HMSA Akamai Advantage 2018 Formulary · and find the name of your drug in the first column . of the list. What are generic drugs? HMSA Akamai Advantage covers both brand name drugs

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

2018FormularyStandard (PPO)Standard Plus (PPO)Complete (PPO)Complete Plus (PPO)Essential Advantage (HMO)

List of Covered DrugsFormulary ID 00018207, version 10

This formulary was updated on 06/01/2018. For more recent information or other questions, please contact HMSA at 948-6000 on Oahu or 1 (800) 660-4672 toll-free. TTY users, call 711. Telephone hours are 8 a.m. to 8 p.m., seven days a week or visit http://www.hmsa.com/advantage.

H3832_5042_8740_7706_FINAL_6H7317_5042_8740_7706_FINAL_6

http://www.hmsa.com/advantage

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means HMSA. When it refers to “plan” or “our plan,” it means HMSA Akamai Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of June 1, 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsur-ance may change on January 1, 2019, and from time to time during the year.

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

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce cov-erage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse informa-tion about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have

continued access for the remainder of the cover-age year to the formulary drugs that were avail-able when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s man-ufacturer removes the drug from the market, we will immediately remove the drug from our for-mulary and provide notice to members who take the drug. The enclosed formulary is current as of June 1, 2018. To get updated information about the drugs covered by HMSA Akamai Advantage, please contact us. Our contact information appears on the front and back cover pages. We will inform mem-bers of any formulary changes to this comprehen-sive formulary through our website.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 34. The Index provides an al-phabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index

i

and find the name of your drug in the first column of the list.

What are generic drugs?HMSA Akamai Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active in-gredient as the brand name drug. Generally, gener-ic drugs cost less than brand name drugs.

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

• Prior Authorization: HMSA Akamai Advantage requires you or your physician to get prior autho-rization for certain drugs. This means that you will need to get approval from HMSA Akamai Advantage before you fill your prescriptions. If you don’t get approval, HMSA Akamai Advantage may not cover the drug.

• Quantity Limits: For certain drugs, HMSA Aka-mai Advantage limits the amount of the drug that HMSA Akamai Advantage will cover. For exam-ple, HMSA Akamai Advantage provides 30 tablets per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, HMSA Akamai Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For exam-ple, if Drug A and Drug B both treat your medi-cal condition, HMSA Akamai Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HMSA Akamai Advan-tage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our con-tact information, along with the date we last up-dated the formulary, appears on the front and back cover pages.

You can ask HMSA Akamai Advantage to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition. See the section, “How do I request an exception to the HMSA Akamai Advantage formu-lary?” on this page for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact our Cus-tomer Relations and ask if your drug is covered. If you learn that HMSA Akamai Advantage does not cover your drug, you have two options:

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

• You can ask HMSA Akamai Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the HMSA Akamai Advantage Formulary?You can ask HMSA Akamai Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

• You can ask us to waive coverage restrictions or limits on your drug. For example, for cer-tain drugs, HMSA Akamai Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, HMSA Akamai Advantage will only approve your request for an exception if the alter-

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native drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization re-strictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or uti-lization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s sup-porting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formu-lary but your ability to get it is limited. For exam-ple, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to deter-mine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care (LTC) facility, we will allow you to refill your prescrip-tion until we have provided you with a 93-day transition supply consistent with the dispensing

increment (unless you have a prescription writ-ten for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Transition policyNew members in our Plan may be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization. Current members may also be affected by chang-es in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See the section above, “How do I request an exception to HMSA’s Akamai Advantage formulary?” to learn more about how to request an exception. Please contact Customer Relations if your drug is not on our formulary, is subject to certain restrictions such as prior authori-zation, and you need to switch to a different drug that we cover or request a formulary exception. During the period of time members are talking to their doctors to determine a course of action, we may provide a temporary supply of a non-formu-lary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affect-ed by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a Part D drug), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transi-tion policy again. We will provide you with a writ-ten notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your

iii

doctor to decide if you should switch to an appro-priate drug that we cover.

If a new member is a resident of a long-term care facility (like a nursing home), we will also cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn’t on our formulary or is subject to other restrictions, such as dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Current members are also eligible to receive a transition fill under certain conditions. If a current member enters a long-term care (LTC) facility, or is in an LTC facility and requires an emergency sup-ply of non-formulary drugs, we will cover a tempo-rary 31-day transition supply (unless the prescrip-tion is written for fewer days). We will cover more than one refill of these drugs for these members for the first 90 days. A member may experience a change in their level of care at an inpatient hospital facility or skilled nursing facility which results in non-coverage of drugs previously covered by Medi-care Part D. For current members experiencing a level of care change, we will also cover a tempo-rary 31-day transition supply as outlined above.

Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.

For more informationFor more detailed information about your HMSA Akamai Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about HMSA Akamai Advan-tage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare pre-scription drug coverage, please call Medicare at

1 (800) MEDICARE [1 (800) 633-4227] 24 hours a day/seven days a week. TTY users should call 1 (877) 486-2048. Or visit http://www.medicare.gov.

HMSA Akamai Advantage FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by HMSA Akamai Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 34.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., FORTEO) and generic drugs are listed in lower-case italics (e.g., ibuprofen).

The information in the requirements/limits column tells you if HMSA Akamai Advantage has any special requirements for coverage of your drug.

Drug tier index:

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand

Tier 4 - Non-Preferred Drug

Tier 5 - Specialty Tier

Please refer to the Summary of Benefits or Evi-dence of Coverage for the specific copayment or coinsurance amount associated with each tier.

Abbreviations used in this FormularyPA – Prior Authorization: Requires that you or your physician receive approval from HMSA Akamai Advantage before we will cover your prescription.

QL – Quantity Limits: A limit on the amount of the drug that HMSA Akamai Advantage will cover.

ST – Step Therapy: Requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

M – Mail Order: These drugs are available through HMSA’s mail order pharmacy, CVS Caremark.

B/D – B or D: This drug may be covered under Medicare Part B or D depending upon the circum-stances. Information may need to be submitted describing the use and setting of the drug to make the determination. For more information, please call Customer Relations.

iv

http://www.medicare.gov

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

Prescription drugs can be shipped to your home from the HMSA Akamai Advantage Mail Order pharmacy. Usually a mail-order pharmacy order will get to you in no more than 14 days after the pharmacy receives the order. If your drugs do not arrive within this timeframe, please call 1 (855) 479-3659 toll-free, 24 hours a day, seven days a week; TTY users, call 711. You can also choose to sign up for our optional automatic delivery program by calling these numbers.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - Available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab 1 M colchicine w/ probenecid 2 M COLCRYS

QL (120 tabs / 30 days) 3 QL M

MITIGARE QL (60 caps / 30 days)

3 QL M

probenecid 2 M ULORIC 3 M ST NSAIDS celecoxib CAPS 50mg

QL (240 caps / 30 days) 2 QL M

celecoxib CAPS 100mg QL (120 caps / 30 days)

2 QL M


2 QL M


2 QL M

diclofenac potassium QL (120 tabs / 30 days)

2 QL M

diclofenac sodium TB24; TBEC

2 M

diflunisal 2 M etodolac 2 M etodolac er 2 M flurbiprofen TABS 2 M ibu tabs 600mg 1 M ibu tabs 800mg 1 M ibuprofen SUSP 2 M ibuprofen TABS 400mg, 600mg, 800mg

1 M

ketoprofen CAPS 2 M meloxicam TABS 1 M nabumetone TABS 2 M naproxen SUSP 2 M naproxen TABS 1 M naproxen dr 1 M naproxen sodium TABS 275mg, 550mg

2 M

piroxicam CAPS 2 M sulindac TABS 1 M OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000 mL / 30 days)

2 QL M

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

butorphanol tartrate SOLN 1mg/ml, 2mg/ml

4 M

nalbuphine hcl SOLN 4 M tramadol hcl TABS


tramadol-acetaminophen QL (240 tabs / 30 days)

2 QL M

OPIOID ANALGESICS, CII endocet


fentanyl citrate LPOP QL (120 lozenges / 30 days)

5 QL M PA

fentanyl patch 12 mcg/hr QL (10 patches / 30 days)

2 QL M


2 QL M


2 QL M PA


2 QL M PA


2 QL M PA

FENTORA QL (120 tabs / 30 days)

5 QL M PA

hydroco/apap tab 5-325mg QL (360 tabs / 30 days)

2 QL M

hydroco/apap tab 7.5-325 QL (360 tabs / 30 days)

2 QL M

hydroco/apap tab 10-325mg QL (360 tabs / 30 days)

2 QL M

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (5400 mL / 30 days)

2 QL M

hydrocodone-ibuprofen tab 7.5-200 mg


2 QL M

hydromorphone hcl LIQD 2 M hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

4 B/D M

hydromorphone hcl TABS QL (270 tabs / 30 days)

2 QL M


2

Drug Name Drug Tier

Requirements/Limits

HYSINGLA ER 20mg, 30mg, 40mg, 60mg


3 QL M

HYSINGLA ER 80mg, 100mg, 120mg


3 QL M

lorcet hd tab 10-325mg QL (360 tabs / 30 days)

2 QL M

lorcet plus tab 7.5-325 QL (360 tabs / 30 days)

2 QL M

methadone hcl SOLN 5mg/5ml, 10mg/5ml

QL (450 mL / 30 days)

2 QL M

methadone hcl 5mg QL (180 tabs / 30 days)

2 QL M

methadone hcl 10mg QL (180 tabs / 30 days)

2 QL M

methadone hcl intensol QL (120 mL / 30 days)

2 QL M

morphine ext-rel tab 15mg, 30mg, 60mg, 100mg


2 QL M

morphine ext-rel tab 200mg QL (60 tabs / 30 days)

2 QL M

morphine sul inj 1mg/ml 4 B/D M MORPHINE SUL INJ 4MG/ML

4 B/D M

morphine sul inj 10mg/ml 4 B/D M MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml

4 B/D M

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

4 B/D M

morphine sulfate TABS QL (180 tabs / 30 days)

2 QL M

morphine sulfate oral sol 2 M NUCYNTA ER 50mg, 100mg


3 QL M

NUCYNTA ER 150mg, 200mg, 250mg


3 QL M

oxycodone hcl CAPS QL (180 caps / 30 days)

2 QL M

oxycodone hcl CONC; SOLN

2 M

oxycodone hcl TABS QL (180 tabs / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

oxycodone w/ acetaminophen 2.5-325mg


2 QL M

oxycodone w/ acetaminophen 5-325mg


2 QL M

oxycodone w/ acetaminophen 7.5-325mg


2 QL M

oxycodone w/ acetaminophen 10-325mg


2 QL M

ANESTHETICS LOCAL ANESTHETICS lidocaine inj 0.5% 2 B/D M lidocaine inj 0.5% preservative free (pf)

2 B/D M

lidocaine inj 1% 2 B/D M lidocaine inj 1% preservative free (pf)

2 B/D M

lidocaine inj 1.5% preservative free (pf)

2 B/D M

lidocaine inj 2% 2 B/D M ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 2 M gentamicin in saline 2 M gentamicin sulfate SOLN 2 M neomycin sulfate TABS 2 M paromomycin sulfate CAPS 2 M streptomycin sulfate SOLR 2 M SULFADIAZINE TABS 4 M tobramycin NEBU 5 PA tobramycin inj 1.2 gm/30ml 2 M tobramycin inj 1.2gm 5 M tobramycin inj 10mg/ml 2 M tobramycin inj 40mg/ml 2 M tobramycin inj 80mg/2ml 2 M ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 5 M ALINIA 5 M atovaquone SUSP 5 M AZACTAM IN ISO-OSMOTIC DE

4 M

AZACTAM/DEX INJ 4 M aztreonam 2 M BILTRICIDE 3 M CAYSTON 5 LA PA clindamycin cap 75mg 1 M


3

Drug Name Drug Tier

Requirements/Limits

clindamycin cap 300mg 1 M clindamycin hcl cap 150 mg 1 M clindamycin phosphate in d5w 2 M CLINDAMYCIN PHOSPHATE IN NACL

4 M

clindamycin phosphate inj 2 M clindamycin soln 75mg/5ml 2 M colistimethate sodium SOLR 2 M dapsone TABS 2 M daptomycin 5 M EMVERM 5 M imipenem-cilastatin 2 M INVANZ 4 M ivermectin TABS 2 M linezolid 5 M linezolid in sodium chloride 5 M meropenem 2 M methenamine hippurate 2 M metronidazole TABS 1 M metronidazole in nacl 2 M NEBUPENT 4 B/D M nitrofurantoin macrocrystal 50mg, 100mg

PA applies if 65 years and older after a 90 day supply in a calendar year

4 M PA

nitrofurantoin monohyd macro PA applies if 65 years and older after a 90 day supply in a calendar year

4 M PA

PENTAM 300 4 M SIVEXTRO 5 M sulfamethoxazole-trimethop ds

1 M

sulfamethoxazole-trimethoprim SUSP

2 M

sulfamethoxazole-trimethoprim TABS

1 M

sulfamethoxazole-trimethoprim inj

2 M

SYNERCID 5 M tigecycline 50mg 5 M TIGECYCLINE 50mg 5 M trimethoprim TABS 1 M vancomycin hcl CAPS 5 M vancomycin hcl SOLR 10gm, 500mg, 750mg, 1000mg, 5000mg

2 M

VANCOMYCIN IN NACL 4 M ANTIFUNGALS

Drug Name Drug Tier

Requirements/Limits

ABELCET 5 B/D M AMBISOME 5 B/D M amphotericin b SOLR 2 B/D M CANCIDAS 5 M caspofungin acetate 50mg, 70mg

5 M

CASPOFUNGIN ACETATE 50mg, 70mg

5 M

fluconazole SUSR 2 M fluconazole TABS 50mg, 100mg, 200mg

2 M

fluconazole TABS 150mg 1 M fluconazole in dextrose 2 M FLUCONAZOLE INJ NACL 100

3 M

fluconazole inj nacl 200 2 M fluconazole inj nacl 400 2 M flucytosine CAPS 5 M griseofulvin microsize 2 M griseofulvin ultramicrosize 2 M itraconazole CAPS 2 M PA ketoconazole TABS 2 M PA MYCAMINE 5 M NOXAFIL SUSP

QL (630 mL / 30 days) 5 QL M

NOXAFIL TBEC QL (93 tabs / 30 days)

5 QL M

nystatin TABS 2 M terbinafine hcl TABS


voriconazole SOLR 2 M voriconazole SUSR; TABS 5 M ANTIMALARIALS atovaquone-proguanil hcl 2 M chloroquine phosphate TABS

2 M

COARTEM 4 M mefloquine hcl 2 M PRIMAQUINE PHOSPHATE 3 M quinine sulfate CAPS 2 M PA ANTIRETROVIRAL AGENTS abacavir sulfate 2 M APTIVUS 5 M atazanavir sulfate 5 M CRIXIVAN 4 M didanosine 2 M EDURANT 5 M efavirenz CAPS 50mg 2 M efavirenz CAPS 200mg 5 M


4

Drug Name Drug Tier

Requirements/Limits

efavirenz TABS 5 M EMTRIVA 3 M fosamprenavir tab 700 mg 5 M FUZEON 5 INTELENCE 25mg 4 M INTELENCE 100mg, 200mg 5 M INVIRASE 5 M ISENTRESS CHEW 25mg 3 M ISENTRESS CHEW 100mg 5 M ISENTRESS PACK 5 M ISENTRESS TABS 5 M ISENTRESS HD 5 M lamivudine 2 M LEXIVA SUSP 4 M LEXIVA TABS 5 M nevirapine 2 M NORVIR 3 M PREZISTA SUSP

QL (400 mL / 30 days) 5 QL M

PREZISTA TABS 75mg QL (480 tabs / 30 days)

3 QL M


5 QL M


5 QL M


5 QL M

RESCRIPTOR 4 M RETROVIR IV INFUSION 4 M REYATAZ PACK 5 M ritonavir 2 M SELZENTRY SOLN 5 M SELZENTRY TABS 25mg 4 M SELZENTRY TABS 75mg, 150mg, 300mg

5 M

stavudine 2 M SUSTIVA TABS 5 M tenofovir disoproxil fumarate 5 M TIVICAY 10mg 3 M TIVICAY 25mg, 50mg 5 M TYBOST 3 M VIDEX EC 125mg 4 M VIDEX PEDIATRIC 4 M VIRACEPT 5 M VIRAMUNE SUSP 4 M VIREAD 5 M ZERIT SOLR 5 M zidovudine cap 100mg 2 M zidovudine syp 50mg/5ml 2 M

Drug Name Drug Tier

Requirements/Limits

zidovudine tab 300mg 2 M ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine 5 M abacavir sulfate-lamivudine-zidovudine

5 M

ATRIPLA 5 M BIKTARVY 5 M COMPLERA 5 M DESCOVY 5 M EVOTAZ 5 M GENVOYA 5 M JULUCA 5 M KALETRA TAB 100-25MG 4 M KALETRA TAB 200-50MG 5 M lamivudine-zidovudine 2 M lopinavir-ritonavir 5 M ODEFSEY 5 M PREZCOBIX 5 M STRIBILD 5 M SYMFI LO 5 M TRIUMEQ 5 M TRUVADA TAB 100-150


TRUVADA TAB 133-200 QL (30 tabs / 30 days)

5 QL M


5 QL M


5 QL M

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 4 M cycloserine CAPS 5 M ethambutol hcl TABS 2 M isoniazid TABS 1 M isoniazid inj 100 mg/ml 2 M isoniazid syp 50mg/5ml 2 M PASER D/R 4 M PRIFTIN 4 M pyrazinamide TABS 2 M rifabutin 2 M rifampin CAPS; SOLR 2 M RIFATER 4 M SIRTURO 5 M LA PA TRECATOR 4 M ANTIVIRALS acyclovir CAPS; TABS 1 M acyclovir SUSP 2 M acyclovir sodium 2 B/D M


5

Drug Name Drug Tier

Requirements/Limits

adefovir dipivoxil 5 M BARACLUDE SOLN 5 M DAKLINZA 5 PA entecavir 5 M EPCLUSA 5 PA EPIVIR HBV SOLN 4 M famciclovir TABS 2 M ganciclovir inj 500mg 2 B/D M GANCICLOVIR INJ 500MG/10ML

2 B/D M

HARVONI 5 PA lamivudine (hbv) 2 M MAVYRET 5 PA moderiba tab 200mg 2 oseltamivir phosphate CAPS 30mg

QL (168 caps / year)

2 QL M

oseltamivir phosphate CAPS 45mg, 75mg

QL (84 caps / year)

2 QL M

oseltamivir phosphate SUSR QL (1080 mL / year)

2 QL M

PEGASYS 5 PA PEGASYS PROCLICK 5 PA REBETOL SOLN 5 RELENZA DISKHALER

QL (6 inhalers / year) 3 QL M

ribasphere CAPS 2 ribasphere TABS 200mg 2 ribasphere TABS 400mg, 600mg

5

ribavirin 200mg 2 rimantadine hydrochloride 2 M SOVALDI 5 PA valacyclovir hcl TABS 2 M valganciclovir hcl 5 M VEMLIDY 5 M VOSEVI 5 PA ZEPATIER 5 PA CEPHALOSPORINS cefaclor 2 M CEFACLOR MONOHYDRATE ER

4 M

cefadroxil CAPS 1 M cefadroxil SUSR; TABS 2 M CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3 M

cefazolin inj 2 M

Drug Name Drug Tier

Requirements/Limits

cefazolin sodium SOLR 1gm, 20gm

2 M

CEFAZOLIN SODIUM 1 GM/50ML

3 M

cefdinir 2 M cefepime hcl 2 M cefixime 2 M cefotaxime sodium 1gm, 2gm, 500mg

2 M

cefoxitin sodium 2 M cefpodoxime proxetil 2 M cefprozil 2 M ceftazidime SOLR 2 M CEFTAZIDIME/DEXTROSE 4 M ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

2 M

cefuroxime axetil 2 M cefuroxime sodium 2 M cephalexin CAPS 250mg, 500mg

1 M

cephalexin SUSR 2 M SUPRAX CAPS 3 M SUPRAX CHEW 4 M SUPRAX SUSR 500mg/5ml 3 M tazicef SOLR 2 M TEFLARO 5 M ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR

2 M

azithromycin TABS 1 M clarithromycin TABS 2 M clarithromycin er 2 M clarithromycin for susp 2 M DIFICID 5 M e.e.s 400 2 M ery-tab 2 M ERYTHROCIN LACTOBIONATE

4 M

erythrocin stearate 2 M erythromycin base 2 M erythromycin cap 250mg ec 2 M erythromycin ethylsuccinate TABS

2 M

FLUOROQUINOLONES ciprofloxacin SUSR 2 M ciprofloxacin hcl tab 100mg 2 M ciprofloxacin hcl tab 250mg, 500mg, 750mg

1 M


6

Drug Name Drug Tier

Requirements/Limits

ciprofloxacin in d5w 2 M ciprofloxacin inj 2 M levofloxacin TABS 1 M levofloxacin in d5w 2 M levofloxacin inj 25mg/ml 2 M levofloxacin oral soln 25 mg/ml

2 M

PENICILLINS amoxicillin CAPS; SUSR; TABS

1 M

amoxicillin CHEW 2 M amoxicillin & pot clavulanate 2 M ampicillin & sulbactam sodium 2 M ampicillin cap 250mg 1 M ampicillin cap 500mg 1 M ampicillin inj 2 M ampicillin sodium 2 M ampicillin susp 2 M BICILLIN L-A 4 M dicloxacillin sodium 2 M nafcillin sodium 1gm, 2gm 2 M nafcillin sodium 10gm 5 M oxacillin sodium 1gm, 2gm 2 M oxacillin sodium 10gm 5 M PENICILLIN G POT IN DEXTROSE 2MU

4 M

PENICILLIN G POT IN DEXTROSE 3MU

4 M

PENICILLIN G PROCAINE 4 M penicillin g sodium 2 M penicillin v potassium SOLR 2 M penicillin v potassium TABS 1 M penicilln gk inj 5mu 2 M penicilln gk inj 20mu 2 M pfizerpen-g inj 5mu 2 M pfizerpen-g inj 20mu 2 M piper/tazoba inj 2-0.25gm 2 M piper/tazoba inj 3-0.375gm 2 M piper/tazoba inj 4-0.5gm 2 M PIPER/TAZOBA INJ 12-1.5GM

4 M

piper/tazoba inj 36-4.5gm 2 M TETRACYCLINES doxy 100 2 M doxycycline (monohydrate) CAPS 50mg, 100mg

2 M

doxycycline (monohydrate) TABS

2 M

doxycycline hyclate CAPS 2 M

Drug Name Drug Tier

Requirements/Limits

doxycycline hyclate SOLR 2 M doxycycline hyclate TABS 20mg, 100mg

2 M

minocycline hcl CAPS 2 M morgidox cap 1x50mg 2 M ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 5 B/D busulfan 5 B/D M CYCLOPHOSPHAMIDE CAPS

4 B/D M

cyclophosphamide SOLR 5 B/D M dacarbazine 2 B/D M EMCYT 4 M GLEOSTINE 4 M HEXALEN 5 M IFEX INJ 3GM 4 B/D M ifosfamide inj 1gm 2 B/D M ifosfamide inj 1gm/20ml 2 B/D M IFOSFAMIDE INJ 3GM 4 B/D M ifosfamide inj 3gm/60ml 2 B/D M LEUKERAN 4 M melphalan hcl 5 B/D M MUSTARGEN 5 B/D M ANTHRACYCLINES adriamycin 2 B/D M doxorubicin hcl 2 B/D M doxorubicin hcl liposomal inj 2mg/ml

5 B/D M

doxorubicin hcl soln 2mg/ml 2 B/D M epirubicin hcl 2 B/D M ANTIBIOTICS bleomycin sulfate 2 B/D M mitomycin SOLR 5 B/D M ANTIMETABOLITES adrucil 2 B/D M ALIMTA 5 B/D M azacitidine 5 B/D cladribine 5 B/D M cytarabine 20mg/ml 2 B/D M fludarabine phosphate 2 B/D M fluorouracil SOLN 2 B/D M gemcitabine inj soln 2 B/D M gemcitabine inj solr 5 B/D M mercaptopurine TABS 2 M methotrexate sodium inj 2 B/D M NIPENT 5 B/D M PURIXAN 5 TABLOID 4 M


7

Drug Name Drug Tier

Requirements/Limits

ANTIMITOTIC, TAXOIDS ABRAXANE 5 B/D M docetaxel CONC 20mg/ml, 80mg/4ml

5 B/D M

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

5 B/D M

DOCETAXEL SOLN 5 B/D M paclitaxel 2 B/D M TAXOTERE 80mg/4ml 5 B/D M ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 B/D M vincasar pfs 2 B/D M vincristine sulfate 2 B/D M vinorelbine tartrate 2 B/D M BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 LA PA BELEODAQ 5 PA BORTEZOMIB 5 PA ERIVEDGE 5 LA PA FARYDAK 5 LA PA HERCEPTIN 5 PA IBRANCE 5 LA PA IDHIFA 5 LA PA KADCYLA 5 B/D KEYTRUDA 5 PA KISQALI 5 PA KISQALI FEMARA 200 DOSE 5 PA KISQALI FEMARA 400 DOSE 5 PA KISQALI FEMARA 600 DOSE 5 PA LYNPARZA 5 LA PA MYLOTARG 5 LA PA NINLARO 5 PA ODOMZO 5 LA PA RITUXAN 5 LA PA RITUXAN HYCELA 5 LA PA RUBRACA 5 LA PA TECENTRIQ 5 LA PA VELCADE 5 PA VENCLEXTA 10mg, 50mg 4 LA PA VENCLEXTA 100mg 5 LA PA VENCLEXTA STARTING PACK

5 LA PA

VERZENIO 5 LA PA YERVOY 5 PA ZEJULA 5 LA PA ZOLINZA 5 PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS 2 M

Drug Name Drug Tier

Requirements/Limits

bicalutamide 2 M DEPO-PROVERA INJ 400/ML 4 B/D M ERLEADA 5 LA PA exemestane 2 M FARESTON 5 M FASLODEX 5 B/D M flutamide 2 M hydroxyprogesterone caproate (antineoplastic)

5 B/D M

letrozole TABS 2 M leuprolide inj 1mg/0.2 2 PA LUPRON DEPOT (1-MONTH) 3.75mg

5 PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

5 PA

LYSODREN 3 M megestrol ac sus 40mg/ml

PA if 65 years and older 4 M PA

megestrol ac tab 20mg PA if 65 years and older

4 M PA

megestrol ac tab 40mg PA if 65 years and older

4 M PA

megestrol sus 625mg/5ml 4 M PA nilutamide 5 M SOLTAMOX 4 M tamoxifen citrate TABS 1 M TRELSTAR DEP INJ 3.75MG 5 PA TRELSTAR LA INJ 11.25MG 5 PA XTANDI 5 LA PA ZYTIGA 5 LA PA IMMUNOMODULATORS POMALYST CAP 1MG 5 LA PA POMALYST CAP 2MG 5 LA PA POMALYST CAP 3MG 5 LA PA POMALYST CAP 4MG 5 LA PA REVLIMID

QL (28 caps / 28 days) 5 QL LA PA

THALOMID 50mg, 100mg QL (30 caps / 30 days)

5 QL PA

THALOMID 150mg, 200mg QL (60 caps / 30 days)

5 QL PA

KINASE INHIBITORS AFINITOR

QL (30 tabs / 30 days) 5 QL PA

AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)

5 QL PA


5 QL PA


8

Drug Name Drug Tier

Requirements/Limits


5 QL PA

ALECENSA 5 LA PA ALUNBRIG 5 LA PA BOSULIF 5 PA CABOMETYX

QL (30 tabs / 30 days) 5 QL LA PA

CALQUENCE 5 LA PA CAPRELSA 5 LA PA COMETRIQ 5 LA PA COTELLIC 5 LA PA GILOTRIF TAB 20MG 5 LA PA GILOTRIF TAB 30MG 5 LA PA GILOTRIF TAB 40MG 5 LA PA ICLUSIG 5 LA PA imatinib mesylate 100mg


imatinib mesylate 400mg QL (60 tabs / 30 days)

5 QL PA

IMBRUVICA 5 LA PA INLYTA 1mg


INLYTA 5mg QL (120 tabs / 30 days)

5 QL LA PA

IRESSA 5 LA PA JAKAFI


LENVIMA 8 MG DAILY DOSE 5 LA PA LENVIMA 10 MG DAILY DOSE

5 LA PA

LENVIMA 14 MG DAILY DOSE

5 LA PA


5 LA PA


5 LA PA


5 LA PA

MEKINIST 5 LA PA NERLYNX 5 LA PA NEXAVAR 5 LA PA RYDAPT 5 PA SPRYCEL 5 PA STIVARGA 5 LA PA SUTENT 5 PA TAFINLAR 5 LA PA TAGRISSO 5 LA PA TARCEVA 25mg


Drug Name Drug Tier

Requirements/Limits

TARCEVA 100mg, 150mg QL (30 tabs / 30 days)

5 QL LA PA

TASIGNA 5 PA TYKERB 5 LA PA VOTRIENT 5 LA PA XALKORI 5 LA PA ZELBORAF 5 LA PA ZYDELIG 5 LA PA ZYKADIA 5 LA PA MISCELLANEOUS bexarotene 5 PA DROXIA 3 M hydroxyurea CAPS 2 M LONSURF 5 PA MATULANE 5 M LA mitoxantrone hcl 2 B/D SYLATRON KIT 200MCG 5 PA SYLATRON KIT 300MCG 5 PA SYLATRON KIT 600MCG 5 PA SYNRIBO 5 PA tretinoin (chemotherapy) 5 M TRISENOX 5 B/D M PLATINUM-BASED AGENTS carboplatin 2 B/D M cisplatin 2 B/D M oxaliplatin inj 50mg 5 B/D M oxaliplatin inj 50mg/10ml 2 B/D M oxaliplatin inj 100mg 5 B/D M oxaliplatin inj 100mg/20ml 2 B/D M PROTECTIVE AGENTS dexrazoxane 5 B/D M ELITEK 5 B/D M leucovorin calcium SOLR 2 B/D M leucovorin calcium TABS 2 M levoleucovorin calcium 175mg/17.5ml

5 B/D

LEVOLEUCOVORIN CALCIUM 250mg/25ml

5 B/D

levoleucovorin calcium 50mg 5 B/D LEVOLEUCOVORIN CALCIUM 175MG

5 B/D

mesna 2 B/D M MESNEX TABS 5 M TOPOISOMERASE INHIBITORS etoposide SOLN 2 B/D M irinotecan hcl 2 B/D M toposar 2 B/D M topotecan inj 4mg 5 B/D M TOPOTECAN INJ 4MG/4ML 5 B/D M


9

Drug Name Drug Tier

Requirements/Limits

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine--benazepril hcl cap 10-20 mg

1 M

amlodipine-benazepril hcl cap 2.5-10 mg

1 M

amlodipine-benazepril hcl cap 5-10 mg

1 M


1 M


1 M

amlodipine-benazepril hcl cap 10-40mg

1 M

benazepril & hydrochlorothiazide

1 M

captopril & hydrochlorothiazide

1 M

enalapril maleate & hydrochlorothiazide

1 M

fosinopril sodium & hydrochlorothiazide

1 M

lisinopril & hydrochlorothiazide

1 M

moexipril-hydrochlorothiazide 1 M quinapril-hydrochlorothiazide 1 M ACE INHIBITORS benazepril hcl TABS 1 M captopril TABS 1 M enalapril maleate TABS 1 M fosinopril sodium 1 M lisinopril TABS 1 M moexipril hcl 1 M perindopril erbumine 1 M quinapril hcl 1 M ramipril 1 M trandolapril 1 M ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 2 M spironolactone TABS 1 M ALPHA BLOCKERS doxazosin mesylate TABS 1mg, 2mg, 4mg


2 QL M

doxazosin mesylate TABS 8mg

2 M

prazosin hcl 2 M terazosin hcl 1 M

Drug Name Drug Tier

Requirements/Limits

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil

1 M

amlodipine besylate-valsartan tab 5-160 mg

1 M


1 M


1 M


1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1 M

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1 M


1 M


1 M

ENTRESTO 3 M irbesartan-hydrochlorothiazide 1 M losartan-hydrochlorothiazide 1 M olmesartan medoxomil-amlodipine-hydrochlorothiazide

1 M

olmesartan medoxomil-hydrochlorothiazide

1 M

valsartan-hydrochlorothiazide 1 M ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan 1 M losartan potassium 1 M olmesartan medoxomil TABS

1 M

valsartan 1 M ANTIARRHYTHMICS amiodarone hcl SOLN 2 M amiodarone hcl TABS 100mg, 400mg

2 M

amiodarone hcl TABS 200mg

1 M

disopyramide phosphate PA if 65 years and older

4 M PA

dofetilide 2 flecainide acetate 2 M


10

Drug Name Drug Tier

Requirements/Limits

mexiletine hcl 2 M MULTAQ 4 M NORPACE CR


pacerone 100mg, 400mg 2 M pacerone 200mg 1 M propafenone hcl 2 M propafenone hcl 12hr 2 M quinidine gluconate TBCR 2 M quinidine sulfate TABS 2 M sorine 2 M sotalol hcl 2 M sotalol hcl (afib/afl) 2 M ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS 1 M lovastatin 1 M pravastatin sodium 1 M rosuvastatin calcium


simvastatin TABS 5mg, 10mg, 20mg, 40mg

1 M

simvastatin TABS 80mg QL (30 tabs / 30 days)

1 QL M

ANTILIPEMICS, MISCELLANEOUS cholestyramine 2 M cholestyramine light 2 M colestipol hcl gran 2 M colestipol hcl pack 2 M colestipol hcl tabs 2 M ezetimibe 2 M fenofibrate TABS 48mg, 54mg, 145mg, 160mg

2 M

fenofibrate micronized 67mg, 134mg, 200mg

2 M

gemfibrozil TABS 1 M JUXTAPID 5 LA PA KYNAMRO 5 PA niacin er (antihyperlipidemic) 500mg


2 QL M

niacin er (antihyperlipidemic) 750mg, 1000mg

2 M

niacor 2 M omega-3-acid ethyl esters 2 M PRALUENT 5 PA prevalite 2 M VASCEPA 4 M WELCHOL 3 M

Drug Name Drug Tier

Requirements/Limits

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 2 M bisoprolol & hydrochlorothiazide

1 M

metoprolol & hctz tab 50-25mg

2 M


2 M


2 M

propranolol & hydrochlorothiazide

2 M

BETA-BLOCKERS acebutolol hcl CAPS 2 M atenolol TABS 1 M bisoprolol fumarate 2 M BYSTOLIC 2.5mg, 5mg, 10mg


4 QL M

BYSTOLIC 20mg QL (60 tabs / 30 days)

4 QL M

carvedilol 1 M labetalol hcl TABS 2 M metoprolol succinate 2 M metoprolol tartrate SOCT 2 M metoprolol tartrate SOLN 2 M metoprolol tartrate TABS 25mg, 50mg, 100mg

1 M

nadolol TABS 2 M pindolol 2 M propranolol cap er 2 M propranolol hcl SOLN; TABS 2 M propranolol oral sol 2 M timolol maleate TABS 2 M CALCIUM CHANNEL BLOCKERS afeditab cr 2 M amlodipine besylate TABS 1 M cartia xt cap 120/24hr 2 M cartia xt cap 180/24hr 2 M cartia xt cap 240/24hr 2 M cartia xt cap 300/24hr 2 M dilt-xr cap 2 M diltiazem cap 120mg cd 2 M diltiazem cap 180mg cd 2 M diltiazem cap 240mg cd 2 M diltiazem cap 300mg cd 2 M diltiazem cap 360mg cd 2 M diltiazem cap er/12hr 2 M


11

Drug Name Drug Tier

Requirements/Limits

diltiazem hcl TABS 2 M diltiazem hcl cap sr 24hr 2 M diltiazem hcl coated beads cap sr 24hr

2 M

diltiazem hcl extended release beads cap sr

2 M

diltiazem inj 2 M felodipine 2 M isradipine 2 M nicardipine hcl CAPS 2 M nifedical xl 2 M nifedipine TB24 2 M nifedipine er 2 M nimodipine CAPS 5 M NYMALIZE 5 M taztia xt 2 M verapamil cap er 2 M verapamil hcl SOLN 2 M verapamil hcl TABS 1 M verapamil hcl tab er 1 M DIGITALIS GLYCOSIDES digitek .25mg


digitek .125mg QL (30 tabs / 30 days)

2 QL M

digox 125mcg QL (30 tabs / 30 days)

2 QL M

digox 250mcg PA if 65 years and older

2 M PA

digoxin TABS 125mcg QL (30 tabs / 30 days)

2 QL M

digoxin TABS 250mcg PA if 65 years and older

2 M PA

digoxin inj 2 M digoxin sol 50mcg/ml


DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 4 M TEKTURNA HCT 4 M DIURETICS acetazolamide CP12; TABS 2 M amiloride & hydrochlorothiazide

2 M

amiloride hcl TABS 2 M bumetanide 2 M chlorothiazide tabs 2 M chlorthalidone 2 M furosemide SOLN; TABS 1 M

Drug Name Drug Tier

Requirements/Limits

furosemide inj 2 M hydrochlorothiazide CAPS; TABS

1 M

indapamide 2 M methazolamide TABS 2 M methyclothiazide 2 M metolazone 2 M spironolactone & hydrochlorothiazide

2 M

torsemide tabs 2 M triamterene & hydrochlorothiazide cap 37.5-25 mg

1 M

triamterene & hydrochlorothiazide tabs

1 M

MISCELLANEOUS clonidine hcl PTWK 2 M clonidine hcl TABS 1 M CORLANOR 4 M DEMSER 5 M hydralazine hcl SOLN; TABS 2 M midodrine hcl 2 M minoxidil TABS 2 M NORTHERA 5 LA PA RANEXA 3 M NITRATES isosorb mononitrate tab 1 M isosorbide dinitrate 2 M isosorbide dinitrate er 2 M isosorbide mononitrate er 2 M minitran 2 M NITRO-BID 3 M NITRO-DUR DIS 0.3MG/HR 4 M NITRO-DUR DIS 0.8MG/HR 4 M nitroglycerin SUBL 2 M nitroglycerin td patch 2 M PULMONARY ARTERIAL HYPERTENSION ADCIRCA


ADEMPAS QL (90 tabs / 30 days)

5 QL LA PA

LETAIRIS QL (30 tabs / 30 days)

5 QL LA PA

OPSUMIT QL (30 tabs / 30 days)

5 QL LA PA

REMODULIN 5 LA PA


12

Drug Name Drug Tier

Requirements/Limits

sildenafil citrate (pulmonary hypertension) TABS


2 QL PA

TRACLEER TABS 62.5mg QL (120 tabs / 30 days)

5 QL LA PA

TRACLEER TABS 125mg QL (60 tabs / 30 days)

5 QL LA PA

VENTAVIS 5 PA CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg


alprazolam tab 0.25mg QL (480 tabs / 30 days)

1 QL M

alprazolam tab 1mg QL (120 tabs / 30 days)

1 QL M

alprazolam tab 2mg QL (150 tabs / 30 days)

1 QL M

buspirone hcl TABS 2 M fluvoxamine maleate TABS 25mg, 50mg


2 QL M

fluvoxamine maleate TABS 100mg

2 M

lorazepam SOLN 2 M lorazepam TABS


lorazepam intensol QL (150 mL / 30 days)

2 QL M

ANTICONVULSANTS APTIOM 200mg


APTIOM 400mg QL (90 tabs / 30 days)

5 QL M

APTIOM 600mg, 800mg QL (60 tabs / 30 days)

5 QL M

BANZEL SUS 40MG/ML 5 M PA BANZEL TAB 200MG 5 M PA BANZEL TAB 400MG 5 M PA BRIVIACT SOLN 10mg/ml 5 M PA BRIVIACT SOLN 50mg/5ml 4 M PA BRIVIACT TABS 5 M PA carbamazepine CHEW; CP12; SUSP; TABS; TB12

2 M

CELONTIN 4 M clonazepam TABS 1mg


clonazepam TABS 2mg QL (300 tabs / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits

clonazepam TABS .5mg QL (240 tabs / 30 days)

1 QL M

clonazepam TBDP 1mg QL (120 tabs / 30 days)

2 QL M

clonazepam TBDP 2mg QL (300 tabs / 30 days)

2 QL M

clonazepam TBDP .5mg QL (240 tabs / 30 days)

2 QL M


2 QL M


2 QL M

clorazepate dipotassium 3.75mg, 7.5mg

QL (120 tabs / 30 days) PA if 65 years and older

2 QL M PA

clorazepate dipotassium 15mg


2 QL M PA

DIASTAT ACUDIAL 4 M DIASTAT PEDIATRIC 4 M diazepam SOLN 1mg/ml

QL (1200 mL / 30 days) PA if 65 years and older

2 QL M PA

diazepam SOLN 5mg/ml 2 M diazepam TABS


1 QL M PA

diazepam gel 2 M diazepam intensol

QL (240 mL / 30 days) PA if 65 years and older

2 QL M PA

DILANTIN 3 M DILANTIN-125 SUS 125/5ML 4 M divalproex sodium CSDR; TB24; TBEC

2 M

epitol 2 M ethosuximide CAPS; SOLN 2 M felbamate SUSP 5 M felbamate TABS 2 M FYCOMPA SUSP

QL (720 mL / 30 days) 5 QL M PA

FYCOMPA TABS 2mg QL (180 tabs / 30 days)

4 QL M PA


5 QL M PA


5 QL M PA


13

Drug Name Drug Tier

Requirements/Limits

FYCOMPA TABS 8mg, 10mg, 12mg


5 QL M PA

gabapentin CAPS 100mg QL (1080 caps / 30 days)

1 QL M


1 QL M


1 QL M

gabapentin SOLN QL (2160 mL / 30 days)

2 QL M

gabapentin TABS 600mg QL (180 tabs / 30 days)

2 QL M

gabapentin TABS 800mg QL (120 tabs / 30 days)

2 QL M

GABITRIL 12mg, 16mg 4 M lamotrigine CHEW; TB24 2 M lamotrigine TABS 1 M levetiracetam SOLN; TABS; TB24

2 M

levetiracetam in sodium chloride

2 M

levetiracetam oral soln 100 mg/ml

2 M

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg

QL (120 caps / 30 days)

3 QL M

LYRICA CAPS 200mg QL (90 caps / 30 days)

3 QL M

LYRICA CAPS 225mg, 300mg


3 QL M

LYRICA SOLN QL (946 mL / 30 days)

3 QL M

ONFI 5 M PA oxcarbazepine 2 M PEGANONE 4 M phenobarbital ELIX; TABS


PHENOBARBITAL SODIUM SOLN 65mg/ml

PA if 65 years and older

4 M PA

phenobarbital sodium SOLN 130mg/ml


4 M PA

PHENYTEK 3 M phenytoin CHEW; SUSP 2 M phenytoin sodium SOLN 2 M phenytoin sodium extended 2 M

Drug Name Drug Tier

Requirements/Limits

primidone TABS 2 M roweepra 2 M roweepra xr 2 M SABRIL TABS


SPRITAM 4 M TEGRETOL 4 M TEGRETOL-XR 4 M tiagabine hcl 2 M topiramate CPSP 2 M topiramate TABS 1 M valproate sodium SOLN 2 M valproic acid 2 M vigabatrin powd pack 500mg

QL (180 packets / 30 days)

5 QL LA PA

VIMPAT SOLN 10mg/ml QL (1200 mL / 30 days)

5 QL M

VIMPAT SOLN 200mg/20ml 5 M VIMPAT TABS 50mg


VIMPAT TABS 100mg, 150mg, 200mg


5 QL M

zonisamide CAPS 2 M ANTIDEMENTIA donepezil hydrochloride TABS 5mg


2 QL M

donepezil hydrochloride TABS 10mg, 23mg

2 M

donepezil hydrochloride TBDP 5mg


2 QL M

donepezil hydrochloride TBDP 10mg

2 M

galantamine hydrobromide SOLN

2 M

galantamine hydrobromide TABS 4mg


2 QL M



2 QL M


2 M

galantamine hydrobromide er 8mg, 16mg


2 QL M


14

Drug Name Drug Tier

Requirements/Limits

galantamine hydrobromide er 24mg

2 M

memantine hcl cp24 PA if < 30 yrs

2 M PA

memantine hcl soln PA if < 30 yrs

2 M PA

memantine hcl tabs PA if < 30 yrs

2 M PA

NAMENDA XR PA if < 30 yrs

4 M PA

NAMENDA XR TITRATION PACK

PA if < 30 yrs

4 M PA

NAMZARIC 4 M rivastigmine tartrate 2 M rivastigmine td patch 24hr 4.6 mg/24hr

QL (30 patches / 30 days)

2 QL M

rivastigmine td patch 24hr 9.5 mg/24hr


2 QL M

rivastigmine td patch 24hr 13.3 mg/24hr


2 QL M

ANTIDEPRESSANTS amitriptyline hcl TABS


amoxapine tab 25mg 2 M amoxapine tab 50mg 2 M amoxapine tab 100mg 2 M amoxapine tab 150mg 2 M bupropion hcl TABS 2 M bupropion hcl TB12 2 M bupropion hcl TB24 150mg


bupropion hcl TB24 300mg QL (30 tabs / 30 days)

2 QL M

citalopram hydrobromide SOLN

2 M

citalopram hydrobromide TABS 10mg, 20mg


1 QL M

citalopram hydrobromide TABS 40mg


1 QL M

clomipramine hcl CAPS PA if 65 years and older

4 M PA

Drug Name Drug Tier

Requirements/Limits

desipramine hcl TABS 2 M desvenlafaxine succinate


doxepin hcl CAPS; CONC PA if 65 years and older

4 M PA

duloxetine hcl CPEP 20mg QL (180 caps / 30 days)

2 QL M


2 QL M


2 QL M

EMSAM QL (30 patches / 30 days)

5 QL M PA

escitalopram oxalate SOLN QL (600 mL / 30 days)

2 QL M

escitalopram oxalate TABS 5mg, 10mg


1 QL M

escitalopram oxalate TABS 20mg


1 QL M

FETZIMA 20mg QL (180 caps / 30 days)

4 QL M

FETZIMA 40mg QL (90 caps / 30 days)

4 QL M

FETZIMA 80mg, 120mg QL (30 caps / 30 days)

4 QL M

FETZIMA TITRATION PACK 4 M fluoxetine cap 10mg


fluoxetine cap 20mg QL (120 caps / 30 days)

1 QL M

fluoxetine cap 40mg 1 M fluoxetine hcl SOLN 2 M imipramine hcl TABS


maprotiline hcl 2 M MARPLAN TAB 10MG


mirtazapine TABS 7.5mg, 15mg


1 QL M

mirtazapine TABS 30mg, 45mg

1 M

mirtazapine TBDP 15mg QL (30 tabs / 30 days)

2 QL M

mirtazapine TBDP 30mg, 45mg

2 M

nefazodone hcl 2 M


15

Drug Name Drug Tier

Requirements/Limits

nortriptyline hcl CAPS 1 M nortriptyline hcl SOLN 2 M paroxetine hcl tabs 10mg, 20mg, 40mg


1 QL M

paroxetine hcl tabs 30mg QL (60 tabs / 30 days)

1 QL M

PAXIL SUSP QL (900 mL / 30 days)

4 QL M

phenelzine sulfate TABS 2 M protriptyline hcl 2 M sertraline hcl CONC 2 M sertraline hcl TABS 25mg, 50mg


1 QL M

sertraline hcl TABS 100mg 1 M tranylcypromine sulfate 2 M trazodone hcl TABS 50mg, 100mg, 150mg

1 M

trimipramine maleate CAPS 25mg

QL (240 caps / 30 days) PA if 65 years and older

4 QL M PA



4 QL M PA



4 QL M PA

TRINTELLIX 5mg QL (120 tabs / 30 days)

4 QL M


4 QL M


4 QL M

venlafaxine hcl CP24 37.5mg, 75mg


1 QL M

venlafaxine hcl CP24 150mg QL (60 caps / 30 days)

1 QL M

venlafaxine hcl TABS 2 M VIIBRYD STARTER PACK 4 M VIIBRYD TAB


ANTIPARKINSONIAN AGENTS amantadine hcl CAPS


Drug Name Drug Tier

Requirements/Limits

amantadine hcl SYRP; TABS

2 M

APOKYN 5 LA PA benztropine mesylate SOLN 2 M benztropine mesylate TABS


bromocriptine mesylate CAPS; TABS

2 M

carbidopa-levodopa 2 M carbidopa/levodopa/entacapone

2 M

entacapone 2 M NEUPRO 4 M pramipexole tab 0.5mg 2 M pramipexole tab 0.25mg 2 M pramipexole tab 0.75mg 2 M pramipexole tab 0.125mg 2 M pramipexole tab 1.5mg 2 M pramipexole tab 1mg 2 M rasagiline mesylate TABS 2 M ropinirole tab 0.5mg 2 M ropinirole tab 0.25mg 2 M ropinirole tab 1mg 2 M ropinirole tab 2mg 2 M ropinirole tab 3mg 2 M ropinirole tab 4mg 2 M ropinirole tab 5mg 2 M selegiline hcl CAPS; TABS 2 M trihexyphenidyl hcl


ANTIPSYCHOTICS ABILIFY MAINTENA

QL (1 injection / 28 days)

5 QL M

aripiprazole odt QL (60 tabs / 30 days)

5 QL M

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

5 QL M

aripiprazole tab 2mg, 5mg, 10mg, 15mg


2 QL M

aripiprazole tab 20mg, 30mg QL (30 tabs / 30 days)

5 QL M

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml


5 QL M


16

Drug Name Drug Tier

Requirements/Limits

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)

5 QL M

chlorpromazine hcl TABS 2 M CHLORPROMAZINE INJ 4 M clozapine odt 12.5mg, 25mg 2 M PA clozapine odt 100mg

QL (270 tabs / 30 days) 2 QL M PA

clozapine odt 150mg QL (180 tabs / 30 days)

2 QL M PA

clozapine odt 200mg QL (135 tabs / 30 days)

5 QL M PA

clozapine tab 25mg 2 M clozapine tab 50mg 2 M clozapine tab 100mg


clozapine tab 200mg QL (135 tabs / 30 days)

2 QL M

FANAPT QL (60 tabs / 30 days)

4 QL M

FANAPT TITRATION PACK 4 M fluphenazine decanoate SOLN

2 M

fluphenazine hcl 2 M GEODON SOLR

QL (6 mL / 3 days) 4 QL M

haloperidol TABS 2 M haloperidol conc 2mg/ml 2 M haloperidol decanoate SOLN 2 M haloperidol inj 5mg/ml 2 M haloperidol lactate inj 5 mg/ml 2 M INVEGA SUST INJ 39 MG/0.25 ML


4 QL M

INVEGA SUST INJ 78 MG/0.5 ML


5 QL M



5 QL M

INVEGA SUST INJ 156MG/ML


5 QL M

Drug Name Drug Tier

Requirements/Limits



5 QL M

INVEGA TRINZA QL (1 injection / 90 days)

5 QL M

LATUDA 20mg QL (240 tabs / 30 days)

4 QL M

LATUDA 40mg, 120mg QL (30 tabs / 30 days)

4 QL M

LATUDA 60mg, 80mg QL (60 tabs / 30 days)

4 QL M

loxapine succinate 2 M NUPLAZID


olanzapine SOLR QL (3 vials / 1 day)

2 QL M

olanzapine TABS 2.5mg QL (240 tabs / 30 days)

2 QL M

olanzapine TABS 5mg QL (120 tabs / 30 days)

2 QL M

olanzapine TABS 7.5mg QL (30 tabs / 30 days)

2 QL M

olanzapine TABS 10mg, 15mg, 20mg


2 QL M

olanzapine TBDP 5mg QL (30 tabs / 30 days)

2 QL M

olanzapine TBDP 10mg, 15mg, 20mg


2 QL M

paliperidone 1.5mg, 3mg, 9mg


5 QL M

paliperidone 6mg QL (60 tabs / 30 days)

5 QL M

perphenazine TABS 2 M pimozide 2 M quetiapine fumarate TABS


quetiapine fumarate TB24 50mg


2 QL M

quetiapine fumarate TB24 150mg, 200mg


2 QL M

quetiapine fumarate TB24 300mg, 400mg


2 QL M


17

Drug Name Drug Tier

Requirements/Limits

REXULTI 1mg QL (90 tabs / 30 days)

5 QL M

REXULTI 2mg QL (60 tabs / 30 days)

5 QL M

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

5 QL M

REXULTI .5mg QL (180 tabs / 30 days)

5 QL M

REXULTI .25mg QL (360 tabs / 30 days)

5 QL M

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

4 QL M

RISPERDAL INJ 25MG QL (2 injections / 28 days)

4 QL M

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

5 QL M

RISPERDAL INJ 50MG QL (2 injections / 28 days)

5 QL M

risperidone SOLN QL (240 mL / 30 days)

2 QL M

risperidone TABS 1mg, 2mg, 3mg


2 QL M

risperidone TABS 4mg QL (120 tabs / 30 days)

2 QL M

risperidone TABS .25mg, .5mg


2 QL M

risperidone TBDP 1mg, 2mg, 3mg


2 QL M

risperidone TBDP 4mg QL (120 tabs / 30 days)

2 QL M

risperidone TBDP .25mg, .5mg


2 QL M

SAPHRIS 2.5mg QL (240 tabs / 30 days)

4 QL M

SAPHRIS 5mg QL (120 tabs / 30 days)

4 QL M

SAPHRIS 10mg QL (60 tabs / 30 days)

4 QL M

thioridazine hcl TABS PA if 65 years and older

4 M PA

thiothixene 2 M trifluoperazine hcl 2 M

Drug Name Drug Tier

Requirements/Limits

VERSACLOZ QL (600 mL / 30 days)

5 QL M PA

VRAYLAR 1.5mg QL (120 caps / 30 days)

5 QL M PA

VRAYLAR 3mg QL (60 caps / 30 days)

5 QL M PA

VRAYLAR 4.5mg, 6mg QL (30 caps / 30 days)

5 QL M PA

VRAYLAR THERAPY PACK 4 M PA ziprasidone hcl


ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

5 QL M PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

5 QL M PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

4 QL M PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg


2 QL M

amphetamine-dextroamphetamine cap sr 24hr 10 mg


2 QL M



2 QL M



2 QL M



2 QL M



2 QL M

amphetamine-dextroamphetamine tab 5 mg


2 QL M

amphetamine-dextroamphetamine tab 7.5 mg


2 QL M



2 QL M


18

Drug Name Drug Tier

Requirements/Limits

amphetamine-dextroamphetamine tab 12.5 mg


2 QL M



2 QL M



2 QL M



2 QL M

atomoxetine hcl 10mg, 18mg, 25mg


2 QL M

atomoxetine hcl 40mg QL (60 caps / 30 days)

2 QL M

atomoxetine hcl 60mg, 80mg, 100mg


2 QL M

guanfacine er (adhd) PA if 65 years and older

4 M PA

metadate er tab 20mg QL (90 tabs / 30 days)

2 QL M

methylphenidate hcl TABS 5mg, 10mg


2 QL M

methylphenidate hcl TABS 20mg


2 QL M

methylphenidate hcl oral soln 5mg/5ml

QL (1800 mL / 30 days)

2 QL M

methylphenidate hcl oral soln 10mg/5ml

QL (900 mL / 30 days)

2 QL M

methylphenidate tab 10mg er QL (90 tabs / 30 days)

2 QL M

methylphenidate tab 20mg er QL (90 tabs / 30 days)

2 QL M

HYPNOTICS HETLIOZ 5 LA PA SILENOR 3mg


SILENOR 6mg QL (30 tabs / 30 days)

3 QL M

Drug Name Drug Tier

Requirements/Limits

temazepam 7.5mg QL (30 caps / 30 days)


2 QL M PA

temazepam 15mg QL (60 caps / 30 days)


2 QL M PA

zolpidem tartrate TABS QL (30 tabs / 30 days)


4 QL M PA

MIGRAINE dihydroergotamine mesylate 1mg/ml

5 M

dihydroergotamine mesylate nasal

QL (8 mL / 30 days)

5 QL M

eletriptan hydrobromide QL (12 tabs / 30 days)

2 QL M

ergotamine w/ caffeine 2 M migergot 5 M naratriptan hcl


rizatriptan benzoate QL (18 tabs / 30 days)

2 QL M

rizatriptan benzoate odt QL (18 tabs / 30 days)

2 QL M

sumatriptan SOLN 5mg/act QL (24 inhalers / 30 days)

2 QL M

sumatriptan SOLN 20mg/act QL (12 inhalers / 30 days)

2 QL M

sumatriptan inj 4mg/0.5ml QL (18 injections / 30 days)

2 QL M

sumatriptan inj 6mg/0.5ml QL (12 injections / 30 days)

2 QL M

sumatriptan succinate TABS QL (12 tabs / 30 days)

2 QL M

zolmitriptan TABS QL (12 tabs / 30 days)

2 QL M

zolmitriptan odt QL (12 tabs / 30 days)

2 QL M

MISCELLANEOUS


19

Drug Name Drug Tier

Requirements/Limits

AUSTEDO 6mg QL (60 tabs / 30 days)

5 QL LA PA

AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)

5 QL LA PA

lithium carbonate CAPS; TABS

1 M

lithium carbonate er 2 M LITHIUM SOLN 8MEQ/5ML 3 M NUEDEXTA 4 M PA pyridostigmine tab 60mg 2 M riluzole 2 M tetrabenazine 12.5mg


tetrabenazine 25mg QL (120 tabs / 30 days)

5 QL PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 5 LA PA BETASERON

QL (14 syringes / 28 days)

5 QL PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

5 QL PA

glatiramer acetate 20mg/ml QL (30 syringes / 30 days)

5 QL PA

glatiramer acetate 40mg/ml QL (12 syringes / 28 days)

5 QL PA

glatopa 20mg/ml QL (30 syringes / 30 days)

5 QL PA

glatopa 40mg/ml QL (12 syringes / 28 days)

5 QL PA

TYSABRI 5 LA PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 10mg, 20mg 2 M cyclobenzaprine hcl TABS 5mg, 10mg


4 M PA

dantrolene sodium CAPS 2 M tizanidine hcl TABS 2 M NARCOLEPSY/CATAPLEXY armodafinil 50mg

QL (150 tabs / 30 days) 2 QL M PA

armodafinil 150mg QL (60 tabs / 30 days)

2 QL M PA

armodafinil 200mg, 250mg QL (30 tabs / 30 days)

2 QL M PA

Drug Name Drug Tier

Requirements/Limits

XYREM QL (540 mL / 30 days)

5 QL LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2 M buprenorphine hcl SUBL 2 M PA buprenorphine hcl-naloxone hcl sl


2 QL M PA

bupropion hcl (smoking deterrent)

2 M

CHANTIX 4 M PA CHANTIX CONTINUING MONTH

4 M PA

CHANTIX STARTER PACK 4 M PA disulfiram TABS 2 M naloxone inj 0.4mg/ml 2 M naloxone inj 1mg/ml 2 M naltrexone hcl TABS 2 M NICOTROL INHALER 4 M NICOTROL NS 4 M SUBOXONE MIS 2-0.5MG

QL (120 SL films / 30 days)

4 QL M PA

SUBOXONE MIS 4-1MG QL (120 SL films / 30 days)

4 QL M PA


4 QL M PA


4 QL M PA

VIVITROL 5 ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 5 M PA ANDRODERM


4 QL M PA

ANDROGEL 1.62% QL (150 grams / 30 days)

3 QL M PA

ANDROGEL PUMP QL (150 grams / 30 days)

3 QL M PA

oxandrolone TABS 2 M PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

QL (300 gm / 30 days)

2 QL M PA


20

Drug Name Drug Tier

Requirements/Limits

testosterone cypionate SOLN

2 M PA

testosterone enanthate SOLN

2 M PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 3 M BASAGLAR KWIKPEN 3 M BYDUREON BCISE

QL (4 pens / 28 days) 3 QL M

BYDUREON INJ QL (4 vials / 28 days)

3 QL M

BYDUREON PEN QL (4 pens / 28 days)

3 QL M

BYETTA QL (1 pen / 30 days)

4 QL M

FIASP 3 M FIASP FLEXTOUCH 3 M GAUZE PADS 2" X 2" 3 M HUMULIN R INJ U-500 5 B/D M HUMULIN R U-500 KWIKPEN 5 M INSULIN PEN NEEDLE 3 M INSULIN SAFETY NEEDLES 3 M INSULIN SYRINGE 3 M LEVEMIR 3 M LEVEMIR FLEXTOUCH 3 M NOVOLIN 70/30

(brand RELION not covered)

3 M

NOVOLIN N (brand RELION not covered)

3 M

NOVOLIN R (brand RELION not covered)

3 M

NOVOLOG 3 M NOVOLOG 70/30 FLEXPEN 3 M NOVOLOG FLEXPEN 3 M NOVOLOG MIX 70/30 3 M NOVOLOG PENFILL 3 M OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

3 QL M

OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)

3 QL M

SOLIQUA 100/33 QL (10 pens / 30 days)

3 QL M

TRESIBA FLEXTOUCH 3 M TRULICITY

QL (4 pens / 28 days) 3 QL M

Drug Name Drug Tier

Requirements/Limits

VICTOZA QL (3 pens / 30 days)

3 QL M

XULTOPHY 100/3.6 QL (5 pens / 30 days)

3 QL M

ANTIDIABETICS, ORAL acarbose 2 M FARXIGA 5mg


FARXIGA 10mg QL (30 tabs / 30 days)

3 QL M

glimepiride 1mg QL (240 tabs / 30 days)

1 QL M


1 QL M


1 QL M

glip/metform tab 2.5-250mg QL (240 tabs / 30 days)

1 QL M

glip/metform tab 2.5-500mg QL (120 tabs / 30 days)

1 QL M

glip/metform tab 5-500mg QL (120 tabs / 30 days)

1 QL M

glipizide TABS 5mg QL (240 tabs / 30 days)

1 QL M

glipizide TABS 10mg QL (120 tabs / 30 days)

1 QL M

glipizide TB24 2.5mg QL (240 tabs / 30 days)

1 QL M

glipizide TB24 5mg QL (120 tabs / 30 days)

1 QL M

glipizide TB24 10mg QL (60 tabs / 30 days)

1 QL M

glipizide xl 2.5mg QL (240 tabs / 30 days)

1 QL M

glipizide xl 5mg QL (120 tabs / 30 days)

1 QL M

INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)

3 QL M

INVOKAMET TAB 50-1000MG


3 QL M



3 QL M



3 QL M

INVOKAMET XR TAB 50-500MG


3 QL M


21

Drug Name Drug Tier

Requirements/Limits



3 QL M



3 QL M



3 QL M

INVOKANA 100mg QL (90 tabs / 30 days)

3 QL M

INVOKANA 300mg QL (30 tabs / 30 days)

3 QL M

JANUMET QL (60 tabs / 30 days)

3 QL M

JANUMET XR TAB 50-500MG


3 QL M

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

3 QL M

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

3 QL M

JANUVIA QL (30 tabs / 30 days)

3 QL M

JENTADUETO QL (60 tabs / 30 days)

3 QL M

JENTADUETO TAB XR 2.5-1000 MG


3 QL M

JENTADUETO TAB XR 5-1000 MG


3 QL M

metformin er 500mg QL (120 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M

metformin er 750mg QL (60 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M

metformin hcl TABS 500mg QL (150 tabs / 30 days)

1 QL M


1 QL M


1 QL M

nateglinide QL (90 tabs / 30 days)

1 QL M

pioglitazone hcl QL (30 tabs / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits

repaglinide 2mg QL (240 tabs / 30 days)

1 QL M

repaglinide .5mg, 1mg QL (120 tabs / 30 days)

1 QL M

TRADJENTA QL (30 tabs / 30 days)

3 QL M

XIGDUO XR TAB 2.5-1000 MG


3 QL M

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

3 QL M


3 QL M


3 QL M


3 QL M

BISPHOSPHONATES alendronate sodium TABS 5mg, 10mg, 40mg

1 M

alendronate sodium TABS 35mg, 70mg


1 QL M

PAMIDRONATE DISODIUM 6mg/ml

3 B/D M

pamidronate disodium 30mg/10ml, 90mg/10ml

2 B/D M

pamidronate inj 30mg 2 B/D M pamidronate inj 90mg 2 B/D M zoledronic acid 5mg/100ml 2 B/D zoledronic inj 4mg/5ml 2 B/D CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg, 90mg

QL (120 tabs / 30 days) 5 B/D QL

SENSIPAR 60mg QL (60 tabs / 30 days)

5 B/D QL

CHELATING AGENTS CHEMET 4 M DEPEN TITRATABS 5 M JADENU 5 LA PA JADENU SPRINKLE 5 LA PA kionex sus 15gm/60ml 2 M sodium polystyrene sulfonate 2 M sps susp 15gm/60ml 2 M SYPRINE 5 M trientine hcl 5 M CONTRACEPTIVES altavera tab 2 M alyacen 1/35 2 M


22

Drug Name Drug Tier

Requirements/Limits

apri 2 M aranelle 2 M aubra 2 M aviane 2 M balziva 2 M bekyree 2 M blisovi fe 1.5/30 2 M blisovi fe 1/20 2 M briellyn 2 M camila 2 M caziant pak 2 M cryselle-28 2 M cyclafem 1/35 2 M cyclafem 7/7/7 2 M cyred tab 2 M dasetta 1/35 2 M dasetta 7/7/7 2 M deblitane 2 M delyla 2 M desogestrel & ethinyl estradiol 2 M desogestrel-ethinyl estradiol (biphasic)

2 M

drospirenone-ethinyl estradiol 2 M ELLA 4 M emoquette 2 M enpresse-28 2 M enskyce 2 M errin 2 M estarylla tab 0.25-35 2 M ethynodiol diacet & eth estrad 2 M ethynodiol tab 1-50 2 M falmina 2 M femynor 2 M gianvi 2 M gildagia 2 M heather 2 M introvale 2 M isibloom 2 M jolessa tab 0.15-0.03 mg 2 M jolivette 2 M juleber 2 M junel 1.5/30 2 M junel 1/20 2 M junel fe 1.5/30 2 M junel fe 1/20 2 M kariva 2 M kelnor 1/35 2 M kelnor 1/50 2 M kimidess 2 M

Drug Name Drug Tier

Requirements/Limits

kurvelo 2 M larin 1.5/30 2 M larin 1/20 2 M larin fe 1.5/30 2 M larin fe 1/20 2 M larissia tab 2 M leena 2 M lessina 2 M levonest 2 M levonor/ethi tab 2 M levonorgestrel & eth estradiol 2 M levonorgestrel-ethinyl estradiol (91-day)

2 M

levora 0.15/30-28 2 M loryna 2 M low-ogestrel 2 M lutera 2 M lyza 2 M marlissa 2 M medroxyprogesterone acetate (contraceptive)

2 M

microgestin 1.5/30 2 M microgestin 1/20 2 M microgestin fe 1.5/30 2 M microgestin fe 1/20 2 M mono-linyah tab 0.25-35 2 M mononessa 2 M myzilra 2 M necon 0.5/35-28 2 M necon 1/50-28 2 M necon 7/7/7 2 M nikki 2 M nora-be tab 2 M norethindrone (contraceptive) 2 M norethindrone acet & eth estra 2 M norgest/ethi tab 0.25/35 2 M norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

2 M

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

2 M

norlyroc 2 M nortrel 0.5/35 (28) 2 M nortrel 1/35 2 M nortrel 7/7/7 2 M NUVARING 4 M


23

Drug Name Drug Tier

Requirements/Limits

ocella tab 3-0.03mg 2 M orsythia 2 M philith 2 M pimtrea 2 M pirmella 1/35 2 M portia-28 2 M previfem 2 M quasense 2 M reclipsen 2 M setlakin tab 2 M sharobel 2 M sprintec 28 2 M sronyx 2 M syeda 2 M tarina fe 1/20 2 M tilia fe 2 M tri-legest fe 2 M tri-linyah 2 M tri-lo marzia 2 M tri-lo-estarylla 2 M tri-lo-sprintec 2 M tri-previfem 2 M tri-sprintec 2 M trinessa 2 M trinessa lo 2 M trivora-28 2 M velivet 2 M vestura 2 M vienva 2 M viorele 2 M vyfemla 2 M xulane 2 M zarah 2 M zenchent 2 M zovia 1/35e 2 M zovia 1/50e 2 M ENDOMETRIOSIS danazol CAPS 2 M SYNAREL 5 M ENZYME REPLACEMENTS ADAGEN 5 LA PA ALDURAZYME 5 LA PA CARBAGLU 5 LA PA CERDELGA 5 PA CEREZYME 5 LA PA CYSTADANE 5 LA CYSTAGON 4 LA PA FABRAZYME 5 LA PA KUVAN 5 LA PA

Drug Name Drug Tier

Requirements/Limits

levocarnitine (metabolic modifiers)

2 B/D M

LUMIZYME 5 LA PA NAGLAZYME 5 LA PA ORFADIN 5 LA PA sodium phenylbutyrate 5 PA ZAVESCA 5 LA PA ESTROGENS DELESTROGEN 10mg/ml 4 M estradiol PTWK; TABS


estradiol vaginal cream 2 M estradiol vaginal tab 2 M estradiol valerate OIL 2 M fyavolv tab 1-5mg


jinteli PA if 65 years and older

4 M PA

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg


4 M PA

yuvafem vaginal tablet 10 mcg

2 M

GLUCOCORTICOIDS cortisone acetate TABS 2 M DEXAMETHASONE CONC 4 M dexamethasone ELIX; SOLN 2 M dexamethasone TABS 1 M dexamethasone sodium phosphate

2 M

fludrocortisone acetate TABS

2 M

hydrocortisone TABS 2 M methylpr ace inj 40mg/ml 2 B/D M methylpr ace inj 80mg/ml 2 B/D M methylpr ss inj 1gm 2 B/D M methylpr ss inj 40mg 2 B/D M methylpr ss inj 125mg 2 B/D M methylpred pak 4mg 2 M methylpred tab 4mg 2 B/D M methylpred tab 8mg 2 B/D M methylpred tab 16mg 2 B/D M methylpred tab 32mg 2 B/D M pred sod pho sol 5mg/5ml 2 B/D M prednisolone sodium phosphate SOLN 15mg/5ml

2 B/D M

prednisolone sol 15mg/5ml 2 B/D M prednisolone sol 25mg/5ml 2 B/D M PREDNISONE CON 5MG/ML 4 B/D M


24

Drug Name Drug Tier

Requirements/Limits

prednisone pak 5mg 2 M prednisone pak 10mg 2 M prednisone sol 5mg/5ml 2 B/D M prednisone tab 1mg 1 B/D M prednisone tab 2.5mg 1 B/D M prednisone tab 5mg 1 B/D M prednisone tab 10mg 1 B/D M prednisone tab 20mg 1 B/D M prednisone tab 50mg 1 B/D M SOLU-CORTEF 250mg 4 M GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 3 M GLUCAGON EMERGENCY KIT

3 M

PROGLYCEM SUS 50MG/ML 4 M HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO 5 PA MISCELLANEOUS cabergoline 2 M calcitonin (salmon) 2 B/D M FORTEO 5 PA INCRELEX 5 LA PA KORLYM 5 LA PA LUPRON DEP-PED INJ 7.5MG

5 PA

LUPRON DEP-PED INJ 11.25MG

5 PA

LUPRON DEP-PED INJ 11.25MG (3-MONTH)

5 PA

LUPRON DEP-PED INJ 15MG

5 PA

LUPRON DEP-PED INJ 30MG (3-MONTH)

5 PA

MIACALCIN 5 B/D M NATPARA 5 PA octreotide acetate 50mcg/ml, 100mcg/ml, 200mcg/ml

2 PA

octreotide acetate 500mcg/ml, 1000mcg/ml

5 PA

PROLIA QL (1 injection / 180 days)

4 QL

raloxifene hcl 2 M SANDOSTATIN LAR DEPOT 5 PA SIGNIFOR 5 LA PA SOMATULINE DEPOT 5 PA SOMAVERT 5 LA PA XGEVA 5 PA PHOSPHATE BINDER AGENTS

Drug Name Drug Tier

Requirements/Limits

AURYXIA QL (360 tabs / 30 days)

5 QL M

calcium acetate (phosphate binder) CAPS


2 QL M

calcium acetate (phosphate binder) TABS


2 QL M

sevelamer carbonate PACK 2.4gm

QL (180 packs / 30 days)

2 QL M

sevelamer carbonate PACK .8gm

QL (540 packs / 30 days)

2 QL M

sevelamer carbonate TABS QL (540 tabs / 30 days)

2 QL M

PROGESTINS medroxyprogesterone acetate tab

1 M

norethindrone acetate TABS 2 M THYROID AGENTS levo-t 2 M levothyroxine sodium TABS 1 M levoxyl 2 M liothyronine sodium TABS 2 M methimazole TABS 1 M propylthiouracil TABS 2 M SYNTHROID 3 M unithroid 2 M VASOPRESSINS desmopressin acetate spray 2 M desmopressin acetate spray refrigerated

2 M

desmopressin acetate tabs 2 M desmopressin inj 4mcg/ml 2 M desmopressin sol 0.01% 2 M STIMATE 5 GASTROINTESTINAL ANTIEMETICS aprepitant 2 B/D M aprepitant pak 80mg & 125mg 2 B/D M compro 2 M dronabinol

QL (60 caps / 30 days) 2 B/D QL M

EMEND SUSR 4 B/D M granisetron hcl SOLN 2 M granisetron hcl TABS 2 B/D M


25

Drug Name Drug Tier

Requirements/Limits

meclizine hcl TABS 2 M metoclopramide hcl SOLN 2 M metoclopramide hcl TABS 1 M metoclopramide inj 2 M ondansetron hcl TABS 2 B/D M ondansetron hcl inj 2 M ondansetron hcl oral soln 2 B/D M ondansetron odt 2 B/D M prochlorperazine inj 2 M prochlorperazine maleate TABS

1 M

prochlorperazine supp 2 M promethazine hcl SOLN; SYRP; TABS


4 M PA

scopolamine patch QL (10 patches / 30 days)


4 QL M PA

ANTISPASMODICS dicyclomine hcl CAPS 1 M dicyclomine hcl SOLN 10mg/5ml

2 M

dicyclomine hcl TABS 1 M glycopyrrolate TABS 2 M glycopyrrolate inj 2 M H2-RECEPTOR ANTAGONISTS famotidine SUSR 2 M famotidine TABS 20mg, 40mg

1 M

famotidine inj 2 M ranitidine hcl TABS 1 M ranitidine hcl inj 2 M ranitidine syrup 2 M INFLAMMATORY BOWEL DISEASE APRISO 3 M balsalazide disodium 2 M budesonide ec 5 M CANASA 4 M colocort enema 100mg 2 M DELZICOL 4 M hydrocortisone (enema) 2 M mesalamine ENEM 2 M mesalamine TBEC 800mg 2 M mesalamine w/ cleanser 2 M sulfasalazine TABS 2 M sulfasalazine ec 2 M LAXATIVES constulose 2 M

Drug Name Drug Tier

Requirements/Limits

enulose 2 M gavilyte-c 2 M gavilyte-g 2 M gavilyte-n/flavor pack 2 M generlac 2 M GOLYTELY 3 M lactulose 2 M lactulose (encephalopathy) 2 M MOVIPREP 4 M NULYTELY/FLAVOR PACKS 3 M peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2 M

peg 3350-potassium chloride-sod bicarbonate-sod chloride

2 M

peg 3350/electrolytes 2 M polyethylene glycol 3350 PACK; POWD

2 M

SUPREP BOWEL PREP KIT 4 M trilyte 2 M MISCELLANEOUS alosetron hcl 5 M PA AMITIZA CAP 8MCG


AMITIZA CAP 24MCG QL (60 caps / 30 days)

3 QL M

cromolyn sodium (mastocytosis)

5 M

diphenoxylate w/ atropine 2 M GATTEX 5 LA PA LINZESS 72mcg, 290mcg


LINZESS 145mcg QL (60 caps / 30 days)

3 QL M

loperamide hcl CAPS 2 M misoprostol TABS 2 M MOVANTIK 12.5mg


MOVANTIK 25mg QL (30 tabs / 30 days)

3 QL M

RELISTOR SOLN 5 M PA sucralfate TABS 2 M ursodiol CAPS; TABS 2 M XIFAXAN 550mg 5 M PA PANCREATIC ENZYMES CREON 3 M ZENPEP 4 M PROTON PUMP INHIBITORS


26

Drug Name Drug Tier

Requirements/Limits

DEXILANT QL (30 caps / 30 days)

4 QL M

esomeprazole magnesium QL (30 caps / 30 days)

2 QL M

esomeprazole sodium inj 2 M omeprazole cap 10mg


omeprazole cap 20mg QL (60 caps / 30 days)

1 QL M

omeprazole cap 40mg QL (30 caps / 30 days)

1 QL M

pantoprazole sodium tbec QL (30 tabs / 30 days)

1 QL M

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl


dutasteride CAPS QL (30 caps / 30 days)

2 QL M

dutasteride-tamsulosin hcl QL (30 caps / 30 days)

2 QL M

finasteride TABS 5mg 1 M tamsulosin hcl 2 M MISCELLANEOUS bethanechol chloride TABS 2 M potassium citrate (alkalinizer) er tabs

2 M

URINARY ANTISPASMODICS MYRBETRIQ 25mg


MYRBETRIQ 50mg QL (30 tabs / 30 days)

4 QL M

oxybutynin chloride SYRP 1 M oxybutynin chloride TABS 2 M oxybutynin chloride TB24 5mg


2 QL M

oxybutynin chloride TB24 10mg, 15mg


2 QL M

tolterodine tartrate cap er QL (30 caps / 30 days)

2 QL M

tolterodine tartrate tabs 2 M TOVIAZ


trospium chloride TABS QL (60 tabs / 30 days)

2 QL M

VESICARE QL (30 tabs / 30 days)

4 QL M

VAGINAL ANTI-INFECTIVES

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate vaginal

2 M

metronidazole vaginal 2 M terconazole vaginal 2 M vandazole 2 M HEMATOLOGIC ANTICOAGULANTS COUMADIN 4 M ELIQUIS 3 M ELIQUIS STARTER PACK 3 M enoxaparin sodium 2 M fondaparinux sodium 2.5mg/0.5ml

2 M

fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

5 M

heparin sod (porcine) in d5w 3 M heparin sod inj 1000/ml 2 B/D M heparin sod inj 5000/ml 2 B/D M heparin sod inj 10000/ml 2 B/D M heparin sod inj 20000/ml 2 B/D M heparin sodium/d5w 3 M HEPARIN SODIUM/NACL 0.45%

3 M

jantoven 1 M PRADAXA 4 M warfarin sodium 1 M XARELTO 3 M XARELTO STARTER PACK 3 M HEMATOPOIETIC GROWTH FACTORS GRANIX 5 PA MOZOBIL 5 PA NEUPOGEN 5 PA PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 PA

PROCRIT 20000unit/ml, 40000unit/ml

5 PA

MISCELLANEOUS anagrelide hcl 2 M cilostazol 2 M CINRYZE

QL (20 vials / 30 days) 5 QL LA PA

ENDARI 5 LA PA FIRAZYR


5 QL PA

HAEGARDA 2000unit QL (30 vials / 30 days)

5 QL LA PA


27

Drug Name Drug Tier

Requirements/Limits

HAEGARDA 3000unit QL (20 vials / 30 days)

5 QL LA PA

pentoxifylline TBCR 2 M PROMACTA 12.5mg


PROMACTA 25mg QL (180 tabs / 30 days)

5 QL LA PA


5 QL LA PA


5 QL LA PA

tranexamic acid SOLN; TABS

2 M

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole 2 M BRILINTA 3 M clopidogrel bisulfate TABS 75mg

1 M

prasugrel hcl 2 M ZONTIVITY 4 M IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) HUMIRA INJ 10MG/0.2ML


5 QL PA

HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)

5 QL PA

HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)

5 QL PA

HUMIRA PEDIATRIC CROHNS DISEASE

5 PA

HUMIRA PEN 40mg/0.8ml QL (6 pens / 28 days)

5 QL PA

HUMIRA PEN-CROHNS DISEASE

5 PA

HUMIRA PEN-PSORIASIS 5 PA hydroxychloroquine sulfate 1 M leflunomide TABS 2 M methotrexate sodium tabs 2 M REMICADE 5 PA XATMEP 4 B/D M XELJANZ


XELJANZ XR QL (30 tabs / 30 days)

5 QL PA

IMMUNOGLOBULINS

Drug Name Drug Tier

Requirements/Limits

BIVIGAM 5 PA CARIMUNE NANOFILTERED 5 PA FLEBOGAMMA DIF 5 PA GAMASTAN S/D 3 B/D GAMMAGARD LIQUID 5 PA GAMMAGARD S/D 5 PA GAMMAKED 5 PA GAMMAPLEX 5 PA GAMMAPLEX 10GM/100ML 5 PA GAMUNEX-C 5 PA OCTAGAM 5 PA PRIVIGEN 5 PA IMMUNOMODULATORS ACTIMMUNE 5 LA PA ARCALYST 5 PA INTRON-A INJ 10MU 5 B/D INTRON-A INJ 18MU 5 B/D INTRON-A INJ 25MU 5 B/D INTRON-A INJ 50MU 5 B/D IMMUNOSUPPRESSANTS AZATHIOPRINE SOLR 4 B/D M azathioprine TABS 2 B/D M BENLYSTA 5 PA cyclosporine CAPS; SOLN 2 B/D M cyclosporine modified (for microemulsion)

2 B/D M

gengraf 2 B/D M mycophenolate mofetil CAPS; TABS

2 B/D M

mycophenolate mofetil SUSR

5 B/D M

mycophenolate sodium 2 B/D M NULOJIX 5 B/D M RAPAMUNE SOLN 5 B/D M SANDIMMUNE SOLN 100mg/ml

3 B/D M

sirolimus TABS 2mg 5 B/D M sirolimus TABS .5mg, 1mg 2 B/D M tacrolimus CAPS 2 B/D M ZORTRESS TAB 0.5MG 5 B/D M ZORTRESS TAB 0.25MG 5 B/D M ZORTRESS TAB 0.75MG 5 B/D M VACCINES ACTHIB 3 ADACEL 3 BCG VACCINE 3 BEXSERO 3 BOOSTRIX 3


28

Drug Name Drug Tier

Requirements/Limits

DAPTACEL 3 DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D GARDASIL 9 3 HAVRIX 3 HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 KINRIX 3 M-M-R II 3 MENACTRA 3 MENVEO 3 PEDIARIX 3 PEDVAX HIB 3 PENTACEL 3 PROQUAD 3 QUADRACEL 3 RABAVERT 3 RECOMBIVAX HB 3 B/D ROTARIX 3 ROTATEQ 3 SHINGRIX

QL (2 vials per lifetime) 3 QL

SYNAGIS 5 TENIVAC 3 B/D TETANUS/DIPHTHERIA TOXOID

3 B/D

TRUMENBA 3 TWINRIX INJ 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX

QL (1 vial per lifetime) 3 QL

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 2 M klor-con 10 2 M klor-con m10 2 M KLOR-CON M15 3 M klor-con m20 2 M klor-con pak 20meq 2 M klor-con spr cap 8meq 2 M

Drug Name Drug Tier

Requirements/Limits

klor-con spr cap 10meq 2 M MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3 M

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

3 M

MAGNESIUM SULFATE IN D5W

3 M

magnesium sulfate in dextrose

3 M

potassium chloride CPCR 2 M potassium chloride PACK 2 M potassium chloride SOLN 10%, 20%

2 M

potassium chloride TBCR 2 M potassium chloride microencapsulated crystals er

2 M

potassium chloride tab cr 10 meq

2 M

sodium chloride SOLN 2.5meq/ml

2 M

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

2 M

tpn electrolytes 4 B/D M IV NUTRITION AMINOSYN 4 B/D M AMINOSYN 7%/ELECTROLYTES

4 B/D M

aminosyn 8.5%/electrolyte 4 B/D M aminosyn ii 8.5%/electrol 4 B/D M AMINOSYN II INJ 8.5% 4 B/D M AMINOSYN II INJ 10% 4 B/D M AMINOSYN M 4 B/D M AMINOSYN-HBC 4 B/D M AMINOSYN-PF 7% 4 B/D M AMINOSYN-PF INJ 10% 4 B/D M AMINOSYN-RF 4 B/D M CLINIMIX 2.75%/DEXTROSE 5%

4 B/D M

CLINIMIX 4.25%/DEXTROSE 5%

4 B/D M

CLINIMIX 4.25%/DEXTROSE 25%

4 B/D M

CLINIMIX 5%/DEXTROSE 15%

4 B/D M


4 B/D M


29

Drug Name Drug Tier

Requirements/Limits


4 B/D M

CLINIMIX INJ 4.25/D10 4 B/D M CLINIMIX INJ 4.25/D20 4 B/D M FREAMINE HBC 6.9% 4 B/D M FREAMINE III 4 B/D M hepatamine 4 B/D M INTRALIPID 30% 4 B/D M intralipid inj 20% 4 B/D M NEPHRAMINE 4 B/D M nutrilipid inj 20% 4 B/D M premasol sol 6% 2 B/D M PREMASOL SOL 10% 4 B/D M PROCALAMINE 4 B/D M PROSOL 4 B/D M TRAVASOL 4 B/D M TROPHAMINE INJ 10% 4 B/D M IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% 2 M dextrose 5% 2 M DEXTROSE 5% /ELECTROLYTE

3 M

dextrose 5%/lactated ring 2 M dextrose 5%/nacl 0.2% 2 M DEXTROSE 5%/NACL 0.3% 4 M dextrose 5%/nacl 0.9% 2 M dextrose 5%/nacl 0.33% 2 M dextrose 5%/nacl 0.45% 2 M dextrose 5%/nacl 0.225% 2 M dextrose 5%/potassium chl 2 M dextrose 10% flex contain 2 M DEXTROSE 10%/NACL 0.2% 3 M dextrose 10%/nacl 0.45% 2 M dextrose 50% 2 M dextrose inj 70% 2 M IONOSOL-MB/DEXTROSE 5%

4 M

ISOLYTE P 4 M ISOLYTE S 4 M kcl0.15%/d5w/nacl0.2% 2 M KCL 0.3%/D5W/NACL 0.9% 4 M kcl 0.3%/d5w/nacl 0.45% 2 M kcl 0.15%/d5w/nacl 0.9% 2 M KCL 0.15%/D5W/NACL 0.225%

3 M

kcl 0.075%/d5w/nacl 0.45% 2 M kcl/d5w inj 0.3% 2 M kcl/d5w/nacl inj 0.22%/0.45% 2 M kcl/d5w/nacl inj .15/.33% 2 M

Drug Name Drug Tier

Requirements/Limits

kcl/d5w/nacl inj .15/.45% 2 M kcl/nacl inj 0.3-0.9 2 M kcl/nacl inj 0.15%-0.9% 2 M lactated ringer's inj 2 M NORMOSOL-M IN D5W 4 M NORMOSOL-R 4 M NORMOSOL-R IN D5W 4 M PLASMA-LYTE A 4 M PLASMA-LYTE-148 4 M pot chloride inj 2meq/ml 2 M potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

2 M

potassium chloride in nacl 2 M ringer's 2 M sodium chloride SOLN 3%, 5%

2 M

sodium chloride 0.45% 2 M sodium chloride inj 0.9% 2 M VITAMINS calcitriol CAPS 2 B/D M calcitriol inj 2 B/D M calcitriol oral soln 1 mcg/ml 2 B/D M paricalcitol CAPS 2 B/D M prenatal vitamin/folic acid > 0.8 mg (generic)

2 M

RAYALDEE 5 M OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 2 M BLEPHAMIDE OINT 4 M neomycin-polymy-dexameth 2 M neomycin-polymyxin-hc (ophth)

2 M

sulfacetamide sod-prednisolone

2 M

TOBRADEX OINT 3 M TOBRADEX ST 3 M tobramycin-dexamethasone 2 M ZYLET 3 M ANTI-INFECTIVES bacitracin (ophthalmic) 2 M bacitracin-polymyxin b (ophth) 2 M BESIVANCE 3 M CILOXAN OINT 3 M ciprofloxacin hcl (ophth) 1 M erythromycin (ophth) 1 M gatifloxacin (ophth) 2 M


30

Drug Name Drug Tier

Requirements/Limits

gentak 2 M gentamicin sulfate soln (ophth)

1 M

MOXEZA 3 M moxifloxacin hcl (ophth) 2 M NATACYN 4 M neomycin-bacitracin zn-polymyxin

2 M

neomycin-polymyxin-gramicidin

2 M

ofloxacin (ophth) 2 M polymyxin b-trimethoprim 1 M sulfacet sod oin 10% op 2 M sulfacetamide sodium (ophth) 2 M tobramycin (ophth) 1 M trifluridine SOLN 2 M ZIRGAN 4 M ANTI-INFLAMMATORIES ALREX 3 M bromfenac sodium (ophth) 2 M BROMSITE 4 M dexamethasone sodium phosphate (ophth)

2 M

diclofenac sodium (ophth) 2 M DUREZOL 3 M fluorometholone 2 M flurbiprofen sodium 2 M ILEVRO 3 M ketorolac tromethamine (ophth)

2 M

LOTEMAX 3 M prednisolone acetate (ophth) 2 M PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

3 M

PROLENSA 3 M ANTIALLERGICS azelastine drop 0.05% 2 M BEPREVE 3 M cromolyn sodium (ophth) 1 M LASTACAFT 4 M olopatadine hcl 0.2% 2 M PAZEO 3 M ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 3 M AZOPT 3 M betaxolol hcl (ophth) 2 M BETOPTIC-S 3 M brimonidine sol 0.2% 1 M brimonidine sol 0.15% 2 M

Drug Name Drug Tier

Requirements/Limits

carteolol hcl (ophth) 2 M COMBIGAN 3 M dorzolamide hcl 2 M dorzolamide hcl-timolol maleate

2 M

latanoprost SOLN 1 M levobunolol hcl 2 M LUMIGAN 3 M metipranolol 2 M PHOSPHOLINE IODIDE 4 M pilocarpine hcl SOLN 2 M SIMBRINZA 3 M timolol maleate (ophth) soln 1 M timolol maleate gel 2 M timolol maleate ophth soln 0.5% (once-daily)

2 M

TRAVATAN Z 3 M MISCELLANEOUS CYSTARAN 5 LA PA proparacaine hcl SOLN 2 M RESTASIS

QL (64 single use vials / 30 days)

3 QL M

RESTASIS MULTIDOSE QL (1 bottle / 30 days)

3 QL M

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA

QL (60 blisters / 30 days)

3 QL M

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

3 QL M

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

4 QL M

ipratropium-albuterol nebu 2 B/D M TRELEGY ELLIPTA

QL (60 blisters / 30 days)

3 QL M

ANTICHOLINERGICS ATROVENT HFA

QL (2 inhalers / 30 days) 4 QL M

INCRUSE ELLIPTA QL (30 blisters / 30 days)

3 QL M

ipratropium bromide SOLN 2 B/D M ipratropium bromide (nasal) 2 M ANTIHISTAMINES azelastine spr 0.1% 2 M


31

Drug Name Drug Tier

Requirements/Limits

azelastine spr 0.15% 2 M cetirizine syrup 1 M cyproheptadine hcl SYRP; TABS


4 M PA

diphenhydramine inj 2 M hydroxyzine hcl SOLN; SYRP; TABS


4 M PA

hydroxyzine pamoate CAPS 25mg, 50mg


4 M PA

levocetirizine dihydrochloride 2 M BETA AGONISTS albuterol sulfate NEBU 2 B/D M albuterol sulfate SYRP 1 M albuterol sulfate TABS; TB12

2 M

levalbuterol hcl NEBU 1.25mg/3ml

2 B/D M

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml

2 B/D M

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

2 QL M

SEREVENT DISKUS QL (60 inhalations / 30 days)

3 QL M

terbutaline sulfate TABS 2 M VENTOLIN HFA

QL (2 inhalers / 30 days) 3 QL M

LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS

2 M

zafirlukast 2 M MAST CELL STABILIZERS cromolyn sodium nebu 2 B/D M MISCELLANEOUS acetylcysteine SOLN 10%, 20%

2 B/D M

ARALAST NP 5 LA PA DALIRESP 4 M epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

(generic of Adrenaclick)

2 M

ESBRIET 5 PA KALYDECO 5 PA OFEV 5 PA ORKAMBI 5 PA PROLASTIN-C 5 LA PA

Drug Name Drug Tier

Requirements/Limits

PULMOZYME 5 PA XOLAIR 5 LA PA ZEMAIRA 5 LA PA NASAL STEROIDS flunisolide (nasal)

QL (3 bottles / 30 days) 2 QL M

fluticasone propionate (nasal) QL (1 bottle / 30 days)

2 QL M

STEROID INHALANTS ARNUITY ELLIPTA

QL (30 inhalations / 30 days)

3 QL M

budesonide (inhalation) .25mg/2ml, .5mg/2ml

2 B/D M

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


3 QL M

FLOVENT DISKUS 250mcg/blist


3 QL M

FLOVENT HFA QL (2 inhalers / 30 days)

3 QL M

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

3 QL M

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS


3 QL M

ADVAIR HFA QL (1 inhaler / 30 days)

3 QL M

BREO ELLIPTA QL (60 blisters / 30 days)

3 QL M

SYMBICORT QL (1 inhaler / 30 days)

3 QL M

XANTHINES aminophylline inj 2 M THEO-24 4 M theophylline 2 M TOPICAL DERMATOLOGY, ACNE amnesteem 2 M PA avita 2 M PA benzoyl peroxide-erythromycin

2 M

claravis 2 M PA


32

Drug Name Drug Tier

Requirements/Limits

clindacin-p 2 M clindamycin phosphate (topical) GEL; LOTN; SOLN; SWAB

2 M

ery pad 2% 2 M erythromycin (acne aid) 2 M isotretinoin CAPS 2 M PA myorisan 2 M PA sulfacetamide sodium (acne) 2 M tretinoin CREA 2 M PA tretinoin GEL .01%, .025% 2 M PA zenatane 2 M PA DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) 2 M mafenide acetate PACK 2 M mupirocin OINT 1 M silver sulfadiazine CREA 2 M ssd 2 M SULFAMYLON CREA 4 M SULFAMYLON PACK 5 M DERMATOLOGY, ANTIFUNGALS ciclopirox CREA; GEL; SUSP

2 M

ciclopirox shampoo 1% 2 M clotrimazole (topical) 2 M ketoconazole cream 2 M nyamyc 2 M nystatin (topical) 2 M nystatin pow 100000 2 M nystop 2 M DERMATOLOGY, ANTIPSORIATICS acitretin 5 M PA calcipotriene CREA; SOLN 2 M tazarotene CREA 2 M PA TAZORAC CREA .05% 4 M PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1 M selenium sulfide LOTN 1 M DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 M alclometasone dipropionate 2 M betamethasone dipropionate (topical)

2 M

betamethasone dipropionate augmented

2 M

betamethasone valerate CREA; LOTN; OINT

2 M

desoximetasone CREA; GEL; OINT

2 M

Drug Name Drug Tier

Requirements/Limits

fluocinolone acetonide CREA; OIL; OINT; SOLN

2 M

fluocinolone acetonide oil body

2 M

fluocinonide CREA .05% 2 M fluocinonide GEL 2 M fluocinonide SOLN 2 M fluocinonide emulsified base 2 M fluticasone propionate CREA; OINT

2 M

halobetasol propionate 2 M hydrocortisone (topical) CREA

1 M

hydrocortisone (topical) LOTN

2 M

hydrocortisone (topical) OINT 1%

2 M

hydrocortisone (topical) OINT 2.5%

1 M

hydrocortisone butyrate cream 0.1%

2 M

hydrocortisone butyrate oint 0.1%

2 M

hydrocortisone butyrate soln 0.1%

2 M

hydrocortisone valerate 2 M mometasone furoate CREA; OINT; SOLN

2 M

TEXACORT SOLN 2.5% 4 M triamcinolone acetonide (topical) CREA; OINT

1 M

triamcinolone acetonide (topical) LOTN

2 M

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) 2 QL M PA

lidocaine PTCH QL (3 patches / 1 day)

2 QL M PA

lidocaine hcl GEL QL (30 mL / 30 days)

2 QL M PA

lidocaine hcl SOLN 4% QL (50 mL / 30 days)

2 QL M PA

lidocaine oint 5% QL (50 gm / 30 days)

2 QL M PA

lidocaine-prilocaine QL (30 gm / 30 days)

2 QL M PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN

2 M


33

Drug Name Drug Tier

Requirements/Limits

diclofenac sodium (topical) 1% gel

2 M PA

doxepin hcl (antipruritic) 2 M fluorouracil (topical) CREA 5%

2 M

fluorouracil (topical) SOLN 2 M imiquimod CREA 2 M metronidazole (topical) CREA; LOTN

2 M

metronidazole gel 0.75% 2 M PANRETIN 5 M PICATO 3 M podofilox SOLN 2 M procto-med hc 2 M procto-pak 2 M proctosol hc cre 2.5% 2 M proctozone-hc 2 M rosadan 2 M tacrolimus (topical) 2 M TARGRETIN GEL 5 PA VALCHLOR 5 LA PA DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion 2 M permethrin cre 5% 2 M DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 2 M REGRANEX 5 M PA SANTYL 4 M sodium chlor sol 0.9% irr 2 M sterile water irrigation 2 M MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 2 M chlorhexidine gluconate (mouth-throat)

1 M

clotrimazole LOZG 2 M lidocaine hcl (mouth-throat) 1 M nystatin (mouth-throat) 2 M paroex sol 0.12% 1 M periogard 1 M pilocarpine hcl (oral) 2 M triamcinolone acetonide (mouth)

2 M

OTIC acetic acid (otic) 2 M CIPRODEX 3 M fluocinolone acetonide (otic) 2 M neomycin-polymyxin-hc (otic) 2 M ofloxacin (otic) 2 M

34

Index A abacavir sulfate ...................3 abacavir sulfate-lamivudine.4 abacavir sulfate-lamivudine-zidovudine ..........................................4 ABELCET............................3 ABILIFY MAINTENA ......... 15 ABRAXANE ........................7 acamprosate calcium ........ 19 acarbose ........................... 20 acebutolol hcl .................... 10 acetaminophen w/ codeine .1 acetazolamide ................... 11 acetic acid ......................... 33 acetic acid (otic) ................ 33 acetylcysteine ................... 31 acitretin ............................. 32 ACTHIB ............................. 27 ACTIMMUNE .................... 27 acyclovir ..............................4 acyclovir sodium .................4 ADACEL............................ 27 ADAGEN ........................... 23 ADCIRCA .......................... 11 adefovir dipivoxil .................5 ADEMPAS ........................ 11 adriamycin...........................6 adrucil .................................6 ADVAIR DISKUS .............. 31 ADVAIR HFA .................... 31 afeditab cr ......................... 10 AFINITOR ...........................7 AFINITOR DISPERZ ....... 7, 8 ala-cort .............................. 32 ALBENZA............................2 albuterol sulfate ................. 31 alclometasone dipropionate .......................................... 32 ALCOHOL SWABS ........... 20 ALDURAZYME ................. 23 ALECENSA .........................8 alendronate sodium .......... 21 alfuzosin hcl ...................... 26 ALIMTA ...............................6 ALINIA ................................2 allopurinol tab ......................1 alosetron hcl ...................... 25 ALPHAGAN P SOL 0.1% .. 30

alprazolam tab 0.25mg ..... 12 alprazolam tab 0.5mg ....... 12 alprazolam tab 1mg .......... 12 alprazolam tab 2mg .......... 12 ALREX .............................. 30 altavera tab ....................... 21 ALUNBRIG ......................... 8 alyacen 1/35 ..................... 21 amantadine hcl ................. 15 AMBISOME ........................ 3 amikacin sulfate .................. 2 amiloride & hydrochlorothiazide ........... 11 amiloride hcl ...................... 11 aminophylline inj ............... 31 AMINOSYN ....................... 28 AMINOSYN 7%/ELECTROLYTES ....... 28 aminosyn 8.5%/electrolyte 28 aminosyn ii 8.5%/electrol .. 28 AMINOSYN II INJ 10% ..... 28 AMINOSYN II INJ 8.5% .... 28 AMINOSYN M ................... 28 AMINOSYN-HBC .............. 28 AMINOSYN-PF 7% ........... 28 AMINOSYN-PF INJ 10% .. 28 AMINOSYN-RF ................. 28 amiodarone hcl ................... 9 AMITIZA CAP 24MCG ...... 25 AMITIZA CAP 8MCG ........ 25 amitriptyline hcl ................. 14 amlodipine besylate .......... 10 amlodipine besylate-olmesartan medoxomil .......................... 9 amlodipine besylate-valsartan tab 10-160 mg ........................... 9 amlodipine besylate-valsartan tab 10-320 mg ........................... 9 amlodipine besylate-valsartan tab 5-160 mg ....................................... 9 amlodipine besylate-valsartan tab 5-320 mg ....................................... 9 amlodipine--benazepril hcl cap 10-20 mg ...................... 9

amlodipine-benazepril hcl cap 10-40mg ....................... 9 amlodipine-benazepril hcl cap 2.5-10 mg ..................... 9 amlodipine-benazepril hcl cap 5-10 mg ........................ 9 amlodipine-benazepril hcl cap 5-20 mg ........................ 9 amlodipine-benazepril hcl cap 5-40 mg ........................ 9 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg............................................ 9 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg . 9 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg . 9 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg 9 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ... 9 ammonium lactate ............ 32 amnesteem ....................... 31 amoxapine tab 100mg ...... 14 amoxapine tab 150mg ...... 14 amoxapine tab 25mg ........ 14 amoxapine tab 50mg ........ 14 amoxicillin ........................... 6 amoxicillin & pot clavulanate............................................ 6 amphetamine-dextroamphetamine cap sr 24hr 10 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 15 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 20 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 25 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 30 mg .. 17 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 17 amphetamine-dextroamphetamine tab 10 mg ............... 17 amphetamine-dextroamphetamine tab 12.5 mg ............ 18 amphetamine-dextroamphetamine tab 15 mg ............... 18 amphetamine-dextroamphet

35

amine tab 20 mg ............... 18 amphetamine-dextroamphetamine tab 30 mg ............... 18 amphetamine-dextroamphetamine tab 5 mg ................. 17 amphetamine-dextroamphetamine tab 7.5 mg .............. 17 amphotericin b ....................3 ampicillin & sulbactam sodium ................................6 ampicillin cap 250mg ..........6 ampicillin cap 500mg ..........6 ampicillin inj .........................6 ampicillin sodium .................6 ampicillin susp .....................6 AMPYRA ........................... 19 ANADROL-50 ................... 19 anagrelide hcl .................... 26 anastrozole .........................7 ANDRODERM .................. 19 ANDROGEL 1.62% ........... 19 ANDROGEL PUMP .......... 19 ANORO ELLIPTA ............. 30 APOKYN ........................... 15 aprepitant .......................... 24 aprepitant pak 80mg & 125mg ............................... 24 apri .................................... 22 APRISO ............................ 25 APTIOM ............................ 12 APTIVUS.............................3 ARALAST NP .................... 31 aranelle ............................. 22 ARCALYST ....................... 27 aripiprazole odt ................. 15 aripiprazole oral solution 1 mg/ml ................................ 15 aripiprazole tab ................. 15 ARISTADA .................. 15, 16 armodafinil ........................ 19 ARNUITY ELLIPTA ........... 31 aspirin-dipyridamole .......... 27 atazanavir sulfate ................3 atenolol ............................. 10 atenolol & chlorthalidone ... 10 atomoxetine hcl ................. 18 atorvastatin calcium .......... 10 atovaquone .........................2 atovaquone-proguanil hcl ....3 ATRIPLA .............................4

ATROVENT HFA .............. 30 aubra................................. 22 AURYXIA .......................... 24 AUSTEDO ........................ 19 AVASTIN ............................ 7 aviane ............................... 22 avita .................................. 31 azacitidine ........................... 6 AZACTAM IN ISO-OSMOTIC DE .............. 2 AZACTAM/DEX INJ ............ 2 azathioprine ...................... 27 AZATHIOPRINE ............... 27 azelastine drop 0.05% ...... 30 azelastine spr 0.1% .......... 30 azelastine spr 0.15%......... 31 azithromycin ........................ 5 AZOPT .............................. 30 aztreonam ........................... 2 B bacitracin (ophthalmic) ...... 29 bacitracin-polymyxin b (ophth) .............................. 29 bacitracin-poly-neomycin-hc .......................................... 29 baclofen ............................ 19 balsalazide disodium......... 25 balziva ............................... 22 BANZEL SUS 40MG/ML ... 12 BANZEL TAB 200MG ....... 12 BANZEL TAB 400MG ....... 12 BARACLUDE ...................... 5 BASAGLAR KWIKPEN ..... 20 BCG VACCINE ................. 27 bekyree ............................. 22 BELEODAQ ........................ 7 benazepril & hydrochlorothiazide ............. 9 benazepril hcl ...................... 9 BENDEKA ........................... 6 BENLYSTA ....................... 27 benzoyl peroxide-erythromycin ...... 31 benztropine mesylate ........ 15 BEPREVE ......................... 30 BESIVANCE ..................... 29 betamethasone dipropionate (topical) ............................. 32 betamethasone dipropionate augmented ........................ 32

betamethasone valerate ... 32 BETASERON ................... 19 betaxolol hcl (ophth) ......... 30 bethanechol chloride ......... 26 BETOPTIC-S .................... 30 BEVESPI AEROSPHERE 30 bexarotene .......................... 8 BEXSERO ........................ 27 bicalutamide ....................... 7 BICILLIN L-A ...................... 6 BIKTARVY .......................... 4 BILTRICIDE ........................ 2 bisoprolol & hydrochlorothiazide ........... 10 bisoprolol fumarate ........... 10 BIVIGAM ........................... 27 bleomycin sulfate ................ 6 BLEPHAMIDE .................. 29 blisovi fe 1.5/30 ................. 22 blisovi fe 1/20 .................... 22 BOOSTRIX ....................... 27 BORTEZOMIB .................... 7 BOSULIF ............................ 8 BREO ELLIPTA ................ 31 briellyn .............................. 22 BRILINTA ......................... 27 brimonidine sol 0.15% ...... 30 brimonidine sol 0.2% ........ 30 BRIVIACT ......................... 12 bromfenac sodium (ophth) 30 bromocriptine mesylate ..... 15 BROMSITE ....................... 30 budesonide (inhalation) .... 31 budesonide ec .................. 25 bumetanide ....................... 11 buprenorphine hcl ............. 19 buprenorphine hcl-naloxone hcl sl ................................. 19 bupropion hcl .................... 14 bupropion hcl (smoking deterrent) .......................... 19 buspirone hcl .................... 12 busulfan .............................. 6 butorphanol tartrate ............ 1 BYDUREON BCISE .......... 20 BYDUREON INJ ............... 20 BYDUREON PEN ............. 20 BYETTA ............................ 20 BYSTOLIC ........................ 10

36

C cabergoline ....................... 24 CABOMETYX .....................8 calcipotriene ...................... 32 calcitonin (salmon) ............ 24 calcitriol ............................. 29 calcitriol inj ........................ 29 calcitriol oral soln 1 mcg/ml .......................................... 29 calcium acetate (phosphate binder) ............................... 24 CALQUENCE ......................8 camila ............................... 22 CANASA ........................... 25 CANCIDAS .........................3 CAPASTAT SULFATE ........4 CAPRELSA .........................8 captopril ..............................9 captopril & hydrochlorothiazide .............9 CARBAGLU ...................... 23 carbamazepine ................. 12 carbidopa/levodopa/entacapone .................................... 15 carbidopa-levodopa .......... 15 carboplatin ..........................8 CARIMUNE NANOFILTERED .............. 27 carteolol hcl (ophth) .......... 30 cartia xt cap 120/24hr ....... 10 cartia xt cap 180/24hr ....... 10 cartia xt cap 240/24hr ....... 10 cartia xt cap 300/24hr ....... 10 carvedilol ........................... 10 caspofungin acetate ............3 CASPOFUNGIN ACETATE 3 CAYSTON ...........................2 caziant pak ........................ 22 cefaclor ...............................5 CEFACLOR MONOHYDRATE ER ..........5 cefadroxil.............................5 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ..................5 cefazolin inj .........................5 cefazolin sodium .................5 CEFAZOLIN SODIUM 1 GM/50ML ............................5 cefdinir ................................5 cefepime hcl ........................5

cefixime ............................... 5 cefotaxime sodium .............. 5 cefoxitin sodium .................. 5 cefpodoxime proxetil ........... 5 cefprozil .............................. 5 ceftazidime .......................... 5 CEFTAZIDIME/DEXTROSE ............................................ 5 ceftriaxone sodium .............. 5 cefuroxime axetil ................. 5 cefuroxime sodium .............. 5 celecoxib ............................. 1 CELONTIN ........................ 12 cephalexin ........................... 5 CERDELGA ...................... 23 CEREZYME ...................... 23 cetirizine syrup .................. 31 cevimeline hcl ................... 33 CHANTIX .......................... 19 CHANTIX CONTINUING MONTH ............................. 19 CHANTIX STARTER PACK .......................................... 19 CHEMET ........................... 21 chlorhexidine gluconate (mouth-throat) ................... 33 chloroquine phosphate........ 3 chlorothiazide tabs ............ 11 chlorpromazine hcl ............ 16 CHLORPROMAZINE INJ .. 16 chlorthalidone ................... 11 cholestyramine .................. 10 cholestyramine light .......... 10 ciclopirox ........................... 32 ciclopirox shampoo 1% ..... 32 cilostazol ........................... 26 CILOXAN .......................... 29 CINRYZE .......................... 26 CIPRODEX ....................... 33 ciprofloxacin ........................ 5 ciprofloxacin hcl (ophth) .... 29 ciprofloxacin hcl tab ............ 5 ciprofloxacin in d5w ............ 6 ciprofloxacin inj ................... 6 cisplatin ............................... 8 citalopram hydrobromide .. 14 cladribine ............................ 6 claravis .............................. 31 clarithromycin ...................... 5 clarithromycin er ................. 5

clarithromycin for susp ........ 5 clindacin-p ........................ 32 clindamycin cap 300mg ...... 3 clindamycin cap 75mg ........ 2 clindamycin hcl cap 150 mg 3 clindamycin phosphate (topical) ............................. 32 clindamycin phosphate in d5w ..................................... 3 CLINDAMYCIN PHOSPHATE IN NACL ...... 3 clindamycin phosphate inj ... 3 clindamycin phosphate vaginal .............................. 26 clindamycin soln 75mg/5ml . 3 CLINIMIX 2.75%/DEXTROSE 5% ..... 28 CLINIMIX 4.25%/DEXTROSE 25% ... 28 CLINIMIX 4.25%/DEXTROSE 5% ..... 28 CLINIMIX 5%/DEXTROSE 15% .................................. 28 CLINIMIX 5%/DEXTROSE 20% .................................. 28 CLINIMIX 5%/DEXTROSE 25% .................................. 29 CLINIMIX INJ 4.25/D10 .... 29 CLINIMIX INJ 4.25/D20 .... 29 clomipramine hcl ............... 14 clonazepam ...................... 12 clonidine hcl ...................... 11 clopidogrel bisulfate .......... 27 clorazepate dipotassium ... 12 clotrimazole ...................... 33 clotrimazole (topical) ......... 32 clozapine odt .................... 16 clozapine tab 100mg ......... 16 clozapine tab 200mg ......... 16 clozapine tab 25mg ........... 16 clozapine tab 50mg ........... 16 COARTEM .......................... 3 colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 colestipol hcl gran ............. 10 colestipol hcl pack............. 10 colestipol hcl tabs ............. 10 colistimethate sodium ......... 3 colocort enema 100mg ..... 25 COMBIGAN ...................... 30

37

COMBIVENT RESPIMAT . 30 COMETRIQ .........................8 COMPLERA ........................4 compro .............................. 24 constulose ......................... 25 CORLANOR ...................... 11 cortisone acetate ............... 23 COTELLIC ..........................8 COUMADIN ...................... 26 CREON ............................. 25 CRIXIVAN ...........................3 cromolyn sodium (mastocytosis) ................... 25 cromolyn sodium (ophth) .. 30 cromolyn sodium nebu ...... 31 cryselle-28......................... 22 cyclafem 1/35 .................... 22 cyclafem 7/7/7 ................... 22 cyclobenzaprine hcl .......... 19 cyclophosphamide ..............6 CYCLOPHOSPHAMIDE .....6 cycloserine ..........................4 cyclosporine ...................... 27 cyclosporine modified (for microemulsion) .................. 27 cyproheptadine hcl ............ 31 cyred tab ........................... 22 CYSTADANE .................... 23 CYSTAGON ...................... 23 CYSTARAN ...................... 30 cytarabine ...........................6 D dacarbazine ........................6 DAKLINZA ..........................5 DALIRESP ........................ 31 danazol ............................. 23 dantrolene sodium ............ 19 dapsone ..............................3 DAPTACEL ....................... 28 daptomycin ..........................3 dasetta 1/35 ...................... 22 dasetta 7/7/7 ..................... 22 deblitane ........................... 22 DELESTROGEN ............... 23 delyla ................................ 22 DELZICOL ........................ 25 DEMSER........................... 11 DEPEN TITRATABS ......... 21 DEPO-PROVERA INJ 400/ML ................................7

DESCOVY .......................... 4 desipramine hcl ................. 14 desmopressin acetate spray .......................................... 24 desmopressin acetate spray refrigerated ....................... 24 desmopressin acetate tabs .......................................... 24 desmopressin inj 4mcg/ml 24 desmopressin sol 0.01% ... 24 desogestrel & ethinyl estradiol ............................ 22 desogestrel-ethinyl estradiol (biphasic) .......................... 22 desoximetasone ................ 32 desvenlafaxine succinate .. 14 dexamethasone ................ 23 DEXAMETHASONE ......... 23 dexamethasone sodium phosphate ......................... 23 dexamethasone sodium phosphate (ophth) ............. 30 DEXILANT ........................ 26 dexrazoxane ....................... 8 dextrose 10% flex contain . 29 DEXTROSE 10%/NACL 0.2%.................................. 29 dextrose 10%/nacl 0.45% . 29 dextrose 2.5%/nacl 0.45% 29 dextrose 5% ...................... 29 DEXTROSE 5% /ELECTROLYTE ............... 29 dextrose 5%/lactated ring . 29 dextrose 5%/nacl 0.2% ..... 29 dextrose 5%/nacl 0.225% . 29 DEXTROSE 5%/NACL 0.3% .......................................... 29 dextrose 5%/nacl 0.33% ... 29 dextrose 5%/nacl 0.45% ... 29 dextrose 5%/nacl 0.9% ..... 29 dextrose 5%/potassium chl .......................................... 29 dextrose 50% .................... 29 dextrose inj 70% ............... 29 DIASTAT ACUDIAL .......... 12 DIASTAT PEDIATRIC....... 12 diazepam .......................... 12 diazepam gel .................... 12 diazepam intensol ............. 12 diclofenac potassium .......... 1

diclofenac sodium ............... 1 diclofenac sodium (ophth) . 30 diclofenac sodium (topical) 1% gel ............................... 33 dicloxacillin sodium ............. 6 dicyclomine hcl ................. 25 didanosine .......................... 3 DIFICID ............................... 5 diflunisal .............................. 1 digitek ............................... 11 digox ................................. 11 digoxin .............................. 11 digoxin inj .......................... 11 digoxin sol 50mcg/ml ........ 11 dihydroergotamine mesylate 1mg/ml .............................. 18 dihydroergotamine mesylate nasal ................................. 18 DILANTIN ......................... 12 DILANTIN-125 SUS 125/5ML ............................ 12 diltiazem cap 120mg cd .... 10 diltiazem cap 180mg cd .... 10 diltiazem cap 240mg cd .... 10 diltiazem cap 300mg cd .... 10 diltiazem cap 360mg cd .... 10 diltiazem cap er/12hr ........ 10 diltiazem hcl ...................... 11 diltiazem hcl cap sr 24hr ... 11 diltiazem hcl coated beads cap sr 24hr ........................ 11 diltiazem hcl extended release beads cap sr ........ 11 diltiazem inj ....................... 11 dilt-xr cap .......................... 10 diphenhydramine inj .......... 31 diphenoxylate w/ atropine . 25 DIPHTHERIA/TETANUS TOXOID ............................ 28 disopyramide phosphate ..... 9 disulfiram .......................... 19 divalproex sodium ............. 12 docetaxel ............................ 7 DOCETAXEL ...................... 7 dofetilide ............................. 9 donepezil hydrochloride .... 13 dorzolamide hcl................. 30 dorzolamide hcl-timolol maleate ............................. 30 doxazosin mesylate ............ 9

38

doxepin hcl ........................ 14 doxepin hcl (antipruritic) .... 33 doxorubicin hcl ....................6 doxorubicin hcl liposomal inj 2mg/ml ................................6 doxorubicin hcl soln 2mg/ml 6 doxy 100 .............................6 doxycycline (monohydrate) .6 doxycycline hyclate .............6 dronabinol ......................... 24 drospirenone-ethinyl estradiol ............................ 22 DROXIA ..............................8 duloxetine hcl .................... 14 DUREZOL ......................... 30 dutasteride ........................ 26 dutasteride-tamsulosin hcl 26 E e.e.s 400 .............................5 EDURANT ...........................3 efavirenz ......................... 3, 4 eletriptan hydrobromide .... 18 ELIQUIS ............................ 26 ELIQUIS STARTER PACK .......................................... 26 ELITEK ...............................8 ELLA ................................. 22 EMCYT ...............................6 EMEND ............................. 24 emoquette ......................... 22 EMSAM ............................. 14 EMTRIVA ............................4 EMVERM ............................3 enalapril maleate .................9 enalapril maleate & hydrochlorothiazide .............9 ENDARI ............................ 26 endocet ...............................1 ENGERIX-B ...................... 28 enoxaparin sodium ............ 26 enpresse-28 ...................... 22 enskyce ............................. 22 entacapone ....................... 15 entecavir .............................5 ENTRESTO ........................9 enulose ............................. 25 EPCLUSA ...........................5 epinephrine (anaphylaxis) . 31 epirubicin hcl .......................6 epitol ................................. 12

EPIVIR HBV ........................ 5 eplerenone .......................... 9 ergotamine w/ caffeine ...... 18 ERIVEDGE ......................... 7 ERLEADA ........................... 7 errin................................... 22 ery pad 2% ........................ 32 ery-tab ................................. 5 ERYTHROCIN LACTOBIONATE ................ 5 erythrocin stearate .............. 5 erythromycin (acne aid) .... 32 erythromycin (ophth) ......... 29 erythromycin base .............. 5 erythromycin cap 250mg ec 5 erythromycin ethylsuccinate 5 ESBRIET .......................... 31 escitalopram oxalate ......... 14 esomeprazole magnesium 26 esomeprazole sodium inj .. 26 estarylla tab 0.25-35 ......... 22 estradiol ............................ 23 estradiol vaginal cream ..... 23 estradiol vaginal tab .......... 23 estradiol valerate .............. 23 ethambutol hcl .................... 4 ethosuximide ..................... 12 ethynodiol diacet & eth estrad ................................ 22 ethynodiol tab 1-50 ........... 22 etodolac .............................. 1 etodolac er .......................... 1 etoposide ............................ 8 EVOTAZ ............................. 4 exemestane ........................ 7 ezetimibe .......................... 10 F FABRAZYME .................... 23 falmina .............................. 22 famciclovir ........................... 5 famotidine ......................... 25 famotidine inj ..................... 25 FANAPT ............................ 16 FANAPT TITRATION PACK .......................................... 16 FARESTON ........................ 7 FARXIGA .......................... 20 FARYDAK ........................... 7 FASLODEX ......................... 7 felbamate .......................... 12

felodipine .......................... 11 femynor ............................. 22 fenofibrate ......................... 10 fenofibrate micronized ...... 10 fentanyl citrate .................... 1 fentanyl patch 100 mcg/hr .. 1 fentanyl patch 12 mcg/hr .... 1 fentanyl patch 25 mcg/hr .... 1 fentanyl patch 50 mcg/hr .... 1 fentanyl patch 75 mcg/hr .... 1 FENTORA .......................... 1 FETZIMA .......................... 14 FETZIMA TITRATION PACK.......................................... 14 FIASP ............................... 20 FIASP FLEXTOUCH ......... 20 finasteride ......................... 26 FIRAZYR .......................... 26 FLEBOGAMMA DIF .......... 27 flecainide acetate ................ 9 FLOVENT DISKUS ........... 31 FLOVENT HFA ................. 31 fluconazole ......................... 3 fluconazole in dextrose ....... 3 FLUCONAZOLE INJ NACL 100 ...................................... 3 fluconazole inj nacl 200 ...... 3 fluconazole inj nacl 400 ...... 3 flucytosine ........................... 3 fludarabine phosphate ........ 6 fludrocortisone acetate ..... 23 flunisolide (nasal) .............. 31 fluocinolone acetonide ...... 32 fluocinolone acetonide (otic).......................................... 33 fluocinolone acetonide oil body .................................. 32 fluocinonide ...................... 32 fluocinonide emulsified base.......................................... 32 fluorometholone ................ 30 fluorouracil .......................... 6 fluorouracil (topical) .......... 33 fluoxetine cap 10mg .......... 14 fluoxetine cap 20mg .......... 14 fluoxetine cap 40mg .......... 14 fluoxetine hcl ..................... 14 fluphenazine decanoate .... 16 fluphenazine hcl ................ 16 flurbiprofen .......................... 1

39

flurbiprofen sodium ........... 30 flutamide .............................7 fluticasone propionate ....... 32 fluticasone propionate (nasal) ............................... 31 fluvoxamine maleate ......... 12 fondaparinux sodium ......... 26 FORTEO ........................... 24 fosamprenavir tab 700 mg ..4 fosinopril sodium .................9 fosinopril sodium & hydrochlorothiazide .............9 FREAMINE HBC 6.9% ...... 29 FREAMINE III ................... 29 furosemide ........................ 11 furosemide inj .................... 11 FUZEON .............................4 fyavolv tab 1-5mg .............. 23 FYCOMPA .................. 12, 13 G gabapentin ........................ 13 GABITRIL.......................... 13 galantamine hydrobromide 13 galantamine hydrobromide er ................................. 13, 14 GAMASTAN S/D ............... 27 GAMMAGARD LIQUID ..... 27 GAMMAGARD S/D ........... 27 GAMMAKED ..................... 27 GAMMAPLEX ................... 27 GAMMAPLEX 10GM/100ML .......................................... 27 GAMUNEX-C .................... 27 ganciclovir inj 500mg ..........5 GANCICLOVIR INJ 500MG/10ML ......................5 GARDASIL 9 ..................... 28 gatifloxacin (ophth) ............ 29 GATTEX............................ 25 GAUZE PADS 2 ................ 20 gavilyte-c ........................... 25 gavilyte-g........................... 25 gavilyte-n/flavor pack ........ 25 gemcitabine inj soln ............6 gemcitabine inj solr .............6 gemfibrozil......................... 10 generlac ............................ 25 gengraf .............................. 27 gentak ............................... 30 gentamicin in saline ............2

gentamicin sulfate ............... 2 gentamicin sulfate (topical) .......................................... 32 gentamicin sulfate soln (ophth) .............................. 30 GENVOYA .......................... 4 GEODON .......................... 16 gianvi ................................ 22 gildagia ............................. 22 GILENYA CAP 0.5MG ...... 19 GILOTRIF TAB 20MG......... 8 GILOTRIF TAB 30MG......... 8 GILOTRIF TAB 40MG......... 8 glatiramer acetate 20mg/ml .......................................... 19 glatiramer acetate 40mg/ml .......................................... 19 glatopa .............................. 19 GLEOSTINE ....................... 6 glimepiride ........................ 20 glip/metform tab 2.5-250mg .......................................... 20 glip/metform tab 2.5-500mg .......................................... 20 glip/metform tab 5-500mg . 20 glipizide ............................. 20 glipizide xl ......................... 20 GLUCAGEN HYPOKIT ..... 24 GLUCAGON EMERGENCY KIT .................................... 24 glycopyrrolate ................... 25 glycopyrrolate inj ............... 25 glydo ................................. 32 GOLYTELY ....................... 25 granisetron hcl .................. 24 GRANIX ............................ 26 griseofulvin microsize.......... 3 griseofulvin ultramicrosize ... 3 guanfacine er (adhd) ......... 18 H HAEGARDA ................ 26, 27 halobetasol propionate...... 32 haloperidol ........................ 16 haloperidol conc 2mg/ml ... 16 haloperidol decanoate....... 16 haloperidol inj 5mg/ml ....... 16 haloperidol lactate inj 5 mg/ml ................................ 16 HARVONI ........................... 5 HAVRIX ............................ 28

heather ............................. 22 heparin sod (porcine) in d5w.......................................... 26 heparin sod inj 1000/ml ..... 26 heparin sod inj 10000/ml ... 26 heparin sod inj 20000/ml ... 26 heparin sod inj 5000/ml ..... 26 heparin sodium/d5w .......... 26 HEPARIN SODIUM/NACL 0.45% ............................... 26 hepatamine ....................... 29 HERCEPTIN ....................... 7 HETLIOZ .......................... 18 HEXALEN ........................... 6 HIBERIX ........................... 28 HUMIRA INJ 10MG/0.2ML 27 HUMIRA KIT 20MG/0.4ML 27 HUMIRA KIT 40MG/0.8ML 27 HUMIRA PEDIATRIC CROHNS DISEASE .......... 27 HUMIRA PEN ................... 27 HUMIRA PEN-CROHNS DISEASE .......................... 27 HUMIRA PEN-PSORIASIS.......................................... 27 HUMULIN R INJ U-500 ..... 20 HUMULIN R U-500 KWIKPEN ......................... 20 hydralazine hcl .................. 11 hydrochlorothiazide ........... 11 hydroco/apap tab 10-325mg............................................ 1 hydroco/apap tab 5-325mg . 1 hydroco/apap tab 7.5-325 ... 1 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 1 hydrocodone-ibuprofen tab 7.5-200 mg ......................... 1 hydrocortisone .................. 23 hydrocortisone (enema) .... 25 hydrocortisone (topical) .... 32 hydrocortisone butyrate cream 0.1% ...................... 32 hydrocortisone butyrate oint 0.1% ................................. 32 hydrocortisone butyrate soln 0.1% ................................. 32 hydrocortisone valerate .... 32 hydromorphone hcl ............. 1 hydroxychloroquine sulfate

40

.......................................... 27 hydroxyprogesterone caproate (antineoplastic) .....7 hydroxyurea ........................8 hydroxyzine hcl ................. 31 hydroxyzine pamoate ........ 31 HYSINGLA ER ....................2 I IBRANCE ............................7 ibu tabs 600mg ...................1 ibu tabs 800mg ...................1 ibuprofen .............................1 ICLUSIG..............................8 IDHIFA ................................7 IFEX INJ 3GM .....................6 ifosfamide inj 1gm ...............6 ifosfamide inj 1gm/20ml ......6 IFOSFAMIDE INJ 3GM .......6 ifosfamide inj 3gm/60ml ......6 ILEVRO ............................. 30 imatinib mesylate ................8 IMBRUVICA ........................8 imipenem-cilastatin .............3 imipramine hcl ................... 14 imiquimod.......................... 33 IMOVAX RABIES (H.D.C.V.) .......................................... 28 INCRELEX ........................ 24 INCRUSE ELLIPTA .......... 30 indapamide ....................... 11 INFANRIX ......................... 28 INLYTA ...............................8 INSULIN PEN NEEDLE .... 20 INSULIN SAFETY NEEDLES ......................... 20 INSULIN SYRINGE ........... 20 INTELENCE ........................4 INTRALIPID 30% .............. 29 intralipid inj 20% ................ 29 INTRON-A INJ 10MU ........ 27 INTRON-A INJ 18MU ........ 27 INTRON-A INJ 25MU ........ 27 INTRON-A INJ 50MU ........ 27 introvale ............................ 22 INVANZ ...............................3 INVEGA SUST INJ 117 MG/0.75 ML ...................... 16 INVEGA SUST INJ 156MG/ML ........................ 16 INVEGA SUST INJ 234

MG/1.5 ML ........................ 16 INVEGA SUST INJ 39 MG/0.25 ML ...................... 16 INVEGA SUST INJ 78 MG/0.5 ML ........................ 16 INVEGA TRINZA .............. 16 INVIRASE ........................... 4 INVOKAMET TAB 150-1000MG ..................... 20 INVOKAMET TAB 150-500MG ....................... 20 INVOKAMET TAB 50-1000MG ....................... 20 INVOKAMET TAB 50-500MG ......................... 20 INVOKAMET XR TAB 150-1000MG ..................... 21 INVOKAMET XR TAB 150-500MG ....................... 21 INVOKAMET XR TAB 50-1000MG ....................... 21 INVOKAMET XR TAB 50-500MG ......................... 20 INVOKANA ....................... 21 IONOSOL-MB/DEXTROSE 5% .................................... 29 IPOL INACTIVATED IPV .. 28 ipratropium bromide .......... 30 ipratropium bromide (nasal) .......................................... 30 ipratropium-albuterol nebu 30 irbesartan ............................ 9 irbesartan-hydrochlorothiazide .......................................... 9 IRESSA ............................... 8 irinotecan hcl ....................... 8 ISENTRESS ....................... 4 ISENTRESS HD ................. 4 isibloom ............................. 22 ISOLYTE P ....................... 29 ISOLYTE S ....................... 29 isoniazid .............................. 4 isoniazid inj 100 mg/ml........ 4 isoniazid syp 50mg/5ml ....... 4 isosorb mononitrate tab .... 11 isosorbide dinitrate ............ 11 isosorbide dinitrate er........ 11 isosorbide mononitrate er . 11 isotretinoin ........................ 32 isradipine .......................... 11

itraconazole ........................ 3 ivermectin ........................... 3 IXIARO ............................. 28 J JADENU ........................... 21 JADENU SPRINKLE ......... 21 JAKAFI ............................... 8 jantoven ............................ 26 JANUMET ......................... 21 JANUMET XR TAB 100-1000 .......................... 21 JANUMET XR TAB 50-1000.......................................... 21 JANUMET XR TAB 50-500MG ......................... 21 JANUVIA .......................... 21 JENTADUETO .................. 21 JENTADUETO TAB XR 2.5-1000 MG ..................... 21 JENTADUETO TAB XR 5-1000 MG ........................ 21 jinteli ................................. 23 jolessa tab 0.15-0.03 mg .. 22 jolivette ............................. 22 juleber ............................... 22 JULUCA .............................. 4 junel 1.5/30 ....................... 22 junel 1/20 .......................... 22 junel fe 1.5/30 ................... 22 junel fe 1/20 ...................... 22 JUXTAPID ........................ 10 K KADCYLA ........................... 7 KALETRA TAB 100-25MG . 4 KALETRA TAB 200-50MG . 4 KALYDECO ...................... 31 kariva ................................ 22 kcl 0.075%/d5w/nacl 0.45%.......................................... 29 KCL 0.15%/D5W/NACL 0.225% ............................. 29 kcl 0.15%/d5w/nacl 0.9% .. 29 kcl 0.3%/d5w/nacl 0.45% .. 29 KCL 0.3%/D5W/NACL 0.9%.......................................... 29 kcl/d5w inj 0.3% ................ 29 kcl/d5w/nacl inj .15/.33% .. 29 kcl/d5w/nacl inj .15/.45% .. 29 kcl/d5w/nacl inj 0.22%/0.45%.......................................... 29

41

kcl/nacl inj 0.15%-0.9% ..... 29 kcl/nacl inj 0.3-0.9 ............. 29 kcl0.15%/d5w/nacl0.2% .... 29 kelnor 1/35 ........................ 22 kelnor 1/50 ........................ 22 ketoconazole .......................3 ketoconazole cream .......... 32 ketoconazole shampoo ..... 32 ketoprofen ...........................1 ketorolac tromethamine (ophth) .............................. 30 KEYTRUDA ........................7 kimidess ............................ 22 KINRIX .............................. 28 kionex sus 15gm/60ml ...... 21 KISQALI ..............................7 KISQALI FEMARA 200 DOSE ..................................7 KISQALI FEMARA 400 DOSE ..................................7 KISQALI FEMARA 600 DOSE ..................................7 klor-con 10 ........................ 28 klor-con 8 .......................... 28 klor-con m10 ..................... 28 KLOR-CON M15 ............... 28 klor-con m20 ..................... 28 klor-con pak 20meq .......... 28 klor-con spr cap 10meq .... 28 klor-con spr cap 8meq ...... 28 KORLYM ........................... 24 kurvelo .............................. 22 KUVAN ............................. 23 KYNAMRO ........................ 10 L labetalol hcl ....................... 10 lactated ringer's inj ............ 29 lactulose ............................ 25 lactulose (encephalopathy) .......................................... 25 lamivudine ...........................4 lamivudine (hbv) ..................5 lamivudine-zidovudine ........4 lamotrigine ........................ 13 larin 1.5/30 ........................ 22 larin 1/20 ........................... 22 larin fe 1.5/30 .................... 22 larin fe 1/20 ....................... 22 larissia tab ......................... 22 LASTACAFT ..................... 30

latanoprost ........................ 30 LATUDA ............................ 16 leena ................................. 22 leflunomide ....................... 27 LENVIMA 10 MG DAILY DOSE .................................. 8 LENVIMA 14 MG DAILY DOSE .................................. 8 LENVIMA 18 MG DAILY DOSE .................................. 8 LENVIMA 20 MG DAILY DOSE .................................. 8 LENVIMA 24 MG DAILY DOSE .................................. 8 LENVIMA 8 MG DAILY DOSE .................................. 8 lessina ............................... 22 LETAIRIS .......................... 11 letrozole .............................. 7 leucovorin calcium .............. 8 LEUKERAN ........................ 6 leuprolide inj 1mg/0.2 .......... 7 levalbuterol hcl .................. 31 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .......... 31 levalbuterol tartrate hfa ..... 31 LEVEMIR .......................... 20 LEVEMIR FLEXTOUCH ... 20 levetiracetam .................... 13 levetiracetam in sodium chloride ............................. 13 levetiracetam oral soln 100 mg/ml ................................ 13 levobunolol hcl .................. 30 levocarnitine (metabolic modifiers) .......................... 23 levocetirizine dihydrochloride .......................................... 31 levofloxacin ......................... 6 levofloxacin in d5w .............. 6 levofloxacin inj 25mg/ml ...... 6 levofloxacin oral soln 25 mg/ml .................................. 6 levoleucovorin calcium ........ 8 LEVOLEUCOVORIN CALCIUM ............................ 8 LEVOLEUCOVORIN CALCIUM 175MG ............... 8 levoleucovorin calcium 50mg ............................................ 8

levonest ............................ 22 levonor/ethi tab ................. 22 levonorgestrel & eth estradiol.......................................... 22 levonorgestrel-ethinyl estradiol (91-day) .............. 22 levora 0.15/30-28 .............. 22 levo-t ................................. 24 levothyroxine sodium ........ 24 levoxyl ............................... 24 LEXIVA ............................... 4 lidocaine ........................... 32 lidocaine hcl ...................... 32 lidocaine hcl (mouth-throat).......................................... 33 lidocaine inj 0.5% ................ 2 lidocaine inj 0.5% preservative free (pf) ........... 2 lidocaine inj 1% ................... 2 lidocaine inj 1% preservative free (pf) ............................... 2 lidocaine inj 1.5% preservative free (pf) ........... 2 lidocaine inj 2% ................... 2 lidocaine oint 5%............... 32 lidocaine-prilocaine ........... 32 linezolid ............................... 3 linezolid in sodium chloride . 3 LINZESS ........................... 25 liothyronine sodium ........... 24 lisinopril ............................... 9 lisinopril & hydrochlorothiazide ............. 9 lithium carbonate .............. 19 lithium carbonate er .......... 19 LITHIUM SOLN 8MEQ/5ML.......................................... 19 LONSURF .......................... 8 loperamide hcl .................. 25 lopinavir-ritonavir ................ 4 lorazepam ......................... 12 lorazepam intensol ............ 12 lorcet hd tab 10-325mg ....... 2 lorcet plus tab 7.5-325 ........ 2 loryna ................................ 22 losartan potassium .............. 9 losartan-hydrochlorothiazide............................................ 9 LOTEMAX ........................ 30 lovastatin .......................... 10

42

low-ogestrel ....................... 22 loxapine succinate ............ 16 LUMIGAN.......................... 30 LUMIZYME ....................... 23 LUPRON DEPOT (1-MONTH) .........................7 LUPRON DEPOT INJ 11.25MG (3-MONTH) .........7 LUPRON DEP-PED INJ 11.25MG ........................... 24 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 24 LUPRON DEP-PED INJ 15MG ................................ 24 LUPRON DEP-PED INJ 30MG (3-MONTH) ............ 24 LUPRON DEP-PED INJ 7.5MG ............................... 24 lutera ................................. 22 LYNPARZA .........................7 LYRICA ............................. 13 LYSODREN ........................7 lyza ................................... 22 M mafenide acetate .............. 32 magnesium sulfate ............ 28 MAGNESIUM SULFATE ... 28 MAGNESIUM SULFATE IN D5W .................................. 28 magnesium sulfate in dextrose ............................ 28 malathion .......................... 33 maprotiline hcl ................... 14 marlissa............................. 22 MARPLAN TAB 10MG ...... 14 MATULANE ........................8 MAVYRET ...........................5 meclizine hcl ..................... 25 medroxyprogesterone acetate (contraceptive) ..... 22 medroxyprogesterone acetate tab ........................ 24 mefloquine hcl .....................3 megestrol ac sus 40mg/ml ..7 megestrol ac tab 20mg .......7 megestrol ac tab 40mg .......7 megestrol sus 625mg/5ml ...7 MEKINIST ...........................8 meloxicam ...........................1 melphalan hcl ......................6

memantine hcl cp24 .......... 14 memantine hcl soln ........... 14 memantine hcl tabs ........... 14 MENACTRA ...................... 28 MENVEO .......................... 28 mercaptopurine ................... 6 meropenem ......................... 3 mesalamine ...................... 25 mesalamine w/ cleanser ... 25 mesna ................................. 8 MESNEX ............................. 8 metadate er tab 20mg ....... 18 metformin er ...................... 21 metformin hcl .................... 21 methadone hcl .................... 2 methadone hcl 10mg .......... 2 methadone hcl 5mg ............ 2 methadone hcl intensol ....... 2 methazolamide ................. 11 methenamine hippurate ...... 3 methimazole ..................... 24 methotrexate sodium inj ...... 6 methotrexate sodium tabs . 27 methyclothiazide ............... 11 methylphenidate hcl .......... 18 methylphenidate hcl oral soln .......................................... 18 methylphenidate tab 10mg er .......................................... 18 methylphenidate tab 20mg er .......................................... 18 methylpr ace inj 40mg/ml .. 23 methylpr ace inj 80mg/ml .. 23 methylpr ss inj 125mg ....... 23 methylpr ss inj 1gm ........... 23 methylpr ss inj 40mg ......... 23 methylpred pak 4mg ......... 23 methylpred tab 16mg ........ 23 methylpred tab 32mg ........ 23 methylpred tab 4mg .......... 23 methylpred tab 8mg .......... 23 metipranolol ...................... 30 metoclopramide hcl ........... 25 metoclopramide inj ............ 25 metolazone ....................... 11 metoprolol & hctz tab 100-25mg .......................... 10 metoprolol & hctz tab 100-50mg .......................... 10 metoprolol & hctz tab

50-25mg ........................... 10 metoprolol succinate ......... 10 metoprolol tartrate............. 10 metronidazole ..................... 3 metronidazole (topical) ..... 33 metronidazole gel 0.75% .. 33 metronidazole in nacl .......... 3 metronidazole vaginal ....... 26 mexiletine hcl .................... 10 MIACALCIN ...................... 24 microgestin 1.5/30 ............ 22 microgestin 1/20 ............... 22 microgestin fe 1.5/30 ........ 22 microgestin fe 1/20 ........... 22 midodrine hcl .................... 11 migergot ............................ 18 minitran ............................. 11 minocycline hcl ................... 6 minoxidil ............................ 11 mirtazapine ....................... 14 misoprostol ....................... 25 MITIGARE .......................... 1 mitomycin ........................... 6 mitoxantrone hcl ................. 8 M-M-R II ............................ 28 moderiba tab 200mg ........... 5 moexipril hcl ........................ 9 moexipril-hydrochlorothiazide.......................................... 9 mometasone furoate ......... 32 mono-linyah tab 0.25-35 ... 22 mononessa ....................... 22 montelukast sodium .......... 31 morgidox cap 1x50mg ........ 6 morphine ext-rel tab ............ 2 morphine sul inj 10mg/ml .... 2 morphine sul inj 1mg/ml ...... 2 MORPHINE SUL INJ 4MG/ML .............................. 2 morphine sulfate ................. 2 MORPHINE SULFATE ....... 2 morphine sulfate oral sol ..... 2 MOVANTIK ....................... 25 MOVIPREP ....................... 25 MOXEZA .......................... 30 moxifloxacin hcl (ophth) .... 30 MOZOBIL ......................... 26 MULTAQ ........................... 10 mupirocin .......................... 32 MUSTARGEN ..................... 6

43

MYCAMINE .........................3 mycophenolate mofetil ...... 27 mycophenolate sodium ..... 27 MYLOTARG ........................7 myorisan ........................... 32 MYRBETRIQ ..................... 26 myzilra .............................. 22 N nabumetone ........................1 nadolol .............................. 10 nafcillin sodium ...................6 NAGLAZYME .................... 23 nalbuphine hcl .....................1 naloxone inj 0.4mg/ml ....... 19 naloxone inj 1mg/ml .......... 19 naltrexone hcl .................... 19 NAMENDA XR .................. 14 NAMENDA XR TITRATION PACK ................................ 14 NAMZARIC ....................... 14 naproxen .............................1 naproxen dr .........................1 naproxen sodium ................1 naratriptan hcl ................... 18 NATACYN ......................... 30 nateglinide......................... 21 NATPARA ......................... 24 NEBUPENT ........................3 necon 0.5/35-28 ................ 22 necon 1/50-28 ................... 22 necon 7/7/7 ....................... 22 nefazodone hcl .................. 14 neomycin sulfate .................2 neomycin-bacitracin zn-polymyxin ..................... 30 neomycin-polymy-dexameth .......................................... 29 neomycin-polymyxin-gramicidin ..................................... 30 neomycin-polymyxin-hc (ophth) .............................. 29 neomycin-polymyxin-hc (otic) .......................................... 33 NEPHRAMINE .................. 29 NERLYNX ...........................8 NEUPOGEN ..................... 26 NEUPRO........................... 15 nevirapine ...........................4 NEXAVAR ...........................8 niacin er (antihyperlipidemic)

.......................................... 10 niacor ................................ 10 nicardipine hcl ................... 11 NICOTROL INHALER ....... 19 NICOTROL NS ................. 19 nifedical xl ......................... 11 nifedipine .......................... 11 nifedipine er ...................... 11 nikki................................... 22 nilutamide ........................... 7 nimodipine ........................ 11 NINLARO ............................ 7 NIPENT ............................... 6 NITRO-BID ....................... 11 NITRO-DUR DIS 0.3MG/HR .......................................... 11 NITRO-DUR DIS 0.8MG/HR .......................................... 11 nitrofurantoin macrocrystal .. 3 nitrofurantoin monohyd macro .................................. 3 nitroglycerin ...................... 11 nitroglycerin td patch ......... 11 nora-be tab ....................... 22 NORDITROPIN FLEXPRO .......................................... 24 norethindrone (contraceptive) .................. 22 norethindrone acet & eth estra .................................. 22 norethindrone acetate ....... 24 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg .. 23 norgest/ethi tab 0.25/35 .... 22 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................. 22 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ............................. 22 norlyroc ............................. 22 NORMOSOL-M IN D5W ... 29 NORMOSOL-R ................. 29 NORMOSOL-R IN D5W .... 29 NORPACE CR .................. 10 NORTHERA ...................... 11 nortrel 0.5/35 (28) ............. 22 nortrel 1/35 ........................ 22

nortrel 7/7/7 ...................... 22 nortriptyline hcl ................. 15 NORVIR .............................. 4 NOVOLIN 70/30................ 20 NOVOLIN N ...................... 20 NOVOLIN R ...................... 20 NOVOLOG ....................... 20 NOVOLOG 70/30 FLEXPEN.......................................... 20 NOVOLOG FLEXPEN ...... 20 NOVOLOG MIX 70/30 ...... 20 NOVOLOG PENFILL ........ 20 NOXAFIL ............................ 3 NUCYNTA ER .................... 2 NUEDEXTA ...................... 19 NULOJIX .......................... 27 NULYTELY/FLAVOR PACKS ............................. 25 NUPLAZID ........................ 16 nutrilipid inj 20%................ 29 NUVARING ....................... 22 nyamyc ............................. 32 NYMALIZE ........................ 11 nystatin ............................... 3 nystatin (mouth-throat) ...... 33 nystatin (topical)................ 32 nystatin pow 100000 ......... 32 nystop ............................... 32 O ocella tab 3-0.03mg .......... 23 OCTAGAM ....................... 27 octreotide acetate ............. 24 ODEFSEY .......................... 4 ODOMZO ........................... 7 OFEV ................................ 31 ofloxacin (ophth) ............... 30 ofloxacin (otic) .................. 33 olanzapine ........................ 16 olmesartan medoxomil ........ 9 olmesartan medoxomil-amlodipine-hydrochlorothiazide ..................... 9 olmesartan medoxomil-hydrochlorothiazide ........................................ 9 olopatadine hcl 0.2% ........ 30 omega-3-acid ethyl esters 10 omeprazole cap 10mg ...... 26 omeprazole cap 20mg ...... 26 omeprazole cap 40mg ...... 26

44

ondansetron hcl ................ 25 ondansetron hcl inj ............ 25 ondansetron hcl oral soln .. 25 ondansetron odt ................ 25 ONFI ................................. 13 OPSUMIT.......................... 11 ORFADIN .......................... 23 ORKAMBI ......................... 31 orsythia ............................. 23 oseltamivir phosphate .........5 oxacillin sodium ...................6 oxaliplatin inj 100mg ...........8 oxaliplatin inj 100mg/20ml ...8 oxaliplatin inj 50mg .............8 oxaliplatin inj 50mg/10ml .....8 oxandrolone ...................... 19 oxcarbazepine ................... 13 oxybutynin chloride ........... 26 oxycodone hcl .....................2 oxycodone w/ acetaminophen 10-325mg ..2 oxycodone w/ acetaminophen 2.5-325mg .2 oxycodone w/ acetaminophen 5-325mg ....2 oxycodone w/ acetaminophen 7.5-325mg .2 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 20 OZEMPIC INJ 1MG/DOSE .......................................... 20 P pacerone ........................... 10 paclitaxel .............................7 paliperidone ...................... 16 pamidronate disodium ....... 21 PAMIDRONATE DISODIUM .......................................... 21 pamidronate inj 30mg ....... 21 pamidronate inj 90mg ....... 21 PANRETIN ........................ 33 pantoprazole sodium tbec . 26 paricalcitol ......................... 29 paroex sol 0.12% .............. 33 paromomycin sulfate ...........2 paroxetine hcl tabs ............ 15 PASER D/R .........................4 PAXIL ................................ 15 PAZEO .............................. 30 PEDIARIX ......................... 28

PEDVAX HIB .................... 28 peg 3350/electrolytes ........ 25 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 25 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 25 PEGANONE ..................... 13 PEGASYS ........................... 5 PEGASYS PROCLICK ....... 5 PENICILLIN G POT IN DEXTROSE 2MU ............... 6 PENICILLIN G POT IN DEXTROSE 3MU ............... 6 PENICILLIN G PROCAINE . 6 penicillin g sodium .............. 6 penicillin v potassium .......... 6 penicilln gk inj 20mu ........... 6 penicilln gk inj 5mu ............. 6 PENTACEL ....................... 28 PENTAM 300 ...................... 3 pentoxifylline ..................... 27 perindopril erbumine ........... 9 periogard ........................... 33 permethrin cre 5% ............ 33 perphenazine .................... 16 pfizerpen-g inj 20mu ........... 6 pfizerpen-g inj 5mu ............. 6 phenelzine sulfate ............. 15 phenobarbital .................... 13 phenobarbital sodium........ 13 PHENOBARBITAL SODIUM .......................................... 13 PHENYTEK ...................... 13 phenytoin .......................... 13 phenytoin sodium .............. 13 phenytoin sodium extended .......................................... 13 philith ................................ 23 PHOSPHOLINE IODIDE ... 30 PICATO ............................ 33 pilocarpine hcl ................... 30 pilocarpine hcl (oral).......... 33 pimozide ........................... 16 pimtrea .............................. 23 pindolol ............................. 10 pioglitazone hcl ................. 21 PIPER/TAZOBA INJ 12-1.5GM ............................ 6 piper/tazoba inj 2-0.25gm ... 6

piper/tazoba inj 3-0.375gm . 6 piper/tazoba inj 36-4.5gm ... 6 piper/tazoba inj 4-0.5gm ..... 6 pirmella 1/35 ..................... 23 piroxicam ............................ 1 PLASMA-LYTE A.............. 29 PLASMA-LYTE-148 .......... 29 podofilox ........................... 33 polyethylene glycol 3350 .. 25 polymyxin b-trimethoprim .. 30 POMALYST CAP 1MG ....... 7 POMALYST CAP 2MG ....... 7 POMALYST CAP 3MG ....... 7 POMALYST CAP 4MG ....... 7 portia-28 ........................... 23 pot chloride inj 2meq/ml .... 29 potassium chloride ...... 28, 29 potassium chloride in nacl 29 potassium chloride microencapsulated crystals er ...................................... 28 potassium chloride tab cr 10 meq ................................... 28 potassium citrate (alkalinizer) er tabs ............................... 26 PRADAXA ........................ 26 PRALUENT ...................... 10 pramipexole tab 0.125mg . 15 pramipexole tab 0.25mg ... 15 pramipexole tab 0.5mg ..... 15 pramipexole tab 0.75mg ... 15 pramipexole tab 1.5mg ..... 15 pramipexole tab 1mg ........ 15 prasugrel hcl ..................... 27 pravastatin sodium ............ 10 prazosin hcl ........................ 9 pred sod pho sol 5mg/5ml 23 prednisolone acetate (ophth).......................................... 30 prednisolone sodium phosphate ......................... 23 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) .... 30 prednisolone sol 15mg/5ml.......................................... 23 prednisolone sol 25mg/5ml.......................................... 23 PREDNISONE CON 5MG/ML ............................ 23 prednisone pak 10mg ....... 24

45

prednisone pak 5mg ......... 24 prednisone sol 5mg/5ml .... 24 prednisone tab 10mg ........ 24 prednisone tab 1mg .......... 24 prednisone tab 2.5mg ....... 24 prednisone tab 20mg ........ 24 prednisone tab 50mg ........ 24 prednisone tab 5mg .......... 24 PREMASOL SOL 10% ...... 29 premasol sol 6% ............... 29 prenatal vitamin/folic acid > 0.8 mg (generic) ................ 29 prevalite ............................ 10 previfem ............................ 23 PREZCOBIX .......................4 PREZISTA ..........................4 PRIFTIN ..............................4 PRIMAQUINE PHOSPHATE ............................................3 primidone .......................... 13 PRIVIGEN ......................... 27 probenecid ..........................1 PROCALAMINE ................ 29 prochlorperazine inj ........... 25 prochlorperazine maleate.. 25 prochlorperazine supp ...... 25 PROCRIT .......................... 26 procto-med hc ................... 33 procto-pak ......................... 33 proctosol hc cre 2.5% ....... 33 proctozone-hc ................... 33 PROGLYCEM SUS 50MG/ML .......................... 24 PROLASTIN-C .................. 31 PROLENSA ...................... 30 PROLIA ............................. 24 PROMACTA ...................... 27 promethazine hcl ............... 25 propafenone hcl ................ 10 propafenone hcl 12hr ........ 10 proparacaine hcl ............... 30 propranolol & hydrochlorothiazide ........... 10 propranolol cap er ............. 10 propranolol hcl .................. 10 propranolol oral sol ........... 10 propylthiouracil .................. 24 PROQUAD ........................ 28 PROSOL ........................... 29 protriptyline hcl .................. 15

PULMICORT FLEXHALER .......................................... 31 PULMOZYME ................... 31 PURIXAN ............................ 6 pyrazinamide ...................... 4 pyridostigmine tab 60mg ... 19 Q QUADRACEL ................... 28 quasense .......................... 23 quetiapine fumarate .......... 16 quinapril hcl ......................... 9 quinapril-hydrochlorothiazide ............................................ 9 quinidine gluconate ........... 10 quinidine sulfate ................ 10 quinine sulfate ..................... 3 R RABAVERT ...................... 28 raloxifene hcl ..................... 24 ramipril ................................ 9 RANEXA ........................... 11 ranitidine hcl ...................... 25 ranitidine hcl inj ................. 25 ranitidine syrup ................. 25 RAPAMUNE ..................... 27 rasagiline mesylate ........... 15 RAYALDEE ....................... 29 REBETOL SOLN ................ 5 reclipsen ........................... 23 RECOMBIVAX HB ............ 28 REGRANEX ...................... 33 RELENZA DISKHALER ...... 5 RELISTOR ........................ 25 REMICADE ....................... 27 REMODULIN .................... 11 repaglinide ........................ 21 RESCRIPTOR .................... 4 RESTASIS ........................ 30 RESTASIS MULTIDOSE .. 30 RETROVIR IV INFUSION ... 4 REVLIMID ........................... 7 REXULTI ........................... 17 REYATAZ ........................... 4 ribasphere ........................... 5 ribavirin 200mg ................... 5 rifabutin ............................... 4 rifampin ............................... 4 RIFATER ............................ 4 riluzole .............................. 19 rimantadine hydrochloride ... 5

ringer's .............................. 29 RISPERDAL INJ 12.5MG . 17 RISPERDAL INJ 25MG .... 17 RISPERDAL INJ 37.5MG . 17 RISPERDAL INJ 50MG .... 17 risperidone ........................ 17 ritonavir ............................... 4 RITUXAN ............................ 7 RITUXAN HYCELA ............. 7 rivastigmine tartrate .......... 14 rivastigmine td patch 24hr 13.3 mg/24hr .................... 14 rivastigmine td patch 24hr 4.6 mg/24hr ...................... 14 rivastigmine td patch 24hr 9.5 mg/24hr ...................... 14 rizatriptan benzoate .......... 18 rizatriptan benzoate odt .... 18 ropinirole tab 0.25mg ........ 15 ropinirole tab 0.5mg .......... 15 ropinirole tab 1mg ............. 15 ropinirole tab 2mg ............. 15 ropinirole tab 3mg ............. 15 ropinirole tab 4mg ............. 15 ropinirole tab 5mg ............. 15 rosadan ............................. 33 rosuvastatin calcium ......... 10 ROTARIX .......................... 28 ROTATEQ ........................ 28 roweepra ........................... 13 roweepra xr ....................... 13 RUBRACA .......................... 7 RYDAPT ............................. 8 S SABRIL ............................. 13 SANDIMMUNE ................. 27 SANDOSTATIN LAR DEPOT ............................. 24 SANTYL ............................ 33 SAPHRIS .......................... 17 scopolamine patch ............ 25 selegiline hcl ..................... 15 selenium sulfide ................ 32 SELZENTRY ...................... 4 SENSIPAR ....................... 21 SEREVENT DISKUS ........ 31 sertraline hcl ..................... 15 setlakin tab ....................... 23 sevelamer carbonate ........ 24 sharobel ............................ 23

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SHINGRIX ......................... 28 SIGNIFOR ......................... 24 sildenafil citrate (pulmonary hypertension) .................... 12 SILENOR .......................... 18 silver sulfadiazine .............. 32 SIMBRINZA ...................... 30 simvastatin ........................ 10 sirolimus ............................ 27 SIRTURO ............................4 SIVEXTRO ..........................3 sodium chlor sol 0.9% irr ... 33 sodium chloride ........... 28, 29 sodium chloride 0.45% ...... 29 sodium chloride inj 0.9% ... 29 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 28 sodium phenylbutyrate ...... 23 sodium polystyrene sulfonate .......................................... 21 SOLIQUA 100/33 .............. 20 SOLTAMOX ........................7 SOLU-CORTEF ................ 24 SOMATULINE DEPOT ..... 24 SOMAVERT ...................... 24 sorine ................................ 10 sotalol hcl .......................... 10 sotalol hcl (afib/afl) ............ 10 SOVALDI ............................5 spironolactone .....................9 spironolactone & hydrochlorothiazide ........... 11 sprintec 28 ........................ 23 SPRITAM .......................... 13 SPRYCEL ...........................8 sps susp 15gm/60ml ......... 21 sronyx ............................... 23 ssd .................................... 32 stavudine.............................4 sterile water irrigation ........ 33 STIMATE .......................... 24 STIVARGA ..........................8 streptomycin sulfate ............2 STRIBILD ............................4 SUBOXONE MIS 12-3MG 19 SUBOXONE MIS 2-0.5MG .......................................... 19 SUBOXONE MIS 4-1MG .. 19 SUBOXONE MIS 8-2MG .. 19 sucralfate .......................... 25

sulfacet sod oin 10% op .... 30 sulfacetamide sodium (acne) .......................................... 32 sulfacetamide sodium (ophth) .............................. 30 sulfacetamide sod-prednisolone .............. 29 SULFADIAZINE .................. 2 sulfamethoxazole-trimethop ds ........................................ 3 sulfamethoxazole-trimethoprim ......................................... 3 sulfamethoxazole-trimethoprim inj .................................... 3 SULFAMYLON ................. 32 sulfasalazine ..................... 25 sulfasalazine ec ................ 25 sulindac ............................... 1 sumatriptan ....................... 18 sumatriptan inj 4mg/0.5ml . 18 sumatriptan inj 6mg/0.5ml . 18 sumatriptan succinate ....... 18 SUPRAX ............................. 5 SUPREP BOWEL PREP KIT .......................................... 25 SUSTIVA ............................ 4 SUTENT ............................. 8 syeda ................................ 23 SYLATRON KIT 200MCG ... 8 SYLATRON KIT 300MCG ... 8 SYLATRON KIT 600MCG ... 8 SYMBICORT .................... 31 SYMFI LO ........................... 4 SYNAGIS .......................... 28 SYNAREL ......................... 23 SYNERCID ......................... 3 SYNRIBO ............................ 8 SYNTHROID ..................... 24 SYPRINE .......................... 21 T TABLOID ............................ 6 tacrolimus ......................... 27 tacrolimus (topical) ............ 33 TAFINLAR .......................... 8 TAGRISSO ......................... 8 tamoxifen citrate ................. 7 tamsulosin hcl ................... 26 TARCEVA ........................... 8 TARGRETIN ..................... 33 tarina fe 1/20 ..................... 23

TASIGNA ............................ 8 TAXOTERE ........................ 7 tazarotene ......................... 32 tazicef ................................. 5 TAZORAC ........................ 32 taztia xt ............................. 11 TECENTRIQ ....................... 7 TEFLARO ........................... 5 TEGRETOL ...................... 13 TEGRETOL-XR ................ 13 TEKTURNA ...................... 11 TEKTURNA HCT .............. 11 temazepam ....................... 18 TENIVAC .......................... 28 tenofovir disoproxil fumarate............................................ 4 terazosin hcl ....................... 9 terbinafine hcl ..................... 3 terbutaline sulfate ............. 31 terconazole vaginal ........... 26 testosterone ...................... 19 testosterone cypionate ...... 20 testosterone enanthate ..... 20 TETANUS/DIPHTHERIA TOXOID ............................ 28 tetrabenazine .................... 19 TEXACORT SOLN 2.5% .. 32 THALOMID ......................... 7 THEO-24 .......................... 31 theophylline ...................... 31 thioridazine hcl .................. 17 thiothixene ........................ 17 tiagabine hcl ..................... 13 tigecycline ........................... 3 TIGECYCLINE .................... 3 tilia fe ................................ 23 timolol maleate ................. 10 timolol maleate (ophth) soln.......................................... 30 timolol maleate gel ............ 30 timolol maleate ophth soln 0.5% (once-daily) .............. 30 TIVICAY .............................. 4 tizanidine hcl ..................... 19 TOBRADEX ...................... 29 TOBRADEX ST ................ 29 tobramycin .......................... 2 tobramycin (ophth) ............ 30 tobramycin inj 1.2 gm/30ml . 2 tobramycin inj 1.2gm ........... 2

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tobramycin inj 10mg/ml .......2 tobramycin inj 40mg/ml .......2 tobramycin inj 80mg/2ml .....2 tobramycin-dexamethasone .......................................... 29 tolterodine tartrate cap er .. 26 tolterodine tartrate tabs ..... 26 topiramate ......................... 13 toposar ................................8 topotecan inj 4mg ................8 TOPOTECAN INJ 4MG/4ML ............................................8 torsemide tabs .................. 11 TOVIAZ ............................. 26 tpn electrolytes .................. 28 TRACLEER ....................... 12 TRADJENTA ..................... 21 tramadol hcl ........................1 tramadol-acetaminophen ....1 trandolapril ..........................9 tranexamic acid ................. 27 tranylcypromine sulfate ..... 15 TRAVASOL ....................... 29 TRAVATAN Z .................... 30 trazodone hcl .................... 15 TRECATOR ........................4 TRELEGY ELLIPTA .......... 30 TRELSTAR DEP INJ 3.75MG ...............................7 TRELSTAR LA INJ 11.25MG ............................................7 TRESIBA FLEXTOUCH .... 20 tretinoin ............................. 32 tretinoin (chemotherapy) .....8 triamcinolone acetonide (mouth) ............................. 33 triamcinolone acetonide (topical) ............................. 32 triamterene & hydrochlorothiazide cap 37.5-25 mg ........................ 11 triamterene & hydrochlorothiazide tabs ... 11 trientine hcl ........................ 21 trifluoperazine hcl .............. 17 trifluridine .......................... 30 trihexyphenidyl hcl ............ 15 tri-legest fe ........................ 23 tri-linyah ............................ 23 tri-lo marzia ....................... 23

tri-lo-estarylla .................... 23 tri-lo-sprintec ..................... 23 trilyte ................................. 25 trimethoprim ........................ 3 trimipramine maleate ........ 15 trinessa ............................. 23 trinessa lo ......................... 23 TRINTELLIX ..................... 15 tri-previfem ........................ 23 TRISENOX ......................... 8 tri-sprintec ......................... 23 TRIUMEQ ........................... 4 trivora-28 ........................... 23 TROPHAMINE INJ 10% ... 29 trospium chloride .............. 26 TRULICITY ....................... 20 TRUMENBA ...................... 28 TRUVADA TAB 100-150 ..... 4 TRUVADA TAB 133-200 ..... 4 TRUVADA TAB 167-250 ..... 4 TRUVADA TAB 200-300 ..... 4 TWINRIX INJ .................... 28 TYBOST ............................. 4 TYKERB ............................. 8 TYPHIM VI ........................ 28 TYSABRI .......................... 19 U ULORIC .............................. 1 unithroid ............................ 24 ursodiol ............................. 25 V valacyclovir hcl .................... 5 VALCHLOR ...................... 33 valganciclovir hcl ................. 5 valproate sodium .............. 13 valproic acid ...................... 13 valsartan ............................. 9 valsartan-hydrochlorothiazide .......................................... 9 vancomycin hcl ................... 3 VANCOMYCIN IN NACL .... 3 vandazole ......................... 26 VAQTA .............................. 28 VARIVAX .......................... 28 VASCEPA ......................... 10 VELCADE ........................... 7 velivet ................................ 23 VEMLIDY ............................ 5 VENCLEXTA ...................... 7 VENCLEXTA STARTING

PACK .................................. 7 venlafaxine hcl .................. 15 VENTAVIS ........................ 12 VENTOLIN HFA................ 31 verapamil cap er ............... 11 verapamil hcl .................... 11 verapamil hcl tab er .......... 11 VERSACLOZ .................... 17 VERZENIO ......................... 7 VESICARE ....................... 26 vestura .............................. 23 VICTOZA .......................... 20 VIDEX EC ........................... 4 VIDEX PEDIATRIC ............. 4 vienva ............................... 23 vigabatrin powd pack 500mg.......................................... 13 VIIBRYD STARTER PACK.......................................... 15 VIIBRYD TAB ................... 15 VIMPAT ............................ 13 vinblastine sulfate ............... 7 vincasar pfs ........................ 7 vincristine sulfate ................ 7 vinorelbine tartrate .............. 7 viorele ............................... 23 VIRACEPT .......................... 4 VIRAMUNE ......................... 4 VIREAD .............................. 4 VIVITROL ......................... 19 voriconazole ....................... 3 VOSEVI .............................. 5 VOTRIENT ......................... 8 VRAYLAR ......................... 17 VRAYLAR THERAPY PACK.......................................... 17 vyfemla ............................. 23 W warfarin sodium ................ 26 WELCHOL ........................ 10 X XALKORI ............................ 8 XARELTO ......................... 26 XARELTO STARTER PACK.......................................... 26 XATMEP ........................... 27 XELJANZ .......................... 27 XELJANZ XR .................... 27 XGEVA ............................. 24 XIFAXAN .......................... 25

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XIGDUO XR TAB 10-1000MG ....................... 21 XIGDUO XR TAB 10-500MG .......................................... 21 XIGDUO XR TAB 2.5-1000 MG .................................... 21 XIGDUO XR TAB 5-1000MG .......................................... 21 XIGDUO XR TAB 5-500MG .......................................... 21 XOLAIR ............................. 31 XTANDI ...............................7 xulane ............................... 23 XULTOPHY 100/3.6 .......... 20 XYREM ............................. 19 Y YERVOY .............................7 YF-VAX ............................. 28 yuvafem vaginal tablet 10 mcg ................................... 23

Z zafirlukast .......................... 31 zarah ................................. 23 ZAVESCA ......................... 23 ZEJULA .............................. 7 ZELBORAF ......................... 8 ZEMAIRA .......................... 31 zenatane ........................... 32 zenchent ........................... 23 ZENPEP ........................... 25 ZEPATIER .......................... 5 ZERIT ................................. 4 zidovudine cap 100mg ........ 4 zidovudine syp 50mg/5ml ... 4 zidovudine tab 300mg ......... 4 ziprasidone hcl .................. 17 ZIRGAN ............................ 30 zoledronic acid .................. 21 zoledronic inj 4mg/5ml ...... 21 ZOLINZA ............................. 7

zolmitriptan ....................... 18 zolmitriptan odt ................. 18 zolpidem tartrate ............... 18 zonisamide ....................... 13 ZONTIVITY ....................... 27 ZORTRESS TAB 0.25MG 27 ZORTRESS TAB 0.5MG .. 27 ZORTRESS TAB 0.75MG 27 ZOSTAVAX ...................... 28 zovia 1/35e ....................... 23 zovia 1/50e ....................... 23 ZYDELIG ............................ 8 ZYKADIA ............................ 8 ZYLET .............................. 29 ZYPREXA RELPREVV ..... 17 ZYPREXA RELPREVV INJ 210MG .............................. 17 ZYTIGA ............................... 7


HAWAI‘I MEDICAL SERVICE ASSOCIATIONhmsa.com/advantage

PHONECall 8 a.m. to 8 p.m., seven days a week

948-6000 on Oahu 1 (800) 660-4672 toll-freeTTY users, call 711

ONLINEhttp://www.hmsa.com/advantage

HMSA CENTERSConvenient evening and Saturday hours:

HMSA Center @ Honolulu818 Keeaumoku St.Monday - Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Pearl CityPearl City Gateway | 1132 Kuala St., Suite 400 Monday - Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ HiloWaiakea Center | 303A E. Makaala St.

Monday - Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.

OFFICESVisit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:

Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329-5291Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295

Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393

HMSA’s mission is to provide the people of Hawaii access to a sustainable, quality health care system

that improves the overall health and well-being of our state.

HMSA Akamai Advantage is a PPO and Essential Advantage is an HMO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage and Essential Advantage depends on contract renewal.

This formulary was updated on 06/01/2018. For more recent information or other questions, please contact HMSA at:

(00) 8740-7706JUNE 5.18 LE



Documents

HMSA Akamai Advantage 2018 Formulary · and find the name of your drug in the first column . of the list. What are generic drugs? HMSA Akamai Advantage covers both brand name drugs