP

AZATHIOPRINE SOLR IJ 100 MG 1

azathioprine tabs or 100mg 50 mg 75 mg 1

CELLCEPT CAPS 250 MG (Use mycophenolatemofetil)

CELLCEPT TABS 500 MG (Use mycophenolatemofetil)

cyclosporine caps 1

cyclosporine modified (formicroemulsion) caps 1

cyclosporine modified (formicroemulsion) soln 1

Drug Name DrugTier

RequirementsLimits

cyclosporine soln 1

everolimus (immunosuppressant) tabs025 mg 05 mg 075 mg

IMURAN TABS (Use azathioprine) NF

mycophenolate mofetilcaps or 250 mg 1

mycophenolate mofetil tabsor 500 mg 1

mycophenolate sodiumtbec 1

MYFORTIC TBEC (Use mycophenolate sodium) NF

NEORAL CAPS (Use cyclosporine modified (formicroemulsion))

NEORAL SOLN (Use cyclosporine modified (formicroemulsion))

NULOJIX SOLR 4 PA SP

PROGRAF CAPS OR 05 MG 1 MG 5 MG (Use tacrolimus)

PROGRAF PACK OR 02 MG 1 MG 2 PA

PROGRAF SOLN IV 5 MGML 2

RAPAMUNE TABS 05 MG 1 MG 2 MG (Use sirolimus)

SANDIMMUNE CAPS OR 100 MG 25 MG (Use cyclosporine)

SANDIMMUNE SOLN IV 50 MGML (Use cyclosporine)

SIMULECT SOLR 3

sirolimus tabs 05 mg 1mg 2 mg 1

tacrolimus caps 1

THYMOGLOBULIN SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

ZORTRESS TABS 025 MG 05 MG 075 MG (Use everolimus (immunosuppressant))

PA QL(20 eadaily) SP

Irrigation Solutions irrigation solutionsphysiological soln 1

lactated ringers (irrigation)soln 1

ringers irrigation soln 1

water for irrigation sterilesoln 1

Potassium Removing Agents sodium polystyrenesulfonate powd 1

sodium polystyrenesulfonate susp 1

MOUTHTHROATDENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 2 1 QL(4 ml daily)

lidocaine hcl (mouth-throat)soln 4 1

Anti-infectives - Throat clotrimazole troc 1

nystatin (mouth-throat) susp 1

Antiseptics - MouthThroat chlorhexidine gluconate(mouth-throat) soln 1

DEBACTEROL SOLN 2

PERIDEX SOLN (Use chlorhexidine gluconate(mouth-throat))

Dental Products

stannous fluoride conc 0 RXOTC

Steroids - MouthThroatDental triamcinolone acetonide (mouth) pste 1

Drug Name DrugTier

RequirementsLimits

Throat Products - Misc cevimeline hcl caps 1

EVOXAC CAPS (Use cevimeline hcl) NF

pilocarpine hcl (oral) tabs 1

SALAGEN TABS (Use pilocarpine hcl (oral)) NF

MULTIVITAMINS

Prenatal Vitamins CLASSIC PRENATAL TABS 2 QL(1 ea daily)

CVS PRENATAL TABS 2 QL(1 ea daily)

EQL PRENATAL FORMULA TABS 2 QL(1 ea daily)

GNP PRENATAL TABS 2 QL(1 ea daily)

GOODSENSE PRENATAL VITAMINS TABS 2 QL(1 ea daily)

HM PRENATAL TABS 2 QL(1 ea daily)

KP PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily)

M-NATAL PLUS TABS 2 QL(1 ea daily)RXOTC

MULTI PRENATAL TABS 2 QL(1 ea daily)

NEONATAL COMPLETE TABS 02 MG-184 MG-2 MG-2 MG-3 MG-5 MG-92 MG-10 MCG-10 MG-12 MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1000 MCG-1200 MCG

QL(1 ea daily)RXOTC

NEONATAL PLUS TABS 2 QL(1 ea daily)RXOTC

NEONATAL VITAMIN TABS 2 QL(1 ea daily)

NIVA-PLUS TABS 2 QL(1 ea daily)RXOTC

O-CAL FA TABS 2 QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

ONE VITE WOMENS PRENATALVITAMIN PLUS TABS

ONE VITE WOMENS PRENATALVITAMIN TABS 2 QL(1 ea daily)

PRENATAL LOW IRON TABS 2 QL(1 ea daily)

PRENATAL MULTIVITAMIN TABS 2 QL(1 ea daily)

PRENATAL ONE DAILY TABS 2 QL(1 ea daily)

PRENATAL TABS 08 MG-15 MG-17 MG-26 MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 MG-263 MG-400 UNIT-4000 UNIT 08 MG-17 MG-18 MG-26 MG-8 MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-4000 UNIT 15 MG-17 MG-26 MG-4 MCG-5 MG-10 MCG-18 MG-25 MG-27 MG-100 MG-200 MG-800 MCG-1200 MCG 17 MG-18 MG-26 MG-8 MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-800 MCG-4000 UNIT 17 MG-184 MG-26 MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 MG-160 MG-200 MG-400 UNIT-800 MCG-4000 UNIT

QL(1 ea daily)

PRENATAL TABS 1 MG-184 MG-2 MG-3 MG-10 MCG-10 MG-10 MG-12 MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1200 MCG

QL(1 ea daily)RXOTC

PRENATAL VITAMIN amp MINERAL TABS 2 QL(1 ea daily)

PRENATAL VITAMIN TABS 2 QL(1 ea daily)

PRENATAL VITAMINIRON TABS 2 QL(1 ea daily)

PRENATAL VITAMINS PLUS LOW IRON TABS 2 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

PRENATAL VITAMINS TABS 2 QL(1 ea daily)

PRENATRIX TABS 2 QL(1 ea daily)RXOTC

PRENATRYL TABS 2 QL(1 ea daily)RXOTC

PREPLUS TABS 2 QL(1 ea daily)RXOTC

PX PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily)

QC PRENATAL TABS 2 QL(1 ea daily)

RA PRENATAL FORMULAFOLICACIDTABS

2 QL(1 ea daily)

RA PRENATAL TABS 2 QL(1 ea daily)

RIGHT STEP PRENATAL TABS 2 QL(1 ea daily)

SM PRENATAL VITAMINS TABS 2 QL(1 ea daily)

THERANATAL CORE NUTRITION TABS 2 QL(1 ea daily)

TRICARE TABS 2 QL(1 ea daily)RXOTC

VITATHELYGINGERTABS 2 QL(1 ea daily)

VOL-PLUS TABS 2 QL(1 ea daily)RXOTC

WESTAB PLUS TABS 2 QL(1 ea daily)RXOTC

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants baclofen tabs or 10 mg 20 mg 1

carisoprodol tabs 1

chlorzoxazone tabs 500 mg 1 QL(6 ea daily)

cyclobenzaprine hcl tabs10 mg 5 mg 1 QL(3 ea daily)

metaxalone tabs 800 mg 1 QL(4 ea daily)

methocarbamol tabs or 500 mg 750 mg 1

Drug Name DrugTier

RequirementsLimits

orphenadrine citrate tb12or 100 mg 1 QL(2 ea daily)

ROBAXIN-750 TABS (Use methocarbamol) NF

SKELAXIN TABS (Use metaxalone) NF QL(4 ea daily)

SOMA TABS (Use carisoprodol) NF

tizanidine hcl caps 1

tizanidine hcl tabs 1

ZANAFLEX CAPS (Use tizanidine hcl) NF

ZANAFLEX TABS (Use tizanidine hcl) NF

Direct Muscle Relaxants DANTRIUM CAPS (Use dantrolene sodium) NF QL(4 ea daily)

dantrolene sodium caps or100 mg 25 mg 50 mg 1 QL(4 ea daily)

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Antiallergy

azelastine hcl soln 1

olopatadine hcl (nasal) soln 1

PATANASE SOLN (Use olopatadine hcl (nasal)) NF

Nasal Anticholinergics ipratropium bromide (nasal)soln 003 1 QL(1 ml daily)

ipratropium bromide (nasal)soln 006 1

Nasal Steroids

budesonide (nasal) susp 1

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use fluticasone propionate (nasal))

Limit 2 inhalers permonthQL(32ml per 30 daysretail) RXOTC

Drug Name DrugTier

RequirementsLimits

FLONASE ALLERGY RELIEF SUSP (Use fluticasone propionate(nasal))

flunisolide (nasal) soln 1 1 rtl pack lmtper fill

fluticasone propionate(nasal) susp 1

mometasone furoate (nasal) susp 1 PA QL(114

gm daily) NASACORT ALLERGY 24HR AERO (Use triamcinolone acetonide (nasal))

NASACORT ALLERGY 24HR CHILDRENS AERO (Use triamcinolone acetonide (nasal))

NASONEX SUSP (Use mometasone furoate (nasal))

NF PA QL(114gm daily)

triamcinolone acetonide (nasal) aero 1

NEUROMUSCULAR AGENTS - Drugs toRelaxParalyze Muscles

ALS Agents RILUTEK TABS (Use riluzole) NF

riluzole tabs 3

Neuromuscular Blocking Agent - Neurotoxins

BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS

Proteins CLINIMIX 425DEXTROSE 10SOLN

Drug Name DrugTier

RequirementsLimits

CLINIMIX 425DEXTROSE 25SOLN

CLINIMIX 5DEXTROSE25 SOLN 3

CLINIMIX E 5DEXTROSE 20SOLN

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

LACRISERT INST 3

Beta-blockers - Ophthalmic

betaxolol hcl (ophth) soln 1

carteolol hcl (ophth) soln 1

COMBIGAN SOLN 2

COSOPT SOLN (Use dorzolamide hcl-timolol maleate)

dorzolamide hcl-timolol maleate soln 05 -2 5mgml-20 mgml 68mgml-223 mgml

levobunolol hcl soln 1

timolol maleate (ophth)solg 025 05 1

timolol maleate (ophth)soln 025 05 1

TIMOPTIC SOLN (Use timolol maleate (ophth)) NF

TIMOPTIC-XE SOLG (Use timolol maleate (ophth)) NF

Cycloplegic Mydriatics MYDRIACYL SOLN (Use tropicamide) NF

tropicamide soln 1

Miotics

Drug Name DrugTier

RequirementsLimits

ISOPTO CARPINE SOLN (Use pilocarpine hcl) NF

PHOSPHOLINE IODIDE SOLR 3

pilocarpine hcl soln 1

Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 015 (Use brimonidine tartrate)

apraclonidine hcl soln 1

brimonidine tartrate soln 1

IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA

Ophthalmic Anti-infectives

AZASITE SOLN 3

bacitracin (ophthalmic) oint 3

BLEPH-10 SOLN (Use sulfacetamide sodium (ophth))

CILOXAN SOLN (Use ciprofloxacin hcl (ophth)) NF

ciprofloxacin hcl (ophth)soln 1

erythromycin (ophth) oint 1

gatifloxacin (ophth) soln 1

gentamicin sulfate (ophth)oint 1

gentamicin sulfate (ophth)soln 1

KLARITY-A SOLN 3

levofloxacin (ophth) soln 1

moxifloxacin hcl (ophth)soln 1

NATACYN SUSP 2

Drug Name DrugTier

RequirementsLimits

neomycin-bacitracin zn-polymyxin oint 1

OCUFLOX SOLN (Use ofloxacin (ophth)) NF

ofloxacin (ophth) soln 1

polymyxin b-trimethoprimsoln 1

POLYTRIM SOLN (Use polymyxin b-trimethoprim) NF

sulfacetamide sodium (ophth) soln 1

tobramycin (ophth) soln 1

TOBREX SOLN (Use tobramycin (ophth)) NF

trifluridine soln 1

VIGAMOX SOLN (Use moxifloxacin hcl (ophth)) NF

ZIRGAN GEL 2

ZYMAXID SOLN (Use gatifloxacin (ophth)) NF

Ophthalmic Immunomodulators

RESTASIS EMUL 2 PA

RESTASIS MULTIDOSE EMUL 2 PA

Ophthalmic Local Anesthetics ALCAINE SOLN (Use proparacaine hcl) NF

proparacaine hcl soln 1

Ophthalmic Nerve Growth Factors

OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA

dexamethasone sodium phosphate (ophth) soln 1

difluprednate emul 1 PA

DUREZOL EMUL (Use difluprednate) 3 PA

Drug Name DrugTier

RequirementsLimits

fluorometholone (ophth) susp 1

FML FORTE SUSP 3 PA

FML LIQUIFILM SUSP (Use fluorometholone (ophth))

FML OINT 3 PA

LOTEMAX GEL (Use loteprednol etabonate) 3 PA

LOTEMAX OINT 3 PA

LOTEMAX SUSP (Use loteprednol etabonate) NF PA

loteprednol etabonate gel 1 PA

loteprednol etabonate susp 1 PA

MAXIDEX SUSP 3 PA

MAXITROL OINT (Use neomycin-polymy-dexameth)

MAXITROL SUSP (Use neomycin-polymy-dexameth)

neomycin-polymy-dexameth oint 1

neomycin-polymy-dexameth susp 1

neomycin-polymyxin-hc(ophth) susp 1

PRED FORTE SUSP (Use prednisolone acetate(ophth))

PRED MILD SUSP 3 PA

prednisolone acetate(ophth) susp 1

PREDNISOLONE ACETATE P-F SUSP 1

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1

TOBRADEX SUSP (Use tobramycin-dexamethasone)

Drug Name DrugTier

RequirementsLimits

tobramycin-dexamethasone susp 1

Ophthalmics - Misc ACULAR LS SOLN (Use ketorolac tromethamine (ophth))

ACULAR SOLN (Use ketorolac tromethamine (ophth))

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA

azelastine hcl (ophth) soln 1

bepotastine besilate soln 3 PA

BEPREVE SOLN (Use bepotastine besilate) 3 PA

bromfenac sodium (ophth)soln 1

cromolyn sodium (ophth)soln 1

CYSTARAN SOLN 2 PA QL(2143ml daily)

diclofenac sodium (ophth)soln 1

dorzolamide hcl soln 1

epinastine hcl (ophth) soln 1

flurbiprofen sodium soln 1

ILEVRO SUSP 3 ST QL(02 mldaily)

ketorolac tromethamine (ophth) soln 1

ketotifen fumarate (ophth)soln 1

LASTACAFT SOLN 3 PA

NEVANAC SUSP 3 ST QL(02 mldaily)

olopatadine hcl soln 1 RXOTC

PATADAY SOLN (Use olopatadine hcl) NF RXOTC

Drug Name DrugTier

RequirementsLimits

PATANOL SOLN (Use olopatadine hcl) NF RXOTC

TRUSOPT SOLN (Use dorzolamide hcl) NF

ZADITOR SOLN (Use ketotifen fumarate (ophth)) NF

ZERVIATE SOLN 3 PA

Prostaglandins - Ophthalmic

bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST

TRAVATAN Z SOLN (Use travoprost) NF

travoprost soln 1

XALATAN SOLN (Use latanoprost) NF

ZIOPTAN SOLN 2

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln 1

Otic Anti-infectives CETRAXAL SOLN (Use ciprofloxacin hcl (otic)) 1

ciprofloxacin hcl (otic) soln 1

ofloxacin (otic) soln 1

Otic Combinations

CIPRO HC SUSP 3

CIPRODEX SUSP (Use ciprofloxacin-dexamethasone)

ciprofloxacin-dexamethasone susp 1 PA

ciprofloxacin-fluocinoloneacetonide soln 1 PA QL(05 ea

daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits

CORTISPORIN-TC SUSP 3

neomycin-polymyxin-hc(otic) soln 1

neomycin-polymyxin-hc(otic) susp 1

OTOVEL SOLN (Use ciprofloxacin-fluocinoloneacetonide)

3 PA QL(05 eadaily)

Otic Steroids DERMOTIC OIL (Use fluocinolone acetonide (otic))

fluocinolone acetonide (otic) oil 1

hydrocortisone waceticacid soln 1

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums CUVITRU SOLN 1 GM5ML 10 GM50ML 2GM10ML 4 GM20ML

4 PA SP

GAMMAGARD LIQUID SOLN 1 GM10ML 10GM100ML 25 GM25ML20 GM200ML 5 GM50ML

GAMMAGARD LIQUID SOLN 30 GM300ML 4 PA

GAMMAGARD SD IGALESS THAN 1MCGMLSOLR

4 PA SP

GAMMAKED SOLN 4 PA SP

GAMUNEX-C SOLN 4 PA SP

HIZENTRA SOLN 1 GM5ML 10 GM50ML 2GM10ML 4 GM20ML

4 PA SP

Passive Immunizing Agents - Combinations

HYQVIA KIT 4 PA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1

ampicillin sodium solr ij 1 gm 1

ampicillin sodium solr iv 10 gm 1

Natural Penicillins PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE SOLN 40000 UNITML60000 UNITML

penicillin g potassium solr5000000 unit 1

PENICILLIN G PROCAINE SUSP 3

penicillin g sodium solr 3

penicillin v potassium solr 1

penicillin v potassium tabs 1

Penicillin Combinations amoxicillin amp potclavulanate chew 1

amoxicillin amp potclavulanate susr 1

amoxicillin amp potclavulanate tabs 1

amoxicillin amp potclavulanate tb12 1

ampicillin amp sulbactamsodium solr ij 05 gm-1 gm1 gm-2 gm

ampicillin amp sulbactamsodium solr iv 5 gm-10 gm 1

AUGMENTIN ES-600 SUSR (Use amoxicillin amp pot clavulanate)

Drug Name DrugTier

RequirementsLimits

AUGMENTIN SUSR 625 MG5ML-250 MG5ML(Use amoxicillin amp potclavulanate)

AUGMENTIN TABS 125 MG-500 MG (Use amoxicillin amp potclavulanate)

piperacillin sodium-tazobactam sodium solr 1

UNASYN BULK PACK SOLR (Use ampicillin ampsulbactam sodium)

UNASYN SOLR (Use ampicillin amp sulbactamsodium)

ZOSYN SOLR 025 GM-2 GM 0375 GM-3 GM 05 GM-4 GM 45 GM-36 GM (Use piperacillin sodium-tazobactam sodium)

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps 1

nafcillin sodium solr ij 1 gm 1

nafcillin sodium solr iv 10 gm 1

oxacillin sodium solr ij 1 gm 1

oxacillin sodium solr iv 10 gm 1

PROGESTINS - Hormone ReplacementModifyingDrugs

Progestins AYGESTIN TABS (Use norethindrone acetate) NF

medroxyprogesteroneacetate tabs 1

MEGACE ES SUSP (Use megestrol acetate(appetite))

megestrol acetate(appetite) susp 1 PA

norethindrone acetate tabs 0

Drug Name DrugTier

RequirementsLimits

progesterone caps or 100mg 200 mg 1

PROMETRIUM CAPS (Use progesterone) NF

PROVERA TABS (Use medroxyprogesterone acetate)

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec 1

ANTABUSE TABS (Use disulfiram) NF

disulfiram tabs 1

LUCEMYRA TABS 3 PA QL(224 eaper 14 daysretail)

Anti-Cataplectic Agents

XYREM SOLN 4 PA QL(18 mldaily) SP

Antidementia Agents ARICEPT TABS 10 MG (Use donepezilhydrochloride)

NF QL(2 ea daily)

ARICEPT TABS 5 MG (Use donepezilhydrochloride)

NF QL(1 ea daily)

donepezil hydrochloridetabs 10 mg 1 QL(2 ea daily)

donepezil hydrochloridetbdp 10 mg 1 QL(2 ea daily)

galantamine hydrobromidecp24 16 mg 24 mg 8 mg 1 QL(1 ea daily)

galantamine hydrobromidesoln 4 mgml 1 QL(6 ml daily)

galantamine hydrobromidetabs 12 mg 4 mg 8 mg 1 QL(2 ea daily)

memantine hcl tabs 1

Drug Name DrugTier

RequirementsLimits

memantine hcl tabs 10 mg 1 QL(2 ea daily)

NAMENDA TABS 10 MG (Use memantine hcl) NF QL(2 ea daily)

NAMENDA TITRATION PAK TABS (Use memantine hcl)

RAZADYNE ER CP24 (Use galantamine hydrobromide) NF QL(1 ea daily)

RAZADYNE TABS (Use galantamine hydrobromide) NF QL(2 ea daily)

rivastigmine tartrate caps 1

Combination Psychotherapeutics perphenazine-amitriptylinetabs 1 QL(4 ea daily)

Fibromyalgia Agents

SAVELLA TABS 2 PA QL(2 eadaily)

SAVELLA TITRATION PACK MISC 2 PA

Movement Disorder Drug Therapy

AUSTEDO TABS 4 PA QL(4 eadaily)

tetrabenazine tabs 4 PA QL(3 eadaily) SP

XENAZINE TABS (Use tetrabenazine) NF PA QL(3 ea

daily) SP

Multiple Sclerosis Agents AMPYRA TB12 (Use dalfampridine) NF PA QL(2 ea

daily) SP

AUBAGIO TABS 4 PA

AVONEX PEN AJKT 4 PA QL(00714ml daily) SP

AVONEX PSKT 4 PA QL(00714ml daily) SP

BETASERON KIT 4 PA QL(05 eadaily) SP

Drug Name DrugTier

RequirementsLimits

COPAXONE SOSY 20 MGML (Use glatiramer acetate)

3 PA QL(0429ml daily) SP

dalfampridine tb12 4 PA QL(2 eadaily) SP

dimethyl fumarate cpdr 4 PA

dimethyl fumarate misc 4 PA

EXTAVIA KIT 4 PA QL(05 eadaily) SP

GILENYA CAPS 4 PA

glatiramer acetate sosy 20mgml 3 PA QL(1 ml

daily) SP glatiramer acetate sosy 40mgml 3 PA QL(0429

ml daily) SP

MAVENCLAD TBPK 4 PA

MAYZENT STARTER PACK TBPK 4 PA

MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA

PLEGRIDY SOPN SC 4 PA QL(0036ml daily)

PLEGRIDY SOSY IM 4 PA QL(0036ml daily)

PLEGRIDY SOSY SC 4 PA

PLEGRIDY STARTER PACK SOPN 4 PA

PLEGRIDY STARTER PACK SOSY 4 PA QL(0036

ml daily)

REBIF REBIDOSE SOAJ 4 PA QL(0214ml daily) SP

REBIF REBIDOSE TITRATIONPACK SOAJ 4 PA SP

REBIF SOSY 4 PA QL(0214ml daily) SP

REBIF TITRATION PACK SOSY 4 PA SP

Drug Name DrugTier

RequirementsLimits

TECFIDERA CPDR (Use dimethyl fumarate) NF PA

TECFIDERA STARTER PACK MISC (Use dimethyl fumarate)

TYSABRI CONC 4 PA QL(0536ml daily) SP

Postherpetic Neuralgia (PHN)Neuropathic Pain LYRICA CR TB24 165 MG 825 MG (Use pregabalin(once-daily))

3 PA QL(1 eadaily)

LYRICA CR TB24 330 MG (Use pregabalin (once-daily))

3 PA QL(2 eadaily)

pregabalin (once-daily)tb24 165 mg 825 mg 3 PA QL(1 ea

daily) pregabalin (once-daily)tb24 330 mg 3 PA QL(2 ea

daily) Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS 3 PA

Psychotherapeutic and Neurological Agents -ergoloid mesylates tabs 1

pimozide tabs 1

Restless Leg Syndrome (RLS) Agents

HORIZANT TBCR 3 PA QL(2 eadaily)

Smoking Deterrents

APO-VARENICLINE TABS 0 QL(2 ea daily)

bupropion hcl (smokingdeterrent) tb12 0 QL(2 ea daily)

CHANTIX CONTINUING MONTHPAK TABS 0 QL(2 ea daily)

CHANTIX STARTING MONTH PAK TABS 0

CHANTIX TABS 0 QL(2 ea daily)

NICODERM CQ PT24 (Use nicotine) NF QL(1 ea daily)

NICORETTE GUM (Use nicotine polacrilex) NF

Drug Name DrugTier

RequirementsLimits

NICORETTE LOZG (Use nicotine polacrilex) NF

NICORETTE MINI LOZG (Use nicotine polacrilex) NF

NICORETTE STARTER KIT GUM (Use nicotine polacrilex)

nicotine polacrilex gum 0

nicotine polacrilex lozg 0

nicotine pt24 0 QL(1 ea daily)

NICOTINE TRANSDERMAL SYSTEM KIT

NICOTROL INHALER INHA 0

NICOTROL NS SOLN 0

VARENICLINE TARTRATE TABS 0 QL(2 ea daily)

Transthyretin Amyloidosis Agents

TEGSEDI SOSY 4 PA

RESPIRATORY AGENTS - MISC - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human) ARALAST NP SOLR 1000 MG 4 PA SP

ARALAST NP SOLR 500 MG 4 PA

PROLASTIN-C SOLN 1000 MG20ML 4 PA

PROLASTIN-C SOLR 1000 MG 4 PA SP

ZEMAIRA SOLR 4 PA SP

Cystic Fibrosis Agents

KALYDECO TABS 150 MG 4 PA QL(2 eadaily) SP

ORKAMBI PACK 100 MG-125 MG 150 MG-188 MG 4 PA QL(2 ea

daily) ORKAMBI TABS 100 MG-125 MG 125 MG-200 MG 4 PA QL(4 ea

daily)

Drug Name DrugTier

RequirementsLimits

PULMOZYME SOLN 4 PA QL(25 mldaily) SP

TRIKAFTA TBPK 50 MG-100 MG 4 PA QL(3 ea

daily) Pulmonary Fibrosis Agents

OFEV CAPS 4 PA QL(2 eadaily)

SULFONAMIDES - Drugs to Treat BacterialInfections

Sulfonamides

SULFADIAZINE TABS 1

TETRACYCLINES - Drugs to Treat BacterialInfections

Glycylcyclines

tigecycline solr 1

TYGACIL SOLR (Use tigecycline) NF

Tetracyclines

demeclocycline hcl tabs 1

doxycycline (monohydrate)caps 50 mg 100 mg 1 QL(2 ea daily)

doxycycline (monohydrate)caps 75 mg 1

doxycycline (monohydrate)tabs 100 mg 1 QL(2 ea daily)

doxycycline (monohydrate)tabs 50 mg 1

doxycycline hyclate caps or50 mg 100 mg 1 QL(2 ea daily)

doxycycline hyclate solr iv100 mg 1

doxycycline hyclate tabs or20 mg 100 mg 1 QL(2 ea daily)

MINOCIN CAPS OR 50 MG (Use minocycline hcl) NF QL(3 ea daily)

minocycline hcl caps 100mg 50 mg 75 mg 1 QL(3 ea daily)

minocycline hcl tabs 100mg 50 mg 75 mg 1 QL(3 ea daily)

TARGADOX TABS (Use doxycycline hyclate) NF

Drug Name DrugTier

RequirementsLimits

tetracycline hcl caps 1 QL(8 ea daily)

VIBRAMYCIN CAPS 100 MG (Use doxycyclinehyclate)

NF QL(2 ea daily)

XIMINO CP24 135 MG 45 MG 90 MG (Use minocycline hcl)

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents

methimazole tabs 1

propylthiouracil tabs 1

TAPAZOLE TABS (Use methimazole) NF

Thyroid Hormones ARMOUR THYROID TABS 120 MG 15 MG 30 MG 60 MG 90 MG (Use thyroid)

QL(1 ea daily)

ARMOUR THYROID TABS 180 MG 240 MG 300 MG 2 QL(1 ea daily)

CYTOMEL TABS (Use liothyronine sodium) NF

levothyroxine sodium tabsor 300 mcg 100 mcg 112mcg 125 mcg 137 mcg150 mcg 175 mcg 200mcg 25 mcg 50 mcg 75mcg 88 mcg

liothyronine sodium soln 1

liothyronine sodium tabs 1

NATURE-THROID NT-25 TABS 2

NATURE-THROID TABS 2

SYNTHROID TABS (Use levothyroxine sodium) 2

thyroid tabs 1 QL(1 ea daily)

TRIOSTAT SOLN (Use liothyronine sodium) NF

Drug Name DrugTier

RequirementsLimits

WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0

DIPHTHERIATETANUSTOXOIDS ADSORBED PEDIATRIC SUSP

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0

TENIVAC INJ 0

TETANUSDIPHTHERIATOXOIDS-ADSORBED ADULT SUSP

ULCER DRUGS - Drugs to Treat Bowel Intestineand Stomach Conditions

Antispasmodics atropine sulfate soln ij 04mgml 1 mgml 1

atropine sulfate sosy ij 025mg5ml 1

chlordiazepoxide hcl-clidinium bromide caps 1

dicyclomine hcl caps or 10 mg 1

dicyclomine hcl soln or 10mg5ml 1

Drug Name DrugTier

RequirementsLimits

dicyclomine hcl tabs or 20 mg 1

glycopyrrolate soln ij 4mg20ml 1

glycopyrrolate tabs or 1mg 2 mg 1

LIBRAX CAPS (Use chlordiazepoxide hcl-clidinium bromide)

methscopolamine bromidetabs 1

H-2 Antagonists cimetidine hcl soln 300 mg5ml 1 QL(20 ml daily)

cimetidine tabs 200 mg 1 RXOTC

cimetidine tabs 300 mg400 mg 800 mg 1

famotidine in nacl soln 1

famotidine soln iv 20 mg2ml 200 mg20ml 40mg4ml

famotidine susr or 40 mg5ml 1 QL(10 ml daily)

famotidine tabs or 20 mg 1 RXOTC

famotidine tabs or 40 mg 1

nizatidine caps 150 mg300 mg 1

nizatidine soln 15 mgml 1 QL(20 ml daily)

PEPCID AC MAXIMUM STRENGTH TABS (Use famotidine)

NF RXOTC

PEPCID AC TABS (Use famotidine) NF RXOTC

PEPCID TABS 20 MG (Use famotidine) NF RXOTC

PEPCID TABS 40 MG (Use famotidine) NF

ranitidine hcl caps or 150mg 300 mg 1

ranitidine hcl soln ij 150mg6ml 1

Drug Name DrugTier

RequirementsLimits

ranitidine hcl syrp or 15mgml 150 mg10ml 75mg5ml

1 QL(40 ml daily)

ranitidine hcl tabs or 150 mg 1 RXOTC

ranitidine hcl tabs or 300 mg 1

TAGAMET HB TABS (Use cimetidine) NF RXOTC

ZANTAC 150 MAXIMUM STRENGTH TABS (Use ranitidine hcl)

NF RXOTC

Misc Anti-Ulcer CARAFATE SUSP 1 GM10ML (Use sucralfate) NF QL(40 ml daily)

CARAFATE TABS 1 GM (Use sucralfate) NF QL(4 ea daily)

sucralfate susp 1 gm10ml 1 QL(40 ml daily)

sucralfate tabs 1 gm 1 QL(4 ea daily)

Proton Pump Inhibitors ACIPHEX TBEC (Use rabeprazole sodium) NF QL(1 ea daily)

DEXILANT CPDR 3 PA QL(1 eadaily)

esomeprazole magnesiumcpdr 20 mg 1 QL(2 ea daily)

RXOTC esomeprazole magnesiumcpdr 40 mg 3 QL(1 ea daily)

esomeprazole magnesiumtbec 20 mg 1 QL(2 ea daily)

lansoprazole cpdr 15 mg 1 QL(2 ea daily)RXOTC

lansoprazole cpdr 30 mg 1

NEXIUM 24HR TBEC (Use esomeprazole magnesium) 1 QL(2 ea daily)

NEXIUM CPDR 20 MG (Use esomeprazolemagnesium)

NF QL(1 ea daily)

omeprazole cpdr 10 mg 40 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

omeprazole cpdr 20 mg 1 QL(2 ea daily)RXOTC

omeprazole magnesiumcpdr 1 QL(4 ea daily)

omeprazole magnesiumtbec 1 QL(4 ea daily)

omeprazole tbec 20 mg 1 QL(2 ea daily)

pantoprazole sodium tbecor 20 mg 1 QL(1 ea daily)

pantoprazole sodium tbecor 40 mg 1

PREVACID 24HR CPDR (Use lansoprazole) NF QL(2 ea daily)

RXOTC PREVACID CPDR 15 MG (Use lansoprazole) NF QL(2 ea daily)

RXOTC PREVACID CPDR 30 MG (Use lansoprazole) NF

PRILOSEC OTC TBEC (Use omeprazolemagnesium)

1 QL(4 ea daily)

PROTONIX TBEC OR 20 MG (Use pantoprazolesodium)

NF QL(1 ea daily)

rabeprazole sodium tbec 1 QL(1 ea daily)

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use misoprostol) NF QL(4 ea daily)

misoprostol tabs 1 QL(4 ea daily)

Ulcer Therapy Combinations omeprazole-sodiumbicarbonate caps 20 mg-1100 mg

ZEGERID CAPS 20 MG-1100 MG (Use omeprazole-sodiumbicarbonate)

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics

Drug Name DrugTier

RequirementsLimits

darifenacin hydrobromidetb24 1 QL(1 ea daily)

DETROL LA CP24 (Use tolterodine tartrate) NF QL(1 ea daily)

DETROL TABS (Use tolterodine tartrate) NF

DITROPAN XL TB24 (Use oxybutynin chloride) NF

ENABLEX TB24 (Use darifenacin hydrobromide) NF QL(1 ea daily)

oxybutynin chloride syrp 1

oxybutynin chloride tabs 1

oxybutynin chloride tb24 1

solifenacin succinate tabs 1 PA QL(1 eadaily)

tolterodine tartrate cp24 2mg 4 mg 1 QL(1 ea daily)

tolterodine tartrate tabs 1 mg 2 mg 1

TOVIAZ TB24 3 PA QL(1 eadaily)

trospium chloride cp24 60 mg 1 QL(1 ea daily)

trospium chloride tabs 20 mg 1

VESICARE TABS (Use solifenacin succinate) NF PA QL(1 ea

daily) Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 25 MG 50 MG 3 PA

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs 10 mg 5 mg 50 mg 1 QL(4 ea daily)

bethanechol chloride tabs 25 mg 1

URECHOLINE TABS 10 MG 5 MG 50 MG (Use bethanechol chloride)

NF QL(4 ea daily)

URECHOLINE TABS 25 MG (Use bethanechol chloride)

Urinary Antispasmodics - Direct Muscle Relaxants

Drug Name DrugTier

RequirementsLimits

flavoxate hcl tabs 1

VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0

PNEUMOVAX 231 DOSEINJ 0

PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

AFLURIA QUADRIVALENT 2019-2020 SUSP 0

Limit 1 dose per season1 rtlMAX fill180 rtl day(s) supply

AFLURIA QUADRIVALENT 2019-2020 SUSY 0

Drug Name DrugTier

RequirementsLimits

ENGERIX-B INJ 0

3 rtl MAX fill365 rtl day(s) supply3mail MAX fill365 mail day(s) supply

ENGERIX-B SUSP 0

FLUAD 2019-2020 SUSY 0

FLUAD QUADRIVALENT 2021-2022 PRSY 0

FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS PRSY

0 1 rtl MAX fill180 rtl day(s) supply

FLUARIX QUADRIVALENT 2019-2020 SUSY 0

FLUBLOK QUADRIVALENT 2019-2020 SOSY

Drug Name DrugTier

RequirementsLimits

FLUCELVAX QUADRIVALENT 2019-2020 SUSP

FLUCELVAX QUADRIVALENT 2019-2020 SUSY

FLULAVAL QUADRIVALENT 2019-2020 SUSP

FLULAVAL QUADRIVALENT 2019-2020 SUSY

Drug Name DrugTier

RequirementsLimits

FLUMIST QUADRIVALENT SUSP 0

FLUZONE HIGH-DOSE PF 2019-2020 SUSY 0

FLUZONE QUADRIVALENT 2019-2020 SUSP

FLUZONE QUADRIVALENT 2019-2020 SUSY

GARDASIL 9 SUSP 0 3 rtl MAX fill365 rtl day(s) supply

GARDASIL 9 SUSY 0 3 rtl MAX fill365 rtl day(s) supply

HAVRIX SUSP 0

HEPLISAV-B SOSY 0

Drug Name DrugTier

RequirementsLimits

IPOL INACTIVATED IPV INJ 0

M-M-R II SOLR 0 1 rtl MAX fill365 rtl day(s) supply

RECOMBIVAX HB SUSP 0

ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0

2 rtl pack lmtamt999 rtl pack lmtday(s) AL(Atleast 18 yrsold)

TWINRIX SUSY 0

VAQTA SUSP 0

VARIVAX INJ 0 2 rtl MAX fill365 rtl day(s) supply

ZOSTAVAX SUSR 0

VAGINAL AND RELATED PRODUCTS

Miscellaneous Vaginal Products

INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0

Vaginal Anti-infectives CLEOCIN CREA VA 2 (Use clindamycinphosphate vaginal)

clindamycin phosphatevaginal crea 1

clotrimazole vaginal crea 1

Drug Name DrugTier

RequirementsLimits

GYNAZOLE-1 CREA 3

GYNE-LOTRIMIN CREA (Use clotrimazole vaginal) NF

metronidazole vaginal gel 1

miconazole nitrate vaginal supp 1

terconazole vaginal crea 1

terconazole vaginal supp 1

Vaginal Contraceptive - pH Modulators

PHEXXI GEL 0 PV

Vaginal Estrogens ESTRACE CREA (Use estradiol vaginal) NF

estradiol vaginal crea 1

estradiol vaginal tabs 1

FEMRING RING 3

PREMARIN CREA 2

VAGIFEM TABS (Use estradiol vaginal) NF

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents ADRENALIN SOLN IJ 30 MG30ML (Use epinephrine (anaphylaxis))

epinephrine (anaphylaxis)soaj 015 mg03ml 1

QL(2 ea per fillretail2 ea perfill mail)2 rtlMAX fill365 rtl day(s) supply2mail MAX fill365 mail day(s) supply

QL(2 ea per fillretail)2 rtl MAXfill365 rtl day(s) supply

Drug Name DrugTier

RequirementsLimits

EPIPEN 2-PAK SOAJ (Use epinephrine (anaphylaxis)) NF

EPIPEN-JR 2-PAK SOAJ (Use epinephrine(anaphylaxis))

Vasopressors

midodrine hcl tabs 1

VITAMINS

Oil Soluble Vitamins cholecalciferol caps 125mg 50000 unit 1

cholecalciferol tabs 400 unit 0

DRISDOL CAPS (Use ergocalciferol) 0

ergocalciferol caps or 125mg 50000 unit 0

ergocalciferol soln or 200mcgml 8000 unitml 1

VITAMIN D2 TABS 0 AL(At least 65yrs old)

Water Soluble Vitamins niacin cpcr or 500 mg 250 mg 1

niacin tabs or 250 mg 50mg 100 mg 500 mg 1

niacin tbcr or 750 mg 250mg 500 mg 1

NIACIN TR TBCR 1

niacinamide tabs or 100 mg 500 mg 1

Drug Name DrugTier

RequirementsLimits

SLO-NIACIN TBCR (Use niacin) 1

Index 1ST TIER UNILET COMFORTOUCH LANCETS 28G 78 1ST TIER UNILET COMFORTOUCH LANCETS 30G 78 abacavir sulfate 4445 abacavir sulfate-lamivudine 45 abacavir sulfate-lamivudine-zidovudine 45 ABELCET 27 ABILIFY 44 abiraterone acetate 3637 ABRAXANE 40 ABSORICA 56 acamprosate calcium 123 acarbose 23 ACCOLATE 14 ACCU-CHEK FASTCLIX LANCETS 78 ACCU-CHEK MULTICLIX LANCETS 78 ACCU-CHEK SAFE-T-PRO LANCETS 78 ACCU-CHEK SAFE-T-PRO PLUSLANCETS 78 ACCU-CHEK SOFTCLIX LANCETS 78 ACCUPRIL 30 ACCURETIC 31 acebutolol hcl 49 acetaminophen w codeine 8 acetaminophen-caff-dihydrocod 8 acetazolamide 65 acetazolamide sodium 65 acetic acid 72 acetic acid (otic) 121 acetylcysteine 56 ACIPHEX 128 acitretin 60 ACTHAR 67 ACTHIB 129 ACTI-LANCE LANCETS 28G 78 ACTI-LANCE LITE SAFETY LANCETS 28G 78 ACTI-LANCE SPECIAL SAFETY LANCETS 17G 78 ACTI-LANCE SPECIAL SAFETYLANCETS 17G 78 ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G 78

ACTIGALL 70 ACTIMMUNE 40 ACTIQ 6 ACTONEL 66 ACTOPLUS MET 23 ACTOS 24 ACULAR 121 ACULAR LS 121 acyclovir 48 acyclovir topical 61 ADACEL 127 ADALAT CC 49 adapalene 56 adapalene-benzoylperoxide 56 ADCETRIS 36 ADCIRCA 51 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 47 ADEMPAS 51 ADIPEX-P 1 ADJUSTABLE LANCING DEVICE 78 ADRENALIN 132 ADVAIR DISKUS 14 ADVAIR HFA 14 ADVANCED MOBILE LANCET 30G 78 ADVOCATE INSULIN SYRINGEU-10003ML29GX12 89 ADVOCATE INSULIN SYRINGEU-10003ML30GX516 89 ADVOCATE INSULIN SYRINGEU-10003ML31GX516 90 ADVOCATE INSULIN SYRINGEU-10005ML29GX12 90 ADVOCATE INSULIN SYRINGEU-10005ML30GX516 90 ADVOCATE INSULIN SYRINGEU-10005ML31GX516 90 ADVOCATE INSULIN SYRINGEU-1001ML29GX12 90 ADVOCATE INSULIN SYRINGEU-1001ML30GX516 90

ADVOCATE INSULIN SYRINGEU-1001ML31GX516

90 ADVOCATE LANCETS 78 ADVOCATE LANCETS 30G 78 ADVOCATE LANCING DEVICE 78 ADVOCATE RAPID-SAFE LANCING DEVICE 78 ADVOCATE SAFETY LANCETS 78 ADVOCATE SAFETY LANCETS 26G 78 ADZENYS ER 1 AFINITOR 38 AFLURIA QUADRIVALENT 2019-2020 129 AFLURIA QUADRIVALENT 2020-2021 129 AFLURIA QUADRIVALENT 2021-2022 129 AGAMATRIX ULTRA-THIN LANCETS 33G 78 AGGRENOX 73 AGRYLIN 73 AIMOVIG 111 AIMSCO LUBRICATED 76 AIMSCO TWIST LANCETS 32G 78 AIMSCO TWIST LANCETS 33G 78 AIRDUO RESPICLICK 11314 14 AIRDUO RESPICLICK 23214 14 AIRDUO RESPICLICK 551414 AKYNZEO 26 albendazole 10 ALBENZA 10 albuterol sulfate 1415 ALCAINE 120 alclometasone dipropionate 61 ALDACTAZIDE 65 ALDACTONE 66 ALDARA 64 ALDURAZYME 68 ALECENSA 38 alendronate sodium 66 alfuzosin hcl 72 ALIMTA 35 ALINIA 11 aliskiren fumarate 33

Index 1

ALKERAN 35 amlodipine besylate-olmesartan ARIMIDEX 37 medoxomil 31 ALLEGRA ALLERGY 28 aripiprazole 44 amlodipine besylate-ALLEGRA ALLERGY ARIXTRA 16 valsartan 31 CHILDRENS 28 amlodipine-valsartan- armodafinil 2 ALLEGRA-D 12 HOUR hydrochlorothiazide 31 ARMOUR THYROID 126 ALLERGY amp CONGESTION 55 amoxapine 22 ALLEGRA-D 24 HOUR ARNUITY ELLIPTA 14

ALLERGY amp CONGESTION 55 amoxicillin 122 AROMASIN 37 allopurinol 72 amoxicillin amp pot ARRANON 35 clavulanate 122 almotriptan malate 112 amphetamine- arsenic trioxide 40 ALOCRIL 121 dextroamphetamine 1 ARTHROTEC 50 4 alogliptin benzoate 24 amphotericin b 27 ARTHROTEC 75 4 ALOMIDE 121 ampicillin 122 ARZERRA 36 alosetron hcl 71 ampicillin amp sulbactam ASACOL HD 70 sodium 122 ALOXI 26 asenapine maleate 43 ampicillin sodium 122 ALPHAGAN P 119 aspirin 6 AMPYRA 124 alprazolam 13 aspirin-dipyridamole 73 ANADROL-50 9 ALREX 120 ASSURE HAEMOLANCE PLUS ANAFRANIL 22 ALTABAX 57 HIGH FLOW 18G 78

anagrelide hcl 73 ASSURE HAEMOLANCE PLUS ALTACE 30 anastrozole 37 LOW FLOW 25G 78 ALTERNATE SITE LANCING ASSURE HAEMOLANCE PLUS DEVICE 78 ANCOBON 27 MICRO FLOW 28G 78 ALTOPREV 30 ANDRODERM 9 ASSURE HAEMOLANCE PLUS

ALUNBRIG 38 ANDROGEL 9 NORMAL FLOW 21G 79 alvimopan 71 ANNOVERA 53 ASSURE HAEMOLANCE PLUS

PEDIATRIC BLADE 79 amantadine hcl 41 ANORO ELLIPTA 15 ASSURE ID INSULIN AMARYL 25 ANTABUSE 123 SAFETYSYRINGEU-AMBIEN 74 ANUSOL-HC 10 10005ML29G X 12 90

ASSURE ID INSULIN AMBIEN CR 74 ANZEMET 26 SAFETYSYRINGEU-AMBISOME 27 APIDRA 24 1001ML29G X 12 90 ambrisentan 51 24 APIDRA SOLOSTAR ASSURE LANCE LANCETS 79 amcinonide 61 APO-VARENICLINE 125 ASSURE LANCE LANCETS AMCINONIDE 61 APOKYN 41 21G 79

ASSURE LANCE PLUS AMERGE 112 apraclonidine hcl 119 SAFETYLANCETS 25G 79 AMICAR 74 aprepitant 27 ASSURE LANCE PLUS amikacin sulfate 3 APRISO 70 SAFETYLANCETS 30G 79 amiloride amp ASSURE LANCE SAFETY APTIOM 17 hydrochlorothiazide 65 LANCET 28G 79 APTIVUS 45 amiloride hcl 66 ASSURE LANCETS 79 AQUA LANCE ADJUSTABLE aminocaproic acid 74 LANCING DEVICE 78 ATACAND 31 aminophylline 15 ARALAST NP 125 ATACAND HCT 31 amiodarone hcl 13 ARANESP ALBUMIN atazanavir sulfate 45

FREE 73 AMITIZA 70 ATELVIA 66 ARAVA 5 amitriptyline hcl 22 atenolol 49 ARCALYST 4 amlodipine besylate 49 atenolol amp chlorthalidone 31 ARCAPTA NEOHALER 15 amlodipine besylate-atorvastatin ATGAM 115

calcium 50 arformoterol tartrate 15 ATIVAN 13 amlodipine besylate-benazepril ARICEPT 123 atomoxetine hcl 2 hcl 31 ARIKAYCE 3

Index 2

atorvastatin calcium 30 B-D INSULIN SYRINGE BD INSULIN SYRINGE ULTRAFINE II03ML31G X SAFETYGLIDE1ML29G Xatovaquone 11 516 90 12 90 atovaquone-proguanil hcl 33 B-D INSULIN SYRINGE BD INSULIN SYRINGE SLIP

ATRIPLA 45 ULTRAFINE II05ML31G X TIPU-1001ML 90 atropine sulfate 127 516 90 BD INSULIN SYRINGE ULTRA-

B-D INSULIN SYRINGE FINE03ML30G X 127MM 90 ATROVENT HFA 14 ULTRAFINE II1ML31G X BD INSULIN SYRINGE ULTRA-AUBAGIO 124 516 90 FINE03ML31G X 8MM 90 AUGMENTIN 123 B-D INSULIN SYRINGE BD INSULIN SYRINGE ULTRA-

ULTRAFINE03ML30G X FINE05ML30G X 127MM 90 AUGMENTIN ES-600 122 12 90 BD INSULIN SYRINGE ULTRA-AURORA LANCET SUPER B-D INSULIN SYRINGE FINE05ML31G X 8MM 90 THIN30G 79 ULTRAFINE05ML30G X BD INSULIN SYRINGE ULTRA-AURORA LANCET THIN 12 90 FINE12 UNIT03ML31G X23G 79 8MM 91 bacitracin 10 AUSTEDO 124 BD INSULIN SYRINGE ULTRA-bacitracin (ophthalmic) 119 AUTO-LANCET 79 FINE1ML30G X 127MM 91 baclofen 117 BD INSULIN SYRINGE ULTRA-AUTO-LANCET MINI 79 BACTRIM 10 FINE1ML31G X 8MM 91 AUTOLET IMPRESSION BD INSULIN SYRINGE LANCING DEVICE 79 BACTRIM DS 10 ULTRAFINE HALF-AUTOLET LANCING BALCOLTRA 52 UNIT03ML31G X 516 91 DEVICE 79 balsalazide disodium 71 BD INSULIN SYRINGE AUTOLET MINI 79 BALVERSA 38 ULTRAFINE03ML30G X

AUTOLET PLUS 79 12 91 BANZEL 17 AVALIDE 32 BD INSULIN SYRINGE BAQSIMI ONE PACK 24 ULTRAFINE03ML31G XAVANDIA 24 BAQSIMI TWO PACK 24 516 91 AVAPRO 31 BD INSULIN SYRINGE BARACLUDE 47 AVELOX 70 ULTRAFINE05ML30G XBASAGLAR KWIKPEN 24 AVODART 72 12 91 BAXDELA 70 BD INSULIN SYRINGE AVONEX 124 BD LO-DOSE INSULIN ULTRAFINE05ML31G X

AVONEX PEN 124 SYRINGE MICROFINE 516 91 AVSOLA 70 IV05ML28G X 12 90 BD INSULIN SYRINGE AYGESTIN 123 BD AUTOSHIELD 29G X ULTRAFINE1ML30G X

316 90 12 91 AYVAKIT 37 BD AUTOSHIELD 29G X BD INSULIN SYRINGE azacitidine 35 516 90 ULTRAFINEU-10003ML29G XAZACTAM 11 BD AUTOSHIELD DUO 30G X 12 91

5MM 90 BD INSULIN SYRINGE AZASITE 119 BD INSULIN SYRINGE LUER- ULTRAFINEU-10005ML29G XAZATHIOPRINE 115 LOKU-1001ML 90 12 91 azathioprine 115 BD INSULIN SYRINGE BD INSULIN SYRINGE azelaic acid 64 MICROFINE IVU- ULTRAFINEU-1001ML29G X

10005ML28G X 12 90 12 91 azelastine hcl 118 BD INSULIN SYRINGE BD INSULIN SYRINGE azelastine hcl (ophth) 121 MICROFINE IVU- ULTRAFINEU-1001ML31G XAZELEX 56 1001ML27G X 58 90 516 91

BD INSULIN SYRINGE BD INSULIN AZILECT 42 MICROFINE IVU- SYRINGE03ML29G Xazithromycin 76 1001ML28G X 12 90 127MM 91 AZOR 32 BD INSULIN SYRINGE BD INSULIN aztreonam 11 MICROFINEU-1001ML27G X SYRINGE05ML29G X

58 90 127MM 91 AZULFIDINE 71 BD INSULIN SYRINGE BD INSULIN SYRINGE1ML27GAZULFIDINE EN-TABS 70 MICROFINEU-1001ML28G X X 127MM 91

Index 3

BD INSULIN SYRINGE1ML29G BD VEO INSULIN SYRINGE BLEPH-10 119 X 127MM 91 ULTRA-FINEU-1001ML31G BONIVA 66 BD INSULIN X 1564 92 BOOSTRIX 127 SYRINGEDETACHABLE BELSOMRA 75 NEEDLEU-1001ML25G X BORTEZOMIB 38 BELVIQ 2 1 91 benazepril amp bosentan 51 BD INSULIN hydrochlorothiazide 32 BOSULIF 38 SYRINGEDETACHABLE benazepril hcl 30 BOTOX 118 NEEDLEU-1001ML25G X58 91 BENICAR 31 BRAFTOVI 38 BD INSULIN BENICAR HCT 32 BREO ELLIPTA 15 SYRINGEDETACHABLE BENZACLIN 56 BRILINTA 73 NEEDLEU-1001ML26G X12 91 BENZACLIN WITH PUMP 56 brimonidine tartrate 119 BD INSULIN SYRINGEU- BENZAMYCIN 56 BRIVIACT 17 1001ML27G X 12 91 benzonatate 55 bromfenac sodium (ophth) 121 BD LANCET ULTRAFINE 30G 79 benzoyl peroxide 56 bromocriptine mesylate 41

BENZOYL PEROXIDE BD LANCET ULTRAFINE BROVANA 15 CLEANSER 56 33G 79 BRUKINSA 38 BD MICROTAINER benzoyl peroxide-

LANCETS 79 erythromycin 56 budesonide 54 BD PEN benztropine mesylate 41 budesonide (inhalation) 14 NEEDLEMICROULTRA- bepotastine besilate 121 budesonide (nasal) 118 FINE32G X 6MM 91 BEPREVE 121 budesonide-formoterol fumarate BD PEN NEEDLEMINIULTRA- betamethasone dipropionate dihydrate 15 FINE31G X 5MM 91 BULLSEYE MINI SAFETY (topical) 61 BD PEN NEEDLENANO 2ND betamethasone dipropionate LANCETS 79 GEN32G X 532 91 BULLSEYE SAFETY augmented 61 BD PEN LANCETS 79 betamethasone valerate 61 NEEDLENANOULTRA- bumetanide 66 FINE32G X 4MM 91 BETAPACE 49

BUMEX 66 BD PEN BETAPACE AF 49 NEEDLEORIGINALULTRA- BUNAVAIL 9 BETASERON 124 FINE29G X 127MM 91 BUPHENYL 68 BD PEN betaxolol hcl 49

BUPRENEX 9 NEEDLESHORTULTRA- betaxolol hcl (ophth) 119 FINE31G X 8MM 91 buprenorphine 9 bethanechol chloride 129 BD SAFETY-GLIDE INSULIN buprenorphine hcl 9 BEVESPI AEROSPHERE 15 SYRINGE05ML29G X 12 91 buprenorphine hcl-naloxone hclBD SAFETY-LOK INSULIN BEVYXXA 15 dihydrate 9 SYRINGEPERM bexarotene 40 bupropion hcl 20 NEEDLEUF1ML29G X BEXSERO 129 bupropion hcl (smoking12 92 deterrent) 125 BEYAZ 52 BD SAFETYGLIDE INSULIN buspirone hcl 12 SYRINGE03ML29G X 12 92 bicalutamide 37 BD SAFETYGLIDE INSULIN busulfan 35 BICNU 35 SYRINGE03ML31G X BUSULFEX 35 BIDIL 50 516 92 butalbital-acetaminophen 5 BD SAFETYGLIDE INSULIN BIKTARVY 45 butalbital-acetaminophen-SYRINGE1ML31G X BILTRICIDE 10 caffeine 5 1564 92 bimatoprost 121 butalbital-acetaminophen-BD SAFETYGLIDE INSULIN

bisacodyl 75 caffeine w codeine 8 SYSYRINGE05ML30G X516 92 bisoprolol amp butalbital-aspirin-caffeine 5 BD VEO INSULIN SYRINGE hydrochlorothiazide 32 butalbital-aspirin-caffeineULTRA-FINE1ML31G X bisoprolol fumarate 49 wcod 8

BUTALBITALACETAMINOPHEN6MM 92 bleomycin sulfate 38 5

Index 4

butenafine hcl 58 CARDURA 31 carvedilol 49 butorphanol tartrate 9 CAREONE ADVANCED CASODEX 37

LANCINGDEVICE 79 BUTRANS 9 caspofungin acetate 27 CAREONE INSULIN BYSTOLIC 49 CATAPRES 31 SYRINGES03ML30G Xcabergoline 69 12 92 CATAPRES-TTS-1 31

CAREONE INSULIN CABLIVI 73 CATAPRES-TTS-2 31 SYRINGES03ML31G XCADUET 50 CATAPRES-TTS-3 31 516 92

CAFERGOT 112 CAREONE INSULIN CAYA 76 CALAN SR 49 SYRINGES05ML30G X CAYSTON 11

12 92 calcipotriene 60 cefaclor 52 CAREONE INSULIN calcipotriene-betamethasone cefadroxil 51 SYRINGES05ML31G Xdipropionate 61 516 92 cefazolin sodium 52 calcitonin (salmon) 66 CAREONE INSULIN cefdinir 52 calcitriol 68 SYRINGES1ML30G X cefditoren pivoxil 52 calcitriol (topical) 60 12 92

CAREONE INSULIN cefepime hcl 52 calcium acetate (phosphateSYRINGES1ML31GX516 cefixime 52 binder) 71

calcium chloride (dihydrate)113 92 CEFOTAN 52 CAREONE LANCET SUPER CALCIUM GLUCONATE 113 cefotaxime sodium 52 THIN30G 79 calcium gluconate 113 CAREONE LANCET THIN 79 cefotetan disodium 52 calcium polycarbophil 75 CARESENS LANCETS 79 cefoxitin sodium 52 CAMPTOSAR 41 CARETOUCH INSULIN cefpodoxime proxetil 52 CANASA 71 SYRINGE03ML31GX516 cefprozil 52

92 CANCIDAS 27 ceftazidime 52 CARETOUCH INSULIN candesartan cilexetil 31 SYRINGE05ML31GX516 ceftriaxone sodium 52 candesartan cilexetil- 92 cefuroxime axetil 52 hydrochlorothiazide 32 CARETOUCH INSULIN cefuroxime sodium 52 CAPASTAT SULFATE 34 SYRINGE1ML30GX516 CELEBREX 4 capecitabine 35 92

CARETOUCH INSULIN celecoxib 4 CAPRELSA 38 SYRINGE1ML31GX516 CELESTONE SOLUSPAN 54 captopril 30 92 CELESTONE-SOLUSPAN 54 CARETOUCH INSULIN CARAC 59 CELEXA 21 SYRINGE05ML30GX516CARAFATE 128 92 CELLCEPT 115 CARBAGLU 68 CARETOUCH LANCING CELONTIN 20 carbamazepine 17 DEVICEWITH EJECTOR 79 cephalexin 52 CARETOUCH SAFETY CARBATROL 17

LANCETS26G 79 CERDELGA 73 carbidopa 41 CARETOUCH SAFETY CEREBYX 19 carbidopa-levodopa 41 LANCETS28G 79 CEREZYME 73 carbidopa-levodopa-entacapone CARETOUCH SAFETY cetirizine hcl 28 41 LANCETS30G 79 CARBIDOPALEVODOPA CARETOUCH TWIST cetirizine-pseudoephedrine 55 ODT 41 LANCETS 28G 79 CETRAXAL 121

CARETOUCH TWIST carbinoxamine maleate 28 CETROTIDE 67 LANCETS 30G 79 carboplatin 35 CARETOUCH TWIST cevimeline hcl 116 CARDIOCOM LANCING LANCETS 33G 79 CHANTIX 125 DEVICE 79 carisoprodol 117 CHANTIX CONTINUING CARDIZEM 49 carmustine 35 MONTHPAK 125 CARDIZEM CD 49 CHANTIX STARTING MONTH carteolol hcl (ophth) 119 CARDIZEM LA 49 PAK 125

Index 5

CHEMET 25 CLARITIN 28 CLEVER CHOICE COMFORT

CHEMSTRIP-K CHILDRENS ADVIL CHILDRENS MOTRIN chloramphenicol sodiumsuccinate

65 4 4

CLARITIN ALLERGY CHILDRENS CLARITIN CHILDRENS CLARITIN REDITABS CLARITIN-D 12 HOUR

28 28 28 55

EZINSULIN SYRINGE10ML30G X 12 93 CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML28GX 12 93 CLEVER CHOICE COMFORT

chlordiazepoxide hcl 13 chlordiazepoxide hcl-clidiniumbromide 127 chlorhexidine gluconate (mouth-throat) 116 chloroquine phosphate 33 chlorpromazine hcl 44 chlorthalidone 66

CLARITIN-D 24 HOUR CLASSIC PRENATAL CLEANLET LANCETS 28G CLEMASTINE FUMARATE clemastine fumarate CLENPIQ

55 116

28 28 75

EZINSULIN SYRINGE1ML29GX 12 93 CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML30GX 516 93 CLEVER CHOICE COMFORT EZINSULIN SYRINGEU-1001ML31GX516 93 CLIMARA 69

chlorzoxazone 117 CLEOCIN 11131 CLIMARA PRO 69 CHOLBAM 70 cholecalciferol 132 cholestyramine 29 cholestyramine light 29 choline fenofibrate 29 CHORIONIC GONADOTROPIN 67 CIALIS 51 ciclopirox 58 ciclopirox olamine 58 cidofovir 47 cilostazol 73 CILOXAN 119 CIMDUO 45 cimetidine 127 cimetidine hcl 127 cinacalcet hcl 68 CINRYZE 72 CIPRO 70 CIPRO HC 121 CIPRODEX 121 ciprofloxacin 70 ciprofloxacin hcl 70 ciprofloxacin hcl (ophth) 119 ciprofloxacin hcl (otic) 121 ciprofloxacin in d5w 70 ciprofloxacin-dexamethasone

121 ciprofloxacin-fluocinoloneacetonide 121 cisplatin 35 citalopram hydrobromide 21 CLARINEX 28 clarithromycin 76

CLEOCIN PEDIATRIC GRANULES 11 CLEOCIN PHOSPHATE 11 CLEOCIN-T 56 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML29G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML30G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML30G X516 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML31G X516 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML28G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML29G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML30G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML30G X516 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML31G X516 93

CLINDAGEL 56 clindamycin hcl 11 clindamycin palmitatehydrochloride 11 clindamycin phosphate 11 clindamycin phosphate(topical) 56 clindamycin phosphatevaginal 131 clindamycin phosphate-benzoylperoxide 57 clindamycin phosphate-benzoylperoxide (refrigerate) 57 clindamycin phosphate-tretinoin 57 CLINIMIX 425DEXTROSE10 118 CLINIMIX 425DEXTROSE25 119 CLINIMIX 425DEXTROSE5 119 CLINIMIX 5DEXTROSE25 119 CLINIMIX E 5DEXTROSE20 119 clobazam 17 clobetasol propionate 61 clobetasol propionate emollientbase 61 clocortolone pivalate 61 CLODERM 61 clofarabine 35 CLOLAR 35 clomipramine hcl 23 clonazepam 17 clonidine 31 clonidine hcl 31 clonidine hcl (adhd) 2

Index 6

clopidogrel bisulfate 73 COMFORT ASSURED CVS LANCETS MICRO THIN LANCETS MICRO THIN 33G 79 clorazepate dipotassium 13 33G 79 CVS LANCETS MICRO-THIN

clotrimazole 116 COMFORT ASSURED 33G 79 clotrimazole (topical) clotrimazole vaginal clotrimazole wbetamethasone clozapine CLOZARIL COAGUCHEK LANCETS COARTEM CODEINE SULFATE codeine sulfate COGENTIN COLACE COLAZAL colchicine colchicine w probenecid COLCRYS colesevelam hcl COLESTID

58 131

58 43 43 79 33

41 75 71 72 72 72 29 29

LANCETS SUPER THIN 28G 79 COMFORT EZ INSULIN SYRINGEU-10005ML31G X516 93 COMFORT EZ INSULIN SYRINGEU-1001ML31G X516 93 COMFORT LANCETS 79 COMPLERA 45 COMTAN 41 CONCERTA 2 CONTRAVE 2 CONZIP 6 COPAXONE 124 COPIKTRA 38 CORDRAN 61 COREG 49 CORGARD 49

CVS LANCETS ORIGINAL 79 CVS LANCETS THIN 26G 80 CVS LANCETS ULTRA THIN 30G 80 CVS LANCETS ULTRA-THIN 30G 80 CVS LANCING DEVICE 80 CVS PRENATAL 116 CVS ULTRA THIN LANCETS 80 cyanocobalamin 73 cyclobenzaprine hcl 117 cyclophosphamide 35 cycloserine 34 CYCLOSET 24 cyclosporine 115 cyclosporine modified (formicroemulsion) 115 CYKLOKAPRON 74

COLESTID FLAVORED 29 CORLANOR 51 CYMBALTA 22

colestipol hcl COLY-MYCIN S

29 121

CORTEF CORTENEMA

cyproheptadine hcl CYSTADANE

COLYTE-FLAVOR PACKS 75 cortisone acetate 54 CYSTAGON 71

COMBIGAN 119 CORTISPORIN-TC 122 CYSTARAN 121

COMBIVIR 45 COSENTYX 60 cytarabine 35

COMETRIQ 38 COMFORT ASSIST INSULIN SYRINGE 03ML29G X 12 93 COMFORT ASSIST INSULIN SYRINGE03ML30G X516 93 COMFORT ASSIST INSULIN SYRINGE03ML31G X516 93 COMFORT ASSIST INSULIN SYRINGE05ML29G X 12 93 COMFORT ASSIST INSULIN SYRINGE05ML30G X516 93 COMFORT ASSIST INSULIN SYRINGE05ML31G X516 93 COMFORT ASSIST INSULIN SYRINGE1ML29G X 12 93 COMFORT ASSIST INSULIN SYRINGE1ML30G X 516 93 COMFORT ASSIST INSULIN SYRINGE1ML31G X 516 93

COSENTYX SENSOREADY PEN 60 COSMEGEN 38 COSOPT 119 COUMADIN 15 COZAAR 31 CREON 65 CRESEMBA 27 CRESTOR 30 CRIXIVAN 45 cromolyn sodium 13 cromolyn sodium (ophth) 121 crotamiton 64 CUBICIN 11 CUBICIN RF 11 CUPRIMINE 115 CUTIVATE 62 CUVITRU 122 CVS LANCETS 21G 79

CYTOMEL CYTOTEC CYTOVENE DHE 45 dacarbazine DACOGEN dactinomycin dalfampridine DALIRESP danazol DANTRIUM dantrolene sodium dapsone DAPTACEL DAPTOMYCIN daptomycin DARAPRIM darifenacin hydrobromide DAUNORUBICIN

126 128

47 112

40 35 38

124 14

9 118 118

11 127

11 11 33

HYDROCHLORIDE 38

Index 7

DAURISMO 36 DETROL 129 difluprednate 120 DAYPRO 4 DETROL LA 129 digoxin 50 DAYTRANA 2 dexamethasone 54 dihydroergotamineDDAVP 6869 DEXAMETHASONE mesylate 112

INTENSOL 54 DILANTIN 19 DEBACTEROL 116 dexamethasone sodium DILANTIN INFATABS 19 decitabine 35 phosphate 54 DILANTIN-125 19 deferasirox 25 dexamethasone sodium DILAUDID 6 phosphate (ophth) 120 deferiprone 25 dexchlorpheniramine diltiazem hcl 50 DELESTROGEN 69 maleate 27 DILTIAZEM HCL 50 DELSTRIGO 45 DEXEDRINE 1 diltiazem hcl 50 DELZICOL 71 DEXILANT 128 diltiazem hcl coated beads 49 demeclocycline hcl 126 dexmethylphenidate hcl 2 diltiazem hcl extended release

DEMEROL 6 dextroamphetamine sulfate 1 beads 50 DENAVIR 61 DEXTROSE 5NACL dimethyl fumarate 124 DEPAKOTE 20 03 113 DIOVAN 31 dextrose in lactated DEPAKOTE ER 20 DIOVAN HCT 32 ringers 113 DEPEN TITRATABS 115 DEXTROSESODIUM DIPENTUM 71 DEPO-ESTRADIOL 69 CHLORIDE 113 diphenhydramine hcl 28

DIACOMIT 17 DEPO-MEDROL 54 diphenoxylate w atropine 25 DEPO-PROVERA DIASTAT ACUDIAL 17 DIPHTHERIATETANUSCONTRACEPTIVE 54 DIASTAT PEDIATRIC 17 TOXOIDS ADSORBED DEPO-SUBQ PROVERA PEDIATRIC 127 DIATHRIVE LANCETS 80 104 54 DIPROLENE 62 DIATHRIVE LANCETS ULTRA DEPO-TESTOSTERONE 9 THIN 30G 80 DIPROLENE AF 62 DERMA-SMOOTHEFS DIATHRIVE LANCING dipyridamole 73 BODY 62 DEVICE 80 DERMA-SMOOTHEFS disopyramide phosphate 13 diazepam 13 SCALP 62 disulfiram 123 diazepam (anticonvulsant) 17 DERMOTIC 122 DITROPAN XL 129 diazoxide 24 DESCOVY 45 DIURIL 66 DIBENZYLINE 31 desipramine hcl 23 divalproex sodium 20 DICLEGIS 26 desloratadine 28 DIVIGEL 69 diclofenac epolamine 57 desmopressin acetate 69 docetaxel 40 DESMOPRESSIN diclofenac potassium 4 DOCETAXEL 40 ACETATE 69 diclofenac sodium 4 docetaxel 40 desmopressin acetate 69 diclofenac sodium (actinic

keratoses) 59 docusate calcium 75 desmopressin acetate spray 69 desmopressin acetate spray diclofenac sodium (ophth)121 docusate sodium 75 refrigerated 69 diclofenac sodium (topical) 57 dofetilide 13 desogestrel amp ethinyl diclofenac w misoprostol 4 donepezil hydrochloride 123 estradiol 52 dicloxacillin sodium 123 DOPTELET 73 desogestrel-ethinyl estradiol(biphasic) 52 dicyclomine hcl 127 DORAL 74 desogestrel-ethinyl estradiol didanosine 45 dorzolamide hcl 121 (triphasic) 52 dorzolamide hcl-timolol DIFFERIN 57 desonide 62 maleate 119 DIFICID 76 DESOWEN 62 DOVATO 45 diflorasone diacetate 62 desoximetasone 62 DOVONEX 60 DIFLUCAN 27 DESOXYN 1 doxazosin mesylate 31 diflunisal 6 desvenlafaxine succinate 22 doxepin hcl 23

Index 8

doxepin hcl (antipruritic) 60 doxepin hcl (sleep) 74 doxercalciferol 68 DOXIL 38 doxorubicin hcl 38 doxorubicin hcl liposomal 38 doxycycline (monohydrate) 126 doxycycline hyclate 126 doxylamine-pyridoxine 26 DRISDOL 132 dronabinol 26 DROPLET GENTEEL LANCING DEVICE 80 DROPLET INSULIN SYRINGE 03ML29G X 12 93 DROPLET INSULIN SYRINGE 05ML29G X 12 93 DROPLET INSULIN SYRINGE 1ML29G X 12 93 DROPLET INSULIN SYRINGE U-1000331G X 516 93 DROPLET INSULIN SYRINGE U-10003ML30G X 12 93 DROPLET INSULIN SYRINGE U-10003ML30G X 516 93 DROPLET INSULIN SYRINGE U-10005ML30G X 12 93 DROPLET INSULIN SYRINGE U-10005ML30G X 516 93 DROPLET INSULIN SYRINGE U-10005ML31G X 516 94 DROPLET INSULIN SYRINGE U-1001ML30G X 12 94 DROPLET INSULIN SYRINGE U-1001ML30G X 516 94 DROPLET INSULIN SYRINGE U-1001ML31G X 1564 94 DROPLET INSULIN SYRINGE U-1001ML31G X 516 94 DROPLET INSULIN SYRINGEU-10003ML31G X516 94 DROPLET INSULIN SYRINGEU-10005ML30G X12 94 DROPLET INSULIN SYRINGEU-10005ML31G X516 94 DROPLET INSULIN SYRINGEU-1001ML30G X12 94 DROPLET INSULIN SYRINGEU-1001ML31G X1564 94

DROPLET INSULIN SYRINGEU-1001ML31G X516 94 DROPLET LANCETS ULTRA THIN 30G 80 DROPLET LANCING DEVICE 80 DROPLET PERSONAL LANCETS30G 80 drospirenone-ethinylestradiol 52 drospirenone-ethinyl estradiol-levomefolate calcium 52 DROXIA 73 DRUG MART ADJUSTABLE LANCING DEVICE 80 DRUG MART LANCETS THIN 80 DRUG MART ON-THE-GO LANCETS GENTLE 30G 80 DRUG MART UNILET LANCETSSUPER THIN 30G 80 DRUG MART UNILET LANCETSULTRA THIN 28G 80 DRUG MART UNILET MICRO THIN LANCETS 33G 80 DUAC 57 DUAVEE 69 DUETACT 23 DULCOLAX 75 duloxetine hcl 22 DUPIXENT 63 DURAGESIC 6 DUREX EXTRA SENSITIVE 76 DUREZOL 120 dutasteride 72 DYAZIDE 65 DYRENIUM 66 DYSPORT 118 E-Z JECT LANCETS 80 E-Z JECT LANCETS 21G 80 E-Z JECT LANCETS COLOR 80 E-Z JECT LANCETS SUPER THIN 30G 80 E-Z JECT LANCETS THIN 26G 80 E-ZJECT LANCETS MICRO-THIN 33G 80 EES GRANULES 76

EASY COMFORT INSULIN SYRINGE05ML30G X516 94 EASY COMFORT INSULIN SYRINGE05ML31G X516 94 EASY COMFORT INSULIN SYRINGE1ML30G X 516 94 EASY COMFORT INSULIN SYRINGE1ML31G X 516 94 EASY COMFORT INSULIN SYRINGEU-10005ML30G X12 94 EASY COMFORT INSULIN SYRINGEU-1001ML30G X12 94 EASY MINI EJECT LANCING DEVICE 80 EASY MINI LANCING DEVICE 80 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML29GX12 94 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML30GX12 94 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML30GX516 94 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML31GX516 94 EASY TOUCH INSULIN SYRINGE03ML30G X516 94 EASY TOUCH INSULIN SYRINGE03ML31G X516 94 EASY TOUCH INSULIN SYRINGE05ML29G X 12 94 EASY TOUCH INSULIN SYRINGE05ML30G X516 94 EASY TOUCH INSULIN SYRINGE1ML30G X 516 94 EASY TOUCH INSULIN SYRINGESAFETYU-10005ML29G X 12 94 EASY TOUCH INSULIN SYRINGESAFETYU-10005ML30G X 516 95 EASY TOUCH INSULIN SYRINGESAFETYU-1001ML29G X 12 95 EASY TOUCH INSULIN SYRINGESAFETYU-1001ML30G X 12 95

Index 9

EASY TOUCH INSULIN EASY TOUCH LANCETS EFFIENT 73 SYRINGEU-10003ML30G X12 95 EASY TOUCH INSULIN SYRINGEU-10005ML27G X12 95 EASY TOUCH INSULIN SYRINGEU-10005ML28G X12 95 EASY TOUCH INSULIN SYRINGEU-10005ML29G X12 95 EASY TOUCH INSULIN SYRINGEU-10005ML30G X12 95 EASY TOUCH INSULIN SYRINGEU-10005ML31G X516 95 EASY TOUCH INSULIN SYRINGEU-1001ML27G X12 95 EASY TOUCH INSULIN SYRINGEU-1001ML28G X12 95 EASY TOUCH INSULIN SYRINGEU-1001ML29G X12 95 EASY TOUCH INSULIN SYRINGEU-1001ML30G X12 95 EASY TOUCH INSULIN SYRINGEU-1001ML31G X516 95 EASY TOUCH LANCETS 21GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 23GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 26GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 26GPULL-TOP 80 EASY TOUCH LANCETS 28GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 28GPULL-TOP 80 EASY TOUCH LANCETS

30GTWIST 80 EASY TOUCH LANCETS 32GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 32GPULL-TOP 80 EASY TOUCH LANCETS 32GTWIST 80 EASY TOUCH LANCETS 33GTWIST 81 EASY TOUCH LANCING DEVICEEJECTOR 81 EASY TOUCH SAFETY LANCETS21GPRESSUREACTIVATED 81 EASY TOUCH SAFETY LANCETS23GPRESSUREACTIVATED 81 EASY TOUCH SAFETY LANCETS26GBUTTONACTIVATED 81 EASY TOUCH SAFETY LANCETS26GPRESSUREACTIVATED 81 EASY TOUCH SAFETY LANCETS28GBUTTONACTIVATED 81 EASY TOUCH SAFETY LANCETS28GPRESSUREACTIVATED 81 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML29GX12 95 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML30GX516 95 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML31GX516 95 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML30GX12 95 EASY TWIST amp CAP LANCETS 81 EC-NAPROSYN 4 econazole nitrate 58 EDARBI 31 EDECRIN 66

EFUDEX 59 EGRIFTA 67 EGRIFTA SV 67 ELAPRASE 68 ELELYSO 73 ELESTRIN 69 eletriptan hydrobromide 112 ELIDEL 64 ELIGARD 37 ELIMITE 64 ELIQUIS 16 ELIQUIS STARTER PACK 16 ELITE-THIN INSULIN SYRINGE03ML31G X516 95 ELITE-THIN INSULIN SYRINGE05ML29G X 12 95 ELITE-THIN INSULIN SYRINGE05ML30G X516 95 ELITE-THIN INSULIN SYRINGE1ML30G X 516 95 ELITE-THIN INSULIN SYRINGEU-10005ML28G X12 95 ELITE-THIN INSULIN SYRINGEU-10005ML31G X516 95 ELITE-THIN INSULIN SYRINGEU-1001ML28G X12 95 ELITE-THIN INSULIN SYRINGEU-1001ML29G X12 95 ELITE-THIN INSULIN SYRINGEU-1001ML31G X516 95 ELIXOPHYLLIN 15 ELLA 54 ELLENCE 38 ELMIRON 72 ELOCON 62 EMBRACE LANCETS ULTRA THIN 30G 81

28GTWIST EASY TOUCH LANCETS 30GBUTTON-ACTIVATED EASY TOUCH LANCETS 30GPRESSUREACTIVATED EASY TOUCH LANCETS 30GPULL-TOP

EDURANT 45 efavirenz 45 efavirenz-emtricitabine-tenofovir disoproxilfumarate 45 efavirenz-lamivudine-tenofovir disoproxil fumarate 45 EFFEXOR XR 22

EMBRACE LANCING DEVICE WITH EJECTOR 81 EMCYT 37 EMEND 27 EMEND TRIPACK 27 EMFLAZA 54 EMGALITY 111112

Index 10

EMSAM 21 EQL INSULIN ethacrynic acid 66 SYRINGE05ML30G Xemtricitabine 45 ethambutol hcl 34 516 96 emtricitabine-tenofovir disoproxil ethosuximide 20 EQL INSULIN fumarate 45 SYRINGE05ML31G X ethynodiol diacet amp eth

EMTRIVA 45 estrad 52 516 96 EMVERM 10 EQL INSULIN etidronate disodium 66 ENABLEX enalapril maleate enalapril maleate amphydrochlorothiazide ENBREL ENBREL MINI ENBREL SURECLICK ENGERIX-B enoxaparin sodium entacapone entecavir ENTEREG

129 30

32 5 5 5

130 16 41 47 71

SYRINGE1ML29G X 12 96 EQL INSULIN SYRINGE1ML30G X516 96 EQL INSULIN SYRINGE1ML31G X516 96 EQL PRENATAL FORMULA 116 EQL SUPER THIN LANCETS 30G 81 EQL THIN LANCETS 26G 81 EQUETRO 42 ERAXIS 27

etodolac 4 etonogestrel-ethinyl estradiol53 ETOPOPHOS 40 etoposide 40 etravirine 45 EUCRISA 64 EURAX 64 EVAMIST 70 everolimus 38 everolimus (immunosuppressant) 115 EVISTA 67

ENTOCORT EC 54 ERBITUX 36 EVOCLIN 57 ENTRESTO 50 EPCLUSA 47 EPIDIOLEX 17 EPIDUO 57 epinastine hcl (ophth) 121 epinephrine (anaphylaxis) 132 EPIPEN 2-PAK 132 EPIPEN-JR 2-PAK 132 epirubicin hcl 38 EPIVIR 45 EPIVIR HBV 47 eplerenone 33 EPOGEN 73 epoprostenol sodium 51 eprosartan mesylate 31 EPZICOM 45 EQL COLOR LANCETS 21G81 EQL COLOR LANCETS MICRO THIN 33G 81 EQL INSULIN SYRINGE03ML29G X 12 96 EQL INSULIN SYRINGE03ML30G X516 96 EQL INSULIN SYRINGE03ML31G X516 96 EQL INSULIN SYRINGE05ML29G X 12 96

ergocalciferol ergoloid mesylates ERGOMAR ergotamine w caffeine ERIVEDGE erlotinib hcl ERTACZO ertapenem sodium ERWINASE ERWINAZE ERYPED 200 ERYPED 400 erythromycin (acne aid) erythromycin (ophth) erythromycin base erythromycinethylsuccinate escitalopram oxalate ESGIC esomeprazolemagnesium estazolam ESTRACE estradiol estradiol vaginal estradiol valerate ESTROGEL ESTROSTEP FE eszopiclone

132 125 112 112

36 36 58 11 40 40 76 76 57

119 76

128 74 69 69

132 69 70 52 74

EVOXAC 116 EXEL COMFORT POINT INSULIN SYRINGE03ML29G X12 96 EXEL COMFORT POINT INSULIN SYRINGE03ML30G X516 96 EXEL COMFORT POINT INSULIN SYRINGE05ML28G X12 96 EXEL COMFORT POINT INSULIN SYRINGE05ML29G X12 96 EXEL COMFORT POINT INSULIN SYRINGE05ML30G X516 96 EXEL COMFORT POINT INSULIN SYRINGE1ML28G X12 96 EXEL COMFORT POINT INSULIN SYRINGE1ML29G X12 96 EXEL COMFORT POINT INSULIN SYRINGE1ML30G X516 96 EXELDERM 58 exemestane 37 EXFORGE 32 EXFORGE HCT 32 EXJADE 25 EXTAVIA 124 EZ-LETS LANCETS 21G 81 EZ-LETS LANCETS 26G SUPER-SOFT 81

Index 11

EZ-LETS LANCETS 28G FIASP 24 FLUAD QUADRIVALENT 2021-ULTRA-SOFT 81 2022 130 FIASP FLEXTOUCH 24 EZ-LETS LANCETS 30G 81 FLUAD QUADRIVALENT

FIASP PENFILL 24 INFLUENZA VACCINE FOR ezetimibe 30 FIBERCON 75 ADULTS 130 ezetimibe-simvastatin 29 FLUARIX QUADRIVALENT FIBRICOR 30 FABRAZYME 68 2019-2020 130 FIFTY50 SAFETY SEAL FLUARIX QUADRIVALENT FALESSA 53 LANCETS 30G 81 2020-2021 130 famciclovir 48 FIFTY50 SAFETY SEAL FLUARIX QUADRIVALENT LANCETS 32G 81 famotidine 127 2021-2022 130 FIFTY50 SUPERIOR famotidine in nacl 127 FLUBLOK QUADRIVALENT COMFORTINSULIN 2019-2020 130 FANAPT 43 SYRINGE03ML31G X FLUBLOK QUADRIVALENT FANAPT TITRATION PACK 43 516 96 2020-2021 130 FIFTY50 SUPERIOR FANTASY LUBRICATED 77 FLUBLOK QUADRIVALENT COMFORTINSULIN FANTASY 2021-2022 130 SYRINGE05ML31G XLUBRICATEDSPERMICIDE FLUCELVAX QUADRIVALENT 516 96

77 2019-2020 130 FIFTY50 SUPERIOR FLUCELVAX QUADRIVALENT FARESTON 37 COMFORTINSULIN 2020-2021 130 FARXIGA 25 SYRINGE1ML31G X FLUCELVAX QUADRIVALENT 516 96 FASENRA 13 2021-2022 130 FIFTY50 UNILET LANCETS FASENRA PEN 13 fluconazole 27 33G 81 FASLODEX 37 flucytosine 27 FINACEA 64 FAZACLO 43 fludarabine phosphate 35 finasteride 72 FC FEMALE CONDOM 77 fludrocortisone acetate 55 FINE 30 81 febuxostat 72 FLULAVAL QUADRIVALENT FINGERSTIX LANCETS 81 2019-2020 130 felbamate 19 FIORICET 5 FLULAVAL QUADRIVALENT FELBATOL 19 FIORICETCODEINE 8 2020-2021 130 FELDENE 4 FLULAVAL QUADRIVALENT FIORINAL 6 2021-2022 130 felodipine 50 FIORINALCODEINE 3 8 FLUMADINE 48 FEMARA 37 FIRAZYR 72 FLUMIST QUADRIVALENT131 FEMCAP 77 FIRDAPSE 34 flunisolide (nasal) 118 FEMHRT 69 FIRMAGON 37 fluocinolone acetonide 62 FEMRING 132 FIRVANQ 11 fluocinolone acetonide fenofibrate 29 FLAGYL 10 (otic) 122 fenofibrate micronized 29 flavoxate hcl 129 fluocinonide 62 fenoprofen calcium 4 flecainide acetate 13 fluocinonide emulsified base 62 FENSOLVI 68 FLECTOR 57 fluorometholone (ophth) 120 fentanyl 6 FLOLAN 51 fluorouracil 35 fentanyl citrate 6 FLOMAX 72 fluorouracil (topical) 59 FENTORA 6 FLONASE ALLERGY fluoxetine hcl 21 FER-IN-SOL 74 RELIEF 118 FLUOXETINE

FLONASE ALLERGY RELIEF HYDROCHLORIDE 21 FERRIPROX 26 CHILDRENS 118 fluphenazine hcl 44 ferrous fumarate-folic acid 74 FLOVENT DISKUS 14 flurandrenolide 62 ferrous sulfate 74 FLOVENT HFA 14 flurbiprofen 4 FETZIMA 22 floxuridine 35 flurbiprofen sodium 121 FETZIMA TITRATION PACK22 FLUAD 2019-2020 130 flutamide 37 fexofenadine hcl 28 FLUAD 2020-2021 130 fexofenadine-pseudoephedrine fluticasone propionate 62

Index 12

fluticasone propionate(nasal) 118 fluticasone-salmeterol 15 fluvastatin sodium 30 fluvoxamine maleate 21 FLUZONE HIGH-DOSE PF 2019-2020 131 FLUZONE HIGH-DOSE PF 2020-2021 131 FLUZONE HIGH-DOSE PF 2021-2022 131 FLUZONE QUADRIVALENT 2019-2020 131 FLUZONE QUADRIVALENT 2020-2021 131 FLUZONE QUADRIVALENT 2021-2022 131 FML 120

FREESTYLE PRECISION INSULIN SYRINGEU-10005ML30G X 516 96 FREESTYLE PRECISION INSULIN SYRINGEU-10005ML31G X 516 96 FREESTYLE PRECISION INSULIN SYRINGEU-1001ML31G X 516 96 FREESTYLE PRECISION INSULIN SYRINGESU-1001ML30G X 516 96 FREESTYLE UNISTICK II LANCETS 81 FROVA 112 frovatriptan succinate 112 FULPHILA 73 fulvestrant 37

GENTEEL LANCING DEVICEGLORIOUS GOLD 81 GENTEEL LANCING DEVICEPRECIOUSPLATINUM 81 GENTEEL LANCING DEVICESTATELY SILVER 81 GENTEEL PLUS LANCING DEVICEBUFF BLACK 81 GENTEEL PLUS LANCING DEVICEBUTTERFLY BLUE 81 GENTEEL PLUS LANCING DEVICEPLAYFUL PURPLE 81 GENTEEL PLUS LANCING DEVICEPRINCESS PINK 82 GENTEEL PLUS LANCING DEVICEWILLOWY WHITE 82 GENTLE-LET GP LANCETS 82 GENTLE-LET LANCETS

FML FORTE 120 furosemide 66 GENERAL PURPOSE FML LIQUIFILM 120 FOCALIN 2 FOCALIN XR 2 folic acid 73 FOLOTYN 35 fondaparinux sodium 16 FORA GTEL BLOOD KETONE TEST STRIPS 65 FORA LANCETS 81 FORA LANCING DEVICE 81 FORA LANCING DEVICECLEARCAP 81 FORFIVO XL 20 FORTAZ 52 FOSAMAX 66 FOSAMAX PLUS D 66 fosamprenavir calcium 45 fosfomycin tromethamine 12 fosinopril sodium 30 fosinopril sodium amphydrochlorothiazide 32 fosphenytoin sodium 19

FUZEON 45 FYCOMPA 17 gabapentin 18 GABITRIL 19 GALAFOLD 68 galantaminehydrobromide 123 GAMMAGARD LIQUID 122 GAMMAGARD SD IGA LESSTHAN 1MCGML 122 GAMMAKED 122 GAMUNEX-C 122 ganciclovir sodium 47 ganirelix acetate 67 GANIRELIX ACETATE 67 GARDASIL 9 131 gatifloxacin (ophth) 119 gemcitabine hcl 36 GEMCITABINE HYDROCHLORIDE 36 gemfibrozil 30 GENERESS FE 53

STYLEFINE POINT 82 GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINT 82 GENTLE-LET LANCETS SAFETY STYLEFINEPOINT 82 GENTLE-LET LANCETS SAFETY STYLEMEDIUMPOINT 82 GENVOYA 45 GEODON 43 GILENYA 124 GILOTRIF 36 glatiramer acetate 124 GLEEVEC 38 GLEOSTINE 35 glimepiride 25 glipizide 25 glipizide-metformin hcl 23 GLOBAL EASY GLIDE INSULIN SYRINGE1ML31G X1564 96 GLOBAL EASY GLIDE

FOSRENOL 71 FRAGMIN 16 FREDS PHARMACY AUTOLET LANCING DEVICE 81 FREDS PHARMACY UNILET LANCETS SUPER THIN 30G 81 FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G 81 FREESTYLE LANCETS 81

GENOTROPIN 67 GENOTROPIN MINIQUICK 67 gentamicin in saline 3 gentamicin sulfate 3 gentamicin sulfate(ophth) 119 gentamicin sulfate (topical) 57 GENTEEL BUTTERFLY TOUCH LANCETS 81

INSULINSYRINGEU-10003ML31G X 516 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML29G X12 97 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML30G X12 97 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML30G X516 97

Index 13

GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGEU-10003ML31G X516 97 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML28G X12 97 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML29G X12 97 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML30G X12 97 GLOBAL INJECT EASE INSULIN

SYRINGEU-10005ML30G X12 97 GLUCOPRO INSULIN SYRINGEU-10005ML30G X516 97 GLUCOPRO INSULIN SYRINGEU-10005ML31G X516 97 GLUCOPRO INSULIN SYRINGEU-1001ML30G X12 97 GLUCOPRO INSULIN

SYRINGE1ML31G X 516 98 GNP INSULIN SYRINGES03ML30GX516

98 GNP INSULIN SYRINGES12ML29GX12

98 GNP INSULIN SYRINGES1ML28GX12 98 GNP INSULIN SYRINGES1ML29GX12 98 GNP INSULIN

SYRINGEU-10005ML30G X516 97 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML31G X516 97 GLOBAL INJECT EASE INSULIN

SYRINGEU-1001ML30G X516 97 GLUCOPRO INSULIN SYRINGEU-1001ML31G X516 98 GLUCOTROL 25

SYRINGES1ML30GX516 98 GNP INSULIN SYRINGES3ML31GX516 98 GNP LANCETS 21G 82 GNP LANCETS MICRO THIN 33G 82

SYRINGEU-1001ML28G X12 97 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML29G X12 97 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML30G X12 97 GLOBAL INJECT EASE INSULIN

GLUCOTROL XL glyburide glyburide micronized glyburide-metformin glycine (gu irrigant) glycopyrrolate GLYNASE

25 25 25 23 72

127 25

GNP LANCETS SUPER THIN 30G 82 GNP LANCETS THIN 82 GNP LANCETS THIN 26G 82 GNP LANCING SYSTEM DEVICE 82 GNP PRENATAL 116 GNP ULTRA COMFORT

SYRINGEU-1001ML30G X516 97 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML31G X516 97 GLOBAL INSULIN SYRINGEU-10003ML30G X 12 97 GLOBAL INSULIN SYRINGESU-10003ML30GX516 97 GLOBAL LANCING DEVICE 82 GLUCAGEN DIAGNOSTIC 65 GLUCAGEN HYPOKIT 24 glucagon (rdna) 24 GLUCAGON EMERGENCY KIT 24 GLUCOCOM LANCETS 28G 82 GLUCOCOM LANCETS 30G 82 GLUCOCOM LANCETS 33G 82 GLUCOPRO INSULIN SYRINGEU-10003ML30G X12 97 GLUCOPRO INSULIN SYRINGEU-10003ML30G X516 97 GLUCOPRO INSULIN SYRINGEU-10003ML31G X516 97

GLYSET 23 GLYXAMBI 23 GNP INSULIN SYRINGE03ML29G X12 98 GNP INSULIN SYRINGE03ML30G X516 98 GNP INSULIN SYRINGE03ML31G X516 98 GNP INSULIN SYRINGE05ML28G X12 98 GNP INSULIN SYRINGE05ML29G X12 98 GNP INSULIN SYRINGE05ML30G X516 98 GNP INSULIN SYRINGE05ML31G X516 98 GNP INSULIN SYRINGE1ML28G X 12 98 GNP INSULIN SYRINGE1ML29G X 12 98 GNP INSULIN SYRINGE1ML30G X516 98

INSULIN SYRINGE03ML29G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE03ML30G X516 SHORT 98 GNP ULTRA COMFORT INSULIN SYRINGE05ML28G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE05ML29G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE1ML28G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE1ML29G X12 98 GOJJI BLOOD KETONE TEST STRIPS 65 GOJJI LANCING DEVICECLEAR CAP 82 GOJJI STERILE LANCETS 30G 82 GOLYTELY 75 GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL 82 GOODSENSE LANCETS MICRO-THIN 33G 82

Index 14

GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL 82 GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL 82 GOODSENSE LANCETS ULTRA-THIN 30G 82 GOODSENSE LANCETS ULTRA-THIN 30G UNIVERSAL 82 GOODSENSE LANCING DEVICE 82 GOODSENSE PRENATAL VITAMINS 116 granisetron hcl 26 GRASTEK 3 griseofulvin microsize 27 griseofulvin ultramicrosize 27 guanfacine hcl 31 guanfacine hcl (adhd) 2 GUANIDINE HCL 34 GVOKE PFS 24 GYNAZOLE-1 132 GYNE-LOTRIMIN 132 H-E-B INCONTROL ADVANCEDLANCING DEVICE 82 H-E-B INCONTROL LANCETS MICRO THIN 33G 82 H-E-B INCONTROL LANCETS SUPER THIN 30G 82 H-E-B INCONTROL LANCETS ULTRA THIN 28G 82 HAEGARDA 72 HAEMOLANCE 82 HAEMOLANCE LOW FLOW LANCETS 82 HAEMOLANCE PLUS 82 HAEMOLANCE PLUS HIGH FLOW 82 HAEMOLANCE PLUS LOW FLOW 82 HAEMOLANCE PLUS MAX FLOW 82 HAEMOLANCE PLUS PEDIATRIC FLOW 82 HALAVEN 40 halcinonide 62 HALCION 74 HALDOL 43 HALDOL DECANOATE 100 43 HALDOL DECANOATE 50 43 halobetasol propionate 62

HALOG 62 haloperidol 43 haloperidol decanoate 43 haloperidol lactate 43 HAVRIX 131 HEALTH CARE LANCING DEVICE 82 HEALTHWISE INSULIN SYRINGEU-10003ML30G X516 98 HEALTHWISE INSULIN SYRINGEU-10003ML31G X516 98 HEALTHWISE INSULIN SYRINGEU-10005ML30G X516 98 HEALTHWISE INSULIN SYRINGEU-10005ML31G X516 98 HEALTHWISE INSULIN SYRINGEU-1001ML30G X516 99 HEALTHWISE INSULIN SYRINGEU-1001ML31G X516 99 HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE 83 HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G 83 HECTOROL 68 HEMANGEOL 49 HEPARIN LOCK FLUSH 16 heparin sod (porcine) ind5w 16 heparin sodium (porcine) 16 HEPARIN SODIUMNACL045 16 HEPLISAV-B 131 HEPSERA 47 HERCEPTIN 36 HETLIOZ 75 HIBERIX 129 HIPREX 12 HIZENTRA 122 HM PRENATAL 116 HM ULTICARE INSULIN SYRINGE1ML30G X 12 99 HM ULTICARE INSULIN SYRINGEU-10003ML31G X516 99 HORIZANT 125 HUMATIN 3

HUMATROPE 67 HUMATROPE COMBO PACK 67 HUMIRA 4 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 3 HUMIRA PEN 3 HUMIRA PEN-CDUCHSSTARTER 34 HUMIRA PEN-PEDIATRIC UC STARTER PACK 4 HUMIRA PEN-PSUVSTARTER 4 HUMULIN R U-500 (CONCENTRATED) 24 HUMULIN R U-500 KWIKPEN 24 HY-VEE LANCETS 83 HY-VEE THIN LANCETS 83 HYCAMTIN 41 hydralazine hcl 33 HYDREA 40 HYDRO 35 63 hydrochlorothiazide 66 hydrocodone bitartrate 6 HYDROCODONE BITARTRATE ER 6 hydrocodone polistirex-chlorpheniramine polistirex 56 hydrocodone-acetaminophen 8 hydrocodone-ibuprofen 8 hydrocortisone 54 hydrocortisone (intrarectal) 10 hydrocortisone (rectal) 10 hydrocortisone (topical) 62 hydrocortisone acetate(rectal) 10 hydrocortisone butyrate 62 hydrocortisone valerate 63 hydrocortisone waceticacid 122 hydromorphone hcl 6 HYDROMORPHONE HYDROCHLORIDE 6 hydroxychloroquine sulfate 33 hydroxyurea 40 hydroxyzine hcl 12 hydroxyzine pamoate 12 HYPER-SAL 56 HYPERSAL 56 HYQVIA 122

Index 15

HYZAAR 32 INSULIN SYRINGE05ML27G INSULIN X 12 99 SYRINGES05ML31GX516ibandronate sodium 66 INSULIN SYRINGE05ML28G 100 IBRANCE 38 X 12 99 INSULIN

ibuprofen 4 INSULIN SYRINGE05ML30G SYRINGES1ML27GX12X 12 99 100 icatibant acetate 72 INSULIN SYRINGE05ML30G INSULIN ICLUSIG 3839 X 516 99 SYRINGES1ML27GX12 100

icosapent ethyl 29 INSULIN SYRINGE05ML31G INSULIN IDAMYCIN PFS 38 X 516 99 SYRINGES1ML28GX12 100

INSULIN SYRINGE1ML28G X INSULIN idarubicin hcl 38 12 99 SYRINGES1ML29GX12 100 IFEX 35 INSULIN SYRINGE1ML29G X INSULIN ifosfamide 35 12 99 SYRINGES1ML30GX12 100

INSULIN SYRINGE1ML30G X INSULIN ILARIS 4 516 99 SYRINGES1ML31GX516ILEVRO 121 INSULIN SYRINGENEEDLE 100 imatinib mesylate 39 03ML30G X 516 99 INTELENCE 45 IMBRUVICA 39 INSULIN SYRINGENEEDLE INTRAROSA 131 03ML31G X 516 99 imipenem-cilastatin 11 INSULIN SYRINGENEEDLE INTRON A 40 imipramine hcl 23 05ML29G X 12 99 INTUNIV 2 imipramine pamoate 23 INSULIN SYRINGENEEDLE INVANZ 11 05ML30G X 516 99 imiquimod 64 INVEGA 43 INSULIN SYRINGENEEDLEIMITREX 112 05ML31G X 516 99 INVIRASE 46 IMITREX STATDOSE INSULIN SYRINGENEEDLE IONOSOL-MBDEXTROSEREFILL 112 1ML29G X 12 99 5 113 IMITREX STATDOSE INSULIN SYRINGENEEDLE IOPIDINE 119 SYSTEM 112 1ML30G X 516 99 IPOL INACTIVATED IPV 131 IMODIUM A-D 25 INSULIN SYRINGENEEDLE

1ML31G X 516 99 ipratropium bromide 14 IMPAVIDO 10 INSULIN SYRINGEU- ipratropium bromide (nasal)118 IMURAN 115 10003ML29G X 12 99 IN TOUCH LANCING ipratropium-albuterol 15 INSULIN SYRINGEU-

DEVICE 83 irbesartan 31 10005ML29G X 12 99 IN TOUCH STERILE INSULIN SYRINGEU- irbesartan-hydrochlorothiazideLANCETS30G 83 32 1001ML29G X 12 99 INCRELEX 68 INSULIN SYRINGEU- irinotecan hcl 41 INCRUSE ELLIPTA 14 1001ML30G X 516 99 irrigation solutionsindapamide 66 INSULIN SYRINGEU- physiological 116

1001ML31G X 516 99 ISENTRESS 46 INDERAL LA 49 INSULIN ISENTRESS HD 46 indomethacin 45 SYRINGES05ML27GX12ISOLYTE-PDEXTROSE99 INFANRIX 127 5 113 INSULIN INFLECTRA 71 SYRINGES05ML28GX12 ISOLYTE-S 114

INLYTA 36 100 isoniazid 34 INREBIC 39 INSULIN ISOPTO CARPINE 119 SYRINGES05ML29GX12INSPRA 33 ISORDIL TITRADOSE 12 INSULIN SYRINGE03ML29G X 100

INSULIN isosorbide dinitrate 12 1 99 SYRINGES05ML30GX516INSULIN SYRINGE03ML29G X100

isosorbide mononitrate 12 12 99 isotretinoin 57 INSULIN INSULIN SYRINGE03ML30G X SYRINGES05ML31GX isradipine 50 516 99 516 100 ISTODAX (OVERFILL) 39 INSULIN SYRINGE03ML31G X516 99 itraconazole 27

ivermectin 10

Index 16

IVERMECTIN 64 KIMONO PLUS SPERMICIDE KROGER INSULIN LUBRICATED 77 SYRINGE03ML29G Xivermectin (pediculicide) 64 KIMONO PLUS 12 100 IXEMPRA KIT 40 SPERMICIDELUBRICATED KROGER INSULIN

JADENU 26 77 SYRINGE03ML30G XJADENU SPRINKLE 26 KIMONO PS 516 100

LUBRICATED 77 KROGER INSULIN JAKAFI 39 KIMONO PS PLUS SYRINGE03ML31G XJANUMET 23 SPERMICIDELUBRICATED 516 100 JANUMET XR 23 77 KROGER INSULIN

KIMONO SENSATION SYRINGE05ML29G XJANUVIA 24 LUBRICATED 77 12 100 JARDIANCE 25 KIMONO SENSATION PLUS KROGER INSULIN JEVTANA 40 SPERMICIDE SYRINGE05ML30G XJUBLIA 58 LUBRICATED 77 516 100

KIMONO SPECIAL 77 KROGER INSULIN JULUCA 46 SYRINGE05ML31G XKINNEY LANCETS 83 JYNARQUE 69 516 100 KINNEY THIN LANCETS 83 K-TAB 114 KROGER INSULIN K-Y ME amp YOU EXTRA KINRAY INSULIN SYRINGE SYRINGE1ML29G X 12 100 LUBRICATED 77 PREFERRED KROGER INSULIN

PLUS03ML31G X 516 100 SYRINGE1ML30G XK-Y ME amp YOU INTENSE 77 KINRAY INSULIN SYRINGE 516 100 KADIAN 6 PREFERRED KROGER INSULIN KALETRA 46 PLUS05ML31G X 516 100 SYRINGE1ML31G X

KINRAY INSULIN SYRINGE KALYDECO 125 516 100 PREFERRED PLUS1ML31G KROGER LANCETS 83 KAMELEON LUBRICATED 77 X 516 100 KROGER LANCETS 21G 83 KAPVAY 2 KINRAY INSULIN

KAZANO 23 SYRINGE05ML29G X KROGER LANCETS MICRO THIN33G 83 KCL 03D5WNACL 12 100 KROGER LANCETS SUPER 09 114 KINRIX 127 THIN 83 KEFLEX 52 KISQALI 39 KROGER LANCETS THIN 83

KENALOG-40 55 KISQALI FEMARA 200 KROGER LANCETS THIN DOSE 38 KEPIVANCE 40 26G 83 KISQALI FEMARA 400 KROGER LANCETS KEPPRA 18 DOSE 38 ULTRATHIN30G 83 KEPPRA XR 18 KISQALI FEMARA 600 KROGER LANCING DOSE 38 KERYDIN 58 DEVICE 83 KITABIS PAK 3 ketoconazole 27 KRYSTEXXA 72 KLARITY-A 119 ketoconazole (topical) 58 KUVAN 68 KLARON 57 KETONE 65 KYLEENA 54 KLONOPIN 17 KETONE TEST STRIPS 65 KYPROLIS 39 KMART VALU PLUS INSULIN ketoprofen 5 labetalol hcl 49 SYRINGE1ML29G 100

ketorolac tromethamine 5 KMART VALU PLUS INSULIN LAC-HYDRIN 63 ketorolac tromethamine SYRINGE1ML30G 100 LAC-HYDRIN TWELVE 63 (ophth) 121 KOSELUGO 39 LACRISERT 119 KETOSTIX 65 KP PRENATAL lactated ringers 114 ketotifen fumarate (ophth) 121 MULTIVITAMINS 116

lactated ringers (irrigation) 116 KRINTAFEL 34 KEVEYIS 65 lactic acid (ammoniumKROGER AUTOLET LANCING KHEDEZLA 22 lactate) 63 DEVICE 83 KIMONO COLORS 77 lactulose 75 KROGER HEALTHPRO TWIST KIMONO LUBRICATED 77 LANCETS26G 83 lactulose (encephalopathy) 71 KIMONO MICRO THIN PLUS LAMICTAL 18 SPERMICIDE LUBRICATED77

Index 17

LAMICTAL CHEWABLE LEADER INSULIN levalbuterol tartrate 15 DISPERSIBLE 18 SYRINGE03ML29G X LEVAQUIN 70 LAMICTAL ODT 18 12 100 LEVEMIR 24 LEADER INSULIN lamivudine 46 SYRINGE03ML30G X LEVEMIR FLEXTOUCH 24 lamivudine (hbv) 47 516 100 levetiracetam 18 lamivudine-zidovudine 46 LEADER INSULIN levobunolol hcl 119 lamotrigine 18 SYRINGE03ML31G X

516 100 levocetirizine dihydrochloride28 LANCET DEVICE LEADER INSULIN levofloxacin 70 ADJUSTABLE 83 SYRINGE05ML28G XLANCET DEVICE WITH levofloxacin (ophth) 119 12 100 EJECTOR 83 levofloxacin in d5w 70 LEADER INSULIN LANCETS 83 SYRINGE05ML29G X levonorgestrel amp ethLANCETS 26G TWIST TOP 83 12 100 estradiol 53

levonorgestrel (emergencyLANCETS 30G 83 LEADER INSULIN SYRINGE05ML30G X oc) 54 LANCETS 30G TWIST TOP 83 levonorgestrel-eth estradiol516 101 LANCETS 30GTWIST TOP 83 LEADER INSULIN (triphasic) 53

LANCETS 31G TWIST TOP 83 levonorgestrel-ethinyl estradiolSYRINGE05ML31G XLANCETS 33G EXTRA 516 101 (91-day) 53

levonorgestrel-ethinyl estradiolFINE 83 LEADER INSULIN LANCETS MICRO THIN SYRINGE1ML28G X (continuous) 53 33G 83 12 101 levorphanol tartrate 6 LANCETS SAFETY SEAL LEADER INSULIN levothyroxine sodium 126 21G 83 SYRINGE1ML29G X LEXAPRO 21 LANCETS SAFETY SEAL 12 101 LEXIVA 46 26G 83 LEADER INSULIN LANCETS SAFETY SEAL SYRINGE1ML30G X LIALDA 71 28G 83 516 101 LIBERTY MEDICAL LANCETS LANCETS SAFETY SEAL LEADER INSULIN 30G 83 30G 83 SYRINGE1ML31G X LIBERTY MINI LANCING LANCETS SUPER THIN 516 101 DEVICE 83 28G 83 leflunomide 5 LIBRAX 127 LANCETS THIN 83 LENVIMA 10 MG DAILY lidocaine 64 LANCETS TWIST TOP 83 DOSE 36 lidocaine hcl 64 LENVIMA 12MG DAILY LANCETS ULTRA THIN 83 lidocaine hcl (local anesth) 76 DOSE 36 LANCETS ULTRA THIN LENVIMA 14 MG DAILY lidocaine hcl (mouth-throat) 116 30G 83 DOSE 36 LANCETSBULLSEYE lidocaine-prilocaine 64 LENVIMA 18 MG DAILY SAFETY 83 LIDODERM 64 DOSE 36 LANCING DEVICE 83 LIFESCAN UNISTIK 2 DEEP LENVIMA 20 MG DAILY LANCING DEVICE PENETRATION 84 DOSE 36 ADJUSTABLE 83 LIFESCAN UNISTIK II LENVIMA 24 MG DAILY LANOXIN 50 DOSE 36 LANCETS 84 lansoprazole 128 LENVIMA 4 MG DAILY LILETTA 54

DOSE 36 LINCOCIN 11 lanthanum carbonate 71 LENVIMA 8 MG DAILY LANZO 83 lincomycin hcl 11 DOSE 36 lapatinib ditosylate 39 LETAIRIS 51 lindane 64

linezolid 12 LASIX 66 letrozole 37 LINZESS 71 LASTACAFT 121 leucovorin calcium 40

latanoprost 121 liothyronine sodium 126 LEUKERAN 35 LIPITOR 30 LATUDA 43 LEUKINE 73

LEADER ADVANCED LANCING LIPOFEN 30 leuprolide acetate 37 DEVICE 83 lisinopril 30 levalbuterol hcl 15

Index 18

lisinopril amphydrochlorothiazide LITE TOUCH LANCETS LITE TOUCH LANCING PEN

LIVALO 30 LIVE BETTER ADVANCED LANCING DEVICE 84 LIVE BETTER LANCET SUPERTHIN 30G 84

loxapine succinate lubiprostone LUCEMYRA luliconazole

123 58

LITETOUCH INSULIN LIVE BETTER LANCET LUMIGAN 121 SYRINGE03ML29G X12 101 LITETOUCH INSULIN SYRINGE03ML30G X516 101 LITETOUCH INSULIN SYRINGE03ML31G X516 101 LITETOUCH INSULIN SYRINGE05ML30G X516 101 LITETOUCH INSULIN SYRINGE05ML31G X516 101 LITETOUCH INSULIN SYRINGE1ML30G X516 101 LITETOUCH INSULIN SYRINGEU-10003ML30G X516 101 LITETOUCH INSULIN

ULTRATHIN 28G 84 LO LOESTRIN FE 53 LOCOID 63 LODINE 5 LODOSYN 41 LOMOTIL 25 LONGS INSULIN SYRINGE05ML31G X516 101 LONGS LANCETS STANDARD 84 LONGS LANCETS THIN 84 LONGS LANCETS ULTRA THIN 84 loperamide hcl 25 LOPID 30 lopinavir-ritonavir 46 LOPRESSOR 49

LUMIZYME LUNESTA LUPANETA PACK LUPRON DEPOT (1-MONTH) LUPRON DEPOT (3-MONTH) LUPRON DEPOT (4-MONTH) LUPRON DEPOT (6-MONTH) LUPRON DEPOT-PED (1-MONTH) LUPRON DEPOT-PED (3-MONTH) LUXIQ LUZU LYNPARZA LYRICA

68 75 68

68 63 58 39 18

SYRINGEU-10003ML31G X516 101 LITETOUCH INSULIN SYRINGEU-10005ML28G X12 101 LITETOUCH INSULIN SYRINGEU-10005ML29G X12 101 LITETOUCH INSULIN SYRINGEU-10005ML30G X516 101 LITETOUCH INSULIN SYRINGEU-10005ML31G X516 101 LITETOUCH INSULIN SYRINGEU-1001ML28G X12 101 LITETOUCH INSULIN SYRINGEU-1001ML29G X12 101 LITETOUCH INSULIN SYRINGEU-1001ML30G X516 101 LITETOUCH INSULIN SYRINGEU-1001ML31G X516 101 LITETOUCH LANCETS MICRO THIN 33G 84 LITHIUM 42 lithium carbonate 42

LOPRESSOR HCT 32 LOPROX 58 LOPROX SHAMPOO 58 loratadine 28 loratadine amp pseudoephedrine 56 lorazepam 13 LORBRENA 39 LORTAB 8 losartan potassium 31 losartan potassium amphydrochlorothiazide 32 LOSEASONIQUE 53 LOTEMAX 120 LOTENSIN 30 LOTENSIN HCT 32 loteprednol etabonate 120 LOTREL 32 LOTRIMIN AF 58 LOTRIMIN AF JOCK ITCH 58 LOTRIMIN ULTRA 58 LOTRISONE 58 LOTRONEX 71 lovastatin 30 LOVAZA 29

LYRICA CR 125 LYSODREN 37 LYSTEDA 74 M-M-R II 131 M-NATAL PLUS 116 MACROBID 12 MACRODANTIN 12 mafenide acetate 61 MAGELLAN INSULIN SAFETY SYRINGEU-10003ML29G X12 101 MAGELLAN INSULIN SAFETY SYRINGEU-10003ML30G X516 101 MAGELLAN INSULIN SAFETY SYRINGEU-10005ML29G X12 101 MAGELLAN INSULIN SAFETY SYRINGEU-10005ML30G X516 101 MAGELLAN INSULIN SAFETY SYRINGEU-1001ML29G X12 101 MAGELLAN INSULIN SAFETY SYRINGEU-1001ML30G X516 102 magnesium sulfate 114 MALARONE 33

LITHOBID 42 LOVENOX 1617 malathion 64

Index 19

maprotiline hcl 20 MEDLANCE PLUS EXTRA MENOSTAR 70 LANCETS 21G 84 MARCAINE 76 MENQUADFI 129 MEDLANCE PLUS

MARINOL 26 MENVEO 129 LANCETS 84 MARPLAN 21 MEDLANCE PLUS LANCETS meperidine hcl 67

LITE 25G 84 MATULANE 40 meprobamate 12 MEDLANCE PLUS LITE MAVENCLAD 124 MEPRON 11 LANCETS 25G 84 MAVYRET 48 MEDLANCE PLUS SPECIAL mercaptopurine 36 MAXALT 112 LANCETS 08MM 84 meropenem 11

MEDLANCE PLUS MAXALT-MLT 112 MERREM 11 SUPERLITE 30G 84 MAXI-COMFORT INSULIN mesalamine 71 MEDLANCE PLUS SYRINGEU- SUPERLITE 30GCOMFORT MESTINON 34 10005ML28GX12 102 MAX 84 MESTINON TIMESPAN 34 MAXI-COMFORT INSULIN MEDLANCE PLUS SYRINGEU-1001ML28GX12 metaxalone 117 UNIVERSAL LANCETS 102 21G 84 metformin hcl 24

MAXICOMFORT INSULIN MEDLANCE PLUSLITE methadone hcl 7 SYRINGES 27G X 12 102 25G 84 METHADONE HCL 7 MAXIDEX 120 MEDLANCEEXTRA 84 methadone hcl 7 MAXIPIME 52 MEDLANCELITE 84 METHADOSE 7 MAXITROL 120 MEDLANCEUNIVERSAL 84 METHADOSE SUGAR-FREE 7 MAXX LUBRICATED 77 MEDROL 55 MAXX PLUS SPERMICIDE methamphetamine hcl 1

MEDROL DOSEPAK 55 LUBRICATED 77 methazolamide 65 medroxyprogesterone MAXZIDE 66 methenamine hippurate 12 acetate 123 MAXZIDE-25 66 medroxyprogesterone acetate methimazole 126 MAYZENT 124 (contraceptive) 54 METHITEST 10 MAYZENT STARTER mefenamic acid 5 methocarbamol 117 PACK 124 mefloquine hcl 34 METHOTREXATE 4 meclizine hcl 26 MEGACE ES 123 methotrexate sodium 36 meclofenamate sodium 5 megestrol acetate 37 methoxsalen rapid 60 MEDIC INSULIN megestrol acetateSYRINGE03ML30G X methscopolamine bromide 127 (appetite) 123 516 102 MEIJER COLOR LANCETS METHYLIN 2 MEDIC INSULIN UNIVERSAL 33G 84 methylphenidate hcl 2 SYRINGE05ML30G X516 102 MEIJER LANCETS 84 methylprednisolone 55

MEIJER LANCETS THIN 84 MEDICHOICE PRE-SET methylprednisolone acetate 55 SAFETY LANCET DUAL MEIJER LANCETS methylprednisolone sod

UNIVERSAL21G 84 USE 84 succ 55 MEDICHOICE PRE-SET MEIJER LANCETS metoclopramide hcl 70 SAFETY LANCET LOW UNIVERSAL30G 84

metolazone 66 FLOW 84 MEIJER LANCETS MEDICHOICE PRE-SET UNIVERSAL33G 84 metoprolol ampSAFETY LANCET MEDIUM MEIJER SUPER THIN hydrochlorothiazide 32 FLOW 84 LANCETS 84 metoprolol succinate 49 MEDICHOICE PRE-SET MEKINIST 39 metoprolol tartrate 49 SAFETY LANCET MODERATE MEKTOVI 39 METROCREAM 64 FLOW 84 meloxicam 5 METROGEL 64 MEDICHOICE SAFETY LANCETEXTRA 84 melphalan 35 METROLOTION 64 MEDICHOICE SAFETY melphalan hcl 35 metronidazole 10 LANCETNORMAL 84 memantine hcl 123124 metronidazole (topical) 64 MEDISENSE THIN LANCETS 84 MENEST 70 metronidazole vaginal 132

Index 20

mexiletine hcl 13 mometasone furoate MONOJECT ULTRA COMFORT INSULIN SYRINGE03ML29G Xmicafungin sodium 27 (nasal) 118

MONISTAT SOOTHING CARE 12 103 MICARDIS 31 ITCH RELIEF 63 MONOJECT ULTRA COMFORT MICARDIS HCT 32 MONOJECT INSULIN INSULIN SYRINGE03ML30G Xmiconazole nitrate vaginal 132 SYRINGE1ML 102 516 103

MONOJECT INSULIN MONOJECT ULTRA COMFORT MICROLET LANCETS 84 SYRINGE1ML31G X INSULIN SYRINGE03ML31G XMICROLET NEXT 84 516 102 516 103 midodrine hcl 132 MONOJECT INSULIN MONOJECT ULTRA COMFORT

SYRINGEDETACH INSULIN SYRINGE05ML28G Xmiglitol 23 NEEDLE1ML25G X 58 102 12 103 miglustat 73 MONOJECT INSULIN MONOJECT ULTRA COMFORT MIGRANAL 112 SYRINGEDETACH INSULIN SYRINGE05ML29G XMILLIPRED 55 NEEDLE1ML27G X 12 102 12 103

MONOJECT INSULIN MONOJECT ULTRA COMFORT MILLIPRED DP 55 SYRINGEPERM INSULIN SYRINGE05ML30G XMINASTRIN 24 FE 53 NEEDLE1ML28G X 12 102 516 103 MINI LANCING DEVICE 84 MONOJECT INSULIN MONOJECT ULTRA COMFORT MINIPRESS 31 SYRINGEPERM NEEDLEU- INSULIN SYRINGE05ML31G X

10005ML28G X 12 102 516 103 MINIVELLE 70 MONOJECT INSULIN MONOJECT ULTRA COMFORT MINOCIN 126 SYRINGESAFETYPERM INSULIN SYRINGE1ML28G Xminocycline hcl 126 NEEDLE03ML29G X 12 103

12 102 MONOJECT ULTRA COMFORT minoxidil 33 MONOJECT INSULIN INSULIN SYRINGE1ML29G XMIRAPEX 41 SYRINGESAFETYPERM 12 103 MIRCERA 73 NEEDLE03ML29GX12 MONOLET LANCETS 85

102 MIRCETTE 53 MONOLET OPD LANCETS 85 MONOJECT INSULIN MIRENA 54 MONOLETTOR SAFETY SYRINGESAFETYPERM LANCETS 85 mirtazapine 20 NEEDLE05ML29G X montelukast sodium 14 MIRVASO 64 12 102 MONOJECT INSULIN MONUROL 12 misoprostol 128 SYRINGESAFETYPERM MORPHABOND ER 7 MITIGARE 72 NEEDLE1ML29G X 12 102 morphine sulfate 7 mitomycin 38 MONOJECT INSULIN

mitoxantrone hcl 38 SYRINGESOFTPACK1ML27 MORPHINE SULFATE 7

MM INSULIN SYRINGEU- G X 12 102 morphine sulfate 7 MONOJECT INSULIN 10003ML30G X 516 102 MOTOFEN 25

MM INSULIN SYRINGEU- SYRINGESOFTPACKU- MOVIPREP 75 10003ML31G X 516 102 10005ML28G X 12 102 70 MM INSULIN SYRINGEU- MONOJECT INSULIN moxifloxacin hcl

10012ML30G X 516 102 SYRINGEU-10003ML30G X moxifloxacin hcl (ophth) 119 MM INSULIN SYRINGEU- 516 102 moxifloxacin hcl in sodium 10012ML31G X 516 102 MONOJECT INSULIN chloride 70 MM INSULIN SYRINGEU- SYRINGEU-10005ML30G X MOZOBIL 74 1001ML30G X 516 102 516 102 MPD SAFETY LANCET MM INSULIN SYRINGEU- MONOJECT INSULIN 21G18MM 85 1001ML31G X 516 102 SYRINGEU-1001ML28G X MPD SAFETY LANCET MM LANCING DEVICE 85 12 103 28G18MM 85 MONOJECT INSULIN MM TWIST LANCETS 85 MPD SAFETY LANCET SYRINGEU-1001ML30G X 30G18MM 85 MOBIC 5 516 103 MPD SAFETY LANCETS modafinil 23 MONOJECT INSULIN 23G18MM 85 SYRINGEREGULAR LUER moexipril hcl 30 MS CONTIN 7 TIPSOFTPACK1ML 103 mometasone furoate 63

Index 21

MS INSULIN NAROPIN 76 niacinamide 132 SYRINGE03ML31G X516 103 MS INSULIN SYRINGE05ML31G X516 103 MS INSULIN SYRINGE1ML31GX 516 103 MULPLETA 73 MULTAQ 13 MULTI PRENATAL 116 MULTI-LANCET DEVICE 85 mupirocin 58 MVASI 36 MYALEPT 68 MYAMBUTOL 34 MYCAMINE 27 MYCOBUTIN 34 mycophenolate mofetil 115 mycophenolate sodium 115 MYDRIACYL 119 MYFORTIC 115 MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G 85 MYLERAN 35 MYRBETRIQ 129 MYSOLINE 18 nabumetone 5 nadolol 49

NASACORT ALLERGY 24HR 118 NASACORT ALLERGY 24HR CHILDRENS 118 NASONEX 118 NATACYN 119 NATAZIA 53 nateglinide 25 NATROBA 64 NATURE-THROID 126 NATURE-THROID NT-25 126 NAVELBINE 41 NAYZILAM 17 nebivolol hcl 49 NEBUSAL 56 nefazodone hcl 22 nelarabine 36 NEO-SYNALAR 58 neomycin sulfate 3 neomycin-bacitracin zn-polymyxin 120 neomycin-polymy-dexameth 120 neomycin-polymyxin-hc(ophth) 120 neomycin-polymyxin-hc(otic) 122 NEONATAL COMPLETE 116 NEONATAL PLUS 116

NIASPAN 30 nicardipine hcl 50 NICODERM CQ 125 NICORETTE 125 NICORETTE MINI 125 NICORETTE STARTER KIT 125 nicotine 125 nicotine polacrilex 125 NICOTINE TRANSDERMAL SYSTEM 125 NICOTROL INHALER 125 NICOTROL NS 125 nifedipine 50 NILANDRON 37 nilutamide 37 nimodipine 50 NINLARO 39 NIPENT 40 nisoldipine 50 nitazoxanide 11 nitisinone 68 NITRO-BID 12 NITRO-DUR 12 nitrofurantoin 12 nitrofurantoin macrocrystal 12 nitrofurantoin monohyd macro 12

nafcillin sodium 123 NEONATAL VITAMIN 116 nitroglycerin 12 naftifine hcl NAFTIFINE HYDROCHLORIDE NAFTIN NAGLAZYME nalbuphine hcl NALFON naloxone hcl naltrexone hcl NAMENDA NAMENDA TITRATION PAK NAPROSYN naproxen naproxen sodium naratriptan hcl NARCAN

59 59 68

124 5 5 5

112 26

NEORAL 115 NEOSTIGMINE METHYLSULFATE 34 NESINA 24 NEULASTA 73 NEULASTA ONPRO KIT 73 NEUPOGEN 73 NEUPRO 41 NEURONTIN 18 NEVANAC 121 nevirapine 46 NEXAVAR 39 NEXIUM 128 NEXIUM 24HR 128 NEXPLANON 54 niacin 132

NITROGLYCERIN 12 nitroglycerin 12 NITROSTAT 12 NIVA-PLUS 116 NIVESTYM 73 NIX CREME RINSE 65 nizatidine 127 NIZORAL 59 NORCO 8 NORDITROPIN FLEXPRO 67 norelgestromin-ethinylestradiol 53 norethin acet amp estrad-fe 53 norethindrone amp eth estradiol53 norethindrone amp ethinyl estradiol-fe 53 norethindrone

niacin (antihyperlipidemic) 30 (contraceptive) NARDIL 21 NIACIN TR 132

Index 22

norethindrone acet amp eth NUCYNTA 7 ONE VITE WOMENS estra 53 norethindrone acetate 123 norethindrone acetate-ethinylestradiol 69 norethindrone acetate-ethinylestradiol-fe 53 norethindrone-eth estradiol (triphasic) 53 norgestimate-ethinylestradiol 53 norgestimate-ethinyl estradiol(triphasic) 53 norgestrel amp ethinyl estradiol 53 NORMOSOL-M IN D5W 114

NUCYNTA ER NUEDEXTA NULOJIX NUTROPIN AQ NUSPIN 10 NUVARING NUVIGIL nystatin nystatin (mouth-throat) nystatin (topical) nystatin-triamcinolone O-CAL FA

7 125 115

116 59 59

PRENATALVITAMIN PLUS 117 ONETOUCH CLUB LANCETS FINE POINT 85 ONETOUCH DELICA LANCETS EXTRA FINE 33G 85 ONETOUCH DELICA LANCETS FINE 30G 85 ONETOUCH DELICA LANCING DEVICE 85 ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G 85 ONETOUCH DELICA PLUS LANCETS FINE 30G 85 ONETOUCH DELICA PLUS

NORMOSOL-MD5W NORMOSOL-R NORPACE

114 114

OCREVUS octreotide acetate OCUFLOX

124 69

LANCING DEVICE 85 ONETOUCH DELICA SAFETY LANCING DEVICE 85 ONETOUCH FINEPOINT

NORPRAMIN 23 nortriptyline hcl 23 NORVASC 50 NORVIR 46 NOVA MAX PLUS KETONE TESTSTRIPS 65 NOVA SAFETY LANCETS

ODEFSEY ODOMZO OFEV ofloxacin ofloxacin (ophth) ofloxacin (otic)

126 70

120 121

LANCETS ONETOUCH ULTRASOFT LANCETS ONFI OPANA OPSUMIT ORACEA

7 51 64

23G 85 NOVA SAFETY LANCETS 28G 85 NOVA SUREFLEX LANCETS 85 NOVA SUREFLEX LANCING DEVICE 85 NOVAREL 67 NOVOLIN 7030 24 NOVOLIN 7030 FLEXPEN 24 NOVOLIN 7030 FLEXPENRELION 24 NOVOLIN 7030 RELION 24 NOVOLIN N 25 NOVOLIN N RELION 24 NOVOLIN R 25 NOVOLIN R RELION 25 NOVOLOG 25

olanzapine 4344 olmesartan medoxomil 31 olmesartan medoxomil-amlodipine-hydrochlorothiazide

32 olmesartan medoxomil-hydrochlorothiazide 32 olopatadine hcl 121 olopatadine hcl (nasal) 118 OLUX 63 omega-3-acid ethyl esters 29 omeprazole 128 omeprazole magnesium 128 omeprazole-sodiumbicarbonate 128 OMNIFLEX DIAPHRAGM 77 OMNITROPE 67 ON CALL LANCING

ORAPRED ODT ORENITRAM ORFADIN ORKAMBI orphenadrine citrate ORTHO MICRONOR ORTHO TRI-CYCLEN LO ORTHO-NOVUM 135 ORTHO-NOVUM 777 oseltamivir phosphate OSENI OSMOPREP OSPHENA OTEZLA OTOVEL OVIDE

55 51 68

125 118

54 53 53 53 48 23 75 67

65 NOVOLOG FLEXPEN NOVOLOG MIX 7030 NOVOLOG MIX 7030PREFILLED FLEXPEN NOVOLOG PENFILL

DEVICE 85 ON CALL PLUS LANCING DEVICE 85 ONCASPAR 40 ondansetron 26

oxacillin sodium oxaliplatin oxandrolone oxaprozin

123 35

NOXAFIL 27 ondansetron hcl 26 OXAYDO 7

NPLATE NUBEQA NUCALA

74 37 13

ONE VITE WOMENS PRENATALVITAMIN 117

oxazepam OXBRYTA oxcarbazepine

13 73 18

Index 23

OXERVATE 120 PEMAZYRE 39 PIFELTRO 46 oxiconazole nitrate 59 penicillamine 115 pilocarpine hcl 119 OXISTAT 59 penicillin g potassium 122 pilocarpine hcl (oral) 116 OXSORALEN ULTRA 60 PENICILLIN G POTASSIUM IN pimecrolimus 64

ISO-OSMOTIC oxybutynin chloride 129 pimozide 125 DEXTROSE 122 oxycodone hcl 7 pindolol 49 PENICILLIN G oxycodone w acetaminophen 8 PROCAINE 122 pioglitazone hcl 24 oxycodone-ibuprofen 9 penicillin g sodium 122 pioglitazone hcl-glimepiride 23 OXYCONTIN 7 penicillin v potassium 122 pioglitazone hcl-metforminoxymorphone hcl 7 PENLAC NAIL LACQUER 59 hcl 23

PIP LANCETS28G 85 OZEMPIC 24 PENTACEL 127 PIP LANCETS30G 85 paclitaxel 41 pentazocine w naloxone hcl9 piperacillin sodium-tazobactam

paliperidone 43 pentoxifylline 72 sodium 123 palonosetron hcl 26 PEPCID 127 PIQRAY 200MG DAILY PALYNZIQ 68 PEPCID AC 127 DOSE 39

PIQRAY 250MG DAILY PEPCID AC MAXIMUM PAMELOR 23 DOSE 39 STRENGTH 127 pamidronate disodium 66 PIQRAY 300MG DAILY PERCOCET 9 PAMIDRONATE DISODIUM 67 DOSE 39

PERFECT LANCETS 30G 85 piroxicam 5 pamidronate disodium 67 PERFECT PRESSURE PLAN B ONE-STEP 54 PANRETIN 59 ACTIVATED SAFETY PLAQUENIL 34 pantoprazole sodium 128 LANCETS 28G 85

PARAGARD INTRAUTERINE PERIDEX 116 PLASMA-LYTE A 114 COPPER CONTRACEPTIVE perindopril erbumine 30 PLASMA-LYTE-148 114 T380A 54 PERJETA 36 PLAVIX 73 parenteral electrolytes 114 permethrin 65 PLEGISOL 50 paricalcitol 68 perphenazine 44 PLEGRIDY 124 PARLODEL 41 perphenazine-amitriptyline PLEGRIDY STARTER PARNATE 21 124 PACK 124 paromomycin sulfate 3 PERSERIS 43 PNEUMOVAX 23 129 paroxetine hcl 21 PHARMACY COUNTER PNEUMOVAX 231 DOSE 129

LANCETS 85 PASER 34 podofilox 64 phenazopyridine hcl 72 PATADAY 121 polymyxin b sulfate 12 phendimetrazine tartrate 1 PATANASE 118 polymyxin b-trimethoprim 120 phenelzine sulfate 21 PATANOL 121 POLYTRIM 120 PHENERGAN 29 PAXIL 22 POMALYST 37 phenobarbital 74 PAXIL CR 21 potassium acetate 114 phenoxybenzamine hcl 31 PC LANCETS SUPER THIN potassium bicarbonate 114

30G 85 phentermine hcl 2 potassium chloride 114 PEDIAPRED 55 PHENYTEK 20 POTASSIUM CHLORIDE 114 PEDIARIX 127 phenytoin 20 potassium chloride 114 PEDVAX HIB 129 phenytoin sodium 20 POTASSIUM CHLORIDE 114 peg 3350-kcl-nacl-na sulfate-na phenytoin sodium potassium chloride 114 ascorbate-ascorbic acid 75 extended 20 peg 3350-kcl-sod bicarb-sod PHEXXI 132 potassium chloride inchloride-sod sulfate 75 dextrose 114 PHOSLYRA 71 potassium chloride in dextrose ampPEGANONE 19 PHOSPHOLINE IODIDE 119 sodium chloride 114 PEGASYS 48 PHOTOFRIN 40 potassium chloride in nacl 114 PEGINTRON 48 PICATO 59

Index 24

potassium chloride PREDNISOLONE SODIUM PRENATRYL 117 microencapsulated crystals PHOSPHATE 120 PREPLUS 117 er 114 prednisone 55 PREPOPIK 75 POTASSIUM PREFERRED PLUS INSULIN CHLORIDEDEXTROSELACTA SYRINGEU-10003ML29G X PRESSURE ACTIVATED TED RINGERS 114 SAFETYLANCET 21G 85 12 103 POTASSIUM PREVACID 128 PREFERRED PLUS INSULIN CHLORIDESODIUM SYRINGEU-10003ML30G X PREVACID 24HR 128 CHLORIDE 114 516 103 PREVNAR 13 129 potassium citrate PREFERRED PLUS INSULIN (alkalinizer) 71 SYRINGEU-10005ML28G X PREZCOBIX 46 potassium phosphates 114 12 103 PREZISTA 46 pramipexole dihydrochloride 42 PREFERRED PLUS INSULIN PRIFTIN 34

SYRINGEU-10005ML29G Xprasugrel hcl 73 PRILOSEC OTC 128 12 104 PRAVACHOL 30 primaquine phosphate 34 PREFERRED PLUS INSULIN pravastatin sodium 30 SYRINGEU-10005ML30G X PRIMAQUINE PHOSPHATE 34 praziquantel 10 516 104 PRIMAXIN IV 11

PREFERRED PLUS INSULIN prazosin hcl 31 primidone 18 SYRINGEU-1001ML28G XPRECISION SURE-DOSE PRINIVIL 30 12 104 INSULIN SYRINGE03ML30G X PREFERRED PLUS INSULIN PRISTIQ 22 516 103 SYRINGEU-1001ML29G X PRO COMFORT INSULIN PRECISION SURE-DOSE 12 104 SYRINGES05ML30G XINSULIN SYRINGE05ML28G X PREFERRED PLUS INSULIN 12 104 12 103 SYRINGEU-1001ML30G X PRO COMFORT INSULIN PRECISION SURE-DOSE 516 104 SYRINGES05ML30G XINSULIN SYRINGE05ML29G X PREFERRED PLUS LANCETS 516 104 12 103 COLORED 21G 85 PRO COMFORT INSULIN PRECISION SURE-DOSE PREFERRED PLUS LANCETS SYRINGES05ML31G XINSULIN SYRINGE05ML30G X SUPER THIN 30G 85 516 104 38 103 PREFERRED PLUS LANCETS PRO COMFORT INSULIN PRECISION SURE-DOSE THIN 26G 85 SYRINGES1ML30G XINSULIN SYRINGE1ML28G X pregabalin 18 12 104 12 103 PRECISION SURE-DOSE pregabalin (once-daily) 125 PRO COMFORT INSULIN

SYRINGES1ML30G XPLUSINSULIN PREGNYL WDILUENT516 104 SYRINGE03ML29G X BENZYLALCOHOLNACL 67 PRO COMFORT INSULIN 12 103 PREMARIN 70 SYRINGES1ML31G XPRECISION SURE-DOSE PREMIUM CONDOMS 516 104 PLUSINSULIN LUBRICATED 77 PROAIR HFA 15 SYRINGE1ML29G X 12 103 PREMPHASE 69

PRECISION THINS GP probenecid 72 PREMPRO 69 LANCET 85 procainamide hcl 13 PRENATAL 117 PRECISION XTRA 65 PROCARDIA 50 PRENATAL LOW IRON 117 PRECOSE 23 PROCARDIA XL 50 PRENATAL PRED FORTE 120 MULTIVITAMIN 117 prochlorperazine 44 PRED MILD 120 PRENATAL ONE DAILY 117 prochlorperazine maleate 44 prednicarbate 63 PRENATAL VITAMIN 117 PROCRIT 74 prednisolone 55 PRENATAL VITAMIN amp PROCTOCORT 10 prednisolone acetate MINERAL 117 PRODIGY INSULIN SYRINGU-(ophth) 120 PRENATAL 10003ML31G X 516 104 PREDNISOLONE ACETATE P- VITAMINIRON 117 PRODIGY INSULIN F 120 PRENATAL VITAMINS 117 SYRINGE12ML31G Xprednisolone sodium PRENATAL VITAMINS PLUS 516 104 phosphate 55 LOW IRON 117 PRODIGY INSULIN

PRENATRIX 117 SYRINGE1ML28G X 12 104

Index 25

PRODIGY LANCING PX LANCETS ULTRA THIN rabeprazole sodium 128 DEVICE 85 28G 86 raloxifene hcl 68 PRODIGY PRESSURE PX PRENATAL

ramelteon 75 ACTIVATED SAFETY MULTIVITAMINS 117 LANCETS 85 pyrazinamide 34 ramipril 31 PRODIGY SAFETY PYRIDIUM 72 RANEXA 12 LANCETS 86 pyridostigmine bromide 34 ranitidine hcl 127128 PRODIGY TWIST TOP LANCETS 86 pyrimethamine 34 ranolazine 12 progesterone 123 QC ADVANCED LANCING RAPAFLO 72

DEVICE 86 PROGLYCEM 24 RAPAMUNE 115 QC LANCETS SUPER PROGRAF 115 rasagiline mesylate 42 THIN 86 PROLASTIN-C 125 QC LANCETS ULTRA RAZADYNE 124 PROLEUKIN 40 THIN 86 RAZADYNE ER 124 PROLIA 67 QC PRENATAL 117 READYLANCE SAFETY

QC UNILET LANCETS LANCETS21G22MM 86 PROMACTA 74 28GULTRA THIN 86 READYLANCE SAFETY promethazine hcl 29 QC UNILET LANCETS LANCETS23G18MM 86 PROMETRIUM 123 33GMICRO THIN 86 READYLANCE SAFETY propafenone hcl 13 QINLOCK 39 LANCETS26G18MM 86

READYLANCE SAFETY proparacaine hcl 120 QUADRACEL 127 LANCETS28G18MM 86 propranolol hcl 49 QUALAQUIN 34 READYLANCE SAFETY propylthiouracil 126 QUARTETTE 53 LANCETS30G16MM 86

REALITY INSULIN SYRINGEU-PROSCAR 72 QUDEXY XR 18 10005ML28G X 12 104

PROTONIX 128 QUESTRAN 29 REALITY INSULIN SYRINGEU-PROTOPIC 64 QUESTRAN LIGHT 29 10005ML29G X 12 104

quetiapine fumarate REALITY INSULIN SYRINGEU-protriptyline hcl 23 44 1001ML28G X 12 104 PROVENTIL HFA 15 quinapril hcl 30 REALITY INSULIN SYRINGEU-quinapril-hydrochlorothiazidePROVERA 123

32 1001ML29G X 12 104 PROVIGIL 3 REALITY LANCETS 86 quinidine sulfate 13 REALITY LATEX PROZAC 22 quinine sulfate 34 CONDOMSLUBRICATED 77 PRUDOXIN 60 QVAR REDIHALER 14 REALITY LATEXULTRAPSORCON 63 RA E-ZJECT LANCETS TEXTURED 77 PSS SELECT GP LANCETS 86 28G 86 REALITY LATEXULTRAPSS SELECT SAFETY RA E-ZJECT LANCETS THIN THIN 77 LANCETS 86 26G 86 REALITY TRIGGER PTS PANELS KETONE RA E-ZJECT LANCETS THIN LANCETS 86 TEST 65 28G 86 REBIF 124

RA E-ZJECT LANCETS PULMICORT 14 REBIF REBIDOSE 124 ULTRATHIN 30G 86 PULMICORT FLEXHALER 14 REBIF REBIDOSE RA INSULIN TITRATIONPACK 124 PULMOZYME 126 SYRINGE05ML29G X REBIF TITRATION PACK 124 PUSH BUTTON SAFETY 12 104

LANCETS 21G 86 RA INSULIN RECLAST 67 PUSH BUTTON SAFETY SYRINGE1ML29G X RECOMBIVAX HB 131 LANCETS 28G 86 12 104 RECTIV 10 PX ADVANCED LANCING RA INSULIN SYRINGEU-DEVICE 86 10005ML30G X 516 104 REGLAN 70 PX INSULIN SYRINGEU- RA INSULIN SYRINGEU- REGRANEX 65 10005ML30G X 12 104 1001 ML30G X 516 104 RELENZA DISKHALER 48 PX LANCET AUTO RA PRENATAL 117 RELION 2-IN-1 LANCET INJECTOR 86 RA PRENATAL DEVICES 30G 86 PX LANCETS ULTRA THIN 86 FORMULAFOLICACID 117

Index 26

RELION 2-IN-1 LANCING DEVICE 25G RELION 2-IN-1 LANCING DEVICE 30G

RETACRIT RETEVMO RETIN-A

74 39 57

ROTATEQ ROXICODONE ROZEREM

75 RELION INSULIN SYRINGE RETIN-A MICRO 57 ROZLYTREK 39 1ML31GX1564 104 RELION INSULIN SYRINGEU-10003ML31G X 516 104 RELION INSULIN SYRINGEU-10005ML29G X 12 104 RELION INSULIN SYRINGEU-10005ML31G X 516 104 RELION INSULIN SYRINGEU-1001ML31G X 1564 104 RELION INSULIN SYRINGEU-1001ML31G X 516 104 RELION KETONE TEST STRIPS 65 RELION LANCETS MICRO-THIN33G 86 RELION LANCETS THIN 26G 86 RELION LANCETS ULTRA-THIN30G 86 RELION LANCING DEVICE 86 RELION TRUE METRIX BLOODGLUCOSE TEST STRIPS 65 RELION ULTRA THIN LANCETS30G 86 RELION ULTRA THIN LANCETS30G 86 RELION ULTRA THIN PLUS LANCETS 32G 86 RELION ULTRA THIN PLUS LANCETS 33G 86 RELISTOR 71 RELPAX 112 REMERON 20 REMERON SOLTAB 20 RENFLEXIS 71

RETIN-A MICRO PUMP 57 RETROVIR 46 RETROVIR IV INFUSION 46 REVATIO 51 REVLIMID 115 REXALL LANCETS ULTRA THIN 86 REXULTI 44 REYATAZ 46 ribavirin (hepatitis c) 48 RIDAURA 4 rifabutin 34 RIFADIN 34 RIFAMATE 34 rifampin 34 RIFATER 34 RIGHT STEP PRENATAL 117 RIGHTEST GD500 LANCING DEVICE 86 RIGHTEST GL300 LANCETS 86 RILUTEK 118 riluzole 118 rimantadine hydrochloride 48 ringers 114 ringers irrigation 116 RINVOQ 4 risedronate sodium 67 RISPERDAL 43 RISPERDAL CONSTA 43

RUBRACA 39 RUCONEST 72 rufinamide 18 RUKOBIA 46 RUXIENCE 36 RUZURGI 34 RYTHMOL SR 13 SABRIL 19 SAFE-T-LANCE LOW FLOW 25G 86 SAFE-T-LANCE NORMAL FLOW21G 87 SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW 87 SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW 87 SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW 87 SAFESNAP INSULIN SYRINGE03ML30G X516 105 SAFESNAP INSULIN SYRINGE05ML29G X12 105 SAFESNAP INSULIN SYRINGE05ML30G X516 105 SAFESNAP INSULIN SYRINGE1ML28G X 12 105 SAFESNAP INSULIN SYRINGE1ML29G X 12 105 SAFETY INSULIN SYRINGES

RENVELA repaglinide repaglinide-metformin hcl

71 25 23

risperidone RITALIN RITALIN LA

43 3 3

05ML29GX12 105 SAFETY INSULIN SYRINGES 05ML30GX516 105 SAFETY INSULIN SYRINGES

REPATHA 30 REPATHA PUSHTRONEX SYSTEM 30 REPATHA SURECLICK 30 REQUIP XL 42 RESCRIPTOR 46 RESECTISOL 72 RESTASIS 120 RESTASIS MULTIDOSE 120 RESTORIL 75

ritonavir RITUXAN rivastigmine tartrate rizatriptan benzoate ROBAXIN-750 ROCALTROL ROMIDEPSIN ropinirole hydrochloride rosuvastatin calcium ROTARIX

124 113 118

68 39 42 30

1ML27GX12 105 SAFETY INSULIN SYRINGES 1ML29GX12 105 SAFETY INSULIN SYRINGES 1ML30GX12 105 SAFETY LANCET 21GPRESSUREACTIVATED 87 SAFETY LANCET 23GPRESSUREACTIVATED 87

Index 27

SAFETY LANCET sertraline hcl 22 SMART SENSE STANDARD 28GPRESSUREACTIVATED SAFETY LANCETS 21G SAFETY LANCETS 28G SAFETY LET LANCETS SAFYRAL SAIZEN SAIZENPREP RECONSTITUTIONKIT SALAGEN salsalate SAMSCA

87 87 87 87 53 67

67 116

sevelamer carbonate 71 SHINGRIX 131 SHOPKO AUTOLET LANCING DEVICE 87 SHOPKO ON-THE-GO COMFORTLANCETS 30G 87 SHOPKO UNILET LANCETS SUPER THIN 30G 87 SHOPKO UNILET LANCETS ULTRA THIN 28G 87 SHUR-SEAL 131 SIDE BUTTON SAFETY LANCET21G 87

LANCETS UNIVERSAL 21G 87 SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G 87 SMART SENSE THIN LANCETSUNIVERSAL 26G 87 SMARTEST LANCETS 28G 87 SODIUM ACETATE 113 sodium acetate 113 sodium chloride 114115 sodium chloride (gu irrigant) 72 sodium chloride (inhalant) 56 sodium citrate amp citric acid 71

SANDIMMUNE 115 SIGNIFOR 69 sodium fluoride 114

SANDOSTATIN 69 SANTYL 63 SAPHRIS 44 sapropterin dihydrochloride 68 SAVELLA 124 SAVELLA TITRATION PACK 124 SB INSULIN SYRINGEU-10005ML29G X 12 105 SB INSULIN SYRINGEU-10005ML30G X 516 105 SB INSULIN SYRINGEU-1001ML29G X 12 105 SB INSULIN SYRINGEU-1001ML30G X 516 105 SB INSULIN SYRINGEU-1001ML31G X 516 105 SB LANCETS THIN 87 SB LANCETS ULTRA THIN 87 scopolamine 26 SEASONIQUE 53 SECURESAFE SAFETY INSULIN SYRINGESU-10005ML29GX12 105 SECURESAFE SAFETY INSULIN SYRINGESU-1001ML29GX12 105 SEGLUROMET 23

sildenafil citrate 51 sildenafil citrate (pulmonaryhypertension) 51 SILENOR 74 silodosin 72 SILVADENE 61 silver sulfadiazine 61 SIMBRINZA 119 SIMPLE DIAGNOSTICS LANCING DEVICE 87 SIMULECT 115 simvastatin 30 SINEMET 42 SINEMET CR 42 SINGLE-LET 87 SINGULAIR 14 sirolimus 115 SIRTURO 34 SIVEXTRO 12 SKELAXIN 118 SKLICE 65 SKYLA 54 SKYRIZI 60 SKYRIZI PEN 60 SLO-NIACIN 133

sodium phenylbutyrate 68 sodium polystyrenesulfonate 116 SOFOSBUVIRVELPATASVIR

48 solifenacin succinate 129 SOLIRIS 72 SOLOSEC 3 SOLU-CORTEF 55 SOLU-MEDROL 55 SOLUS V2 LANCING DEVICE 87 SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G 87 SOLUS V2 TWIST LANCETS 30G 87 SOMA 118 SOMATULINE DEPOT 69 SOMAVERT 67 SOOLANTRA 64 SORBITOL 72 SORBITOL-MANNITOL 72 SORBITOLMANNITOLIRRIGATION 72 SORIATANE 60 sotalol hcl 49

SELECT-LITE LANCING DEVICE selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL SEROQUEL XR SEROSTIM

87 42 60 46 68 15 44 44 67

SLYND 54 SM MICRO THIN LANCETS 33G 87 SM PRENATAL VITAMINS 117 SM TRUEDRAW LANCING DEVICE 87 SMART DIABETES VANTAGE LANCING DEVICE 87 SMART SENSE COLOR LANCETS UNIVERSAL 33G 87

sotalol hcl (afibafl) spinosad SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone amphydrochlorothiazide SPORANOX SPORANOX PULSEPAK SPRAVATO 56MG DOSE

49 65 14 14 66

66 27 27 21

Index 28

SPRAVATO 84MG DOSE 21 SUNOSI 2 SURE COMFORT LANCETS

SPRYCEL STALEVO 100 STALEVO 125

39 42 42

SUPER THIN LANCETS SUPRAX SUPREP BOWEL PREP

30G 87 SURE COMFORT LANCING PEN 87 SURE-JECT INSULIN

KIT 75 SYRINGEU-10003ML29G XSTALEVO 150 42 SURE COMFORT INSULIN 12 106 STALEVO 200 42 SYRINGEU-10003ML29G X SURE-JECT INSULIN STALEVO 50 42 12 105 SYRINGEU-10003ML30G XSTALEVO 75 42 SURE COMFORT INSULIN 516 106

SYRINGEU-10003ML30G X SURE-JECT INSULIN stannous fluoride 116 12 105 SYRINGEU-10003ML31G XSTARLIX 25 SURE COMFORT INSULIN 516 106 stavudine 46 SYRINGEU-10003ML30G X SURE-JECT INSULIN STAVUDINE 46 516 105 SYRINGEU-10005ML28G X

SURE COMFORT INSULIN 12 106 STEGLATRO 25 SYRINGEU-10003ML31G X SURE-JECT INSULIN STELARA 6071 516 105 SYRINGEU-10005ML29G XSTENDRA 51 SURE COMFORT INSULIN 12 106

SYRINGEU-10003ML31G X SURE-JECT INSULIN STERILANCE TL 87 516 105 SYRINGEU-10005ML30G XSTIMATE 69 SURE COMFORT INSULIN 516 106 STIVARGA 39 SYRINGEU-10005ML28G X SURE-JECT INSULIN STRATTERA 2 12 105 SYRINGEU-10005ML31G X

SURE COMFORT INSULIN 516 106 streptomycin sulfate 3 SYRINGEU-10005ML29G X SURE-JECT INSULIN STRIBILD 46 12 105 SYRINGEU-1001ML28G XSTRIVERDI RESPIMAT 15 SURE COMFORT INSULIN 12 106

SYRINGEU-10005ML30G X SURE-JECT INSULIN STROMECTOL 10 12 105 SYRINGEU-1001ML29G XSUBOXONE 9 SURE COMFORT INSULIN 12 106 SUBSYS 7 SYRINGEU-10005ML30G X SURE-JECT INSULIN SUCRAID 65 516 105 SYRINGEU-1001ML30G X

SURE COMFORT INSULIN 516 106 sucralfate 128 SYRINGEU-10005ML31G X SURE-JECT INSULIN SULAR 50 516 105 SYRINGEU-1001ML31G Xsulconazole nitrate 59 SURE COMFORT INSULIN 516 106

SYRINGEU-1001ML28G Xsulfacetamide sodium (acne)57 SURE-LANCE FLAT 12 105 LANCETS 88 sulfacetamide sodium SURE COMFORT INSULIN SURE-LANCE LANCETS (ophth) 120 SYRINGEU-1001ML29G X 26G 88 sulfacetamide sodium w 12 106 SURE-LANCE THIN LANCETS sulfur 57 SURE COMFORT INSULIN 28G 88 sulfacetamide sodium-sulfur in SYRINGEU-1001ML30G X SURE-LANCE ULTRA THIN urea vehicle 57 12 106 LANCETS 88 SULFADIAZINE 126 SURE COMFORT INSULIN SURE-PEN 88 sulfamethoxazole-trimethoprim SYRINGEU-1001ML30G X SURE-TOUCH LANCETS 10 516 106 UNIVERSAL 88 SULFAMYLON 61 SURE COMFORT INSULIN SURELITE LANCETS 88 sulfasalazine 71 SYRINGEU-1001ML31G X

SUSTIVA 4647 516 106 sulindac 5 SURE COMFORT LANCETS SUTENT 39 SUMADAN WASH 57 18G 87 SYMBICORT 15 sumatriptan 113 SURE COMFORT LANCETS SYMFI 47 sumatriptan succinate 113 21G 87 SURE COMFORT LANCETS SYMFI LO 47 sumatriptan-naproxen

sodium 112 23G 87 SYMLINPEN 120 23 SURE COMFORT LANCETS sunitinib malate 39 SYMLINPEN 60 23 28G 87

Index 29

SYMTUZA 47 TECHLITE INSULIN TENORMIN 49 SYNALAR SYNAREL

SYRINGEU-10003ML31G X516 106 TECHLITE INSULIN

TEPADINA terazosin hcl

SYNERA SYNJARDY SYNJARDY XR SYNRIBO SYNTHROID

64 23 23 40

SYRINGEU-10005ML29G X12 106 TECHLITE INSULIN SYRINGEU-10005ML30G X12 106 TECHLITE INSULIN

terbinafine hcl terbutaline sulfate terconazole vaginal TESSALON PERLES TESTIM

132 55 10

SYPRINE TABLOID TABRECTA TACLONEX tacrolimus tacrolimus (topical) tadalafil

115 36 39 63

115 64 51

SYRINGEU-10005ML30G X516 106 TECHLITE INSULIN SYRINGEU-10005ML31G X516 106 TECHLITE INSULIN SYRINGEU-1001ML29G X12 106 TECHLITE INSULIN

TESTOSTERONE CYPIONATE testosterone cypionate testosterone enanthate TETANUSDIPHTHERIATOXOIDS-ADSORBED ADULT tetrabenazine

10 10 10

127 124

tadalafil (pulmonaryhypertension) TAFINLAR TAGAMET HB TAKHZYRO TALZENNA TAMIFLU tamoxifen citrate tamsulosin hcl TAPAZOLE

128 72 39 48 37 72

SYRINGEU-1001ML30G X12 106 TECHLITE INSULIN SYRINGEU-1001ML30G X516 106 TECHLITE INSULIN SYRINGEU-1001ML31G X1564 107 TECHLITE INSULIN SYRINGEU-1001ML31G X516 107 TECHLITE LANCETS 88

tetracycline hcl 126 TGT LANCET MICRO THIN 33G 88 TGT LANCET THIN 26G 88 TGT LANCET ULTRA THIN 30G 88 TGT LANCING DEVICE 88 THALOMID 115 theophylline 15 THERANATAL CORE NUTRITION 117

TARCEVA 36 TECHLITE LANCETS 30G 88 THINLETS GP LANCETS 88 TARGADOX 126 TEFLARO 52 thioridazine hcl 44 TARGRETIN 4060 TEGRETOL 19 thiotepa 35 TARKA 32 TEGRETOL-XR 19 thiothixene 44 TASIGNA 39 TEGSEDI 125 THYMOGLOBULIN 115 TASMAR 41 TEKTURNA 33 thyroid 126 tavaborole 59 telmisartan 31 tiagabine hcl 19 TAXOTERE 41 TAYTULLA 53 tazarotene 60 TAZORAC 60 TAZVERIK 39 TDVAX 127 TECFIDERA 125 TECFIDERA STARTER PACK 125 TECHLITE AST LANCETS 88 TECHLITE INSULIN SYRINGEU-10003ML29G X 12 106 TECHLITE INSULIN SYRINGEU-10003ML30G X 12 106 TECHLITE INSULIN SYRINGEU-10003ML30G X 516 106

telmisartan-amlodipine 32 telmisartan-hydrochlorothiazide

32 temazepam 75 TEMIXYS 47 TEMODAR 35 TEMOVATE 63 temozolomide 35 temsirolimus 39 TENIPOSIDE 41 TENIVAC 127 tenofovir disoproxilfumarate 47 TENORETIC 100 32 TENORETIC 50 32

TIAZAC TIBSOVO TIGAN tigecycline TIKOSYN timolol maleate timolol maleate (ophth) TIMOPTIC TIMOPTIC-XE TIVICAY tizanidine hcl TOBI TOBRADEX tobramycin

50 39 26

126 13 49

119 119 119

47 118

Index 30

tobramycin (ophth) 120 topotecan hcl 41 triazolam 75 tobramycin sulfate 3 tobramycin-dexamethasone 121 TOBREX 120 TODAY SPONGE 131 TODAYS HEALTH ADVANCED LANCING DEVICE 88

TOPROL XL toremifene citrate TORISEL torsemide TOVIAZ TRACLEER

49 37 39 66

129 51

TRIBENZOR TRICARE TRICOR TRIDESILON trientine hcl trifluoperazine hcl

33 117

115 44

TODAYS HEALTH SUPER tramadol hcl 8 trifluridine 120 THINLANCETS 30G TODAYS HEALTH ULTRA THINLANCETS 28G

tramadol-acetaminophen trandolapril

trihexyphenidyl hcl TRIJARDY XR

TOFRANIL 23 tolbutamide 25 tolcapone 41 tolmetin sodium 5 TOLSURA 27 tolterodine tartrate 129 tolvaptan 69 TOPAMAX 19 TOPAMAX SPRINKLE 19 TOPCARE LANCETS MICRO-THIN 33G 88 TOPCARE ULTRA COMFORT INSULIN SYRINGE03ML30G X516 107 TOPCARE ULTRA COMFORT INSULIN SYRINGE03ML31G X516 107 TOPCARE ULTRA COMFORT INSULIN SYRINGE05ML30G X516 107 TOPCARE ULTRA COMFORT INSULIN SYRINGE05ML31G X516 107 TOPCARE ULTRA COMFORT INSULIN SYRINGE1ML30G X516 107 TOPCARE ULTRA COMFORT INSULIN SYRINGE1ML31G X516 107 TOPCARE ULTRA COMFORT INSULIN SYRINGEU-10003ML29G X 12 107 TOPCARE ULTRA COMFORT INSULIN SYRINGEU-10005ML29G X 12 107 TOPCARE ULTRA COMFORT INSULIN SYRINGEU-1001ML29G X 12 107 TOPICORT 63 topiramate 19 topotecan hcl 41 TOPOTECAN HCL 41

trandolapril-verapamil hcl 32 TRANDOLAPRILVERAPAMILHCL ER 32 tranexamic acid 74 TRANSDERM SCOP 26 TRANSDERM-SCOP 26 TRANXENE T 13 tranylcypromine sulfate 21 TRAVATAN Z 121 TRAVEL LANCETS 30G 88 TRAVEL LANCETS ADVANCED 28G 88 travoprost 121 trazodone hcl 22 TREANDA 35 TRECATOR 35 TRELEGY ELLIPTA 15 TRELSTAR MIXJECT 37 TREMFYA 60 treprostinil 51 TRESIBA 25 TRESIBA FLEXTOUCH 25 tretinoin 57 tretinoin (chemotherapy) 40 tretinoin microsphere 57 TREXALL 36 TREXIMET 112 triamcinolone acetonide 55 triamcinolone acetonide (mouth) 116 triamcinolone acetonide (nasal) 118 triamcinolone acetonide (topical) 63 triamcinolone acetonide-dimethicone-silicone 63 triamterene 66 triamterene amp hydrochlorothiazide 66

TRIKAFTA 126 TRILEPTAL 19 TRILIPIX 30 trimethobenzamide hcl 26 trimethoprim 10 trimipramine maleate 23 TRINTELLIX 22 TRIOSTAT 126 TRIUMEQ 47 TRIZIVIR 47 tropicamide 119 trospium chloride 129 TRUE COMFORT INSULIN SYRINGE05ML31G X516 107 TRUE COMFORT INSULIN SYRINGE1ML31G X516 107 TRUE COMFORT PRO INSULINSYRINGE05ML30G X516 107 TRUE COMFORT PRO INSULINSYRINGE05ML31G X516 107 TRUE COMFORT PRO INSULINSYRINGE1ML30G X516 107 TRUE COMFORT PRO INSULINSYRINGE1ML31G X516 107 TRUE COMFORT PRO INSULINSYRINGEU-10005ML30G X 12 107 TRUE COMFORT PRO INSULINSYRINGEU-1001ML30G X 12 107 TRUE METRIX BLOOD GLUCOSETEST STRIPS 65 TRUE METRIX CONTROL SOLUTION LEVEL 3 88 TRUEDRAW LANCING DEVICE 88

Index 31

TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGEU-10003ML29G X LUBRICATEDRIBBEDSTUDD SYRINGE03ML29G X12 107 ED 77 12 108 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGEU-10003ML30G X LUBRICATEDSPERMICIDE SYRINGE03ML30G X516 107 77 12 108 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGEU-10003ML31G X LUBRICATEDSPERMICIDE SYRINGE03ML30G X516 107 EXTRA LARGE 77 516 108 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGEU-10005ML28G X LUBRICATEDSPERMICIDE SYRINGE05ML28G X12 107 EXTRA STRENGTH 77 12 108 TRUEPLUS INSULIN TRUSTEX NATURAL ULTICARE INSULIN SYRINGEU-10005ML29G X CONDOMS SYRINGE05ML29G X12 107 +LUBELUBRICATED 77 12 108 TRUEPLUS INSULIN TRUSTEX WITH ULTICARE INSULIN SYRINGEU-10005ML30G X NONOXYNOL- SYRINGE05ML30G X516 107 9RIBBEDSTUDDED 77 12 108 TRUEPLUS INSULIN TRUSTEXRIA ULTICARE INSULIN SYRINGEU-10005ML31G X LUBRICATED 77 SYRINGE05ML30G X516 108 TRUSTEXRIA LUBRICATED 516 108 TRUEPLUS INSULIN SPERMICIDE 77 ULTICARE INSULIN SYRINGEU-1001ML28G X TRUSTEXRIA SYRINGE1ML28G X 12 108 12 108 LUBRICATEDSPERMICIDE ULTICARE INSULIN TRUEPLUS INSULIN 77 SYRINGE1ML29G X 12 108 SYRINGEU-1001ML29G X TRUVADA 47 ULTICARE INSULIN 12 108 SYRINGE1ML30G X 12 108 TUKYSA 36 TRUEPLUS INSULIN ULTICARE INSULIN

TURALIO 39 SYRINGEU-1001ML30G X SYRINGE1ML30G X516 108 TUZISTRA XR 56 516 108 TRUEPLUS INSULIN ULTICARE INSULIN TWINRIX 131 SYRINGEU-1001ML31G X SYRINGESHORT03ML30G XTWIRLA 53 516 108 516 108

TWYNSTA 33 ULTICARE INSULIN TRUEPLUS LANCETS 26G 88 TYBLUME 53 SYRINGESHORT03ML31G XTRUEPLUS LANCETS 28G 88 516 108 TYBOST 47 TRUEPLUS LANCETS 28G ULTICARE INSULIN SUPER THIN 88 TYGACIL 126 SYRINGESHORT05ML30G X

TRUEPLUS LANCETS 30G 88 TYKERB 39 516 108 TRUEPLUS LANCETS 30G ULTICARE INSULIN TYLENOLCODEINE 3 9 ULTRA THIN 88 SYRINGESHORT05ML31G XTYLENOLCODEINE 4 9 TRUEPLUS LANCETS 33G 88 516 108

TYMLOS 67 TRUEPLUS LANCETS 33G ULTICARE INSULIN MICRO THIN 88 TYSABRI 125 SYRINGESHORT1ML30G XTRUEPLUS SAFETY LANCETS UCERIS 10 516 108 28G 88 ULTICARE INSULIN UDENYCA 74 TRUETRACK TEST 65 SYRINGESHORT1ML31G X

ULESFIA 65 516 108 TRULICITY 24 ULORIC 72 ULTICARE INSULIN TRUMENBA 129 ULTI-LANCE AUTOMATIC SYRINGEU-10003ML30G XTRUSOPT 121 CLEAR TIP 88 12 108 TRUSTEX COLOR CONDOMS + ULTICARE INSULIN SAFETY ULTICARE INSULIN LUBE 77 SYRINGE05ML29G X SYRINGEU-10003ML31G XTRUSTEX LUBRICATED 77 12 108 516 108

ULTICARE INSULIN TRUSTEX LUBRICATED ULTICARE INSULIN SAFETY EXTRALARGE 77 SYRINGE1ML29G X SYRINGEU-10005ML30G X

12 108 TRUSTEX LUBRICATED 12 108 EXTRASTRENGTH 77

Index 32

ULTICARE INSULIN SYRINGEU-10005ML31G X516 108 ULTICARE INSULIN SYRINGEU-1001ML30G X12 108 ULTICARE INSULIN SYRINGEU-1001ML31G X516 109 ULTICARE INSULIN SYRINGEULTRAFINE U-10003ML31G X 516 109 ULTICARE INSULIN SYRINGEULTRAFINE U-10005ML31G X 516 109 ULTICARE INSULIN SYRINGEULTRAFINE U-1001ML31G X 516 109 ULTIGUARD SAFEPACK INSULIN SYRINGE 03ML30G X12SHARPS C 109 ULTIGUARD SAFEPACK INSULIN SYRINGE 12ML 30G X12SHARPS C 109 ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 30G X 12SHARPS CON 109 ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 31G X 516SHARPS CO 109 ULTIGUARD SAFEPACK INSULIN SYRINGE03ML30G X12SHARPS C 109 ULTIGUARD SAFEPACK INSULIN SYRINGE03ML31G X516SHARPS 109 ULTIGUARD SAFEPACK INSULIN SYRINGE05ML30G X12SHARPS C 109 ULTIGUARD SAFEPACKSYRINGENEEDLE31G X 516SHARPSCONTAIN 109 ULTILET CLASSIC LANCETS 88 ULTILET INSULIN SYRINGE03ML30G X8MM 109 ULTILET INSULIN SYRINGE03ML31G X8MM 109 ULTILET INSULIN SYRINGE05ML30G X8MM 109 ULTILET INSULIN SYRINGE1ML30G X 8MM109 ULTILET INSULIN SYRINGE1ML31G X 8MM109

ULTILET INSULIN SYRINGESHORT03ML30GX 127MM 109 ULTILET INSULIN SYRINGESHORT03ML30GX 516 109 ULTILET INSULIN SYRINGESHORT03ML31GX 516 109 ULTILET INSULIN SYRINGESHORT05ML30GX 516 109 ULTILET INSULIN SYRINGESHORT05ML31GX 516 109 ULTILET INSULIN SYRINGESHORT1ML30G X516 109 ULTILET INSULIN SYRINGESHORT1ML31G X516 109 ULTILET INSULIN SYRINGEU-10005ML30G X12 109 ULTILET INSULIN SYRINGEU-1001ML30G X12 109 ULTILET LANCETS 88 ULTILET LANCETS 33G 88 ULTILET SAFETY LANCETS 21G X 22MM 88 ULTILET SAFETY LANCETS 23G 88 ULTRA COMFORT INSULIN SYRINGEU-10003ML30G X516 ULTRA FLO INSULIN

SYRINGE 03ML29G X12 ULTRA FLO INSULIN

SYRINGE 03ML30GX12 ULTRA FLO INSULIN

SYRINGE 05ML30GX516 110

ULTRA FLO INSULIN SYRINGE 05ML31GX516 110 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML30GX12 110 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML30GX516

110 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML31GX516

110 ULTRA FLO INSULIN SYRINGE 1M29GX12 110 ULTRA FLO INSULIN SYRINGE 1ML30GX12 110 ULTRA FLO INSULIN SYRINGE 1ML30GX516 110 ULTRA FLO INSULIN SYRINGE 1ML31GX516 110 ULTRA THIN LANCETS 31G 88 ULTRA-COMFORT INSULIN SYRINGEU-10003ML29G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-10003ML30G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-10003ML31G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML28G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML29G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML30G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML31G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML28G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML29G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML30G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML31G X516 110 ULTRA-THIN II AUTO LANCET 88 ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML30GX516 110

Index 33

ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML31GX516 111 ULTRA-THIN II INSULIN SYRINGE SHORTU-10005ML30GX516 111 ULTRA-THIN II INSULIN SYRINGE SHORTU-10005ML31GX516 111 ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML30GX516 111 ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML31GX516 111 ULTRA-THIN II INSULIN SYRINGEU-10005ML29GX12 111 ULTRA-THIN II INSULIN SYRINGEU-1001ML29GX12

111 ULTRA-THIN II LANCETS 28G 88 ULTRA-THIN II LANCETS 30G 88 ULTRACARE INSULIN SYRINGEU-10003ML30G X516 111 ULTRACARE INSULIN SYRINGEU-10003ML31G X516 111 ULTRACARE INSULIN SYRINGEU-10005ML30G X12 111 ULTRACARE INSULIN SYRINGEU-10005ML30G X516 111 ULTRACARE INSULIN SYRINGEU-10005ML31G X516 111 ULTRACARE INSULIN SYRINGEU-1001ML30G X12 111 ULTRACARE INSULIN SYRINGEU-1001ML30G X516 111 ULTRACARE INSULIN

UNILET GP LANCET 89 UNILET GP SUPERLITE LANCET 89 UNILET GP 28 ULTRA THIN 89 UNILET LANCET 89 UNILET LANCETS MICRO-THIN33G 89 UNILET LANCETS SUPER-THIN30G 89 UNILET LANCETS ULTRA-THIN 28G 89 UNILET SUPERLITE LANCET 89 UNISTIK 3 GENTLE 89 UNISTIK PRO SAFETY LANCET 21G 89 UNISTIK PRO SAFETY LANCET 25G 89 UNISTIK PRO SAFETY LANCET 28G 89 UNISTIK SAFETY LANCETS 28G 89 UNISTIK SAFETY LANCETS 30G 89 UNISTIK TOUCH SAFETY LANCETS 21G 89 UNISTIK TOUCH SAFETY LANCETS 23G 89 UNISTIK TOUCH SAFETY LANCETS 28G 89 UNISTIK TOUCH SAFETY LANCETS 30G 89 UNIVERSAL 1 LANCETS THIN26G 89 UNIVERSAL 1 LANCETS ULTRA THIN 30G 89 UNIVERSAL 1 LANCETS33GMICRO-THIN

89 URECHOLINE 129 UROCIT-K 10 71 UROXATRAL 72 URSO 250 70 URSO FORTE 70

valproic acid 20 valrubicin 38 valsartan 31 valsartan-hydrochlorothiazide

33 VALSTAR 38 VALTOCO 17 VALTREX 48 VALUE HEALTH INSULIN SYRINGEU-10005ML29G X12 111 VALUE HEALTH INSULIN SYRINGEU-1001ML29G X12 111 VALUE PLUS LANCETS STANDARD 21G 89 VALUE PLUS LANCETS SUPERTHIN 30G 89 VALUE PLUS LANCETS THIN 26G 89 VALUE PLUS LANCING DEVICE 89 VALUMARK LANCET SUPER THIN 30G 89 VALUMARK LANCET ULTRA THIN 28G 89 VANCOCIN 11 VANCOCIN HCL 11 vancomycin hcl 11 VANCOMYCIN HYDROCHLORIDE 11 VANISHPOINT INSULIN SYRINGE05ML30G X12 111 VANISHPOINT INSULIN SYRINGE05ML30G X516 111 VANISHPOINT INSULIN SYRINGE1ML29G X 12 111 VANISHPOINT INSULIN SYRINGE1ML30G X516 111 VAQTA 131 VARENICLINE TARTRATE 125

SYRINGEU-1001ML31G X516 111 ULTRACET 9 ULTRAM 8 UNASYN 123 UNASYN BULK PACK 123 UNILET COMFORTOUCH LANCET 88

ursodiol UTIBRON NEOHALER UVADEX VAGIFEM valacyclovir hcl VALCYTE valganciclovir hcl

70 15 40

132 48 47 47

VARIVAX VARUBI VASCEPA VASERETIC VASOTEC VECAMYL VECTIBIX

131 27 29 33 31 33 36

UNILET EXCELITE 88 VALIUM 13 VECTICAL 60

UNILET EXCELITE II 88 valproate sodium 20 VELCADE 39

Index 34

VELETRI 51 VOGELXO PUMP 10 XALKORI 40 VELPHORO 71 VOL-PLUS 117 XANAX 13 VELTIN 57 VOLTAREN 57 XANAX XR 13 VEMLIDY 48 VORAXAZE 40 XARELTO 16 venlafaxine hcl 22 voriconazole 27 XARELTO STARTER PACK 16 VENTAVIS 51 VOSEVI 48 XELJANZ 4 VENTOLIN HFA 15 VOTRIENT 40 XELJANZ XR 4 verapamil hcl 50 VP INSULIN SYRINGEU- XELODA 36

10003ML29G X 12 111 VEREGEN 57 XENAZINE 124 VPRIV 73 VERELAN 50 XEOMIN 118 VUSION 59 VERELAN PM 50 XGEVA 67 VYNDAMAX 51 VERZENIO 39 XIFAXAN 10 VYNDAQEL 51 VESICARE 129 XIGDUO XR 2324 VYTORIN 29 VFEND 27 XIMINO 126 VYVANSE 1 VIAGRA 51 XOLAIR 1314 WALGREENS ADVANCED

VIBRAMYCIN 126 XOPENEX 15 TRAVELLANCETS 28G 89 VICTOZA 24 WALGREENS COMFORT XOPENEX CONCENTRATE 15 VIDA MIA AUTOLET ASSUREDLANCETS MICRO XOPENEX HFA 15 LANCINGDEVICE 89 THIN33G 89 XOSPATA 40 VIDA MIA UNILET LANCETS WALGREENS COMFORT

XPOVIO 100 MG ONCE SUPER THIN 30G 89 ASSUREDLANCETS SUPER WEEKLY 37 VIDA MIA UNILET LANCETS THIN28G 89 XPOVIO 60 MG ONCE ULTRA THIN 28G 89 WALGREENS LANCETS 89 WEEKLY 37 VIDAZA 36 WALGREENS THIN XPOVIO 80 MG ONCE LANCETS 89 VIDEX EC 47 WEEKLY 37 WALGREENS ULTRA THIN VIDEXPEDIATRIC 47 XPOVIO 80 MG TWICE LANCETS 89 WEEKLY 38 vigabatrin 19 warfarin sodium 15 XTAMPZA ER 8 VIGAMOX 120 water for irrigation sterile 116 XTANDI 37 VIIBRYD 22 WELCHOL 29 XULTOPHY 10036 24 VIIBRYD STARTER PACK 22 WELLBUTRIN SR 20 XYLOCAINE 76 VIMPAT 19 WELLBUTRIN XL 2021 XYLOCAINE-MPF 76 vincristine sulfate 41 WESTAB PLUS 117 XYREM 123 vinorelbine tartrate 41 WESTHROID 127 XYZAL ALLERGY 24HR 28 VIRACEPT 47 WIDE-SEAL SILICONE XYZAL ALLERGY 24HR

VIRAMUNE 47 DIAPHRAGM KIT 60 78 CHILDRENS 28 WIDE-SEAL SILICONE VIRAMUNE XR 47 YASMIN 28 53 DIAPHRAGM KIT 65 78 VIREAD 47 53 WIDE-SEAL SILICONE YAZ VISTARIL 13 DIAPHRAGM KIT 70 78 YERVOY 36

WIDE-SEAL SILICONE VISTOGARD 26 YONSA 37 DIAPHRAGM KIT 75 78 VITAMIN D2 132 ZADITOR 121 WIDE-SEAL SILICONE VITATHELYGINGER 117 DIAPHRAGM KIT 80 78 zafirlukast 14 VITRAKVI 40 WIDE-SEAL SILICONE zaleplon 75

DIAPHRAGM KIT 85 78 VIVAGUARD LANCETS 89 ZALTRAP 36 WIDE-SEAL SILICONE VIVAGUARD LANCING DIAPHRAGM KIT 90 78 ZANAFLEX 118 DEVICE 89 WIDE-SEAL SILICONE ZANOSAR 35 VIVELLE-DOT 70 DIAPHRAGM KIT 95 78 ZANTAC 150 MAXIMUM VIZIMPRO 36 WP THYROID 127 STRENGTH 128 VOGELXO 10 XALATAN 121 ZARONTIN 20

Index 35

ZARXIO 74 ZAVESCA 73 ZEGERID 128 ZEJULA 40 ZELBORAF 40 ZEMAIRA 125 ZEMPLAR 68 ZENPEP 65 ZEPATIER 48 ZERVIATE 121 ZESTORETIC 33 ZESTRIL 31 ZETIA 30 ZEVRX INSULIN SYRINGE05ML30G X12 ZEVRX INSULIN

SYRINGE05ML30G X516 ZEVRX INSULIN

SYRINGE1ML30G X 12 111 ZEVRX INSULIN SYRINGE1ML30G X516 111 ZIAC 33 ZIAGEN 47 ZIANA 57 zidovudine 47 ZIEXTENZO 74 zileuton 14 ZIOPTAN 121 ziprasidone hcl 43 ZIRABEV 36 ZIRGAN 120 ZITHROMAX 76 ZITHROMAX TRI-PAK 76 ZITHROMAX Z-PAK 76 ZOCOR 30 ZOFRAN 26 ZOHYDRO ER 8 ZOLADEX 37 zoledronic acid 67 ZOLEDRONIC ACID 67 zoledronic acid 67 ZOLINZA 40 zolmitriptan 113 ZOLOFT 22 zolpidem tartrate 75

ZOMACTON 67 ZOMIG 113 ZOMIG ZMT 113 ZONALON 60 ZONEGRAN 19 zonisamide 19 ZONTIVITY 73 ZORBTIVE 67 ZORTRESS 116 ZOSTAVAX 131 ZOSYN 123 ZOVIRAX 4861 ZYCLARA 64 ZYCLARA PUMP 64 ZYDELIG 40 ZYLOPRIM 72 ZYMAXID 120 ZYPREXA 44 ZYPREXA ZYDIS 44 ZYRTEC ALLERGY 29 ZYRTEC CHILDRENS ALLERGY 29 ZYRTEC-D ALLERGYCONGESTION 56 ZYTIGA 37 ZYVOX 12

Index 36

bull FRoM I coordinated care

Statement of Non-Discrimination

Ambetter from Coordinated Care Corporation complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Ambetter from Coordinated Care does not exclude people or treat them differently because of race color national origin age disability or sex

Ambetter from Coordinated Care

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

Qualified sign language interpreters

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Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages

If you need these services contact Ambetter from Coordinated Care at 1-877-687-1197 (TTYTDD 1-877-941-9238)

If you believe that Ambetter from Coordinated Care 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 Grievances Coordinator Coordinated Care 1145 Broadway Suite 300 Tacoma WA 98402 1-877-687-1197 (TTYTDD 1-877-941-9238) Fax 1-855-218-0588 You can file a grievance by mail fax or email WAqualitydeptcentenecom If you need help filing a grievance Ambetter from Coordinated Care is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Spanish

Si usted o alguien a quien estaacute ayudando tiene preguntas acerca de Ambetter de Coordinated Care tiene derecho a obtener

ayuda e informacioacuten en su idioma sin costo alguno Para hablar con un inteacuterprete llame al 1-877-687-1197

(TTYTDD 1-877-941-9238)

Chinese

如果您或是您正在協助的對象有關於 Ambetter from Coordinated Care 方面的問題您有權利免費以您的母語得到幫助和訊

息如果要與一位翻譯員講話請撥電話 1-877-687-1197 (TTYTDD 1-877-941-9238)

Vietnamese

Nếu quyacute vị hay người magrave quyacute vị đang giuacutep đỡ coacute cacircu hỏi về Ambetter from Coordinated Care quyacute vị sẽ coacute quyền được giuacutep vagrave

coacute thecircm thocircng tin bằng ngocircn ngữ của migravenh miễn phiacute Để noacutei chuyện với một thocircng dịch viecircn xin gọi 1-877-687-1197

(TTYTDD 1-877-941-9238)

Korean

Russian

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정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 그렇게 통역사와 얘기하기 위해서는 1-877-687-1197

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В случае возникновения у вас или у лица которому вы помогаете каких-либо вопросов о программе страхования Ambetter

from Coordinated Care вы имеете право получить бесплатную помощь и информацию на своем родном языке Чтобы

поговорить с переводчиком позвоните по телефону 1-877-687-1197 (TTYTDD 1-877-941-9238)

Tagalog

Kung ikaw o ang iyong tinutulangan ay may mga katanungan tungkol sa Ambetter from Coordinated Care may karapatan ka na

makakuha nang tulong at impormasyon sa iyong wika ng walang gastos Upang makausap ang isang tagasalin tumawag sa

1-877-687-1197 (TTYTDD 1-877-941-9238)

Ukrainian

В разі виникнення у вас або особи якій ви допомагаєте будь-яких запитань щодо програми страхування Ambetter from

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перекладачем зателефонуйте за номером 1-877-687-1197 (TTYTDD 1-877-941-9238)

Mon-Khmer Cambodian

បរសនលោកអនកឬ នរណាមនន កដែលអនកកពងដែជយមននរញហា អព Ambetter from Coordinated Care Corporation អនកមននសទធទទលបានជនយ

នងពែមននជាភាសាលោកអនកលោយឥែគែថលៃ ស មនយាយលៅកានអនករកដបរតាមលលខ 1-877-687-1197 (TTYTDD 1-877-941-9238)

Japanese Ambetter from Coordinated Careについて何かご質問がございましたらご連絡くださいご希望の言語によるサポートや情報を無料でご提供いたし

ます通訳が必要な場合は 1-877-687-1197 (TTYTDD 1-877-941-9238) までお電話ください

Amharic እርስዎ ወይም እርሰዎ የሚርዱት ሰው ስለ Ambetter from Coordinated Care Corporation ግብር ጥያቄ ካለዎት ያለምንም ወጪ በቋንቋዎ ድጋፍም

እንዲሁም መረጃ የማግኘት መብት አለዎት አስተርጓሚ ለማነጋገር በ 1-877-687-1197 (TTYTDD 1-877-941-9238) ይደውሉ

Cushite

Yoo sii ykn namaa gargaaraa jirtuu waee Ambetter from Coordinated Care (Kuununsaa Qindeeffamaa) irra gaaffi qabaatan taee

gargaarsaa fi odeeffanoo afaan ketiin kaffaltii alla argachuuf mirgaa qabdaa Turjumaana wajiin dubadhuu1-877-687-1197 irra

bilbilli (TTYTDD 1-877-941-9238)

ن م تكغلبية رورضالتماولعمالو دة عمساال لى ع صول حال ق في Ambetter ح ال ك from Coordinated Care لة حول ئأسده عتسا شخص لدىو أ ديك لن كا ا ذإ ديلArabic

(TTYTDD 1-877-941-9238) ـبصل ات رجم ت كتأية ن ود 1-877-687-1197 م عم ث دحتلل لفة

ਤਤ

ਜ ਤਹਾਡ ਜਾਾ ਹਾਡੀ ਮਦਦ ਲ ਰਹ ਕਿਸ ਕਿਅਿਤੀ ਦ ਮਨ ਕਿਚ Ambetter from Coordinated Care ਦ ਬਾਰ ਿਈ ਸਿਾਲ ਹਨ ਤਾਾ ਹਾਨ ਆਪਣੀ ਭਾਸ਼ਾ ਕਿਚ ਮਫਤ ਮਦਦPunjabi ਣ ਦਾ ਪ ਰਾ ਹਿ ਹ ਦਭਾਸ਼ੀਏ ਨਾਲ ਗਲ ਿਰਨ ਲਈ 1-877-687-1197 (TTYTDD 1-877-941-9238)ਤ ਿਾਲ ਿਰ

Falls Sie oder jemand dem Sie helfen Fragen zu Ambetter from Coordinated Care hat haben Sie das Recht kostenlose Hilfe und

German Informationen in Ihrer Sprache zu erhalten Um mit einem Dolmetscher zu sprechen rufen Sie bitte die Nummer 1-877-687-1197

(TTYTDD 1-877-941-9238) an

ຖາທານ ຫຄນທທານກາລງຊວຍເຫອ ມຄາຖາມກຽວກບ Ambetter from Coordinated Care ທານ

Laotian ມສດທຈະໄດຮບການຊວຍເຫອແລະຂມນຂາວສານທເປນພາສາຂອງທານ ໂດຍບມຄາໃຊຈາຍ

ເພອຈະເວາກບນາຍພາສາ ໃຫໂທຫາ 1-877-687-1197 (TTYTDD 1-877-941-9238)

Classes

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to Treat ADHD Sleep and Eating Disorders


AMEBICIDES

AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections

ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain Swelling Muscle and Joint Conditions

ANALGESICS - NonNarcotic - Drugs to Treat Pain Muscle and Joint Conditions

ANALGESICS - OPIOID - Drugs to Treat Pain Muscle and Joint Conditions


ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain Swelling and Itching










ANTIDIABETICS - Drugs to Regulate Blood Sugar



ANTIEMETICS - Drugs to Treat Nausea and Vomiting



ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol

ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure

ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections)


ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections)

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer


ANTIPSYCHOTICSANTIMANIC AGENTS - Drugs to Treat Mood Disorders


BETA BLOCKERS - Drugs to Treat High Blood Pressure

CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure

CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm

CARDIOVASCULAR AGENTS - MISC - Drugs to Treat Heart and Circulation Conditions

CEPHALOSPORINS - Drugs to Treat Bacterial Infections

CONTRACEPTIVES - Drugs to Prevent Pregnancy

CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions

COUGHCOLDALLERGY - Drugs to Treat Cough Cold and Allergy Symptoms

DERMATOLOGICALS - Drugs to Treat Skin Conditions

DIAGNOSTIC PRODUCTS

DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes

DIURETICS - Drugs to Treat Heart Circulation Conditions and Blood Pressure

ENDOCRINE AND METABOLIC AGENTS - MISC - Drugs to Treat Bone Disease and Regulate Hormones

ESTROGENS - Hormone ReplacementModifying Drugs

FLUOROQUINOLONES - Drugs to Treat Bacterial Infections

GASTROINTESTINAL AGENTS - MISC - Miscellaneous Gastrointestinal Drugs

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System


HEMATOLOGICAL AGENTS - MISC - Drugs to Treat Blood Disorders

HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders

HEMOSTATICS - Drugs to Stop BleedingTreat Blood Disorders

HYPNOTICSSEDATIVESSLEEP DISORDER AGENTS


LOCAL ANESTHETICS-Parenteral - Drugs for Numbing

MACROLIDES - Drugs to Treat Bacterial Infections


MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches




MULTIVITAMINS

MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms

NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus

NEUROMUSCULAR AGENTS - Drugs to RelaxParalyze Muscles

NUTRIENTS



PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune System


PROGESTINS - Hormone ReplacementModifying Drugs

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental and Emotional Conditions

RESPIRATORY AGENTS - MISC - Drugs to Treat Lung Conditions

SULFONAMIDES - Drugs to Treat Bacterial Infections

TETRACYCLINES - Drugs to Treat Bacterial Infections

THYROID AGENTS - Drugs to Regulate Thyroid Hormones

TOXOIDS

ULCER DRUGS - Drugs to Treat Bowel Intestine and Stomach Conditions

URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms

VACCINES


VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions

VITAMINS

Formulary Introduction FORMULARY

The Ambetter from Coordinated Care Preferred Drug ListFormulary is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug beneft Generic drugs have the same active ingredients as their brand name counterparts and should be considered the frst line of treatment The FDA requires generics to be safe and work the same as brand name drugs If there is no generic available there may be more than one brand name drug to treat a condition Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate safe and cost-efective treatment options if a generic medication on the formulary is not suitable for your condition

Please note the Formulary is not meant to be a complete list of the drugs covered under your prescription beneft Not all dosage forms or strengths of a drug may be covered This list is periodically reviewed and updated and may be subject to change Drugs may be added or removed or additional requirements may be added in order to approve continued usage of a specifc drug

Specifc prescription beneft plan designs may not cover certain products or categories regardless of their appearance in this document Please check your benefts for coverage limitations and your share of cost for your drugs

Drug List Key

Brand name drugs are listed in CAPS and generic drugs are lower case Drugs are covered under diferent copay tiers depending on your beneft

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Afordable Care Act Select oral contraceptives vitamin D folic acid for women of child bearing age over-the-counter (OTC) aspirin and smoking cessation products may be covered under this tier Certain age or gender limits apply

Tier 1 - Lowest copayment for those drugs that ofer the greatest value compared to other drugs used to treat similar conditions Select over-the-counter (OTC) generic or brand name drugs may be covered under this tier

Tier 2 - Medium copayment covers brand name drugs that are generally more afordable or may be preferred compared to other drugs to treat the same conditions

Tier 3 - Highest copayment covers higher cost brand name drugs This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage

Tier 4 - Coverage for this tier is for ldquospecialtyrdquo drugs used to treat complex chronic conditions that may require special handling storage or clinical management For members who do not have a Tier 4 plan these drugs may be covered under Tier 3

Prior Authorization for Non-Formulary Drugs

To obtain prior authorization for a non-formulary drug your provider must fill out the Prior Authorization form Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgent requests and within 72 hours for non-urgent requests unless state law requires faster response If the request is disapproved the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request or if the request was incomplete the explanation will identify the missing material information that is necessary to complete the request

ST Step Therapy

NF Non-formulary

Drug Name DrugTier

RequirementsLimits

QL(3 ea daily)

QL(2 ea daily)

QL(1 ea daily)

QL(2 ea daily)

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(2 ea daily)

QL(3 ea daily)

QL(2 ea daily)

QL(4 ea daily)

3 ST QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

Anti-Obesity Agents

SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

yrs old)

Drug Name DrugTier

RequirementsLimits

Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA

Aminoglycosides

ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits

ea daily)

Drug Name DrugTier

RequirementsLimits

ea daily)

Gold Compounds

Drug Name DrugTier

RequirementsLimits

celecoxib caps 1 PA

daily)

flurbiprofen tabs 1

Drug Name DrugTier

RequirementsLimits

nabumetone tabs 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4

ml daily)

ml daily) SP

Drug Name DrugTier

RequirementsLimits

Salicylates

diflunisal tabs 1

salsalate tabs 1

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(4 eadaily)

1 QL(034 eadaily)

1 PA QL(2 eadaily)

daily)

PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

NF QL(10 ml daily)

1 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

OXAYDO TABS 5 MG 2

3 PA QL(2 eadaily)

1 PA QL(2 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

Opioid Combinations

Drug Name DrugTier

RequirementsLimits

LORTAB ELIX 2

Drug Name DrugTier

RequirementsLimits

1 QL(3 ea daily)

1 QL(2 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(0143ea daily)

QL(3 ea daily)

QL(2 ea daily)

Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens

danazol caps 1

Drug Name DrugTier

RequirementsLimits

METHITEST TABS 3

Vasodilating Agents

Anthelmintics

Drug Name DrugTier

RequirementsLimits

EMVERM CHEW 2

trimethoprim tabs 1

Drug Name DrugTier

RequirementsLimits

atovaquone susp 1

Carbapenems

meropenem solr 1

Glycopeptides

Drug Name DrugTier

RequirementsLimits

Leprostatics

dapsone tabs 1

aztreonam solr 1

Oxazolidinones

Drug Name DrugTier

RequirementsLimits

daily) Polymyxins

Drug Name DrugTier

RequirementsLimits

NITRO-BID OINT 3

meprobamate tabs 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

dofetilide caps 1

MULTAQ TABS 3

FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Steroid Inhalants

Drug Name DrugTier

RequirementsLimits

daily)

FLOVENT HFA AERO 2

daily)

ADVAIR HFA AERO 2

Drug Name DrugTier

RequirementsLimits

1 QL(15 ml daily)

daily)

BREO ELLIPTA AEPB 2

1 PA QL(12 mldaily)

Drug Name DrugTier

RequirementsLimits

daily) Xanthines

ELIXOPHYLLIN ELIX 1

BEVYXXA CAPS 3

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

Drug Name DrugTier

RequirementsLimits

NF QL(6 ml daily)

NF QL(2 ml daily)

NF QL(16 mldaily)

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

EPIDIOLEX SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF QL(30 ml daily)

NF QL(4 ea daily)

NF QL(20 ea daily)

NF QL(100 eadaily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(3 eadaily)

1 PA QL(3 eadaily)

daily)

primidone tabs 1

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(6 ea daily)

NF QL(8 ea daily)

NF QL(40 ml daily)

NF QL(3 ea daily)

3 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

Carbamates

PEGANONE TABS 3

Drug Name DrugTier

RequirementsLimits

phenytoin chew 1

phenytoin susp 1

Succinimides

NF QL(30 ml daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(3 ea daily)

NF QL(2 ea daily)

NF QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

FETZIMA CP24 3 PA

NF QL(4 ea daily)

NF QL(1 ea daily)

1 QL(3 ea daily)

Tricyclic Agents

amoxapine tabs 3

Drug Name DrugTier

RequirementsLimits

doxepin hcl caps 1

doxepin hcl conc 1

miglitol tabs 1

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

1 QL(2 ea daily)

1 QL(4 ea daily)

GLYXAMBI TABS 2

2 QL(2 ea daily)

TRIJARDY XR TB24 2

3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

diazoxide susp 1

daily)

3 QL(0035 eadaily)

Drug Name DrugTier

RequirementsLimits

ml daily)

Insulin

APIDRA SOLN 3 PA

FIASP SOLN 2

LEVEMIR SOLN 2

NOVOLIN 7030 SUSP 2

Drug Name DrugTier

RequirementsLimits

NOVOLIN N SUSP 2

NOVOLIN R SOLN 2

NOVOLOG SOLN 2

TRESIBA SOLN 2

Drug Name DrugTier

RequirementsLimits

MOTOFEN TABS 3

CHEMET CAPS 3

deferiprone tabs 1

Drug Name DrugTier

RequirementsLimits

VISTOGARD PACK 4 PA

NARCAN LIQD 3

daily)

Drug Name DrugTier

RequirementsLimits

dronabinol caps 1

Drug Name DrugTier

RequirementsLimits

ea daily)

VARUBI TBPK 3 PA

ERAXIS SOLR 3

MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3

flucytosine caps 1

yrs old)

Drug Name DrugTier

RequirementsLimits

nystatin tabs 1

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

daily)

TOLSURA CAPS 4 PA

Drug Name DrugTier

RequirementsLimits

QL(30 ml daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(6 gm daily)

NF QL(6 ea daily)

NF QL(252 gmdaily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

captopril tabs 1

lisinopril tabs 1

Drug Name DrugTier

RequirementsLimits

ramipril caps 1

trandolapril tabs 1

Drug Name DrugTier

RequirementsLimits

daily)

QL(3 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

EXFORGE HCT TABS 2

QL(1 ea daily)

QL(2 ea daily)

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

1 QL(3 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

eplerenone tabs 1

Vasodilators

minoxidil tabs 1

Drug Name DrugTier

RequirementsLimits

COARTEM TABS 2

Antimalarials

Drug Name DrugTier

RequirementsLimits

FIRDAPSE TABS 4 PA

Drug Name DrugTier

RequirementsLimits

RIFAMATE CAPS 3

isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA

rifampin caps 1

rifampin solr 1

Drug Name DrugTier

RequirementsLimits

melphalan tabs 1

Drug Name DrugTier

RequirementsLimits

Antimetabolites

Drug Name DrugTier

RequirementsLimits

daily)

MVASI SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

ZIRABEV SOLN 4 PA

TUKYSA TABS 4 PA

RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP

VIZIMPRO TABS 4 PA

DAURISMO TABS 4 PA

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

EMCYT CAPS 4 PA SP

letrozole tabs 1

ea daily) SP

Drug Name DrugTier

RequirementsLimits

ea daily) SP

NUBEQA TABS 4 PA

YONSA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

daily) SP

BALVERSA TABS 4 PA

daily) SP

BRUKINSA CAPS 4 PA

COPIKTRA CAPS 4 PA

daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

daily)

Drug Name DrugTier

RequirementsLimits

daily)

4 PA QL(1 eadaily)

INREBIC CAPS 4 PA

daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA

LORBRENA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA

ROZLYTREK CAPS 4 PA

TABRECTA TABS 4 PA

TALZENNA CAPS 4 PA

daily) SP

TAZVERIK TABS 4 PA

TIBSOVO TABS 4 PA

ml daily) SP

TURALIO CAPS 4 PA

daily) SP

VERZENIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

XOSPATA TABS 4 PA

hydroxyurea caps 1

NIPENT SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

UVADEX SOLN 4 PA SP

Mitotic Inhibitors

Drug Name DrugTier

RequirementsLimits

NF PA SP

4 PA SP

NF PA SP

carbidopa tabs 1

Drug Name DrugTier

RequirementsLimits

tolcapone tabs 1

APOKYN SOCT 4 PA

NF QL(4 ea daily)

NEUPRO PT24 2

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF ST QL(2 eadaily)

NF ST QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

Antimanic Agents

LITHIUM SOLN 1

Drug Name DrugTier

RequirementsLimits

daily)

Benzisoxazoles

NF QL(1 ea daily)

NF QL(4 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

NF QL(0036 mldaily)

Drug Name DrugTier

RequirementsLimits

NF QL(0036 mldaily)

haloperidol tabs 1

Drug Name DrugTier

RequirementsLimits

3 PA QL(2 eadaily)

daily)

NF PA QL(1 eadaily)

NF PA QL(2 eadaily)

NF QL(2 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

perphenazine tabs 1

REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

0 QL(1 ea daily)

NF QL(1 ea daily)

FUZEON SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

NF QL(125 mldaily)

2 QL(4 ea daily)

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

RUKOBIA TB12 4 PA

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

CMV Agents

cidofovir soln 3

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

ZEPATIER TABS 4 PA

Herpes Agents

daily)

Drug Name DrugTier

RequirementsLimits

NF QL(5 ea daily)

Alpha-Beta Blockers

Drug Name DrugTier

RequirementsLimits

carvedilol tabs 1

atenolol tabs 1

2 PA QL(1 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

nadolol tabs 1

pindolol tabs 1

Drug Name DrugTier

RequirementsLimits

felodipine tb24 1

isradipine caps 1

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1

Drug Name DrugTier

RequirementsLimits

Cardiac Glycosides

digoxin soln 1

digoxin tabs 1

BIDIL TABS 2

NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents

Drug Name DrugTier

RequirementsLimits

daily) SP

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(6 mldaily)

4 PA QL(6 mldaily)

daily) SP

cefadroxil caps 1

cefadroxil susr 1

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1

cefaclor caps 1

cefaclor susr 1

cefprozil susr 1

cefprozil tabs 1

cefdinir caps 1

cefdinir susr 1

Drug Name DrugTier

RequirementsLimits

cefepime hcl solr 1

TEFLARO SOLR 3

Drug Name DrugTier

RequirementsLimits

FALESSA KIT 0

NATAZIA TABS 0

Drug Name DrugTier

RequirementsLimits

TYBLUME CHEW 0

Drug Name DrugTier

RequirementsLimits

ELLA TABS 0

KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0

NEXPLANON IMPL 0

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

MEDROL TABS 2 MG 3

MILLIPRED DP TBPK 3

MILLIPRED TABS 3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1

Drug Name DrugTier

RequirementsLimits

Mineralocorticoids

Antitussives

QL(2 ea daily)

QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

QL(2 ea daily)

HYPERSAL NEBU 35 1

NEBUSAL NEBU 1

Mucolytics

Drug Name DrugTier

RequirementsLimits

12 yrs old)

yrs old)

Drug Name DrugTier

RequirementsLimits

12 yrs old)

Drug Name DrugTier

RequirementsLimits

VEREGEN OINT 3

daily) RXOTC

Drug Name DrugTier

RequirementsLimits

mupirocin oint 1

ERTACZO CREA 3

EXELDERM SOLN 3

JUBLIA SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

OXISTAT LOTN 2

PANRETIN GEL 3

PICATO GEL 0015 2

PICATO GEL 005 2

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(4 ea daily)

ml daily) SP

TAZORAC CREA 005 2

Drug Name DrugTier

RequirementsLimits

Burn Products

amcinonide crea 1

amcinonide lotn 3

AMCINONIDE OINT 3

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA

Drug Name DrugTier

RequirementsLimits

daily)

PSORCON CREA 2 PA

daily)

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

2 yrs old)

podofilox soln 1

SYNERA PTCH 3

Drug Name DrugTier

RequirementsLimits

Rosacea Agents

EURAX CREA 3

lindane sham 1

malathion lotn 1

Drug Name DrugTier

RequirementsLimits

permethrin crea 1

permethrin liqd 1

spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS

CHEMSTRIP-K STRP 1

KETONE STRP 1

KETOSTIX STRP 1

Drug Name DrugTier

RequirementsLimits

Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

furosemide soln 1

furosemide tabs 1

torsemide tabs 1

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

4 PA SP

PROLIA SOSY 4

TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP

Corticotropin

ACTHAR GEL 4 PA

4 PA SP

CETROTIDE KIT 4 PA

Drug Name DrugTier

RequirementsLimits

4 PA SP

SAIZEN SOLR 4 PA SP

4 PA SP

OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits

Metabolic Modifiers

calcitriol caps 1

calcitriol soln 1

Drug Name DrugTier

RequirementsLimits

MYALEPT SOLR 4 PA

PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1

Drug Name DrugTier

RequirementsLimits

NF QL(6 ea daily)

NF QL(8 ea daily)

4 PA SP

cabergoline tabs 1

Somatostatic Agents

SIGNIFOR SOLN 4 PA

ml daily) SP

daily) SP

Drug Name DrugTier

RequirementsLimits

CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA

PREMPHASE TABS 2

PREMPRO TABS 2

ELESTRIN GEL 3

QL(0286 eadaily)

Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3

daily)

PREMARIN SOLR 2

PREMARIN TABS 2

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA

levofloxacin soln 1

levofloxacin tabs 1

Drug Name DrugTier

RequirementsLimits

ofloxacin tabs 1

daily)

AVSOLA SOLR 4 PA

Drug Name DrugTier

RequirementsLimits

DIPENTUM CAPS 2

Drug Name DrugTier

RequirementsLimits

alvimopan caps 1

PHOSLYRA SOLN 2

VELPHORO CHEW 3 PA

Cystinosis Agents

CYSTAGON CAPS 3 PA

Drug Name DrugTier

RequirementsLimits

acetic acid soln 1

RESECTISOL SOLN 1

SORBITOL SOLN 1

ELMIRON CAPS 2

Urinary Analgesics

Drug Name DrugTier

RequirementsLimits

Gout Agents

allopurinol tabs 1

KRYSTEXXA SOLN 4 PA

Uricosurics

probenecid tabs 1

daily)

CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA

SOLIRIS SOLN 4 PA

TAKHZYRO SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1

dipyridamole tabs 1

ZONTIVITY TABS 3 PA

VPRIV SOLR 4 PA SP

daily) SP

Drug Name DrugTier

RequirementsLimits

DROXIA CAPS 3

OXBRYTA TABS 4 PA

Folic AcidFolates

4 PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA

MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

UDENYCA SOSY 4 PA

ZIEXTENZO SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

estazolam tabs 1

eszopiclone tabs 1

Drug Name DrugTier

RequirementsLimits

triazolam tabs 1

BELSOMRA TABS 3 PA

ramelteon tabs 1

Bulk Laxatives

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 3 PA

PREPOPIK PACK 3 PA

Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1

Drug Name DrugTier

RequirementsLimits

Azithromycin

daily)

Drug Name DrugTier

RequirementsLimits

Clarithromycin

Fidaxomicin

CAYA DPRH 0

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

FEMCAP DEVI 0

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

AUTO-LANCET MISC 1

AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

LANZO MISC 1

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

SURE-PEN MISC 1

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

Serotonin Agonists

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

sumatriptan soln 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1

NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1

ringers soln 1

Fluoride

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily) SP

ATGAM INJ 4 PA SP

cyclosporine caps 1

Drug Name DrugTier

RequirementsLimits

cyclosporine soln 1

SIMULECT SOLR 3

tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits

DEBACTEROL SOLN 2

Dental Products

Drug Name DrugTier

RequirementsLimits

MULTIVITAMINS

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

2 QL(1 ea daily)

carisoprodol tabs 1

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Nasal Steroids

Drug Name DrugTier

RequirementsLimits

riluzole tabs 3

BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS

Drug Name DrugTier

RequirementsLimits

LACRISERT INST 3

COMBIGAN SOLN 2

tropicamide soln 1

Miotics

Drug Name DrugTier

RequirementsLimits

IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA

AZASITE SOLN 3

KLARITY-A SOLN 3

NATACYN SUSP 2

Drug Name DrugTier

RequirementsLimits

trifluridine soln 1

ZIRGAN GEL 2

RESTASIS EMUL 2 PA

OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

FML FORTE SUSP 3 PA

FML OINT 3 PA

LOTEMAX OINT 3 PA

MAXIDEX SUSP 3 PA

PRED MILD SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA

LASTACAFT SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

ZERVIATE SOLN 3 PA

bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST

travoprost soln 1

ZIOPTAN SOLN 2

Otic Combinations

CIPRO HC SUSP 3

daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits

3 PA QL(05 eadaily)

4 PA SP

HYQVIA KIT 4 PA

Aminopenicillins

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

disulfiram tabs 1

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Fibromyalgia Agents

daily) SP

AUBAGIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

GILENYA CAPS 4 PA

ml daily) SP

MAVENCLAD TBPK 4 PA

MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA

ml daily)

Drug Name DrugTier

RequirementsLimits

3 PA QL(1 eadaily)

3 PA QL(2 eadaily)

NUEDEXTA CAPS 3 PA

pimozide tabs 1

Smoking Deterrents

Drug Name DrugTier

RequirementsLimits

NICOTROL NS SOLN 0

TEGSEDI SOSY 4 PA

daily)

Drug Name DrugTier

RequirementsLimits

Sulfonamides

SULFADIAZINE TABS 1

Glycylcyclines

tigecycline solr 1

Tetracyclines

Drug Name DrugTier

RequirementsLimits

NF QL(2 ea daily)

Antithyroid Agents

methimazole tabs 1

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0

TENIVAC INJ 0

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(40 ml daily)

NF RXOTC

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0

PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits

ENGERIX-B INJ 0

ENGERIX-B SUSP 0

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HAVRIX SUSP 0

HEPLISAV-B SOSY 0

Drug Name DrugTier

RequirementsLimits

ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0

TWINRIX SUSY 0

VAQTA SUSP 0

ZOSTAVAX SUSR 0

INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0

Drug Name DrugTier

RequirementsLimits

GYNAZOLE-1 CREA 3

PHEXXI GEL 0 PV

FEMRING RING 3

PREMARIN CREA 2

Drug Name DrugTier

RequirementsLimits

Vasopressors

VITAMINS

NIACIN TR TBCR 1

Drug Name DrugTier

RequirementsLimits

Index 1

Index 2

Index 3

Index 4

Index 5

65 4 4

28 28 28 55

55 116

28 28 75

Index 6

58 131

58 43 43 79 33

41 75 71 72 72 72 29 29

29 121

CORTEF CORTENEMA

126 128

47 112

40 35 38

124 14

9 118 118

11 127

11 11 33

HYDROCHLORIDE 38

Index 7

Index 8

Index 9

Index 10

129 30

32 5 5 5

130 16 41 47 71

132 125 112 112

36 36 58 11 40 40 76 76 57

119 76

128 74 69 69

132 69 70 52 74

Index 11

Index 12

Index 13

25 25 25 23 72

127 25

Index 14

Index 15

ivermectin 10

Index 16

Index 17

Index 18

123 58

68 75 68

68 63 58 39 18

Index 19

Index 20

Index 21

59 59 68

124 5 5 5

112 26

Index 22

7 125 115

116 59 59

114 114

124 69

126 70

120 121

7 51 64

55 51 68

125 118

54 53 53 53 48 23 75 67

123 35

74 37 13

13 73 18

Index 23

Index 24

Index 25

Index 26

74 39 57

71 25 23

43 3 3

124 113 118

68 39 42 30

Index 27

87 87 87 87 53 67

67 116

87 42 60 46 68 15 44 44 67

49 65 14 14 66

66 27 27 21

Index 28

39 42 42

Index 29

64 23 23 40

132 55 10

115 36 39 63

115 64 51

10 10 10

127 124

128 72 39 48 37 72

50 39 26

126 13 49

119 119 119

47 118

Index 30

49 37 39 66

129 51

33 117

115 44

Index 31

Index 32

Index 33

70 15 40

132 48 47 47

131 27 29 33 31 33 36

Index 34

Index 35

Index 36

Spanish

(TTYTDD 1-877-941-9238)

Chinese

Vietnamese

(TTYTDD 1-877-941-9238)

Korean

Russian

Tagalog

1-877-687-1197 (TTYTDD 1-877-941-9238)

Ukrainian

Mon-Khmer Cambodian

Cushite

ਤਤ

(TTYTDD 1-877-941-9238) an

Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

ST Step Therapy

NF Non-formulary

Drug Name DrugTier

RequirementsLimits

QL(3 ea daily)

QL(2 ea daily)

QL(1 ea daily)

QL(2 ea daily)

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(2 ea daily)

QL(3 ea daily)

QL(2 ea daily)

QL(4 ea daily)

3 ST QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

Anti-Obesity Agents

SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

yrs old)

Drug Name DrugTier

RequirementsLimits

Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA

Aminoglycosides

ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits

ea daily)

Drug Name DrugTier

RequirementsLimits

ea daily)

Gold Compounds

Drug Name DrugTier

RequirementsLimits

celecoxib caps 1 PA

daily)

flurbiprofen tabs 1

Drug Name DrugTier

RequirementsLimits

nabumetone tabs 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4

ml daily)

ml daily) SP

Drug Name DrugTier

RequirementsLimits

Salicylates

diflunisal tabs 1

salsalate tabs 1

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(4 eadaily)

1 QL(034 eadaily)

1 PA QL(2 eadaily)

daily)

PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

NF QL(10 ml daily)

1 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

OXAYDO TABS 5 MG 2

3 PA QL(2 eadaily)

1 PA QL(2 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

Opioid Combinations

Drug Name DrugTier

RequirementsLimits

LORTAB ELIX 2

Drug Name DrugTier

RequirementsLimits

1 QL(3 ea daily)

1 QL(2 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(0143ea daily)

QL(3 ea daily)

QL(2 ea daily)

Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens

danazol caps 1

Drug Name DrugTier

RequirementsLimits

METHITEST TABS 3

Vasodilating Agents

Anthelmintics

Drug Name DrugTier

RequirementsLimits

EMVERM CHEW 2

trimethoprim tabs 1

Drug Name DrugTier

RequirementsLimits

atovaquone susp 1

Carbapenems

meropenem solr 1

Glycopeptides

Drug Name DrugTier

RequirementsLimits

Leprostatics

dapsone tabs 1

aztreonam solr 1

Oxazolidinones

Drug Name DrugTier

RequirementsLimits

daily) Polymyxins

Drug Name DrugTier

RequirementsLimits

NITRO-BID OINT 3

meprobamate tabs 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

dofetilide caps 1

MULTAQ TABS 3

FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Steroid Inhalants

Drug Name DrugTier

RequirementsLimits

daily)

FLOVENT HFA AERO 2

daily)

ADVAIR HFA AERO 2

Drug Name DrugTier

RequirementsLimits

1 QL(15 ml daily)

daily)

BREO ELLIPTA AEPB 2

1 PA QL(12 mldaily)

Drug Name DrugTier

RequirementsLimits

daily) Xanthines

ELIXOPHYLLIN ELIX 1

BEVYXXA CAPS 3

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

Drug Name DrugTier

RequirementsLimits

NF QL(6 ml daily)

NF QL(2 ml daily)

NF QL(16 mldaily)

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

EPIDIOLEX SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF QL(30 ml daily)

NF QL(4 ea daily)

NF QL(20 ea daily)

NF QL(100 eadaily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(3 eadaily)

1 PA QL(3 eadaily)

daily)

primidone tabs 1

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(6 ea daily)

NF QL(8 ea daily)

NF QL(40 ml daily)

NF QL(3 ea daily)

3 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

Carbamates

PEGANONE TABS 3

Drug Name DrugTier

RequirementsLimits

phenytoin chew 1

phenytoin susp 1

Succinimides

NF QL(30 ml daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(3 ea daily)

NF QL(2 ea daily)

NF QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

FETZIMA CP24 3 PA

NF QL(4 ea daily)

NF QL(1 ea daily)

1 QL(3 ea daily)

Tricyclic Agents

amoxapine tabs 3

Drug Name DrugTier

RequirementsLimits

doxepin hcl caps 1

doxepin hcl conc 1

miglitol tabs 1

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

1 QL(2 ea daily)

1 QL(4 ea daily)

GLYXAMBI TABS 2

2 QL(2 ea daily)

TRIJARDY XR TB24 2

3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

diazoxide susp 1

daily)

3 QL(0035 eadaily)

Drug Name DrugTier

RequirementsLimits

ml daily)

Insulin

APIDRA SOLN 3 PA

FIASP SOLN 2

LEVEMIR SOLN 2

NOVOLIN 7030 SUSP 2

Drug Name DrugTier

RequirementsLimits

NOVOLIN N SUSP 2

NOVOLIN R SOLN 2

NOVOLOG SOLN 2

TRESIBA SOLN 2

Drug Name DrugTier

RequirementsLimits

MOTOFEN TABS 3

CHEMET CAPS 3

deferiprone tabs 1

Drug Name DrugTier

RequirementsLimits

VISTOGARD PACK 4 PA

NARCAN LIQD 3

daily)

Drug Name DrugTier

RequirementsLimits

dronabinol caps 1

Drug Name DrugTier

RequirementsLimits

ea daily)

VARUBI TBPK 3 PA

ERAXIS SOLR 3

MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3

flucytosine caps 1

yrs old)

Drug Name DrugTier

RequirementsLimits

nystatin tabs 1

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

daily)

TOLSURA CAPS 4 PA

Drug Name DrugTier

RequirementsLimits

QL(30 ml daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(6 gm daily)

NF QL(6 ea daily)

NF QL(252 gmdaily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

captopril tabs 1

lisinopril tabs 1

Drug Name DrugTier

RequirementsLimits

ramipril caps 1

trandolapril tabs 1

Drug Name DrugTier

RequirementsLimits

daily)

QL(3 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

EXFORGE HCT TABS 2

QL(1 ea daily)

QL(2 ea daily)

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

1 QL(3 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

eplerenone tabs 1

Vasodilators

minoxidil tabs 1

Drug Name DrugTier

RequirementsLimits

COARTEM TABS 2

Antimalarials

Drug Name DrugTier

RequirementsLimits

FIRDAPSE TABS 4 PA

Drug Name DrugTier

RequirementsLimits

RIFAMATE CAPS 3

isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA

rifampin caps 1

rifampin solr 1

Drug Name DrugTier

RequirementsLimits

melphalan tabs 1

Drug Name DrugTier

RequirementsLimits

Antimetabolites

Drug Name DrugTier

RequirementsLimits

daily)

MVASI SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

ZIRABEV SOLN 4 PA

TUKYSA TABS 4 PA

RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP

VIZIMPRO TABS 4 PA

DAURISMO TABS 4 PA

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

EMCYT CAPS 4 PA SP

letrozole tabs 1

ea daily) SP

Drug Name DrugTier

RequirementsLimits

ea daily) SP

NUBEQA TABS 4 PA

YONSA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

daily) SP

BALVERSA TABS 4 PA

daily) SP

BRUKINSA CAPS 4 PA

COPIKTRA CAPS 4 PA

daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

daily)

Drug Name DrugTier

RequirementsLimits

daily)

4 PA QL(1 eadaily)

INREBIC CAPS 4 PA

daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA

LORBRENA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA

ROZLYTREK CAPS 4 PA

TABRECTA TABS 4 PA

TALZENNA CAPS 4 PA

daily) SP

TAZVERIK TABS 4 PA

TIBSOVO TABS 4 PA

ml daily) SP

TURALIO CAPS 4 PA

daily) SP

VERZENIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

XOSPATA TABS 4 PA

hydroxyurea caps 1

NIPENT SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

UVADEX SOLN 4 PA SP

Mitotic Inhibitors

Drug Name DrugTier

RequirementsLimits

NF PA SP

4 PA SP

NF PA SP

carbidopa tabs 1

Drug Name DrugTier

RequirementsLimits

tolcapone tabs 1

APOKYN SOCT 4 PA

NF QL(4 ea daily)

NEUPRO PT24 2

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF ST QL(2 eadaily)

NF ST QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

Antimanic Agents

LITHIUM SOLN 1

Drug Name DrugTier

RequirementsLimits

daily)

Benzisoxazoles

NF QL(1 ea daily)

NF QL(4 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

NF QL(0036 mldaily)

Drug Name DrugTier

RequirementsLimits

NF QL(0036 mldaily)

haloperidol tabs 1

Drug Name DrugTier

RequirementsLimits

3 PA QL(2 eadaily)

daily)

NF PA QL(1 eadaily)

NF PA QL(2 eadaily)

NF QL(2 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

perphenazine tabs 1

REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

0 QL(1 ea daily)

NF QL(1 ea daily)

FUZEON SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

NF QL(125 mldaily)

2 QL(4 ea daily)

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

RUKOBIA TB12 4 PA

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

CMV Agents

cidofovir soln 3

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

ZEPATIER TABS 4 PA

Herpes Agents

daily)

Drug Name DrugTier

RequirementsLimits

NF QL(5 ea daily)

Alpha-Beta Blockers

Drug Name DrugTier

RequirementsLimits

carvedilol tabs 1

atenolol tabs 1

2 PA QL(1 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

nadolol tabs 1

pindolol tabs 1

Drug Name DrugTier

RequirementsLimits

felodipine tb24 1

isradipine caps 1

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1

Drug Name DrugTier

RequirementsLimits

Cardiac Glycosides

digoxin soln 1

digoxin tabs 1

BIDIL TABS 2

NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents

Drug Name DrugTier

RequirementsLimits

daily) SP

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(6 mldaily)

4 PA QL(6 mldaily)

daily) SP

cefadroxil caps 1

cefadroxil susr 1

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1

cefaclor caps 1

cefaclor susr 1

cefprozil susr 1

cefprozil tabs 1

cefdinir caps 1

cefdinir susr 1

Drug Name DrugTier

RequirementsLimits

cefepime hcl solr 1

TEFLARO SOLR 3

Drug Name DrugTier

RequirementsLimits

FALESSA KIT 0

NATAZIA TABS 0

Drug Name DrugTier

RequirementsLimits

TYBLUME CHEW 0

Drug Name DrugTier

RequirementsLimits

ELLA TABS 0

KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0

NEXPLANON IMPL 0

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

MEDROL TABS 2 MG 3

MILLIPRED DP TBPK 3

MILLIPRED TABS 3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1

Drug Name DrugTier

RequirementsLimits

Mineralocorticoids

Antitussives

QL(2 ea daily)

QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

QL(2 ea daily)

HYPERSAL NEBU 35 1

NEBUSAL NEBU 1

Mucolytics

Drug Name DrugTier

RequirementsLimits

12 yrs old)

yrs old)

Drug Name DrugTier

RequirementsLimits

12 yrs old)

Drug Name DrugTier

RequirementsLimits

VEREGEN OINT 3

daily) RXOTC

Drug Name DrugTier

RequirementsLimits

mupirocin oint 1

ERTACZO CREA 3

EXELDERM SOLN 3

JUBLIA SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

OXISTAT LOTN 2

PANRETIN GEL 3

PICATO GEL 0015 2

PICATO GEL 005 2

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(4 ea daily)

ml daily) SP

TAZORAC CREA 005 2

Drug Name DrugTier

RequirementsLimits

Burn Products

amcinonide crea 1

amcinonide lotn 3

AMCINONIDE OINT 3

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA

Drug Name DrugTier

RequirementsLimits

daily)

PSORCON CREA 2 PA

daily)

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

2 yrs old)

podofilox soln 1

SYNERA PTCH 3

Drug Name DrugTier

RequirementsLimits

Rosacea Agents

EURAX CREA 3

lindane sham 1

malathion lotn 1

Drug Name DrugTier

RequirementsLimits

permethrin crea 1

permethrin liqd 1

spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS

CHEMSTRIP-K STRP 1

KETONE STRP 1

KETOSTIX STRP 1

Drug Name DrugTier

RequirementsLimits

Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

furosemide soln 1

furosemide tabs 1

torsemide tabs 1

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

4 PA SP

PROLIA SOSY 4

TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP

Corticotropin

ACTHAR GEL 4 PA

4 PA SP

CETROTIDE KIT 4 PA

Drug Name DrugTier

RequirementsLimits

4 PA SP

SAIZEN SOLR 4 PA SP

4 PA SP

OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits

Metabolic Modifiers

calcitriol caps 1

calcitriol soln 1

Drug Name DrugTier

RequirementsLimits

MYALEPT SOLR 4 PA

PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1

Drug Name DrugTier

RequirementsLimits

NF QL(6 ea daily)

NF QL(8 ea daily)

4 PA SP

cabergoline tabs 1

Somatostatic Agents

SIGNIFOR SOLN 4 PA

ml daily) SP

daily) SP

Drug Name DrugTier

RequirementsLimits

CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA

PREMPHASE TABS 2

PREMPRO TABS 2

ELESTRIN GEL 3

QL(0286 eadaily)

Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3

daily)

PREMARIN SOLR 2

PREMARIN TABS 2

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA

levofloxacin soln 1

levofloxacin tabs 1

Drug Name DrugTier

RequirementsLimits

ofloxacin tabs 1

daily)

AVSOLA SOLR 4 PA

Drug Name DrugTier

RequirementsLimits

DIPENTUM CAPS 2

Drug Name DrugTier

RequirementsLimits

alvimopan caps 1

PHOSLYRA SOLN 2

VELPHORO CHEW 3 PA

Cystinosis Agents

CYSTAGON CAPS 3 PA

Drug Name DrugTier

RequirementsLimits

acetic acid soln 1

RESECTISOL SOLN 1

SORBITOL SOLN 1

ELMIRON CAPS 2

Urinary Analgesics

Drug Name DrugTier

RequirementsLimits

Gout Agents

allopurinol tabs 1

KRYSTEXXA SOLN 4 PA

Uricosurics

probenecid tabs 1

daily)

CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA

SOLIRIS SOLN 4 PA

TAKHZYRO SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1

dipyridamole tabs 1

ZONTIVITY TABS 3 PA

VPRIV SOLR 4 PA SP

daily) SP

Drug Name DrugTier

RequirementsLimits

DROXIA CAPS 3

OXBRYTA TABS 4 PA

Folic AcidFolates

4 PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA

MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

UDENYCA SOSY 4 PA

ZIEXTENZO SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

estazolam tabs 1

eszopiclone tabs 1

Drug Name DrugTier

RequirementsLimits

triazolam tabs 1

BELSOMRA TABS 3 PA

ramelteon tabs 1

Bulk Laxatives

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 3 PA

PREPOPIK PACK 3 PA

Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1

Drug Name DrugTier

RequirementsLimits

Azithromycin

daily)

Drug Name DrugTier

RequirementsLimits

Clarithromycin

Fidaxomicin

CAYA DPRH 0

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

FEMCAP DEVI 0

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

AUTO-LANCET MISC 1

AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

LANZO MISC 1

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

SURE-PEN MISC 1

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

Serotonin Agonists

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

sumatriptan soln 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1

NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1

ringers soln 1

Fluoride

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily) SP

ATGAM INJ 4 PA SP

cyclosporine caps 1

Drug Name DrugTier

RequirementsLimits

cyclosporine soln 1

SIMULECT SOLR 3

tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits

DEBACTEROL SOLN 2

Dental Products

Drug Name DrugTier

RequirementsLimits

MULTIVITAMINS

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

2 QL(1 ea daily)

carisoprodol tabs 1

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Nasal Steroids

Drug Name DrugTier

RequirementsLimits

riluzole tabs 3

BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS

Drug Name DrugTier

RequirementsLimits

LACRISERT INST 3

COMBIGAN SOLN 2

tropicamide soln 1

Miotics

Drug Name DrugTier

RequirementsLimits

IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA

AZASITE SOLN 3

KLARITY-A SOLN 3

NATACYN SUSP 2

Drug Name DrugTier

RequirementsLimits

trifluridine soln 1

ZIRGAN GEL 2

RESTASIS EMUL 2 PA

OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

FML FORTE SUSP 3 PA

FML OINT 3 PA

LOTEMAX OINT 3 PA

MAXIDEX SUSP 3 PA

PRED MILD SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA

LASTACAFT SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

ZERVIATE SOLN 3 PA

bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST

travoprost soln 1

ZIOPTAN SOLN 2

Otic Combinations

CIPRO HC SUSP 3

daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits

3 PA QL(05 eadaily)

4 PA SP

HYQVIA KIT 4 PA

Aminopenicillins

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

disulfiram tabs 1

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Fibromyalgia Agents

daily) SP

AUBAGIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

GILENYA CAPS 4 PA

ml daily) SP

MAVENCLAD TBPK 4 PA

MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA

ml daily)

Drug Name DrugTier

RequirementsLimits

3 PA QL(1 eadaily)

3 PA QL(2 eadaily)

NUEDEXTA CAPS 3 PA

pimozide tabs 1

Smoking Deterrents

Drug Name DrugTier

RequirementsLimits

NICOTROL NS SOLN 0

TEGSEDI SOSY 4 PA

daily)

Drug Name DrugTier

RequirementsLimits

Sulfonamides

SULFADIAZINE TABS 1

Glycylcyclines

tigecycline solr 1

Tetracyclines

Drug Name DrugTier

RequirementsLimits

NF QL(2 ea daily)

Antithyroid Agents

methimazole tabs 1

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0

TENIVAC INJ 0

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(40 ml daily)

NF RXOTC

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0

PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits

ENGERIX-B INJ 0

ENGERIX-B SUSP 0

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HAVRIX SUSP 0

HEPLISAV-B SOSY 0

Drug Name DrugTier

RequirementsLimits

ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0

TWINRIX SUSY 0

VAQTA SUSP 0

ZOSTAVAX SUSR 0

INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0

Drug Name DrugTier

RequirementsLimits

GYNAZOLE-1 CREA 3

PHEXXI GEL 0 PV

FEMRING RING 3

PREMARIN CREA 2

Drug Name DrugTier

RequirementsLimits

Vasopressors

VITAMINS

NIACIN TR TBCR 1

Drug Name DrugTier

RequirementsLimits

Index 1

Index 2

Index 3

Index 4

Index 5

65 4 4

28 28 28 55

55 116

28 28 75

Index 6

58 131

58 43 43 79 33

41 75 71 72 72 72 29 29

29 121

CORTEF CORTENEMA

126 128

47 112

40 35 38

124 14

9 118 118

11 127

11 11 33

HYDROCHLORIDE 38

Index 7

Index 8

Index 9

Index 10

129 30

32 5 5 5

130 16 41 47 71

132 125 112 112

36 36 58 11 40 40 76 76 57

119 76

128 74 69 69

132 69 70 52 74

Index 11

Index 12

Index 13

25 25 25 23 72

127 25

Index 14

Index 15

ivermectin 10

Index 16

Index 17

Index 18

123 58

68 75 68

68 63 58 39 18

Index 19

Index 20

Index 21

59 59 68

124 5 5 5

112 26

Index 22

7 125 115

116 59 59

114 114

124 69

126 70

120 121

7 51 64

55 51 68

125 118

54 53 53 53 48 23 75 67

123 35

74 37 13

13 73 18

Index 23

Index 24

Index 25

Index 26

74 39 57

71 25 23

43 3 3

124 113 118

68 39 42 30

Index 27

87 87 87 87 53 67

67 116

87 42 60 46 68 15 44 44 67

49 65 14 14 66

66 27 27 21

Index 28

39 42 42

Index 29

64 23 23 40

132 55 10

115 36 39 63

115 64 51

10 10 10

127 124

128 72 39 48 37 72

50 39 26

126 13 49

119 119 119

47 118

Index 30

49 37 39 66

129 51

33 117

115 44

Index 31

Index 32

Index 33

70 15 40

132 48 47 47

131 27 29 33 31 33 36

Index 34

Index 35

Index 36

Spanish

(TTYTDD 1-877-941-9238)

Chinese

Vietnamese

(TTYTDD 1-877-941-9238)

Korean

Russian

Tagalog

1-877-687-1197 (TTYTDD 1-877-941-9238)

Ukrainian

Mon-Khmer Cambodian

Cushite

ਤਤ

(TTYTDD 1-877-941-9238) an

Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Drug Name DrugTier

RequirementsLimits

QL(3 ea daily)

QL(2 ea daily)

QL(1 ea daily)

QL(2 ea daily)

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(2 ea daily)

QL(3 ea daily)

QL(2 ea daily)

QL(4 ea daily)

3 ST QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

Anti-Obesity Agents

SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

yrs old)

Drug Name DrugTier

RequirementsLimits

Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA

Aminoglycosides

ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits

ea daily)

Drug Name DrugTier

RequirementsLimits

ea daily)

Gold Compounds

Drug Name DrugTier

RequirementsLimits

celecoxib caps 1 PA

daily)

flurbiprofen tabs 1

Drug Name DrugTier

RequirementsLimits

nabumetone tabs 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4

ml daily)

ml daily) SP

Drug Name DrugTier

RequirementsLimits

Salicylates

diflunisal tabs 1

salsalate tabs 1

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(4 eadaily)

1 QL(034 eadaily)

1 PA QL(2 eadaily)

daily)

PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

NF QL(10 ml daily)

1 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

OXAYDO TABS 5 MG 2

3 PA QL(2 eadaily)

1 PA QL(2 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

Opioid Combinations

Drug Name DrugTier

RequirementsLimits

LORTAB ELIX 2

Drug Name DrugTier

RequirementsLimits

1 QL(3 ea daily)

1 QL(2 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(0143ea daily)

QL(3 ea daily)

QL(2 ea daily)

Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens

danazol caps 1

Drug Name DrugTier

RequirementsLimits

METHITEST TABS 3

Vasodilating Agents

Anthelmintics

Drug Name DrugTier

RequirementsLimits

EMVERM CHEW 2

trimethoprim tabs 1

Drug Name DrugTier

RequirementsLimits

atovaquone susp 1

Carbapenems

meropenem solr 1

Glycopeptides

Drug Name DrugTier

RequirementsLimits

Leprostatics

dapsone tabs 1

aztreonam solr 1

Oxazolidinones

Drug Name DrugTier

RequirementsLimits

daily) Polymyxins

Drug Name DrugTier

RequirementsLimits

NITRO-BID OINT 3

meprobamate tabs 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

dofetilide caps 1

MULTAQ TABS 3

FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Steroid Inhalants

Drug Name DrugTier

RequirementsLimits

daily)

FLOVENT HFA AERO 2

daily)

ADVAIR HFA AERO 2

Drug Name DrugTier

RequirementsLimits

1 QL(15 ml daily)

daily)

BREO ELLIPTA AEPB 2

1 PA QL(12 mldaily)

Drug Name DrugTier

RequirementsLimits

daily) Xanthines

ELIXOPHYLLIN ELIX 1

BEVYXXA CAPS 3

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

Drug Name DrugTier

RequirementsLimits

NF QL(6 ml daily)

NF QL(2 ml daily)

NF QL(16 mldaily)

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

EPIDIOLEX SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF QL(30 ml daily)

NF QL(4 ea daily)

NF QL(20 ea daily)

NF QL(100 eadaily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(3 eadaily)

1 PA QL(3 eadaily)

daily)

primidone tabs 1

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(6 ea daily)

NF QL(8 ea daily)

NF QL(40 ml daily)

NF QL(3 ea daily)

3 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

Carbamates

PEGANONE TABS 3

Drug Name DrugTier

RequirementsLimits

phenytoin chew 1

phenytoin susp 1

Succinimides

NF QL(30 ml daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(3 ea daily)

NF QL(2 ea daily)

NF QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

FETZIMA CP24 3 PA

NF QL(4 ea daily)

NF QL(1 ea daily)

1 QL(3 ea daily)

Tricyclic Agents

amoxapine tabs 3

Drug Name DrugTier

RequirementsLimits

doxepin hcl caps 1

doxepin hcl conc 1

miglitol tabs 1

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

1 QL(2 ea daily)

1 QL(4 ea daily)

GLYXAMBI TABS 2

2 QL(2 ea daily)

TRIJARDY XR TB24 2

3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

diazoxide susp 1

daily)

3 QL(0035 eadaily)

Drug Name DrugTier

RequirementsLimits

ml daily)

Insulin

APIDRA SOLN 3 PA

FIASP SOLN 2

LEVEMIR SOLN 2

NOVOLIN 7030 SUSP 2

Drug Name DrugTier

RequirementsLimits

NOVOLIN N SUSP 2

NOVOLIN R SOLN 2

NOVOLOG SOLN 2

TRESIBA SOLN 2

Drug Name DrugTier

RequirementsLimits

MOTOFEN TABS 3

CHEMET CAPS 3

deferiprone tabs 1

Drug Name DrugTier

RequirementsLimits

VISTOGARD PACK 4 PA

NARCAN LIQD 3

daily)

Drug Name DrugTier

RequirementsLimits

dronabinol caps 1

Drug Name DrugTier

RequirementsLimits

ea daily)

VARUBI TBPK 3 PA

ERAXIS SOLR 3

MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3

flucytosine caps 1

yrs old)

Drug Name DrugTier

RequirementsLimits

nystatin tabs 1

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

daily)

TOLSURA CAPS 4 PA

Drug Name DrugTier

RequirementsLimits

QL(30 ml daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(6 gm daily)

NF QL(6 ea daily)

NF QL(252 gmdaily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

captopril tabs 1

lisinopril tabs 1

Drug Name DrugTier

RequirementsLimits

ramipril caps 1

trandolapril tabs 1

Drug Name DrugTier

RequirementsLimits

daily)

QL(3 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

EXFORGE HCT TABS 2

QL(1 ea daily)

QL(2 ea daily)

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

1 QL(3 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

eplerenone tabs 1

Vasodilators

minoxidil tabs 1

Drug Name DrugTier

RequirementsLimits

COARTEM TABS 2

Antimalarials

Drug Name DrugTier

RequirementsLimits

FIRDAPSE TABS 4 PA

Drug Name DrugTier

RequirementsLimits

RIFAMATE CAPS 3

isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA

rifampin caps 1

rifampin solr 1

Drug Name DrugTier

RequirementsLimits

melphalan tabs 1

Drug Name DrugTier

RequirementsLimits

Antimetabolites

Drug Name DrugTier

RequirementsLimits

daily)

MVASI SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

ZIRABEV SOLN 4 PA

TUKYSA TABS 4 PA

RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP

VIZIMPRO TABS 4 PA

DAURISMO TABS 4 PA

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

EMCYT CAPS 4 PA SP

letrozole tabs 1

ea daily) SP

Drug Name DrugTier

RequirementsLimits

ea daily) SP

NUBEQA TABS 4 PA

YONSA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

daily) SP

BALVERSA TABS 4 PA

daily) SP

BRUKINSA CAPS 4 PA

COPIKTRA CAPS 4 PA

daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

daily)

Drug Name DrugTier

RequirementsLimits

daily)

4 PA QL(1 eadaily)

INREBIC CAPS 4 PA

daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA

LORBRENA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA

ROZLYTREK CAPS 4 PA

TABRECTA TABS 4 PA

TALZENNA CAPS 4 PA

daily) SP

TAZVERIK TABS 4 PA

TIBSOVO TABS 4 PA

ml daily) SP

TURALIO CAPS 4 PA

daily) SP

VERZENIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

XOSPATA TABS 4 PA

hydroxyurea caps 1

NIPENT SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

UVADEX SOLN 4 PA SP

Mitotic Inhibitors

Drug Name DrugTier

RequirementsLimits

NF PA SP

4 PA SP

NF PA SP

carbidopa tabs 1

Drug Name DrugTier

RequirementsLimits

tolcapone tabs 1

APOKYN SOCT 4 PA

NF QL(4 ea daily)

NEUPRO PT24 2

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF ST QL(2 eadaily)

NF ST QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

Antimanic Agents

LITHIUM SOLN 1

Drug Name DrugTier

RequirementsLimits

daily)

Benzisoxazoles

NF QL(1 ea daily)

NF QL(4 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

NF QL(0036 mldaily)

Drug Name DrugTier

RequirementsLimits

NF QL(0036 mldaily)

haloperidol tabs 1

Drug Name DrugTier

RequirementsLimits

3 PA QL(2 eadaily)

daily)

NF PA QL(1 eadaily)

NF PA QL(2 eadaily)

NF QL(2 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

perphenazine tabs 1

REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

0 QL(1 ea daily)

NF QL(1 ea daily)

FUZEON SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

NF QL(125 mldaily)

2 QL(4 ea daily)

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

RUKOBIA TB12 4 PA

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

CMV Agents

cidofovir soln 3

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

ZEPATIER TABS 4 PA

Herpes Agents

daily)

Drug Name DrugTier

RequirementsLimits

NF QL(5 ea daily)

Alpha-Beta Blockers

Drug Name DrugTier

RequirementsLimits

carvedilol tabs 1

atenolol tabs 1

2 PA QL(1 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

nadolol tabs 1

pindolol tabs 1

Drug Name DrugTier

RequirementsLimits

felodipine tb24 1

isradipine caps 1

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1

Drug Name DrugTier

RequirementsLimits

Cardiac Glycosides

digoxin soln 1

digoxin tabs 1

BIDIL TABS 2

NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents

Drug Name DrugTier

RequirementsLimits

daily) SP

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(6 mldaily)

4 PA QL(6 mldaily)

daily) SP

cefadroxil caps 1

cefadroxil susr 1

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1

cefaclor caps 1

cefaclor susr 1

cefprozil susr 1

cefprozil tabs 1

cefdinir caps 1

cefdinir susr 1

Drug Name DrugTier

RequirementsLimits

cefepime hcl solr 1

TEFLARO SOLR 3

Drug Name DrugTier

RequirementsLimits

FALESSA KIT 0

NATAZIA TABS 0

Drug Name DrugTier

RequirementsLimits

TYBLUME CHEW 0

Drug Name DrugTier

RequirementsLimits

ELLA TABS 0

KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0

NEXPLANON IMPL 0

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

MEDROL TABS 2 MG 3

MILLIPRED DP TBPK 3

MILLIPRED TABS 3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1

Drug Name DrugTier

RequirementsLimits

Mineralocorticoids

Antitussives

QL(2 ea daily)

QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

QL(2 ea daily)

HYPERSAL NEBU 35 1

NEBUSAL NEBU 1

Mucolytics

Drug Name DrugTier

RequirementsLimits

12 yrs old)

yrs old)

Drug Name DrugTier

RequirementsLimits

12 yrs old)

Drug Name DrugTier

RequirementsLimits

VEREGEN OINT 3

daily) RXOTC

Drug Name DrugTier

RequirementsLimits

mupirocin oint 1

ERTACZO CREA 3

EXELDERM SOLN 3

JUBLIA SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

OXISTAT LOTN 2

PANRETIN GEL 3

PICATO GEL 0015 2

PICATO GEL 005 2

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(4 ea daily)

ml daily) SP

TAZORAC CREA 005 2

Drug Name DrugTier

RequirementsLimits

Burn Products

amcinonide crea 1

amcinonide lotn 3

AMCINONIDE OINT 3

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA

Drug Name DrugTier

RequirementsLimits

daily)

PSORCON CREA 2 PA

daily)

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

2 yrs old)

podofilox soln 1

SYNERA PTCH 3

Drug Name DrugTier

RequirementsLimits

Rosacea Agents

EURAX CREA 3

lindane sham 1

malathion lotn 1

Drug Name DrugTier

RequirementsLimits

permethrin crea 1

permethrin liqd 1

spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS

CHEMSTRIP-K STRP 1

KETONE STRP 1

KETOSTIX STRP 1

Drug Name DrugTier

RequirementsLimits

Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

furosemide soln 1

furosemide tabs 1

torsemide tabs 1

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

4 PA SP

PROLIA SOSY 4

TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP

Corticotropin

ACTHAR GEL 4 PA

4 PA SP

CETROTIDE KIT 4 PA

Drug Name DrugTier

RequirementsLimits

4 PA SP

SAIZEN SOLR 4 PA SP

4 PA SP

OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits

Metabolic Modifiers

calcitriol caps 1

calcitriol soln 1

Drug Name DrugTier

RequirementsLimits

MYALEPT SOLR 4 PA

PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1

Drug Name DrugTier

RequirementsLimits

NF QL(6 ea daily)

NF QL(8 ea daily)

4 PA SP

cabergoline tabs 1

Somatostatic Agents

SIGNIFOR SOLN 4 PA

ml daily) SP

daily) SP

Drug Name DrugTier

RequirementsLimits

CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA

PREMPHASE TABS 2

PREMPRO TABS 2

ELESTRIN GEL 3

QL(0286 eadaily)

Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3

daily)

PREMARIN SOLR 2

PREMARIN TABS 2

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA

levofloxacin soln 1

levofloxacin tabs 1

Drug Name DrugTier

RequirementsLimits

ofloxacin tabs 1

daily)

AVSOLA SOLR 4 PA

Drug Name DrugTier

RequirementsLimits

DIPENTUM CAPS 2

Drug Name DrugTier

RequirementsLimits

alvimopan caps 1

PHOSLYRA SOLN 2

VELPHORO CHEW 3 PA

Cystinosis Agents

CYSTAGON CAPS 3 PA

Drug Name DrugTier

RequirementsLimits

acetic acid soln 1

RESECTISOL SOLN 1

SORBITOL SOLN 1

ELMIRON CAPS 2

Urinary Analgesics

Drug Name DrugTier

RequirementsLimits

Gout Agents

allopurinol tabs 1

KRYSTEXXA SOLN 4 PA

Uricosurics

probenecid tabs 1

daily)

CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA

SOLIRIS SOLN 4 PA

TAKHZYRO SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1

dipyridamole tabs 1

ZONTIVITY TABS 3 PA

VPRIV SOLR 4 PA SP

daily) SP

Drug Name DrugTier

RequirementsLimits

DROXIA CAPS 3

OXBRYTA TABS 4 PA

Folic AcidFolates

4 PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA

MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

UDENYCA SOSY 4 PA

ZIEXTENZO SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

estazolam tabs 1

eszopiclone tabs 1

Drug Name DrugTier

RequirementsLimits

triazolam tabs 1

BELSOMRA TABS 3 PA

ramelteon tabs 1

Bulk Laxatives

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 3 PA

PREPOPIK PACK 3 PA

Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1

Drug Name DrugTier

RequirementsLimits

Azithromycin

daily)

Drug Name DrugTier

RequirementsLimits

Clarithromycin

Fidaxomicin

CAYA DPRH 0

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

FEMCAP DEVI 0

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

AUTO-LANCET MISC 1

AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

LANZO MISC 1

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

SURE-PEN MISC 1

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

Serotonin Agonists

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

sumatriptan soln 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1

NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1

ringers soln 1

Fluoride

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily) SP

ATGAM INJ 4 PA SP

cyclosporine caps 1

Drug Name DrugTier

RequirementsLimits

cyclosporine soln 1

SIMULECT SOLR 3

tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits

DEBACTEROL SOLN 2

Dental Products

Drug Name DrugTier

RequirementsLimits

MULTIVITAMINS

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

2 QL(1 ea daily)

carisoprodol tabs 1

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Nasal Steroids

Drug Name DrugTier

RequirementsLimits

riluzole tabs 3

BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS

Drug Name DrugTier

RequirementsLimits

LACRISERT INST 3

COMBIGAN SOLN 2

tropicamide soln 1

Miotics

Drug Name DrugTier

RequirementsLimits

IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA

AZASITE SOLN 3

KLARITY-A SOLN 3

NATACYN SUSP 2

Drug Name DrugTier

RequirementsLimits

trifluridine soln 1

ZIRGAN GEL 2

RESTASIS EMUL 2 PA

OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

FML FORTE SUSP 3 PA

FML OINT 3 PA

LOTEMAX OINT 3 PA

MAXIDEX SUSP 3 PA

PRED MILD SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA

LASTACAFT SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

ZERVIATE SOLN 3 PA

bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST

travoprost soln 1

ZIOPTAN SOLN 2

Otic Combinations

CIPRO HC SUSP 3

daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits

3 PA QL(05 eadaily)

4 PA SP

HYQVIA KIT 4 PA

Aminopenicillins

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

disulfiram tabs 1

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Fibromyalgia Agents

daily) SP

AUBAGIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

GILENYA CAPS 4 PA

ml daily) SP

MAVENCLAD TBPK 4 PA

MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA

ml daily)

Drug Name DrugTier

RequirementsLimits

3 PA QL(1 eadaily)

3 PA QL(2 eadaily)

NUEDEXTA CAPS 3 PA

pimozide tabs 1

Smoking Deterrents

Drug Name DrugTier

RequirementsLimits

NICOTROL NS SOLN 0

TEGSEDI SOSY 4 PA

daily)

Drug Name DrugTier

RequirementsLimits

Sulfonamides

SULFADIAZINE TABS 1

Glycylcyclines

tigecycline solr 1

Tetracyclines

Drug Name DrugTier

RequirementsLimits

NF QL(2 ea daily)

Antithyroid Agents

methimazole tabs 1

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0

TENIVAC INJ 0

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(40 ml daily)

NF RXOTC

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0

PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits

ENGERIX-B INJ 0

ENGERIX-B SUSP 0

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HAVRIX SUSP 0

HEPLISAV-B SOSY 0

Drug Name DrugTier

RequirementsLimits

ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0

TWINRIX SUSY 0

VAQTA SUSP 0

ZOSTAVAX SUSR 0

INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0

Drug Name DrugTier

RequirementsLimits

GYNAZOLE-1 CREA 3

PHEXXI GEL 0 PV

FEMRING RING 3

PREMARIN CREA 2

Drug Name DrugTier

RequirementsLimits

Vasopressors

VITAMINS

NIACIN TR TBCR 1

Drug Name DrugTier

RequirementsLimits

Index 1

Index 2

Index 3

Index 4

Index 5

65 4 4

28 28 28 55

55 116

28 28 75

Index 6

58 131

58 43 43 79 33

41 75 71 72 72 72 29 29

29 121

CORTEF CORTENEMA

126 128

47 112

40 35 38

124 14

9 118 118

11 127

11 11 33

HYDROCHLORIDE 38

Index 7

Index 8

Index 9

Index 10

129 30

32 5 5 5

130 16 41 47 71

132 125 112 112

36 36 58 11 40 40 76 76 57

119 76

128 74 69 69

132 69 70 52 74

Index 11

Index 12

Index 13

25 25 25 23 72

127 25

Index 14

Index 15

ivermectin 10

Index 16

Index 17

Index 18

123 58

68 75 68

68 63 58 39 18

Index 19

Index 20

Index 21

59 59 68

124 5 5 5

112 26

Index 22

7 125 115

116 59 59

114 114

124 69

126 70

120 121

7 51 64

55 51 68

125 118

54 53 53 53 48 23 75 67

123 35

74 37 13

13 73 18

Index 23

Index 24

Index 25

Index 26

74 39 57

71 25 23

43 3 3

124 113 118

68 39 42 30

Index 27

87 87 87 87 53 67

67 116

87 42 60 46 68 15 44 44 67

49 65 14 14 66

66 27 27 21

Index 28

39 42 42

Index 29

64 23 23 40

132 55 10

115 36 39 63

115 64 51

10 10 10

127 124

128 72 39 48 37 72

50 39 26

126 13 49

119 119 119

47 118

Index 30

49 37 39 66

129 51

33 117

115 44

Index 31

Index 32

Index 33

70 15 40

132 48 47 47

131 27 29 33 31 33 36

Index 34

Index 35

Index 36

Spanish

(TTYTDD 1-877-941-9238)

Chinese

Vietnamese

(TTYTDD 1-877-941-9238)

Korean

Russian

Tagalog

1-877-687-1197 (TTYTDD 1-877-941-9238)

Ukrainian

Mon-Khmer Cambodian

Cushite

ਤਤ

(TTYTDD 1-877-941-9238) an

Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Drug Name DrugTier

RequirementsLimits

Anti-Obesity Agents

SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

yrs old)

Drug Name DrugTier

RequirementsLimits

Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA

Aminoglycosides

ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits

ea daily)

Drug Name DrugTier

RequirementsLimits

ea daily)

Gold Compounds

Drug Name DrugTier

RequirementsLimits

celecoxib caps 1 PA

daily)

flurbiprofen tabs 1

Drug Name DrugTier

RequirementsLimits

nabumetone tabs 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4

ml daily)

ml daily) SP

Drug Name DrugTier

RequirementsLimits

Salicylates

diflunisal tabs 1

salsalate tabs 1

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(4 eadaily)

1 QL(034 eadaily)

1 PA QL(2 eadaily)

daily)

PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

NF QL(10 ml daily)

1 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

OXAYDO TABS 5 MG 2

3 PA QL(2 eadaily)

1 PA QL(2 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

Opioid Combinations

Drug Name DrugTier

RequirementsLimits

LORTAB ELIX 2

Drug Name DrugTier

RequirementsLimits

1 QL(3 ea daily)

1 QL(2 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(0143ea daily)

QL(3 ea daily)

QL(2 ea daily)

Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens

danazol caps 1

Drug Name DrugTier

RequirementsLimits

METHITEST TABS 3

Vasodilating Agents

Anthelmintics

Drug Name DrugTier

RequirementsLimits

EMVERM CHEW 2

trimethoprim tabs 1

Drug Name DrugTier

RequirementsLimits

atovaquone susp 1

Carbapenems

meropenem solr 1

Glycopeptides

Drug Name DrugTier

RequirementsLimits

Leprostatics

dapsone tabs 1

aztreonam solr 1

Oxazolidinones

Drug Name DrugTier

RequirementsLimits

daily) Polymyxins

Drug Name DrugTier

RequirementsLimits

NITRO-BID OINT 3

meprobamate tabs 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

dofetilide caps 1

MULTAQ TABS 3

FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Steroid Inhalants

Drug Name DrugTier

RequirementsLimits

daily)

FLOVENT HFA AERO 2

daily)

ADVAIR HFA AERO 2

Drug Name DrugTier

RequirementsLimits

1 QL(15 ml daily)

daily)

BREO ELLIPTA AEPB 2

1 PA QL(12 mldaily)

Drug Name DrugTier

RequirementsLimits

daily) Xanthines

ELIXOPHYLLIN ELIX 1

BEVYXXA CAPS 3

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

Drug Name DrugTier

RequirementsLimits

NF QL(6 ml daily)

NF QL(2 ml daily)

NF QL(16 mldaily)

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

EPIDIOLEX SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF QL(30 ml daily)

NF QL(4 ea daily)

NF QL(20 ea daily)

NF QL(100 eadaily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

PA QL(3 eadaily)

1 PA QL(3 eadaily)

daily)

primidone tabs 1

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(6 ea daily)

NF QL(8 ea daily)

NF QL(40 ml daily)

NF QL(3 ea daily)

3 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

Carbamates

PEGANONE TABS 3

Drug Name DrugTier

RequirementsLimits

phenytoin chew 1

phenytoin susp 1

Succinimides

NF QL(30 ml daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

NF QL(3 ea daily)

NF QL(2 ea daily)

NF QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

FETZIMA CP24 3 PA

NF QL(4 ea daily)

NF QL(1 ea daily)

1 QL(3 ea daily)

Tricyclic Agents

amoxapine tabs 3

Drug Name DrugTier

RequirementsLimits

doxepin hcl caps 1

doxepin hcl conc 1

miglitol tabs 1

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

1 QL(2 ea daily)

1 QL(4 ea daily)

GLYXAMBI TABS 2

2 QL(2 ea daily)

TRIJARDY XR TB24 2

3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

diazoxide susp 1

daily)

3 QL(0035 eadaily)

Drug Name DrugTier

RequirementsLimits

ml daily)

Insulin

APIDRA SOLN 3 PA

FIASP SOLN 2

LEVEMIR SOLN 2

NOVOLIN 7030 SUSP 2

Drug Name DrugTier

RequirementsLimits

NOVOLIN N SUSP 2

NOVOLIN R SOLN 2

NOVOLOG SOLN 2

TRESIBA SOLN 2

Drug Name DrugTier

RequirementsLimits

MOTOFEN TABS 3

CHEMET CAPS 3

deferiprone tabs 1

Drug Name DrugTier

RequirementsLimits

VISTOGARD PACK 4 PA

NARCAN LIQD 3

daily)

Drug Name DrugTier

RequirementsLimits

dronabinol caps 1

Drug Name DrugTier

RequirementsLimits

ea daily)

VARUBI TBPK 3 PA

ERAXIS SOLR 3

MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3

flucytosine caps 1

yrs old)

Drug Name DrugTier

RequirementsLimits

nystatin tabs 1

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

daily)

TOLSURA CAPS 4 PA

Drug Name DrugTier

RequirementsLimits

QL(30 ml daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(6 gm daily)

NF QL(6 ea daily)

NF QL(252 gmdaily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

daily)

captopril tabs 1

lisinopril tabs 1

Drug Name DrugTier

RequirementsLimits

ramipril caps 1

trandolapril tabs 1

Drug Name DrugTier

RequirementsLimits

daily)

QL(3 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

EXFORGE HCT TABS 2

QL(1 ea daily)

QL(2 ea daily)

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(2 ea daily)

1 QL(3 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

eplerenone tabs 1

Vasodilators

minoxidil tabs 1

Drug Name DrugTier

RequirementsLimits

COARTEM TABS 2

Antimalarials

Drug Name DrugTier

RequirementsLimits

FIRDAPSE TABS 4 PA

Drug Name DrugTier

RequirementsLimits

RIFAMATE CAPS 3

isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA

rifampin caps 1

rifampin solr 1

Drug Name DrugTier

RequirementsLimits

melphalan tabs 1

Drug Name DrugTier

RequirementsLimits

Antimetabolites

Drug Name DrugTier

RequirementsLimits

daily)

MVASI SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

ZIRABEV SOLN 4 PA

TUKYSA TABS 4 PA

RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP

VIZIMPRO TABS 4 PA

DAURISMO TABS 4 PA

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

daily) SP

EMCYT CAPS 4 PA SP

letrozole tabs 1

ea daily) SP

Drug Name DrugTier

RequirementsLimits

ea daily) SP

NUBEQA TABS 4 PA

YONSA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

daily) SP

BALVERSA TABS 4 PA

daily) SP

BRUKINSA CAPS 4 PA

COPIKTRA CAPS 4 PA

daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

daily)

Drug Name DrugTier

RequirementsLimits

daily)

4 PA QL(1 eadaily)

INREBIC CAPS 4 PA

daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA

LORBRENA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA

ROZLYTREK CAPS 4 PA

TABRECTA TABS 4 PA

TALZENNA CAPS 4 PA

daily) SP

TAZVERIK TABS 4 PA

TIBSOVO TABS 4 PA

ml daily) SP

TURALIO CAPS 4 PA

daily) SP

VERZENIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

XOSPATA TABS 4 PA

hydroxyurea caps 1

NIPENT SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

UVADEX SOLN 4 PA SP

Mitotic Inhibitors

Drug Name DrugTier

RequirementsLimits

NF PA SP

4 PA SP

NF PA SP

carbidopa tabs 1

Drug Name DrugTier

RequirementsLimits

tolcapone tabs 1

APOKYN SOCT 4 PA

NF QL(4 ea daily)

NEUPRO PT24 2

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF ST QL(2 eadaily)

NF ST QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

daily)

Antimanic Agents

LITHIUM SOLN 1

Drug Name DrugTier

RequirementsLimits

daily)

Benzisoxazoles

NF QL(1 ea daily)

NF QL(4 ea daily)

1 QL(4 ea daily)

1 QL(2 ea daily)

NF QL(0036 mldaily)

Drug Name DrugTier

RequirementsLimits

NF QL(0036 mldaily)

haloperidol tabs 1

Drug Name DrugTier

RequirementsLimits

3 PA QL(2 eadaily)

daily)

NF PA QL(1 eadaily)

NF PA QL(2 eadaily)

NF QL(2 ea daily)

NF QL(4 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

perphenazine tabs 1

REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

0 QL(1 ea daily)

NF QL(1 ea daily)

FUZEON SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

NF QL(125 mldaily)

2 QL(4 ea daily)

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(1 ea daily)

RUKOBIA TB12 4 PA

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

CMV Agents

cidofovir soln 3

daily) SP

Drug Name DrugTier

RequirementsLimits

daily)

ZEPATIER TABS 4 PA

Herpes Agents

daily)

Drug Name DrugTier

RequirementsLimits

NF QL(5 ea daily)

Alpha-Beta Blockers

Drug Name DrugTier

RequirementsLimits

carvedilol tabs 1

atenolol tabs 1

2 PA QL(1 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

nadolol tabs 1

pindolol tabs 1

Drug Name DrugTier

RequirementsLimits

felodipine tb24 1

isradipine caps 1

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1

Drug Name DrugTier

RequirementsLimits

Cardiac Glycosides

digoxin soln 1

digoxin tabs 1

BIDIL TABS 2

NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents

Drug Name DrugTier

RequirementsLimits

daily) SP

daily)

Drug Name DrugTier

RequirementsLimits

PA QL(6 mldaily)

4 PA QL(6 mldaily)

daily) SP

cefadroxil caps 1

cefadroxil susr 1

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1

cefaclor caps 1

cefaclor susr 1

cefprozil susr 1

cefprozil tabs 1

cefdinir caps 1

cefdinir susr 1

Drug Name DrugTier

RequirementsLimits

cefepime hcl solr 1

TEFLARO SOLR 3

Drug Name DrugTier

RequirementsLimits

FALESSA KIT 0

NATAZIA TABS 0

Drug Name DrugTier

RequirementsLimits

TYBLUME CHEW 0

Drug Name DrugTier

RequirementsLimits

ELLA TABS 0

KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0

NEXPLANON IMPL 0

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

MEDROL TABS 2 MG 3

MILLIPRED DP TBPK 3

MILLIPRED TABS 3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1

Drug Name DrugTier

RequirementsLimits

Mineralocorticoids

Antitussives

QL(2 ea daily)

QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(1 ea daily)

1 QL(2 ea daily)

1 QL(1 ea daily)

QL(2 ea daily)

HYPERSAL NEBU 35 1

NEBUSAL NEBU 1

Mucolytics

Drug Name DrugTier

RequirementsLimits

12 yrs old)

yrs old)

Drug Name DrugTier

RequirementsLimits

12 yrs old)

Drug Name DrugTier

RequirementsLimits

VEREGEN OINT 3

daily) RXOTC

Drug Name DrugTier

RequirementsLimits

mupirocin oint 1

ERTACZO CREA 3

EXELDERM SOLN 3

JUBLIA SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

OXISTAT LOTN 2

PANRETIN GEL 3

PICATO GEL 0015 2

PICATO GEL 005 2

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily)

NF QL(4 ea daily)

ml daily) SP

TAZORAC CREA 005 2

Drug Name DrugTier

RequirementsLimits

Burn Products

amcinonide crea 1

amcinonide lotn 3

AMCINONIDE OINT 3

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA

Drug Name DrugTier

RequirementsLimits

daily)

PSORCON CREA 2 PA

daily)

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

2 yrs old)

podofilox soln 1

SYNERA PTCH 3

Drug Name DrugTier

RequirementsLimits

Rosacea Agents

EURAX CREA 3

lindane sham 1

malathion lotn 1

Drug Name DrugTier

RequirementsLimits

permethrin crea 1

permethrin liqd 1

spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS

CHEMSTRIP-K STRP 1

KETONE STRP 1

KETOSTIX STRP 1

Drug Name DrugTier

RequirementsLimits

Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

furosemide soln 1

furosemide tabs 1

torsemide tabs 1

Drug Name DrugTier

RequirementsLimits

NF PA SP

Drug Name DrugTier

RequirementsLimits

4 PA SP

PROLIA SOSY 4

TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP

Corticotropin

ACTHAR GEL 4 PA

4 PA SP

CETROTIDE KIT 4 PA

Drug Name DrugTier

RequirementsLimits

4 PA SP

SAIZEN SOLR 4 PA SP

4 PA SP

OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits

Metabolic Modifiers

calcitriol caps 1

calcitriol soln 1

Drug Name DrugTier

RequirementsLimits

MYALEPT SOLR 4 PA

PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1

Drug Name DrugTier

RequirementsLimits

NF QL(6 ea daily)

NF QL(8 ea daily)

4 PA SP

cabergoline tabs 1

Somatostatic Agents

SIGNIFOR SOLN 4 PA

ml daily) SP

daily) SP

Drug Name DrugTier

RequirementsLimits

CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA

PREMPHASE TABS 2

PREMPRO TABS 2

ELESTRIN GEL 3

QL(0286 eadaily)

Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3

daily)

PREMARIN SOLR 2

PREMARIN TABS 2

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA

levofloxacin soln 1

levofloxacin tabs 1

Drug Name DrugTier

RequirementsLimits

ofloxacin tabs 1

daily)

AVSOLA SOLR 4 PA

Drug Name DrugTier

RequirementsLimits

DIPENTUM CAPS 2

Drug Name DrugTier

RequirementsLimits

alvimopan caps 1

PHOSLYRA SOLN 2

VELPHORO CHEW 3 PA

Cystinosis Agents

CYSTAGON CAPS 3 PA

Drug Name DrugTier

RequirementsLimits

acetic acid soln 1

RESECTISOL SOLN 1

SORBITOL SOLN 1

ELMIRON CAPS 2

Urinary Analgesics

Drug Name DrugTier

RequirementsLimits

Gout Agents

allopurinol tabs 1

KRYSTEXXA SOLN 4 PA

Uricosurics

probenecid tabs 1

daily)

CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA

SOLIRIS SOLN 4 PA

TAKHZYRO SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1

dipyridamole tabs 1

ZONTIVITY TABS 3 PA

VPRIV SOLR 4 PA SP

daily) SP

Drug Name DrugTier

RequirementsLimits

DROXIA CAPS 3

OXBRYTA TABS 4 PA

Folic AcidFolates

4 PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA

MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA

Drug Name DrugTier

RequirementsLimits

UDENYCA SOSY 4 PA

ZIEXTENZO SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

estazolam tabs 1

eszopiclone tabs 1

Drug Name DrugTier

RequirementsLimits

triazolam tabs 1

BELSOMRA TABS 3 PA

ramelteon tabs 1

Bulk Laxatives

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 3 PA

PREPOPIK PACK 3 PA

Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1

Drug Name DrugTier

RequirementsLimits

Azithromycin

daily)

Drug Name DrugTier

RequirementsLimits

Clarithromycin

Fidaxomicin

CAYA DPRH 0

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

FEMCAP DEVI 0

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

QL(2 ea daily)

0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

AUTO-LANCET MISC 1

AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

LANZO MISC 1

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(66667 eadaily)

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

SURE-PEN MISC 1

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

1 QL(66667 eadaily)

daily)

Drug Name DrugTier

RequirementsLimits

1 QL(66667 eadaily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

QL(5 ea daily)RXOTC

QL(5 ea daily)

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(5 ea daily)

QL(5 ea daily)RXOTC

1 QL(5 ea daily)

daily)

Drug Name DrugTier

RequirementsLimits

daily)

Serotonin Agonists

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

sumatriptan soln 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1

NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1

ringers soln 1

Fluoride

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

daily) SP

ATGAM INJ 4 PA SP

cyclosporine caps 1

Drug Name DrugTier

RequirementsLimits

cyclosporine soln 1

SIMULECT SOLR 3

tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits

DEBACTEROL SOLN 2

Dental Products

Drug Name DrugTier

RequirementsLimits

MULTIVITAMINS

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

QL(1 ea daily)

QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

2 QL(1 ea daily)

carisoprodol tabs 1

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Nasal Steroids

Drug Name DrugTier

RequirementsLimits

riluzole tabs 3

BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS

Drug Name DrugTier

RequirementsLimits

LACRISERT INST 3

COMBIGAN SOLN 2

tropicamide soln 1

Miotics

Drug Name DrugTier

RequirementsLimits

IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA

AZASITE SOLN 3

KLARITY-A SOLN 3

NATACYN SUSP 2

Drug Name DrugTier

RequirementsLimits

trifluridine soln 1

ZIRGAN GEL 2

RESTASIS EMUL 2 PA

OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

FML FORTE SUSP 3 PA

FML OINT 3 PA

LOTEMAX OINT 3 PA

MAXIDEX SUSP 3 PA

PRED MILD SUSP 3 PA

Drug Name DrugTier

RequirementsLimits

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA

LASTACAFT SOLN 3 PA

Drug Name DrugTier

RequirementsLimits

ZERVIATE SOLN 3 PA

bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST

travoprost soln 1

ZIOPTAN SOLN 2

Otic Combinations

CIPRO HC SUSP 3

daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits

3 PA QL(05 eadaily)

4 PA SP

HYQVIA KIT 4 PA

Aminopenicillins

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

disulfiram tabs 1

NF QL(2 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

Fibromyalgia Agents

daily) SP

AUBAGIO TABS 4 PA

Drug Name DrugTier

RequirementsLimits

GILENYA CAPS 4 PA

ml daily) SP

MAVENCLAD TBPK 4 PA

MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA

ml daily)

Drug Name DrugTier

RequirementsLimits

3 PA QL(1 eadaily)

3 PA QL(2 eadaily)

NUEDEXTA CAPS 3 PA

pimozide tabs 1

Smoking Deterrents

Drug Name DrugTier

RequirementsLimits

NICOTROL NS SOLN 0

TEGSEDI SOSY 4 PA

daily)

Drug Name DrugTier

RequirementsLimits

Sulfonamides

SULFADIAZINE TABS 1

Glycylcyclines

tigecycline solr 1

Tetracyclines

Drug Name DrugTier

RequirementsLimits

NF QL(2 ea daily)

Antithyroid Agents

methimazole tabs 1

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0

TENIVAC INJ 0

Drug Name DrugTier

RequirementsLimits

NF RXOTC

Drug Name DrugTier

RequirementsLimits

1 QL(40 ml daily)

NF RXOTC

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1 QL(4 ea daily)

NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0

PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits

ENGERIX-B INJ 0

ENGERIX-B SUSP 0

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

HAVRIX SUSP 0

HEPLISAV-B SOSY 0

Drug Name DrugTier

RequirementsLimits

ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0

TWINRIX SUSY 0

VAQTA SUSP 0

ZOSTAVAX SUSR 0

INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0

Drug Name DrugTier

RequirementsLimits

GYNAZOLE-1 CREA 3

PHEXXI GEL 0 PV

FEMRING RING 3

PREMARIN CREA 2

Drug Name DrugTier

RequirementsLimits

Vasopressors

VITAMINS

NIACIN TR TBCR 1

Drug Name DrugTier

RequirementsLimits

Index 1

Index 2

Index 3

Index 4

Index 5

65 4 4

28 28 28 55

55 116

28 28 75

Index 6

58 131

58 43 43 79 33

41 75 71 72 72 72 29 29

29 121

CORTEF CORTENEMA

126 128

47 112

40 35 38

124 14

9 118 118

11 127

11 11 33

HYDROCHLORIDE 38

Index 7

Index 8

Index 9

Index 10

129 30

32 5 5 5

130 16 41 47 71

132 125 112 112

36 36 58 11 40 40 76 76 57

119 76

128 74 69 69

132 69 70 52 74

Index 11

Index 12

Index 13

25 25 25 23 72

127 25

Index 14

Index 15

ivermectin 10

Index 16

Index 17

Index 18

123 58

68 75 68

68 63 58 39 18

Index 19

Index 20

Index 21

59 59 68

124 5 5 5

112 26

Index 22

7 125 115

116 59 59

114 114

124 69

126 70

120 121

7 51 64

55 51 68

125 118

54 53 53 53 48 23 75 67

123 35

74 37 13

13 73 18

Index 23

Index 24

Index 25

Index 26

74 39 57

71 25 23

43 3 3

124 113 118

68 39 42 30

Index 27

87 87 87 87 53 67

67 116

87 42 60 46 68 15 44 44 67

49 65 14 14 66

66 27 27 21

Index 28

39 42 42

Index 29

64 23 23 40

132 55 10

115 36 39 63

115 64 51

10 10 10

127 124

128 72 39 48 37 72

50 39 26

126 13 49

119 119 119

47 118

Index 30

49 37 39 66

129 51

33 117

115 44

Index 31

Index 32

Index 33

70 15 40

132 48 47 47

131 27 29 33 31 33 36

Index 34

Index 35

Index 36

Spanish

(TTYTDD 1-877-941-9238)

Chinese

Vietnamese

(TTYTDD 1-877-941-9238)

Korean

Russian

Tagalog

1-877-687-1197 (TTYTDD 1-877-941-9238)

Ukrainian

Mon-Khmer Cambodian

Cushite

ਤਤ

(TTYTDD 1-877-941-9238) an

Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Documents

2021 Prescription Drug List - Coordinated Care Health