Your 2020 Prescription Drug List · What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a generic euivalent

Your 2020 Prescription Drug List Flex Base 3-Tier

Effective September 1, 2020

This Prescription Drug List (PDL) is accurate as of September 1, 2020 and is subject to change

after this date. This PDL applies to members of our UnitedHealthcare and Oxford medical plans

with a pharmacy benefit subject to the Flex Base 3-Tier PDL. Your estimated coverage and

copayment/coinsurance may vary based on the benefit plan you choose and the effective date

of the plan.

Table of Contents

Understanding your Prescription Drug List. . .3

Medication tips . . . . . . . . . . . . . . . . . . . . . . . . . .5

Reading your PDL . . . . . . . . . . . . . . . . . . . . . . . .6

Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Drugs by category . . . . . . . . . . . . . . . . . . . . . . 10

Analgesics

Drugs for Pain . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Drugs for Pain and Inflammation. . . . . . . . . . . . . 11

Anti-Addiction / Substance Abuse

Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . 11

Antibacterials

Drugs for Infections . . . . . . . . . . . . . . . . . . . . . . . 12

Anticoagulants

Drugs to Treat or Prevent Blood Clots. . . . . . . . . 13

Anticonvulsants

Drugs for Seizures. . . . . . . . . . . . . . . . . . . . . . . . 13

Antidementia Agents

Drugs for Alzheimer’s Disease and Dementia . . . 14

Antidepressants

Drugs for Depression . . . . . . . . . . . . . . . . . . . . . 14

Antiemetics

Drugs for Nausea and Vomiting . . . . . . . . . . . . . 14

Antifungals

Drugs for Fungal Infections . . . . . . . . . . . . . . . . . 15

Antigout Agents

Drugs for Gout. . . . . . . . . . . . . . . . . . . . . . . . . . .15

Antimigraine Agents

Drugs for Migraines. . . . . . . . . . . . . . . . . . . . . . . 15

Antineoplastics

Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . 15

Antiparasitics

Drugs for Parasitic Infections . . . . . . . . . . . . . . . 16

Antiparkinson Agents

Drugs for Parkinson’s Disease . . . . . . . . . . . . . . 16

Antiplatelets

Drugs for Heart Attack and Stroke Prevention . . 16

Antipsychotics

Drugs for Mood Disorders. . . . . . . . . . . . . . . . . . 16

Antivirals

Drugs for Viral Infections. . . . . . . . . . . . . . . . . . . 16

Anxiolytics

Drugs for Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . 17

Bipolar Agents

Drugs for Mood Disorders. . . . . . . . . . . . . . . . . . 17

Cardiovascular Agents

Drugs for Heart and Circulation Conditions . . . . 17

Central Nervous System Agents

Drugs for Attention Deficit Disorder . . . . . . . . . .20

Drugs for Multiple Sclerosis . . . . . . . . . . . . . . . .20

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Dental and Oral Agents

Drugs for Mouth and Throat Conditions . . . . . . .21

Dermatological Agents

Drugs for Skin Conditions . . . . . . . . . . . . . . . . . .21

Diabetes

Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . .23

Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . .24

Drugs for Blood Disorders. . . . . . . . . . . . . . . .25

Drugs for Sexual Dysfunction . . . . . . . . . . . . .25

Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . .26

Gastrointestinal Agents

Drugs for Acid Reflux and Ulcer . . . . . . . . . . . . .26

Drugs for Bowel, Intestine and Stomach

Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Genetic or Enzyme Disorder Drugs for Replacement, Modification, Treatment . .27

Genitourinary Agents

Drugs for Bladder, *enital and .idney

Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Drugs for Prostate Conditions . . . . . . . . . . . . . . .28

Hormonal Agents

Hormone Replacement and Birth Control . . . . . .28

Oral Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Testosterone Replacement . . . . . . . . . . . . . . . . .32

Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Immunological Agents

Drugs for Immune System Stimulation

or Suppression . . . . . . . . . . . . . . . . . . . . . . . . . .32

Infertility Agents . . . . . . . . . . . . . . . . . . . . . . . .33

Inflammatory Bowel Disease Agents . . . . . . .33

Metabolic Bone Disease Agents

Drugs for Osteoporosis . . . . . . . . . . . . . . . . . . . .3�

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3�

Ophthalmic Agents

Drugs for Eye Allergy, Infection and

Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . .3�

Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . .3�

Drugs for Miscellaneous Eye Conditions . . . . . .3�

Otic Agents

Drugs for Ear Conditions. . . . . . . . . . . . . . . . . . .3�

Respiratory

Drugs for Anaphylaxis . . . . . . . . . . . . . . . . . . . . .3�

Respiratory Tract / Pulmonary Agents

Drugs for Allergies, Cough, Cold. . . . . . . . . . . . .3�

Drugs for Asthma and C2PD . . . . . . . . . . . . . . .3�

Drugs for Cystic Fibrosis . . . . . . . . . . . . . . . . . . .3�

Drugs for Pulmonary Hypertension. . . . . . . . . . . 3�

Skeletal Muscle Relaxants

Drugs for Muscle Pain and Spasm . . . . . . . . . . .3�

Sleep Disorder Agents . . . . . . . . . . . . . . . . . . .3�

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3�

2

Understanding your Prescription Drug List (PDL)

What is a PDL?

This document is a list of the most commonly

prescribed medications. It includes both brand-name

and generic prescription medications approved by the

Food and Drug Administration �FDA�. Medications are

listed by common categories or classes and placed

in tiers that represent the cost you pay out-of-pocket.

They are then listed in alphabetical order.

How do I use my PDL?

You and your doctor can consult the PDL to help you

select the most cost-effective prescription medications.

This guide tells you if a medication is generic or a

brand name, and if there are coverage reTuirements or

limits. Bring this list with you when you see your doctor.

If your medication is not listed here, please visit your

plan¶s member website or call the toll-free member

phone number on your health plan ID card.

What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost,

set by your employer or benefit plan. This is how much you will pay when you fill a prescription.

See page 6 for more information.

When does the PDL change?

PDL changes typically occur 2-3 times per year. However, changes that have a positive impact for

you ² such as coverage for new medications or cost savings ² may occur at any time. You can

log in to the member website listed on your ID card at any time to check your medication coverage

and lower-cost options.

About this PDL

Where differences exist between

this PDL and your benefit plan

documents, the benefit plan

documents rule. This PDL is not

a complete list of medications,

and not all medications listed

may be covered by your plan.

Please look at the benefit plan

documents provided by your

employer or health plan to see

which medications are covered

under your plan.

3

Understanding your Prescription Drug List (continued)

Why are some medications excluded from coverage?

:e review medications based on their total value, including effectiveness and safety, how

much they cost, and the availability of alternative medications to treat the same or similar

medical conditions. Certain medications may be excluded from coverage or be subject to prior

authori]ation �sometimes referred to as precertification� 1

1. Depending on your benefit, you may have notification or medical necessity reTuirements for

select medications.

if similar alternatives are available at

a lower cost. Examples include medications that work the same way, but one is much more

expensive than the other, or options that are available without a prescription �also referred to as

over-the-counter medications 2

2. For New York and New -ersey plans, a prescription drug product that is therapeutically eTual to

an over-the-counter drug may be covered if it is determined to be medically necessary.

). There are also some instances where the same product can be

made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-

cost product may be covered.

You should review your benefit plan documents to confirm if any medications are excluded from

your plan. You can log in to the member website listed on your ID card at any time to check your

medication coverage. Talk to your doctor to see if there are lower-cost options or over-the-counter

medications available.

Who decides which medications are covered?

Thousands of medications are already available and more come to the market regularly. 2ften,

several medications are available to treat the same condition. The UnitedHealthcare® Pharmacy

and Therapeutics Committee, which includes both internal and external doctors and pharmacists,

meets regularly to provide clinical reviews of all medications. Using this information, the PDL

Management Committee, which includes senior UnitedHealth *roup® doctors and business

leaders, meets to evaluate overall health care value. They also set coverage and tier status

for all medications.

4

Medication tips

What is the difference between brand-name and

generic medications?

*eneric medications contain the same active

ingredients (what makes the medication work) as

brand-name medications, but they often cost less.

2nce the patent for a brand-name medication ends,

the FDA can approve a generic version with the same

active ingredients. These types of medications are

known as generic medications. Sometimes, the same

company that makes a brand-name medication also

makes the generic version.

What if my doctor writes a brand-name prescription?

If your doctor gives you a prescription for a brand-name

medication, ask if a generic eTuivalent or lower-cost

option is available and could be right for you. *eneric

medications are usually your lowest-cost option, but

not always. For some benefit plans, if a brand-name

drug is prescribed and a generic eTual is available,

your cost-share may be the copayment PLUS the cost

difference between the brand-name drug and the generic

eTuivalent.

What if I am taking a specialty medication?

Specialty medications are high-cost and are used to treat rare or complex conditions that reTuire

additional care and support. For most plans, these medications are managed through the specialty

pharmacy program. Take advantage of personali]ed support designed to help you get the most out

of your treatment plan. 9isit the member website listed on your ID card or call the toll-free phone

number on your ID card to learn more.

Please note, not all specialty medications are listed here. If you’re taking a specialty medication that

is on a higher tier, call the toll-free phone number on your ID card to talk with a pharmacist about

finding lower-cost options.

Over-the-counter

(OTC) medications

An 2TC medication may be

the right treatment option for

some conditions. Talk to your

doctor about available 2TC

options. Even though these

medications may not be

covered by your pharmacy

benefit, they may cost less

than a prescription medication.

5

Reading your PDL

The PDL gives you choices so you and your doctor can decide your best course of treatment.

In this PDL, brand-name medications are shown in UPPERCASE and generic medications in

lowercase.

Tier information.

Using lower-tier medications can help you pay your lowest out-of-pocket cost. Your plan may have

multiple or no tiers. Please note� If you have a high deductible plan, the tier cost levels may apply

once you hit your deductible.

In the chart below, overall value indicates medications¶ effectiveness and safety, cost, and the

availability of alternative medications to treat the same or similar medical condition�s�.

Drug Tier Includes Helpful Tips

Tier 1 $ Lower-cost

Medications that provide the highest

overall value. Mostly generic drugs. Some

brand-name drugs may also be included.

Use Tier 1 drugs for the

lowest out-of-pocket costs.

Tier 2 $$ Mid-range cost

Medications that provide good overall value.

Mainly preferred brand-name drugs.

Use Tier 2 drugs, instead of

Tier 3, to help reduce your

out-of-pocket costs.

Tier 3 $$$ Highest-cost

Medications that provide the lowest

overall value.

Ask your doctor if a Tier 1 or Tier 2

option could work for you.

6

Reading your PDL (continued)

Drug list information.

In this drug list, some medications are noted with letters next to them to help you see which ones

may have coverage reTuirements or limits. Your benefit plan sets how these medications may be

covered for you.

E May be excluded from coverage or subject to Prior Authorization in

Connecticut, New Jersey and New York. (Referred to as First Start in

New Jersey)

Lower-cost options are available and covered.

H Health Care Reform Preventive

This medication is part of a health care reform preventive benefit and may be

available at no additional cost to you.

H-PA Health Care Reform Preventive with Prior Authorization

May be part of health care reform preventive and available at no additional

cost to you if prior authorization criteria is met.

PA Prior Authorization (sometimes referred to as precertification) 3

3. Depending on your benefit, you may have notification or medical necessity reTuirements for

select medications.

ReTuires your doctor to provide information about why you are taking

a medication to determine how it may be covered by your plan.

QL Quantity Limits

Specifies the largest Tuantity of medication covered per copayment

or in a defined period of time.

RS Refill and Save Program 4

4. Not applicable to Oxford plans.

Save money on your copayment when you refill your prescription on time

as prescribed. Program eligibility may vary.

SP Specialty Medication

Specialty medications treat complex or rare conditions and may reTuire special

storage and handling. You may be reTuired to obtain these medications from a

specialty pharmacy.

ST Step Therapy (referred to as First Start in New Jersey)

ReTuires prior authori]ation and may reTuire you to try one or more other

medications before the medication you are reTuesting may be covered.

7

Reading your PDL (continued)

Coverage details.

Some drug classes in this PDL have additional/important coverage details. Review this list to see

if drug classes that apply to you are noted.

Diabetes: Blood Glucose Monitoring; Insulin; Non-Insulin

Diabetic supplies and prescription medications may be subject to different cost-share

arrangements for 2xford plans. Please see your Summary of Benefits and Coverage �SBC�

for specifics. Medications that reTuire step therapy may reTuire prior authori]ation �sometimes

referred to as precertification� if covered under another benefit.

Diabetes: Continuous Glucose Monitors, Sensors

Coverage is set by the consumer¶s prescription drug benefit plan. Please consult plan

documents regarding benefit coverage and cost-share. Diabetic self-management items,

including continuous glucose monitors, may be covered under the consumer¶s medical

benefit plan.

Endocrine: Growth Hormone


documents regarding benefit coverage and cost-share.

Infertility


documents regarding benefit coverage and cost-share. Prior authori]ation �sometimes referred

to as precertification� may be reTuired for 2xford plans or where a state mandates infertility

drug coverage.

Medications for Sexual Dysfunction


documents regarding benefit coverage and cost-share. Prior authori]ation �sometimes referred

to as precertification� may be reTuired for 2xford plans.

8

Questions

For the most current list of covered medications or if you have questions:

Call the toll-free member phone number

on your ID card.

Visit your plan’s member website listed

on your ID card to:

• 9iew your pharmacy benefit and coverage

information, including prescription history

• View medication interactions and side effects

• Locate a participating retail pharmacy

by ZIP code

• Look up possible lower-cost medication

alternatives

• Compare medication pricing and options

And, if home delivery services

are included in your pharmacy

benefit, you can also�

• Refill prescriptions

• Check the status of your order

• Set up reminders for refills

• Manage your account

9

Drug RequirementsDrug Name

Tier & Limits

See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY.

Drug NameDrug

Tier

Requirements

& Limits

Analgesics - Drugs for Pain

acetaminophen-codeine 1

acetaminophen-codeine �2 1

acetaminophen-codeine �3 1

acetaminophen-codeine �� 1

apap-caff-dihydrocodeine oral

capsule1

ARYM2 ER 3 PA, ST, QL

BELBUCA 3 PA, QL

butalbital-apap-caffeine 1

C2N=IP 3 QL

DILAUDID ORAL 3

DVORAH E

endocet 1

ES*IC 3

fentanyl 1 PA, QL

FI2RICET 3

hydrocodone-acetaminophen oral

solution 10-32� mg/1�ml,

�.�-32� mg/1�ml

1


tablet1

hydromorphone hcl er 1 PA, ST, QL

hydromorphone hcl oral 1

hydromorphone hcl rectal 1

HYSIN*LA ER E PA, QL

.ADIAN 2RAL CAPSULE

EXTENDED RELEASE 24 HOUR

200 MG

3 PA, ST, QL

lidocaine external ointment 1

lidocaine external patch 5 % 1

lidocaine-prilocaine external

cream1

lorcet 1

lorcet hd 1

lorcet plus 1

L2RTAB 3

M2RPHAB2ND ER 3 PA, ST, QL

morphine sulfate (concentrate)

oral solution 100 mg/5ml,

20 mg/ml

1

morphine sulfate er oral capsule

extended release 24 hour1 PA, ST, QL

morphine sulfate er oral tablet

extended release1 PA, QL

morphine sulfate oral 1

morphine sulfate rectal 1

MS C2NTIN 3 PA, ST, QL

NAL2CET 3

N2RC2 3

NUCYNTA 2 QL

NUCYNTA ER 3 PA, QL

2;AYD2 E QL

2;YC2D2NE HCL ER E PA, QL

oxycodone hcl oral capsule 1

oxycodone hcl oral concentrate

100 mg/5ml1

oxycodone hcl oral solution 1

oxycodone hcl oral tablet 1

oxycodone-acetaminophen oral

tablet 10-32� mg, 2.�-32� mg,

�-32� mg, �.�-32� mg

1

2;YC2NTIN E PA, QL

premium lidocaine 1

PRIMLEV 3

R2;IC2D2NE 3

SUBSYS 3 PA, QL

tramadol hcl er (biphasic) 1 QL

TRAMAD2L HCL ER 2RAL

CAPSULE E;TENDED

RELEASE 24 HOUR 100 MG,

200 M*, 300 M*

3 QL

10


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

tramadol hcl er oral capsule

extended release 24 hour 150 mg1 QL

tramadol hcl er oral tablet

extended release 24 hour1 QL

tramadol hcl oral tablet 50 mg 1

TREZIX 1

TYLEN2L :ITH C2DEINE �3 3

ULTRAM 3

VANATOL LQ 2

VANATOL S 2

vicodin hp oral tablet 10-300 mg 1

XTAMPZA ER 2 PA, QL

=EBUTAL 3

=2HYDR2 ER 3 PA, QL

ZTLIDO 3

Analgesics - Drugs for Pain and Inflammation

celecoxib oral 1

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium oral 1

diclofenac sodium transdermal

gel 1 %1


solution1

EC-NAPR2SYN 3

ec-naproxen 1

etodolac 1

etodolac er 1

ibu 1

ibuprofen oral suspension E

ibuprofen oral tablet 400 mg,

600 mg, 800 mg1

IND2CIN 3

indomethacin er 1

indomethacin oral capsule 25 mg,

50 mg1

ketorolac tromethamine oral 1

meloxicam oral 1

M2BIC 3

nabumetone oral 1

NAPRELAN 2RAL TABLET


750 MG

E

NAPR2SYN 2RAL

SUSPENSION3

naproxen dr 1

naproxen oral 1

naproxen sodium er 1

naproxen sodium oral tablet

275 mg, 550 mg1

PENNSAID E

QMIIZ ODT 3

RELAFEN DS 3

SPRIX 3

VIVLODEX 3

ZIPSOR 3

Anti-Addiction / Substance Abuse Treatment Agents

BUNA9AIL E

buprenorphine hcl sublingual 1

buprenorphine hcl-naloxone hcl 1

CHANTI; 2 PA, H

CHANTI; C2NTINUIN* M2NTH

PA.2 PA, H

CHANTI; STARTIN* M2NTH

PA.2 PA, H

EVZIO 3

naloxone hcl injection solution 1

naloxone hcl injection solution

cartridge1


prefilled syringe1

11


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

naltrexone hcl oral 1

NARCAN 2

=UBS2L9 1

Antibacterials - Drugs for Infections

amoxicillin 1

amoxicillin-potassium clavulanate

er1

amoxicillin-potassium clavulanate

oral1

AUGMENTIN ORAL

SUSPENSION

REC2NSTITUTED

12�-31.2� M*/�ML

3

avidoxy 1

azithromycin oral 1

BACTRIM 3

BACTRIM DS 3

cefadroxil 1

cefdinir 1

cefuroxime axetil 1

CENTANY 3

CENTANY AT 3

cephalexin 1

CIPR2 2RAL TABLET 3

ciprofloxacin hcl oral 1

clarithromycin er 1

clarithromycin oral 1

CLE2CIN 2RAL CAPSULE

1�0 M*, 300 M*3


75 MG2

clindamycin hcl oral 1

CLINDESSE 2

coremino 1

DIFICID 3

D2RY; MPC 3

doxycycline hyclate oral 1

doxycycline monohydrate oral 1

FLA*YL 3

.EFLE; 3

LE9A4UIN 2RAL TABLET

500 MG, 750 MG3

levofloxacin oral 1

MACR2BID 3

MACR2DANTIN 3

metronidazole oral 1

metronida]ole vaginal 1

minocycline hcl er oral tablet

extended release 24 hour1

minocycline hcl oral 1

MINOLIRA 3

mondoxyne nl 1

morgidox oral 1

mupirocin calcium 1

mupirocin external 1

nitrofurantoin macrocrystal oral 1

nitrofurantoin monohydrate

macrocrystals1

NUVESSA 3

okebo 1

penicillin v potassium 1

S2L2DYN 3

sulfamethoxa]ole-trimethoprim

oral1

sulfatrim pediatric 1

TARGADOX 3

vanda]ole 1

9IBRAMYCIN 2RAL CAPSULE 3

12


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

9IBRAMYCIN 2RAL

SUSPENSION

REC2NSTITUTED

3

XEPI 3

XIMINO 3

ZITHROMAX ORAL 3

=ITHR2MA; TRI-PA. 3

=ITHR2MA; =-PA. 3

Anticoagulants - Drugs to Treat or Prevent Blood

Clots

BE9Y;;A 3

C2UMADIN 3

ELIQUIS 2

enoxaparin sodium 1

jantoven 1

PRADAXA 2

warfarin sodium oral 1

XARELTO 2

Anticonvulsants - Drugs for Seizures

carbamazepine er 1

carbamazepine oral 1

CARBATR2L 3

DEPA.2TE 3

DEPA.2TE ER 3

DEPA.2TE SPRIN.LES 3

divalproex sodium er 1

divalproex sodium oral 1

epitol 1

gabapentin oral 1

.EPPRA 2RAL 3

.EPPRA ;R 3

LAMICTAL 3

LAMICTAL 2DT 3

LAMICTAL STARTER 3

LAMICTAL ;R 3

lamotrigine er 1

lamotrigine oral 1

levetiracetam er 1

levetiracetam oral 1

NAY=ILAM SPRAY � M* 3

NEURONTIN 3

oxcarbazepine 1

OXTELLAR XR 3

4UDE;Y ;R 3

roweepra 1

roweepra xr 1

SPRITAM 3

subvenite 1

TEGRETOL 3

TE*RET2L-;R 3

TOPAMAX 3

T2PAMA; SPRIN.LE 3

topiramate er 1

topiramate oral 1

TRILEPTAL 3

TR2.ENDI ;R 3

9ALT2C2 3

VIMPAT ORAL 2

ZONEGRAN 3

zonisamide oral 1

13


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

Antidementia Agents - Drugs for Alzheimer's

Disease and Dementia

ARICEPT 2RAL TABLET 10 M*,

5 MG3

donepezil hcl 1

Antidepressants - Drugs for Depression

amitriptyline hcl oral 1

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet

extended release 24 hour

1�0 mg, 300 mg

1

BUPR2PI2N HCL ER �;L� 2RAL

TABLET E;TENDED RELEASE

24 HOUR 450 MG

3

bupropion hcl oral 1

citalopram hydrobromide 1

desvenlafaxine succinate er 1

doxepin hcl oral capsule 1

doxepin hcl oral concentrate 1

DRI=ALMA SPRIN.LE 3

duloxetine hcl oral 1

escitalopram oxalate 1

fluoxetine hcl oral 1

fluvoxamine maleate 1

fluvoxamine maleate er 1

F2RFI92 ;L 3

mirtazapine oral 1

nortriptyline hcl oral 1

PAMELOR 3

paroxetine hcl 1

paroxetine hcl er 1

PAXIL 3

PA;IL CR 3

REMERON 3

REMER2N S2LTAB 3

sertraline hcl oral 1

trazodone hcl oral 1

TRINTELLIX 3

venlafaxine hcl 1

venlafaxine hcl er 1

9IIBRYD 2

Antiemetics - Drugs for Nausea and Vomiting

B2N-ESTA 2

doxylamine-pyridoxine 1

metoclopramide hcl oral solution

5 mg/5ml1

metoclopramide hcl oral tablet 1

metoclopramide hcl oral tablet

dispersible1

ondansetron hcl oral 1

ondansetron odt 1

phenadoz 1

prochlorperazine maleate oral 1

promethazine hcl oral tablet 1

promethazine hcl rectal 1

promethegan 1

REGLAN 3

scopolamine 1

TRANSDERM SC2P �1.� M*� 3

TRANSDERM-SC2P �1.� M*� 3

9ARUBI �1�0 M* D2SE� 2

=2FRAN 3

ZUPLENZ 3

14


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

Antifungals - Drugs for Fungal Infections

ciclodan 1

ciclopirox 1

CRESEMBA 2RAL 3

DIFLUCAN 3

EXTINA 3

flucona]ole oral 1

*YNA=2LE-1 3

ketoconazole external 1

ketodan external foam 1

NIZORAL 3

nyamyc 1

nystatin external 1

nystatin mouth/throat 1

nystop 1

terbinafine hcl oral 1

terconazole 1

XOLEGEL 3

Antigout Agents - Drugs for Gout

allopurinol oral 1

C2LCHICINE 2RAL CAPSULE E

colchicine oral tablet E

C2LCRYS E

febuxostat 1

*L2PERBA 3 PA

MITIGARE 2

=YL2PRIM 3

Antimigraine Agents - Drugs for Migraines

AIMOVIG 2

AMERGE 3

eletriptan hydrobromide 1

EM*ALITY 2

naratriptan hcl 1

ONZETRA XSAIL 3

rizatriptan benzoate 1

sumatriptan succinate oral 1

sumatriptan succinate refill 1

sumatriptan succinate

subcutaneous1

=EMBRACE SYMT2UCH 3

Antineoplastics - Drugs for Cancer

anastrozole oral 1

bexarotene E SP

capecitabine E SP

ERLEADA 2 PA, SP

ERLEADA 2RAL TABLET �0 M* 2 PA, SP

IBRANCE 2RAL CAPSULE 2 PA, SP

IDHIFA 2 PA, SP

imatinib mesylate 1 PA, SP

letrozole oral 1

LYNPAR=A 2 PA, SP

mercaptopurine oral 1

NUBE4A 2 PA, SP

PURIXAN 3 PA, SP

REVLIMID 2 PA, SP

SOLTAMOX 3

tamoxifen citrate oral tablet 10 mg 1

tamoxifen citrate oral tablet 20 mg 1 H-PA

TARGRETIN EXTERNAL 3 SP

TARGRETIN ORAL 1 SP

TASIGNA 2 PA, ST, SP

VERZENIO 2 PA, SP

XELODA 1 SP

=E-ULA 2 SP

15


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

Antiparasitics - Drugs for Parasitic Infections

ARA.2DA 3

atovaTuone-proguanil hcl 1

ELIMITE 3

hydroxychloroTuine sulfate oral 1

.RINTAFEL 1

MALARONE 3

permethrin external 1

Antiparkinson Agents - Drugs for Parkinson's

Disease

carbidopa-levodopa 1

carbidopa-levodopa er 1

DUOPA 3

INBRI-A 3 PA, SP

MIRAPEX 3

N2URIAN= 2RAL TABLET 3

pramipexole dihydrochloride 1

pramipexole dihydrochloride er 1

ropinirole hcl 1

ropinirole hcl er 1

RYTARY 3

SINEMET 3

Antiplatelets - Drugs for Heart Attack and Stroke

Prevention

BRILINTA 2

clopidogrel bisulfate oral 1

=2NTI9ITY 3

Antipsychotics - Drugs for Mood Disorders

ABILIFY MYCITE E

aripiprazole 1

LATUDA 2

olanzapine oral 1

Tuetiapine fumarate 1

Tuetiapine fumarate er 1

risperidone 1

SAPHRIS 3

ziprasidone hcl 1

Antivirals - Drugs for Viral Infections

acyclovir oral 1

ATRIPLA E ST, SP

BARACLUDE 2RAL S2LUTI2N 2 SP

CIMDU2 2 SP

DESC29Y 3 ST, SP

DOVATO 2 SP

entecavir 1 SP

EPCLUSA 2 PA, SP

*EN92YA 3 SP

HARVONI 2 PA, SP, ST

ISENTRESS 2 SP

ISENTRESS HD 2 SP

-ULUCA 2 SP

LEDIPAS9IR-S2F2SBU9IR 2 PA, SP

LEDIP-S2F2SB 2RAL TABLET

�0-�00M*2 PA, SP

MA9YRET 2 PA, SP

N2R9IR 2RAL PAC.ET 2 SP

NORVIR ORAL SOLUTION 2 SP

2DEFSEY 3 SP

oseltamivir phosphate oral 1

PRE=C2BI; 2 SP

PREZISTA 2 SP

ritonavir 1 SP

SITAVIG 3

16


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

S2F2S/9ELPAT 2RAL TABLET

�00-1002 PA, SP

S2F2SBU9IR-9ELPATAS9IR 2 PA, SP

STRIBILD 3 SP

SYMFI 2 SP

SYMFI L2 2 SP

TEMI;YS 3 SP

tenofovir disoproxil fumarate 1 SP

TI9ICAY 3 SP

TRIUMEQ 2 SP

TRUVADA 3 H-PA, SP

valacyclovir hcl oral 1

9EMLIDY 3 ST, SP

VIREAD ORAL POWDER 3 SP

9IREAD 2RAL TABLET 1�0 M*,

200 MG, 250 MG2 SP

VOSEVI 2 PA, SP

;2FLU=A 3

ZEPATIER 2 PA, SP

ZOVIRAX ORAL SUSPENSION 3

Anxiolytics - Drugs for Anxiety

alprazolam er 1

alprazolam intensol 1

alprazolam oral 1

alprazolam xr 1

buspirone hcl oral 1

clonazepam oral 1

diazepam intensol 1

diazepam oral 1

HALCI2N 3

hydroxyzine hcl oral 1

hydroxyzine pamoate oral 1

lorazepam intensol 1

lorazepam oral concentrate

2 mg/ml1

lorazepam oral tablet 1

triazolam 1

VISTARIL 3

Bipolar Agents - Drugs for Mood Disorders

lithium carbonate er 1

lithium carbonate oral 1

LITH2BID 3

Cardiovascular Agents - Drugs for Heart and

Circulation Conditions

ACCUPRIL 3

acetazolamide er 1

acetazolamide oral 1

ADALAT CC 2RAL TABLET


60 MG

3

ALDACT2NE 3

aliskiren fumarate 1

ALTACE 3

ALTOPREV 3

amiodarone hcl oral 1

amlodipine besylate oral 1

amlodipine besylate-bena]epril

hcl1

amlodipine besylate-valsartan 1

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral tablet

10 mg, 20 mg1 H-PA


40 mg, 80 mg1

AVALIDE 3

AVAPRO 3

benazepril hcl oral 1

17


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

bena]epril-hydrochlorothia]ide 1

BIDIL 2

bisoprolol fumarate 1

bisoprolol-hydrochlorothia]ide 1

BYST2LIC 2

CALAN SR 3

CARDI=EM LA 2RAL TABLET


120 MG

E

CARDURA 3

CAR2SPIR 3

cartia xt 1

carvedilol 1

CATAPRES 3

chlorthalidone 1

clonidine hcl oral 1

colesevelam hcl E

C2RE* 3

C2R*ARD 3

C2RLAN2R 3

C2=AAR 3

diltiazem hcl er coated beads 1

diltiazem hcl er oral capsule

extended release 12 hour1

diltiazem hcl oral 1

dilt-xr 1

doxazosin mesylate oral 1

DYA=IDE 3

EDARBI 2

EDARBYCL2R 2

enalapril maleate oral 1

EPANED 3

E=ALL2R SPRIN.LE 3

ezetimibe 1

e]etimibe-simvastatin 1

fenofibrate oral capsule 1�0 mg,

50 mg1

fenofibrate oral tablet 1

flecainide acetate 1

FL2LIPID 3

furosemide oral 1

gemfibro]il oral 1

GONITRO 3

guanfacine hcl 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral 1

HY=AAR 3

irbesartan 1

irbesartan-hydrochlorothia]ide 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

.APSPAR*2 SPRIN.LE 3

labetalol hcl oral 1

LASIX 3

LIP2FEN 3

lisinopril oral 1

lisinopril-hydrochlorothia]ide 1

LOPID 3

LOPRESSOR 3

losartan potassium 1

losartan potassium-hct] 1

LOTENSIN 3

L2TENSIN HCT 3

LOTREL 3

18


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

lovastatin 1 H

matzim la 1

MAXZIDE 3

MA;=IDE-2� 3

metoprolol succinate er 1

metoprolol tartrate oral 1

MINIPRESS 3

minitran 1

MULTAQ 3

nadolol oral 1

niacin (antihyperlipidemic) 1

niacin er (antihyperlipidemic) 1

niacor 1

NIASPAN 3

nifedipine er 1

nifedipine er osmotic release 1

nifedipine oral 1

NITR2-BID 2

NITR2-DUR 3

nitroglycerin sublingual 1

nitroglycerin transdermal 1

nitroglycerin translingual 1

NITROMIST 3

NITROSTAT 3

nitro-time 1

olmesartan medoxomil oral 1

olmesartan medoxomil-hct] 1

omega-3-acid ethyl esters 1

PACER2NE 2RAL TABLET

100 MG, 400 MG3

pacerone oral tablet 200 mg 1

PRALUENT 2 PA, ST

PRA9ACH2L 3

pravastatin sodium 1

prazosin hcl oral 1

PRINIVIL 3

PR2CARDIA 3

PR2CARDIA ;L 3

propranolol hcl er 1

propranolol hcl oral 1

4BRELIS 3

Tuinapril hcl 1

ramipril 1

ranolazine er 1

REPATHA 2 PA, ST

rosuvastatin calcium 1

simvastatin oral tablet 10 mg,

20 mg, 40 mg, 5 mg1 H-PA

simvastatin oral tablet �0 mg 1

sotalol hcl oral 1

S2TYLI=E 3

spironolactone oral 1

TE.TURNA 3

TE.TURNA HCT 3

telmisartan 1

TOPROL XL 3

torsemide 1

triamterene-hct] 1

valsartan 1

valsartan-hydrochlorothia]ide 1

9ASCEPA 2

verapamil hcl er 1

verapamil hcl oral 1

VERELAN 3

19


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

VERELAN PM 3

:ELCH2L 1

=IAC 3

=2C2R 2RAL TABLET 10 M*,

20 MG, 40 MG, 80 MG3

Central Nervous System Agents - Drugs for

Attention Deficit Disorder

ADDERALL XR 1

ADHANSIA XR 3

amphetamine-

dextroamphetamine1

amphetamine-

dextroamphetamine erE

APTENSIO XR 3

atomoxetine hcl 1

C2NCERTA 1

dexmethylphenidate hcl 1

dexmethylphenidate hcl er 1

dextroamphetamine sulfate 1

dextroamphetamine sulfate er 1

F2CALIN 3

guanfacine hcl er 1

-2RNAY PM 3

metadate er 1

METHYLIN 3

methylphenidate hcl er (cd) 1

methylphenidate hcl er (la) 1

methylphenidate hcl er oral tablet

extended release 10 mg, 20 mg1


extended release 18 mg, 27 mg,

3� mg, �� mg, �2 mg

E


extended release 24 hourE

methylphenidate hcl oral 1

MYDAYIS 2

PR2CENTRA 3

4UILLICHE: ER 3

QUILLIVANT XR 3

relexxii E

RITALIN 3

9Y9ANSE 2

=EN=EDI 2RAL TABLET 1� M*,

2.� M*, 20 M*, 30 M*, �.� M*E

Central Nervous System Agents - Drugs for Multiple

Sclerosis

AUBA*I2 3 PA, SP

AVONEX PEN 2 PA, SP

A92NE; PREFILLED 2 PA, SP

BETASER2N 2 PA, SP

dalfampridine er 1 PA, SP

EXTAVIA E PA, ST, SP

*ILENYA 2RAL CAPSULE

0.25 MG3 PA, SP


0.5 MG3 PA, SP

glatiramer acetate 1 PA, SP

glatopa 1 PA, SP

MA9ENCLAD 3 PA, ST, SP

MAY=ENT 3 PA, SP

PLE*RIDY 3 PA, SP

REBIF 3 PA, ST, SP

REBIF REBID2SE 3 PA, ST, SP

TECFIDERA 2 PA, SP

Central Nervous System Agents - Miscellaneous

AUSTEDO 2 PA, SP

LYRICA 3

LYRICA CR 2

NUEDEXTA 2

20


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

pregabalin oral 1

RILUTE. 3 SP

riluzole 1 SP

TI*LUTI. 3 PA

Dental and Oral Agents - Drugs for Mouth and

Throat Conditions

cavarest 1

chlorhexidine gluconate mouth/

throat1

clinpro 5000 1

denta 5000 plus 1

dentagel 1

fluoridex 1

fluoridex enhanced whitening 1

lidocaine hcl mouth/throat 1

lidocaine viscous hcl 1

NAFRINSE DAILY/NEUTRAL 2

NAFRINSE :EE.LY 3

neutral sodium fluoride 1

paroex 1

PERIDEX 3

periogard 1

PREVIDENT 3

PRE9IDENT �000 B22STER

PLUS3

PRE9IDENT �000 DRY M2UTH 3

PREVIDENT 5000 ORTHO

DEFENSE3

PREVIDENT 5000 PLUS 3

sf 1

sf 5000 plus 1

sodium fluoride �000 plus 1

sodium fluoride dental 1

Dermatological Agents - Drugs for Skin Conditions

ABS2RICA 3

AC=2NE E;TERNAL *EL � � 1

AC=2NE E;TERNAL *EL �.� � 2

ALA SCALP 3

ala-cort external cream 1 � E

ala-cort external cream 2.� � 1

ALDARA 3

ALTRENO 3 PA

amnesteem 1

AMZEEQ AER 4% 3

avita 1 PA

azelaic acid external 1

betamethasone dipropionate aug 1

betamethasone dipropionate

external1

bp 10-1 1

calcipotriene-betameth diprop

external ointment1

calcitriol external 1

CAPE; 2

CARAC 2

claravis 1

CLE2CIN-T 3

clindacin etz external swab 1

clindacin-p 1

CLINDA*EL 3

clindamycin phos-ben]oyl perox

external gel 1.2-� �1

clindamycin phosphate external

foam1


lotion1

21


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits


solution1


swab1

CLINDAMYCIN PH2SPHATE

GEL 1 % EXTERNAL3

clindamycin phosphate gel 1 %

external1

clobetasol propionate external 1

clodan external shampoo 1

clotrima]ole-betamethasone 1

dapsone external gel 5 % E

DERMA-SM22THE/FS B2DY 3

DERMA-SM22THE/FS SCALP 3

DESONATE 3

desonide external 1

DESOWEN 3

DIPROLENE 3

DIPR2LENE AF 3

DUPIXENT 3 PA, ST, SP

EFUDE; 3

ENSTILAR 3

EUCRISA 3 ST

E92CLIN 3

FINACEA E;TERNAL *EL 3

fluocinolone acetonide body 1

fluocinolone acetonide external 1

fluocinolone acetonide scalp 1

fluocinonide external 1

FLU2R2PLE; 3

FLU2R2URACIL E;TERNAL

CREAM 0.� �3

fluorouracil external cream � � 1

fluorouracil external solution 1

hydrocortisone external cream

1 %E


2.5 %1

hydrocortisone external lotion

2.5 %1

hydrocortisone external ointment

1 %, 2.5 %1

imiTuimod external 1

IMIQUIMOD PUMP 3

IMP2Y= 3

isotretinoin oral 1

METR2CREAM 3

METROLOTION 3

metronidazole external 1

MIRVASO 3

mometasone furoate external 1

myorisan 1

neuac external gel 1

NORITATE 3

PICAT2 3

RH2FADE CREAM 1� 3

rosadan external cream 1

rosadan external gel 1

SERNIVO 3

S22LANTRA CREAM 1� 3

sss 10-� 1

sulfacetamide sodium-sulfur 1

sulfamez wash 1

SYNALAR 3

TACL2NE; E;TERNAL

SUSPENSION3

tazarotene external 1 PA

22


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

TA=2RAC E;TERNAL CREAM

0.1 %3 PA

TA=2RAC E;TERNAL *EL 2 PA

TEMOVATE 3

TE;AC2RT 2

T2LA. 3

tretinoin external 1 PA

triamcinolone acetonide external 1

trianex 1

triderm 1

TRIDESILON 1

VERDESO 3

zenatane 1

=YCLARA 3

=YCLARA PUMP 3

Diabetes - Glucose Monitoring

ACCU-CHE. A9I9A C2NNECT

.IT :/DE9ICEE

ACCU-CHE. A9I9A DE9ICE E

ACCU-CHE. A9I9A PLUS .IT

:/DE9ICEE

ACCU-CHE. C2MPACT PLUS

CARE .ITE


TEST STRIPSE

ACCU-CHE. *UIDE .IT

:/DE9ICEE

ACCU-CHE. NAN2

SMART9IE: .IT :/DE9ICEE

ACCU-CHE. SMART9IE:

TEST STRIPSE

ACCU-CHE. S2FTCLI;

LANCET DE9ICE .IT1

BD AUT2SHIELD DU2 PEN

NEEDLES2

BD ULTRA-FINE INSULIN

SYRIN*ES2

BD ULTRA-FINE PEN NEEDLES 2

C2NT2UR NE;T M2NIT2R 2

C2NT2UR NE;T TEST 2

C2NT2UR TEST E

DE;C2M *� / *� / *�

RECEI9ER, TRANSMITTER,

SENS2R �INCLUDIN*

PLATINUM, PLATINUM

PEDIATRIC�

3

DE;C2M *� / *� / *�

RECEI9ER, TRANSMITTER,

SENS2R �INCLUDIN*

PLATINUM, PLATINUM

PEDIATRIC� DE9ICE

3

FREESTYLE LIBRE 1� DAY

READER3


SENSOR3

FREESTYLE LIBRE READER 3

FREESTYLE LIBRE SENS2R

SYSTEM3

INSULIN SYRIN*ES 2

LANCETS 3

N292FINE AUT2C29ER PEN

NEEDLE2

N292FINE PEN NEEDLE 2

N292FINE PLUS PEN NEEDLE 2

2NET2UCH ULTRA 2 .IT

:/DE9ICE1

2NET2UCH ULTRA BLUE TEST

STRIPS IN VITRO STRIP1

2NET2UCH ULTRA MINI .IT

:/DE9ICE1

2NET2UCH 9ERI2 FLE;

SYSTEM .IT :/DE9ICE1

2NET2UCH 9ERI2 I4 SYSTEM 1

2NET2UCH 9ERI2 .IT

:/DE9ICE1

2NET2UCH 9ERI2 SYNC

SYSTEM .IT :/DE9ICE1

2NET2UCH 9ERI2 TEST

STRIPS1

23


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

S2FTCLI; 1

Diabetes - Insulin

ADMELOG E

ADMELOG SOLOSTAR E

AFRE==A 3

BASA*LAR .:I.PEN E

HUMAL2* .:I.PEN 2

HUMAL2* MI; �0/�0 .:I.PEN 2

HUMALOG MIX 50/50 VIAL 1

HUMAL2* MI; ��/2� .:I.PEN 2

HUMALOG MIX 75/25 VIAL 1

HUMAL2* SUBCUTANE2US

SOLUTION1


S2LUTI2N CARTRID*E2

HUMAL2* U-100 -UNI2R

.:I.PEN2

HUMULIN �0/30 .:I.PEN 2

HUMULIN �0/30 9IAL 1

HUMULIN N .:I.PEN 2

HUMULIN N VIAL 1

HUMULIN R U-�00 .:I.PEN 2

HUMULIN R U-�00 9IAL

�C2NCENTRATED�1

HUMULIN R VIAL 1

INSULIN ASPART E

INSULIN ASPART FLE;PEN E ST

INSULIN ASPART PENFILL E ST

INSULIN LISPRO E

INSULIN LISPRO (1 UNIT DIAL) E

LANTUS SOLOSTAR 1

LANTUS U-100 9IAL 1

LE9EMIR U-100 FLE;T2UCH E

LE9EMIR U-100 9IAL E

N292LIN �0/30 FLE;PEN E

N292LIN �0/30 FLE;PEN

RELIONE

N292LIN �0/30 RELI2N E

N292LIN �0/30 9IAL E

N292LIN N FLE;PEN E

N292LIN N FLE;PEN RELI2N E

NOVOLIN N RELION E

NOVOLIN N VIAL E

N292LIN R FLE;PEN E

N292LIN R FLE;PEN RELI2N E

NOVOLIN R RELION E

NOVOLIN R VIAL E

N292L2* FLE;PEN E ST

N292L2* PENFILL E ST

N292L2* U-100 9IAL E

T2U-E2 MA; S2L2STAR E

T2U-E2 S2L2STAR 2

TRESIBA E

TRESIBA FLE;T2UCH E

Diabetes - Non-Insulin Agents

ADLY;IN 3

AL2*LIPTIN BEN=2ATE E

AL2*LIPTIN-METF2RMIN HCL E

AL2*LIPTIN-PI2*LITA=2NE E

AMARYL 3

BA4SIMI 2

BYDURE2N 2

BYDURE2N BCISE

AUT2IN-ECT2R2

BYETTA PEN 2

FAR;I*A E ST

24


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

*LUCA*2N EMER*ENCY .IT

IN-ECTI2N .IT2

*LUC2TR2L 3

*LUC2TR2L ;L 3

*LUC29ANCE 2RAL TABLET

�-�00 M*3

GLUMETZA 3

glyburide oral 1

glyburide-metformin 1

*LY;AMBI 2 ST

*92.E PFS 2

IN92.ANA E ST

-ANU9IA E ST

-ARDIANCE 2

-ENTADUET2 2

-ENTADUET2 ;R 2

.A=AN2 2

.2MBI*LY=E ;R 2

metformin hcl er 1

metformin hcl er (mod) 1

metformin hcl er (osm) 1

METF2RMIN HCL 2RAL

SOLUTION3

metformin hcl oral tablet 1

NESINA 2

2N*LY=A 2

OSENI 2

2=EMPIC 2

pioglitazone hcl 1

RIOMET 3

RYBELSUS 2

SOLIQUA 2

SYN-ARDY 2

SYN-ARDY ;R 2

TRAD-ENTA 2

TRULICITY 2

9ICT2=A S2LUTI2N PEN-

IN-ECT2R 1� M*/3ML

SUBCUTANE2US

2 (2 Pak)



SUBCUTANE2US

3 �3 Pak�

Drugs for Blood Disorders

AFSTYLA INTRA9EN2US .IT

1000 UNIT, 2000 UNIT, 250 UNIT,

3000 UNIT, �00 UNIT

3 PA


1500 UNIT, 2500 UNIT3 PA, SP

ARANESP �ALBUMIN FREE� 2 SP

EL2CTATE 3 PA, SP

-I9I 3 PA, SP

.2*ENATE FS 2 SP

.29ALTRY 2 PA, ST, SP

MULPLETA 2 PA, SP

NOVOEIGHT 2 SP

NUWIQ 2 SP

REC2MBINATE 3 PA, ST, SP

RETACRIT 2 SP

ZARXIO 2 SP

Drugs for Sexual Dysfunction

ADDYI 3

IM9E;;Y 3

INTRAROSA 2

25


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

OSPHENA 2

sildenafil citrate oral tablet

100 mg, 25 mg, 50 mg1 QL

STENDRA 2 QL

tadalafil oral 1 QL

9YLEESI 3

Electrolytes / Vitamins

DRISDOL 3

ER*2CAL 3

ergocalciferol oral capsule 1

FL2RI9A PLUS 3

folic acid oral tablet 1 mg 1

klor-con 1

klor-con 10 1

klor-con m10 1

.L2R-C2N M1� 3

klor-con m20 1

klor-con sprinkle 1

.-TAB 3

L2.ELMA 3

multi-vitamin/fluoride 1

multivitamin/fluoride oral solution 1

multivitamin/fluoride oral tablet

chewable 0.25 mg, 0.5 mg, 1 mg1

multivitamins/fluoride 1

mvc-fluoride 1

NASC2BAL 3

P2LY-9I-FL2R 3

potassium chloride crys er 1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1

4UFL2RA PEDIATRIC 3

UR2CIT-. 10 3

UR2CIT-. 1� 3

UR2CIT-. � 3

VELTASSA 3

vitamin d �ergocalciferol� oral

capsule 1.25 mg (50000 ut)1

Gastrointestinal Agents - Drugs for Acid Reflux and

Ulcer

ACIPHE; SPRIN.LE 3

CARAFATE 3

CYT2TEC 3

DEXILANT 2

misoprostol oral 1

2MECLAM2;-PA. 3

omeprazole oral capsule delayed

release1

pantoprazole sodium tablet

delayed release1

PR2T2NI; 2RAL PAC.ET 3

PYLERA 3

RABEPRA=2LE S2DIUM 2RAL

CAPSULE SPRIN.LE3

rabeprazole sodium oral tablet

delayed release1

sucralfate oral 1

Gastrointestinal Agents - Drugs for Bowel, Intestine

and Stomach Conditions

ACTI*ALL 3

ANASPAZ 2

CLENPI4 2

dicyclomine hcl oral 1

diphenoxylate-atropine 1

ed-spa] 1

gavilyte-c 1 H

26


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

gavilyte-g 1 H

*2LYTELY 2RAL S2LUTI2N

REC2NSTITUTED 22�.1 *M2


REC2NSTITUTED 23� *M3

hyoscyamine sulfate er 1

hyoscyamine sulfate oral 1

hyoscyamine sulfate sublingual 1

hyosyne 1

LE9BID 3

LEVSIN ORAL 3

LEVSIN/SL 3

LINZESS 2

LOMOTIL 3

M2TE*RITY 3 PA

MOVIPREP 2

NULEV 3

oscimin 1

oscimin sr 1

peg-33�0/electrolytes 1 H

PLENVU 2

PREP2PI. 2

SUPREP B2:EL PREP .IT 2

SYMA; DU2TAB 3

symax-sl 1

symax-sr 1

SYMPR2IC 2 PA

URSO 250 3

URS2 F2RTE 3

ursodiol oral 1

9IBER=I 3

ZELNORM 3

Genetic or Enzyme Disorder - D

Replacement, Modification, Tre

rugs f

atment

or

CERDEL*A 2 PA, SP

cloviTue E PA, SP

CRE2N 2

CUPRIMINE 3 SP

DEPEN TITRATABS 2 SP

ENDARI 3

nitisinone E PA, SP

NITYR 2 PA, SP

2RFADIN 2RAL CAPSULE

20 MGE PA, SP

2RFADIN 2RAL SUSPENSI2N E PA, SP

PANCREA=E 3 ST

penicillamine oral capsule 1 SP

PERT=YE 3 ST

STRENSIQ 2 PA, SP

SYPRINE 1 PA, SP

TEGSEDI 2 PA, SP

trientine hcl E PA, SP

9I2.ACE 3 ST

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital

and Kidney Conditions

AURY;IA 3

DITROPAN XL 3

GELNIQUE 3

oxybutynin chloride er 1

oxybutynin chloride oral 1

phenazo oral tablet 200 mg 1

phenazopyridine hcl oral tablet

100 mg, 200 mg1

27


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

PYRIDIUM 3

TOVIAZ 2

VELPHORO 2

Genitourinary Agents - Drugs for Prostate

Conditions

alfuzosin hcl er 1

finasteride oral tablet � mg 1

PR2SCAR 3

tamsulosin hcl 1

terazosin hcl 1

UROXATRAL 3

Hormonal Agents - Hormone Replacement and Birth

Control

afirmelle 1 H

AL2RA TRANSDERMAL PATCH

T:ICE :EE.LY

0.025 MG/24HR,

0.075 MG/24HR, 0.1 MG/24HR

3

altavera 1 H

alyacen 1/3� 1 H

amethia 1 H

amethia lo 1 H

apri 1 H

ashlyna 1 H

aubra 1 H

aubra eT 1 H

aurovela 1.�/30 1 H

aurovela 1/20 1 H

aurovela 2� fe 1 H

aurovela fe 1.�/30 1 H

aurovela fe 1/20 1 H

aviane 1 H

AY*ESTIN 3

ayuna 1 H

azurette 1 H

bal]iva 1 H

bekyree 1 H

BI-U9A 3

blisovi 2� fe 1 H

blisovi fe 1.�/30 1 H

blisovi fe 1/20 1 H

briellyn 1 H

camila 1 H

camrese 1 H

camrese lo 1 H

chateal 1 H

chateal eT 1 H

CLIMARA PR2 2

cryselle-2� 1 H

cyclafem 1/3� 1 H

cyred 1 H

cyred eT 1 H

dasetta 1/3� 1 H

daysee 1 H

deblitane 1 H

delyla 1 H

DEP2-PR29ERA

INTRAMUSCULAR

SUSPENSION 150 MG/ML

3

DEP2-PR29ERA

INTRAMUSCULAR

SUSPENSI2N PREFILLED

SYRIN*E

3

DEP2-SUB4 PR29ERA 10� 2

desogestrel-ethinyl estradiol 1 H

28


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

DIVIGEL TRANSDERMAL GEL

0.25 MG/0.25GM, 0.5 MG/0.5GM,

0.75 MG/0.75GM, 1 MG/GM,

1.25 MG/1.25GM

2

dotti E

drospiren-eth estrad-levomefol 1

drospirenone-ethinyl estradiol 1 H

DUAVEE 3

ELESTRIN 3

elinest 1 H

eluryng E

emoTuette 1 H

enskyce 1 H

errin 1 H

estarylla 1 H

ESTRACE 2RAL 3

ESTRACE 9A*INAL 1

estradiol oral 1

estradiol patch twice weekly

transdermal �generic for Minivelle�1


transdermal (generic for

9ivelle-Dot�

E QL

estradiol transdermal patch

weekly �generic for Climara�1 QL

estradiol vaginal cream E

estradiol vaginal tablet 1

ESTRING 2

ESTROGEL 3

etonogestrel-ethinyl estradiol E

EVAMIST 2

falmina 1 H

fayosim 1

femynor 1 H

gianvi 1 H

hailey 1.�/30 1 H

hailey 24 fe 1 H

heather 1 H

incassia 1 H

introvale 1 H

isibloom 1 H

jasmiel 1 H

jencycla 1 H

jolessa 1 H

juleber 1 H

junel 1.�/30 1 H

junel 1/20 1 H

junel fe 1.�/30 1 H

junel fe 1/20 1 H

junel fe 24 1 H

kalliga 1 H

kariva 1 H

kurvelo 1 H

larin 1.�/30 1 H

larin 1/20 1 H

larin 24 fe 1 H

larin fe 1.�/30 1 H

larin fe 1/20 1 H

larissia 1 H

lessina 1 H

levonorgest-eth est eth est 1

levonorgest-eth estrad �1-day 1 H

levonorgestrel-ethinyl estrad oral

tablet 0.1-20 mg-mcg,

0.1�-30 mg-mcg

1 H

29


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

levora 0.1�/30 �2�� 1 H

lillow 1 H

L2 L2ESTRIN FE 2

L2ESTRIN 1.�/30 �21� 3

LOESTRIN 1/20 (21) 3

L2ESTRIN FE 1.�/30 3

L2ESTRIN FE 1/20 3

loryna 1 H

LOSEASONIQUE 3

low-ogestrel 1 H

lo-]umandimine 1 H

lutera 1 H

lyza 1 H

marlissa 1 H

medroxyprogesterone acetate

intramuscular1 H


oral1

melodetta 24 fe 1

MENOSTAR 3

mibelas 24 fe 1

microgestin 1.�/30 1 H

microgestin 1/20 1 H

microgestin fe 1.�/30 1 H

microgestin fe 1/20 1 H

mili 1 H

MIRCETTE 3

mono-linyah 1 H

NATAZIA 2

necon 0.�/3� �2�� 1 H

nikki 1 H

nora-be 1 H

norethin ace-eth estrad-fe oral

tablet1 H


tablet chewable1

norethindrone acetate oral 1

norethindrone acet-ethinyl est 1 H

norethindrone oral 1 H

norgestimate-eth estradiol 1 H

norgestimate-ethinyl estradiol

triphasic1 H

norlyda 1 H

norlyroc 1 H

nortrel 0.�/3� �2�� 1 H

nortrel 1/3� �21� 1 H

nortrel 1/3� �2�� 1 H

NUVARING 1 H

ocella 1 H

ogestrel 1 H

orsythia 1 H

2RTH2 MICR2N2R 3

philith 1 H

pimtrea 1 H

pirmella 1/3� 1 H

portia-2� 1 H

PREMARIN ORAL 2

PREMARIN VAGINAL 3

PREMPHASE 2

PREMPRO 2

previfem 1 H

progesterone micronized oral 1

PROVERA 3

reclipsen 1 H

30


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

rivelsa 1

SEASONIQUE 3

setlakin 1 H

sharobel 1 H

simliya 1 H

simpesse 1 H

sprintec 28 1 H

sronyx 1 H

syeda 1 H

tarina 24 fe 1 H

tarina fe 1/20 1 H

tarina fe 1/20 eT 1 H

TAYTULLA 3

tri femynor 1 H

tri-estarylla 1 H

tri-linyah 1 H

tri-lo-estarylla 1 H

tri-lo-mili 1 H

tri-lo-sprintec 1 H

tri-mili 1 H

tri-previfem 1 H

tri-sprintec 1 H

tri-vylibra 1 H

tri-vylibra lo 1 H

tulana 1 H

tydemy 1

vienva 1 H

viorele 1 H

9I9ELLE-D2T 1

vyfemla 1 H

vylibra 1 H

wera 1 H

xulane 1 H

YASMIN 2� 3

YA= 3

yuvafem 1

zarah 1 H

zumandimine 1 H

Hormonal Agents - Oral Steroids

C2RTEF 3

dexamethasone intensol 1

dexamethasone oral 1

hydrocortisone oral 1

MEDR2L 2RAL TABLET 1� M*,

32 M*, � M*, � M*3

MEDR2L 2RAL TABLET 2 M* 2

methylprednisolone oral 1

MILLIPRED 2

ORAPRED ODT 3

PEDIAPRED 2

prednisolone oral solution 1

prednisolone sodium phosphate

oral1

prednisone intensol 1

prednisone oral 1

RAY2S 3

Hormonal Agents - Other

cabergoline 1

DDA9P IN-ECTI2N 3

DDAVP ORAL 3

desmopressin acetate injection 1

desmopressin acetate oral 1

GENOTROPIN E PA, SP

31


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

*EN2TR2PIN MINI4UIC. E PA, SP

HUMATROPE E PA, SP

N2CDURNA 3

N2RDITR2PIN FLE;PR2 E PA, SP

NUTROPIN AQ NUSPIN 10 2 PA, SP



OMNITROPE E PA, SP

ORILISSA 3

STIMATE 3

=2MACT2N E PA, SP

Hormonal Agents - Testosterone Replacement

ANDRODERM 2

DEP2-TEST2STER2NE 3

NATESTO E

STRIANT 3

TESTIM 1

TEST2STER2NE CYPI2NATE

IN-ECTI2N3

testosterone cypionate

intramuscular1

testosterone enanthate

intramuscular1

testosterone transdermal E

;Y2STED 3

Hormonal Agents - Thyroid

ARM2UR THYR2ID 2

euthyrox 1

levo-t 1

levothyroxine sodium oral 1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THR2ID 2RAL

TABLET 113.�� M*, 130 M*,

146.25 MG, 16.25 MG, 162.5 MG,

1�� M*, 2�0 M*, 32.� M*,

32� M*, ��.�� M*, �� M*,

81.25 MG

2

NATURE-THR2ID TABLET

97.5 MG ORAL3


97.5 MG ORAL2

np thyroid 1

SYNTHR2ID E

TAPAZOLE 3

thyroid oral tablet 120 mg, 15 mg,

30 mg, �0 mg, �0 mg1

TIROSINT 3

TIR2SINT-S2L 3

unithroid 1

WESTHROID 3

:P THYR2ID 3

Immunological Agents - Drugs for Immune System

Stimulation or Suppression

ACTEMRA 3 PA, ST, SP

ASTA*RAF ;L 3 SP

AZASAN 3

azathioprine oral 1

CIM=IA 2 PA, SP

C2SENTY; 3 PA, ST, SP

cyclosporine modified 1 SP

ENBREL 3 PA, ST, SP

ENVARSUS XR 3 SP

FIRA=YR 1 PA, SP

gengraf 1 SP

HAEGARDA 2 PA, SP

HUMIRA 2 PA, SP

32


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

icatibant acetate E PA, SP

methotrexate oral 1

methotrexate sodium oral 1

mycophenolate mofetil 1 SP

mycophenolate sodium 1 SP

OLUMIANT 2 PA, SP

OTEZLA 2 PA, SP

2TRE;UP SUBCUTANE2US

S2LUTI2N AUT2-IN-ECT2R

10 MG/0.4ML, 12.5 MG/0.4ML,

15 MG/0.4ML, 17.5 MG/0.4ML,

22.5 MG/0.4ML, 25 MG/0.4ML

3



20 MG/0.4ML

E

PR2*RAF 2RAL PAC.ET 3 SP

RAPAMUNE ORAL SOLUTION 3 SP

RASUVO 2

RINVOQ 2 PA, SP

RUC2NEST 3 PA, SP

SIMPONI 2 PA, SP

sirolimus oral 1 SP

S.YRI=I �1�0 M* D2SE� 2 PA, SP

STELARA 2 PA, SP

tacrolimus oral 1 SP

TA.H=YR2 2 PA, SP

TREMFYA 2 PA, SP

TREXALL 2

;EL-AN= 2 PA, ST, SP

;EL-AN= ;R 2RAL TABLET


11 MG

2 PA, ST, SP

Infertility Agents

chorionic gonadotropin

intramuscular1 SP

CRIN2NE 9A*INAL *EL � � 3 PA, ST

CRIN2NE 9A*INAL *EL � � 3 PA, ST

ENDOMETRIN 2 PA

F2LLISTIM A4 2 SP

ganirelix acetate solution

prefilled syringe 2�0 mcg/0.�ml

subcutaneous

4 �Ferring�, SP



subcutaneous

2(Merck/

Organon), SP

novarel intramuscular solution

reconstituted 10000 unit3 SP

N29AREL INTRAMUSCULAR

S2LUTI2N REC2NSTITUTED

5000 UNIT

3 SP

pregnyl 1 SP

Inflammatory Bowel Disease Agents

ANALPRAM HC 3

ANALPRAM HC SIN*LES 3

ANALPRAM-HC 3

APRISO 1

A=ULFIDINE 3

A=ULFIDINE EN-TABS 3

budesonide er E

budesonide oral 1

C2RTIF2AM 2

DIPENTUM 3

hydrocortisone ace-pramoxine

external cream 1-1 �1

hydrocort-pramoxine �perianal� 1

LIALDA 1

mesalamine er E

33


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

mesalamine oral E

mesalamine rectal 1

PENTASA E

PR2C2RT 3

PR2CT2F2AM HC 2

SFR2:ASA 3

sulfasalazine oral tablet 1

UCERIS 2RAL 1

UCERIS RECTAL 2

Metabolic Bone Disease Agents - Drugs for

Osteoporosis

alendronate sodium 1

B2NI9A 2RAL 3

F2RTE2 3 PA, SP

F2SAMA; 3

ibandronate sodium oral 1

TYML2S 3 SP

Metabolic Bone Disease Agents - Other

calcitriol oral 1

R2CALTR2L 3

Ophthalmic Agents - Drugs for Eye Allergy, Infection

and Inflammation

ACULAR 3

ACULAR LS 3

ACU9AIL 3

ALREX 3

AZASITE 3

azelastine hcl ophthalmic 1

BESI9ANCE 3

CIL2;AN 3

ciprofloxacin hcl ophthalmic 1

erythromycin ophthalmic 1

ILEVRO 3

IN9ELTYS 3

ketorolac tromethamine

ophthalmic1

LASTACAFT 3

LOTEMAX 3

LOTEMAX SM 3

loteprednol etabonate 1

MAXITROL 3

MOXEZA 3

moxifloxacin hcl ophthalmic 1

neomycin-polymyxin-dexameth

ophthalmic ointment1


ophthalmic suspension

3.�-10000-0.1

1

NE9ANAC 3

2CUFL2; 3

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic 1

PAZEO 3

polymyxin b-trimethoprim 1

P2LYTRIM 3

PRED F2RTE 3

PRED MILD 3

prednisolone acetate ophthalmic 1

T2BRADE; 3

T2BRADE; ST 3

tobramycin ophthalmic 1

tobramycin-dexamethasone 1

T2BRE; 3

3�


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

Ophthalmic Agents - Drugs for Glaucoma

ALPHA*AN P 2PHTHALMIC

SOLUTION 0.1 %2


SOLUTION 0.15 %3

AZOPT 2

BETIM2L 2

bimatoprost ophthalmic 1

brimonidine tartrate ophthalmic 1

C2MBI*AN 2

C2S2PT 3

dor]olamide hcl-timolol mal 1

dor]olamide hcl-timolol mal pf 1

ISTALOL 3

latanoprost ophthalmic 1

LUMIGAN 2

RHOPRESSA 3

R2C.LATAN 3

timolol maleate ophthalmic 1

TIM2PTIC 3

TIM2PTIC 2CUD2SE 2

TIM2PTIC-;E 3

TRAVATAN Z 3

travoprost �bak free� 1

9Y=ULTA 3

XELPROS 3

Ophthalmic Agents - Drugs for Miscellaneous Eye

Conditions

CE4UA E

RESTASIS 2

RESTASIS MULTIDOSE 3

XIIDRA 2

Otic Agents - Drugs for Ear Conditions

CIPR2DE; 3

neomycin-polymyxin-hc otic 1

ofloxacin otic 1

Respiratory - Drugs for Anaphylaxis

AU9I-4 3

epinephrine solution auto-injector

0.1� mg/0.3ml injection �generic

EpiPen -r.�

1


0.3 mg/0.3ml injection �generic

EpiPen)

1

SYM-EPI 2

Respiratory Tract / Pulmonary Agents - Drugs for

Allergies, Cough, Cold

azelastine hcl nasal 1

benzonatate 1

bromfed dm 1

cyproheptadine hcl oral 1

fluticasone propionate nasal 1

hydrocodone polst-cpm polst er 1 PA

ipratropium bromide nasal 1

levocetiri]ine dihydrochloride oral 1

OMNARIS 3

prometha]ine-codeine 1 PA

prometha]ine-dm 1

pseudoephedrine-bromphen-dm 1

TESSALON PERLES 3

TUSSICAPS 3

;HANCE 3

ZETONNA 3

3�


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits


Asthma and COPD

AD9AIR DIS.US 1

AD9AIR HFA 2 RS

AIRDU2 RESPICLIC. E

albuterol sulfate er 1

albuterol sulfate hfa aerosol

solution 108 (90 base) mcg/act

inhalation �generic ProAir HFA�

1

ALBUTER2L SULFATE HFA

AEROSOL SOLUTION 108 (90

BASE� MC*/ACT INHALATI2N

�Proventil HFA�

3

ALBUTER2L SULFATE HFA

AEROSOL SOLUTION 108 (90

BASE� MC*/ACT INHALATI2N

�9entolin HFA�

3

albuterol sulfate inhalation 1

albuterol sulfate oral 1

AL9ESC2 E

ANORO ELLIPTA 3

ARCAPTA NE2HALER 3

ARNUITY ELLIPTA 1

ASMANEX E

ATR29ENT HFA 2

BE9ESPI AER2SPHERE 2

BRE2 ELLIPTA 2 RS

budesonide inhalation 1

C2MBI9ENT RESPIMAT 2

FASENRA PEN 3 PA

FL29ENT DIS.US 1

FL29ENT HFA 1

fluticasone-salmeterol inhalation

aerosol powder breath activated

100-�0 mcg/dose, 2�0-�0 mcg/

dose, �00-�0 mcg/dose

E

FLUTICAS2NE-SALMETER2L

INHALATION AEROSOL

P2:DER BREATH ACTI9ATED

113-1� MC*/ACT, 232-1� MC*/

ACT, ��-1� MC*/ACT

1

INCRUSE ELLIPTA 2

ipratropium-albuterol 1

LE9ALBUTER2L HFA

INHALATION AEROSOL

�� MC*/ACT

3

montelukast sodium oral 1

NUCALA AUT2IN-ECT2R,

PREFILLED SYRIN*E3 PA, SP

PERF2R2MIST 3

PROAIR DIGIHALER E

PR2AIR HFA 2

PR2AIR RESPICLIC. 2

PR29ENTIL HFA 3

PULMIC2RT FLE;HALER 1

QVAR REDIHALER E

SIN*ULAIR 2RAL PAC.ET 3

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

STRIVERDI RESPIMAT 2

SYMBIC2RT 3 RS

TRELE*Y ELLIPTA 3 RS

9ENT2LIN HFA 2

wixela inhub E

;2PENE; HFA 3

YUPELRI 3


Cystic Fibrosis

BETH.IS 1 PA, SP

.ITABIS PA. E PA, SP

3�


Tier & Limits


Drug NameDrug

Tier

Requirements

& Limits

PULM2=YME 2 PA, SP

T2BI P2DHALER 3 PA, SP

tobramycin nebulization solution

300 mg/�ml inhalation1 PA, SP


300 mg/�ml inhalationE PA, SP

T2BRAMYCIN NEBULI=ATI2N

S2LUTI2N 300 M*/�ML

INHALATION

E PA, SP


Pulmonary Hypertension

ADEMPAS 2 PA, SP

bosentan 1 PA, SP

OPSUMIT 2 PA, SP

ORENITRAM 3 PA, SP

TRACLEER 2 PA, SP

TY9AS2 2 PA, SP

Skeletal Muscle Relaxants - Drugs for Muscle Pain

and Spasm

AMRIX 3

baclofen oral 1

carisoprodol oral 1

cyclobenzaprine hcl er 1

cyclobenzaprine hcl oral 1

FE;MID 3

metaxalone 1

methocarbamol oral 1

2=2BA; 3

R2BA;IN-��0 3

S2MA 2RAL TABLET 3�0 M* 3

tizanidine hcl oral 1

=ANAFLE; 2RAL CAPSULE 3

Sleep Disorder Agents

EDLUAR 3

eszopiclone 1

modafinil 1

RESTORIL 3

SUNOSI 3 PA

temazepam 1

:A.I; 3 PA, SP

;YREM 3 PA, SP

zolpidem tartrate 1

zolpidem tartrate er 1

3�

Index

A

ABILIFY MYCITE .......................... 16

ABS2RICA .................................... 21

ACCU-CHE. A9I9A C2NNECT

.IT :/DE9ICE ........................... 23

ACCU-CHE. A9I9A DE9ICE ....... 23

ACCU-CHE. A9I9A PLUS .IT

:/DE9ICE ................................. 23


CARE .IT ................................... 23


TEST STRIPS ............................ 23

ACCU-CHE. *UIDE .IT

:/DE9ICE ................................. 23

ACCU-CHE. NAN2 SMART9IE:

.IT :/DE9ICE ........................... 23

ACCU-CHE. SMART9IE: TEST

STRIPS ...................................... 23

ACCU-CHE. S2FTCLI; LANCET

DE9ICE .IT ............................... 23

ACCUPRIL .................................... 17

acetaminophen-codeine ................ 10

acetaminophen-codeine �2 ........... 10

acetaminophen-codeine �3 ........... 10

acetaminophen-codeine �� .......... 10

acetazolamide er ........................... 17

acetazolamide oral ........................ 17

ACIPHE; SPRIN.LE .................... 26

ACTEMRA ..................................... 32

ACTI*ALL ..................................... 26

ACULAR ........................................ 3�

ACULAR LS .................................. 3�

ACU9AIL ....................................... 3�

acyclovir oral ................................. 16

AC=2NE E;TERNAL *EL � � .... 21

AC=2NE E;TERNAL *EL

7.5 % .......................................... 21

ADALAT CC 2RAL TABLET

EXTENDED RELEASE

24 HOUR 60 MG ........................ 17

ADDERALL XR ............................. 20

ADDYI ............................................ 25

ADEMPAS ..................................... 3�

ADHANSIA XR .............................. 20

ADLY;IN ....................................... 24

ADMELOG .................................... 24

ADMELOG SOLOSTAR ................ 24

AD9AIR DIS.US ........................... 3�

AD9AIR HFA ................................. 3�

afirmelle ......................................... 28

AFRE==A ...................................... 24


1000 UNIT, 2000 UNIT, 250 UNIT,

3000 UNIT, �00 UNIT ................ 25


1500 UNIT, 2500 UNIT ............... 25

AIMOVIG ....................................... 15

AIRDU2 RESPICLIC. .................. 3�

ALA SCALP ................................... 21

ala-cort external cream 1 � .......... 21

ala-cort external cream 2.� � ....... 21

albuterol sulfate er ......................... 3�

albuterol sulfate hfa aerosol

solution 108 (90 base) mcg/act

inhalation .................................... 3�

albuterol sulfate inhalation ............. 3�

albuterol sulfate oral ...................... 3�

ALDACT2NE ................................. 17

ALDARA ........................................ 21

alendronate sodium ....................... 3�

alfuzosin hcl er .............................. 28

aliskiren fumarate .......................... 17

allopurinol oral ............................... 15

AL2*LIPTIN BEN=2ATE ............. 24

AL2*LIPTIN-METF2RMIN HCL .. 24

AL2*LIPTIN-PI2*LITA=2NE ..... 24

AL2RA TRANSDERMAL PATCH

T:ICE :EE.LY 0.02� M*/

24HR, 0.075 MG/24HR,

0.1 MG/24HR .............................. 28


SOLUTION 0.1 % ....................... 3�


SOLUTION 0.15 % ..................... 3�

alprazolam er ................................. 17

alprazolam intensol ....................... 17

alprazolam oral .............................. 17

alprazolam xr ................................. 17

ALREX ........................................... 3�

ALTACE ......................................... 17

altavera .......................................... 28

ALTOPREV.................................... 17

ALTRENO ...................................... 21

AL9ESC2 ...................................... 3�

alyacen 1/3� .................................. 28

AMARYL ........................................ 24

AMERGE ....................................... 15

amethia .......................................... 28

amethia lo ...................................... 28

amiodarone hcl oral ....................... 17

amitriptyline hcl oral ...................... 14

amlodipine besylate oral ................ 17

amlodipine besylate-bena]epril

hcl ............................................... 17

amlodipine besylate-valsartan ....... 17

amnesteem .................................... 21

amoxicillin ...................................... 12

amoxicillin-potassium

clavulanate er ............................. 12

amoxicillin-potassium

clavulanate oral .......................... 12

amphetamine-

dextroamphetamine ................... 20

3�

amphetamine-

dextroamphetamine er ............... 20

AMRIX ........................................... 3�

AMZEEQ AER 4% ......................... 21

ANALPRAM HC ............................ 33

ANALPRAM HC SIN*LES ........... 33

ANALPRAM-HC ............................ 33

ANASPAZ ...................................... 26

anastrozole oral ............................. 15

ANDRODERM ............................... 32

ANORO ELLIPTA .......................... 3�

apap-caff-dihydrocodeine oral

capsule ....................................... 10

apri ................................................ 28

APRISO ......................................... 33

APTENSIO XR .............................. 20

ARA.2DA ..................................... 16

ARANESP �ALBUMIN FREE� ....... 25

ARCAPTA NE2HALER ................. 3�

ARICEPT 2RAL TABLET

10 MG, 5 MG .............................. 14

aripiprazole .................................... 16

ARM2UR THYR2ID ..................... 32

ARNUITY ELLIPTA ....................... 3�

ARYM2 ER ................................... 10

ashlyna .......................................... 28

ASMANEX ..................................... 3�

ASTA*RAF ;L .............................. 32

atenolol oral ................................... 17

atenolol-chlorthalidone .................. 17

atomoxetine hcl ............................. 20


10 mg, 20 mg ............................. 17


40 mg, 80 mg ............................. 17

atovaTuone-proguanil hcl .............. 16

ATRIPLA ........................................ 16

ATR29ENT HFA ........................... 3�

AUBA*I2 ...................................... 20

aubra ............................................. 28

aubra eT ........................................ 28

AUGMENTIN ORAL SUSPENSION

REC2NSTITUTED

12�-31.2� M*/�ML .................... 12

aurovela 1/20 ................................. 28

aurovela 1.�/30 .............................. 28

aurovela 2� fe ................................ 28

aurovela fe 1/20 ............................. 28

aurovela fe 1.�/30 .......................... 28

AURY;IA ....................................... 27

AUSTEDO ..................................... 20

AU9I-4 .......................................... 3�

AVALIDE ........................................ 17

AVAPRO ........................................ 17

aviane ............................................ 28

avidoxy .......................................... 12

avita ............................................... 21

AVONEX PEN ............................... 20

A92NE; PREFILLED ................... 20

AY*ESTIN ..................................... 28

ayuna ............................................. 28

AZASAN ........................................ 32

AZASITE ....................................... 3�

azathioprine oral ............................ 32

azelaic acid external ...................... 21

azelastine hcl nasal ....................... 3�

azelastine hcl ophthalmic .............. 3�

azithromycin oral ........................... 12

AZOPT .......................................... 3�

A=ULFIDINE ................................. 33

A=ULFIDINE EN-TABS ................. 33

azurette ......................................... 28

B

baclofen oral .................................. 3�

BACTRIM ...................................... 12

BACTRIM DS ................................ 12

bal]iva ........................................... 28

BA4SIMI........................................ 24

BARACLUDE 2RAL S2LUTI2N .. 16

BASA*LAR .:I.PEN ................. 24

BD AUT2SHIELD DU2 PEN

NEEDLES .................................. 23

BD ULTRA-FINE INSULIN

SYRIN*ES ................................. 23

BD ULTRA-FINE PEN

NEEDLES .................................. 23

bekyree .......................................... 28

BELBUCA ...................................... 10

benazepril hcl oral ......................... 17

bena]epril-hydrochlorothia]ide ..... 18

benzonatate ................................... 3�

BESI9ANCE .................................. 3�

betamethasone dipropionate aug .. 21

betamethasone dipropionate

external ...................................... 21

BETASER2N ................................ 20

BETH.IS ....................................... 3�

BETIM2L ....................................... 3�

BE9ESPI AER2SPHERE ............. 3�

BE9Y;;A ..................................... 13

bexarotene ..................................... 15

BIDIL ............................................. 18

BI-U9A .......................................... 28

bimatoprost ophthalmic ................. 3�

bisoprolol fumarate ........................ 18

bisoprolol-hydrochlorothia]ide ...... 18

blisovi 2� fe .................................... 28

blisovi fe 1/20 ................................. 28

blisovi fe 1.�/30.............................. 28

B2NI9A 2RAL .............................. 3�

B2N-ESTA .................................... 14

bosentan ........................................ 3�

bp 10-1 .......................................... 21

BRE2 ELLIPTA ............................. 3�

briellyn ........................................... 28

BRILINTA ...................................... 16

brimonidine tartrate ophthalmic ..... 3�

bromfed dm ................................... 3�

3�

budesonide er ................................ 33

budesonide inhalation ................... 3�

budesonide oral ............................. 33

BUNA9AIL ......................................11

buprenorphine hcl sublingual .........11

buprenorphine hcl-naloxone hcl .....11

bupropion hcl er (sr) ...................... 14

bupropion hcl er (xl) oral tablet


1�0 mg, 300 mg ......................... 14

BUPR2PI2N HCL ER �;L� 2RAL

TABLET E;TENDED RELEASE

24 HOUR 450 MG ...................... 14

bupropion hcl oral .......................... 14

buspirone hcl oral .......................... 17

butalbital-apap-caffeine ................ 10

BYDURE2N .................................. 24

BYDURE2N BCISE

AUT2IN-ECT2R ....................... 24

BYETTA PEN ................................ 24

BYST2LIC ..................................... 18

C

cabergoline .................................... 31

CALAN SR .................................... 18

calcipotriene-betameth diprop

external ointment ........................ 21

calcitriol external ........................... 21

calcitriol oral .................................. 3�

camila ............................................ 28

camrese ......................................... 28

camrese lo ..................................... 28

capecitabine .................................. 15

CAPE; .......................................... 21

CARAC .......................................... 21

CARAFATE ................................... 26

carbamazepine er.......................... 13

carbamazepine oral ....................... 13

CARBATR2L ................................. 13

carbidopa-levodopa ....................... 16

carbidopa-levodopa er .................. 16

CARDI=EM LA 2RAL TABLET


120 MG ....................................... 18

CARDURA .................................... 18

carisoprodol oral ............................ 3�

CAR2SPIR .................................... 18

cartia xt .......................................... 18

carvedilol ....................................... 18

CATAPRES .................................... 18

cavarest ......................................... 21

cefadroxil ....................................... 12

cefdinir ........................................... 12

cefuroxime axetil ........................... 12

celecoxib oral .................................11

CENTANY ..................................... 12

CENTANY AT ................................ 12

cephalexin ..................................... 12

CE4UA .......................................... 3�

CERDEL*A ................................... 27

CHANTI; ........................................11

CHANTI; C2NTINUIN* M2NTH

PA. .............................................11

CHANTI; STARTIN* M2NTH

PA. .............................................11

chateal ........................................... 28

chateal eT ...................................... 28

chlorhexidine gluconate

mouth/throat ............................... 21

chlorthalidone ................................ 18

chorionic gonadotropin

intramuscular .............................. 33

ciclodan ......................................... 15

ciclopirox ....................................... 15

CIL2;AN ....................................... 3�

CIMDU2 ........................................ 16

CIM=IA .......................................... 32

CIPR2 2RAL TABLET .................. 12

CIPR2DE; .................................... 3�

ciprofloxacin hcl ophthalmic .......... 3�

ciprofloxacin hcl oral ...................... 12

citalopram hydrobromide ............... 14

claravis .......................................... 21

clarithromycin er ............................ 12

clarithromycin oral ......................... 12

CLENPI4 ....................................... 26


1�0 M*, 300 M* ........................ 12


75 MG ......................................... 12

CLE2CIN-T ................................... 21

Climara .................................... 28, 29

CLIMARA PR2 ............................. 28

clindacin etz external swab ........... 21

clindacin-p ..................................... 21

CLINDA*EL .................................. 21

clindamycin hcl oral ....................... 12

clindamycin phos-ben]oyl perox

external gel 1.2-� � ................... 21


foam ........................................... 21


lotion ........................................... 21


solution ....................................... 22


swab ........................................... 22

CLINDAMYCIN PH2SPHATE

GEL 1 % EXTERNAL ................ 22

CLINDESSE .................................. 12

clinpro 5000 ................................... 21

clobetasol propionate external ...... 22

clodan external shampoo .............. 22

clonazepam oral ............................ 17

clonidine hcl oral............................ 18

clopidogrel bisulfate oral ............... 16

clotrima]ole-betamethasone ......... 22

cloviTue ......................................... 27

C2LCHICINE 2RAL CAPSULE ... 15

40

colchicine oral tablet ...................... 15

C2LCRYS ..................................... 15

colesevelam hcl ............................. 18

C2MBI*AN ................................... 3�

C2MBI9ENT RESPIMAT .............. 3�

C2NCERTA .................................. 20

C2NT2UR NE;T M2NIT2R ....... 23

C2NT2UR NE;T TEST ............... 23

C2NT2UR TEST .......................... 23

C2N=IP ......................................... 10

C2RE* ......................................... 18

coremino ........................................ 12

C2R*ARD .................................... 18

C2RLAN2R .................................. 18

C2RTEF ........................................ 31

C2RTIF2AM ................................. 33

C2SENTY; .................................. 32

C2S2PT ....................................... 3�

C2UMADIN ................................... 13

C2=AAR ....................................... 18

CRE2N ......................................... 27

CRESEMBA 2RAL ....................... 15

CRIN2NE 9A*INAL *EL � � ...... 33

CRIN2NE 9A*INAL *EL � � ...... 33

cryselle-2� ..................................... 28

CUPRIMINE .................................. 27

cyclafem 1/3� ................................ 28

cyclobenzaprine hcl er .................. 3�

cyclobenzaprine hcl oral ................ 3�

cyclosporine modified .................... 32

cyproheptadine hcl oral ................. 3�

cyred .............................................. 28

cyred eT ......................................... 28

CYT2TEC ..................................... 26

D

dalfampridine er ............................. 20

dapsone external gel 5 % .............. 22

dasetta 1/3� ................................... 28

daysee ........................................... 28

DDA9P IN-ECTI2N ...................... 31

DDAVP ORAL ............................... 31

deblitane ........................................ 28

delyla ............................................. 28

denta 5000 plus ............................. 21

dentagel ......................................... 21

DEPA.2TE ................................... 13

DEPA.2TE ER ............................. 13

DEPA.2TE SPRIN.LES .............. 13

DEPEN TITRATABS ...................... 27

DEP2-PR29ERA

INTRAMUSCULAR

SUSPENSION 150 MG/ML ........ 28

DEP2-PR29ERA

INTRAMUSCULAR

SUSPENSI2N PREFILLED

SYRIN*E ................................... 28

DEP2-SUB4 PR29ERA 10� ....... 28

DEP2-TEST2STER2NE .............. 32

DERMA-SM22THE/FS B2DY ..... 22

DERMA-SM22THE/FS SCALP ... 22

DESC29Y ..................................... 16

desmopressin acetate injection ..... 31

desmopressin acetate oral ............ 31

desogestrel-ethinyl estradiol ......... 28

DESONATE ................................... 22

desonide external .......................... 22

DESOWEN .................................... 22

desvenlafaxine succinate er .......... 14

dexamethasone intensol................ 31

dexamethasone oral ...................... 31

DE;C2M *� / *� / *� RECEI9ER,

TRANSMITTER, SENSOR

�INCLUDIN* PLATINUM,

PLATINUM PEDIATRIC� ............ 23

DE;C2M *� / *� / *� RECEI9ER,

TRANSMITTER, SENSOR

�INCLUDIN* PLATINUM,

PLATINUM PEDIATRIC�

DE9ICE ...................................... 23

DEXILANT ..................................... 26

dexmethylphenidate hcl ................. 20

dexmethylphenidate hcl er ............ 20

dextroamphetamine sulfate ........... 20

dextroamphetamine sulfate er ....... 20

diazepam intensol ......................... 17

diazepam oral ................................ 17

diclofenac potassium ......................11

diclofenac sodium er ......................11

diclofenac sodium oral ....................11


gel 1 % ........................................11


solution ........................................11

dicyclomine hcl oral ....................... 26

DIFICID.......................................... 12

DIFLUCAN..................................... 15

DILAUDID ORAL .......................... 10

dilt-xr .............................................. 18

diltiazem hcl er coated beads ........ 18

diltiazem hcl er oral capsule

extended release 12 hour........... 18

diltiazem hcl oral ............................ 18

DIPENTUM .................................... 33

diphenoxylate-atropine .................. 26

DIPROLENE .................................. 22

DIPR2LENE AF ............................ 22

DITROPAN XL............................... 27

divalproex sodium er ..................... 13

divalproex sodium oral .................. 13

DIVIGEL TRANSDERMAL GEL 0.25

MG/0.25GM, 0.5 MG/0.5GM, 0.75

MG/0.75GM, 1 MG/GM,

1.25 MG/1.25GM ........................ 29

donepezil hcl ................................. 14

D2RY; MPC ................................. 12

dor]olamide hcl-timolol mal .......... 3�

dor]olamide hcl-timolol mal pf ...... 3�

41

dotti ................................................ 29

DOVATO ........................................ 16

doxazosin mesylate oral ................ 18

doxepin hcl oral capsule ................ 14

doxepin hcl oral concentrate ......... 14

doxycycline hyclate oral ................. 12

doxycycline monohydrate oral ....... 12

doxylamine-pyridoxine .................. 14

DRISDOL ...................................... 26

DRI=ALMA SPRIN.LE ................. 14

drospiren-eth estrad-levomefol ..... 29

drospirenone-ethinyl estradiol ....... 29

DUAVEE ........................................ 29

duloxetine hcl oral.......................... 14

DUOPA .......................................... 16

DUPIXENT .................................... 22

DVORAH ....................................... 10

DYA=IDE ....................................... 18

E

EC-NAPR2SYN .............................11

ec-naproxen ...................................11

ed-spa].......................................... 26

EDARBI ......................................... 18

EDARBYCL2R .............................. 18

EDLUAR ........................................ 3�

EFUDE; ........................................ 22

ELESTRIN ..................................... 29

eletriptan hydrobromide ................. 15

ELIMITE ........................................ 16

elinest ............................................ 29

ELIQUIS ........................................ 13

EL2CTATE .................................... 25

eluryng ........................................... 29

EM*ALITY .................................... 15

emoTuette ..................................... 29

enalapril maleate oral .................... 18

ENBREL ........................................ 32

ENDARI ......................................... 27

endocet .......................................... 10

ENDOMETRIN .............................. 33

enoxaparin sodium ........................ 13

enskyce ......................................... 29

ENSTILAR ..................................... 22

entecavir ........................................ 16

ENVARSUS XR ............................. 32

EPANED ........................................ 18

EPCLUSA ...................................... 16


0.1� mg/0.3ml injection .............. 3�


0.3 mg/0.3ml injection ................ 3�

EpiPen ........................................... 3�

EpiPen -r. ...................................... 3�

epitol .............................................. 13

ER*2CAL ..................................... 26

ergocalciferol oral capsule ............ 26

ERLEADA ...................................... 15

ERLEADA 2RAL TABLET

60 MG ........................................ 15

errin ............................................... 29

erythromycin ophthalmic ............... 3�

escitalopram oxalate ..................... 14

ES*IC ........................................... 10

estarylla ......................................... 29

ESTRACE 2RAL .......................... 29

ESTRACE 9A*INAL ..................... 29

estradiol oral .................................. 29


transdermal ................................ 29

estradiol transdermal patch

weekly ........................................ 29

estradiol vaginal cream ................. 29

estradiol vaginal tablet ................... 29

ESTRING....................................... 29

ESTROGEL ................................... 29

eszopiclone ................................... 3�

etodolac ..........................................11

etodolac er ......................................11

etonogestrel-ethinyl estradiol ........ 29

EUCRISA....................................... 22

euthyrox ......................................... 32

EVAMIST ....................................... 29

E92CLIN ....................................... 22

EVZIO .............................................11

EXTAVIA ....................................... 20

EXTINA ......................................... 15

E=ALL2R SPRIN.LE ................... 18

ezetimibe ....................................... 18

e]etimibe-simvastatin .................... 18

F

falmina ........................................... 29

FAR;I*A ....................................... 24

FASENRA PEN ............................. 3�

fayosim .......................................... 29

febuxostat ...................................... 15

femynor.................................... 2�, 31

fenofibrate oral capsule

150 mg, 50 mg ........................... 18

fenofibrate oral tablet ..................... 18

fentanyl .......................................... 10

FE;MID ......................................... 3�

FINACEA E;TERNAL *EL .......... 22

finasteride oral tablet � mg ............ 28

FI2RICET ...................................... 10

FIRA=YR ....................................... 32

FLA*YL ......................................... 12

flecainide acetate .......................... 18

FL2LIPID ....................................... 18

FL2RI9A PLUS ............................. 26

FL29ENT DIS.US ........................ 3�

FL29ENT HFA .............................. 3�

flucona]ole oral ............................. 15

fluocinolone acetonide body .......... 22

fluocinolone acetonide external ..... 22

fluocinolone acetonide scalp ......... 22

fluocinonide external ..................... 22

fluoridex ......................................... 21

fluoridex enhanced whitening ........ 21

42

FLU2R2PLE; .............................. 22

FLU2R2URACIL E;TERNAL

CREAM 0.� � ............................ 22

fluorouracil external cream � � ..... 22

fluorouracil external solution ......... 22

fluoxetine hcl oral .......................... 14

fluticasone propionate nasal ......... 3�

fluticasone-salmeterol inhalation

aerosol powder breath activated

100-�0 mcg/dose, 2�0-�0 mcg/

dose, �00-�0 mcg/dose ............. 3�

FLUTICAS2NE-SALMETER2L

INHALATION AEROSOL POWDER

BREATH ACTI9ATED

113-1� MC*/ACT, 232-1� MC*/

ACT, ��-1� MC*/ACT ................ 3�

fluvoxamine maleate ...................... 14

fluvoxamine maleate er ................. 14

F2CALIN ....................................... 20

folic acid oral tablet 1 mg............... 26

F2LLISTIM A4 .............................. 33

F2RFI92 ;L ................................. 14

F2RTE2 ........................................ 3�

F2SAMA; ..................................... 3�


READER .................................... 23


SENSOR .................................... 23

FREESTYLE LIBRE READER ...... 23

FREESTYLE LIBRE SENS2R

SYSTEM ..................................... 23

furosemide oral .............................. 18

G

gabapentin oral .............................. 13



subcutaneous ............................. 33

gavilyte-c ....................................... 26

gavilyte-g ....................................... 27

GELNIQUE .................................... 27

gemfibro]il oral .............................. 18

gengraf .......................................... 32

GENOTROPIN .........................31, 32

*EN2TR2PIN MINI4UIC. .......... 32

*EN92YA ..................................... 16

gianvi ............................................. 29


0.25 MG .................................... 20


0.5 MG ....................................... 20

glatiramer acetate .......................... 20

glatopa ........................................... 20

glimepiride ..................................... 25

glipizide er ..................................... 25

glipizide ir ...................................... 25

glipizide xl ...................................... 25

*L2PERBA ................................... 15

*LUCA*2N EMER*ENCY .IT

IN-ECTI2N .IT .......................... 25

*LUC2TR2L ................................ 25

*LUC2TR2L ;L ........................... 25

*LUC29ANCE 2RAL TABLET

�-�00 M* ................................... 25

GLUMETZA ................................... 25

glyburide oral ................................. 25

glyburide-metformin ...................... 25

*LY;AMBI .................................... 25


REC2NSTITUTED 22�.1 *M .... 27


REC2NSTITUTED 23� *M ....... 27

GONITRO ...................................... 18

guanfacine hcl ......................... 18, 20

guanfacine hcl er ........................... 20

*92.E PFS .................................. 25

*YNA=2LE-1 ................................ 15

H

HAEGARDA .................................. 32

hailey 1.�/30 .................................. 29

hailey 24 fe .................................... 29

HALCI2N ...................................... 17

HARVONI ...................................... 16

heather .......................................... 29

HEMANGEOL ............................... 18

HUMAL2* .:I.PEN .................. 24

HUMALOG MIX 50/50

.:I.PEN .................................. 24

HUMALOG MIX 50/50 VIAL .......... 24

HUMALOG MIX 75/25

.:I.PEN .................................. 24

HUMALOG MIX 75/25 VIAL .......... 24


SOLUTION ................................. 24


S2LUTI2N CARTRID*E .......... 24

HUMAL2* U-100 -UNI2R

.:I.PEN .................................. 24

HUMATROPE ................................ 32

HUMIRA ........................................ 32

HUMULIN �0/30 .:I.PEN .......... 24

HUMULIN �0/30 9IAL ................... 24

HUMULIN N .:I.PEN ................. 24

HUMULIN N VIAL ......................... 24

HUMULIN R U-�00 .:I.PEN ..... 24

HUMULIN R U-�00 9IAL

�C2NCENTRATED� ................... 24

HUMULIN R VIAL ......................... 24

hydralazine hcl oral ....................... 18

hydrochlorothiazide oral ................ 18

hydrocodone polst-cpm polst er .... 3�


solution 10-32� mg/1�ml,

�.�-32� mg/1�ml......................... 10


tablet .......................................... 10

�3

hydrocort-pramoxine �perianal� ..... 33

hydrocortisone ace-pramoxine

external cream 1-1 � ................. 33


1 % ............................................. 22


2.5 % .......................................... 22

hydrocortisone external lotion

2.5 % .......................................... 22

hydrocortisone external ointment

1 %, 2.5 % .................................. 22

hydrocortisone oral ........................ 31

hydromorphone hcl er ................... 10

hydromorphone hcl oral................. 10

hydromorphone hcl rectal .............. 10

hydroxychloroTuine sulfate oral ..... 16

hydroxyzine hcl oral ....................... 17

hydroxyzine pamoate oral ............. 17

hyoscyamine sulfate er .................. 27

hyoscyamine sulfate oral ............... 27

hyoscyamine sulfate sublingual ..... 27

hyosyne ......................................... 27

HYSIN*LA ER .............................. 10

HY=AAR ....................................... 18

I

ibandronate sodium oral ................ 3�

IBRANCE 2RAL CAPSULE ......... 15

ibu ...................................................11

ibuprofen oral suspension ..............11

ibuprofen oral tablet 400 mg,

600 mg, 800 mg ..........................11

icatibant acetate ............................ 33

IDHIFA ........................................... 15

ILEVRO ......................................... 3�

imatinib mesylate ........................... 15

imiTuimod external ........................ 22

IMIQUIMOD PUMP ....................... 22

IMP2Y= ......................................... 22

IM9E;;Y ...................................... 25

INBRI-A ......................................... 16

incassia ......................................... 29

INCRUSE ELLIPTA ....................... 3�

IND2CIN ........................................11

indomethacin er ..............................11

indomethacin oral capsule

25 mg, 50 mg ..............................11

INSULIN ASPART ......................... 24

INSULIN ASPART FLE;PEN ....... 24

INSULIN ASPART PENFILL ......... 24

INSULIN LISPRO .......................... 24

INSULIN LISPRO (1 UNIT DIAL) .. 24

INSULIN SYRIN*ES ..................... 23

INTRAROSA ................................. 25

introvale ......................................... 29

IN9ELTYS ..................................... 3�

IN92.ANA .................................... 25

ipratropium bromide nasal ............. 3�

ipratropium-albuterol ..................... 3�

irbesartan ...................................... 18

irbesartan-hydrochlorothia]ide...... 18

ISENTRESS .................................. 16

ISENTRESS HD ............................ 16

isibloom ......................................... 29

isosorbide mononitrate .................. 18

isosorbide mononitrate er .............. 18

isotretinoin oral .............................. 22

ISTALOL ........................................ 3�

J

jantoven ......................................... 13

-ANU9IA ....................................... 25

-ARDIANCE .................................. 25

jasmiel ........................................... 29

jencycla ......................................... 29

-ENTADUET2 ............................... 25

-ENTADUET2 ;R ......................... 25

-I9I ................................................ 25

jolessa ........................................... 29

-2RNAY PM .................................. 20

juleber ............................................ 29

-ULUCA......................................... 16

junel 1/20 ....................................... 29

junel 1.�/30 .................................... 29

junel fe 1/20 ................................... 29

junel fe 1.�/30 ................................ 29

junel fe 24 ...................................... 29

K

.-TAB ............................................ 26

.ADIAN 2RAL CAPSULE


200 MG ...................................... 10

kalliga ............................................ 29

.APSPAR*2 SPRIN.LE ............. 18

kariva ............................................. 29

.A=AN2 ....................................... 25

.EFLE; ......................................... 12

.EPPRA 2RAL ............................. 13

.EPPRA ;R .................................. 13

ketoconazole external ................... 15

ketodan external foam ................... 15

ketorolac tromethamine

ophthalmic .................................. 3�

ketorolac tromethamine oral ...........11

.ITABIS PA. ................................. 3�

klor-con .......................................... 26

klor-con 10 ..................................... 26

klor-con m10 .................................. 26

.L2R-C2N M1� ............................ 26

klor-con m20 .................................. 26

klor-con sprinkle ............................ 26

.2*ENATE FS ............................. 25

.2MBI*LY=E ;R ......................... 25

.29ALTRY .................................... 25

.RINTAFEL ................................... 16

kurvelo ........................................... 29

44

L

labetalol hcl oral ............................ 18

LAMICTAL ..................................... 13

LAMICTAL 2DT ............................ 13

LAMICTAL STARTER ................... 13

LAMICTAL ;R ............................... 13

lamotrigine er ................................. 13

lamotrigine oral .............................. 13

LANCETS ...................................... 23

LANTUS SOLOSTAR .................... 24

LANTUS U-100 9IAL .................... 24

larin 1/20 ........................................ 29

larin 1.�/30 ..................................... 29

larin 24 fe ....................................... 29

larin fe 1/20 .................................... 29

larin fe 1.�/30 ................................. 29

larissia ........................................... 29

LASIX ............................................ 18

LASTACAFT .................................. 3�

latanoprost ophthalmic .................. 3�

LATUDA ........................................ 16

LEDIP-S2F2SB 2RAL TABLET

�0-�00M* .................................. 16

LEDIPAS9IR-S2F2SBU9IR ........ 16

lessina ........................................... 29

letrozole oral .................................. 15

LE9ALBUTER2L HFA

INHALATION AEROSOL

�� MC*/ACT .............................. 3�

LE9A4UIN 2RAL TABLET

500 MG, 750 MG ....................... 12

LE9BID .......................................... 27

LE9EMIR U-100 FLE;T2UCH ..... 24

LE9EMIR U-100 9IAL ................... 24

levetiracetam er ............................. 13

levetiracetam oral .......................... 13

levo-t .............................................. 32

levocetiri]ine dihydrochloride

oral ............................................. 3�

levofloxacin oral ............................. 12

levonorgest-eth est eth est ......... 29

levonorgest-eth estrad �1-day ....... 29

levonorgestrel-ethinyl estrad oral

tablet 0.1-20 mg-mcg,

0.1�-30 mg-mcg ......................... 29

levora 0.1�/30 �2�� ......................... 30

levothyroxine sodium oral .............. 32

levoxyl ............................................ 32

LEVSIN ORAL ............................... 27

LEVSIN/SL .................................... 27

LIALDA .......................................... 33

lidocaine external ointment ........... 10

lidocaine external patch 5 % ......... 10

lidocaine hcl mouth/throat ............. 21

lidocaine viscous hcl ..................... 21

lidocaine-prilocaine external

cream ......................................... 10

lillow ............................................... 30

LINZESS........................................ 27

liothyronine sodium oral ................ 32

LIP2FEN ....................................... 18

lisinopril oral .................................. 18

lisinopril-hydrochlorothia]ide ......... 18

lithium carbonate er ....................... 17

lithium carbonate oral .................... 17

LITH2BID ...................................... 17

L2 L2ESTRIN FE ......................... 30

lo-]umandimine ............................. 30

LOESTRIN 1/20 (21) ...................... 30

L2ESTRIN 1.�/30 �21� ................... 30

L2ESTRIN FE 1/20 ....................... 30

L2ESTRIN FE 1.�/30 .................... 30

L2.ELMA ..................................... 26

LOMOTIL ....................................... 27

LOPID ............................................ 18

LOPRESSOR ................................ 18

lorazepam intensol ........................ 17

lorazepam oral concentrate

2 mg/ml ...................................... 17

lorazepam oral tablet ..................... 17

lorcet .............................................. 10

lorcet hd ......................................... 10

lorcet plus ...................................... 10

L2RTAB ........................................ 10

loryna............................................. 30

losartan potassium ........................ 18

losartan potassium-hct] ................ 18

LOSEASONIQUE .......................... 30

LOTEMAX ..................................... 3�

LOTEMAX SM ............................... 3�

LOTENSIN ..................................... 18

L2TENSIN HCT ............................ 18

loteprednol etabonate .................... 3�

LOTREL ......................................... 18

lovastatin ....................................... 19

low-ogestrel ................................... 30

LUMIGAN ...................................... 3�

lutera.............................................. 30

LYNPAR=A .................................... 15

LYRICA .......................................... 20

LYRICA CR .................................... 20

lyza ................................................ 30

M

MACR2BID ................................... 12

MACR2DANTIN ............................ 12

MALARONE .................................. 16

marlissa ......................................... 30

matzim la ....................................... 19

MA9ENCLAD ................................ 20

MA9YRET ..................................... 16

MAXITROL .................................... 3�

MAXZIDE ...................................... 19

MA;=IDE-2� ................................. 19

MAY=ENT ..................................... 20

MEDR2L 2RAL TABLET 1� M*,

32 M*, � M*, � M* ................... 31

MEDR2L 2RAL TABLET 2 M* .... 31

45


intramuscular .............................. 30


oral ............................................. 30

melodetta 24 fe .............................. 30

meloxicam oral ...............................11

MENOSTAR .................................. 30

mercaptopurine oral ...................... 15

mesalamine er ............................... 33

mesalamine oral ............................ 3�

mesalamine rectal ......................... 3�

metadate er ................................... 20

metaxalone .................................... 3�

metformin hcl er ............................ 25

metformin hcl er (mod) .................. 25

metformin hcl er (osm) ................... 25

METF2RMIN HCL 2RAL

SOLUTION ................................. 25

metformin hcl oral tablet ................ 25

methimazole oral ........................... 32

methocarbamol oral ...................... 3�

methotrexate oral ........................... 33

methotrexate sodium oral .............. 33

METHYLIN .................................... 20

methylphenidate hcl er (cd) ........... 20

methylphenidate hcl er (la) ............ 20


extended release 10 mg,

20 mg ......................................... 20


extended release 18 mg,

2� mg, 3� mg, �� mg, �2 mg ..... 20


extended release 24 hour .......... 20

methylphenidate hcl oral ............... 20

methylprednisolone oral ................ 31

metoclopramide hcl oral solution

5 mg/5ml .................................... 14

metoclopramide hcl oral tablet ...... 14

metoclopramide hcl oral tablet

dispersible .................................. 14

metoprolol succinate er ................. 19

metoprolol tartrate oral .................. 19

METR2CREAM ............................ 22

METROLOTION ............................ 22

metronidazole external .................. 22

metronidazole oral ......................... 12

metronida]ole vaginal ................... 12

mibelas 24 fe ................................. 30

microgestin 1/20 ............................ 30

microgestin 1.�/30 ......................... 30

microgestin fe 1/20 ........................ 30

microgestin fe 1.�/30 ..................... 30

mili ................................................. 30

MILLIPRED ................................... 31

MINIPRESS ................................... 19

minitran .......................................... 19

Minivelle......................................... 29

minocycline hcl er oral tablet


minocycline hcl oral ....................... 12

MINOLIRA ..................................... 12

MIRAPEX ...................................... 16

MIRCETTE .................................... 30

mirtazapine oral ............................. 14

MIRVASO ...................................... 22

misoprostol oral ............................. 26

MITIGARE ..................................... 15

M2BIC ............................................11

modafinil ........................................ 3�

mometasone furoate external ....... 22

mondoxyne nl ................................ 12

mono-linyah ................................... 30

montelukast sodium oral ............... 3�

morgidox oral ................................. 12

M2RPHAB2ND ER ...................... 10

morphine sulfate (concentrate) oral

solution 100 mg/5ml, 20 mg/ml .. 10

morphine sulfate er oral capsule


morphine sulfate er oral tablet

extended release ........................ 10

morphine sulfate oral ..................... 10

morphine sulfate rectal .................. 10

M2TE*RITY ................................. 27

MOVIPREP.................................... 27

MOXEZA ....................................... 3�

moxifloxacin hcl ophthalmic ........... 3�

MS C2NTIN .................................. 10

MULPLETA .................................... 25

MULTAQ ........................................ 19

multi-vitamin/fluoride ..................... 26

multivitamin/fluoride oral solution .. 26

multivitamin/fluoride oral tablet

chewable 0.25 mg, 0.5 mg,

1 mg ........................................... 26

multivitamins/fluoride ..................... 26

mupirocin calcium.......................... 12

mupirocin external ......................... 12

mvc-fluoride ................................... 26

mycophenolate mofetil .................. 33

mycophenolate sodium ................. 33

MYDAYIS....................................... 20

myorisan ........................................ 22

N

nabumetone oral ............................11

nadolol oral .................................... 19

NAFRINSE DAILY/NEUTRAL ....... 21

NAFRINSE :EE.LY .................... 21

NAL2CET ..................................... 10

naloxone hcl injection solution .......11


cartridge ......................................11


prefilled syringe ...........................11

naltrexone hcl oral ......................... 12

46

NAPRELAN 2RAL TABLET


750 MG .......................................11

NAPR2SYN 2RAL

SUSPENSION .............................11

naproxen dr ....................................11

naproxen oral ..................................11

naproxen sodium er ........................11

naproxen sodium oral tablet

275 mg, 550 mg ..........................11

naratriptan hcl ................................ 15

NARCAN ....................................... 12

NASC2BAL ................................... 26

NATAZIA ........................................ 30

NATESTO ...................................... 32

NATURE-THR2ID 2RAL TABLET

113.�� M*, 130 M*, 1��.2� M*,

16.25 MG, 162.5 MG, 195 MG,

2�0 M*, 32.� M*, 32� M*,

48.75 MG, 65 MG, 81.25 MG ..... 32


97.5 MG ORAL ........................... 32

NAY=ILAM SPRAY � M* ............. 13

necon 0.�/3� �2�� .......................... 30


ophthalmic ointment ................... 3�


ophthalmic suspension

3.�-10000-0.1 ............................. 3�

neomycin-polymyxin-hc otic .......... 3�

NESINA ......................................... 25

neuac external gel ......................... 22

NEURONTIN ................................. 13

neutral sodium fluoride .................. 21

NE9ANAC ..................................... 3�

niacin (antihyperlipidemic) ............. 19

niacin er (antihyperlipidemic) ......... 19

niacor ............................................. 19

NIASPAN ....................................... 19

nifedipine er ................................... 19

nifedipine er osmotic release ......... 19

nifedipine oral ................................ 19

nikki ............................................... 30

nitisinone ....................................... 27

NITR2-BID .................................... 19

NITR2-DUR .................................. 19

nitro-time ....................................... 19

nitrofurantoin macrocrystal oral ..... 12

nitrofurantoin monohydrate

macrocrystals ............................. 12

nitroglycerin sublingual .................. 19

nitroglycerin transdermal ............... 19

nitroglycerin translingual ............... 19

NITROMIST ................................... 19

NITROSTAT ................................... 19

NITYR............................................ 27

NIZORAL ....................................... 15

N2CDURNA ................................. 32

nora-be .......................................... 30

N2RC2 ......................................... 10

N2RDITR2PIN FLE;PR2 ........... 32


tablet .......................................... 30


tablet chewable .......................... 30

norethindrone acet-ethinyl est ....... 30

norethindrone acetate oral ............ 30

norethindrone oral ......................... 30

norgestimate-eth estradiol............. 30

norgestimate-ethinyl estradiol

triphasic ...................................... 30

NORITATE ..................................... 22

norlyda ........................................... 30

norlyroc .......................................... 30

nortrel 0.�/3� �2�� .......................... 30

nortrel 1/3� �21� ............................. 30

nortrel 1/3� �2�� ............................. 30

nortriptyline hcl oral ....................... 14

N2R9IR 2RAL PAC.ET .............. 16

NORVIR ORAL SOLUTION .......... 16

N2URIAN= 2RAL TABLET .......... 16

novarel intramuscular solution

reconstituted 10000 unit ............. 33

N29AREL INTRAMUSCULAR

S2LUTI2N REC2NSTITUTED

5000 UNIT .................................. 33

NOVOEIGHT ................................. 25

N292FINE AUT2C29ER PEN

NEEDLE ..................................... 23

N292FINE PEN NEEDLE ............ 23

N292FINE PLUS PEN NEEDLE .. 23

N292LIN �0/30 FLE;PEN ........... 24

N292LIN �0/30 FLE;PEN

RELION ...................................... 24

N292LIN �0/30 RELI2N .............. 24

N292LIN �0/30 9IAL ................... 24

N292LIN N FLE;PEN ................. 24

N292LIN N FLE;PEN RELI2N ... 24

NOVOLIN N RELION .................... 24

NOVOLIN N VIAL .......................... 24

N292LIN R FLE;PEN ................. 24

N292LIN R FLE;PEN RELI2N ... 24

NOVOLIN R RELION .................... 24

NOVOLIN R VIAL .......................... 24

N292L2* FLE;PEN ................... 24

N292L2* PENFILL ..................... 24

N292L2* U-100 9IAL ................. 24

np thyroid ....................................... 32

NUBE4A ....................................... 15

NUCALA AUT2IN-ECT2R,

PREFILLED SYRIN*E .............. 3�

NUCYNTA ..................................... 10

NUCYNTA ER ............................... 10

NUEDEXTA ................................... 20

NULEV .......................................... 27

NUTROPIN AQ NUSPIN 10 .......... 32

NUTROPIN AQ NUSPIN 20 .......... 32

NUTROPIN AQ NUSPIN 5 ............ 32

NUVARING ................................... 30

NUVESSA ..................................... 12

47

NUWIQ .......................................... 25

nyamyc .......................................... 15

nystatin external ............................ 15

nystatin mouth/throat ..................... 15

nystop ............................................ 15

O

ocella ............................................. 30

2CUFL2; ..................................... 3�

2DEFSEY ..................................... 16

ofloxacin ophthalmic ...................... 3�

ofloxacin otic .................................. 3�

ogestrel .......................................... 30

okebo ............................................. 12

olanzapine oral .............................. 16

olmesartan medoxomil oral ........... 19

olmesartan medoxomil-hct] .......... 19

olopatadine hcl ophthalmic ............ 3�

OLUMIANT .................................... 33

2MECLAM2;-PA. ....................... 26

omega-3-acid ethyl esters ............. 19

omeprazole oral capsule delayed

release ....................................... 26

OMNARIS ..................................... 3�

OMNITROPE ................................. 32

ondansetron hcl oral ...................... 14

ondansetron odt ............................ 14

2NET2UCH ULTRA 2 .IT

:/DE9ICE ................................. 23

2NET2UCH ULTRA BLUE TEST

STRIPS IN VITRO STRIP .......... 23

2NET2UCH ULTRA MINI .IT

:/DE9ICE ................................. 23

2NET2UCH 9ERI2 FLE;

SYSTEM .IT :/DE9ICE ........... 23

2NET2UCH 9ERI2 I4

SYSTEM ..................................... 23

2NET2UCH 9ERI2 .IT

:/DE9ICE ................................. 23

2NET2UCH 9ERI2 SYNC

SYSTEM .IT :/DE9ICE ........... 23

2NET2UCH 9ERI2 TEST

STRIPS ...................................... 23

2N*LY=A ..................................... 25

ONZETRA XSAIL .......................... 15

OPSUMIT ...................................... 3�

ORAPRED ODT ............................ 31

ORENITRAM ................................. 3�

2RFADIN 2RAL CAPSULE

20 MG ........................................ 27

2RFADIN 2RAL SUSPENSI2N... 27

ORILISSA ...................................... 32

orsythia .......................................... 30

2RTH2 MICR2N2R .................... 30

oscimin .......................................... 27

oscimin sr ...................................... 27

oseltamivir phosphate oral ............ 16

OSENI ........................................... 25

OSPHENA ..................................... 26

OTEZLA ........................................ 33



10 MG/0.4ML, 12.5 MG/0.4ML,

15 MG/0.4ML, 17.5 MG/0.4ML,

22.5 MG/0.4ML, 25 MG/0.4ML .. 33


S2LUTI2N AUT2-IN-ECT2R 20

MG/0.4ML .................................. 33

2;AYD2 ....................................... 10

oxcarbazepine ............................... 13

OXTELLAR XR ............................. 13

oxybutynin chloride er ................... 27

oxybutynin chloride oral ................ 27

2;YC2D2NE HCL ER ................. 10

oxycodone hcl oral capsule ........... 10

oxycodone hcl oral concentrate

100 mg/5ml ................................ 10

oxycodone hcl oral solution ........... 10

oxycodone hcl oral tablet .............. 10

oxycodone-acetaminophen oral

tablet 10-32� mg, 2.�-32� mg,

�-32� mg, �.�-32� mg ................ 10

2;YC2NTIN ................................. 10

2=EMPIC ...................................... 25

2=2BA; ....................................... 3�

P

PACER2NE 2RAL TABLET

100 MG, 400 MG ....................... 19

pacerone oral tablet 200 mg ......... 19

PAMELOR ..................................... 14

PANCREA=E ................................ 27

pantoprazole sodium tablet

delayed release .......................... 26

paroex ............................................ 21

paroxetine hcl ................................ 14

paroxetine hcl er ............................ 14

PAXIL ............................................ 14

PA;IL CR ...................................... 14

PAZEO .......................................... 3�

PEDIAPRED .................................. 31

peg-33�0/electrolytes .................... 27

penicillamine oral capsule ............. 27

penicillin v potassium .................... 12

PENNSAID .....................................11

PENTASA ...................................... 3�

PERF2R2MIST ............................ 3�

PERIDEX ....................................... 21

periogard ....................................... 21

permethrin external ....................... 16

PERT=YE ...................................... 27

phenadoz ....................................... 14

phenazo oral tablet 200 mg ........... 27

phenazopyridine hcl oral tablet

100 mg, 200 mg ......................... 27

philith ............................................. 30

PICAT2 ......................................... 22

pimtrea .......................................... 30

48

pioglitazone hcl.............................. 25

pirmella 1/3� .................................. 30

PLE*RIDY .................................... 20

PLENVU ........................................ 27

P2LY-9I-FL2R .............................. 26

polymyxin b-trimethoprim .............. 3�

P2LYTRIM .................................... 3�

portia-2� ........................................ 30

potassium chloride crys er ............ 26

potassium chloride er .................... 26

potassium chloride oral ................. 26

potassium citrate er ....................... 26

PRADAXA ..................................... 13

PRALUENT ................................... 19

pramipexole dihydrochloride ......... 16

pramipexole dihydrochloride er ..... 16

PRA9ACH2L ................................ 19

pravastatin sodium ........................ 19

prazosin hcl oral ............................ 19

PRED F2RTE ............................... 3�

PRED MILD ................................... 3�

prednisolone acetate ophthalmic .. 3�

prednisolone oral solution ............. 31

prednisolone sodium phosphate

oral ............................................. 31

prednisone intensol ....................... 31

prednisone oral .............................. 31

pregabalin oral ............................... 21

pregnyl ........................................... 33

PREMARIN ORAL ........................ 30

PREMARIN VAGINAL ................... 30

premium lidocaine ......................... 10

PREMPHASE ................................ 30

PREMPRO .................................... 30

PREP2PI. .................................... 27

PREVIDENT .................................. 21

PRE9IDENT �000 B22STER

PLUS .......................................... 21

PRE9IDENT �000 DRY M2UTH .. 21

PREVIDENT 5000 ORTHO

DEFENSE .................................. 21

PREVIDENT 5000 PLUS .............. 21

previfem ......................................... 30

PRE=C2BI; .................................. 16

PREZISTA ..................................... 16

PRIMLEV ....................................... 10

PRINIVIL ....................................... 19

PROAIR DIGIHALER .................... 3�

ProAir HFA .................................... 3�

PR2AIR RESPICLIC. .................. 3�

PR2CARDIA ................................. 19

PR2CARDIA ;L............................ 19

PR2CENTRA ................................ 20

prochlorperazine maleate oral ....... 14

PR2C2RT .................................... 3�

PR2CT2F2AM HC ....................... 3�

progesterone micronized oral ........ 30

PR2*RAF 2RAL PAC.ET .......... 33

promethazine hcl oral tablet .......... 14

promethazine hcl rectal ................. 14

prometha]ine-codeine .................. 3�

prometha]ine-dm .......................... 3�

promethegan ................................. 14

propranolol hcl er........................... 19

propranolol hcl oral ........................ 19

PR2SCAR ..................................... 28

PR2T2NI; 2RAL PAC.ET ......... 26

Proventil HFA ................................. 3�

PROVERA ............................... 2�, 30

pseudoephedrine-bromphen-dm .. 3�

PULMIC2RT FLE;HALER ........... 3�

PULM2=YME ............................... 3�

PURIXAN ...................................... 15

PYLERA ........................................ 26

PYRIDIUM ..................................... 28

Q

4BRELIS ....................................... 19

QMIIZ ODT .....................................11

4UDE;Y ;R ................................. 13

Tuetiapine fumarate ....................... 16

Tuetiapine fumarate er .................. 16

4UFL2RA PEDIATRIC ................. 26

4UILLICHE: ER .......................... 20

QUILLIVANT XR ........................... 20

Tuinapril hcl ................................... 19

QVAR REDIHALER ....................... 3�

R

RABEPRA=2LE S2DIUM 2RAL

CAPSULE SPRIN.LE ............... 26

rabeprazole sodium oral tablet

delayed release .......................... 26

ramipril ........................................... 19

ranolazine er .................................. 19

RAPAMUNE ORAL SOLUTION ... 33

RASUVO ....................................... 33

RAY2S .......................................... 31

REBIF ............................................ 20

REBIF REBID2SE ........................ 20

reclipsen ........................................ 30

REC2MBINATE ............................ 25

REGLAN........................................ 14

RELAFEN DS .................................11

relexxii ........................................... 20

REMERON .................................... 14

REMER2N S2LTAB ..................... 14

REPATHA ...................................... 19

RESTASIS ..................................... 3�

RESTASIS MULTIDOSE ............... 3�

RESTORIL ..................................... 3�

RETACRIT ..................................... 25

REVLIMID ..................................... 15

RH2FADE CREAM 1� ................. 22

RHOPRESSA ................................ 3�

RILUTE. ....................................... 21

riluzole ........................................... 21

49

RINVOQ ........................................ 33

RIOMET ........................................ 25

risperidone..................................... 16

RITALIN ......................................... 20

ritonavir .......................................... 16

rivelsa ............................................ 31

rizatriptan benzoate ....................... 15

R2BA;IN-��0 ............................... 3�

R2CALTR2L ................................. 3�

R2C.LATAN ................................. 3�

ropinirole hcl .................................. 16

ropinirole hcl er .............................. 16

rosadan external cream................. 22

rosadan external gel ...................... 22

rosuvastatin calcium ...................... 19

roweepra ....................................... 13

roweepra xr ................................... 13

R2;IC2D2NE .............................. 10

RUC2NEST .................................. 33

RYBELSUS ................................... 25

RYTARY ........................................ 16

S

SAPHRIS ....................................... 16

scopolamine .................................. 14

SEASONIQUE .............................. 31

SERNIVO ...................................... 22

sertraline hcl oral ........................... 14

setlakin .......................................... 31

sf ................................................... 21

sf 5000 plus ................................... 21

SFR2:ASA .................................. 3�

sharobel ......................................... 31

sildenafil citrate oral tablet

100 mg, 25 mg, 50 mg ............... 26

simliya ............................................ 31

simpesse ....................................... 31

SIMPONI ....................................... 33

simvastatin oral tablet 10 mg,

20 mg, 40 mg, 5 mg ................... 19

simvastatin oral tablet �0 mg ......... 19

SINEMET ...................................... 16

SIN*ULAIR 2RAL PAC.ET ........ 3�

sirolimus oral ................................. 33

SITAVIG ......................................... 16

S.YRI=I �1�0 M* D2SE� ............. 33

sodium fluoride �000 plus ............. 21

sodium fluoride dental ................... 21

S2F2S/9ELPAT 2RAL TABLET

�00-100 ...................................... 17

S2F2SBU9IR-9ELPATAS9IR ...... 17

S2FTCLI; ............................... 23, 2�

SOLIQUA....................................... 25

S2L2DYN ..................................... 12

SOLTAMOX ................................... 15

S2MA 2RAL TABLET 3�0 M* .... 3�

S22LANTRA CREAM 1� ............ 22

sotalol hcl oral ............................... 19

S2TYLI=E ..................................... 19

SPIRIVA HANDIHALER ................ 3�

SPIRIVA RESPIMAT ..................... 3�

spironolactone oral ........................ 19

sprintec 28 ..................................... 31

SPRITAM ....................................... 13

SPRIX .............................................11

sronyx ............................................ 31

sss 10-� ......................................... 22

STELARA ...................................... 33

STENDRA ..................................... 26

STIMATE ....................................... 32

STRENSIQ .................................... 27

STRIANT ....................................... 32

STRIBILD ...................................... 17

STRIVERDI RESPIMAT ................ 3�

SUBSYS ........................................ 10

subvenite ....................................... 13

sucralfate oral ................................ 26

sulfacetamide sodium-sulfur ......... 22

sulfamethoxa]ole-trimethoprim

oral ............................................. 12

sulfamez wash ............................... 22

sulfasalazine oral tablet ................. 3�

sulfatrim pediatric .......................... 12

sumatriptan succinate oral ............ 15

sumatriptan succinate refill ............ 15

sumatriptan succinate

subcutaneous ............................. 15

SUNOSI ......................................... 3�

SUPREP B2:EL PREP .IT ........ 27

syeda ............................................. 31

SYMA; DU2TAB .......................... 27

symax-sl ........................................ 27

symax-sr ........................................ 27

SYMBIC2RT ................................. 3�

SYMFI ............................................ 17

SYMFI L2 ...................................... 17

SYM-EPI ....................................... 3�

SYMPR2IC ................................... 27

SYNALAR ..................................... 22

SYN-ARDY ................................... 25

SYN-ARDY ;R ............................. 25

SYNTHR2ID ................................. 32

SYPRINE ....................................... 27

T

TACL2NE; E;TERNAL

SUSPENSION ............................ 22

tacrolimus oral ............................... 33

tadalafil oral ................................... 26

TA.H=YR2 ................................... 33

tamoxifen citrate oral tablet

10 mg ......................................... 15

tamoxifen citrate oral tablet

20 mg ......................................... 15

tamsulosin hcl ................................ 28

TAPAZOLE .................................... 32

TARGADOX................................... 12

50

TARGRETIN EXTERNAL ............. 15

TARGRETIN ORAL ....................... 15

tarina 24 fe .................................... 31

tarina fe 1/20.................................. 31

tarina fe 1/20 eT ............................ 31

TASIGNA ....................................... 15

TAYTULLA .................................... 31

tazarotene external........................ 22

TA=2RAC E;TERNAL CREAM

0.1 % .......................................... 23

TA=2RAC E;TERNAL *EL ......... 23

TECFIDERA .................................. 20

TEGRETOL ................................... 13

TE*RET2L-;R ............................. 13

TEGSEDI ....................................... 27

TE.TURNA ................................... 19

TE.TURNA HCT .......................... 19

telmisartan ..................................... 19

temazepam .................................... 3�

TEMI;YS ....................................... 17

TEMOVATE ................................... 23

tenofovir disoproxil fumarate ......... 17

terazosin hcl .................................. 28

terbinafine hcl oral ......................... 15

terconazole .................................... 15

TESSALON PERLES .................... 3�

TESTIM ......................................... 32

TEST2STER2NE CYPI2NATE

IN-ECTI2N ................................ 32

testosterone cypionate

intramuscular .............................. 32

testosterone enanthate

intramuscular .............................. 32

testosterone transdermal ............... 32

TE;AC2RT ................................... 23

thyroid oral tablet 120 mg, 15 mg,

30 mg, �0 mg, �0 mg ................. 32

TI*LUTI. ...................................... 21

timolol maleate ophthalmic ............ 3�

TIM2PTIC ..................................... 3�

TIM2PTIC 2CUD2SE .................. 3�

TIM2PTIC-;E ............................... 3�

TIROSINT ...................................... 32

TIR2SINT-S2L ............................. 32

TI9ICAY ......................................... 17

tizanidine hcl oral ........................... 3�

T2BI P2DHALER ......................... 3�

T2BRADE; .................................. 3�

T2BRADE; ST ............................. 3�


300 mg/�ml inhalation ................ 3�

tobramycin ophthalmic .................. 3�

tobramycin-dexamethasone .......... 3�

T2BRE; ........................................ 3�

T2LA. ........................................... 23

TOPAMAX ..................................... 13

T2PAMA; SPRIN.LE .................. 13

topiramate er ................................. 13

topiramate oral .............................. 13

TOPROL XL .................................. 19

torsemide ....................................... 19

T2U-E2 MA; S2L2STAR ........... 24

T2U-E2 S2L2STAR .................... 24

TOVIAZ ......................................... 28

TRACLEER ................................... 3�

TRAD-ENTA ................................. 25

tramadol hcl er (biphasic) .............. 10

TRAMAD2L HCL ER 2RAL

CAPSULE E;TENDED RELEASE

24 HOUR 100 MG, 200 MG,

300 M* ...................................... 10

tramadol hcl er oral capsule


150 mg ........................................11

tramadol hcl er oral tablet extended

release 24 hour ...........................11

tramadol hcl oral tablet 50 mg ........11

TRANSDERM SC2P �1.� M*� ..... 14

TRANSDERM-SC2P �1.� M*� ..... 14

TRAVATAN Z ................................. 3�

travoprost �bak free� ...................... 3�

trazodone hcl oral .......................... 14

TRELE*Y ELLIPTA ....................... 3�

TREMFYA ..................................... 33

TRESIBA ....................................... 24

TRESIBA FLE;T2UCH ................ 24

tretinoin external ............................ 23

TREXALL ...................................... 33

TREZIX ...........................................11

tri femynor ..................................... 31

tri-estarylla .................................... 31

tri-linyah ......................................... 31

tri-lo-estarylla ................................ 31

tri-lo-mili ........................................ 31

tri-lo-sprintec ................................. 31

tri-mili ............................................. 31

tri-previfem .................................... 31

tri-sprintec ..................................... 31

tri-vylibra ........................................ 31

tri-vylibra lo .................................... 31

triamcinolone acetonide external .. 23

triamterene-hct] ............................ 19

trianex ............................................ 23

triazolam ........................................ 17

triderm ........................................... 23

TRIDESILON ................................. 23

trientine hcl .................................... 27

TRILEPTAL ................................... 13

TRINTELLIX .................................. 14

TRIUMEQ ...................................... 17

TR2.ENDI ;R .............................. 13

TRULICITY .................................... 25

TRUVADA ..................................... 17

tulana ............................................. 31

TUSSICAPS .................................. 3�

tydemy ........................................... 31

TYLEN2L :ITH C2DEINE �3 ......11

TYML2S ........................................ 3�

TY9AS2 ........................................ 3�

51

U

UCERIS 2RAL .............................. 3�

UCERIS RECTAL .......................... 3�

ULTRAM .........................................11

unithroid ......................................... 32

UR2CIT-. 10 ................................ 26

UR2CIT-. 1� ................................ 26

UR2CIT-. � .................................. 26

UROXATRAL ................................ 28

URSO 250 ..................................... 27

URS2 F2RTE ............................... 27

ursodiol oral ................................... 27

V

valacyclovir hcl oral ....................... 17

valsartan ........................................ 19

valsartan-hydrochlorothia]ide ....... 19

9ALT2C2 ...................................... 13

VANATOL LQ .................................11

VANATOL S ....................................11

vanda]ole ...................................... 12

9ARUBI �1�0 M* D2SE� .............. 14

9ASCEPA ...................................... 19

VELPHORO .................................. 28

VELTASSA .................................... 26

9EMLIDY ....................................... 17

venlafaxine hcl ............................... 14

venlafaxine hcl er .......................... 14

9entolin HFA .................................. 3�

verapamil hcl er ............................. 19

verapamil hcl oral .......................... 19

VERDESO ..................................... 23

VERELAN ............................... 19, 20

VERELAN PM ............................... 20

VERZENIO .................................... 15

9IBER=I ........................................ 27

9IBRAMYCIN 2RAL CAPSULE ... 12

9IBRAMYCIN 2RAL SUSPENSI2N

REC2NSTITUTED ..................... 13

vicodin hp oral tablet 10-300 mg ....11



SUBCUTANE2US ..................... 25

vienva ............................................ 31

9IIBRYD ........................................ 14

VIMPAT ORAL .............................. 13

9I2.ACE ...................................... 27

viorele ............................................ 31

VIREAD ORAL POWDER ............. 17

9IREAD 2RAL TABLET 1�0 M*,

200 MG, 250 MG ....................... 17

VISTARIL ....................................... 17

vitamin d �ergocalciferol� oral capsule

1.25 mg (50000 ut) ..................... 26

9ivelle-Dot ............................... 2�, 31

VIVLODEX .....................................11

VOSEVI ......................................... 17

vyfemla .......................................... 31

9YLEESI ....................................... 26

vylibra ............................................ 31

9Y9ANSE ..................................... 20

9Y=ULTA ....................................... 3�

W

:A.I; ........................................... 3�

warfarin sodium oral ...................... 13

:ELCH2L ..................................... 20

wera ............................................... 31

WESTHROID ................................ 32

wixela inhub ................................... 3�

:P THYR2ID ............................... 32

X

XARELTO ...................................... 13

;EL-AN= ....................................... 33

;EL-AN= ;R 2RAL TABLET


11 MG ......................................... 33

XELODA ........................................ 15

XELPROS...................................... 3�

XEPI .............................................. 13

;HANCE ....................................... 3�

XIIDRA .......................................... 3�

XIMINO .......................................... 13

;2FLU=A ...................................... 17

XOLEGEL ...................................... 15

;2PENE; HFA ............................. 3�

XTAMPZA ER ................................11

xulane ............................................ 31

;Y2STED ..................................... 32

;YREM.......................................... 3�

Y

YASMIN 2� .................................... 31

YA= ................................................ 31

YUPELRI ....................................... 3�

yuvafem ......................................... 31

Z

=ANAFLE; 2RAL CAPSULE....... 3�

zarah ............................................. 31

ZARXIO ......................................... 25

=EBUTAL .......................................11

=E-ULA ......................................... 15

ZELNORM ..................................... 27

=EMBRACE SYMT2UCH ............. 15

zenatane ........................................ 23

ZENPEP ........................................ 27

=EN=EDI 2RAL TABLET 1� M*, 2.�

M*, 20 M*, 30 M*, �.� M* ...... 20

ZEPATIER ..................................... 17

ZETONNA ..................................... 3�

=IAC .............................................. 20

ziprasidone hcl .............................. 16

ZIPSOR ..........................................11

ZITHROMAX ORAL ...................... 13

=ITHR2MA; TRI-PA. .................. 13

52

=ITHR2MA; =-PA. ...................... 13

=2C2R 2RAL TABLET 10 M*,

20 MG, 40 MG, 80 MG ............... 20

=2FRAN ........................................ 14

=2HYDR2 ER ...............................11

zolpidem tartrate ........................... 3�

zolpidem tartrate er ....................... 3�

=2MACT2N .................................. 32

ZONEGRAN .................................. 13

zonisamide oral ............................. 13

=2NTI9ITY .................................... 16

ZOVIRAX ORAL SUSPENSION ... 17

ZTLIDO ...........................................11

=UBS2L9 ...................................... 12

zumandimine ................................. 31

ZUPLENZ ...................................... 14

=YCLARA ...................................... 23

=YCLARA PUMP .......................... 23

=YL2PRIM .................................... 15

�3

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54

http://www.hhs.gov/ocr/office/file/index.html

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

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«·½� �Å·�¡��¾½�¯Á·�©�È» �·½ل��½ ½ �م�.Æ�½ م½�م��·½¯»ªÁ�·Æ�©½�¯Á·�·Å��¡ ��¾½ ��ÆÁÆمÁ�«½مÆª�¦«¬Á�(Farsi) م½�فارسی��©½ ��·�Á��¡ÄÅ».Æ¯·¯� �½م»��Æ��Æ¯¸�½م� �¯½¬½¾�

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Multi-language interpreter services Multi-language interpreter services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call�the�toll-free�phone�number�listed�on�\our�identi¿cation�card.

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êéèçæéèå��äãâáàßÞÝÜã�ÛâàÛÚÙ�áãØã×ÖÕß�ÕÖâÞÛáÝÜ�Õàя�àюÕãÒ,�ÑãÒ�ØÖÕÝÖÒ�яÐÜÏ�я×àяãÞâя� русском (Russian).�ÎÖÐ×ÖÝÙÞã�áÖ�äãâáàßÞÝÖÍÛ�ÝÖÍãØÛ�ÞãàãÌÖÝß,�ÛÏßÐßÝÝÖÍÛ�Ýß�×ßËãÒ�ÙÕãÝÞÙÌÙÏßÊÙÖÝÝÖÒ�ÏßØÞã.

�ÉÈÇ�ÆÅÄÅلمÁ�À¾½ÄلمÁ�¼»½ºلÁ�¹¸·�ÉÈÇ�¶½µ»´Á�³½Ä·لÁ�.²م«½°±�ل�±¯¾½ÄلمÁ�±¯Å®ÈلÁ�ÆÇ½¬لمÁ�«½مÆª�©¨§�¦(Arabic) العربية�¥Æ°»»�«¾¤�Á£¢��¡¯ ¾».±¯Åل��Á�¼·م��

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55

2020 Prescription Drug List ² Flex Base 3-Tier �/20

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Documents

Your 2020 Prescription Drug List · What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a generic euivalent