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MEMBER PREFERRED DRUG LIST 2020 For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit Effective January 1, 2020

MEMBER 2020 PREFERRED DRUG LIST · 2020-03-16 · List of Abbreviations G Generic Drug. G-S Generic Specialty Drug. NPB Non-preferred Brand Drug. NPB-S Non-preferred Brand Specialty

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Page 1: MEMBER 2020 PREFERRED DRUG LIST · 2020-03-16 · List of Abbreviations G Generic Drug. G-S Generic Specialty Drug. NPB Non-preferred Brand Drug. NPB-S Non-preferred Brand Specialty

MEMBER

PREFERRED DRUG LIST2020

For group HMO, PPO and EPO members with an insurance plan that includes a prescription drug benefit

Effective January 1, 2020

Page 2: MEMBER 2020 PREFERRED DRUG LIST · 2020-03-16 · List of Abbreviations G Generic Drug. G-S Generic Specialty Drug. NPB Non-preferred Brand Drug. NPB-S Non-preferred Brand Specialty

Blue Cross and Blue Shield of Kansas City 2020 Preferred Drug List

IntroductionThe Prescription Drug List (PDL) has been developed and is maintained by the Medical and Pharmacy Management Committee of Blue Cross and Blue Shield of Kansas City (Blue KC). The committee is composed of practicing doctors and pharmacists within the Kansas City area. Quarterly meetings are held to evaluate new drug therapies and review drug utilization issues.

Medications are evaluated on the basis of safety, effectiveness, adverse events, proven advantages over existing agents and cost. Tier 1 medications are typically generic drugs that contain the same active ingredients as brand name drugs and have the lowest copay. New drugs will require an exception or prior authorization until they are reviewed by the committee.

While extensive, this is not an exhaustive list of all available medications and this list is subject to change. See the most current PDL by visiting your member portal at MyBlueKC.com. If you require additional information or clarification, contact our Clinical Pharmacy unit at 816-395-2176 or 800-228-1436.

Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in the PDL status may occur. The committee may also implement prior authorization or other utilization management processes as deemed necessary. Doctors and pharmacists will be notified of any such changes via direct mailings.

How to use this list:1 Find the page number for your drug by searching the alphabetical index at the end.

2 Locate your drug and identify the Drug Tier. You will also want to note restrictions and preferred alternatives if applicable.

3 Refer to the Drug Tier description tables at the end of this introduction to identify the tier copay for your drug (based on the benefit schedule described in your member certificate or in your Blue KC benefit summary.

Prior Authorization/Drug Utilization ManagementSome drugs have coverage rules or have limits on the amount dispensed. In some cases, the prescriber must do something in order to obtain the drug. For example:

• Prior approval (or prior authorization): For some drugs, the prescriber must get approval from BlueKC before the prescription can be filled. Without that approval, the drug may not be covered.

• Quantity limits: For some drugs, there are limits to the amount of drug that may be obtained.

• Step Therapy: For some drugs, BlueKC requires step therapy. This means that drugs will have to be tried in a certain order for a medical condition. If the doctor feels that the first drugs are not appropriate, the prescriber will have to submit a prior authorization request.

Prescribers may request exceptions to these coverage rules or limits by submitting an electronic prior authorization request form. www.BlueKC.com > Providers > Forms > Prior Authorizations for Medications.

HOW TO REACH USBlue Cross and Blue Shield of Kansas City Pharmacy Services P.O. Box 419169 Kansas City, MO 64141-2735

816-395-2176 or 800-228-1436

www.BlueKC.com

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Frequently asked questionsWhat is the difference between brand name drugs and generic drugs?When a drug company develops a new medication they apply for a patent. This patent protects the drug from being copied by other drug companies for a certain period of time. These drugs are brand name drugs. Once the patent period expires, other manufacturers can produce the same drug as long as they follow strict guidelines established by the Food and Drug Administration's (FDA) guidelines. These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose patents have expired. They are made with the same active ingredients of the brand name drug, but they may have a different color, shape or filler material. The cost of a generic drug is typically less than a brand name drug. All generic medications are approved by the FDA before they are released on the market.

What is the difference between a generic equivalent and a generic alternative?A generic equivalent is a medication that contains the same active ingredient and works the same way as the original brand name drug. A generic alternative is a generic medication that may not have the same active ingredient, but works in the same way as another drug.

What is a maintenance drug?A maintenance drug is a medication used to treat a chronic condition like diabetes or high blood pressure. The FDA must approve maintenance drugs as safe for long-term use. Blue KC uses a national drug information database called Medispan to determine which medications are included on the maintenance drug list. If your prescription is a maintenance drug, you can have it filled for several months instead of just one prescription at a time.

Does Blue KC cover all prescription drugs?Blue KC covers most prescription drugs. However, some drug classes require an additional benefit be added to your health insurance plan in order to be covered. This additional benefit is referred to as a ‘rider.’ Examples of such drug classes are fertility, birth control, impotency, and weight loss.

How is the tier level status determined for medications?The PDL is a list of prescription medications that have been reviewed and recommended by the Blue KC Medical and Pharmacy Management Committee.

The list has a combination of brand name and generic medications. Each of these medications has been reviewed for its safety, effectiveness, clinical outcomes, and cost. Doctors and pharmacists on the committee look at drug utilization issues, the number of adverse events, and any proven advantages over other drugs on the PDL. The most efficient and cost-effective drugs are on Tier 1 of the PDL.

Why does Blue KC require prior authorization for some drugs before they are covered?Blue KC may require prior authorization for some drugs or a class. Medications on the prior authorization list may have safety concerns or have FDA approval, only for a certain use. Some of the prior authorization medications may also have a lower-cost alternative that should be considered first or the drug may not be as effective as something else in the same drug class. Some medications are also on the prior authorization list because they have the potential to be misused. Your doctor and Blue KC will work together to get prior authorization and approval for your prescription when needed.

Do I need to show my member ID card at the pharmacy?Yes, show your member ID card to your pharmacist whenever you have a prescription filled. Your prescription claim is electronically transmitted to Blue KC when you fill your prescription. Please make sure the pharmacy has your most current health insurance information and correct birth date so there won’t be any delays or claim denials when we process your claim.

What do I do if I need to refill my prescription early (i.e., leaving on vacation, the doctor increased my dosage)? To have a prescription refilled early, have your pharmacist call the Pharmacy Customer Service unit at 816-395- 2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

What if I am out of town and need to have a prescription filled?Blue KC contracts with most major pharmacy chains and has a network of over 44,000 pharmacies nationwide. If the pharmacy you are using has difficulty in processing your prescription claim, have them contact the Pharmacy Customer Service unit for assistance at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

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Why must some drugs be purchased through a Specialty Pharmacy?Specialty drugs are those that require special ordering, handling, clinical monitoring and/or customer service. These drugs are best purchased through a Specialty Pharmacy. Blue KC has a network of Specialty Pharmacies available to provide specialized care for patients with complex chronic health conditions to obtain

their medications and manage their health conditions. Specialty medications are limited to a 34 day supply.

What if I have questions about my prescription drug coverage?For more information on your prescription drug coverage, call the Pharmacy Customer Service unit at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

Miscellaneous Information

Specialty PharmacyA Specialty Pharmacy is one that provides specialized care for patients with complex chronic health conditions such as Rheumatoid Arthritis, Multiple Sclerosis or Psoriasis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. These pharmacies do everything from dispense the specialty medication to help patients manage their health condition. Most specialty medications are covered under the pharmacy benefit. Specialty medications are limited to a 34 day supply. The following is a list of other services provided by the Specialty Pharmacies:

• Assigns a Patient Care Coordinator who serves as a personal advocate and point of contact

• Offers access to a dedicated clinical staff of nurses and pharmacists who are knowledgeable about the medications and conditions

• Provides the necessary supplies to administer the medications — at no additional cost

• Offers care management programs to help patients get the most from their medications

• Provides patients with refill reminder calls

• Allows the medications to be delivered to either the physician’s office or patients home

• Works directly with patients to arrange a convenient shipment date

• Ships all medications overnight

• Coordinates with Blue KC to take care of billing issues

These services are provided to you at no additional cost. Prescriptions for a specialty medication will need to be filled at the Specialty Pharmacy listed below.

Optum Specialty Pharmacy Phone: 1-855-427-4682

Drug Tier DescriptionsTo find out what prescription drug tier is on your plan, please see the benefit schedule in your member certificate or in your Blue KC benefit summary.

2-Tier Benefit Drug Tier

Tier 1 copayG

G-S

Tier 2 copayPB

PB-S

Not CoveredNPB

NPB-S

3-Tier Benefit Drug Tier

Tier 1 copayG

G-S

Tier 2 copayPB

PB-S

Tier 3 copayNPB

NPB-S

3-Tier Retail/Specialty Benefit Drug Tier

Tier 1 copay G

Tier 2 copay PB

Tier 3 copay NPB

Generic Specialty copay G-S

Preferred Brand Specialty copay PB-S

Non-Preferred Brand Specialty copay NPB-S

4-Tier Benefit Drug Tier

Tier 1 copayG

G-S

Tier 2 copay PB

Tier 3 copayPB-S

NPB

Tier 4 copay NPB-S

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List of AbbreviationsG Generic Drug.

G-S Generic Specialty Drug.

NPB Non-preferred Brand Drug.

NPB-S Non-preferred Brand Specialty Drug.

PB Preferred Brand Drug.

PB-S Preferred Brand Specialty Drug.

ACA Affordable Care Act. These preventative drugs may be covered at no cost (check your benefits to confirm).

M Maintenance Drug.

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

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

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

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

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Discrimination is Against the LawBlue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue KC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: › Qualified sign language interpreters › Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as: › Qualified interpreters › Information written in other languages

If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected].

If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)

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

If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126.

Chinese: 如果您,或是您正在協助的對象,有關於 Blue KC方面的問題,您 有權利免費以您的母語得到幫 助和訊息。洽詢一位翻譯員,請撥電話1-844-395-7126。

Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126.

German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-844-395-7126 로 전화하십시오.

Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126.

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M57313-C 9/19

Arabic:إن كان لديك أو لدى شخص تساعده أسئلة بخصوص Blue KC ، .فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة

للتحدث مع مترجم اتصل ب. 7126 -1-844-395.

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126.

French: Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126.

Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa1-844-395-7126.

Laotian: ຖ້ າທ່ ານ, ືຫຼ ຄົ ນ ່◌ທທ່ ານກໍ າລັ ງຊ່ ວຍເຫືຼ ອ, ມ ໍ◌ຄາຖາມກ່ ຽວກັ ບ Blue KC, ທ່ ານມ ິ◌ສດ ່◌ທຈະໄດ້ ຮັ ບການຊ່ ວຍເຫືຼ ອແລະໍ◌ຂ້ ມູ ນຂ່ າວສານ ່◌ທເປັ ນພາສາຂອງທ່ າໍນ ່◌ບມ ຄ່ າໃຊ້ ຈ່ າຍ. ການໂອ້ ລົ ມກັ ບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-844-395-7126.

Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe.

Persian:اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد Blue KC ، داشته باشيد حق اين را داريد که کمکو اطالعات به زبان خود را به طور

رايگان دريافت مناييد 7126-395-844-1.متاس حاصل مناييد.

Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa.

Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126.

For TTY services, please call 1-816-842-5607.

An Independent Licensee of the Blue Cross and Blue Shield Association

All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.

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Table of Contents

Analgesics - Drugs for Pain...............................................................................................................................10Analgesics - Drugs for Pain and Inflammation.................................................................................................. 13Anesthetics........................................................................................................................................................15Anti-Addiction / Substance Abuse Treatment Agents....................................................................................... 16Antibacterials.....................................................................................................................................................17Anticoagulants...................................................................................................................................................20Anticonvulsants - Drugs for Seizures................................................................................................................ 21Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 23Antidepressants.................................................................................................................................................23Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 26Antifungals.........................................................................................................................................................27Antigout Agents................................................................................................................................................. 29Anti-inflammatory Agents.................................................................................................................................. 29Antimigraine Agents.......................................................................................................................................... 29Antimyasthenic Agents......................................................................................................................................30Antimycobacterials............................................................................................................................................ 30Antineoplastics - Drugs for Cancer....................................................................................................................31Antiparasitics..................................................................................................................................................... 35Antiparkinson Agents........................................................................................................................................ 36Antiplatelets.......................................................................................................................................................37Antipsychotics - Drugs for Mood Disorders....................................................................................................... 37Antivirals............................................................................................................................................................39Anxiolytics - Drugs for Anxiety...........................................................................................................................42Bipolar Agents - Drugs for Mood Disorders.......................................................................................................42Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................43Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 43Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 51Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 53Central Nervous System Agents - Miscellaneous............................................................................................. 54Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................55Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 56Diabetes - Antidiabetic Agents.......................................................................................................................... 64Diabetes - Glucose Monitoring.......................................................................................................................... 67Diabetes - Glycemic Agents.............................................................................................................................. 68Diabetes - Insulins.............................................................................................................................................68Electrolytes / Minerals / Metals / Vitamins.........................................................................................................70Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................75Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................76Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 78Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................79Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 81Hormonal Agents - Adrenal............................................................................................................................... 81Hormonal Agents - Men's Health.......................................................................................................................83Hormonal Agents - Osteoporosis...................................................................................................................... 84Hormonal Agents - Parathyroid......................................................................................................................... 84Hormonal Agents - Pituitary.............................................................................................................................. 84Hormonal Agents - Prostaglandins....................................................................................................................85Hormonal Agents - Sex Hormones and Birth Control........................................................................................86Hormonal Agents - Thyroid............................................................................................................................... 93Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 94Immunological Agents - Drugs for Vaccination................................................................................................. 96

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Inflammatory Bowel Disease Agents.................................................................................................................97Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 98Metabolic Bone Disease Agents - Other........................................................................................................... 99Miscellaneous Therapeutic Agents................................................................................................................... 99Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation.........................................................100Ophthalmic Agents - Drugs for Glaucoma.......................................................................................................102Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions....................................................................... 103Otic Agents - Drugs for Ear Conditions........................................................................................................... 105Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold......................................................105Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................. 107Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................. 110Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................. 111Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm.................................................................... 111Sleep Disorder Agents.................................................................................................................................... 112

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Drug Name Drug Tier Restrictions / Limits

Analgesics - Drugs for Pain

ABSTRAL NPB ST; QL

acetaminophen-codeine G QL

acetaminophen-codeine #2 G QL

acetaminophen-codeine #3 G QL

acetaminophen-codeine #4 G QL

ACTIQ NPB PA; QL

ALLZITAL NPB ST

APADAZ NPB QL

apap-caff-dihydrocodeine G QL

ARYMO ER NPB ST; QL

ascomp-codeine G

BELBUCA PB ST; QL

BENZHYDROCODONE-ACETAMINOPHEN NPB QL

BUPAP NPB ST

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

G ST; QL

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

NPB ST; QL

BUTALBITAL-ACETAMINOPHEN ORAL CAPSULE

G ST

butalbital-acetaminophen oral tablet G

butalbital-apap-caff-cod G

butalbital-apap-caffeine G

butalbital-asa-caff-codeine G

butalbital-aspirin-caffeine G

butorphanol tartrate nasal G QL

BUTRANS NPB ST; QL

carisoprodol-aspirin-codeine G

codeine sulfate G QL

CONZIP NPB ST; QL

DILAUDID ORAL NPB QL

DOLOPHINE G ST

DSUVIA NPB

DURAGESIC-100 NPB ST; QL

DURAGESIC-12 NPB ST; QL

DURAGESIC-25 NPB ST; QL

DURAGESIC-50 NPB ST; QL

DURAGESIC-75 NPB ST; QL

Last Updated 1/15/2020

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Drug Name Drug Tier Restrictions / Limits

duraxin G

DVORAH G QL

endocet G QL

ESGIC NPB ST

fentanyl G ST; QL

fentanyl citrate buccal lozenge on a handle G PA; QL

FENTANYL CITRATE BUCCAL TABLET NPB ST; QL

FENTORA NPB ST; QL

FIORICET NPB ST

FIORICET/CODEINE NPB

FIORINAL NPB ST

FIORINAL/CODEINE #3 NPB

HYDROCODONE BITARTRATE ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 30 MG, 40 MG, 50 MG

NPB ST; QL

hydrocodone-acetaminophen G QL

hydrocodone-ibuprofen G QL

hydromorphone hcl er G ST; QL

HYDROMORPHONE HCL INJECTION SOLUTION 0.2 MG/ML

NPB

hydromorphone hcl oral G QL

hydromorphone hcl rectal G QL

HYSINGLA ER PB ST; QL

IONSYS NPB

KADIAN NPB ST; QL

LAZANDA NPB ST; QL

levorphanol tartrate oral tablet 2 mg G QL

levorphanol tartrate oral tablet 3 mg NPB

lorcet G QL

lorcet hd G QL

lorcet plus G QL

LORTAB G QL

MEDROX-RX NPB

meperidine hcl oral tablet G QL

methadone hcl intensol G ST

methadone hcl oral G ST

methadose oral concentrate 10 mg/ml G ST

methadose oral tablet soluble G ST

methadose sugar-free G ST

Last Updated 1/15/2020

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Drug Name Drug Tier Restrictions / Limits

MORPHABOND ER NPB ST; QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

G QL

morphine sulfate er G ST; QL

morphine sulfate er beads G ST; QL

morphine sulfate oral G QL

morphine sulfate rectal G QL

MS CONTIN NPB ST; QL

NALOCET NPB QL

NORCO NPB ST; QL

NUCYNTA PB QL

NUCYNTA ER PB ST; QL

OPANA NPB QL

OXAYDO NPB QL

OXYCODONE HCL ER NPB ST; QL

oxycodone hcl oral capsule G QL

oxycodone hcl oral concentrate 100 mg/5ml G QL

oxycodone hcl oral solution G QL

oxycodone hcl oral tablet G QL

oxycodone-acetaminophen G QL

oxycodone-aspirin G QL

oxycodone-ibuprofen G QL

OXYCONTIN PB ST; QL

oxymorphone hcl G QL

oxymorphone hcl er G ST; QL

pentazocine-naloxone hcl G QL

PERCOCET NPB QL

PRIMLEV NPB QL

ROXICODONE NPB QL

SUBSYS NPB PA; QL

SYNAPRYN FUSEPAQ NPB

tencon G

tramadol hcl er (biphasic) G ST; QL

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

NPB ST; QL

tramadol hcl er oral capsule extended release 24 hour 150 mg

G ST; QL

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Drug Name Drug Tier Restrictions / Limits

tramadol hcl er oral tablet extended release 24 hour

G ST; QL

tramadol hcl oral tablet 50 mg G QL

tramadol-acetaminophen G QL

TREZIX NPB QL

TYLENOL WITH CODEINE #3 NPB QL

TYLENOL WITH CODEINE #4 NPB QL

ULTRACET NPB QL

ULTRAM NPB QL

VANATOL LQ NPB ST

VANATOL S NPB ST

vicodin hp G QL

XTAMPZA ER NPB ST; QL

ZEBUTAL NPB ST

ZOHYDRO ER NPB ST; QL

Analgesics - Drugs for Pain and Inflammation

ACTIVE INJECTION KET-L NPB

ACTIVE INJECTION KETMARC-L NPB

ACTIVE-KETOPROFEN NPB

ACTIVE-PREP KIT I NPB

ACTIVE-PREP KIT II NPB

ACTIVE-PREP KIT III NPB

AIF #2 DRUG PREPARATION KIT NPB

AIF #3 DRUG PREPARATION KIT NPB

ARTHROTEC NPB ST

CAMBIA NPB ST; QL

CELEBREX NPB ST; QL

celecoxib oral G QL

choline-mag trisalicylate G

DAYPRO NPB ST

DICLOFENAC EPOLAMINE NPB ST; QL

diclofenac potassium G

diclofenac sodium er G

diclofenac sodium oral G

diclofenac sodium transdermal gel 1 % G QL

diclofenac sodium transdermal solution G

diclofenac-misoprostol G

diflunisal oral G

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Drug Name Drug Tier Restrictions / Limits

DUAL COMPLEX FORMULA 1 KIT NPB

DUEXIS NPB ST; QL

EC-NAPROSYN NPB ST

ec-naproxen G

ENOVARX-DICLOFENAC SODIUM NPB

ENOVARX-IBUPROFEN NPB

ENOVARX-NAPROXEN NPB

etodolac G

etodolac er G

FBL KIT NPB

FELDENE NPB ST

fenoprofen calcium oral capsule NPB ST

fenoprofen calcium oral tablet G ST

fenortho NPB ST

FLECTOR PB ST; QL

flurbiprofen oral G

ibu G

ibuprofen oral tablet 400 mg, 600 mg, 800 mg G

IC 400 NPB

IC 800 NPB

INDOCIN ORAL NPB ST

INDOCIN RECTAL NPB

indomethacin er G

indomethacin oral G

K.B.G.L IN TERODERM NPB

KETOPHENE RAPIDPAQ NPB

ketoprofen er G

ketoprofen oral G

KETOROCAINE-L NPB

KETOROCAINE-LM NPB

KETOROLAC TROMETHAMINE EXTERNAL NPB

KETOROLAC TROMETHAMINE INTRAMUSCULAR

NPB-S

ketorolac tromethamine oral G QL

LIDOPROFEN NPB

LODINE NPB ST

meclofenamate sodium oral G

mefenamic acid oral G

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Drug Name Drug Tier Restrictions / Limits

meloxicam oral G QL

MOBIC NPB ST; QL

nabumetone oral G

NALFON NPB ST

NAPRELAN NPB ST

NAPRO NPB

NAPROSYN ORAL SUSPENSION NPB ST

naproxen dr G

naproxen oral G

naproxen sodium er G

naproxen sodium oral tablet 275 mg, 550 mg G

NP #2 DRUG PREPARATION KIT NPB

oxaprozin G

PENNSAID NPB ST; QL

piroxicam oral G

PRASTERA NPB

QMIIZ ODT NPB ST

READYSHARP ANESTH + KETOROLAC NPB

salsalate oral G

SPRIX NPB-S ST; QL

sulindac oral G

TIVORBEX NPB ST

tolmetin sodium G

TRIPLE COMPLEX FORMULA 3 KIT NPB

VIMOVO NPB ST; QL

VIVLODEX NPB ST

VOLTAREN NPB ST; QL

VOPAC GB NPB

VOPAC KT NPB

VP FC KIT NPB

VP GKL KIT NPB

ZIPSOR NPB ST; QL

ZORVOLEX NPB ST; QL

Anesthetics

ACTIVE INJECTION LM-2 NPB

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE

NPB

CETACAINE EXTERNAL AEROSOL NPB

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Drug Name Drug Tier Restrictions / Limits

cocaine hcl external solution 4 % G

ENOVARX-LIDOCAINE HCL NPB

ethyl chloride G

GEBAUERS PAIN EASE NPB

GEBAUERS SPRAY AND STRETCH NPB

glydo external gel 2 % G

L.E.T. NPB

lidocaine external ointment G

lidocaine external patch 5 % G

lidocaine hcl external solution G

lidocaine hcl urethral/mucosal external gel G

LIDOCAINE HCL-SODIUM CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE 1-0.9 % (3 ML)

NPB

LIDODERM NPB ST

LIDOMAR NPB

marlido G

MARLIDO-25 NPB

P-CARE 100MX NPB

POINT OF CARE LM-2.2 NPB

POINT OF CARE LM-2.5 NPB

READYSHARP-A NPB

ROPIVACAINE HCL INJECTION SOLUTION 33.4 MG/ML

NPB

SYNERA NPB

VENIPUNCTURE PX1 PHLEBOTOMY NPB

ZTLIDO PB ST

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium G

ANTABUSE NPB

BUNAVAIL G QL

buprenorphine hcl sublingual G QL

buprenorphine hcl-naloxone hcl G QL

bupropion hcl er (smoking det) G M; ACA; QL

CHANTIX PB ACA; QL

CHANTIX CONTINUING MONTH PAK PB ACA; QL

CHANTIX STARTING MONTH PAK PB ACA; QL

disulfiram oral G

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Drug Name Drug Tier Restrictions / Limits

EVZIO G ST

LUCEMYRA NPB QL

naloxone hcl injection solution G

naloxone hcl injection solution cartridge G

naloxone hcl injection solution prefilled syringe G

naltrexone hcl oral G

NALTREXONE SUBCUTANEOUS NPB

NARCAN G

NICOTROL NPB M; ACA; QL

NICOTROL NS NPB M; ACA; QL

SUBOXONE G QL

ZUBSOLV G QL

Antibacterials

ACTICLATE NPB ST

ALTABAX NPB

amoxicillin G

amoxicillin-potassium clavulanate er G

amoxicillin-potassium clavulanate oral G

ampicillin G

ARIKAYCE PB-S PA

AUGMENTIN ES-600 NPB

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

PB

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML

NPB

AUGMENTIN ORAL TABLET NPB

avidoxy G

azithromycin oral G

BACTRIM NPB

BACTRIM DS NPB

BAXDELA ORAL NPB

cefaclor G

cefaclor er G

cefadroxil G

cefdinir G

cefditoren pivoxil G

cefixime G

cefpodoxime proxetil G

cefprozil G

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Drug Name Drug Tier Restrictions / Limits

cefuroxime axetil G

CENTANY NPB

cephalexin G

CIPRO NPB

ciprofloxacin hcl oral G

clarithromycin er G

clarithromycin oral G

CLEOCIN NPB

clindamycin hcl oral G

clindamycin palmitate hcl G

clindamycin phosphate vaginal G

CLINDESSE NPB

colistimethate sodium (cba) G

COLY-MYCIN M NPB

coremino G

demeclocycline hcl G

dicloxacillin sodium G

DIFICID NPB

DORYX NPB ST

DORYX MPC NPB ST

doxycycline hyclate oral G

doxycycline monohydrate oral G

E.E.S. 400 NPB

E.E.S. GRANULES NPB

ERYPED 200 NPB

ERYPED 400 NPB

ERY-TAB G

ERYTHROCIN STEARATE G

erythromycin base G

erythromycin ethylsuccinate oral G

FIRST-METRONIDAZOLE NPB

FIRST-VANCOMYCIN NPB

FLAGYL NPB

gentamicin sulfate external G

HIPREX NPB

KEFLEX NPB

LEVAQUIN ORAL TABLET 500 MG, 750 MG NPB

levofloxacin oral G

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Drug Name Drug Tier Restrictions / Limits

linezolid oral G QL

MACROBID NPB

MACRODANTIN NPB

mafenide acetate external G

methenamine hippurate G

methenamine mandelate oral G

METRONIDAZOLE BENZO+SYRSPEND NPB

metronidazole oral G

metronidazole vaginal G

MINOCIN ORAL CAPSULE 50 MG NPB ST

minocycline hcl er G

minocycline hcl oral G

MINOLIRA NPB ST

mondoxyne nl G

MONUROL NPB

morgidox oral G

moxifloxacin hcl oral G

mupirocin calcium G

mupirocin external G

neomycin sulfate oral G

nitrofurantoin G

nitrofurantoin macrocrystal oral G

nitrofurantoin monohydrate macrocrystals G

NUTRIDOX NPB ST

NUVESSA NPB

NUZYRA ORAL NPB

ofloxacin oral G

okebo G

paromomycin sulfate oral G

penicillin v potassium G

PRIMSOL NPB

SEYSARA NPB ST

SILVADENE NPB

silver nitrate external G

silver sulfadiazine external G

SIVEXTRO ORAL NPB QL

SOLODYN NPB ST

SOLOSEC NPB

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Drug Name Drug Tier Restrictions / Limits

SPECTRACEF NPB

ssd G

sulfadiazine oral G

sulfamethoxazole-trimethoprim oral G

SULFAMYLON EXTERNAL CREAM PB

SULFAMYLON EXTERNAL PACKET NPB

sulfatrim pediatric G

SUPRAX NPB

TARGADOX NPB ST

tetracycline hcl oral G

tinidazole oral G

trimethoprim oral G

VANCOCIN HCL NPB

vancomycin hcl oral capsule G

VANCOMYCIN+SYRSPEND SF NPB

vandazole G

VIBRAMYCIN NPB ST

XEPI NPB PA

XIFAXAN PB

XIMINO NPB ST

ZITHROMAX ORAL NPB

ZITHROMAX TRI-PAK NPB

ZITHROMAX Z-PAK NPB

ZYVOX ORAL NPB ST; QL

Anticoagulants

ARIXTRA NPB QL

BEVYXXA NPB QL

COUMADIN NPB

ELIQUIS PB M; QL

ELIQUIS STARTER PACK PB M; QL

enoxaparin sodium subcutaneous G QL

fondaparinux sodium G QL

FRAGMIN PB QL

heparin sodium (porcine) G

heparin sodium (porcine) pf G

jantoven G

LOVENOX SUBCUTANEOUS NPB ST; QL

PRADAXA NPB M; QL

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Drug Name Drug Tier Restrictions / Limits

SAVAYSA NPB M; QL

warfarin sodium oral G

XARELTO PB M; QL

XARELTO STARTER PACK PB M; QL

Anticonvulsants - Drugs for Seizures

APTIOM NPB

BANZEL PB

BRIVIACT ORAL NPB ST

carbamazepine er G

carbamazepine oral G

CARBATROL NPB

CELONTIN PB

clobazam G

DEPAKOTE NPB ST

DEPAKOTE ER NPB ST

DEPAKOTE SPRINKLES NPB ST

DIACOMIT NPB-S PA

DIASTAT ACUDIAL NPB QL

DIASTAT PEDIATRIC NPB QL

diazepam rectal G QL

DILANTIN INFATABS NPB

DILANTIN ORAL CAPSULE 100 MG NPB

DILANTIN ORAL CAPSULE 30 MG PB

DILANTIN ORAL SUSPENSION NPB

divalproex sodium er G

divalproex sodium oral G

EPIDIOLEX PB-S PA

epitol G

EQUETRO NPB

ethosuximide oral G

FANATREX FUSEPAQ NPB

felbamate G

FELBATOL NPB

FYCOMPA PB

gabapentin oral G

GABITRIL NPB

KEPPRA ORAL NPB ST

KEPPRA XR NPB ST

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Drug Name Drug Tier Restrictions / Limits

LAMICTAL NPB ST

LAMICTAL ODT NPB ST

LAMICTAL STARTER NPB ST

LAMICTAL XR NPB ST

lamotrigine er G

lamotrigine oral G

lamotrigine starter kit-blue G

lamotrigine starter kit-green G

lamotrigine starter kit-orange G

levetiracetam er G

levetiracetam oral G

MYSOLINE NPB

NEURONTIN NPB ST

ONFI NPB

oxcarbazepine G

OXTELLAR XR NPB ST

PEGANONE PB

phenobarbital oral G

PHENYTEK NPB

phenytoin infatabs G

phenytoin oral G

phenytoin sodium extended G

primidone oral G

QUDEXY XR PB ST

roweepra G

roweepra xr G

SABRIL NPB-S PA

SPRITAM NPB ST

subvenite G

subvenite starter kit-blue G

subvenite starter kit-green G

subvenite starter kit-orange G

SYMPAZAN NPB ST

TEGRETOL NPB

TEGRETOL-XR NPB

tiagabine hcl G

TOPAMAX NPB ST

TOPAMAX SPRINKLE NPB ST

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Drug Name Drug Tier Restrictions / Limits

topiramate er NPB

topiramate oral G

TRILEPTAL NPB ST

TROKENDI XR NPB ST

valproic acid oral G

vigabatrin G-S PA

vigadrone G-S PA

VIMPAT ORAL PB

ZARONTIN NPB

ZONEGRAN NPB ST

zonisamide oral G

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT NPB ST; M

donepezil hcl G M

EXELON NPB ST; M; QL

galantamine hydrobromide er G M; QL

galantamine hydrobromide oral solution G M; QL

galantamine hydrobromide oral tablet 12 mg G M

galantamine hydrobromide oral tablet 4 mg, 8 mg

G M; QL

memantine hcl er G M; QL

memantine hcl oral solution G M

memantine hcl oral tablet 10 mg, 5 mg G M

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

NPB M

NAMENDA NPB ST; M

NAMENDA TITRATION PAK NPB ST; M

NAMENDA XR NPB ST; M; QL

NAMENDA XR TITRATION PACK NPB ST; M; QL

NAMZARIC PB ST; QL

RAZADYNE ER NPB ST; M; QL

RAZADYNE ORAL TABLET 12 MG NPB ST; M

RAZADYNE ORAL TABLET 4 MG, 8 MG NPB ST; M; QL

rivastigmine G M; QL

rivastigmine tartrate G M; QL

Antidepressants

amitriptyline hcl oral G

amoxapine G

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Drug Name Drug Tier Restrictions / Limits

ANAFRANIL NPB

APLENZIN NPB ST; M; QL

BRISDELLE NPB ST; M; QL

bupropion hcl er (sr) G M; QL

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

G M; QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

NPB ST; M; QL

bupropion hcl oral G M

CELEXA NPB ST; M; QL

chlordiazepoxide-amitriptyline G

citalopram hydrobromide oral solution G M

citalopram hydrobromide oral tablet G M; QL

clomipramine hcl oral G

CYMBALTA NPB ST; M; QL

desipramine hcl oral G

DESVENLAFAXINE ER NPB ST; M; QL

desvenlafaxine succinate er G M; QL

doxepin hcl oral capsule G

doxepin hcl oral concentrate G

duloxetine hcl oral G M; QL

EFFEXOR XR NPB ST; M; QL

EMSAM NPB QL

escitalopram oxalate oral solution G M

escitalopram oxalate oral tablet G M; QL

FETZIMA PB ST; M; QL

FETZIMA TITRATION PB ST; M; QL

fluoxetine hcl (pmdd) oral tablet 10 mg G M; QL

fluoxetine hcl (pmdd) oral tablet 20 mg G M

fluoxetine hcl oral capsule G M; QL

fluoxetine hcl oral capsule delayed release G M; QL

fluoxetine hcl oral solution G M

fluoxetine hcl oral tablet 10 mg, 20 mg G M; QL

fluoxetine hcl oral tablet 60 mg G M

fluvoxamine maleate G M

fluvoxamine maleate er G M; QL

FORFIVO XL NPB ST; M; QL

imipramine hcl oral G

imipramine pamoate G

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Drug Name Drug Tier Restrictions / Limits

KHEDEZLA NPB ST; M; QL

LEXAPRO NPB ST; M; QL

maprotiline hcl G

MARPLAN NPB

mirtazapine oral G QL

NARDIL NPB

nefazodone hcl G M

NORPRAMIN NPB

nortriptyline hcl oral G

olanzapine-fluoxetine hcl G QL

PAMELOR NPB

PARNATE NPB

paroxetine hcl G M; QL

paroxetine hcl er G M; QL

paroxetine mesylate G M; QL

PAXIL CR NPB ST; M; QL

PAXIL ORAL SUSPENSION NPB ST; M

PAXIL ORAL TABLET NPB ST; M; QL

perphenazine-amitriptyline G

PEXEVA NPB ST; M; QL

phenelzine sulfate oral G

PRISTIQ NPB ST; M; QL

protriptyline hcl G

PROZAC NPB ST; M; QL

REMERON NPB QL

REMERON SOLTAB NPB QL

SARAFEM ORAL TABLET 10 MG NPB ST; M; QL

SARAFEM ORAL TABLET 20 MG NPB ST; M

sertraline hcl oral concentrate G M

sertraline hcl oral tablet G M; QL

SPRAVATO (56 MG DOSE) NPB-S PA

SPRAVATO (84 MG DOSE) NPB-S PA

SYMBYAX NPB QL

tranylcypromine sulfate G

trazodone hcl oral G

trimipramine maleate oral G

TRINTELLIX NPB ST; QL

venlafaxine hcl G M; QL

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Drug Name Drug Tier Restrictions / Limits

venlafaxine hcl er oral capsule extended release 24 hour

G M; QL

venlafaxine hcl er oral tablet extended release 24 hour

G ST; M; QL

VIIBRYD PB ST; M; QL

VIIBRYD STARTER PACK PB ST; M; QL

WELLBUTRIN SR NPB ST; M; QL

WELLBUTRIN XL NPB ST; M; QL

ZOLOFT ORAL CONCENTRATE NPB ST; M

ZOLOFT ORAL TABLET NPB ST; M; QL

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO ORAL PB QL

ANZEMET NPB QL

aprepitant G QL

BONJESTA NPB QL

compro G

DICLEGIS NPB QL

dimenhydrinate injection G

doxylamine-pyridoxine G QL

dronabinol G QL

EMEND ORAL NPB QL

EMEND TRI-PACK NPB QL

granisetron hcl oral G QL

MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG

NPB QL

metoclopramide hcl oral G

ONDANSETRON HCL INJECTION SOLUTION 4 MG/2ML

NPB

ondansetron hcl oral G QL

ondansetron odt G QL

perphenazine oral G

prochlorperazine G

prochlorperazine maleate oral G

REGLAN NPB

SANCUSO PB QL

scopolamine G

SYNDROS NPB QL

TIGAN ORAL NPB

TRANSDERM SCOP (1.5 MG) NPB

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Drug Name Drug Tier Restrictions / Limits

TRANSDERM-SCOP (1.5 MG) NPB

trimethobenzamide hcl oral G

VARUBI PB QL

ZOFRAN NPB QL

ZUPLENZ NPB QL

Antifungals

ACTIVE-PREP KIT V NPB

ANCOBON NPB

AVC VAGINAL NPB

BIO-STATIN ORAL CAPSULE NPB

bio-statin oral powder G

ciclodan G

CICLODAN SOLUTION NPB ST

ciclopirox G

ciclopirox olamine external G

clotrimazole mouth/throat G

CRESEMBA ORAL PB

DIFLUCAN ORAL SUSPENSION RECONSTITUTED

NPB

DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG

NPB

DIFLUCAN ORAL TABLET 150 MG NPB QL

econazole nitrate external G

ECOZA NPB

ERTACZO NPB

EXELDERM NPB

exoderm external lotion NPB

EXTINA NPB

fluconazole oral suspension reconstituted G

fluconazole oral tablet 100 mg, 200 mg, 50 mg G

fluconazole oral tablet 150 mg G QL

flucytosine oral G

griseofulvin microsize oral G

griseofulvin ultramicrosize G

GYNAZOLE-1 NPB

itraconazole oral capsule G QL

itraconazole oral solution G

JUBLIA NPB ST; QL

KERYDIN NPB ST; QL

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Drug Name Drug Tier Restrictions / Limits

ketoconazole external G

ketoconazole oral G

ketodan external foam G

LOPROX EXTERNAL CREAM NPB

LOPROX EXTERNAL KIT 0.77 % (SUSP) NPB

LOPROX EXTERNAL SHAMPOO NPB

LOPROX EXTERNAL SUSPENSION NPB

LULICONAZOLE NPB ST; QL

LUZU NPB ST; QL

MENTAX NPB

miconazole 3 vaginal suppository G QL

MICONAZOLE-ZINC OXIDE-PETROLAT NPB

naftifine hcl G

NAFTIN NPB

NIZORAL NPB

NOXAFIL ORAL SUSPENSION PB

NOXAFIL ORAL TABLET DELAYED RELEASE NPB

nyamyc G

nystatin external G

nystatin mouth/throat G

nystatin oral G

nystatin-triamcinolone G

nystop G

ORAVIG NPB

oxiconazole nitrate G

OXISTAT NPB

PENLAC NPB ST

posaconazole G

RECURA NPB

SPORANOX ORAL CAPSULE NPB QL

SPORANOX ORAL SOLUTION NPB

SPORANOX PULSEPAK NPB QL

terbinafine hcl oral G QL

terconazole G QL

TOLSURA NPB ST

VFEND NPB

voriconazole oral G

VUSION NPB

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Drug Name Drug Tier Restrictions / Limits

XOLEGEL NPB

XOLEGEL COREPAK NPB

XOLEGEL DUO/HEAD & SHOULDERS NPB

XOLEGEL DUO/XOLEX NPB

Antigout Agents

allopurinol oral G M

COLCHICINE ORAL CAPSULE NPB ST

colchicine tablet 0.6 mg oral G

COLCHICINE TABLET 0.6 MG ORAL NPB ST

colchicine-probenecid G

COLCRYS PB

febuxostat G ST; M

MITIGARE PB

probenecid G M

ULORIC PB ST; M

ZYLOPRIM NPB M

Anti-inflammatory Agents

EMFLAZA NPB-S PA

Antimigraine Agents

AIMOVIG PB PA; M

AJOVY PB PA; M

almotriptan malate G QL

AMERGE NPB ST; QL

CAFERGOT NPB

D.H.E. 45 NPB

dihydroergotamine mesylate injection G

dihydroergotamine mesylate nasal G QL

eletriptan hydrobromide G QL

EMGALITY PB PA; M

EMGALITY (300 MG DOSE) PB PA; M

ERGOMAR NPB

ergotamine-caffeine G

FROVA NPB ST; QL

frovatriptan succinate G QL

IMITREX NPB ST; QL

IMITREX STATDOSE REFILL NPB ST; QL

IMITREX STATDOSE SYSTEM NPB ST; QL

MAXALT NPB ST; QL

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Drug Name Drug Tier Restrictions / Limits

MAXALT-MLT NPB ST; QL

MIGERGOT G

MIGRANAL NPB QL

naratriptan hcl G QL

ONZETRA XSAIL NPB ST; QL

RELPAX NPB ST; QL

rizatriptan benzoate G QL

sumatriptan nasal G QL

sumatriptan succinate oral G QL

sumatriptan succinate refill G QL

sumatriptan succinate subcutaneous G QL

sumatriptan-naproxen sodium G QL

TREXIMET NPB ST; QL

ZEMBRACE SYMTOUCH NPB ST; QL

zolmitriptan oral G QL

ZOMIG NASAL PB ST; QL

ZOMIG ORAL NPB ST; QL

ZOMIG ZMT NPB ST; QL

Antimyasthenic Agents

GUANIDINE HCL G

MESTINON ORAL TABLET NPB M

MESTINON ORAL TABLET EXTENDED RELEASE

NPB M

pyridostigmine bromide er G M

pyridostigmine bromide oral tablet G M

Antimycobacterials

cycloserine oral NPB

dapsone oral G

ethambutol hcl oral G

isoniazid oral G

MYAMBUTOL NPB

MYCOBUTIN NPB

PASER NPB

PRIFTIN PB

pyrazinamide oral G

rifabutin G

RIFADIN ORAL NPB

RIFAMATE NPB

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Drug Name Drug Tier Restrictions / Limits

rifampin oral G

RIFAMPIN+SYRSPEND SF NPB

RIFATER NPB

SIRTURO PB-S

TRECATOR NPB

Antineoplastics - Drugs for Cancer

abiraterone acetate G-S QL

AFINITOR PB-S QL

AFINITOR DISPERZ PB-S QL

ALECENSA PB-S

ALKERAN ORAL NPB

ALUNBRIG NPB-S PA; QL

anastrozole oral G

ARIMIDEX NPB ST

AROMASIN NPB

BALVERSA NPB PA

bexarotene G-S

bicalutamide G

BOSULIF PB-S

BRAFTOVI NPB-S PA

CABOMETYX PB-S QL

CALQUENCE NPB-S PA

capecitabine G-S

CAPRELSA PB-S QL

CASODEX NPB

COMETRIQ (100 MG DAILY DOSE) NPB-S QL

COMETRIQ (140 MG DAILY DOSE) NPB-S QL

COMETRIQ (60 MG DAILY DOSE) NPB-S QL

COPIKTRA NPB-S PA

COTELLIC PB-S

cyclophosphamide oral G

DAURISMO NPB-S PA

DROXIA PB-S

EMCYT PB-S

ERIVEDGE PB-S

ERLEADA PB-S PA

erlotinib hcl oral tablet 100 mg, 150 mg G-S

erlotinib hcl oral tablet 25 mg G-S QL

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Drug Name Drug Tier Restrictions / Limits

etoposide oral G-S

everolimus G QL

exemestane G

FARESTON NPB-S

FARYDAK NPB-S

FEMARA NPB

flutamide G

GILOTRIF PB-S QL

GLEEVEC NPB-S ST; QL

GLEOSTINE PB-S

HYCAMTIN ORAL PB-S

HYDREA NPB

hydroxyurea oral G

IBRANCE PB-S

ICLUSIG ORAL TABLET 15 MG PB-S QL

ICLUSIG ORAL TABLET 45 MG PB-S

IDHIFA PB-S PA; QL

imatinib mesylate G-S QL

IMBRUVICA PB-S

INLYTA PB-S QL

IRESSA PB-S

JAKAFI ORAL TABLET 10 MG PB-S QL

JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG

PB-S

KISQALI (200 MG DOSE) NPB-S PA

KISQALI (400 MG DOSE) NPB-S PA

KISQALI (600 MG DOSE) NPB-S PA

KISQALI FEMARA (400 MG DOSE) NPB-S PA

KISQALI FEMARA (600 MG DOSE) NPB-S PA

KISQALI FEMARA(200 MG DOSE) NPB-S PA

LENVIMA (10 MG DAILY DOSE) PB-S

LENVIMA (12 MG DAILY DOSE) PB-S

LENVIMA (14 MG DAILY DOSE) PB-S

LENVIMA (18 MG DAILY DOSE) PB-S

LENVIMA (20 MG DAILY DOSE) PB-S

LENVIMA (24 MG DAILY DOSE) PB-S

LENVIMA (4 MG DAILY DOSE) PB-S

LENVIMA (8 MG DAILY DOSE) PB-S

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Drug Name Drug Tier Restrictions / Limits

letrozole oral G

leucovorin calcium oral G

LEUKERAN PB

LONSURF PB-S

LORBRENA PB-S PA

LYNPARZA PB-S

LYSODREN PB-S

MATULANE PB-S

MEKINIST PB-S

MEKTOVI NPB-S PA

melphalan G

mercaptopurine oral G

MESNEX ORAL PB

MYLERAN PB-S

NERLYNX PB-S PA; QL

NEXAVAR PB-S QL

NILANDRON NPB-S

nilutamide G-S

NINLARO PB-S

ODOMZO NPB-S

PANRETIN NPB

PIQRAY (200 MG DAILY DOSE) PB-S PA

PIQRAY (250 MG DAILY DOSE) PB-S PA

PIQRAY (300 MG DAILY DOSE) PB-S PA

POMALYST PB-S QL

PURIXAN PB-S

REVLIMID PB-S

RUBRACA PB-S PA

RYDAPT PB-S PA

SIKLOS NPB-S ST

SOLTAMOX NPB ACA

SPRYCEL PB-S QL

STIVARGA PB-S

SUTENT PB-S QL

TABLOID PB-S

TAFINLAR PB-S

TAGRISSO ORAL TABLET 40 MG PB-S QL

TAGRISSO ORAL TABLET 80 MG PB-S

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Drug Name Drug Tier Restrictions / Limits

TALZENNA PB-S PA

tamoxifen citrate oral G ACA

TARCEVA ORAL TABLET 100 MG, 150 MG PB-S

TARCEVA ORAL TABLET 25 MG PB-S QL

TARGRETIN EXTERNAL PB

TARGRETIN ORAL NPB-S

TASIGNA PB-S QL

TEMODAR ORAL NPB-S

temozolomide G-S

THALOMID PB-S

TIBSOVO PB-S PA

toremifene citrate G-S

tretinoin oral G-S

TURALIO NPB

TYKERB PB-S QL

VALCHLOR PB-S

VENCLEXTA PB-S

VENCLEXTA STARTING PACK PB-S

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG

PB-S

VERZENIO ORAL TABLET 50 MG PB-S PA

VITRAKVI PB-S PA

VIZIMPRO PB-S PA

VOTRIENT PB-S QL

XALKORI ORAL CAPSULE 200 MG PB-S PA; QL

XALKORI ORAL CAPSULE 250 MG PB-S QL

XELODA NPB-S

XOSPATA PB-S PA

XTANDI PB-S QL

YONSA PB-S PA

ZEJULA PB-S PA

ZELBORAF PB-S QL

ZOLINZA PB-S QL

ZYDELIG PB-S

ZYKADIA PB-S

ZYTIGA ORAL TABLET 250 MG NPB-S QL

ZYTIGA ORAL TABLET 500 MG PB-S QL

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Drug Name Drug Tier Restrictions / Limits

Antiparasitics

albendazole oral G

ALBENZA NPB

ALINIA PB

ARAKODA NPB

atovaquone oral G

atovaquone-proguanil hcl G

BENZNIDAZOLE PB

BILTRICIDE NPB

chloroquine phosphate oral G

COARTEM PB

crotan G

DARAPRIM PB-S PA

EGATEN NPB

ELIMITE NPB

EMVERM PB

EURAX EXTERNAL CREAM 10 % NPB

EURAX EXTERNAL LOTION 10 % NPB

hydroxychloroquine sulfate oral G M

IMPAVIDO PB-S

ivermectin oral G

KRINTAFEL NPB

lindane G QL

MALARONE NPB

malathion G

mefloquine hcl G

MEPRON NPB

NATROBA NPB QL

NEBUPENT NPB QL

OVIDE NPB

pentamidine isethionate inhalation G QL

permethrin external G

PLAQUENIL NPB ST; M

praziquantel oral G

primaquine phosphate PB

QUALAQUIN NPB

quinine sulfate oral G

SKLICE NPB

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Drug Name Drug Tier Restrictions / Limits

spinosad G QL

STROMECTOL NPB

sulfurated lime G

ULESFIA NPB

Antiparkinson Agents

amantadine hcl oral G M

APOKYN PB-S QL

AZILECT NPB M

benztropine mesylate oral G

bromocriptine mesylate oral G

carbidopa oral G M

carbidopa-levodopa G M

carbidopa-levodopa er G M

carbidopa-levodopa-entacapone G M

COMTAN NPB M

entacapone G M

GOCOVRI NPB-S PA; M

INBRIJA NPB

LODOSYN NPB M

MIRAPEX NPB M

MIRAPEX ER NPB M

NEUPRO NPB M

OSMOLEX ER NPB ST; M

PARLODEL NPB

pramipexole dihydrochloride G M

pramipexole dihydrochloride er G M

rasagiline mesylate oral G M

REQUIP XL NPB M

ropinirole hcl G M

ropinirole hcl er G M

RYTARY NPB M

selegiline hcl oral G M

SINEMET NPB M

SINEMET CR NPB M

STALEVO 100 NPB M

STALEVO 125 NPB M

STALEVO 150 NPB M

STALEVO 200 NPB M

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Drug Name Drug Tier Restrictions / Limits

STALEVO 50 NPB M

STALEVO 75 NPB M

TASMAR NPB M

tolcapone G M

trihexyphenidyl hcl oral elixir G

trihexyphenidyl hcl oral tablet G

XADAGO NPB ST; M; QL

ZELAPAR NPB M

Antiplatelets

AGGRENOX NPB M

aspirin-dipyridamole er G M

BRILINTA PB M

CABLIVI NPB-S PA; QL

cilostazol G M

clopidogrel bisulfate oral G M

dipyridamole oral G M

DURLAZA NPB ST

EFFIENT NPB ST; M

PLAVIX NPB ST; M

prasugrel hcl G M

ZONTIVITY PB M

Antipsychotics - Drugs for Mood Disorders

ABILIFY NPB-S ST; QL

ABILIFY MAINTENA PB

ABILIFY MYCITE NPB-S PA; QL

ADASUVE NPB

aripiprazole G QL

ARISTADA PB

ARISTADA INITIO PB

chlorpromazine hcl injection G

chlorpromazine hcl oral G

clozapine oral tablet G QL

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

G QL

clozapine oral tablet dispersible 150 mg, 200 mg NPB QL

CLOZARIL NPB QL

FANAPT NPB QL

FANAPT TITRATION PACK NPB QL

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Drug Name Drug Tier Restrictions / Limits

fluphenazine hcl G

GEODON INTRAMUSCULAR NPB

GEODON ORAL NPB QL

HALDOL DECANOATE NPB

haloperidol decanoate intramuscular G

haloperidol lactate oral G

haloperidol oral G

INVEGA NPB QL

INVEGA SUSTENNA NPB

INVEGA TRINZA NPB

LATUDA PB QL

loxapine succinate G

molindone hcl G

NUPLAZID NPB-S

olanzapine oral G QL

paliperidone er G QL

PERSERIS NPB

pimozide G

quetiapine fumarate G QL

quetiapine fumarate er G QL

REXULTI NPB QL

RISPERDAL NPB QL

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG

PB

risperidone G QL

SAPHRIS NPB QL

SEROQUEL NPB ST; QL

SEROQUEL XR NPB ST; QL

thioridazine hcl oral G

thiothixene G

trifluoperazine hcl G

VERSACLOZ NPB QL

VRAYLAR NPB QL

ziprasidone hcl G QL

ZYPREXA ORAL NPB QL

ZYPREXA RELPREVV NPB

ZYPREXA ZYDIS NPB QL

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Drug Name Drug Tier Restrictions / Limits

Antivirals

abacavir sulfate G QL

abacavir sulfate-lamivudine G QL

abacavir-lamivudine-zidovudine G QL

acyclovir external G QL

acyclovir oral G

adefovir dipivoxil G

APTIVUS PB QL

atazanavir sulfate G

ATRIPLA PB ST; QL

BARACLUDE ORAL SOLUTION PB QL

BARACLUDE ORAL TABLET NPB ST; QL

BIKTARVY PB

CIMDUO PB

COMBIVIR NPB QL

COMPLERA PB QL

CRIXIVAN PB QL

DELSTRIGO NPB ST

DENAVIR NPB

DESCOVY PB

didanosine G QL

DOVATO NPB

EDURANT PB QL

efavirenz G QL

EMTRIVA PB QL

entecavir G QL

EPCLUSA PB-S PA; QL

EPIVIR NPB QL

EPIVIR HBV ORAL SOLUTION PB

EPIVIR HBV ORAL TABLET NPB QL

EPZICOM NPB QL

EVOTAZ NPB QL

famciclovir G

fosamprenavir calcium G QL

FUZEON PB

GENVOYA PB

HARVONI PB-S PA; QL

HEPSERA NPB

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Drug Name Drug Tier Restrictions / Limits

INTELENCE PB QL

INTRON A PB-S

INVIRASE PB QL

ISENTRESS PB QL

ISENTRESS HD PB

JULUCA NPB

KALETRA ORAL SOLUTION NPB QL

KALETRA ORAL TABLET PB QL

lamivudine G QL

lamivudine-zidovudine G QL

LEXIVA ORAL SUSPENSION PB QL

LEXIVA ORAL TABLET NPB QL

lopinavir-ritonavir G QL

MAVYRET NPB-S PA; QL

nevirapine G QL

nevirapine er G QL

NORVIR ORAL PACKET PB

NORVIR ORAL SOLUTION PB QL

NORVIR ORAL TABLET NPB QL

ODEFSEY PB

oseltamivir phosphate oral G QL

PEGASYS PB-S QL

PEGASYS PROCLICK PB-S QL

PEGINTRON NPB-S QL

PIFELTRO NPB ST

PREVYMIS ORAL PB

PREZCOBIX NPB

PREZISTA PB QL

RELENZA DISKHALER PB QL

RESCRIPTOR PB QL

RETROVIR ORAL NPB QL

REYATAZ ORAL CAPSULE NPB

REYATAZ ORAL PACKET PB

ribavirin inhalation G-S

ribavirin oral G-S

rimantadine hcl G

ritonavir G QL

SELZENTRY ORAL SOLUTION PB

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Drug Name Drug Tier Restrictions / Limits

SELZENTRY ORAL TABLET 150 MG, 300 MG PB QL

SELZENTRY ORAL TABLET 25 MG, 75 MG PB

SITAVIG NPB QL

SOVALDI NPB-S PA; QL

stavudine G QL

STRIBILD PB QL

SUSTIVA NPB QL

SYLATRON PB-S QL

SYMFI PB

SYMFI LO PB

SYMTUZA NPB

TAMIFLU NPB QL

tenofovir disoproxil fumarate G QL

TIVICAY ORAL TABLET 10 MG, 25 MG PB

TIVICAY ORAL TABLET 50 MG PB QL

TRIUMEQ PB QL

TRIZIVIR NPB QL

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG

PB

TRUVADA ORAL TABLET 200-300 MG PB QL

TYBOST NPB QL

valacyclovir hcl oral G QL

VALCYTE NPB

valganciclovir hcl G

VALTREX NPB ST; QL

VEMLIDY PB

VIDEX PB QL

VIDEX EC NPB QL

VIEKIRA PAK NPB-S PA; QL

VIRACEPT PB QL

VIRAMUNE NPB QL

VIRAMUNE XR NPB QL

VIRAZOLE NPB-S

VIREAD ORAL POWDER PB QL

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

PB QL

VIREAD ORAL TABLET 300 MG NPB QL

VOSEVI PB-S PA

XERESE NPB ST; QL

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Drug Name Drug Tier Restrictions / Limits

XOFLUZA PB QL

ZEPATIER PB-S PA; QL

ZIAGEN NPB QL

zidovudine G QL

ZOVIRAX EXTERNAL NPB QL

ZOVIRAX ORAL NPB

Anxiolytics - Drugs for Anxiety

alprazolam er G QL

alprazolam intensol G QL

alprazolam oral G QL

alprazolam xr G QL

ATIVAN ORAL NPB QL

buspirone hcl oral G M

chlordiazepoxide hcl G QL

clonazepam oral G QL

clorazepate dipotassium G QL

diazepam intensol G

diazepam oral G

DORAL NPB QL

estazolam G QL

HALCION NPB QL

hydroxyzine hcl oral G

hydroxyzine pamoate oral G

KLONOPIN NPB QL

lorazepam intensol G QL

lorazepam oral concentrate 2 mg/ml G QL

lorazepam oral tablet G QL

meprobamate G

oxazepam G QL

quazepam G QL

TRANXENE-T NPB QL

triazolam G QL

VALIUM NPB ST

VISTARIL NPB

XANAX NPB ST; QL

XANAX XR NPB ST; QL

Bipolar Agents - Drugs for Mood Disorders

lithium G

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Drug Name Drug Tier Restrictions / Limits

lithium carbonate er G

lithium carbonate oral G

LITHOBID NPB

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

AGRYLIN NPB M

AMICAR NPB

aminocaproic acid oral G

anagrelide hcl G M

DOPTELET PB-S PA

LYSTEDA NPB

MONSELS FERRIC SUBSULFATE PB

MULPLETA PB-S PA

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG

NPB

PROMACTA PB PA

TAVALISSE NPB-S PA

THROMBIN-JMI NPB

THROMBIN-JMI EPISTAXIS NPB

THROMBOGEN NPB

tranexamic acid oral G

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL NPB M

ACCURETIC NPB ST; M

acebutolol hcl oral G M

acetazolamide oral tablet 125 mg G M

ADALAT CC NPB ST; M

ALDACTAZIDE NPB M

ALDACTONE NPB M

aliskiren fumarate G M

ALTACE NPB M

ALTOPREV NPB ST; M; QL

amiloride hcl oral G M

amiloride-hydrochlorothiazide G M

amiodarone hcl oral G M

AMLODIPINE BES+SYRSPEND SF NPB ST; M

amlodipine besylate oral G M

amlodipine besylate-benazepril hcl G M

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Drug Name Drug Tier Restrictions / Limits

amlodipine besylate-valsartan G M

amlodipine-atorvastatin G M; QL

amlodipine-olmesartan G M

amlodipine-valsartan-hctz G M

ANTARA NPB ST; M; QL

ATACAND NPB ST; M

ATACAND HCT NPB ST; M

atenolol oral G M

ATENOLOL+SYRSPEND SF NPB ST; M

atenolol-chlorthalidone G M

atorvastatin calcium oral tablet 10 mg, 20 mg G M; ACA; QL

atorvastatin calcium oral tablet 40 mg, 80 mg G M; QL

AVALIDE NPB ST; M

AVAPRO NPB ST; M

AZOR NPB ST; M

benazepril hcl oral G M

benazepril-hydrochlorothiazide G M

BENICAR NPB ST; M

BENICAR HCT NPB ST; M

BETAPACE NPB ST; M

BETAPACE AF NPB ST; M

betaxolol hcl oral G M

BIDIL NPB M

bisoprolol fumarate G M

bisoprolol-hydrochlorothiazide G M

BRETYLIUM TOSYLATE NPB

bumetanide oral G M

BUMEX NPB M

BYSTOLIC PB ST; M

CADUET NPB ST; M; QL

CALAN SR NPB ST; M

candesartan cilexetil G M

candesartan cilexetil-hctz G M

captopril oral G M

captopril-hydrochlorothiazide G M

CARDIZEM NPB ST; M

CARDIZEM CD NPB ST; M

CARDIZEM LA NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

CARDURA NPB ST; M; QL

CAROSPIR NPB ST; M

cartia xt G M

carvedilol G M

carvedilol phosphate er G M

CATAPRES NPB M

CATAPRES-TTS-1 NPB M; QL

CATAPRES-TTS-2 NPB M; QL

CATAPRES-TTS-3 NPB M; QL

chlorothiazide G M

chlorthalidone G M

cholestyramine light G M

cholestyramine oral G M

choline fenofibrate G M; QL

clonidine G M; QL

clonidine hcl oral G M

colesevelam hcl G M

COLESTID NPB ST; M

COLESTID FLAVORED NPB ST; M

colestipol hcl G M

COREG NPB ST; M

COREG CR NPB ST; M

CORGARD NPB ST; M

CORLANOR ORAL SOLUTION NPB M; QL

CORLANOR ORAL TABLET PB M; QL

COZAAR NPB ST; M

CRESTOR NPB ST; M; QL

DEMSER PB

DIBENZYLINE NPB

digitek G M

digox G M

digoxin oral G M

DILATRATE-SR PB M

diltiazem hcl er beads G M

diltiazem hcl er coated beads G M

diltiazem hcl er oral capsule extended release 12 hour

G M

diltiazem hcl oral G M

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Drug Name Drug Tier Restrictions / Limits

dilt-xr G M

DIOVAN NPB ST; M

DIOVAN HCT NPB ST; M

disopyramide phosphate G M

DIURIL NPB M

dofetilide G

doxazosin mesylate oral G M; QL

DUTOPROL NPB ST; M

DYAZIDE NPB M

DYRENIUM NPB M

EDARBI PB ST; M

EDARBYCLOR PB ST; M

EDECRIN NPB M

enalapril maleate oral G M

enalapril-hydrochlorothiazide G M

ENTRESTO PB M; QL

EPANED NPB M

eplerenone G M

eprosartan mesylate G M

ethacrynic acid G M

EXFORGE NPB ST; M

EXFORGE HCT NPB ST; M

EZALLOR SPRINKLE NPB ST; M

ezetimibe G M

ezetimibe-simvastatin G M; QL

felodipine er G M

fenofibrate micronized G M; QL

fenofibrate oral capsule 134 mg, 200 mg, 67 mg G M; QL

fenofibrate oral capsule 150 mg, 50 mg NPB M; QL

fenofibrate oral tablet G M; QL

fenofibric acid G M; QL

FENOGLIDE NPB ST; M; QL

FIBRICOR NPB ST; M; QL

FIRST - METOPROLOL NPB ST; M

FIRST-ATENOLOL NPB ST; M

flecainide acetate G M

FLOLIPID NPB ST; M

fluvastatin sodium G M; ACA; QL

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Drug Name Drug Tier Restrictions / Limits

fluvastatin sodium er G M; ACA; QL

fosinopril sodium G M

fosinopril sodium-hctz G M

furosemide oral G M

gemfibrozil oral G M; QL

GONITRO NPB M

guanfacine hcl G M

HEMANGEOL NPB-S M

hydralazine hcl oral G M

hydrochlorothiazide oral G M

HYZAAR NPB ST; M

indapamide G M

INDERAL LA NPB ST; M

INDERAL XL NPB ST; M

INNOPRAN XL NPB ST; M

INSPRA NPB M

irbesartan G M

irbesartan-hydrochlorothiazide G M

ISORDIL TITRADOSE NPB M

isosorbide dinitrate G M

isosorbide mononitrate G M

isosorbide mononitrate er G M

isoxsuprine hcl oral G M

isradipine G M

JUXTAPID PB-S PA; QL

KAPSPARGO SPRINKLE NPB ST; M

labetalol hcl oral G M

LANOXIN ORAL NPB M

LASIX NPB M

LESCOL XL NPB ST; M; QL

LIPITOR NPB ST; M; QL

LIPOFEN PB ST; M; QL

lisinopril oral G M

lisinopril-hydrochlorothiazide G M

LIVALO PB ST; M; QL

LOPID NPB ST; M; QL

LOPRESSOR NPB ST; M

LOPRESSOR HCT NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

losartan potassium G M

losartan potassium-hctz G M

LOTENSIN NPB M

LOTENSIN HCT NPB ST; M

LOTREL NPB ST; M

lovastatin G M; ACA; QL

LOVAZA NPB PA; M

matzim la G M

MAXZIDE NPB M

MAXZIDE-25 NPB ST; M

methyldopa G M

methyldopa-hydrochlorothiazide G M

metolazone G M

metoprolol succinate er G M

metoprolol tartrate oral G M

metoprolol-hydrochlorothiazide G M

mexiletine hcl oral G M

MICARDIS NPB ST; M

MICARDIS HCT NPB ST; M

midodrine hcl G

MINIPRESS NPB M

minitran G M

minoxidil oral G M

moexipril hcl G M

MULTAQ NPB M

nadolol oral G M

niacin (antihyperlipidemic) G M

niacin er (antihyperlipidemic) G M

niacor G M

NIASPAN NPB M

nicardipine hcl oral G M

nifedipine er G M

nifedipine er osmotic release G M

nifedipine oral G M

nimodipine oral G

nisoldipine er G M

NITRO-BID G M

NITRO-DUR NPB M

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Drug Name Drug Tier Restrictions / Limits

nitroglycerin sublingual G M

nitroglycerin transdermal G M

NITROMIST NPB M

NITROSTAT NPB M

nitro-time G M

NORPACE NPB M

NORPACE CR NPB M

NORTHERA NPB-S PA

NORVASC NPB ST; M

NYMALIZE NPB ST

olmesartan medoxomil oral G M

olmesartan medoxomil-hctz G M

olmesartan-amlodipine-hctz G M

OMEGA-3/D-3 WELLNESS PACK NPB

omega-3-acid ethyl esters G PA; M

PACERONE ORAL TABLET 100 MG, 400 MG NPB M

pacerone oral tablet 200 mg G M

papaverine hcl injection G

pentoxifylline er G M

perindopril erbumine G M

phenoxybenzamine hcl oral G

pindolol G M

PRALUENT PB PA; QL

PRAVACHOL NPB ST; M; QL

pravastatin sodium G M; ACA; QL

prazosin hcl oral G M

PRESTALIA NPB ST; M

prevalite G M

PRINIVIL NPB M

PROCARDIA NPB ST; M

PROCARDIA XL NPB ST; M

propafenone hcl G M

propafenone hcl er G M

propranolol hcl er G M

propranolol hcl oral G M

propranolol-hctz G M

QBRELIS NPB M

QUESTRAN NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

QUESTRAN LIGHT NPB ST; M

quinapril hcl G M

quinapril-hydrochlorothiazide G M

quinidine gluconate er G M

quinidine sulfate G M

ramipril G M

RANEXA NPB M

ranolazine er G M

RECTIV PB

REPATHA PB PA; QL

REPATHA PUSHTRONEX SYSTEM PB PA; QL

REPATHA SURECLICK PB PA; QL

rosuvastatin calcium oral tablet 10 mg, 5 mg G M; ACA; QL

rosuvastatin calcium oral tablet 20 mg, 40 mg G M; QL

RYTHMOL SR NPB M

SIMVASTATIN ORAL SUSPENSION NPB ST; M

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

G M; ACA; QL

simvastatin oral tablet 80 mg G M; QL

sorine G M

sotalol hcl (af) G M

sotalol hcl oral G M

spironolactone oral G M

spironolactone-hctz G M

SULAR NPB ST; M

SURE RESULT O3D3 SYSTEM NPB

TARKA NPB ST; M

taztia xt G M

TEKTURNA NPB ST; M

TEKTURNA HCT PB ST; M

telmisartan G M

telmisartan-amlodipine G M

telmisartan-hctz G M

TENORETIC 100 NPB ST; M

TENORETIC 50 NPB ST; M

TENORMIN NPB ST; M

tiadylt er G M

TIAZAC NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

TIKOSYN NPB ST

timolol maleate oral G M

TOPROL XL NPB ST; M

torsemide G M

trandolapril G M

trandolapril-verapamil hcl er G M

triamterene oral G M

triamterene-hctz G M

TRIBENZOR NPB ST; M

TRICOR NPB ST; M; QL

TRIGLIDE NPB ST; M; QL

TRILIPIX NPB ST; M; QL

TWYNSTA NPB ST; M

valsartan G M

valsartan-hydrochlorothiazide G M

VASCEPA PB PA; M

VASERETIC NPB ST; M

VASOTEC NPB M

VECAMYL NPB-S

verapamil hcl er G M

verapamil hcl oral G M

VERELAN NPB ST; M

VERELAN PM NPB ST; M

VYNDAQEL NPB-S PA; QL

VYTORIN NPB ST; M; QL

WELCHOL NPB ST; M

ZESTORETIC NPB ST; M

ZESTRIL NPB M

ZETIA NPB ST; M

ZIAC NPB ST; M

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

NPB ST; M; QL

ZYPITAMAG NPB ST; M

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL NPB ST; QL

ADDERALL XR NPB ST; QL

ADHANSIA XR NPB ST; QL

ADZENYS ER NPB ST; QL

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Drug Name Drug Tier Restrictions / Limits

ADZENYS XR-ODT NPB ST; QL

amphetamine sulfate G QL

amphetamine-dextroamphetamine G QL

amphetamine-dextroamphetamine er G QL

APTENSIO XR NPB ST; QL

atomoxetine hcl G QL

clonidine hcl er G QL

CONCERTA NPB ST; QL

COTEMPLA XR-ODT NPB ST; QL

DAYTRANA PB ST; QL

DESOXYN NPB ST; QL

DEXEDRINE NPB ST; QL

dexmethylphenidate hcl G QL

dexmethylphenidate hcl er G QL

dextroamphetamine sulfate G QL

dextroamphetamine sulfate er G QL

DYANAVEL XR NPB ST; QL

EVEKEO NPB ST; QL

EVEKEO ODT NPB ST; QL

FOCALIN NPB ST; QL

FOCALIN XR NPB ST; QL

guanfacine hcl er G QL

INTUNIV NPB ST; QL

JORNAY PM NPB ST; QL

KAPVAY NPB ST; QL

metadate er G QL

methamphetamine hcl G QL

METHYLIN NPB ST; QL

methylphenidate hcl er (cd) G QL

methylphenidate hcl er (la) G QL

methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

G QL

methylphenidate hcl er oral tablet extended release 24 hour

G QL

methylphenidate hcl er oral tablet extended release 72 mg

NPB QL

methylphenidate hcl oral G QL

MYDAYIS PB QL

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Drug Name Drug Tier Restrictions / Limits

PROCENTRA G ST; QL

QUILLICHEW ER PB ST; QL

QUILLIVANT XR PB ST; QL

relexxii NPB QL

RITALIN NPB ST; QL

RITALIN LA NPB ST; QL

STRATTERA NPB ST; QL

VYVANSE PB QL

ZENZEDI NPB ST; QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA NPB-S ST; QL

AUBAGIO NPB-S QL

AVONEX PEN PB-S QL

AVONEX PREFILLED PB-S QL

BETASERON PB-S QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML

NPB-S ST; QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML

PB-S ST; QL

dalfampridine er G-S PA; QL

EXTAVIA NPB-S ST; QL

GILENYA PB-S QL

glatiramer acetate G-S QL

glatopa G-S QL

MAVENCLAD (10 TABS) NPB-S PA

MAVENCLAD (4 TABS) NPB-S PA

MAVENCLAD (5 TABS) NPB-S PA

MAVENCLAD (6 TABS) NPB-S PA

MAVENCLAD (7 TABS) NPB-S PA

MAVENCLAD (8 TABS) NPB-S PA

MAVENCLAD (9 TABS) NPB-S PA

MAYZENT NPB-S PA; QL

MAYZENT STARTER PACK NPB QL

PLEGRIDY PB-S QL

PLEGRIDY STARTER PACK PB-S QL

REBIF PB-S QL

REBIF REBIDOSE PB-S QL

REBIF REBIDOSE TITRATION PACK PB-S QL

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Drug Name Drug Tier Restrictions / Limits

REBIF TITRATION PACK PB-S QL

TECFIDERA PB-S QL

Central Nervous System Agents - Miscellaneous

ADDYI NPB PA; QL

ADIPEX-P NPB

AUSTEDO PB-S PA; QL

BELVIQ NPB

BELVIQ XR NPB

benzphetamine hcl G

caffeine citrate oral G

CONTRAVE NPB ST

diethylpropion hcl er G

diethylpropion hcl oral G

GRALISE PB ST; QL

GRALISE STARTER PB ST; QL

HORIZANT NPB ST; QL

INGREZZA NPB-S PA; QL

LOMAIRA NPB

LYRICA NPB ST; QL

LYRICA CR NPB ST; QL

NUEDEXTA PB

phendimetrazine tartrate G

phendimetrazine tartrate er G

phentermine hcl oral G

pregabalin oral G QL

QSYMIA NPB ST

RILUTEK NPB QL

riluzole G QL

SAVELLA PB M; QL

SAVELLA TITRATION PACK PB M; QL

SAXENDA NPB

TEGSEDI NPB-S PA

tetrabenazine G-S PA

TIGLUTIK NPB QL

XENAZINE NPB-S ST

XENICAL NPB

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Drug Name Drug Tier Restrictions / Limits

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

cavarest G M

cevimeline hcl G M

chlorhexidine gluconate mouth/throat G

clinpro 5000 NPB M

DEBACTEROL NPB

denta 5000 plus G M

dentagel G M

easygel G M

EVOXAC NPB M

fluoridex NPB M

fluoridex daily renewal G M

fluoridex enhanced whitening NPB M

fluoridex sensitivity relief G M

lidocaine hcl mouth/throat G

lidocaine viscous mouth/throat solution 2 % G

NAFRINSE DAILY ACIDULATED NPB

NAFRINSE DAILY/NEUTRAL NPB M

NAFRINSE WEEKLY NPB M

neutral sodium fluoride G M

NUMOISYN MOUTH/THROAT LOZENGE NPB

oralone G

paroex G

PERIDEX NPB

periogard G

pilocarpine hcl oral G

PREVIDENT 5000 BOOSTER PLUS NPB M

PREVIDENT 5000 DRY MOUTH NPB M

PREVIDENT 5000 ENAMEL PROTECT NPB M

PREVIDENT 5000 ORTHO DEFENSE NPB M

PREVIDENT 5000 PLUS NPB M

PREVIDENT 5000 SENSITIVE NPB M

PREVIDENT DENTAL NPB M

prevident mouth/throat G M

REMESENSE NPB

SALAGEN NPB

sf G M

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Drug Name Drug Tier Restrictions / Limits

sf 5000 plus G M

sodium fluoride 5000 plus G M

sodium fluoride dental gel G M

sodium fluoride dental paste NPB M

TOPEX TOPICAL ANESTHETIC G

triamcinolone acetonide mouth/throat G

Dermatological Agents - Drugs for Skin Conditions

A.A.G.C. KIT IN TERODERM NPB

ABSORICA PB QL

ABSORICA LD NPB

ACANYA NPB ST; QL

acitretin G

ACTIVE-PREP KIT IV NPB

ACTIVE-TRAMADOL NPB

ACZONE NPB ST

adapalene external cream G QL

adapalene external gel 0.3 % G QL

ADAPALENE EXTERNAL PAD NPB ST

ADAPALENE EXTERNAL SOLUTION G ST

adapalene-benzoyl peroxide G QL

AKTIPAK EXTERNAL PACKET 5-3 % NPB ST

ALA SCALP NPB ST

ala-cort external cream 2.5 % G

alclometasone dipropionate G

ALDARA NPB QL

ALTRENO NPB

amcinonide G

ammonium lactate external lotion G

amnesteem G QL

APEXICON E G ST; QL

AQUACEL AG BURN NPB

arzol silver nit applicators G

ATRALIN NPB QL

AVAR LS CLEANSER NPB ST

AVAR-E EMOLLIENT NPB ST

AVAR-E GREEN NPB ST

AVAR-E LS NPB ST

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Drug Name Drug Tier Restrictions / Limits

avita external cream G QL

avita external gel NPB

azelaic acid external G

AZELEX NPB ST; QL

BENZAC AC WASH NPB ST

BENZACLIN NPB ST; QL

BENZACLIN WITH PUMP NPB ST; QL

BENZAMYCIN NPB ST

benzepro external foam 5.3 % G

benzepro foaming cloths G

BENZEPRO SHORT CONTACT NPB ST

BENZIQ NPB ST

BENZIQ LS NPB ST

BENZIQ WASH NPB ST

BENZOYL PEROX-HYDROCORTISONE NPB ST

benzoyl peroxide external foam 9.8 % G

BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 %

NPB

BENZOYL PEROXIDE FORTE- HC NPB

benzoyl peroxide-erythromycin G

beser external lotion G

betamethasone dipropionate aug G

betamethasone dipropionate external G

betamethasone valerate external G

bp cleansing wash G

bp foam G

bp wash external liquid 2.5 % NPB

bpo G

BRYHALI NPB ST

calcipotriene external cream G QL

calcipotriene external ointment G QL

calcipotriene external solution G QL

calcipotriene-betameth diprop external ointment G QL

CALCITRENE NPB QL

calcitriol external G QL

CANTHARIDIN EXTERNAL NPB

CAPEX NPB ST; QL

CARAC PB QL

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Drug Name Drug Tier Restrictions / Limits

claravis G QL

CLEOCIN-T NPB ST

clindacin etz external swab G

clindacin-p G

CLINDAGEL NPB ST

clindamycin phosphate-benzoyl peroxide G QL

clindamycin phosphate external foam G

clindamycin phosphate external lotion G

clindamycin phosphate external solution G

clindamycin phosphate external swab G

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

NPB ST

clindamycin phosphate gel 1 % external G

clindamycin-tretinoin G

CLINOIN NPB

clobetasol prop emollient base G

clobetasol propionate e G

clobetasol propionate emulsion G

clobetasol propionate external G

CLOBEX NPB ST

CLOBEX SPRAY NPB ST

clocortolone pivalate NPB QL

clodan external shampoo G

CLODERM NPB ST; QL

clotrimazole-betamethasone G

coal tar external PB

CONDYLOX NPB

CORDRAN EXTERNAL CREAM NPB ST

CORDRAN EXTERNAL LOTION NPB ST

CORDRAN EXTERNAL OINTMENT NPB ST

CORDRAN EXTERNAL TAPE NPB ST; QL

CORTANE-B NPB

CORTISPORIN NPB

CUTIVATE NPB ST

dapsone external gel 5 % G

DERMA-SMOOTHE/FS BODY NPB ST; QL

DERMA-SMOOTHE/FS SCALP NPB ST; QL

DESONATE NPB ST

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Drug Name Drug Tier Restrictions / Limits

desonide external G QL

DESOWEN NPB ST; QL

desoximetasone external cream G QL

desoximetasone external gel G QL

desoximetasone external liquid G

desoximetasone external ointment G QL

diclofenac sodium transdermal gel 3 % G QL

DIFFERIN EXTERNAL CREAM NPB ST; QL

DIFFERIN EXTERNAL GEL 0.3 % NPB ST; QL

DIFFERIN EXTERNAL LOTION NPB ST; QL

diflorasone diacetate external cream G QL

diflorasone diacetate external ointment G

DIPROLENE NPB ST

DIPROLENE AF NPB ST

DOVONEX NPB QL

doxepin hcl external G QL

doxycycline NPB ST

DRITHO-CREME HP NPB

DRYSOL NPB

DUOBRII NPB ST

DUPIXENT PB-S PA; QL

EFUDEX NPB

ELIDEL NPB ST; QL

ELOCON NPB ST

ENOVARX-TRAMADOL NPB

ENSTILAR PB QL

ENZOCLEAR NPB ST

EPIDUO NPB ST; QL

EPIDUO FORTE PB ST

EPIFOAM NPB ST

ery G

ERYGEL G

erythromycin external G

EUCRISA NPB ST; QL

EVOCLIN NPB ST

FABIOR NPB PA; QL

FINACEA EXTERNAL FOAM PB ST

FINACEA EXTERNAL GEL NPB ST

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Drug Name Drug Tier Restrictions / Limits

fluocinolone acetonide body G QL

fluocinolone acetonide external cream 0.01 % G

fluocinolone acetonide external cream 0.025 % G QL

fluocinolone acetonide external ointment G QL

fluocinolone acetonide external solution G QL

fluocinolone acetonide scalp G QL

fluocinonide emulsified base G

fluocinonide external cream 0.05 % G

fluocinonide external cream 0.1 % G QL

fluocinonide external gel G

fluocinonide external ointment G

fluocinonide external solution G

FLUOROPLEX NPB QL

FLUOROURACIL EXTERNAL CREAM 0.5 % NPB ST; QL

fluorouracil external cream 5 % G

fluorouracil external solution G QL

flurandrenolide G

fluticasone propionate external G

GORDOFILM NPB

grafco silver nit applicator G

halcinonide G

halobetasol propionate external cream G QL

HALOBETASOL PROPIONATE EXTERNAL FOAM

NPB ST

halobetasol propionate external ointment G QL

HALOG NPB ST

HYALUCIL-4 NPB

HYDRO 35 NPB

HYDRO 40 NPB

hydrocortisone ace-pramoxine external G

hydrocortisone butyr lipo base G

hydrocortisone butyrate G

hydrocortisone external cream 2.5 % G

hydrocortisone external lotion 2.5 % G

hydrocortisone external ointment 2.5 % G

hydrocortisone valerate G

imiquimod external G QL

IMIQUIMOD PUMP NPB ST; QL

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Drug Name Drug Tier Restrictions / Limits

IMPOYZ NPB ST

INOVA 4/1 ACNE CONTROL THERAPY NPB ST

INOVA EXTERNAL KIT 4 & 5 % NPB ST

isotretinoin oral G QL

ivermectin external G

KENALOG EXTERNAL NPB ST

KERALYT EXTERNAL GEL 6 % NPB

KLARON NPB ST

lactic acid e G

lactic acid external G

latrix xm G

LEXETTE NPB ST

LOCOID NPB ST

LOCOID LIPOCREAM NPB ST

LOTRISONE NPB

LUXIQ NPB ST

methoxsalen oral G

methoxsalen rapid G

methyl salicylate external liquid G

METROCREAM NPB ST

METROGEL NPB ST

METROLOTION NPB ST

metronidazole external G

MICORT-HC NPB ST

MIRVASO PB PA

mometasone furoate external G

myorisan G QL

NEO-SYNALAR EXTERNAL CREAM NPB

neuac external gel G QL

nolix G

NORITATE NPB ST

OLUX NPB ST

OLUX-E NPB ST

ONEXTON PB ST; QL

ORACEA PB ST

OVACE PLUS EXTERNAL SHAMPOO NPB

OXSORALEN ULTRA NPB

PANDEL NPB ST

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Drug Name Drug Tier Restrictions / Limits

PICATO PB QL

pimecrolimus G QL

PLEXION CLEANSER NPB ST

PLEXION EXTERNAL LOTION NPB ST

podocon NPB

podofilox external G

PRAMOSONE NPB ST

prednicarbate G

PROTOPIC NPB ST; QL

PRUDOXIN G ST; QL

PSORCON NPB ST; QL

PYROGALLIC ACID NPB

QBREXZA PB PA; QL

REGRANEX PB QL

RETIN-A EXTERNAL CREAM 0.025 % NPB QL

RETIN-A EXTERNAL CREAM 0.05 %, 0.1 % NPB

RETIN-A EXTERNAL GEL NPB

RETIN-A MICRO GEL 0.04 %, 0.1 % NPB

RETIN-A MICRO PUMP NPB

RHOFADE NPB PA

RIAX NPB

rosadan external cream G

rosadan external gel G

SALEX EXTERNAL SHAMPOO NPB

salicylic acid er G

salicylic acid external foam G

salicylic acid external gel G

salicylic acid external lotion G

salicylic acid external shampoo G

salicylic acid-cleanser external kit 6 % (lotion) G

SALVAX G

SALVAX DUO PLUS NPB

SANTYL PB

selenium sulfide external G

SERNIVO NPB ST

sodium hyaluronate external G

sodium sulfacetamide G

SODIUM SULFACETAMIDE WASH G

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Drug Name Drug Tier Restrictions / Limits

SOOLANTRA NPB ST

SORIATANE NPB

SORILUX NPB QL

sss 10-5 external foam G

sulfacetamide sodium (acne) G

sulfacetamide sodium external gel G

sulfacetamide sodium-sulfur external cream 10-2 %

G

sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9.8-4.8 %

G

sulfacetamide sodium-sulfur external lotion 10-5 %

G

sulfacetamide sodium-sulfur external pad G

sulfacetamide sodium-sulfur external suspension

G

sulfacetamide-sulfur in urea G

sulfacleanse 8/4 G

SYNALAR NPB ST; QL

TACLONEX EXTERNAL OINTMENT NPB QL

TACLONEX EXTERNAL SUSPENSION PB QL

tacrolimus external G QL

tazarotene external G PA; QL

TAZORAC CREAM 0.05 % EXTERNAL PB PA; QL

TAZORAC EXTERNAL CREAM 0.1 % NPB PA; QL

TAZORAC EXTERNAL GEL PB PA; QL

TEMOVATE NPB ST

TEXACORT NPB ST

TOLAK NPB QL

TOPICORT NPB ST; QL

TOPICORT SPRAY NPB ST

tovet external foam G

tretinoin external cream 0.025 % G QL

tretinoin external cream 0.05 %, 0.1 % G

tretinoin external gel 0.01 %, 0.025 % G

tretinoin external gel 0.05 % G QL

tretinoin microsphere G

tretinoin microsphere pump G

triamcinolone acetonide external G

trianex G

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Drug Name Drug Tier Restrictions / Limits

TRI-CHLOR G

triderm G

TRIDESILON NPB ST; QL

turpentine external PB

ULTRAVATE NPB ST

UMECTA MOUSSE NPB

urea external cream 39 %, 45 % G

urea hydrating G

urea in zn undecyl-lactic acid external emulsion 50 %

G

urea nail G

VANOS NPB ST; QL

VANOXIDE-HC NPB ST

VECTICAL NPB QL

VELTIN NPB ST

VERDESO NPB ST

VEREGEN NPB

VIRASAL NPB

XERAC AC NPB

XERFORM OIL EMULSION ROLL EXTERNAL NPB

XEROFORM OIL EMULSION 2"X2" NPB

XEROFORM OIL EMULSION GAUZE NPB

XEROFORM OIL EMULSION STRIP NPB

XEROFORM PETROLAT GAUZE 1"X8" NPB

XEROFORM PETROLAT GAUZE 5"X9" NPB

XEROFORM PETROLAT PATCH 2"X2" NPB

XEROFORM PETROLAT PATCH 4"X4" NPB

XEROFORM PETROLATUM ROLL 4"X9' NPB

ZACARE NPB ST

zaclir cleansing G

zenatane G QL

ZIANA NPB ST

ZONALON NPB ST; QL

ZYCLARA NPB ST; QL

ZYCLARA PUMP NPB ST; QL

Diabetes - Antidiabetic Agents

acarbose oral G M

ACTOPLUS MET NPB ST; M; QL

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Drug Name Drug Tier Restrictions / Limits

ACTOS NPB M; QL

ADLYXIN NPB ST; M; QL

ADLYXIN STARTER PACK NPB ST; M; QL

ALOGLIPTIN BENZOATE NPB ST; M; QL

ALOGLIPTIN-METFORMIN HCL NPB ST; M; QL

ALOGLIPTIN-PIOGLITAZONE NPB ST; M; QL

AMARYL NPB M

AVANDIA NPB ST; M; QL

BYDUREON PB ST; M; QL

BYDUREON BCISE AUTOINJECTOR PB ST; M; QL

BYETTA 10 MCG PEN PB ST; M; QL

BYETTA 5 MCG PEN PB ST; M; QL

CYCLOSET NPB M; QL

DUETACT NPB ST; M; QL

FARXIGA PB ST; M; QL

FORTAMET NPB ST; M

glimepiride G M

glipizide er G M

glipizide ir G M

glipizide xl G M

glipizide-metformin hcl G M

GLUCOPHAGE NPB ST; M

GLUCOPHAGE XR NPB ST; M

GLUCOTROL NPB M

GLUCOTROL XL NPB M

GLUMETZA NPB ST; M; QL

glyburide micronized G M

glyburide oral G M

glyburide-metformin G M

GLYNASE NPB M

GLYSET NPB M

GLYXAMBI PB ST; M

INVOKAMET PB ST; M; QL

INVOKAMET XR PB ST; M; QL

INVOKANA PB ST; M; QL

JANUMET PB ST; M; QL

JANUMET XR PB ST; M; QL

JANUVIA PB ST; M; QL

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Drug Name Drug Tier Restrictions / Limits

JARDIANCE PB ST; M; QL

JENTADUETO PB ST; M; QL

JENTADUETO XR PB ST; M

KAZANO NPB ST; M; QL

KOMBIGLYZE XR NPB ST; M; QL

metformin hcl er G M

metformin hcl er (mod) G ST; M; QL

metformin hcl er (osm) G ST; M

METFORMIN HCL ORAL SOLUTION NPB ST; M; QL

metformin hcl oral tablet G M

miglitol G M

nateglinide G M

NESINA NPB ST; M; QL

ONGLYZA NPB ST; M; QL

OSENI NPB ST; M; QL

OZEMPIC PB ST; M; QL

pioglitazone hcl G M; QL

pioglitazone hcl-glimepiride G M; QL

pioglitazone hcl-metformin hcl G M; QL

PRECOSE NPB M

QTERN NPB ST; M

repaglinide G M

RIOMET NPB ST; M; QL

SEGLUROMET PB ST; M

SOLIQUA PB ST; M; QL

STARLIX NPB M

STEGLATRO PB ST; M

STEGLUJAN NPB ST; M

SYMLINPEN 120 PB ST; M; QL

SYMLINPEN 60 PB ST; M; QL

SYNJARDY PB ST; M

SYNJARDY XR PB ST; M

tolbutamide G M

TRADJENTA PB ST; QL

TRULICITY PB ST; M; QL

VICTOZA PB ST; M; QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-1000 MG, 5-500 MG

PB ST; M; QL

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Drug Name Drug Tier Restrictions / Limits

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG

PB ST; M

XULTOPHY PB ST; M; QL

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA CONNECT KIT W/DEVICE NPB ST; OTC; QL

ACCU-CHEK AVIVA PLUS NPB ST; OTC; QL

ACCU-CHEK COMPACT PLUS TEST STRIPS NPB ST; OTC; QL

ACCU-CHEK GUIDE NPB ST; OTC; QL

ACCU-CHEK GUIDE ME NPB ST; OTC; QL

ACCU-CHEK GUIDE STRIP IN VITRO NPB OTC; QL

ACCU-CHEK GUIDE STRIP IN VITRO NPB ST; OTC; QL

ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE

NPB ST; OTC; QL

ACCU-CHEK SMARTVIEW TEST STRIPS NPB ST; OTC; QL

BIOTEL CARE BLOOD GLUCOSE SYST NPB ST; OTC; QL

BLOOD GLUCOSE TEST NPB ST; OTC; QL

CONTOUR NEXT MONITOR NPB ST; OTC; QL

CONTOUR NEXT TEST NPB ST; OTC; QL

CONTOUR TEST NPB ST; OTC; QL

DIATHRIVE BLOOD GLUCOSE TEST NPB ST; OTC; QL

DIATHRIVE GLUCOSE TEST NPB ST; OTC; QL

EASYPLUS BLOOD GLUCOSE TEST NPB ST; OTC; QL

EMBRACE TALK GLUCOSE TEST NPB ST; OTC; QL

EMBRACE TALK MONITORING SYSTEM NPB ST; OTC; QL

FORA GTEL BLOOD GLUCOSE TEST NPB ST; OTC; QL

FREESTYLE FREEDOM LITE NPB ST; OTC; QL

FREESTYLE INSULINX SYSTEM NPB ST; OTC; QL

FREESTYLE INSULINX TEST NPB ST; OTC; QL

FREESTYLE LITE TEST NPB ST; OTC; QL

FREESTYLE PRECISION NEO TEST NPB ST; OTC; QL

FREESTYLE TEST NPB ST; OTC; QL

GLUCOCARD 01 SENSOR PLUS NPB ST; OTC; QL

GLUCOCARD EXPRESSION TEST NPB ST; OTC; QL

GLUCOCARD SHINE CONNEX NPB ST; OTC; QL

GLUCOCARD SHINE EXPRESS NPB ST; OTC; QL

GLUCOCARD SHINE TEST NPB ST; OTC; QL

GLUCOCARD VITAL TEST NPB ST; OTC; QL

GOJJI BLOOD GLUCOSE TEST NPB OTC; QL

GOJJI BLOOD TEST STRIP/LANCETS NPB OTC; QL

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Drug Name Drug Tier Restrictions / Limits

HW EMBRACE PRO GLUCOSE TEST NPB ST; OTC; QL

HW EMBRACE TALK GLUCOSE TEST NPB ST; OTC; QL

KROGER HEALTHPRO GLUCOSE TEST NPB ST; OTC; QL

ONE DROP BLOOD GLUCOSE MONITOR NPB ST; OTC; QL

ONE DROP TEST NPB ST; OTC; QL

ONETOUCH ULTRA 2 PB OTC; QL

ONETOUCH ULTRA BLUE TEST STRIPS PB OTC; QL

ONETOUCH ULTRA MINI PB OTC; QL

ONE TOUCH VERIO KIT W/DEVICE PB OTC; QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE

PB OTC; QL

ONETOUCH VERIO TEST STRIPS PB OTC; QL

ONETOUCH VERIO IQ SYSTEM PB OTC; QL

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE

PB OTC; QL

PRECISION LINK NPB ST; OTC; QL

PRECISION PCX PLUS TEST NPB ST; OTC; QL

PRECISION QID TEST NPB ST; OTC; QL

PRECISION SOF-TACT TEST NPB ST; OTC; QL

PRECISION XTRA BLOOD GLUCOSE NPB ST; OTC; QL

PRODIGY NO CODING BLOOD GLUC NPB OTC; QL

RELION BLOOD GLUCOSE TEST NPB ST; OTC; QL

RELION PREMIER TEST NPB ST; OTC; QL

RELION ULTIMA TEST NPB ST; OTC; QL

TRUE METRIX BLOOD GLUCOSE TEST NPB ST; OTC; QL

TRUE METRIX PRO BLOOD GLUCOSE NPB OTC; QL

TRUETRACK TEST NPB ST; OTC; QL

VIVAGUARD INO TEST STRIPS NPB ST; OTC; QL

Diabetes - Glycemic Agents

BAQSIMI ONE PACK NPB

BAQSIMI TWO PACK NPB

GLUCAGEN HYPOKIT PB

GLUCAGON EMERGENCY INJECTION KIT PB

GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED

NPB

GVOKE PFS NPB

PROGLYCEM PB M

Diabetes - Insulins

ADMELOG NPB ST; M; QL

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Drug Name Drug Tier Restrictions / Limits

ADMELOG SOLOSTAR NPB ST; M; QL

AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 UNIT & 90X12 UNIT

NPB M

AFREZZA INHALATION POWDER 4 UNIT NPB M; QL

APIDRA SOLOSTAR NPB ST; M; QL

APIDRA VIAL NPB ST; M; QL

BASAGLAR KWIKPEN NPB ST; M; QL

FIASP NPB ST; M; QL

FIASP FLEXTOUCH NPB ST; M; QL

FIASP PENFILL NPB ST; M; QL

HUMALOG PB M; QL

HUMALOG KWIKPEN PB M; QL

HUMALOG MIX 50/50 KWIKPEN PB M; QL

HUMALOG MIX 50/50 VIAL PB M; QL

HUMALOG MIX 75/25 KWIKPEN PB M; QL

HUMALOG MIX 75/25 VIAL PB M; QL

HUMALOG U-100 JUNIOR KWIKPEN PB M; QL

HUMULIN 70/30 KWIKPEN PB M; OTC; QL

HUMULIN 70/30 VIAL PB M; OTC; QL

HUMULIN N KWIKPEN PB M; OTC

HUMULIN N VIAL PB M; OTC; QL

HUMULIN R U-500 KWIKPEN PB M; QL

HUMULIN R U-500 VIAL (CONCENTRATED) PB M; QL

HUMULIN R VIAL PB M; OTC; QL

INSULIN ASP PROT & ASP FLEXPEN NPB ST; M

INSULIN ASPART NPB ST; M

INSULIN ASPART FLEXPEN NPB ST; M; QL

INSULIN ASPART PENFILL NPB ST; M; QL

INSULIN ASPART PROT & ASPART NPB ST; M

INSULIN LISPRO NPB M; QL

INSULIN LISPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

NPB M; QL

LANTUS SOLOSTAR PB M; QL

LANTUS U-100 VIAL PB M; QL

LEVEMIR U-100 FLEXTOUCH PB M; QL

LEVEMIR U-100 VIAL PB M; QL

NOVOLIN 70/30 FLEXPEN NPB ST; M; OTC; QL

NOVOLIN 70/30 FLEXPEN RELION NPB ST; M; OTC; QL

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Drug Name Drug Tier Restrictions / Limits

NOVOLIN 70/30 RELION NPB ST; M; OTC; QL

NOVOLIN 70/30 VIAL NPB ST; M; OTC; QL

NOVOLIN N FLEXPEN NPB ST; M; OTC

NOVOLIN N FLEXPEN RELION NPB ST; M; OTC

NOVOLIN N RELION NPB ST; M; OTC; QL

NOVOLIN N VIAL NPB ST; M; OTC; QL

NOVOLIN R FLEXPEN NPB ST; M; OTC

NOVOLIN R FLEXPEN RELION NPB ST; M; OTC

NOVOLIN R RELION NPB ST; M; OTC; QL

NOVOLIN R VIAL NPB ST; M; OTC; QL

NOVOLOG FLEXPEN NPB ST; M; QL

NOVOLOG MIX 70/30 FLEXPEN NPB ST; M

NOVOLOG MIX 70/30 VIAL NPB ST; M

NOVOLOG PENFILL NPB ST; M; QL

NOVOLOG U-100 VIAL NPB ST; M

TOUJEO MAX SOLOSTAR PB M; QL

TOUJEO SOLOSTAR PB M; QL

TRESIBA PB M; QL

TRESIBA FLEXTOUCH PB M; QL

Electrolytes / Minerals / Metals / Vitamins

adc/f (0.5mg/ml) G ACA

aminobenzoate potassium G M

ARGININE HCL INJECTION NPB

ATABEX OB NPB

BCAA INJECTION NPB

CALCIFOL NPB

calcium-folic acid plus d G

CARBAGLU PB-S PA

CARNITOR ORAL TABLET NPB M

CHEMET PB

CITRANATAL BLOOM NPB

CITRANATAL MEDLEY NPB

clovique G PA; QL

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

PB M

cytra k crystals G

deferasirox oral tablet G

deferasirox oral tablet soluble G-S

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Drug Name Drug Tier Restrictions / Limits

DEXPANTHENOL INJECTION NPB

DRISDOL NPB

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

NPB M

effer-k oral tablet effervescent 25 meq G M

ELITE-OB NPB

ENBRACE HR NPB

ERGOCAL NPB

ergocalciferol oral capsule G

ESCAVITE NPB

EXJADE PB-S

FERIVA 21/7 NPB

ferotrinsic G

FERRALET 90 NPB

ferraplus 90 G

FERRIPROX PB-S

FERRO-PLEX HEMATINIC NPB

FERROTRIN NPB

FLORIVA ORAL LIQUID NPB M; ACA

FLORIVA ORAL TABLET CHEWABLE NPB

FLORIVA PLUS NPB ACA

FLUORABON NPB M; ACA

fluoritab oral solution G M; ACA

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

G M; ACA

fluoritab oral tablet chewable 2.2 (1 f) mg G M

FLURA-DROPS NPB M; ACA

folic acid oral tablet 1 mg G M

FOLI-D NPB

FOLITE NPB

foltrin G

FOLVITE-D NPB

GALZIN NPB

GENICIN VITA-D NPB

GLUTATHIONE INJECTION NPB

GLYCINE INJECTION NPB

HEMATRON-AF NPB

hemocyte-plus G

hydroxocobalamin acetate G

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Drug Name Drug Tier Restrictions / Limits

iodine strong oral G

IS 24/6 NPB

JADENU PB-S

JADENU SPRINKLE PB-S

JYNARQUE ORAL TABLET PB-S PA; QL

JYNARQUE ORAL TABLET THERAPY PACK NPB-S PA; QL

kionex G

klor-con G M

klor-con 10 G M

klor-con m10 G M

KLOR-CON M15 G M

klor-con m20 G M

klor-con sprinkle G M

klor-con/ef G M

K-PHOS PB

K-PHOS NO 2 NPB

k-prime G M

K-TAB G M

k-tan plus G

levocarnitine oral tablet G M

LIPO NPB

LIPO-C NPB

LOKELMA PB

ludent oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

G M; ACA

ludent oral tablet chewable 2.2 (1 f) mg G M

LYSINE HCL INJECTION NPB

MAGNESIUM SULFATE INJECTION NPB

MAXFE ORAL TABLET NPB

MEPHYTON NPB

METHYLCOBALAMIN INJECTION NPB

M-NATAL PLUS G

multigen G

multi-vit/iron/fluoride G ACA

multi-vitamin/fluoride G ACA

multivitamin/fluoride oral solution G ACA

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg

G ACA

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Drug Name Drug Tier Restrictions / Limits

MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25-0.3 MG, 0.5-0.3 MG, 1-0.3 MG

NPB

multivitamin/fluoride oral tablet chewable 1 mg G

multivitamin/fluoride/iron G ACA

multi-vitamin/fluoride/iron G ACA

multivitamins/fluoride G ACA

mvc-fluoride oral tablet chewable 0.25 mg, 0.5 mg

G ACA

mvc-fluoride oral tablet chewable 1 mg G

nafrinse G M

nafrinse drops G M; ACA

NASCOBAL PB M

NEONATAL COMPLETE G

NEONATAL PLUS G

NEPHRON FA NPB

NESTABS NPB

NESTABS ONE NPB

NIFEREX NPB

NUTRIVIT PB

ORACIT NPB

phospho-trin 250 neutral G

phytonadione oral G

pnv prenatal plus multivit+dha NPB

polysaccharide iron forte G

POLY-VI-FLOR NPB

POLY-VI-FLOR FS NPB

POLY-VI-FLOR/IRON NPB

pot bicarb-pot chloride G M

POTABA NPB M

potassium bicarbonate oral G M

potassium chloride crys er G M

potassium chloride er G M

potassium chloride oral G M

potassium citrate er G M

potassium citrate-citric acid G

PRENAISSANCE NPB

PRENATA NPB

prenatal oral tablet 27-1 mg NPB

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Drug Name Drug Tier Restrictions / Limits

prenatal plus iron G

PRIMACARE NPB

QUFLORA FE NPB

QUFLORA FE PEDIATRIC NPB ACA

QUFLORA GUMMIES NPB

QUFLORA PEDIATRIC ORAL SOLUTION NPB ACA

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG

NPB ACA

QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 1 MG

NPB

RELNATE DHA NPB

RENATABS WITH IRON NPB

SALINE-PHENOL NPB

SAMSCA PB-S PA; QL

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

NPB

sod citrate-citric acid G

sodium fluoride oral solution G M; ACA

sodium fluoride oral tablet 1.1 (0.5 f) mg G M; ACA

sodium fluoride oral tablet 2.2 (1 f) mg G M

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

G M; ACA

sodium fluoride oral tablet chewable 2.2 (1 f) mg G M

sodium polystyrene sulfonate oral G

sodium polystyrene sulfonate rectal suspension 30 gm/120ml

G

sodium polystyrene sulfonate rectal suspension 50 gm/200ml

NPB

sps G

SYPRINE NPB PA; QL

taron-crystals G

TAURINE INJECTION NPB

TRI-AMINO NPB

TRICARE PRENATAL DHA ONE NPB

trientine hcl G PA; QL

trinate G

TRISTART ONE NPB

TRI-VI-FLOR NPB

TRI-VI-FLORO NPB

tri-vitamin/fluoride G ACA

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Drug Name Drug Tier Restrictions / Limits

tri-vite/fluoride G ACA

tryptophan oral G

UROCIT-K 10 NPB M

UROCIT-K 15 NPB M

UROCIT-K 5 NPB M

VELTASSA PB-S

VITAFOL-OB+DHA NPB

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

G

vitamins acd-fluoride G ACA

vp-pnv-dha NPB

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX NPB ST; M; QL

ACIPHEX SPRINKLE NPB ST; M; QL

CARAFATE NPB M

cimetidine hcl G M

cimetidine oral tablet 300 mg, 400 mg, 800 mg G M

CYTOTEC NPB M

DEPRIZINE FUSEPAQ NPB M

DEXILANT NPB ST; M; QL

esomeprazole magnesium PB M; QL

famotidine oral suspension reconstituted G M

famotidine oral tablet 40 mg G M

lansoprazole oral capsule delayed release PB M; QL

lansoprazole oral tablet dispersible 15 mg, 30 mg

PB M; QL

misoprostol oral G M

NEXIUM ORAL CAPSULE DELAYED RELEASE 40 MG

NPB ST; M; QL

NEXIUM ORAL PACKET PB ST; M; QL

nizatidine G M

omeprazole oral capsule delayed release PB M; QL

omeprazole-sodium bicarbonate PB M; QL

pantoprazole sodium oral PB M; QL

PEPCID ORAL TABLET 40 MG NPB M

PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG

NPB ST; M; QL

PREVACID SOLUTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG

NPB ST; M; QL

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Drug Name Drug Tier Restrictions / Limits

PRILOSEC NPB ST; M; QL

PROTONIX ORAL NPB ST; M; QL

rabeprazole sodium oral tablet delayed release PB M; QL

ranitidine hcl oral capsule G M

ranitidine hcl oral syrup G M

ranitidine hcl oral tablet 300 mg G M

ranitidine hcl tablet 150 mg oral (rx) G M

sucralfate oral G M

YOSPRALA NPB ST; QL

ZEGERID NPB ST; M; QL

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL NPB M

alosetron hcl G

AMITIZA PB QL

amoxicill-clarithro-lansopraz G QL

ANASPAZ G

ATROPEN NPB

belladonna alkaloids-opium G

cascara sagrada oral fluid extract NPB

CHENODAL PB-S PA

chlordiazepoxide-clidinium G

CLENPIQ PB ACA

COLYTE WITH FLAVOR PACKS NPB

constulose G

cromolyn sodium oral G

CUVPOSA NPB

dicyclomine hcl oral G

diphenoxylate-atropine G

DONNATAL NPB

ENTEREG NPB

enulose G

GASTROCROM NPB

GATTEX NPB-S

gavilyte-c G ACA

gavilyte-g G ACA

gavilyte-n with flavor pack G ACA

generlac G

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Drug Name Drug Tier Restrictions / Limits

GIALAX NPB ACA

GLYCATE NPB

glycopyrrolate oral tablet 1 mg, 2 mg G

GLYCOPYRROLATE ORAL TABLET 1.5 MG G

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

NPB ACA

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

NPB

hyoscyamine sulfate er G

hyoscyamine sulfate injection G

hyoscyamine sulfate oral elixir G

hyoscyamine sulfate oral solution G

hyoscyamine sulfate oral tablet G

hyoscyamine sulfate sl G

hyoscyamine sulfate sublingual G

hyosyne G

KRISTALOSE NPB

lactulose G

lactulose encephalopathy G

LEVBID NPB

LEVSIN ORAL NPB

LEVSIN/SL NPB

LIBRAX NPB ST

LINZESS PB QL

LOMOTIL NPB

LOTRONEX NPB

methscopolamine bromide oral G

mineral oil heavy oral PB

MOTEGRITY NPB ST

MOTOFEN NPB

MOVANTIK PB QL

MOVIPREP NPB ACA

MYTESI NPB QL

NULYTELY WITH FLAVOR PACKS NPB

OMECLAMOX-PAK NPB QL

opium G

oscimin G

oscimin sr G

OSMOPREP NPB ACA

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Drug Name Drug Tier Restrictions / Limits

paregoric G

PCP 100 NPB

peg 3350-kcl-na bicarb-nacl G ACA

peg-3350/electrolytes G ACA

phenobarbital-belladonna alk G

phenohytro G

PLENVU NPB ACA

PREPOPIK PB ACA

PROBICHEW NPB

propantheline bromide oral G

PYLERA PB

RELISTOR ORAL NPB QL

RELISTOR SUBCUTANEOUS PB QL

SEROSTIM PB-S PA

SUPREP BOWEL PREP KIT PB ACA

SYMAX DUOTAB NPB

symax-sl G

symax-sr G

SYMPROIC PB QL

trilyte G ACA

TRULANCE PB QL

URSO 250 NPB M

URSO FORTE NPB M

ursodiol oral G M

VIBERZI PB QL

VSL#3 DS NPB

XERMELO PB-S PA; QL

ZORBTIVE NPB-S PA

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

BUPHENYL ORAL TABLET NPB

CERDELGA PB-S

CHOLBAM PB-S

CREON PB

CYSTAGON PB-S PA

GALAFOLD NPB-S PA; QL

KUVAN PB-S PA

miglustat G-S

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Drug Name Drug Tier Restrictions / Limits

MYALEPT PB-S PA

nitisinone G-S

NITYR PB-S

OCALIVA PB-S PA; QL

ORFADIN PB-S

PALYNZIQ PB-S PA; QL

PANCREAZE NPB ST

PERTZYE NPB ST

PROCYSBI NPB-S ST

RAVICTI PB-S

sodium phenylbutyrate oral tablet G

STRENSIQ PB-S PA

SUCRAID PB-S

VIOKACE PB

XURIDEN PB-S QL

ZAVESCA NPB-S ST

ZENPEP PB

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

AURYXIA NPB

bethanechol chloride oral G

calcium acetate (phos binder) G

CUPRIMINE NPB ST; M

darifenacin hydrobromide er G M

DEPEN TITRATABS PB M

DETROL NPB ST; M

DETROL LA NPB ST; M

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG

NPB ST; M

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 5 MG

NPB ST; M; QL

ELMIRON PB

ENABLEX NPB ST; M

FEM PH G

flavoxate hcl G M

FOSRENOL NPB ST

GELNIQUE PB ST; M; QL

hyophen G

INTRAROSA NPB

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Drug Name Drug Tier Restrictions / Limits

lanthanum carbonate G

LITHOSTAT NPB

me/naphos/mb/hyo1 G

MYRBETRIQ PB ST

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg

G M

oxybutynin chloride er oral tablet extended release 24 hour 5 mg

G M; QL

oxybutynin chloride oral G M

OXYTROL NPB ST; M; QL

penicillamine oral G M

phenazo oral tablet 200 mg G

phenazopyridine hcl oral tablet 100 mg, 200 mg G

PHOSLYRA PB

phosphasal G

PYRIDIUM NPB

RENAGEL NPB ST

RENVELA NPB

RIMSO-50 NPB

sevelamer carbonate G

sevelamer hcl G

solifenacin succinate G M

THIOLA NPB-S

THIOLA EC NPB-S

tolterodine tartrate G M

tolterodine tartrate er G M

TOVIAZ PB ST

trospium chloride G M

trospium chloride er G M

URECHOLINE NPB

URELLE NPB

uretron d/s G

URIMAR-T NPB

urin ds G

URO-458 NPB

UROGESIC-BLUE G

URYL G

ustell G

uticap G

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Drug Name Drug Tier Restrictions / Limits

utira-c G

utrona-c G

VELPHORO PB

VESICARE PB ST; M

VILEVEV MB NPB

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er G M

AVODART NPB ST; M

CARDURA XL NPB M; QL

dutasteride oral G M

dutasteride-tamsulosin hcl G M

finasteride oral tablet 5 mg G M

FLOMAX NPB ST; M

JALYN NPB ST; M

PROSCAR NPB ST; M

RAPAFLO NPB ST; M

silodosin G M

tamsulosin hcl G M

terazosin hcl G M; QL

UROXATRAL NPB ST; M

Hormonal Agents - Adrenal

ACTIVE INJECTION BLM-1 NPB

ACTIVE INJECTION BM NPB

ACTIVE INJECTION DL NPB

ACTIVE INJECTION DLM NPB

ACTIVE INJECTION KIT L NPB

ACTIVE INJECTION KM NPB

ACTIVE INJECTION LM-DEP-2 NPB

ACTIVE INJECTION M-1 NPB

BETALIDO NPB

BUPIVILOG NPB

CONTRAST ALLERGY PREMED PACK NPB

CORTEF NPB

cortisone acetate oral G

DECADRON G

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

NPB

dexamethasone intensol G

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Drug Name Drug Tier Restrictions / Limits

dexamethasone oral elixir G

dexamethasone oral solution G

dexamethasone oral tablet G

dexamethasone oral tablet therapy pack G ST

DEXLIDO NPB

DEXLIDO-M NPB

DEXOPIN NPB

DEXPAK 10 DAY NPB ST

DEXPAK 13 DAY NPB ST

DEXPAK 6 DAY NPB ST

DXEVO 11-DAY NPB ST

DYURAL-40 NPB

DYURAL-80 NPB

DYURAL-L NPB

DYURAL-LM NPB

fludrocortisone acetate oral G M

HIDEX 6-DAY PB ST

hydrocortisone oral G

lidolog G

LT INJECTION KIT NPB

MARBETA-25 NPB

MARBETA-L NPB

MARDEX-25 NPB

MEDROL NPB

METHYLPREDNISOLONE ACE-LIDO NPB

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

G

methylprednisolone oral G

MILLIPRED G

MILLIPRED DP G

MILLIPRED DP 12-DAY G

MULTI-SPECIALTY NPB

ORAPRED ODT NPB

P-CARE D40MX NPB

P-CARE D80MX NPB

P-CARE K40MX NPB

P-CARE K80MX NPB

PEDIAPRED NPB

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Drug Name Drug Tier Restrictions / Limits

POINT OF CARE KM NPB

POINT OF CARE L.2 NPB

POINT OF CARE L.5 NPB

POINT OF CARE LM DEP 2 NPB

prednisolone oral solution G

prednisolone sodium phosphate oral G

prednisone intensol G

prednisone oral G

RAYOS NPB ST

READYSHARP ANESTH + BETAMETH NPB

READYSHARP ANESTH + DEXAMETH NPB

READYSHARP ANESTH + METHYLPRED NPB

ROPIDEX NPB

SOLU-CORTEF PB

TAPERDEX 12-DAY NPB ST

TAPERDEX 6-DAY NPB ST

TAPERDEX 7-DAY NPB ST

Hormonal Agents - Men's Health

ANDRODERM PB PA

ANDROGEL PUMP NPB

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

NPB

ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), 50 MG/5GM (1%)

NPB ST

danazol oral G

DEPO-TESTOSTERONE NPB PA

FORTESTA NPB ST

METHITEST PB

methyltestosterone oral G

NANDROLONE-TESTOSTERONE CYP NPB

NATESTO NPB ST

STRIANT NPB

TESTIM NPB ST

TESTOSTERONE CYPIONATE INJECTION G PA

testosterone cypionate intramuscular G PA

testosterone enanthate intramuscular G PA

testosterone transdermal G

VOGELXO NPB ST

VOGELXO PUMP NPB ST

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Drug Name Drug Tier Restrictions / Limits

XYOSTED NPB PA

Hormonal Agents - Osteoporosis

EVISTA NPB PA; M

OSPHENA NPB

raloxifene hcl G PA; M

Hormonal Agents - Parathyroid

cinacalcet hcl G

SENSIPAR NPB

Hormonal Agents - Pituitary

cabergoline G M; QL

CETROTIDE PB

chorionic gonadotropin intramuscular G ST; QL

clomiphene citrate oral G

DDAVP NASAL NPB M

DDAVP ORAL NPB M

DDAVP RHINAL TUBE NPB M

desmopressin ace spray refrig G M

desmopressin acetate oral G M

desmopressin acetate spray G M

EGRIFTA PB-S PA; QL

EGRIFTA SV PB-S PA; QL

ELIGARD PB-S QL

FIRMAGON PB-S QL

FOLLISTIM AQ NPB ST

ganirelix acetate subcutaneous solution 250 mcg/0.5ml

G-S ST

GENOTROPIN PB-S PA

GENOTROPIN MINIQUICK PB-S PA

GONAL-F PB ST

GONAL-F RFF PB ST

GONAL-F RFF REDIJECT PB ST

HUMATROPE NPB-S PA

INCRELEX PB-S PA

leuprolide acetate injection G-S

LEUPROLIDE ACETATE-BUPIVACAINE NPB

LUPANETA PACK PB QL

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG

PB-S

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Drug Name Drug Tier Restrictions / Limits

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

NPB-S

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG

PB-S

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG

NPB-S

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

NPB-S

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

NPB-S

LUPRON DEPOT-PED (1-MONTH) PB-S PA

LUPRON DEPOT-PED (3-MONTH) PB PA

MENOPUR PB

NOCDURNA NPB M

NOCTIVA NPB ST; M

NORDITROPIN FLEXPRO PB-S PA

novarel intramuscular solution reconstituted 10000 unit

NPB QL

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

PB

NUTROPIN AQ NUSPIN 10 NPB-S PA

NUTROPIN AQ NUSPIN 20 NPB-S PA

NUTROPIN AQ NUSPIN 5 NPB-S PA

octreotide acetate G-S

OMNITROPE SUBCUTANEOUS SOLUTION PB-S PA

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED

NPB-S PA

ORILISSA PB PA; QL

OVIDREL PB

pregnyl NPB ST; QL

SAIZEN NPB-S PA

SAIZENPREP NPB-S PA

SANDOSTATIN NPB-S

SOMATULINE DEPOT PB-S

SOMAVERT PB-S

STIMATE PB M

SYNAREL PB

ZOMACTON NPB-S PA

Hormonal Agents - Prostaglandins

KORLYM NPB-S PA; QL

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Drug Name Drug Tier Restrictions / Limits

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA NPB M

afirmelle G M; ACA

ALORA NPB M; QL

altavera G M; ACA

alyacen 1/35 G M; ACA

alyacen 7/7/7 G M; ACA

amabelz G M

amethia G M; ACA; QL

amethia lo G M; ACA; QL

amethyst G M; ACA

ANGELIQ NPB M

apri G M; ACA

aranelle G M; ACA

ashlyna G M; ACA; QL

aubra G M; ACA

aubra eq G M; ACA

aurovela 1.5/30 G M; ACA

aurovela 1/20 G M; ACA

aurovela 24 fe G M; ACA

aurovela fe 1.5/30 G M; ACA

aurovela fe 1/20 G M; ACA

aviane G M; ACA

AYGESTIN NPB M

ayuna G M; ACA

azurette G M; ACA

BALCOLTRA NPB ST; M; ACA

balziva G M; ACA

bekyree G M; ACA

BEYAZ NPB ST; M

BI-EST 80:20 PROGESTERONE NPB

BIEST/PROGESTERONE NPB

BIJUVA NPB

blisovi 24 fe G M; ACA

blisovi fe 1.5/30 G M; ACA

blisovi fe 1/20 G M; ACA

briellyn G M; ACA

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Drug Name Drug Tier Restrictions / Limits

camila G M; ACA

camrese G M; ACA; QL

camrese lo G M; ACA; QL

caziant G M; ACA

chateal G M; ACA

chateal eq G M; ACA

CLIMARA NPB M; QL

CLIMARA PRO NPB ST; M; QL

COMBIPATCH PB M

covaryx G

covaryx hs G

CRINONE PB QL

cryselle-28 G M; ACA

cyclafem 1/35 G M; ACA

cyclafem 7/7/7 G M; ACA

cyred G M; ACA

cyred eq G M; ACA

dasetta 1/35 G M; ACA

dasetta 7/7/7 G M; ACA

daysee G M; ACA; QL

deblitane G M; ACA

DELESTROGEN NPB

delyla G M; ACA

DEPO-ESTRADIOL PB

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

NPB QL

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

PB

DEPO-SUBQ PROVERA 104 NPB ACA; QL

desogestrel-ethinyl estradiol G M; ACA

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM

PB M; QL

DIVIGEL TRANSDERMAL GEL 0.75 MG/0.75GM, 1.25 MG/1.25GM

PB M

dotti G M; QL

drospiren-eth estrad-levomefol G M; ACA

drospirenone-ethinyl estradiol G M; ACA

DUAVEE PB

eemt G

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Drug Name Drug Tier Restrictions / Limits

eemt hs G

ELESTRIN NPB M; QL

elinest G M; ACA

ELLA NPB ACA; QL

eluryng G M; ACA; QL

emoquette G M; ACA

ENDOMETRIN NPB ST

enpresse-28 G M; ACA

enskyce G M; ACA

errin G M; ACA

est estrogens-methyltest G

est estrogens-methyltest ds G

est estrogens-methyltest hs G

estarylla G M; ACA

ESTRACE NPB M

estradiol oral G M

estradiol transdermal G M; QL

estradiol vaginal G M

estradiol valerate intramuscular G

estradiol-norethindrone acet G M

ESTRING PB M; QL

ESTROGEL NPB ST; M; QL

ESTROSTEP FE NPB ST; M

ethynodiol diac-eth estradiol G M; ACA

etonogestrel-ethinyl estradiol G M; ACA; QL

EVAMIST NPB M; QL

FALESSA NPB ST; ACA

falmina G M; ACA

fayosim G M; ACA; QL

FEMHRT LOW DOSE NPB M

FEMRING NPB ST; M; QL

femynor G M; ACA

fyavolv G M

GENERESS FE NPB ST; M

gianvi G M; ACA

hailey 1.5/30 G M; ACA

hailey 24 fe G M; ACA

heather G M; ACA

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Drug Name Drug Tier Restrictions / Limits

IMVEXXY MAINTENANCE PACK NPB M

IMVEXXY STARTER PACK NPB M

incassia G M; ACA

introvale G M; ACA; QL

isibloom G M; ACA

jaimiess G M; ACA; QL

jasmiel G M; ACA

jencycla G M; ACA

jinteli G M

jolessa G M; ACA; QL

juleber G M; ACA

junel 1.5/30 G M; ACA

junel 1/20 G M; ACA

junel fe 1.5/30 G M; ACA

junel fe 1/20 G M; ACA

junel fe 24 G M; ACA

kaitlib fe G M; ACA

kalliga G M; ACA

kariva G M; ACA

kelnor 1/35 G M; ACA

kelnor 1/50 G M; ACA

kurvelo G M; ACA

larin 1.5/30 G M; ACA

larin 1/20 G M; ACA

larin 24 fe G M; ACA

larin fe 1.5/30 G M; ACA

larin fe 1/20 G M; ACA

larissia G M; ACA

layolis fe G M; ACA

leena G M; ACA

lessina G M; ACA

levonest G M; ACA

levonorgest-eth est & eth est G M; ACA; QL

levonorgest-eth estrad 91-day G M; ACA; QL

levonorgestrel-ethinyl estrad G M; ACA

levonorg-eth estrad triphasic oral tablet G M; ACA

levora 0.15/30 (28) G M; ACA

lillow G M; ACA

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Drug Name Drug Tier Restrictions / Limits

LO LOESTRIN FE PB ST; M; ACA

LOESTRIN 1.5/30 (21) NPB ST; M

LOESTRIN 1/20 (21) NPB ST; M

LOESTRIN FE 1.5/30 NPB ST; M

LOESTRIN FE 1/20 NPB ST; M

lojaimiess G M; ACA; QL

lopreeza G M

loryna G M; ACA

LOSEASONIQUE NPB ST; M; QL

low-ogestrel G M; ACA

lo-zumandimine G M; ACA

lutera G M; ACA

lyza G M; ACA

marlissa G M; ACA

medroxyprogesterone acetate intramuscular suspension

G ACA; QL

medroxyprogesterone acetate oral G M

MEGACE ES NPB

megestrol acetate oral suspension G

megestrol acetate oral tablet G-S

melodetta 24 fe G M; ACA

MENEST NPB M

MENOSTAR NPB M; QL

mibelas 24 fe G M; ACA

microgestin 1.5/30 G M; ACA

microgestin 1/20 G M; ACA

microgestin fe 1.5/30 G M; ACA

microgestin fe 1/20 G M; ACA

mili G M; ACA

mimvey G M

MINASTRIN 24 FE NPB ST; M

MINIVELLE NPB ST; M; QL

MIRCETTE NPB ST; M

mono-linyah G M; ACA

NATAZIA NPB ST; M; ACA

necon 0.5/35 (28) G M; ACA

nikki G M; ACA

nora-be G M; ACA

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Drug Name Drug Tier Restrictions / Limits

norethin ace-eth estrad-fe G M; ACA

norethindrone acetate oral G M

norethindrone acet-ethinyl est G M; ACA

norethindrone oral G M; ACA

norethindrone-eth estradiol G M

norethin-eth estradiol-fe G M; ACA

norgestimate-eth estradiol G M; ACA

norgestimate-ethinyl estradiol triphasic G M; ACA

norlyda G M; ACA

norlyroc G M; ACA

nortrel 0.5/35 (28) G M; ACA

nortrel 1/35 (21) G M; ACA

nortrel 1/35 (28) G M; ACA

nortrel 7/7/7 G M; ACA

NUVARING NPB M; QL

ocella G M; ACA

ogestrel G M; ACA

orsythia G M; ACA

ORTHO MICRONOR NPB ST; M

ORTHO TRI-CYCLEN LO NPB ST; M

ORTHO-NOVUM 1/35 (28) NPB ST; M

ORTHO-NOVUM 7/7/7 (28) NPB ST; M

philith G M; ACA

pimtrea G M; ACA

pirmella 1/35 G M; ACA

pirmella 7/7/7 G M; ACA

portia-28 G M; ACA

PREFEST NPB M

PREMARIN ORAL PB M

PREMARIN VAGINAL PB M

PREMPHASE PB M

PREMPRO PB M

previfem G M; ACA

progesterone intramuscular G

progesterone micronized oral G

PROMETRIUM NPB

PROVERA NPB M

QUARTETTE NPB ST; M; QL

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Drug Name Drug Tier Restrictions / Limits

reclipsen G M; ACA

rivelsa G M; ACA; QL

SAFYRAL NPB ST; M

SEASONIQUE NPB ST; M; QL

setlakin G M; ACA; QL

sharobel G M; ACA

simliya G M; ACA

simpesse G M; ACA; QL

sprintec 28 G M; ACA

sronyx G M; ACA

syeda G M; ACA

tarina 24 fe G M; ACA

tarina fe 1/20 G M; ACA

tarina fe 1/20 eq G M; ACA

TAYTULLA PB ST; M; ACA

tilia fe G M; ACA

tri femynor G M; ACA

tri-estarylla G M; ACA

tri-legest fe G M; ACA

tri-linyah G M; ACA

tri-lo-estarylla G M; ACA

tri-lo-marzia G M; ACA

tri-lo-mili G M; ACA

tri-lo-sprintec G M; ACA

tri-mili G M; ACA

tri-previfem G M; ACA

tri-sprintec G M; ACA

trivora (28) G M; ACA

tri-vylibra G M; ACA

tri-vylibra lo G M; ACA

tulana G M; ACA

tydemy G M; ACA

VAGIFEM NPB ST; M

velivet G M; ACA

vienva G M; ACA

viorele G M; ACA

VIVELLE-DOT NPB ST; M; QL

volnea G M; ACA

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Drug Name Drug Tier Restrictions / Limits

vyfemla G M; ACA

vylibra G M; ACA

wera G M; ACA

wymzya fe G M; ACA

xulane G M; ACA

YASMIN 28 NPB ST; M

YAZ NPB ST; M

yuvafem G M

zarah G M; ACA

zovia 1/35e (28) G M; ACA

zumandimine G M; ACA

Hormonal Agents - Thyroid

ARMOUR THYROID G M

CYTOMEL NPB ST; M

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

NPB M

levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 88 mcg

NPB M

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 88 mcg

G M

levothyroxine-liothyronine oral tablet 30 mg, 60 mg, 90 mg

G M

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

G M

liothyronine sodium oral G M

methimazole oral G M

NATURE-THROID G M

np thyroid G M

propylthiouracil oral G M

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 88 MCG

NPB M

TAPAZOLE NPB M

thyroid oral tablet 120 mg, 15 mg G M

TIROSINT NPB M

TIROSINT-SOL NPB M

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Drug Name Drug Tier Restrictions / Limits

unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 88 mcg

G M

WESTHROID G M

WP THYROID G M

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN NPB-S PA

ACTEMRA SUBCUTANEOUS NPB-S PA; QL

ARAVA NPB M; QL

ARCALYST NPB-S PA

ASTAGRAF XL NPB ST

AZASAN NPB

azathioprine oral G

BENLYSTA SUBCUTANEOUS PB-S PA

CELLCEPT NPB

CIMZIA PB-S PA

CIMZIA PREFILLED KIT PB-S PA

CIMZIA STARTER KIT PB-S PA

COSENTYX (300 MG DOSE) NPB-S PA; QL

COSENTYX 150 MG/ML NPB-S PA; QL

COSENTYX SENSOREADY (300 MG) NPB-S PA; QL

COSENTYX SENSOREADY PEN NPB-S PA; QL

CUTAQUIG NPB

cyclosporine modified G

cyclosporine oral G

ENBREL NPB-S PA; QL

ENBREL MINI NPB-S PA; QL

ENBREL SURECLICK NPB-S PA; QL

ENVARSUS XR NPB ST

FIRAZYR PB-S PA

gengraf G

HUMIRA PB-S PA; QL

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML

PB-S PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML

PB-S PA; QL

HUMIRA PEN PB-S PA; QL

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Drug Name Drug Tier Restrictions / Limits

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PB-S PA; QL

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML

PB-S PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PB-S PA; QL

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML

PB-S PA

icatibant acetate G-S PA

IMURAN NPB

KEVZARA NPB-S PA

KINERET NPB-S PA; QL

leflunomide oral G M; QL

methotrexate oral G

methotrexate sodium G

methotrexate sodium (pf) G

mycophenolate mofetil G

mycophenolate sodium G

MYFORTIC NPB

NEORAL NPB

OLUMIANT NPB-S PA

ORENCIA CLICKJECT NPB-S PA

ORENCIA SUBCUTANEOUS NPB-S PA

OTEZLA PB-S PA; QL

OTREXUP PB-S QL

PROGRAF ORAL NPB

RAPAMUNE NPB

RASUVO PB-S QL

RIDAURA PB M

RINVOQ PB-S

SANDIMMUNE ORAL CAPSULE NPB

SANDIMMUNE ORAL SOLUTION PB

SILIQ NPB-S PA

SIMPONI PB-S PA; QL

sirolimus oral G

SKYRIZI (150 MG DOSE) PB-S PA

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Drug Name Drug Tier Restrictions / Limits

STELARA SUBCUTANEOUS PB-S PA

tacrolimus oral G

TAKHZYRO NPB-S PA

TALTZ NPB-S PA

TREMFYA PB-S PA

TREXALL NPB

XATMEP NPB-S PA

XELJANZ PB-S PA; QL

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG

PB-S PA; QL

ZORTRESS PB

Immunological Agents - Drugs for Vaccination

ACTHIB PB ACA

ADACEL PB ACA

AFLURIA QUADRIVALENT PB ACA

BEXSERO PB ACA

BOOSTRIX PB ACA

DAPTACEL PB ACA

DIPHTHERIA-TETANUS TOXOIDS DT PB ACA

ENGERIX-B INJECTION PB ACA

ENGERIX-B INTRAMUSCULAR NPB ACA

FLUAD PB ACA

FLUARIX QUADRIVALENT PB ACA

FLUBLOK QUADRIVALENT PB ACA

FLUCELVAX QUADRIVALENT PB ACA

FLULAVAL QUADRIVALENT PB ACA

FLUMIST QUADRIVALENT NPB ACA

FLUZONE HIGH-DOSE PB ACA

FLUZONE QUADRIVALENT PB ACA

GARDASIL 9 PB ACA

HAVRIX NPB ACA

HEPLISAV-B NPB ACA

HIBERIX PB ACA

INFANRIX PB ACA

IPOL PB ACA

KINRIX NPB ACA

MENACTRA PB ACA

MENVEO NPB ACA

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Drug Name Drug Tier Restrictions / Limits

M-M-R II SUBCUTANEOUS INJECTABLE PB ACA

PEDIARIX PB ACA

PEDVAX HIB PB ACA

PENTACEL PB ACA

PNEUMOVAX 23 PB ACA

PREVNAR 13 PB ACA

PROQUAD PB ACA

QUADRACEL PB ACA

RECOMBIVAX HB PB ACA

ROTARIX NPB ACA

ROTATEQ PB ACA

SHINGRIX PB ACA

TDVAX PB ACA

TENIVAC NPB ACA

TRUMENBA PB ACA

TWINRIX PB ACA

VAQTA NPB ACA

VARIVAX PB ACA

ZOSTAVAX NPB ACA

Inflammatory Bowel Disease Agents

ANALPRAM HC NPB

ANALPRAM HC SINGLES NPB

ANALPRAM-HC NPB

anucort-hc G

ANUSOL-HC RECTAL CREAM NPB ST

anusol-hc rectal suppository NPB

APRISO NPB M

ASACOL HD NPB ST; M

AZULFIDINE NPB M

AZULFIDINE EN-TABS NPB M

balsalazide disodium G

budesonide er G

budesonide oral G

CANASA NPB M

COLAZAL NPB

colocort G

CORTENEMA NPB

CORTIFOAM NPB ST

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Drug Name Drug Tier Restrictions / Limits

DELZICOL NPB ST; M

DIPENTUM NPB ST; M

ENTOCORT EC NPB

hemmorex-hc G

hydrocortisone ace-pramoxine rectal G

hydrocortisone acetate rectal G

hydrocortisone rectal G

LIALDA NPB M

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL

NPB

mesalamine er G M

mesalamine oral G M

mesalamine rectal G M

mesalamine-cleanser G

PENTASA PB M

PROCORT NPB

PROCTOCORT RECTAL CREAM NPB ST

PROCTOCORT RECTAL SUPPOSITORY NPB

PROCTOFOAM HC NPB

procto-med hc G

procto-pak G

proctosol hc G

proctozone-hc G

ROWASA NPB

SFROWASA NPB M

sulfasalazine oral G M

UCERIS ORAL NPB

UCERIS RECTAL PB

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 35 MG, 5 MG

NPB ST; M; QL

ACTONEL ORAL TABLET 30 MG NPB ST; M

alendronate sodium G M; QL

ATELVIA NPB ST; M; QL

BINOSTO NPB ST; M; QL

BONIVA ORAL NPB ST; M; QL

calcitonin (salmon) G M; QL

FORTEO PB-S ST; QL

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Drug Name Drug Tier Restrictions / Limits

FOSAMAX NPB ST; M; QL

FOSAMAX PLUS D NPB ST; QL

ibandronate sodium oral G M; QL

RAYALDEE NPB M

risedronate sodium oral tablet 150 mg, 35 mg, 5 mg

G M; QL

risedronate sodium oral tablet 30 mg G M

risedronate sodium oral tablet delayed release G M; QL

TYMLOS PB-S PA

Metabolic Bone Disease Agents - Other

calcitriol oral G M

doxercalciferol oral G M

NATPARA PB-S PA; QL

paricalcitol oral G M

ROCALTROL NPB M

ZEMPLAR ORAL NPB M

Miscellaneous Therapeutic Agents

ALPHA-LIPOIC ACID INJECTION NPB

AMINOPMRMS NPB

APP SLIM RMS NPB

asilnasalrms G

BACTERIOSTATIC WATER(BENZ ALC) NPB

CANDIDA ALBICANS EXTRACT INJECTION NPB

COENZYME Q-10 INJECTION NPB

CYTOTINE ORAL POWDER NPB

DANDELION NPB

ENDARI NPB-S PA

ergoloid mesylates oral G M

FIRDAPSE NPB-S PA

GRASTEK PB QL

HONEY BEE VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

INSPIREASE RESERVOIR BAGS NPB

LENSCALE NPB

methergine G

methylergonovine maleate oral G

mlk f1 G

mlk f2 G

mlk f3 G

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Drug Name Drug Tier Restrictions / Limits

MLK F4 NPB

ODACTRA PB QL

ORAFATE NPB-S

ORALAIR NPB QL

ORALAIR ADULT SAMPLE KIT NPB QL

ORALAIR ADULT STARTER PACK NPB QL

ORALAIR CHILDRENS SAMPLE KIT NPB QL

ORALAIR CHILDRENS STARTER PACK NPB QL

PROTHELIAL NPB-S

RAGWITEK PB QL

RUZURGI NPB-S PA

STEMPHYLIUM NPB

SYRINGE PRECISEDOSE DISPENSER PB

VENOMIL HONEY BEE VENOM NPB

VENOMIL WASP VENOM NPB

VENOMIL WHITE FACED HORNET NPB

VENOMIL YELLOW HORNET VENOM NPB

VENOMIL YELLOW JACKET VENOM NPB

VISTOGARD PB-S

WASP VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

WHITE-FACED HORNET VENOM INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

YELLOW JACKET VENOM PROTEIN INJECTION SOLUTION RECONSTITUTED 1300 MCG

NPB

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR NPB

ACULAR LS NPB

ACUVAIL NPB ST

ALOCRIL NPB ST

ALOMIDE NPB ST

ALREX PB ST

AZASITE PB

azelastine hcl ophthalmic G

bacitracin ophthalmic G

BEPREVE PB ST

BESIVANCE NPB

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Drug Name Drug Tier Restrictions / Limits

BETADINE OPHTHALMIC PREP NPB

BLEPH-10 NPB

bromfenac sodium (once-daily) G QL

BROMSITE NPB QL

CILOXAN NPB

ciprofloxacin hcl ophthalmic G

cromolyn sodium ophthalmic G

dexamethasone sodium phosphate ophthalmic G

diclofenac sodium ophthalmic G

DUREZOL NPB

epinastine hcl G

erythromycin ophthalmic G

FLAREX NPB ST

fluorometholone G

flurbiprofen sodium G

FML NPB ST

FML FORTE NPB ST

FML LIQUIFILM NPB ST

gatifloxacin ophthalmic G

gentak G

gentamicin sulfate ophthalmic G

ILEVRO PB QL

INVELTYS PB ST

ketorolac tromethamine ophthalmic G

KLARITY-A NPB

KLARITY-B NPB

KLARITY-L NPB

levofloxacin ophthalmic G

LOTEMAX OPHTHALMIC GEL PB QL

LOTEMAX OPHTHALMIC OINTMENT PB QL

LOTEMAX OPHTHALMIC SUSPENSION PB

LOTEMAX SM PB

loteprednol etabonate G

MAXIDEX NPB ST

MITOSOL NPB

MOXEZA PB

moxifloxacin hcl ophthalmic G

NATACYN PB

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Drug Name Drug Tier Restrictions / Limits

NEVANAC NPB ST; QL

OCUFLOX NPB

ofloxacin ophthalmic G

olopatadine hcl ophthalmic G

PATADAY NPB ST

PATANOL NPB ST

PAZEO PB ST

POVIDONE-IODINE OPHTHALMIC NPB

PRED FORTE NPB ST

PRED MILD NPB ST

prednisolone sodium phosphate ophthalmic G

PREDNISOLON-MOXIFLOX-NEPAFENAC NPB

PROLENSA PB QL

sulfacetamide sodium ophthalmic G

tobramycin ophthalmic G

TOBREX NPB

trifluridine G

TRIPLE PMB NPB

TRIPLE PMK NPB

VIGAMOX NPB

ZIRGAN NPB

ZYMAXID NPB

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er G M

acetazolamide oral tablet 250 mg G M

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % PB M

ALPHAGAN P OPHTHALMIC SOLUTION 0.15 %

NPB M

apraclonidine hcl G

AZOPT NPB M

betaxolol hcl ophthalmic G M

BETIMOL NPB M

BETOPTIC-S NPB M

bimatoprost ophthalmic G M; QL

brimonidine tartrate ophthalmic G M

carteolol hcl G M

COMBIGAN PB M

COSOPT NPB ST; M

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Drug Name Drug Tier Restrictions / Limits

COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML

NPB ST; M

dorzolamide hcl ophthalmic G M

dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8 mg/ml

G M

DORZOLAMIDE HCL-TIMOLOL MAL SOLUTION 22.3-6.8 MG/ML OPHTHALMIC

NPB ST; M

dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml ophthalmic

G M

IOPIDINE NPB

ISOPTO CARPINE NPB M

ISTALOL NPB ST; M

KEVEYIS NPB-S PA; QL

latanoprost ophthalmic G M

levobunolol hcl G M

LUMIGAN PB M; QL

methazolamide oral G M

PHOSPHOLINE IODIDE PB M

pilocarpine hcl ophthalmic G M

RHOPRESSA PB M

ROCKLATAN NPB ST; M; QL

SIMBRINZA NPB M

timolol maleate ophthalmic G M

TIMOPTIC NPB M

TIMOPTIC OCUDOSE NPB ST; M

TIMOPTIC-XE NPB M

TRAVATAN Z NPB M; QL

travoprost (bak free) G M; QL

VYZULTA NPB M; QL

XELPROS NPB ST; M; QL

ZIOPTAN NPB ST; M; QL

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac G

AKTEN NPB

ALCAINE NPB

altafrin G

atropine sulfate ophthalmic ointment G M

atropine sulfate ophthalmic solution G M

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Drug Name Drug Tier Restrictions / Limits

bacitracin-polymyxin b ophthalmic G

bacitra-neomycin-polymyxin-hc G

BLEPHAMIDE NPB

BLEPHAMIDE S.O.P. NPB

CYCLOGYL NPB M

CYCLOMYDRIL NPB M

cyclopentolate hcl ophthalmic G M

CYSTARAN PB-S PA; QL

DOUBLE PM NPB

GELFILM OPHTHALMIC NPB

homatropaire G M

homatropine hbr G M

ISOPTO ATROPINE NPB M

LACRISERT NPB

LASTACAFT NPB ST

MAXITROL NPB

neomycin-bacitracin zn-polymyx G

neomycin-polymyxin-dexameth ophthalmic ointment

G

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

G

neomycin-polymyxin-gramicidin G

neomycin-polymyxin-hc ophthalmic G

neo-polycin G

neo-polycin hc G

OXERVATE PB-S PA; QL

phenylephrine hcl ophthalmic G

polycin G

polymyxin b-trimethoprim G

POLYTRIM NPB

PRED-G NPB

PRED-G S.O.P. NPB

PREDNISOLONE ACET-MOXIFLOXACIN NPB

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SOLUTION

NPB

proparacaine hcl ophthalmic G

RESTASIS PB M; QL

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

PB M; QL

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Drug Name Drug Tier Restrictions / Limits

sulfacetamide-prednisolone ophthalmic solution G

TOBRADEX OPHTHALMIC OINTMENT PB

TOBRADEX OPHTHALMIC SUSPENSION NPB

TOBRADEX ST PB

tobramycin-dexamethasone G

TROPICAMIDE-PHENYLEPHRINE NPB

XIIDRA PB M

ZYLET PB

Otic Agents - Drugs for Ear Conditions

acetic acid otic G

CETRAXAL NPB ST

CIPRO HC NPB

CIPRODEX PB

ciprofloxacin hcl otic G

COLY-MYCIN S NPB

cortic-nd G

DERMOTIC NPB

exotic-hc G

flac G

fluocinolone acetonide otic G

hydrocortisone-acetic acid G

neomycin-polymyxin-hc otic G

ofloxacin otic G

OTICIN HC NR NPB

OTIPRIO NPB

OTOVEL PB

PRAMOTIC NPB

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL NPB

ASTEPRO NPB QL

azelastine hcl nasal G QL

BECONASE AQ NPB ST; QL

benzonatate G

bromfed dm G

BROMPHENIRAMINE MALEATE INTRAMUSCULAR

NPB

brompheniramine tannate G

carbinoxamine maleate G

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Drug Name Drug Tier Restrictions / Limits

CLARINEX NPB QL

CLARINEX-D 12 HOUR NPB QL

clemastine fumarate oral tablet 2.68 mg G

cyproheptadine hcl oral G

desloratadine PB QL

dexchlorpheniramine maleate oral G

DICOPANOL FUSEPAQ NPB

DICOPANOL RAPIDPAQ NPB

diphen oral elixir G

diphenhydramine hcl oral elixir G

DYMISTA PB ST; QL

flunisolide nasal PB QL

fluticasone propionate nasal PB

GILPHEX TR NPB

GILTUSS TR NPB

guaiatussin ac G OTC; QL

guaifenesin ac G OTC; QL

hydrocodone polst-cpm polst er G QL

hydrocodone-homatropine G QL

hydromet G QL

HYPERSAL NPB

ipratropium bromide nasal G

KARBINAL ER NPB

mometasone furoate nasal PB QL

NASONEX NPB ST; QL

nebusal inhalation nebulization solution 3 % G

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

NPB

NEOTUSS PLUS PB

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED

NPB QL

olopatadine hcl nasal G QL

OMNARIS NPB ST; QL

PATANASE NPB QL

phenadoz G

phenylephrine-guaifenesin oral liquid 1.5-20 mg/ml

G

promethazine hcl oral G

promethazine hcl rectal G

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Drug Name Drug Tier Restrictions / Limits

promethazine-codeine G QL

promethazine-dm G

promethazine-phenyleph-codeine G QL

promethazine-phenylephrine G

promethegan G

pseudoephedrine-bromphen-dm G

pulmosal G

QNASL PB ST; QL

QNASL CHILDRENS PB ST; QL

RYCLORA NPB

ryvent NPB

SEMPREX-D NPB

sodium chloride inhalation G

SSKI NPB

TESSALON PERLES NPB

TUSSICAPS NPB QL

TUXARIN ER NPB QL

TUZISTRA XR NPB QL

virtussin ac w/alc G OTC; QL

XHANCE NPB ST; QL

ZETONNA NPB ST; QL

Z-TUSS AC NPB OTC; QL

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE NPB ST; M; QL

acetylcysteine inhalation G

ADVAIR DISKUS NPB M; QL

ADVAIR HFA PB M; QL

AIRDUO RESPICLICK 113/14 PB M; QL

AIRDUO RESPICLICK 232/14 PB M; QL

AIRDUO RESPICLICK 55/14 PB M; QL

albuterol sulfate er G M

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

G M; QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

NPB M; QL

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Drug Name Drug Tier Restrictions / Limits

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

PB M; QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

G M; QL

albuterol sulfate oral G M

ALVESCO NPB ST; M; QL

ANORO ELLIPTA PB M; QL

ARCAPTA NEOHALER PB M; QL

ARNUITY ELLIPTA PB M; QL

ASMANEX (120 METERED DOSES) PB M; QL

ASMANEX (14 METERED DOSES) PB M; QL

ASMANEX (30 METERED DOSES) PB M; QL

ASMANEX (60 METERED DOSES) PB M; QL

ASMANEX (7 METERED DOSES) PB M; QL

ASMANEX HFA PB M; QL

ATROVENT HFA PB M; QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML

NPB ST; QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.3 MG/0.3ML

NPB ST

BEVESPI AEROSPHERE PB M; QL

BREO ELLIPTA PB M; QL

BROVANA NPB ST; M; QL

budesonide inhalation G M; QL

BUDESONIDE-FORMOTEROL FUMARATE PB M; QL

COMBIVENT RESPIMAT PB QL

cromolyn sodium inhalation G M

DALIRESP ORAL TABLET 250 MCG PB PA

DALIRESP ORAL TABLET 500 MCG PB PA; QL

difil-g forte G

DULERA PB M; QL

ELIXOPHYLLIN NPB M

epinephrine injection solution 0.3 mg/0.3ml NPB

epinephrine injection solution auto-injector 0.15 mg/0.15ml

NPB

epinephrine injection solution auto-injector 0.15 mg/0.3ml

PB QL

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Drug Name Drug Tier Restrictions / Limits

epinephrine injection solution auto-injector 0.3 mg/0.3ml

G

EPIPEN 2-PAK NPB

EPIPEN JR 2-PAK PB QL

ESBRIET ORAL CAPSULE PB-S PA; QL

ESBRIET ORAL TABLET 267 MG PB-S PA; QL

ESBRIET ORAL TABLET 801 MG PB-S PA

FLOVENT DISKUS PB M; QL

FLOVENT HFA PB M; QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

G M; QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

PB M; QL

INCRUSE ELLIPTA PB M; QL

ipratropium bromide inhalation G M; QL

ipratropium-albuterol G QL

levalbuterol hcl inhalation G QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

NPB ST; QL

LONHALA MAGNAIR REFILL KIT NPB M; QL

LONHALA MAGNAIR STARTER KIT NPB M; QL

metaproterenol sulfate oral G M

montelukast sodium oral packet G M

montelukast sodium oral tablet G M; QL

montelukast sodium oral tablet chewable G M; QL

OFEV PB-S PA; QL

PERFOROMIST PB M; QL

PROAIR HFA G M; QL

PROAIR RESPICLICK G M; QL

PROVENTIL HFA NPB ST; M; QL

PULMICORT FLEXHALER PB M; QL

PULMICORT SUSPENSION NPB ST; M; QL

QVAR REDIHALER PB M; QL

SEEBRI NEOHALER NPB M; QL

SEREVENT DISKUS PB M; QL

SINGULAIR ORAL PACKET NPB ST; M

SINGULAIR ORAL TABLET NPB ST; M; QL

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SINGULAIR ORAL TABLET CHEWABLE NPB ST; M; QL

SPIRIVA HANDIHALER PB ST; M; QL

SPIRIVA RESPIMAT PB M; QL

STIOLTO RESPIMAT PB M; QL

STRIVERDI RESPIMAT PB M; QL

SYMBICORT PB M; QL

SYMJEPI NPB

terbutaline sulfate oral G M

THEO-24 NPB M

theophylline G M

theophylline er G M

TRELEGY ELLIPTA PB M; QL

TUDORZA PRESSAIR PB QL

UTIBRON NEOHALER NPB M; QL

VENTOLIN HFA PB M; QL

wixela inhub G M; QL

XOPENEX NPB QL

XOPENEX CONCENTRATE NPB QL

XOPENEX HFA NPB ST; QL

YUPELRI PB M; QL

zafirlukast G M; QL

zileuton er G ST; M; QL

ZYFLO NPB ST; M

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS PB-S QL

CAYSTON PB-S QL

KALYDECO PB-S PA

KITABIS PAK PB-S QL

ORKAMBI PB-S PA; QL

PULMOZYME PB

SYMDEKO PB-S PA; QL

TOBI NEBULIZER NPB QL

TOBI PODHALER PB QL

tobramycin nebulization solution 300 mg/5ml inhalation

G QL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

PB-S QL

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Drug Name Drug Tier Restrictions / Limits

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA NPB-S PA; QL

ADEMPAS PB-S PA; QL

alyq G-S PA; QL

ambrisentan G-S PA; QL

bosentan G-S PA; QL

LETAIRIS PB-S PA; QL

OPSUMIT PB-S PA; QL

ORENITRAM NPB-S PA

REVATIO ORAL NPB-S PA; QL

sildenafil citrate oral suspension reconstituted G PA; QL

sildenafil citrate oral tablet 20 mg G-S PA; QL

tadalafil (pah) G-S PA; QL

TRACLEER PB-S PA; QL

UPTRAVI PB-S PA; QL

VENTAVIS NPB-S PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

ACTIVE-CYCLOBENZAPRINE NPB

AMRIX NPB ST

baclofen external G

baclofen oral tablet 10 mg, 20 mg G

baclofen oral tablet 5 mg NPB

carisoprodol oral G

carisoprodol-aspirin G

chlorzoxazone oral tablet 250 mg G ST

chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg

G

cyclobenzaprine hcl er G

cyclobenzaprine hcl oral G

CYCLOPHENE RAPIDPAQ NPB

DANTRIUM ORAL NPB ST

dantrolene sodium oral G

ENOVARX-BACLOFEN NPB

enovarx-cyclobenzaprine hcl cream 20 mg/gm transdermal

G

ENOVARX-CYCLOBENZAPRINE HCL CREAM 20 MG/GM TRANSDERMAL

NPB

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Drug Name Drug Tier Restrictions / Limits

FEXMID NPB ST

FIRST-BACLOFEN NPB

LORZONE NPB ST

METAXALL CP NPB

metaxalone G

methocarbamol oral G

NORGESIC FORTE NPB ST

orphenadrine citrate er G

orphenadrine-aspirin-caffeine G ST

ORPHENGESIC FORTE G ST

ROBAXIN-750 NPB ST

SKELAXIN NPB ST

SOMA NPB ST

TABRADOL FUSEPAQ NPB

TABRADOL RAPIDPAQ NPB

tizanidine hcl oral G

ZANAFLEX NPB ST

Sleep Disorder Agents

AMBIEN NPB ST; QL

AMBIEN CR NPB ST; QL

armodafinil G PA; QL

BELSOMRA NPB ST; QL

BUTISOL SODIUM NPB

doxepin hcl oral tablet G QL

EDLUAR NPB ST; QL

eszopiclone G QL

flurazepam hcl G QL

HETLIOZ NPB-S ST; QL

INTERMEZZO NPB ST; QL

LUNESTA NPB ST; QL

modafinil G PA; QL

NUVIGIL NPB PA; QL

PROVIGIL NPB PA; QL

ramelteon G QL

RESTORIL NPB QL

ROZEREM NPB ST; QL

SECONAL G

SILENOR NPB ST; QL

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Drug Name Drug Tier Restrictions / Limits

temazepam G QL

XYREM PB-S PA; QL

zaleplon G QL

zolpidem tartrate G QL

zolpidem tartrate er G QL

ZOLPIMIST NPB ST; QL

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Index of Drugs

A.A.G.C. KIT IN TERODERM... 56abacavir sulfate.........................39abacavir sulfate-lamivudine...... 39abacavir-lamivudine-zidovudine.................................39ABILIFY.....................................37ABILIFY MAINTENA................. 37ABILIFY MYCITE...................... 37abiraterone acetate................... 31ABSORICA............................... 56ABSORICA LD..........................56ABSTRAL..................................10acamprosate calcium................ 16ACANYA................................... 56acarbose................................... 64ACCOLATE.............................107ACCU-CHEK AVIVA CONNECT KIT W/DEVICE.......67ACCU-CHEK AVIVA PLUS.......67ACCU-CHEK COMPACT PLUS TEST STRIPS................ 67ACCU-CHEK GUIDE................ 67ACCU-CHEK GUIDE ME..........67ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE...67ACCU-CHEK SMARTVIEW TEST STRIPS...........................67ACCUPRIL................................43ACCURETIC............................. 43acebutolol hcl............................ 43acetaminophen-codeine............10acetaminophen-codeine #2.......10acetaminophen-codeine #3.......10acetaminophen-codeine #4.......10acetazolamide...................43, 102acetazolamide er.....................102acetic acid............................... 105acetylcysteine......................... 107ACIPHEX.................................. 75ACIPHEX SPRINKLE............... 75acitretin..................................... 56ACTEMRA................................ 94ACTEMRA ACTPEN.................94ACTHIB.....................................96ACTICLATE.............................. 17ACTIGALL.................................76ACTIQ....................................... 10ACTIVE INJECTION BLM-1..... 81ACTIVE INJECTION BM...........81ACTIVE INJECTION DL........... 81ACTIVE INJECTION DLM........ 81ACTIVE INJECTION KET-L......13

ACTIVE INJECTION KETMARC-L............................. 13ACTIVE INJECTION KIT L....... 81ACTIVE INJECTION KM...........81ACTIVE INJECTION LM-2........15ACTIVE INJECTION LM-DEP-2................................................ 81ACTIVE INJECTION M-1..........81ACTIVE-CYCLOBENZAPRINE................................................ 111ACTIVE-KETOPROFEN........... 13ACTIVELLA...............................86ACTIVE-PREP KIT I................. 13ACTIVE-PREP KIT II ................ 13ACTIVE-PREP KIT III ............... 13ACTIVE-PREP KIT IV............... 56ACTIVE-PREP KIT V................ 27ACTIVE-TRAMADOL................56ACTONEL................................. 98ACTOPLUS MET...................... 64ACTOS......................................65ACULAR................................. 100ACULAR LS............................ 100ACUVAIL.................................100acyclovir.................................... 39ACZONE................................... 56ADACEL....................................96ADALAT CC..............................43adapalene................................. 56ADAPALENE............................ 56adapalene-benzoyl peroxide.....56ADASUVE.................................37adc/f (0.5mg/ml)........................ 70ADCIRCA................................111ADDERALL............................... 51ADDERALL XR......................... 51ADDYI....................................... 54adefovir dipivoxil ....................... 39ADEMPAS.............................. 111ADHANSIA XR..........................51ADIPEX-P................................. 54ADLYXIN...................................65ADLYXIN STARTER PACK...... 65ADMELOG................................ 68ADMELOG SOLOSTAR........... 69ADRENALIN........................... 105ADVAIR DISKUS.................... 107ADVAIR HFA.......................... 107ADZENYS ER........................... 51ADZENYS XR-ODT.................. 52AFINITOR................................. 31AFINITOR DISPERZ.................31

afirmelle.................................... 86AFLURIA QUADRIVALENT......96AFREZZA..................................69AGGRENOX............................. 37AGRYLIN.................................. 43AIF #2 DRUG PREPARATION KIT............................................ 13AIF #3 DRUG PREPARATION KIT............................................ 13AIMOVIG...................................29AIRDUO RESPICLICK 113/14107AIRDUO RESPICLICK 232/14107AIRDUO RESPICLICK 55/14..107AJOVY...................................... 29ak-poly-bac............................. 103AKTEN.................................... 103AKTIPAK...................................56AKYNZEO.................................26ALA SCALP.............................. 56ala-cort...................................... 56albendazole...............................35ALBENZA..................................35albuterol sulfate.......................108albuterol sulfate er.................. 107ALBUTEROL SULFATE HFA........................................ 107, 108ALCAINE.................................103alclometasone dipropionate...... 56ALDACTAZIDE......................... 43ALDACTONE............................ 43ALDARA....................................56ALECENSA...............................31alendronate sodium.................. 98alfuzosin hcl er.......................... 81ALINIA.......................................35aliskiren fumarate......................43ALKERAN................................. 31allopurinol..................................29ALLZITAL..................................10almotriptan malate.................... 29ALOCRIL.................................100ALOGLIPTIN BENZOATE........ 65ALOGLIPTIN-METFORMIN HCL...........................................65ALOGLIPTIN-PIOGLITAZONE. 65ALOMIDE................................100ALORA......................................86alosetron hcl..............................76ALPHAGAN P......................... 102ALPHA-LIPOIC ACID................99alprazolam................................ 42alprazolam er............................ 42

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alprazolam intensol................... 42alprazolam xr............................ 42ALREX.................................... 100ALTABAX..................................17ALTACE.................................... 43altafrin..................................... 103altavera..................................... 86ALTOPREV...............................43ALTRENO................................. 56ALUNBRIG................................31ALVESCO............................... 108alyacen 1/35..............................86alyacen 7/7/7.............................86alyq......................................... 111amabelz.................................... 86amantadine hcl..........................36AMARYL................................... 65AMBIEN.................................. 112AMBIEN CR............................ 112ambrisentan............................ 111amcinonide................................56AMERGE.................................. 29amethia..................................... 86amethia lo................................. 86amethyst................................... 86AMICAR.................................... 43amiloride hcl..............................43amiloride-hydrochlorothiazide... 43aminobenzoate potassium........ 70aminocaproic acid..................... 43AMINOPMRMS.........................99amiodarone hcl......................... 43AMITIZA....................................76amitriptyline hcl......................... 23AMLODIPINE BES+SYRSPEND SF............... 43amlodipine besylate.................. 43amlodipine besylate-benazepril hcl............................................. 43amlodipine besylate-valsartan.. 44amlodipine-atorvastatin.............44amlodipine-olmesartan..............44amlodipine-valsartan-hctz......... 44ammonium lactate.....................56amnesteem............................... 56amoxapine................................ 23amoxicill-clarithro-lansopraz..... 76amoxicillin................................. 17amoxicillin-potassium clavulanate................................17amoxicillin-potassium clavulanate er............................17amphetamine sulfate.................52

amphetamine-dextroamphetamine.................. 52amphetamine-dextroamphetamine er.............. 52ampicillin................................... 17AMPYRA...................................53AMRIX.....................................111ANAFRANIL..............................24anagrelide hcl............................43ANALPRAM HC........................ 97ANALPRAM HC SINGLES....... 97ANALPRAM-HC........................97ANASPAZ................................. 76anastrozole............................... 31ANCOBON................................27ANDRODERM.......................... 83ANDROGEL..............................83ANDROGEL PUMP.................. 83ANGELIQ.................................. 86ANORO ELLIPTA................... 108ANTABUSE...............................16ANTARA................................... 44anucort-hc................................. 97ANUSOL-HC.............................97anusol-hc.................................. 97ANZEMET.................................26APADAZ....................................10apap-caff-dihydrocodeine......... 10APEXICON E............................ 56APIDRA SOLOSTAR................ 69APIDRA VIAL............................69APLENZIN................................ 24APOKYN................................... 36APP SLIM RMS........................ 99apraclonidine hcl..................... 102aprepitant.................................. 26apri............................................ 86APRISO.................................... 97APTENSIO XR..........................52APTIOM.................................... 21APTIVUS...................................39AQUACEL AG BURN............... 56ARAKODA................................ 35aranelle..................................... 86ARAVA......................................94ARCALYST............................... 94ARCAPTA NEOHALER.......... 108ARGININE HCL........................ 70ARICEPT.................................. 23ARIKAYCE................................17ARIMIDEX.................................31aripiprazole............................... 37ARISTADA................................ 37

ARISTADA INITIO.................... 37ARIXTRA.................................. 20armodafinil .............................. 112ARMOUR THYROID.................93ARNUITY ELLIPTA.................108AROMASIN...............................31ARTHROTEC............................13ARYMO ER...............................10arzol silver nit applicators..........56ASACOL HD............................. 97ascomp-codeine........................10ashlyna......................................86asilnasalrms.............................. 99ASMANEX (120 METERED DOSES).................................. 108ASMANEX (14 METERED DOSES).................................. 108ASMANEX (30 METERED DOSES).................................. 108ASMANEX (60 METERED DOSES).................................. 108ASMANEX (7 METERED DOSES).................................. 108ASMANEX HFA...................... 108aspirin-dipyridamole er..............37ASTAGRAF XL......................... 94ASTEPRO...............................105ATABEX OB..............................70ATACAND.................................44ATACAND HCT........................ 44atazanavir sulfate......................39ATELVIA................................... 98atenolol..................................... 44ATENOLOL+SYRSPEND SF... 44atenolol-chlorthalidone..............44ATIVAN..................................... 42atomoxetine hcl.........................52atorvastatin calcium.................. 44atovaquone............................... 35atovaquone-proguanil hcl..........35ATRALIN...................................56ATRIPLA................................... 39ATROPEN.................................76atropine sulfate....................... 103ATROVENT HFA.................... 108AUBAGIO..................................53aubra.........................................86aubra eq....................................86AUGMENTIN............................ 17AUGMENTIN ES-600............... 17aurovela 1.5/30......................... 86aurovela 1/20............................ 86aurovela 24 fe........................... 86

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aurovela fe 1.5/30..................... 86aurovela fe 1/20........................ 86AURYXIA.................................. 79AUSTEDO.................................54AUVI-Q....................................108AVALIDE...................................44AVANDIA.................................. 65AVAPRO................................... 44AVAR LS CLEANSER.............. 56AVAR-E EMOLLIENT............... 56AVAR-E GREEN.......................56AVAR-E LS............................... 56AVC VAGINAL.......................... 27aviane....................................... 86avidoxy......................................17avita.......................................... 57AVODART.................................81AVONEX PEN...........................53AVONEX PREFILLED.............. 53AYGESTIN................................86ayuna........................................ 86AZASAN....................................94AZASITE................................. 100azathioprine.............................. 94azelaic acid............................... 57azelastine hcl.................. 100, 105AZELEX.................................... 57AZILECT................................... 36azithromycin..............................17AZOPT.................................... 102AZOR........................................ 44AZULFIDINE............................. 97AZULFIDINE EN-TABS............ 97azurette..................................... 86bacitracin.................................100bacitracin-polymyxin b............ 104bacitra-neomycin-polymyxin-hc................................................ 104baclofen.................................. 111BACTERIOSTATIC WATER(BENZ ALC)................. 99BACTRIM..................................17BACTRIM DS............................17BALCOLTRA.............................86balsalazide disodium.................97BALVERSA............................... 31balziva.......................................86BANZEL.................................... 21BAQSIMI ONE PACK............... 68BAQSIMI TWO PACK...............68BARACLUDE............................ 39BASAGLAR KWIKPEN............. 69BAXDELA................................. 17

BCAA........................................ 70BECONASE AQ......................105bekyree..................................... 86BELBUCA................................. 10belladonna alkaloids-opium...... 76BELSOMRA............................ 112BELVIQ..................................... 54BELVIQ XR............................... 54benazepril hcl............................44benazepril-hydrochlorothiazide. 44BENICAR.................................. 44BENICAR HCT..........................44BENLYSTA............................... 94BENZAC AC WASH..................57BENZACLIN..............................57BENZACLIN WITH PUMP........ 57BENZAMYCIN.......................... 57benzepro................................... 57benzepro foaming cloths...........57BENZEPRO SHORT CONTACT.................................57BENZHYDROCODONE-ACETAMINOPHEN...................10BENZIQ.....................................57BENZIQ LS............................... 57BENZIQ WASH.........................57BENZNIDAZOLE...................... 35benzonatate............................ 105BENZOYL PEROX-HYDROCORTISONE................57benzoyl peroxide.......................57BENZOYL PEROXIDE..............57BENZOYL PEROXIDE FORTE- HC.............................. 57benzoyl peroxide-erythromycin. 57benzphetamine hcl....................54benztropine mesylate................36BEPREVE............................... 100beser......................................... 57BESIVANCE........................... 100BETADINE OPHTHALMIC PREP...................................... 101BETALIDO................................ 81betamethasone dipropionate.... 57betamethasone dipropionate aug............................................ 57betamethasone valerate........... 57BETAPACE...............................44BETAPACE AF......................... 44BETASERON............................53betaxolol hcl...................... 44, 102bethanechol chloride.................79BETHKIS.................................110

BETIMOL................................ 102BETOPTIC-S.......................... 102BEVESPI AEROSPHERE.......108BEVYXXA................................. 20bexarotene................................ 31BEXSERO.................................96BEYAZ...................................... 86bicalutamide..............................31BIDIL......................................... 44BI-EST 80:20 PROGESTERONE....................86BIEST/PROGESTERONE........ 86BIJUVA..................................... 86BIKTARVY................................ 39BILTRICIDE.............................. 35bimatoprost............................. 102BINOSTO..................................98BIO-STATIN..............................27bio-statin................................... 27BIOTEL CARE BLOOD GLUCOSE SYST...................... 67bisoprolol fumarate................... 44bisoprolol-hydrochlorothiazide.. 44BLEPH-10............................... 101BLEPHAMIDE.........................104BLEPHAMIDE S.O.P.............. 104blisovi 24 fe............................... 86blisovi fe 1.5/30......................... 86blisovi fe 1/20............................ 86BLOOD GLUCOSE TEST.........67BONIVA.................................... 98BONJESTA............................... 26BOOSTRIX............................... 96bosentan................................. 111BOSULIF...................................31bp cleansing wash.................... 57bp foam..................................... 57bp wash.....................................57bpo............................................ 57BRAFTOVI................................ 31BREO ELLIPTA...................... 108BRETYLIUM TOSYLATE..........44briellyn.......................................86BRILINTA..................................37brimonidine tartrate................. 102BRISDELLE.............................. 24BRIVIACT................................. 21bromfed dm.............................105bromfenac sodium (once-daily)................................................ 101bromocriptine mesylate.............36BROMPHENIRAMINE MALEATE............................... 105

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brompheniramine tannate....... 105BROMSITE............................. 101BROVANA.............................. 108BRYHALI...................................57budesonide....................... 97, 108budesonide er........................... 97BUDESONIDE-FORMOTEROL FUMARATE..108bumetanide............................... 44BUMEX..................................... 44BUNAVAIL................................ 16BUPAP......................................10BUPHENYL...............................78BUPIVACAINE HCL..................15BUPIVILOG...............................81buprenorphine...........................10BUPRENORPHINE...................10buprenorphine hcl..................... 16buprenorphine hcl-naloxone hcl............................................. 16bupropion hcl............................ 24bupropion hcl er (smoking det). 16bupropion hcl er (sr)..................24bupropion hcl er (xl).................. 24BUPROPION HCL ER (XL)...... 24buspirone hcl.............................42BUTALBITAL-ACETAMINOPHEN...................10butalbital-acetaminophen..........10butalbital-apap-caff-cod............ 10butalbital-apap-caffeine.............10butalbital-asa-caff-codeine........10butalbital-aspirin-caffeine.......... 10BUTISOL SODIUM................. 112butorphanol tartrate...................10BUTRANS.................................10BYDUREON..............................65BYDUREON BCISE AUTOINJECTOR...................... 65BYETTA 10 MCG PEN............. 65BYETTA 5 MCG PEN............... 65BYSTOLIC................................ 44cabergoline............................... 84CABLIVI.................................... 37CABOMETYX........................... 31CADUET................................... 44CAFERGOT.............................. 29caffeine citrate...........................54CALAN SR................................ 44CALCIFOL................................ 70calcipotriene..............................57calcipotriene-betameth diprop...57calcitonin (salmon).................... 98

CALCITRENE........................... 57calcitriol ............................... 57, 99calcium acetate (phos binder)...79calcium-folic acid plus d............ 70CALQUENCE............................31CAMBIA.................................... 13camila........................................87camrese.................................... 87camrese lo................................ 87CANASA................................... 97candesartan cilexetil ................. 44candesartan cilexetil-hctz..........44CANDIDA ALBICANS EXTRACT................................. 99CANTHARIDIN......................... 57capecitabine..............................31CAPEX......................................57CAPRELSA...............................31captopril .................................... 44captopril-hydrochlorothiazide.... 44CARAC..................................... 57CARAFATE...............................75CARBAGLU.............................. 70carbamazepine......................... 21carbamazepine er..................... 21CARBATROL............................ 21carbidopa.................................. 36carbidopa-levodopa.................. 36carbidopa-levodopa er.............. 36carbidopa-levodopa-entacapone............................... 36carbinoxamine maleate...........105CARDIZEM............................... 44CARDIZEM CD......................... 44CARDIZEM LA..........................44CARDURA................................ 45CARDURA XL...........................81carisoprodol............................ 111carisoprodol-aspirin.................111carisoprodol-aspirin-codeine.....10CARNITOR............................... 70CAROSPIR............................... 45carteolol hcl.............................102cartia xt..................................... 45carvedilol...................................45carvedilol phosphate er.............45cascara sagrada....................... 76CASODEX................................ 31CATAPRES...............................45CATAPRES-TTS-1................... 45CATAPRES-TTS-2................... 45CATAPRES-TTS-3................... 45cavarest.................................... 55

CAYSTON...............................110caziant.......................................87cefaclor..................................... 17cefaclor er................................. 17cefadroxil ...................................17cefdinir...................................... 17cefditoren pivoxil ....................... 17cefixime.....................................17cefpodoxime proxetil ................. 17cefprozil .....................................17cefuroxime axetil ....................... 18CELEBREX...............................13celecoxib................................... 13CELEXA....................................24CELLCEPT............................... 94CELONTIN................................21CENTANY.................................18cephalexin.................................18CERDELGA.............................. 78CETACAINE............................. 15CETRAXAL............................. 105CETROTIDE............................. 84cevimeline hcl........................... 55CHANTIX.................................. 16CHANTIX CONTINUING MONTH PAK.............................16CHANTIX STARTING MONTH PAK...........................................16chateal...................................... 87chateal eq................................. 87CHEMET...................................70CHENODAL.............................. 76chlordiazepoxide hcl................. 42chlordiazepoxide-amitriptyline...24chlordiazepoxide-clidinium........76chlorhexidine gluconate............ 55chloroquine phosphate..............35chlorothiazide............................45chlorpromazine hcl....................37chlorthalidone............................45chlorzoxazone.........................111CHOLBAM................................ 78cholestyramine..........................45cholestyramine light.................. 45choline fenofibrate.....................45choline-mag trisalicylate............13chorionic gonadotropin..............84ciclodan.....................................27CICLODAN SOLUTION............ 27ciclopirox................................... 27ciclopirox olamine..................... 27cilostazol................................... 37CILOXAN................................ 101

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CIMDUO................................... 39cimetidine..................................75cimetidine hcl............................ 75CIMZIA......................................94CIMZIA PREFILLED KIT...........94CIMZIA STARTER KIT............. 94cinacalcet hcl............................ 84CIPRO.......................................18CIPRO HC.............................. 105CIPRODEX............................. 105ciprofloxacin hcl........ 18, 101, 105citalopram hydrobromide.......... 24CITRANATAL BLOOM..............70CITRANATAL MEDLEY............70claravis......................................58CLARINEX.............................. 106CLARINEX-D 12 HOUR..........106clarithromycin............................18clarithromycin er........................18clemastine fumarate................106CLENPIQ.................................. 76CLEOCIN.................................. 18CLEOCIN-T...............................58CLIMARA.................................. 87CLIMARA PRO......................... 87clindacin etz.............................. 58clindacin-p.................................58CLINDAGEL..............................58clindamycin hcl..........................18clindamycin palmitate hcl.......... 18clindamycin phosphate....... 18, 58CLINDAMYCIN PHOSPHATE.. 58clindamycin phosphate-benzoyl peroxide.......................58clindamycin-tretinoin................. 58CLINDESSE..............................18CLINOIN................................... 58clinpro 5000.............................. 55clobazam...................................21clobetasol prop emollient base. 58clobetasol propionate................58clobetasol propionate e.............58clobetasol propionate emulsion 58CLOBEX................................... 58CLOBEX SPRAY...................... 58clocortolone pivalate................. 58clodan....................................... 58CLODERM................................ 58clomiphene citrate.....................84clomipramine hcl....................... 24clonazepam...............................42clonidine....................................45clonidine hcl.............................. 45

clonidine hcl er.......................... 52clopidogrel bisulfate.................. 37clorazepate dipotassium........... 42clotrimazole...............................27clotrimazole-betamethasone.....58clovique.....................................70clozapine...................................37CLOZARIL................................ 37coal tar...................................... 58COARTEM................................ 35cocaine hcl................................ 16codeine sulfate..........................10COENZYME Q-10.....................99COLAZAL..................................97COLCHICINE............................29colchicine.................................. 29colchicine-probenecid............... 29COLCRYS.................................29colesevelam hcl........................ 45COLESTID................................ 45COLESTID FLAVORED............45colestipol hcl............................. 45colistimethate sodium (cba)...... 18colocort..................................... 97COLY-MYCIN M....................... 18COLY-MYCIN S...................... 105COLYTE WITH FLAVOR PACKS......................................76COMBIGAN............................ 102COMBIPATCH.......................... 87COMBIVENT RESPIMAT....... 108COMBIVIR................................ 39COMETRIQ (100 MG DAILY DOSE).......................................31COMETRIQ (140 MG DAILY DOSE).......................................31COMETRIQ (60 MG DAILY DOSE).......................................31COMPLERA..............................39compro...................................... 26COMTAN.................................. 36CONCERTA..............................52CONDYLOX..............................58constulose.................................76CONTOUR NEXT MONITOR... 67CONTOUR NEXT TEST........... 67CONTOUR TEST......................67CONTRAST ALLERGY PREMED PACK........................81CONTRAVE.............................. 54CONZIP.................................... 10COPAXONE..............................53COPIKTRA................................31

CORDRAN................................58COREG.....................................45COREG CR...............................45coremino................................... 18CORGARD................................45CORLANOR..............................45CORTANE-B.............................58CORTEF................................... 81CORTENEMA........................... 97cortic-nd.................................. 105CORTIFOAM............................ 97cortisone acetate.......................81CORTISPORIN......................... 58COSENTYX (300 MG DOSE)...94COSENTYX 150 MG/ML.......... 94COSENTYX SENSOREADY (300 MG)...................................94COSENTYX SENSOREADY PEN...........................................94COSOPT.................................102COSOPT PF........................... 103COTELLIC................................ 31COTEMPLA XR-ODT............... 52COUMADIN.............................. 20covaryx......................................87covaryx hs.................................87COZAAR................................... 45CREON..................................... 78CRESEMBA..............................27CRESTOR................................ 45CRINONE................................. 87CRIXIVAN................................. 39cromolyn sodium.......76, 101, 108crotan........................................ 35cryselle-28.................................87CUPRIMINE..............................79CUTAQUIG............................... 94CUTIVATE................................ 58CUVPOSA................................ 76CYANOCOBALAMIN................ 70cyclafem 1/35............................87cyclafem 7/7/7...........................87cyclobenzaprine hcl................ 111cyclobenzaprine hcl er............ 111CYCLOGYL............................ 104CYCLOMYDRIL...................... 104cyclopentolate hcl................... 104CYCLOPHENE RAPIDPAQ....111cyclophosphamide.................... 31cycloserine................................ 30CYCLOSET...............................65cyclosporine.............................. 94cyclosporine modified............... 94

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CYMBALTA...............................24cyproheptadine hcl..................106cyred......................................... 87cyred eq.................................... 87CYSTAGON..............................78CYSTARAN............................ 104CYTOMEL.................................93CYTOTEC.................................75CYTOTINE................................99cytra k crystals.......................... 70D.H.E. 45.................................. 29dalfampridine er........................ 53DALIRESP.............................. 108danazol..................................... 83DANDELION............................. 99DANTRIUM............................. 111dantrolene sodium.................. 111dapsone.............................. 30, 58DAPTACEL............................... 96DARAPRIM............................... 35darifenacin hydrobromide er..... 79dasetta 1/35.............................. 87dasetta 7/7/7............................. 87DAURISMO...............................31DAYPRO...................................13daysee...................................... 87DAYTRANA.............................. 52DDAVP......................................84DDAVP RHINAL TUBE.............84DEBACTEROL..........................55deblitane................................... 87DECADRON............................. 81deferasirox................................ 70DELESTROGEN.......................87DELSTRIGO............................. 39delyla.........................................87DELZICOL................................ 98demeclocycline hcl....................18DEMSER...................................45DENAVIR.................................. 39denta 5000 plus........................ 55dentagel.................................... 55DEPAKOTE.............................. 21DEPAKOTE ER........................ 21DEPAKOTE SPRINKLES......... 21DEPEN TITRATABS.................79DEPO-ESTRADIOL.................. 87DEPO-MEDROL....................... 81DEPO-PROVERA..................... 87DEPO-SUBQ PROVERA 104...87DEPO-TESTOSTERONE......... 83DEPRIZINE FUSEPAQ.............75DERMA-SMOOTHE/FS BODY.58

DERMA-SMOOTHE/FS SCALP...................................... 58DERMOTIC.............................105DESCOVY................................ 39desipramine hcl.........................24desloratadine.......................... 106desmopressin ace spray refrig..84desmopressin acetate...............84desmopressin acetate spray..... 84desogestrel-ethinyl estradiol..... 87DESONATE.............................. 58desonide................................... 59DESOWEN............................... 59desoximetasone........................59DESOXYN................................ 52DESVENLAFAXINE ER............24desvenlafaxine succinate er......24DETROL................................... 79DETROL LA.............................. 79dexamethasone........................ 82dexamethasone intensol........... 81dexamethasone sodium phosphate............................... 101dexchlorpheniramine maleate.106DEXEDRINE............................. 52DEXILANT................................ 75DEXLIDO.................................. 82DEXLIDO-M.............................. 82dexmethylphenidate hcl............ 52dexmethylphenidate hcl er........ 52DEXOPIN..................................82DEXPAK 10 DAY...................... 82DEXPAK 13 DAY...................... 82DEXPAK 6 DAY........................ 82DEXPANTHENOL.....................71dextroamphetamine sulfate.......52dextroamphetamine sulfate er.. 52DIACOMIT................................ 21DIASTAT ACUDIAL.................. 21DIASTAT PEDIATRIC...............21DIATHRIVE BLOOD GLUCOSE TEST...................... 67DIATHRIVE GLUCOSE TEST.. 67diazepam............................ 21, 42diazepam intensol..................... 42DIBENZYLINE.......................... 45DICLEGIS................................. 26DICLOFENAC EPOLAMINE.....13diclofenac potassium................ 13diclofenac sodium....... 13, 59, 101diclofenac sodium er................. 13diclofenac-misoprostol.............. 13dicloxacillin sodium................... 18

DICOPANOL FUSEPAQ.........106DICOPANOL RAPIDPAQ....... 106dicyclomine hcl..........................76didanosine.................................39diethylpropion hcl...................... 54diethylpropion hcl er..................54DIFFERIN................................. 59DIFICID..................................... 18difil-g forte............................... 108diflorasone diacetate.................59DIFLUCAN................................ 27diflunisal.................................... 13digitek........................................45digox......................................... 45digoxin.......................................45dihydroergotamine mesylate.....29DILANTIN..................................21DILANTIN INFATABS............... 21DILATRATE-SR........................ 45DILAUDID................................. 10diltiazem hcl.............................. 45diltiazem hcl er.......................... 45diltiazem hcl er beads............... 45diltiazem hcl er coated beads... 45dilt-xr......................................... 46dimenhydrinate......................... 26DIOVAN.................................... 46DIOVAN HCT............................46DIPENTUM............................... 98diphen..................................... 106diphenhydramine hcl...............106diphenoxylate-atropine..............76DIPHTHERIA-TETANUS TOXOIDS DT............................ 96DIPROLENE............................. 59DIPROLENE AF........................59dipyridamole..............................37disopyramide phosphate...........46disulfiram...................................16DITROPAN XL.......................... 79DIURIL...................................... 46divalproex sodium..................... 21divalproex sodium er.................21DIVIGEL....................................87dofetilide....................................46DOLOPHINE.............................10donepezil hcl............................. 23DONNATAL.............................. 76DOPTELET............................... 43DORAL......................................42DORYX..................................... 18DORYX MPC............................ 18dorzolamide hcl.......................103

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DORZOLAMIDE HCL-TIMOLOL MAL........................103dorzolamide hcl-timolol mal.... 103dorzolamide hcl-timolol mal pf 103dotti ........................................... 87DOUBLE PM...........................104DOVATO...................................39DOVONEX................................ 59doxazosin mesylate.................. 46doxepin hcl..................24, 59, 112doxercalciferol...........................99doxycycline............................... 59doxycycline hyclate................... 18doxycycline monohydrate......... 18doxylamine-pyridoxine.............. 26DRISDOL.................................. 71DRITHO-CREME HP................ 59dronabinol................................. 26drospiren-eth estrad-levomefol. 87drospirenone-ethinyl estradiol...87DROXIA.................................... 31DRYSOL................................... 59DSUVIA.....................................10DUAL COMPLEX FORMULA 1 KIT............................................ 14DUAVEE................................... 87DUETACT................................. 65DUEXIS.....................................14DULERA................................. 108duloxetine hcl............................ 24DUOBRII................................... 59DUPIXENT................................59DURAGESIC-100..................... 10DURAGESIC-12....................... 10DURAGESIC-25....................... 10DURAGESIC-50....................... 10DURAGESIC-75....................... 10duraxin...................................... 11DUREZOL...............................101DURLAZA................................. 37dutasteride................................ 81dutasteride-tamsulosin hcl........ 81DUTOPROL.............................. 46DVORAH...................................11DXEVO 11-DAY........................82DYANAVEL XR.........................52DYAZIDE.................................. 46DYMISTA................................ 106DYRENIUM...............................46DYURAL-40.............................. 82DYURAL-80.............................. 82DYURAL-L................................ 82DYURAL-LM............................. 82

E.E.S. 400.................................18E.E.S. GRANULES................... 18easygel......................................55EASYPLUS BLOOD GLUCOSE TEST...................... 67EC-NAPROSYN........................14ec-naproxen.............................. 14econazole nitrate.......................27ECOZA......................................27EDARBI.....................................46EDARBYCLOR......................... 46EDECRIN..................................46EDLUAR................................. 112EDURANT.................................39eemt.......................................... 87eemt hs..................................... 88efavirenz................................... 39EFFER-K...................................71effer-k........................................71EFFEXOR XR........................... 24EFFIENT................................... 37EFUDEX................................... 59EGATEN................................... 35EGRIFTA.................................. 84EGRIFTA SV.............................84ELESTRIN................................ 88eletriptan hydrobromide............ 29ELIDEL......................................59ELIGARD.................................. 84ELIMITE.................................... 35elinest........................................88ELIQUIS....................................20ELIQUIS STARTER PACK....... 20ELITE-OB..................................71ELIXOPHYLLIN...................... 108ELLA......................................... 88ELMIRON..................................79ELOCON...................................59eluryng...................................... 88EMBRACE TALK GLUCOSE TEST.........................................67EMBRACE TALK MONITORING SYSTEM...........67EMCYT..................................... 31EMEND..................................... 26EMEND TRI-PACK................... 26EMFLAZA................................. 29EMGALITY................................29EMGALITY (300 MG DOSE).... 29emoquette................................. 88EMSAM.....................................24EMTRIVA.................................. 39EMVERM.................................. 35

ENABLEX................................. 79enalapril maleate.......................46enalapril-hydrochlorothiazide.... 46ENBRACE HR.......................... 71ENBREL....................................94ENBREL MINI........................... 94ENBREL SURECLICK.............. 94ENDARI.................................... 99endocet..................................... 11ENDOMETRIN..........................88ENGERIX-B.............................. 96ENOVARX-BACLOFEN..........111enovarx-cyclobenzaprine hcl.. 111ENOVARX-CYCLOBENZAPRINE HCL.... 111ENOVARX-DICLOFENAC SODIUM....................................14ENOVARX-IBUPROFEN.......... 14ENOVARX-LIDOCAINE HCL....16ENOVARX-NAPROXEN........... 14ENOVARX-TRAMADOL........... 59enoxaparin sodium....................20enpresse-28.............................. 88enskyce.....................................88ENSTILAR................................ 59entacapone............................... 36entecavir................................... 39ENTEREG.................................76ENTOCORT EC........................98ENTRESTO.............................. 46enulose..................................... 76ENVARSUS XR........................ 94ENZOCLEAR............................ 59EPANED................................... 46EPCLUSA................................. 39EPIDIOLEX............................... 21EPIDUO.................................... 59EPIDUO FORTE....................... 59EPIFOAM..................................59epinastine hcl.......................... 101epinephrine..................... 108, 109EPIPEN 2-PAK....................... 109EPIPEN JR 2-PAK.................. 109epitol......................................... 21EPIVIR...................................... 39EPIVIR HBV..............................39eplerenone................................ 46eprosartan mesylate................. 46EPZICOM..................................39EQUETRO................................ 21ERGOCAL................................ 71ergocalciferol.............................71ergoloid mesylates.................... 99

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ERGOMAR............................... 29ergotamine-caffeine.................. 29ERIVEDGE............................... 31ERLEADA................................. 31erlotinib hcl................................31errin...........................................88ERTACZO.................................27ery............................................. 59ERYGEL................................... 59ERYPED 200............................ 18ERYPED 400............................ 18ERY-TAB.................................. 18ERYTHROCIN STEARATE...... 18erythromycin..................... 59, 101erythromycin base.....................18erythromycin ethylsuccinate......18ESBRIET.................................109ESCAVITE................................ 71escitalopram oxalate................. 24ESGIC.......................................11esomeprazole magnesium........75est estrogens-methyltest...........88est estrogens-methyltest ds...... 88est estrogens-methyltest hs...... 88estarylla.....................................88estazolam..................................42ESTRACE................................. 88estradiol.................................... 88estradiol valerate.......................88estradiol-norethindrone acet..... 88ESTRING.................................. 88ESTROGEL.............................. 88ESTROSTEP FE.......................88eszopiclone............................. 112ethacrynic acid.......................... 46ethambutol hcl...........................30ethosuximide.............................21ethyl chloride.............................16ethynodiol diac-eth estradiol..... 88etodolac.................................... 14etodolac er................................ 14etonogestrel-ethinyl estradiol.... 88etoposide.................................. 32EUCRISA.................................. 59EURAX......................................35euthyrox.................................... 93EVAMIST.................................. 88EVEKEO................................... 52EVEKEO ODT...........................52everolimus.................................32EVISTA..................................... 84EVOCLIN.................................. 59EVOTAZ....................................39

EVOXAC................................... 55EVZIO....................................... 17EXELDERM.............................. 27EXELON................................... 23exemestane.............................. 32EXFORGE................................ 46EXFORGE HCT........................ 46EXJADE.................................... 71exoderm.................................... 27exotic-hc..................................105EXTAVIA...................................53EXTINA..................................... 27EZALLOR SPRINKLE...............46ezetimibe...................................46ezetimibe-simvastatin............... 46FABIOR.....................................59FALESSA..................................88falmina...................................... 88famciclovir................................. 39famotidine................................. 75FANAPT....................................37FANAPT TITRATION PACK..... 37FANATREX FUSEPAQ.............21FARESTON.............................. 32FARXIGA.................................. 65FARYDAK................................. 32fayosim......................................88FBL KIT.....................................14febuxostat................................. 29felbamate.................................. 21FELBATOL................................21FELDENE................................. 14felodipine er.............................. 46FEM PH.................................... 79FEMARA................................... 32FEMHRT LOW DOSE...............88FEMRING................................. 88femynor..................................... 88fenofibrate................................. 46fenofibrate micronized...............46fenofibric acid............................46FENOGLIDE............................. 46fenoprofen calcium....................14fenortho.....................................14fentanyl..................................... 11fentanyl citrate...........................11FENTANYL CITRATE...............11FENTORA.................................11FERIVA 21/7............................. 71ferotrinsic.................................. 71FERRALET 90.......................... 71ferraplus 90............................... 71FERRIPROX............................. 71

FERRO-PLEX HEMATINIC...... 71FERROTRIN............................. 71FETZIMA...................................24FETZIMA TITRATION...............24FEXMID.................................. 112FIASP........................................69FIASP FLEXTOUCH.................69FIASP PENFILL........................ 69FIBRICOR.................................46FINACEA.................................. 59finasteride................................. 81FIORICET................................. 11FIORICET/CODEINE................11FIORINAL................................. 11FIORINAL/CODEINE #3........... 11FIRAZYR...................................94FIRDAPSE................................ 99FIRMAGON...............................84FIRST - METOPROLOL........... 46FIRST-ATENOLOL................... 46FIRST-BACLOFEN................. 112FIRST-METRONIDAZOLE....... 18FIRST-VANCOMYCIN.............. 18flac.......................................... 105FLAGYL.................................... 18FLAREX.................................. 101flavoxate hcl.............................. 79flecainide acetate...................... 46FLECTOR................................. 14FLOLIPID.................................. 46FLOMAX................................... 81FLORIVA...................................71FLORIVA PLUS........................ 71FLOVENT DISKUS................. 109FLOVENT HFA....................... 109FLUAD...................................... 96FLUARIX QUADRIVALENT......96FLUBLOK QUADRIVALENT.....96FLUCELVAX QUADRIVALENT...................... 96fluconazole................................27flucytosine................................. 27fludrocortisone acetate..............82FLULAVAL QUADRIVALENT... 96FLUMIST QUADRIVALENT......96flunisolide................................ 106fluocinolone acetonide...... 60, 105fluocinolone acetonide body..... 60fluocinolone acetonide scalp.....60fluocinonide...............................60fluocinonide emulsified base.....60FLUORABON............................71fluoridex.................................... 55

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fluoridex daily renewal.............. 55fluoridex enhanced whitening... 55fluoridex sensitivity relief........... 55fluoritab..................................... 71fluorometholone...................... 101FLUOROPLEX..........................60FLUOROURACIL......................60fluorouracil ................................ 60fluoxetine hcl............................. 24fluoxetine hcl (pmdd).................24fluphenazine hcl........................ 38FLURA-DROPS........................ 71flurandrenolide.......................... 60flurazepam hcl.........................112flurbiprofen................................ 14flurbiprofen sodium................. 101flutamide................................... 32fluticasone propionate.......60, 106fluticasone-salmeterol............. 109FLUTICASONE-SALMETEROL........................109fluvastatin sodium..................... 46fluvastatin sodium er................. 47fluvoxamine maleate................. 24fluvoxamine maleate er.............24FLUZONE HIGH-DOSE............96FLUZONE QUADRIVALENT.... 96FML.........................................101FML FORTE............................101FML LIQUIFILM...................... 101FOCALIN.................................. 52FOCALIN XR............................ 52folic acid.................................... 71FOLI-D...................................... 71FOLITE..................................... 71FOLLISTIM AQ......................... 84foltrin......................................... 71FOLVITE-D............................... 71fondaparinux sodium.................20FORA GTEL BLOOD GLUCOSE TEST...................... 67FORFIVO XL.............................24FORTAMET.............................. 65FORTEO................................... 98FORTESTA...............................83FOSAMAX................................ 99FOSAMAX PLUS D.................. 99fosamprenavir calcium.............. 39fosinopril sodium....................... 47fosinopril sodium-hctz............... 47FOSRENOL.............................. 79FRAGMIN................................. 20FREESTYLE FREEDOM LITE. 67

FREESTYLE INSULINX SYSTEM................................... 67FREESTYLE INSULINX TEST. 67FREESTYLE LITE TEST.......... 67FREESTYLE PRECISION NEO TEST................................ 67FREESTYLE TEST...................67FROVA......................................29frovatriptan succinate................29furosemide................................ 47FUZEON................................... 39fyavolv.......................................88FYCOMPA................................ 21gabapentin................................ 21GABITRIL..................................21GALAFOLD...............................78galantamine hydrobromide....... 23galantamine hydrobromide er... 23GALZIN..................................... 71ganirelix acetate........................84GARDASIL 9.............................96GASTROCROM........................76gatifloxacin.............................. 101GATTEX....................................76gavilyte-c...................................76gavilyte-g...................................76gavilyte-n with flavor pack.........76GEBAUERS PAIN EASE.......... 16GEBAUERS SPRAY AND STRETCH................................. 16GELFILM.................................104GELNIQUE............................... 79gemfibrozil .................................47GENERESS FE........................ 88generlac.................................... 76gengraf......................................94GENICIN VITA-D...................... 71GENOTROPIN..........................84GENOTROPIN MINIQUICK......84gentak..................................... 101gentamicin sulfate............. 18, 101GENVOYA................................ 39GEODON.................................. 38GIALAX..................................... 77gianvi.........................................88GILENYA.................................. 53GILOTRIF................................. 32GILPHEX TR...........................106GILTUSS TR...........................106glatiramer acetate..................... 53glatopa...................................... 53GLEEVEC................................. 32GLEOSTINE............................. 32

glimepiride.................................65glipizide er.................................65glipizide ir.................................. 65glipizide xl................................. 65glipizide-metformin hcl.............. 65GLUCAGEN HYPOKIT............. 68GLUCAGON EMERGENCY..... 68GLUCOCARD 01 SENSOR PLUS.........................................67GLUCOCARD EXPRESSION TEST.........................................67GLUCOCARD SHINE CONNEX...................................67GLUCOCARD SHINE EXPRESS................................. 67GLUCOCARD SHINE TEST.....67GLUCOCARD VITAL TEST......67GLUCOPHAGE.........................65GLUCOPHAGE XR...................65GLUCOTROL............................65GLUCOTROL XL...................... 65GLUMETZA.............................. 65GLUTATHIONE........................ 71glyburide................................... 65glyburide micronized................. 65glyburide-metformin.................. 65GLYCATE................................. 77GLYCINE.................................. 71glycopyrrolate............................77GLYCOPYRROLATE................77glydo......................................... 16GLYNASE................................. 65GLYSET....................................65GLYXAMBI................................65GOCOVRI................................. 36GOJJI BLOOD GLUCOSE TEST.........................................67GOJJI BLOOD TEST STRIP/LANCETS......................67GOLYTELY............................... 77GONAL-F.................................. 84GONAL-F RFF.......................... 84GONAL-F RFF REDIJECT....... 84GONITRO................................. 47GORDOFILM............................ 60grafco silver nit applicator......... 60GRALISE.................................. 54GRALISE STARTER.................54granisetron hcl.......................... 26GRASTEK.................................99griseofulvin microsize................27griseofulvin ultramicrosize.........27guaiatussin ac......................... 106

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guaifenesin ac.........................106guanfacine hcl...........................47guanfacine hcl er.......................52GUANIDINE HCL......................30GVOKE PFS............................. 68GYNAZOLE-1........................... 27hailey 1.5/30..............................88hailey 24 fe................................88halcinonide................................60HALCION.................................. 42HALDOL DECANOATE............ 38halobetasol propionate..............60HALOBETASOL PROPIONATE.......................... 60HALOG..................................... 60haloperidol................................ 38haloperidol decanoate...............38haloperidol lactate.....................38HARVONI..................................39HAVRIX.....................................96heather......................................88HEMANGEOL........................... 47HEMATRON-AF........................71hemmorex-hc............................ 98hemocyte-plus...........................71heparin sodium (porcine).......... 20heparin sodium (porcine) pf...... 20HEPLISAV-B.............................96HEPSERA.................................39HETLIOZ.................................112HIBERIX....................................96HIDEX 6-DAY........................... 82HIPREX.....................................18homatropaire...........................104homatropine hbr......................104HONEY BEE VENOM PROTEIN.................................. 99HORIZANT................................54HUMALOG................................69HUMALOG KWIKPEN.............. 69HUMALOG MIX 50/50 KWIKPEN................................. 69HUMALOG MIX 50/50 VIAL......69HUMALOG MIX 75/25 KWIKPEN................................. 69HUMALOG MIX 75/25 VIAL......69HUMALOG U-100 JUNIOR KWIKPEN................................. 69HUMATROPE........................... 84HUMIRA....................................94HUMIRA PEDIATRIC CROHNS START......................94HUMIRA PEN........................... 94

HUMIRA PEN-CD/UC/HS STARTER................................. 95HUMIRA PEN-PS/UV/ADOL HS START................................ 95HUMULIN 70/30 KWIKPEN...... 69HUMULIN 70/30 VIAL...............69HUMULIN N KWIKPEN............ 69HUMULIN N VIAL..................... 69HUMULIN R U-500 KWIKPEN..69HUMULIN R U-500 VIAL (CONCENTRATED)..................69HUMULIN R VIAL..................... 69HW EMBRACE PRO GLUCOSE TEST...................... 68HW EMBRACE TALK GLUCOSE TEST...................... 68HYALUCIL-4............................. 60HYCAMTIN............................... 32hydralazine hcl.......................... 47HYDREA................................... 32HYDRO 35................................ 60HYDRO 40................................ 60hydrochlorothiazide...................47HYDROCODONE BITARTRATE ER......................11hydrocodone polst-cpm polst er.............................................106hydrocodone-acetaminophen... 11hydrocodone-homatropine...... 106hydrocodone-ibuprofen............. 11hydrocortisone.............. 60, 82, 98hydrocortisone ace-pramoxine............................................ 60, 98hydrocortisone acetate..............98hydrocortisone butyr lipo base.. 60hydrocortisone butyrate............ 60hydrocortisone valerate.............60hydrocortisone-acetic acid...... 105hydromet................................. 106HYDROMORPHONE HCL........11hydromorphone hcl................... 11hydromorphone hcl er............... 11hydroxocobalamin acetate........ 71hydroxychloroquine sulfate....... 35hydroxyurea.............................. 32hydroxyzine hcl......................... 42hydroxyzine pamoate................42hyophen.................................... 79hyoscyamine sulfate................. 77hyoscyamine sulfate er............. 77hyoscyamine sulfate sl..............77hyosyne.....................................77HYPERSAL.............................106

HYSINGLA ER..........................11HYZAAR................................... 47ibandronate sodium.................. 99IBRANCE.................................. 32ibu............................................. 14ibuprofen................................... 14IC 400....................................... 14IC 800....................................... 14icatibant acetate........................95ICLUSIG....................................32IDHIFA...................................... 32ILEVRO...................................101imatinib mesylate...................... 32IMBRUVICA.............................. 32imipramine hcl...........................24imipramine pamoate................. 24imiquimod..................................60IMIQUIMOD PUMP...................60IMITREX................................... 29IMITREX STATDOSE REFILL..29IMITREX STATDOSE SYSTEM................................... 29IMPAVIDO................................ 35IMPOYZ.................................... 61IMURAN....................................95IMVEXXY MAINTENANCE PACK........................................ 89IMVEXXY STARTER PACK..... 89INBRIJA.................................... 36incassia..................................... 89INCRELEX................................ 84INCRUSE ELLIPTA................ 109indapamide............................... 47INDERAL LA............................. 47INDERAL XL............................. 47INDOCIN...................................14indomethacin.............................14indomethacin er........................ 14INFANRIX................................. 96INGREZZA................................54INLYTA..................................... 32INNOPRAN XL..........................47INOVA.......................................61INOVA 4/1 ACNE CONTROL THERAPY................................. 61INSPIREASE RESERVOIR BAGS........................................ 99INSPRA.....................................47INSULIN ASP PROT & ASP FLEXPEN..................................69INSULIN ASPART.................... 69INSULIN ASPART FLEXPEN... 69INSULIN ASPART PENFILL.....69

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INSULIN ASPART PROT & ASPART....................................69INSULIN LISPRO......................69INTELENCE..............................40INTERMEZZO.........................112INTRAROSA............................. 79INTRON A.................................40introvale.................................... 89INTUNIV....................................52INVEGA.................................... 38INVEGA SUSTENNA................38INVEGA TRINZA...................... 38INVELTYS...............................101INVIRASE................................. 40INVOKAMET.............................65INVOKAMET XR.......................65INVOKANA............................... 65iodine strong............................. 72IONSYS.................................... 11IOPIDINE................................ 103IPOL..........................................96ipratropium bromide........ 106, 109ipratropium-albuterol............... 109irbesartan.................................. 47irbesartan-hydrochlorothiazide..47IRESSA.....................................32IS 24/6.......................................72ISENTRESS..............................40ISENTRESS HD....................... 40isibloom.....................................89isoniazid.................................... 30ISOPTO ATROPINE............... 104ISOPTO CARPINE................. 103ISORDIL TITRADOSE.............. 47isosorbide dinitrate....................47isosorbide mononitrate..............47isosorbide mononitrate er......... 47isotretinoin.................................61isoxsuprine hcl.......................... 47isradipine...................................47ISTALOL................................. 103itraconazole...............................27ivermectin............................35, 61JADENU....................................72JADENU SPRINKLE.................72jaimiess..................................... 89JAKAFI......................................32JALYN.......................................81jantoven.................................... 20JANUMET................................. 65JANUMET XR........................... 65JANUVIA...................................65JARDIANCE..............................66

jasmiel.......................................89jencycla..................................... 89JENTADUETO.......................... 66JENTADUETO XR.................... 66jinteli ..........................................89jolessa.......................................89JORNAY PM............................. 52JUBLIA......................................27juleber....................................... 89JULUCA.................................... 40junel 1.5/30............................... 89junel 1/20.................................. 89junel fe 1.5/30........................... 89junel fe 1/20.............................. 89junel fe 24................................. 89JUXTAPID.................................47JYNARQUE.............................. 72K.B.G.L IN TERODERM........... 14KADIAN.....................................11kaitlib fe.....................................89KALETRA..................................40kalliga........................................89KALYDECO............................ 110KAPSPARGO SPRINKLE.........47KAPVAY....................................52KARBINAL ER........................ 106kariva........................................ 89KAZANO................................... 66KEFLEX.................................... 18kelnor 1/35................................ 89kelnor 1/50................................ 89KENALOG.................................61KEPPRA................................... 21KEPPRA XR............................. 21KERALYT..................................61KERYDIN.................................. 27ketoconazole.............................28ketodan..................................... 28KETOPHENE RAPIDPAQ........ 14ketoprofen................................. 14ketoprofen er.............................14KETOROCAINE-L.....................14KETOROCAINE-LM..................14KETOROLAC TROMETHAMINE.....................14ketorolac tromethamine.... 14, 101KEVEYIS.................................103KEVZARA................................. 95KHEDEZLA............................... 25KINERET.................................. 95KINRIX...................................... 96kionex........................................72KISQALI (200 MG DOSE).........32

KISQALI (400 MG DOSE).........32KISQALI (600 MG DOSE).........32KISQALI FEMARA (400 MG DOSE).......................................32KISQALI FEMARA (600 MG DOSE).......................................32KISQALI FEMARA(200 MG DOSE).......................................32KITABIS PAK.......................... 110KLARITY-A............................. 101KLARITY-B............................. 101KLARITY-L..............................101KLARON................................... 61KLONOPIN............................... 42klor-con..................................... 72klor-con 10................................ 72klor-con m10............................. 72KLOR-CON M15....................... 72klor-con m20............................. 72klor-con sprinkle........................72klor-con/ef................................. 72KOMBIGLYZE XR.....................66KORLYM...................................85K-PHOS.................................... 72K-PHOS NO 2...........................72k-prime...................................... 72KRINTAFEL.............................. 35KRISTALOSE........................... 77KROGER HEALTHPRO GLUCOSE TEST...................... 68K-TAB....................................... 72k-tan plus.................................. 72kurvelo...................................... 89KUVAN......................................78L.E.T......................................... 16labetalol hcl............................... 47LACRISERT............................104lactic acid.................................. 61lactic acid e............................... 61lactulose....................................77lactulose encephalopathy......... 77LAMICTAL................................ 22LAMICTAL ODT........................22LAMICTAL STARTER...............22LAMICTAL XR.......................... 22lamivudine.................................40lamivudine-zidovudine.............. 40lamotrigine................................ 22lamotrigine er............................ 22lamotrigine starter kit-blue.........22lamotrigine starter kit-green...... 22lamotrigine starter kit-orange.... 22LANOXIN.................................. 47

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lansoprazole..............................75lanthanum carbonate................ 80LANTUS SOLOSTAR............... 69LANTUS U-100 VIAL................ 69larin 1.5/30................................ 89larin 1/20................................... 89larin 24 fe.................................. 89larin fe 1.5/30............................ 89larin fe 1/20............................... 89larissia.......................................89LASIX........................................47LASTACAFT........................... 104latanoprost.............................. 103latrix xm.....................................61LATUDA....................................38layolis fe.................................... 89LAZANDA................................. 11leena......................................... 89leflunomide................................95LENSCALE............................... 99LENVIMA (10 MG DAILY DOSE).......................................32LENVIMA (12 MG DAILY DOSE).......................................32LENVIMA (14 MG DAILY DOSE).......................................32LENVIMA (18 MG DAILY DOSE).......................................32LENVIMA (20 MG DAILY DOSE).......................................32LENVIMA (24 MG DAILY DOSE).......................................32LENVIMA (4 MG DAILY DOSE).......................................32LENVIMA (8 MG DAILY DOSE).......................................32LESCOL XL.............................. 47lessina.......................................89LETAIRIS................................ 111letrozole.................................... 33leucovorin calcium.................... 33LEUKERAN...............................33leuprolide acetate......................84LEUPROLIDE ACETATE-BUPIVACAINE..........................84levalbuterol hcl........................ 109LEVALBUTEROL HFA............109LEVAQUIN................................18LEVBID..................................... 77LEVEMIR U-100 FLEXTOUCH.69LEVEMIR U-100 VIAL...............69levetiracetam.............................22levetiracetam er........................ 22

levobunolol hcl........................ 103levocarnitine..............................72levofloxacin....................... 18, 101levonest.....................................89levonorgest-eth est & eth est.... 89levonorgest-eth estrad 91-day.. 89levonorgestrel-ethinyl estrad.....89levonorg-eth estrad triphasic.....89levora 0.15/30 (28)....................89levorphanol tartrate................... 11levo-t......................................... 93levothyroxine sodium................ 93levothyroxine-liothyronine......... 93levoxyl....................................... 93LEVSIN..................................... 77LEVSIN/SL................................77LEXAPRO................................. 25LEXETTE.................................. 61LEXIVA..................................... 40LIALDA......................................98LIBRAX..................................... 77lidocaine....................................16lidocaine hcl........................ 16, 55lidocaine hcl urethral/mucosal...16LIDOCAINE HCL-SODIUM CHLORIDE............................... 16lidocaine viscous.......................55LIDOCAINE-HYDROCORTISONE ACE....... 98LIDODERM............................... 16lidolog........................................82LIDOMAR..................................16LIDOPROFEN...........................14lillow.......................................... 89lindane...................................... 35linezolid..................................... 19LINZESS................................... 77liothyronine sodium................... 93LIPITOR.................................... 47LIPO..........................................72LIPO-C...................................... 72LIPOFEN...................................47lisinopril ..................................... 47lisinopril-hydrochlorothiazide.....47lithium........................................42lithium carbonate.......................43lithium carbonate er.................. 43LITHOBID................................. 43LITHOSTAT.............................. 80LIVALO..................................... 47LO LOESTRIN FE.....................90LOCOID.................................... 61LOCOID LIPOCREAM.............. 61

LODINE.....................................14LODOSYN................................ 36LOESTRIN 1.5/30 (21)..............90LOESTRIN 1/20 (21).................90LOESTRIN FE 1.5/30............... 90LOESTRIN FE 1/20.................. 90lojaimiess.................................. 90LOKELMA................................. 72LOMAIRA..................................54LOMOTIL.................................. 77LONHALA MAGNAIR REFILL KIT.......................................... 109LONHALA MAGNAIR STARTER KIT.........................109LONSURF.................................33LOPID....................................... 47lopinavir-ritonavir.......................40lopreeza.................................... 90LOPRESSOR............................47LOPRESSOR HCT................... 47LOPROX................................... 28lorazepam................................. 42lorazepam intensol....................42LORBRENA.............................. 33lorcet......................................... 11lorcet hd.................................... 11lorcet plus..................................11LORTAB....................................11loryna........................................ 90LORZONE...............................112losartan potassium....................48losartan potassium-hctz............ 48LOSEASONIQUE..................... 90LOTEMAX...............................101LOTEMAX SM........................ 101LOTENSIN................................ 48LOTENSIN HCT........................48loteprednol etabonate............. 101LOTREL.................................... 48LOTRISONE............................. 61LOTRONEX.............................. 77lovastatin...................................48LOVAZA....................................48LOVENOX.................................20low-ogestrel...............................90loxapine succinate.................... 38lo-zumandimine.........................90LT INJECTION KIT................... 82LUCEMYRA.............................. 17ludent........................................ 72LULICONAZOLE.......................28LUMIGAN................................103LUNESTA............................... 112

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LUPANETA PACK.................... 84LUPRON DEPOT (1-MONTH)............................................ 84, 85LUPRON DEPOT (3-MONTH)..85LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..85LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..85LUPRON DEPOT-PED (1-MONTH)....................................85LUPRON DEPOT-PED (3-MONTH)....................................85lutera......................................... 90LUXIQ....................................... 61LUZU.........................................28LYNPARZA............................... 33LYRICA..................................... 54LYRICA CR...............................54LYSINE HCL............................. 72LYSODREN.............................. 33LYSTEDA..................................43lyza............................................90MACROBID...............................19MACRODANTIN....................... 19mafenide acetate...................... 19MAGNESIUM SULFATE...........72MALARONE..............................35malathion.................................. 35maprotiline hcl...........................25MARBETA-25........................... 82MARBETA-L............................. 82MARDEX-25............................. 82MARINOL..................................26marlido...................................... 16MARLIDO-25............................ 16marlissa.....................................90MARPLAN.................................25MATULANE.............................. 33matzim la...................................48MAVENCLAD (10 TABS)..........53MAVENCLAD (4 TABS)............53MAVENCLAD (5 TABS)............53MAVENCLAD (6 TABS)............53MAVENCLAD (7 TABS)............53MAVENCLAD (8 TABS)............53MAVENCLAD (9 TABS)............53MAVYRET.................................40MAXALT....................................29MAXALT-MLT........................... 30MAXFE......................................72MAXIDEX................................101MAXITROL..............................104MAXZIDE.................................. 48

MAXZIDE-25.............................48MAYZENT.................................53MAYZENT STARTER PACK.... 53me/naphos/mb/hyo1................. 80meclofenamate sodium.............14MEDROL...................................82MEDROX-RX............................ 11medroxyprogesterone acetate.. 90mefenamic acid.........................14mefloquine hcl...........................35MEGACE ES.............................90megestrol acetate..................... 90MEKINIST................................. 33MEKTOVI..................................33melodetta 24 fe......................... 90meloxicam.................................15melphalan................................. 33memantine hcl...........................23memantine hcl er...................... 23MENACTRA..............................96MENEST................................... 90MENOPUR................................85MENOSTAR..............................90MENTAX................................... 28MENVEO.................................. 96meperidine hcl...........................11MEPHYTON..............................72meprobamate............................42MEPRON.................................. 35mercaptopurine......................... 33mesalamine...............................98mesalamine er.......................... 98mesalamine-cleanser................98MESNEX...................................33MESTINON............................... 30metadate er...............................52metaproterenol sulfate............ 109METAXALL CP....................... 112metaxalone............................. 112metformin hcl er........................ 66metformin hcl er (mod)..............66metformin hcl er (osm).............. 66METFORMIN HCL IR............... 66metformin hcl ir ......................... 66methadone hcl.......................... 11methadone hcl intensol............. 11methadose................................ 11methadose sugar-free...............11methamphetamine hcl...............52methazolamide........................103methenamine hippurate............ 19methenamine mandelate.......... 19methergine................................ 99

methimazole..............................93METHITEST..............................83methocarbamol....................... 112methotrexate............................. 95methotrexate sodium................ 95methotrexate sodium (pf).......... 95methoxsalen..............................61methoxsalen rapid.....................61methscopolamine bromide........77methyl salicylate........................61METHYLCOBALAMIN.............. 72methyldopa............................... 48methyldopa-hydrochlorothiazide...................48methylergonovine maleate........99METHYLIN................................52methylphenidate hcl.................. 52methylphenidate hcl er..............52methylphenidate hcl er (cd).......52methylphenidate hcl er (la)........52methylprednisolone...................82METHYLPREDNISOLONE ACE-LIDO................................. 82methylprednisolone acetate...... 82methyltestosterone....................83metoclopramide hcl...................26metolazone............................... 48metoprolol succinate er.............48metoprolol tartrate.....................48metoprolol-hydrochlorothiazide.48METROCREAM........................ 61METROGEL..............................61METROLOTION........................61metronidazole..................... 19, 61METRONIDAZOLE BENZO+SYRSPEND................19mexiletine hcl............................ 48mibelas 24 fe.............................90MICARDIS................................ 48MICARDIS HCT........................ 48miconazole 3.............................28MICONAZOLE-ZINC OXIDE-PETROLAT............................... 28MICORT-HC............................. 61microgestin 1.5/30.....................90microgestin 1/20........................90microgestin fe 1.5/30.................90microgestin fe 1/20....................90midodrine hcl.............................48MIGERGOT.............................. 30miglitol.......................................66miglustat....................................78MIGRANAL............................... 30

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mili .............................................90MILLIPRED............................... 82MILLIPRED DP......................... 82MILLIPRED DP 12-DAY........... 82mimvey......................................90MINASTRIN 24 FE....................90mineral oil heavy....................... 77MINIPRESS.............................. 48minitran..................................... 48MINIVELLE............................... 90MINOCIN.................................. 19minocycline hcl..........................19minocycline hcl er..................... 19MINOLIRA.................................19minoxidil .................................... 48MIRAPEX..................................36MIRAPEX ER............................36MIRCETTE................................90mirtazapine............................... 25MIRVASO................................. 61misoprostol................................75MITIGARE.................................29MITOSOL................................101mlk f1........................................ 99mlk f2........................................ 99mlk f3........................................ 99MLK F4................................... 100M-M-R II.................................... 97M-NATAL PLUS........................72MOBIC...................................... 15modafinil ..................................112moexipril hcl.............................. 48molindone hcl............................38mometasone furoate......... 61, 106mondoxyne nl............................19mono-linyah.............................. 90MONSELS FERRIC SUBSULFATE.......................... 43montelukast sodium................ 109MONUROL................................19morgidox................................... 19MORPHABOND ER..................12morphine sulfate....................... 12morphine sulfate (concentrate). 12morphine sulfate er................... 12morphine sulfate er beads........ 12MOTEGRITY.............................77MOTOFEN................................ 77MOVANTIK............................... 77MOVIPREP............................... 77MOXEZA.................................101moxifloxacin hcl.................19, 101MS CONTIN..............................12

MULPLETA............................... 43MULTAQ................................... 48multigen.................................... 72MULTI-SPECIALTY.................. 82multi-vit/iron/fluoride..................72multivitamin/fluoride............ 72, 73MULTIVITAMIN/FLUORIDE..... 73multi-vitamin/fluoride................. 72multivitamin/fluoride/iron........... 73multi-vitamin/fluoride/iron.......... 73multivitamins/fluoride................ 73mupirocin.................................. 19mupirocin calcium..................... 19mvc-fluoride.............................. 73MYALEPT................................. 79MYAMBUTOL........................... 30MYCOBUTIN............................ 30mycophenolate mofetil .............. 95mycophenolate sodium............. 95MYDAYIS..................................52MYFORTIC............................... 95MYLERAN.................................33myorisan................................... 61MYRBETRIQ.............................80MYSOLINE............................... 22MYTESI.....................................77nabumetone.............................. 15nadolol...................................... 48nafrinse..................................... 73NAFRINSE DAILY ACIDULATED........................... 55NAFRINSE DAILY/NEUTRAL...55nafrinse drops........................... 73NAFRINSE WEEKLY................55naftifine hcl................................28NAFTIN..................................... 28NALFON................................... 15NALOCET................................. 12naloxone hcl..............................17NALTREXONE..........................17naltrexone hcl............................17NAMENDA................................ 23NAMENDA TITRATION PAK....23NAMENDA XR.......................... 23NAMENDA XR TITRATION PACK........................................ 23NAMZARIC............................... 23NANDROLONE-TESTOSTERONE CYP .....83NAPRELAN...............................15NAPRO..................................... 15NAPROSYN..............................15naproxen................................... 15

naproxen dr...............................15naproxen sodium...................... 15naproxen sodium er.................. 15naratriptan hcl........................... 30NARCAN...................................17NARDIL.....................................25NASCOBAL.............................. 73NASONEX.............................. 106NATACYN...............................101NATAZIA...................................90nateglinide.................................66NATESTO................................. 83NATPARA................................. 99NATROBA.................................35NATURE-THROID.................... 93NEBUPENT.............................. 35nebusal................................... 106NEBUSAL............................... 106necon 0.5/35 (28)......................90nefazodone hcl..........................25neomycin sulfate....................... 19neomycin-bacitracin zn-polymyx...................................104neomycin-polymyxin-dexameth................................................ 104neomycin-polymyxin-gramicidin................................104neomycin-polymyxin-hc.. 104, 105NEONATAL COMPLETE..........73NEONATAL PLUS.................... 73neo-polycin..............................104neo-polycin hc.........................104NEORAL................................... 95NEO-SYNALAR........................ 61NEOTUSS PLUS.................... 106NEPHRON FA.......................... 73NERLYNX................................. 33NESINA.....................................66NESTABS................................. 73NESTABS ONE........................ 73neuac........................................ 61NEUPRO...................................36NEURONTIN.............................22neutral sodium fluoride..............55NEVANAC...............................102nevirapine................................. 40nevirapine er............................. 40NEXAVAR.................................33NEXIUM.................................... 75niacin (antihyperlipidemic)........ 48niacin er (antihyperlipidemic).... 48niacor........................................ 48NIASPAN.................................. 48

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nicardipine hcl........................... 48NICOTROL............................... 17NICOTROL NS......................... 17nifedipine...................................48nifedipine er.............................. 48nifedipine er osmotic release.... 48NIFEREX.................................. 73nikki...........................................90NILANDRON.............................33nilutamide..................................33nimodipine.................................48NINLARO.................................. 33nisoldipine er.............................48nitisinone...................................79NITRO-BID................................48NITRO-DUR..............................48nitrofurantoin............................. 19nitrofurantoin macrocrystal........19nitrofurantoin monohydrate macrocrystals............................19nitroglycerin...............................49NITROMIST.............................. 49NITROSTAT..............................49nitro-time................................... 49NITYR....................................... 79nizatidine...................................75NIZORAL.................................. 28NOCDURNA............................. 85NOCTIVA.................................. 85nolix...........................................61nora-be......................................90NORCO.....................................12NORDITROPIN FLEXPRO....... 85norethin ace-eth estrad-fe.........91norethindrone............................91norethindrone acetate............... 91norethindrone acet-ethinyl est...91norethindrone-eth estradiol....... 91norethin-eth estradiol-fe............ 91NORGESIC FORTE................112norgestimate-eth estradiol........ 91norgestimate-ethinyl estradiol triphasic.....................................91NORITATE................................61norlyda...................................... 91norlyroc..................................... 91NORPACE................................ 49NORPACE CR.......................... 49NORPRAMIN............................ 25NORTHERA..............................49nortrel 0.5/35 (28)..................... 91nortrel 1/35 (21)........................ 91nortrel 1/35 (28)........................ 91

nortrel 7/7/7...............................91nortriptyline hcl..........................25NORVASC................................ 49NORVIR.................................... 40novarel...................................... 85NOVAREL.................................85NOVOLIN 70/30 FLEXPEN...... 69NOVOLIN 70/30 FLEXPEN RELION.....................................69NOVOLIN 70/30 RELION......... 70NOVOLIN 70/30 VIAL............... 70NOVOLIN N FLEXPEN.............70NOVOLIN N FLEXPEN RELION.....................................70NOVOLIN N RELION................70NOVOLIN N VIAL..................... 70NOVOLIN R FLEXPEN.............70NOVOLIN R FLEXPEN RELION.....................................70NOVOLIN R RELION................70NOVOLIN R VIAL..................... 70NOVOLOG FLEXPEN.............. 70NOVOLOG MIX 70/30 FLEXPEN..................................70NOVOLOG MIX 70/30 VIAL......70NOVOLOG PENFILL................ 70NOVOLOG U-100 VIAL............ 70NOXAFIL...................................28NP #2 DRUG PREPARATION KIT............................................ 15np thyroid.................................. 93NPLATE.................................... 43NUCALA................................. 106NUCYNTA.................................12NUCYNTA ER...........................12NUEDEXTA.............................. 54NULYTELY WITH FLAVOR PACKS......................................77NUMOISYN...............................55NUPLAZID................................ 38NUTRIDOX............................... 19NUTRIVIT................................. 73NUTROPIN AQ NUSPIN 10..... 85NUTROPIN AQ NUSPIN 20..... 85NUTROPIN AQ NUSPIN 5....... 85NUVARING............................... 91NUVESSA.................................19NUVIGIL..................................112NUZYRA................................... 19nyamyc......................................28NYMALIZE................................ 49nystatin......................................28nystatin-triamcinolone............... 28

nystop....................................... 28OCALIVA.................................. 79ocella.........................................91octreotide acetate..................... 85OCUFLOX...............................102ODACTRA.............................. 100ODEFSEY.................................40ODOMZO..................................33OFEV...................................... 109ofloxacin....................19, 102, 105ogestrel..................................... 91okebo........................................ 19olanzapine.................................38olanzapine-fluoxetine hcl.......... 25olmesartan medoxomil..............49olmesartan medoxomil-hctz...... 49olmesartan-amlodipine-hctz......49olopatadine hcl................102, 106OLUMIANT............................... 95OLUX........................................ 61OLUX-E.....................................61OMECLAMOX-PAK.................. 77OMEGA-3/D-3 WELLNESS PACK........................................ 49omega-3-acid ethyl esters.........49omeprazole............................... 75omeprazole-sodium bicarbonate............................... 75OMNARIS............................... 106OMNITROPE............................ 85ONDANSETRON HCL..............26ondansetron hcl........................ 26ondansetron odt........................ 26ONE DROP BLOOD GLUCOSE MONITOR.............. 68ONE DROP TEST.....................68ONE TOUCH VERIO KIT W/DEVICE................................ 68ONETOUCH ULTRA 2..............68ONETOUCH ULTRA BLUE TEST STRIPS...........................68ONETOUCH ULTRA MINI........ 68ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..........68ONETOUCH VERIO IQ SYSTEM................................... 68ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..........68ONEXTON................................ 61ONFI......................................... 22ONGLYZA.................................66ONZETRA XSAIL......................30OPANA..................................... 12

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opium........................................ 77OPSUMIT................................111ORACEA...................................61ORACIT.................................... 73ORAFATE............................... 100ORALAIR................................ 100ORALAIR ADULT SAMPLE KIT.......................................... 100ORALAIR ADULT STARTER PACK...................................... 100ORALAIR CHILDRENS SAMPLE KIT...........................100ORALAIR CHILDRENS STARTER PACK.................... 100oralone...................................... 55ORAPRED ODT........................82ORAVIG.................................... 28ORENCIA..................................95ORENCIA CLICKJECT............. 95ORENITRAM.......................... 111ORFADIN..................................79ORILISSA................................. 85ORKAMBI............................... 110orphenadrine citrate er............112orphenadrine-aspirin-caffeine. 112ORPHENGESIC FORTE........ 112orsythia..................................... 91ORTHO MICRONOR................ 91ORTHO TRI-CYCLEN LO.........91ORTHO-NOVUM 1/35 (28)....... 91ORTHO-NOVUM 7/7/7 (28)...... 91oscimin......................................77oscimin sr..................................77oseltamivir phosphate............... 40OSENI.......................................66OSMOLEX ER.......................... 36OSMOPREP............................. 77OSPHENA................................ 84OTEZLA.................................... 95OTICIN HC NR....................... 105OTIPRIO................................. 105OTOVEL................................. 105OTREXUP.................................95OVACE PLUS........................... 61OVIDE.......................................35OVIDREL.................................. 85oxaprozin.................................. 15OXAYDO...................................12oxazepam................................. 42oxcarbazepine...........................22OXERVATE............................ 104oxiconazole nitrate.................... 28OXISTAT...................................28

OXSORALEN ULTRA...............61OXTELLAR XR......................... 22oxybutynin chloride................... 80oxybutynin chloride er............... 80oxycodone hcl........................... 12OXYCODONE HCL ER............ 12oxycodone-acetaminophen.......12oxycodone-aspirin.....................12oxycodone-ibuprofen................ 12OXYCONTIN.............................12oxymorphone hcl.......................12oxymorphone hcl er.................. 12OXYTROL.................................80OZEMPIC..................................66PACERONE..............................49pacerone................................... 49paliperidone er.......................... 38PALYNZIQ................................ 79PAMELOR................................ 25PANCREAZE............................ 79PANDEL....................................61PANRETIN................................33pantoprazole sodium.................75papaverine hcl...........................49paregoric................................... 78paricalcitol................................. 99PARLODEL...............................36PARNATE................................. 25paroex....................................... 55paromomycin sulfate.................19paroxetine hcl............................25paroxetine hcl er....................... 25paroxetine mesylate..................25PASER......................................30PATADAY............................... 102PATANASE.............................106PATANOL............................... 102PAXIL........................................25PAXIL CR..................................25PAZEO....................................102P-CARE 100MX........................ 16P-CARE D40MX....................... 82P-CARE D80MX....................... 82P-CARE K40MX........................82P-CARE K80MX........................82PCP 100....................................78PEDIAPRED............................. 82PEDIARIX................................. 97PEDVAX HIB............................ 97peg 3350-kcl-na bicarb-nacl......78peg-3350/electrolytes................78PEGANONE..............................22PEGASYS.................................40

PEGASYS PROCLICK............. 40PEGINTRON.............................40penicillamine............................. 80penicillin v potassium................ 19PENLAC....................................28PENNSAID................................15PENTACEL............................... 97pentamidine isethionate............ 35PENTASA................................. 98pentazocine-naloxone hcl......... 12pentoxifylline er......................... 49PEPCID.....................................75PERCOCET.............................. 12PERFOROMIST......................109PERIDEX.................................. 55perindopril erbumine................. 49periogard...................................55permethrin.................................35perphenazine............................ 26perphenazine-amitriptyline........25PERSERIS................................38PERTZYE................................. 79PEXEVA....................................25phenadoz................................ 106phenazo.................................... 80phenazopyridine hcl.................. 80phendimetrazine tartrate........... 54phendimetrazine tartrate er.......54phenelzine sulfate..................... 25phenobarbital............................ 22phenobarbital-belladonna alk....78phenohytro................................ 78phenoxybenzamine hcl............. 49phentermine hcl........................ 54phenylephrine hcl....................104phenylephrine-guaifenesin......106PHENYTEK...............................22phenytoin.................................. 22phenytoin infatabs.....................22phenytoin sodium extended...... 22philith.........................................91PHOSLYRA.............................. 80phosphasal................................80PHOSPHOLINE IODIDE.........103phospho-trin 250 neutral........... 73phytonadione............................ 73PICATO.....................................62PIFELTRO................................ 40pilocarpine hcl................... 55, 103pimecrolimus.............................62pimozide....................................38pimtrea...................................... 91pindolol......................................49

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pioglitazone hcl......................... 66pioglitazone hcl-glimepiride.......66pioglitazone hcl-metformin hcl.. 66PIQRAY (200 MG DAILY DOSE).......................................33PIQRAY (250 MG DAILY DOSE).......................................33PIQRAY (300 MG DAILY DOSE).......................................33pirmella 1/35............................. 91pirmella 7/7/7............................ 91piroxicam...................................15PLAQUENIL..............................35PLAVIX..................................... 37PLEGRIDY................................53PLEGRIDY STARTER PACK... 53PLENVU....................................78PLEXION.................................. 62PLEXION CLEANSER.............. 62PNEUMOVAX 23...................... 97pnv prenatal plus multivit+dha.. 73podocon.................................... 62podofilox....................................62POINT OF CARE KM................83POINT OF CARE L.2................ 83POINT OF CARE L.5................ 83POINT OF CARE LM DEP 2.....83POINT OF CARE LM-2.2..........16POINT OF CARE LM-2.5..........16polycin.....................................104polymyxin b-trimethoprim........104polysaccharide iron forte...........73POLYTRIM..............................104POLY-VI-FLOR......................... 73POLY-VI-FLOR FS................... 73POLY-VI-FLOR/IRON............... 73POMALYST.............................. 33portia-28....................................91posaconazole............................28pot bicarb-pot chloride.............. 73POTABA................................... 73potassium bicarbonate..............73potassium chloride.................... 73potassium chloride crys er........ 73potassium chloride er................73potassium citrate er...................73potassium citrate-citric acid.......73POVIDONE-IODINE............... 102PRADAXA.................................20PRALUENT...............................49pramipexole dihydrochloride..... 36pramipexole dihydrochloride er.36PRAMOSONE...........................62

PRAMOTIC............................. 105PRASTERA...............................15prasugrel hcl............................. 37PRAVACHOL............................49pravastatin sodium....................49praziquantel.............................. 35prazosin hcl...............................49PRECISION LINK..................... 68PRECISION PCX PLUS TEST. 68PRECISION QID TEST.............68PRECISION SOF-TACT TEST. 68PRECISION XTRA BLOOD GLUCOSE................................ 68PRECOSE................................ 66PRED FORTE.........................102PRED MILD............................ 102PRED-G.................................. 104PRED-G S.O.P....................... 104prednicarbate............................ 62prednisolone............................. 83PREDNISOLONE ACET-MOXIFLOXACIN.....................104prednisolone sodium phosphate......................... 83, 102PREDNISOLONE-GATIFLOXACIN......................104PREDNISOLON-MOXIFLOX-NEPAFENAC.......................... 102prednisone................................ 83prednisone intensol...................83PREFEST................................. 91pregabalin................................. 54pregnyl...................................... 85PREMARIN............................... 91PREMPHASE........................... 91PREMPRO................................91PRENAISSANCE......................73PRENATA................................. 73prenatal..................................... 73prenatal plus iron...................... 74PREPOPIK................................78PRESTALIA.............................. 49PREVACID................................75PREVACID SOLUTAB..............75prevalite.................................... 49PREVIDENT............................. 55prevident................................... 55PREVIDENT 5000 BOOSTER PLUS.........................................55PREVIDENT 5000 DRY MOUTH.....................................55PREVIDENT 5000 ENAMEL PROTECT.................................55

PREVIDENT 5000 ORTHO DEFENSE................................. 55PREVIDENT 5000 PLUS.......... 55PREVIDENT 5000 SENSITIVE.55previfem.................................... 91PREVNAR 13............................97PREVYMIS............................... 40PREZCOBIX............................. 40PREZISTA................................ 40PRIFTIN.................................... 30PRILOSEC................................76PRIMACARE.............................74primaquine phosphate.............. 35primidone.................................. 22PRIMLEV.................................. 12PRIMSOL..................................19PRINIVIL................................... 49PRISTIQ....................................25PROAIR HFA.......................... 109PROAIR RESPICLICK............109probenecid................................ 29PROBICHEW............................78PROCARDIA.............................49PROCARDIA XL....................... 49PROCENTRA........................... 53prochlorperazine....................... 26prochlorperazine maleate......... 26PROCORT................................ 98PROCTOCORT........................ 98PROCTOFOAM HC.................. 98procto-med hc........................... 98procto-pak................................. 98proctosol hc...............................98proctozone-hc........................... 98PROCYSBI............................... 79PRODIGY NO CODING BLOOD GLUC.......................... 68progesterone.............................91progesterone micronized.......... 91PROGLYCEM........................... 68PROGRAF................................ 95PROLENSA............................ 102PROMACTA..............................43promethazine hcl.....................106promethazine-codeine............ 107promethazine-dm.................... 107promethazine-phenyleph-codeine................................... 107promethazine-phenylephrine.. 107promethegan...........................107PROMETRIUM......................... 91propafenone hcl........................ 49propafenone hcl er.................... 49

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propantheline bromide.............. 78proparacaine hcl..................... 104propranolol hcl.......................... 49propranolol hcl er...................... 49propranolol-hctz........................ 49propylthiouracil ..........................93PROQUAD................................97PROSCAR................................ 81PROTHELIAL..........................100PROTONIX............................... 76PROTOPIC............................... 62protriptyline hcl..........................25PROVENTIL HFA................... 109PROVERA................................ 91PROVIGIL............................... 112PROZAC................................... 25PRUDOXIN............................... 62pseudoephedrine-bromphen-dm........................................... 107PSORCON................................62PULMICORT FLEXHALER.....109PULMICORT SUSPENSION.. 109pulmosal..................................107PULMOZYME......................... 110PURIXAN.................................. 33PYLERA....................................78pyrazinamide.............................30PYRIDIUM................................ 80pyridostigmine bromide.............30pyridostigmine bromide er.........30PYROGALLIC ACID................. 62QBRELIS.................................. 49QBREXZA.................................62QMIIZ ODT............................... 15QNASL....................................107QNASL CHILDRENS.............. 107QSYMIA.................................... 54QTERN..................................... 66QUADRACEL............................97QUALAQUIN.............................35QUARTETTE............................ 91quazepam................................. 42QUDEXY XR.............................22QUESTRAN.............................. 49QUESTRAN LIGHT.................. 50quetiapine fumarate.................. 38quetiapine fumarate er.............. 38QUFLORA FE........................... 74QUFLORA FE PEDIATRIC.......74QUFLORA GUMMIES.............. 74QUFLORA PEDIATRIC............ 74QUILLICHEW ER......................53QUILLIVANT XR....................... 53

quinapril hcl...............................50quinapril-hydrochlorothiazide.... 50quinidine gluconate er...............50quinidine sulfate........................ 50quinine sulfate...........................35QVAR REDIHALER................ 109rabeprazole sodium.................. 76RAGWITEK.............................100raloxifene hcl.............................84ramelteon................................ 112ramipril ...................................... 50RANEXA................................... 50ranitidine hcl..............................76ranolazine er............................. 50RAPAFLO................................. 81RAPAMUNE..............................95rasagiline mesylate................... 36RASUVO...................................95RAVICTI....................................79RAYALDEE...............................99RAYOS..................................... 83RAZADYNE.............................. 23RAZADYNE ER........................ 23READYSHARP ANESTH + BETAMETH.............................. 83READYSHARP ANESTH + DEXAMETH.............................. 83READYSHARP ANESTH + KETOROLAC............................15READYSHARP ANESTH + METHYLPRED......................... 83READYSHARP-A......................16REBIF....................................... 53REBIF REBIDOSE....................53REBIF REBIDOSE TITRATION PACK.................... 53REBIF TITRATION PACK.........54reclipsen....................................92RECOMBIVAX HB.................... 97RECTIV.....................................50RECURA...................................28REGLAN................................... 26REGRANEX..............................62RELENZA DISKHALER............ 40relexxii .......................................53RELION BLOOD GLUCOSE TEST.........................................68RELION PREMIER TEST......... 68RELION ULTIMA TEST............ 68RELISTOR................................ 78RELNATE DHA.........................74RELPAX....................................30REMERON................................25

REMERON SOLTAB................ 25REMESENSE........................... 55RENAGEL.................................80RENATABS WITH IRON.......... 74RENVELA................................. 80repaglinide................................ 66REPATHA................................. 50REPATHA PUSHTRONEX SYSTEM................................... 50REPATHA SURECLICK........... 50REQUIP XL...............................36RESCRIPTOR.......................... 40RESTASIS.............................. 104RESTASIS MULTIDOSE........ 104RESTORIL.............................. 112RETIN-A....................................62RETIN-A MICRO GEL 0.04 %, 0.1 %.........................................62RETIN-A MICRO PUMP........... 62RETROVIR............................... 40REVATIO................................ 111REVLIMID................................. 33REXULTI...................................38REYATAZ................................. 40RHOFADE................................ 62RHOPRESSA......................... 103RIAX..........................................62ribavirin..................................... 40RIDAURA..................................95rifabutin..................................... 30RIFADIN....................................30RIFAMATE................................30rifampin..................................... 31RIFAMPIN+SYRSPEND SF..... 31RIFATER...................................31RILUTEK...................................54riluzole.......................................54rimantadine hcl..........................40RIMSO-50................................. 80RINVOQ....................................95RIOMET.................................... 66risedronate sodium................... 99RISPERDAL..............................38RISPERDAL CONSTA..............38risperidone................................ 38RITALIN.................................... 53RITALIN LA...............................53ritonavir..................................... 40rivastigmine...............................23rivastigmine tartrate.................. 23rivelsa........................................92rizatriptan benzoate.................. 30ROBAXIN-750.........................112

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ROCALTROL............................ 99ROCKLATAN.......................... 103ROPIDEX..................................83ropinirole hcl..............................36ropinirole hcl er......................... 36ROPIVACAINE HCL................. 16rosadan..................................... 62rosuvastatin calcium................. 50ROTARIX.................................. 97ROTATEQ.................................97ROWASA.................................. 98roweepra................................... 22roweepra xr............................... 22ROXICODONE......................... 12ROZEREM.............................. 112RUBRACA................................ 33RUZURGI................................100RYCLORA...............................107RYDAPT................................... 33RYTARY................................... 36RYTHMOL SR.......................... 50ryvent...................................... 107SABRIL..................................... 22SAFYRAL..................................92SAIZEN..................................... 85SAIZENPREP........................... 85SALAGEN................................. 55SALEX...................................... 62salicylic acid.............................. 62salicylic acid er..........................62salicylic acid-cleanser............... 62SALINE-PHENOL..................... 74salsalate....................................15SALVAX.................................... 62SALVAX DUO PLUS.................62SAMSCA...................................74SANCUSO................................ 26SANDIMMUNE......................... 95SANDOSTATIN........................ 85SANTYL.................................... 62SAPHRIS.................................. 38SARAFEM.................................25SAVAYSA................................. 21SAVELLA.................................. 54SAVELLA TITRATION PACK... 54SAXENDA.................................54scopolamine..............................26SEASONIQUE.......................... 92SECONAL...............................112SEEBRI NEOHALER.............. 109SEGLUROMET.........................66SELECT-OB..............................74selegiline hcl............................. 36

selenium sulfide........................ 62SELZENTRY.......................40, 41SEMPREX-D...........................107SENSIPAR................................84SEREVENT DISKUS.............. 109SERNIVO..................................62SEROQUEL.............................. 38SEROQUEL XR........................ 38SEROSTIM............................... 78sertraline hcl..............................25setlakin......................................92sevelamer carbonate................ 80sevelamer hcl............................80SEYSARA................................. 19sf............................................... 55sf 5000 plus...............................56SFROWASA............................. 98sharobel.................................... 92SHINGRIX.................................97SIKLOS..................................... 33sildenafil citrate....................... 111SILENOR................................ 112SILIQ.........................................95silodosin.................................... 81SILVADENE..............................19silver nitrate...............................19silver sulfadiazine......................19SIMBRINZA............................ 103simliya....................................... 92simpesse...................................92SIMPONI...................................95SIMVASTATIN.......................... 50simvastatin................................ 50SINEMET.................................. 36SINEMET CR............................36SINGULAIR.....................109, 110sirolimus....................................95SIRTURO..................................31SITAVIG....................................41SIVEXTRO................................19SKELAXIN.............................. 112SKLICE..................................... 35SKYRIZI (150 MG DOSE).........95sod citrate-citric acid................. 74sodium chloride.......................107sodium fluoride....................56, 74sodium fluoride 5000 plus......... 56sodium hyaluronate...................62sodium phenylbutyrate..............79sodium polystyrene sulfonate... 74sodium sulfacetamide............... 62SODIUM SULFACETAMIDE WASH....................................... 62

solifenacin succinate.................80SOLIQUA.................................. 66SOLODYN................................ 19SOLOSEC.................................19SOLTAMOX.............................. 33SOLU-CORTEF........................ 83SOMA..................................... 112SOMATULINE DEPOT............. 85SOMAVERT..............................85SOOLANTRA............................63SORIATANE............................. 63SORILUX.................................. 63sorine........................................ 50sotalol hcl.................................. 50sotalol hcl (af)............................50SOVALDI.................................. 41SPECTRACEF..........................20spinosad....................................36SPIRIVA HANDIHALER..........110SPIRIVA RESPIMAT.............. 110spironolactone...........................50spironolactone-hctz...................50SPORANOX..............................28SPORANOX PULSEPAK..........28SPRAVATO (56 MG DOSE)..... 25SPRAVATO (84 MG DOSE)..... 25sprintec 28................................ 92SPRITAM.................................. 22SPRIX....................................... 15SPRYCEL................................. 33sps............................................ 74sronyx....................................... 92ssd............................................ 20SSKI........................................107sss 10-5.................................... 63STALEVO 100.......................... 36STALEVO 125.......................... 36STALEVO 150.......................... 36STALEVO 200.......................... 36STALEVO 50............................ 37STALEVO 75............................ 37STARLIX................................... 66stavudine...................................41STEGLATRO............................ 66STEGLUJAN.............................66STELARA..................................96STEMPHYLIUM...................... 100STIMATE.................................. 85STIOLTO RESPIMAT............. 110STIVARGA................................33STRATTERA.............................53STRENSIQ................................79STRIANT...................................83

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STRIBILD..................................41STRIVERDI RESPIMAT......... 110STROMECTOL......................... 36SUBOXONE..............................17SUBSYS................................... 12subvenite...................................22subvenite starter kit-blue...........22subvenite starter kit-green........ 22subvenite starter kit-orange...... 22SUCRAID..................................79sucralfate.................................. 76SULAR...................................... 50sulfacetamide sodium....... 63, 102sulfacetamide sodium (acne).... 63sulfacetamide sodium-sulfur..... 63sulfacetamide-prednisolone.... 105sulfacetamide-sulfur in urea......63sulfacleanse 8/4........................ 63sulfadiazine............................... 20sulfamethoxazole-trimethoprim.20SULFAMYLON..........................20sulfasalazine............................. 98sulfatrim pediatric......................20sulfurated lime...........................36sulindac.....................................15sumatriptan............................... 30sumatriptan succinate............... 30sumatriptan succinate refill ....... 30sumatriptan-naproxen sodium.. 30SUPRAX................................... 20SUPREP BOWEL PREP KIT....78SURE RESULT O3D3 SYSTEM................................... 50SUSTIVA...................................41SUTENT....................................33syeda........................................ 92SYLATRON...............................41SYMAX DUOTAB..................... 78symax-sl....................................78symax-sr................................... 78SYMBICORT...........................110SYMBYAX.................................25SYMDEKO.............................. 110SYMFI....................................... 41SYMFI LO................................. 41SYMJEPI.................................110SYMLINPEN 120...................... 66SYMLINPEN 60........................ 66SYMPAZAN.............................. 22SYMPROIC...............................78SYMTUZA.................................41SYNALAR................................. 63SYNAPRYN FUSEPAQ............ 12

SYNAREL................................. 85SYNDROS................................ 26SYNERA................................... 16SYNJARDY...............................66SYNJARDY XR.........................66SYNTHROID.............................93SYPRINE.................................. 74SYRINGE PRECISEDOSE DISPENSER........................... 100TABLOID...................................33TABRADOL FUSEPAQ.......... 112TABRADOL RAPIDPAQ......... 112TACLONEX...............................63tacrolimus............................63, 96tadalafil (pah).......................... 111TAFINLAR.................................33TAGRISSO............................... 33TAKHZYRO.............................. 96TALTZ....................................... 96TALZENNA............................... 34TAMIFLU...................................41tamoxifen citrate........................34tamsulosin hcl........................... 81TAPAZOLE............................... 93TAPERDEX 12-DAY................. 83TAPERDEX 6-DAY................... 83TAPERDEX 7-DAY................... 83TARCEVA................................. 34TARGADOX..............................20TARGRETIN............................. 34tarina 24 fe................................ 92tarina fe 1/20............................. 92tarina fe 1/20 eq........................ 92TARKA...................................... 50taron-crystals............................ 74TASIGNA.................................. 34TASMAR................................... 37TAURINE.................................. 74TAVALISSE.............................. 43TAYTULLA................................92tazarotene................................. 63TAZORAC.................................63taztia xt......................................50TDVAX...................................... 97TECFIDERA..............................54TEGRETOL...............................22TEGRETOL-XR........................ 22TEGSEDI.................................. 54TEKTURNA...............................50TEKTURNA HCT...................... 50telmisartan................................ 50telmisartan-amlodipine..............50telmisartan-hctz.........................50

temazepam............................. 113TEMODAR................................ 34TEMOVATE.............................. 63temozolomide............................34tencon....................................... 12TENIVAC.................................. 97tenofovir disoproxil fumarate.....41TENORETIC 100...................... 50TENORETIC 50........................ 50TENORMIN...............................50terazosin hcl..............................81terbinafine hcl............................28terbutaline sulfate....................110terconazole............................... 28TESSALON PERLES..............107TESTIM.....................................83testosterone.............................. 83TESTOSTERONE CYPIONATE............................. 83testosterone cypionate..............83testosterone enanthate............. 83tetrabenazine............................ 54tetracycline hcl.......................... 20TEXACORT.............................. 63THALOMID............................... 34THEO-24.................................110theophylline.............................110theophylline er.........................110THIOLA..................................... 80THIOLA EC............................... 80thioridazine hcl.......................... 38thiothixene.................................38THROMBIN-JMI........................43THROMBIN-JMI EPISTAXIS.... 43THROMBOGEN........................43thyroid....................................... 93tiadylt er.................................... 50tiagabine hcl..............................22TIAZAC..................................... 50TIBSOVO.................................. 34TIGAN....................................... 26TIGLUTIK..................................54TIKOSYN.................................. 51tilia fe.........................................92timolol maleate..................51, 103TIMOPTIC...............................103TIMOPTIC OCUDOSE............103TIMOPTIC-XE.........................103tinidazole...................................20TIROSINT................................. 93TIROSINT-SOL.........................93TIVICAY.................................... 41TIVORBEX................................15

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tizanidine hcl........................... 112TOBI NEBULIZER.................. 110TOBI PODHALER...................110TOBRADEX............................ 105TOBRADEX ST.......................105tobramycin...................... 102, 110TOBRAMYCIN........................ 110tobramycin-dexamethasone....105TOBREX................................. 102TOLAK...................................... 63tolbutamide............................... 66tolcapone.................................. 37tolmetin sodium.........................15TOLSURA................................. 28tolterodine tartrate.....................80tolterodine tartrate er.................80TOPAMAX................................ 22TOPAMAX SPRINKLE..............22TOPEX TOPICAL ANESTHETIC........................... 56TOPICORT............................... 63TOPICORT SPRAY.................. 63topiramate................................. 23topiramate er.............................23TOPROL XL..............................51toremifene citrate...................... 34torsemide.................................. 51TOUJEO MAX SOLOSTAR...... 70TOUJEO SOLOSTAR...............70tovet.......................................... 63TOVIAZ..................................... 80TRACLEER.............................111TRADJENTA.............................66TRAMADOL HCL ER................12tramadol hcl er.................... 12, 13tramadol hcl er (biphasic)..........12tramadol hcl ir ........................... 13tramadol-acetaminophen.......... 13trandolapril ................................ 51trandolapril-verapamil hcl er......51tranexamic acid.........................43TRANSDERM SCOP (1.5 MG).26TRANSDERM-SCOP (1.5 MG).27TRANXENE-T........................... 42tranylcypromine sulfate............. 25TRAVATAN Z..........................103travoprost (bak free)................103trazodone hcl............................ 25TRECATOR.............................. 31TRELEGY ELLIPTA................110TREMFYA.................................96TRESIBA...................................70TRESIBA FLEXTOUCH............70

tretinoin............................... 34, 63tretinoin microsphere................ 63tretinoin microsphere pump...... 63TREXALL.................................. 96TREXIMET................................30TREZIX..................................... 13tri femynor................................. 92triamcinolone acetonide...... 56, 63TRI-AMINO............................... 74triamterene................................51triamterene-hctz........................ 51trianex....................................... 63triazolam................................... 42TRIBENZOR............................. 51TRICARE PRENATAL DHA ONE.......................................... 74TRI-CHLOR.............................. 64TRICOR.................................... 51triderm.......................................64TRIDESILON............................ 64trientine hcl................................74tri-estarylla................................ 92trifluoperazine hcl......................38trifluridine................................ 102TRIGLIDE................................. 51trihexyphenidyl hcl.................... 37tri-legest fe................................ 92TRILEPTAL...............................23tri-linyah.................................... 92TRILIPIX................................... 51tri-lo-estarylla............................ 92tri-lo-marzia............................... 92tri-lo-mili .................................... 92tri-lo-sprintec............................. 92trilyte......................................... 78trimethobenzamide hcl..............27trimethoprim.............................. 20tri-mili ........................................ 92trimipramine maleate................ 25trinate........................................ 74TRINTELLIX..............................25TRIPLE COMPLEX FORMULA 3 KIT......................................... 15TRIPLE PMB...........................102TRIPLE PMK...........................102tri-previfem................................ 92tri-sprintec................................. 92TRISTART ONE........................74TRIUMEQ................................. 41TRI-VI-FLOR.............................74TRI-VI-FLORO.......................... 74tri-vitamin/fluoride......................74tri-vite/fluoride........................... 75

trivora (28).................................92tri-vylibra................................... 92tri-vylibra lo................................92TRIZIVIR................................... 41TROKENDI XR......................... 23TROPICAMIDE-PHENYLEPHRINE..................105trospium chloride.......................80trospium chloride er.................. 80TRUE METRIX BLOOD GLUCOSE TEST...................... 68TRUE METRIX PRO BLOOD GLUCOSE................................ 68TRUETRACK TEST..................68TRULANCE...............................78TRULICITY............................... 66TRUMENBA..............................97TRUVADA.................................41tryptophan................................. 75TUDORZA PRESSAIR........... 110tulana........................................ 92TURALIO.................................. 34turpentine.................................. 64TUSSICAPS............................107TUXARIN ER.......................... 107TUZISTRA XR........................ 107TWINRIX...................................97TWYNSTA................................ 51TYBOST....................................41tydemy...................................... 92TYKERB....................................34TYLENOL WITH CODEINE #3. 13TYLENOL WITH CODEINE #4. 13TYMLOS................................... 99UCERIS.................................... 98ULESFIA................................... 36ULORIC.................................... 29ULTRACET............................... 13ULTRAM................................... 13ULTRAVATE.............................64UMECTA MOUSSE.................. 64unithroid.................................... 94UPTRAVI................................ 111urea...........................................64urea hydrating........................... 64urea in zn undecyl-lactic acid....64urea nail .................................... 64URECHOLINE.......................... 80URELLE.................................... 80uretron d/s.................................80URIMAR-T................................ 80urin ds....................................... 80URO-458...................................80

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UROCIT-K 10............................75UROCIT-K 15............................75UROCIT-K 5..............................75UROGESIC-BLUE.................... 80UROXATRAL............................ 81URSO 250.................................78URSO FORTE.......................... 78ursodiol..................................... 78URYL........................................ 80ustell ..........................................80UTIBRON NEOHALER........... 110uticap........................................ 80utira-c........................................ 81utrona-c.....................................81VAGIFEM..................................92valacyclovir hcl..........................41VALCHLOR...............................34VALCYTE..................................41valganciclovir hcl.......................41VALIUM.....................................42valproic acid.............................. 23valsartan................................... 51valsartan-hydrochlorothiazide... 51VALTREX..................................41VANATOL LQ........................... 13VANATOL S..............................13VANCOCIN HCL.......................20vancomycin hcl......................... 20VANCOMYCIN+SYRSPEND SF............................................. 20vandazole..................................20VANOS..................................... 64VANOXIDE-HC......................... 64VAQTA......................................97VARIVAX.................................. 97VARUBI.....................................27VASCEPA................................. 51VASERETIC..............................51VASOTEC.................................51VECAMYL.................................51VECTICAL................................ 64velivet........................................92VELPHORO.............................. 81VELTASSA............................... 75VELTIN..................................... 64VEMLIDY.................................. 41VENCLEXTA.............................34VENCLEXTA STARTING PACK........................................ 34VENIPUNCTURE PX1 PHLEBOTOMY......................... 16venlafaxine hcl.......................... 25venlafaxine hcl er...................... 26

VENOMIL HONEY BEE VENOM...................................100VENOMIL WASP VENOM...... 100VENOMIL WHITE FACED HORNET.................................100VENOMIL YELLOW HORNET VENOM...................................100VENOMIL YELLOW JACKET VENOM...................................100VENTAVIS.............................. 111VENTOLIN HFA......................110verapamil hcl.............................51verapamil hcl er.........................51VERDESO................................ 64VEREGEN................................ 64VERELAN................................. 51VERELAN PM...........................51VERSACLOZ............................ 38VERZENIO................................34VESICARE................................81VFEND......................................28VIBERZI.................................... 78VIBRAMYCIN............................20vicodin hp..................................13VICTOZA.................................. 66VIDEX....................................... 41VIDEX EC................................. 41VIEKIRA PAK............................41vienva........................................92vigabatrin.................................. 23vigadrone.................................. 23VIGAMOX............................... 102VIIBRYD....................................26VIIBRYD STARTER PACK....... 26VILEVEV MB.............................81VIMOVO....................................15VIMPAT.....................................23VIOKACE.................................. 79viorele....................................... 92VIRACEPT................................ 41VIRAMUNE............................... 41VIRAMUNE XR......................... 41VIRASAL...................................64VIRAZOLE................................ 41VIREAD.....................................41virtussin ac w/alc.....................107VISTARIL.................................. 42VISTOGARD...........................100VITAFOL-OB+DHA...................75vitamin d (ergocalciferol)...........75vitamins acd-fluoride................. 75VITRAKVI..................................34

VIVAGUARD INO TEST STRIPS..................................... 68VIVELLE-DOT...........................92VIVLODEX................................ 15VIZIMPRO.................................34VOGELXO................................ 83VOGELXO PUMP..................... 83volnea....................................... 92VOLTAREN...............................15VOPAC GB............................... 15VOPAC KT................................15voriconazole..............................28VOSEVI.....................................41VOTRIENT................................34VP FC KIT.................................15VP GKL KIT.............................. 15vp-pnv-dha................................ 75VRAYLAR................................. 38VSL#3 DS................................. 78VUSION.................................... 28vyfemla......................................93vylibra........................................93VYNDAQEL.............................. 51VYTORIN.................................. 51VYVANSE................................. 53VYZULTA................................103warfarin sodium.........................21WASP VENOM PROTEIN...... 100WELCHOL................................ 51WELLBUTRIN SR.....................26WELLBUTRIN XL..................... 26wera.......................................... 93WESTHROID............................ 94WHITE-FACED HORNET VENOM...................................100wixela inhub............................ 110WP THYROID........................... 94wymzya fe................................. 93XADAGO...................................37XALKORI.................................. 34XANAX......................................42XANAX XR................................42XARELTO................................. 21XARELTO STARTER PACK.....21XATMEP................................... 96XELJANZ.................................. 96XELJANZ XR............................ 96XELODA................................... 34XELPROS............................... 103XENAZINE................................ 54XENICAL...................................54XEPI..........................................20XERAC AC................................64

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XERESE................................... 41XERFORM OIL EMULSION ROLL.........................................64XERMELO................................ 78XEROFORM OIL EMULSION 2"X2"......................................... 64XEROFORM OIL EMULSION GAUZE......................................64XEROFORM OIL EMULSION STRIP....................................... 64XEROFORM PETROLAT GAUZE 1"X8"............................64XEROFORM PETROLAT GAUZE 5"X9"............................64XEROFORM PETROLAT PATCH 2"X2"............................64XEROFORM PETROLAT PATCH 4"X4"............................64XEROFORM PETROLATUM ROLL 4"X9'............................... 64XHANCE................................. 107XIFAXAN...................................20XIGDUO XR........................66, 67XIIDRA.................................... 105XIMINO..................................... 20XOFLUZA................................. 42XOLEGEL................................. 29XOLEGEL COREPAK...............29XOLEGEL DUO/HEAD & SHOULDERS............................29XOLEGEL DUO/XOLEX........... 29XOPENEX...............................110XOPENEX CONCENTRATE.. 110XOPENEX HFA...................... 110XOSPATA................................. 34XTAMPZA ER........................... 13XTANDI.....................................34xulane....................................... 93XULTOPHY...............................67XURIDEN..................................79XYOSTED.................................84XYREM................................... 113YASMIN 28............................... 93YAZ........................................... 93YELLOW JACKET VENOM PROTEIN................................ 100YONSA..................................... 34YOSPRALA...............................76YUPELRI.................................110yuvafem.................................... 93ZACARE................................... 64zaclir cleansing......................... 64zafirlukast................................110

zaleplon...................................113ZANAFLEX............................. 112zarah......................................... 93ZARONTIN................................23ZAVESCA................................. 79ZEBUTAL..................................13ZEGERID.................................. 76ZEJULA.....................................34ZELAPAR..................................37ZELBORAF............................... 34ZEMBRACE SYMTOUCH........ 30ZEMPLAR................................. 99zenatane................................... 64ZENPEP....................................79ZENZEDI...................................53ZEPATIER................................ 42ZESTORETIC........................... 51ZESTRIL................................... 51ZETIA........................................51ZETONNA...............................107ZIAC..........................................51ZIAGEN.....................................42ZIANA....................................... 64zidovudine.................................42zileuton er............................... 110ZIOPTAN................................ 103ziprasidone hcl.......................... 38ZIPSOR.....................................15ZIRGAN.................................. 102ZITHROMAX.............................20ZITHROMAX TRI-PAK..............20ZITHROMAX Z-PAK................. 20ZOCOR..................................... 51ZOFRAN................................... 27ZOHYDRO ER.......................... 13ZOLINZA...................................34zolmitriptan................................30ZOLOFT....................................26zolpidem tartrate..................... 113zolpidem tartrate er................. 113ZOLPIMIST............................. 113ZOMACTON............................. 85ZOMIG...................................... 30ZOMIG ZMT..............................30ZONALON.................................64ZONEGRAN..............................23zonisamide................................23ZONTIVITY............................... 37ZORBTIVE................................ 78ZORTRESS.............................. 96ZORVOLEX.............................. 15ZOSTAVAX...............................97zovia 1/35e (28)........................ 93

ZOVIRAX.................................. 42ZTLIDO..................................... 16Z-TUSS AC............................. 107ZUBSOLV................................. 17zumandimine.............................93ZUPLENZ..................................27ZYCLARA................................. 64ZYCLARA PUMP...................... 64ZYDELIG...................................34ZYFLO.................................... 110ZYKADIA...................................34ZYLET.....................................105ZYLOPRIM................................29ZYMAXID................................ 102ZYPITAMAG............................. 51ZYPREXA................................. 38ZYPREXA RELPREVV............. 38ZYPREXA ZYDIS......................38ZYTIGA..................................... 34ZYVOX......................................20

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