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Medicare Parte D de Health Net
Formulario del Grupo
del Empleador de
5 Niveles de 2013
(Lista de Medicamentos Cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS
QUE CUBRIMOS EN ESTE PLAN
El formulario adjunto se actualizó por última vez el 1 de diciembre de 2013 para el año de beneficios 2013.
Los medicamentos enumerados en este formulario están sujetos a la disponibilidad en el mercado. Para
obtener información actualizada sobre los medicamentos que cubrimos, visite nuestro sitio Web en
www.healthnet.com/medicare.
Nota para los afiliados existentes: Se han registrado cambios en este formulario a partir del año pasado.
Revise este documento para asegurarse de que aún incluya los medicamentos que usted toma.
Los beneficiarios deben usar las farmacias de la red para acceder a su beneficio de medicamentos que requieren
receta médica. Los beneficios, el formulario, la red de farmacias, la prima y/o los co-pagos/el coseguro pueden
cambiar a partir del 1 de enero de 2014.
This information is available for free in other languages. Please contact our Customer Service department
at the toll-free number listed at the beginning of this booklet.
Esta información está disponible en forma gratuita en otros idiomas. Comuníquese con nuestro departamento
de Servicio al Cliente al número de teléfono gratuito que aparece al comienzo de este folleto.
Health Net es una organización de Medicare Advantage que tiene un contrato con Medicare.
Health Net es un plan de Atención Coordinada que tiene un contrato con Medicare y un contrato con los
programas Medicaid de California y Arizona.
Health Net es un plan de Atención Coordinada que tiene un contrato con Medicare.
CA108768-1
Material ID# Y0035_EG_2013_0005_SPN (H0351, H0562, H5439, H5520, H6815, EG)
Compliance Approved 07302012
HPMS Approved Formulary File Submission ID 13506, Version 21

Si desea comunicarse con Health Net,
busque la información de contacto
correspondiente a su estado a continuación:
Arizona
Health Net
Attn: Arizona Medicare Program
P.O. Box 10420
Van Nuys, CA 91410-0420
Fax- 1-866-214-1992
Horario de atención: de 8:00 a.m.
a 8:00 p.m., los siete días de la semana.
Todos los Planes Médicos
1-800-977-7522, TTY 1-800-977-6757
California
Health Net
P.O. Box 10198
Van Nuys, CA 91410-0198
Fax- 1-866-214-1992
Horario de atención: de 8:00 a.m.
a 8:00 p.m., los siete días de la semana.
Todos los Planes Médicos
1-800-275-4737, TTY 1-800-929-9955
i

Bienvenido a Health Net.
Nos complace que haya
elegido nuestro plan para sus
necesidades de medicamentos
que requieren receta médica.
Este formulario fácil de leer
le brinda información valiosa
sobre el formulario (también
conocido como “lista de
medicamentos”) que se aplica a
su beneficio, los medicamentos
que requieren receta médica
que cubrimos, los niveles
de co-pago o coseguro, y la
manera de utilizar su beneficio.
Para encontrar rápidamente su
medicamento, consulte el índice
al final de este folleto. Para
obtener información detallada
sobre cómo leer el formulario,
consulte la página ix.
¿Qué es el formulario de Medicare
Parte D de Health Net?
Este formulario representa la lista
completa de los medicamentos de la
Parte D cubiertos por Health Net. Un
formulario es una lista de medicamentos
cubiertos seleccionados por Health Net
en consulta con un equipo de proveedores
de cuidado de la salud, que incluye las
terapias con medicamentos que requieren
receta médica consideradas como una
parte necesaria de un programa de
tratamiento de calidad. Generalmente,
Health Net cubrirá los medicamentos
enumerados en el formulario, siempre
que el medicamento sea médicamente
necesario, que la receta sea surtida en una
farmacia de la red de Health Net y que
se cumpla con las demás reglas del plan.
Para obtener más información sobre cómo
surtir sus recetas, revise su Evidencia de
Cobertura (por sus siglas en inglés, EOC).
¿El formulario puede cambiar?
Generalmente, si usted está tomando un
medicamento de nuestro formulario de
2013 que estaba cubierto al comienzo del
año, no interrumpiremos ni reduciremos
la cobertura de dicho medicamento
durante 2013, excepto cuando un nuevo
medicamento genérico, menos costoso,
se encuentre disponible y se ofrezca en
un nivel más bajo o a un costo menor
para usted, o cuando se divulgue nueva
información sobre la seguridad o la
eficacia de un medicamento.
En la mayoría de los casos, los cambios
en el formulario, tales como aplicar
una restricción nueva o revisada a un
medicamento, agregar un límite de
cantidad a un medicamento, pasar un
medicamento a un nivel más costoso
o eliminar un medicamento del
formulario, no le afectarán si actualmente
está tomando el medicamento. El
medicamento seguirá estando disponible
al mismo costo por el resto del año.
Sin embargo, en algunos casos, estos
tipos de cambios en el formulario pueden
afectarle. Si un cambio en el formulario
le afectará, debemos notificárselo con
anticipación. Recibirá la notificación al
menos 60 días antes de que el cambio
entre en vigencia. Si realizamos algún
cambio en el formulario que no sea de
mantenimiento durante el año, se lo
notificaremos por correo, y los cambios se
publicarán en nuestro sitio Web.
iii

Si la Administración de Drogas y
Alimentos de los Estados Unidos (por sus
siglas en inglés, FDA) considera que un
medicamento del formulario no es seguro
o si el fabricante del medicamento lo
retira del mercado, nosotros retiraremos
de inmediato dicho medicamento del
formulario y le enviaremos un aviso si
usted lo está recibiendo actualmente.
Para obtener la información más
actualizada sobre los medicamentos
cubiertos por Health Net, visite nuestro
sitio Web en www.healthnet.com/
medicare, donde puede ver e imprimir
un formulario. También puede llamar
a nuestro departamento de Servicio al
Cliente al número de teléfono gratuito
que aparece al comienzo de este folleto.
¿Qué sucede si mi medicamento
no está en el formulario?
Si su medicamento no está incluido en
el formulario, usted debe comunicarse
primero con Servicio al Cliente y
preguntar si su medicamento está
cubierto. Si se entera de que Health Net
no cubre su medicamento, tiene dos
opciones:
• Puede solicitar a Servicio al Cliente
que le proporcione una lista de
medicamentos similares que estén
cubiertos por Health Net. Cuando
reciba la lista, muéstresela a su médico u
otra persona que receta y solicíteles que
le indiquen un medicamento similar
que esté cubierto por Health Net.
• Puede solicitar a Health Net que haga
una excepción y cubra su medicamento.
Consulte “¿Cómo solicito una excepción
al formulario de Medicare Parte D de
Health Net?” para obtener información
sobre cómo solicitar una excepción.
¿Qué son los medicamentos
de venta libre (OTC)?
Los medicamentos de venta libre son
aquellos que no requieren receta médica
y habitualmente no están cubiertos por
un Plan de Medicamentos que Requieren
Receta Médica de Medicare. Los únicos
medicamentos de venta libre cubiertos
conforme a Medicare Parte D son
algunos tipos de insulinas y suministros
para insulina. Ciertos medicamentos se
encuentran disponibles tanto en forma de
medicamento que requiere receta médica
como en forma de venta libre. Salvo
algunos tipos de insulinas y suministros
para insulina, los planes Medicare
Parte D de Health Net sólo cubren los
medicamentos que requieren receta
médica.
¿Hay alguna restricción en
mi cobertura?
Algunos medicamentos pueden tener
requisitos o limitaciones adicionales
en la cobertura. Puede averiguar si
su medicamento tiene restricciones o
limitaciones consultando la columna
Límites del formulario.
iv

La tabla a continuación proporciona una descripción de las abreviaturas que pueden
aparecer en la columna Límites del formulario:
Abreviatura Definición Descripción
AL Límite de Edad Es posible que algunos medicamentos
requieran una autorización previa si su edad
no está dentro de las recomendaciones
clínicas, del fabricante o de la FDA.
B Medicare Parte B Algunos medicamentos enumerados en el
formulario sólo están cubiertos conforme a
Medicare Parte B. En algunos casos, estos
medicamentos pueden obtenerse en una
farmacia si usted cuenta con la cobertura de
la Parte B a través de Health Net. Consulte
los documentos de su plan para conocer el
co-pago o el coseguro correspondientes.
B/D
Medicare Parte B frente
a Medicare Parte D
Algunos medicamentos requieren
autorización previa para determinar
la cobertura conforme al beneficio de
Medicare Parte B o Parte D, de acuerdo
con las pautas de Medicare. Es posible
que su médico u otra persona que receta
deban proporcionar información adicional,
que le permitirá a Health Net tomar la
determinación de cobertura.
GL Límite de Género Algunos medicamentos sólo están
cubiertos para hombres o mujeres según las
recomendaciones clínicas, del fabricante o
de la FDA.
LA Acceso Limitado Algunos medicamentos pueden estar
sujetos a un acceso limitado o restringido.
Esto significa que un medicamento sólo
puede estar disponible en una farmacia
o en una cantidad limitada de farmacias.
El acceso limitado puede deberse a los
siguientes motivos:
• La FDA ha restringido la distribución de
un medicamento a determinados centros,
farmacias o profesionales que recetan; o
bien,
• Determinados medicamentos requieren
un manejo especial, una coordinación de
la atención o una educación del paciente
que no pueden proporcionarse en una
farmacia de venta minorista.
Usted debe hablar con su médico u otra
persona que receta, o con su farmacéutico
para solicitar detalles sobre cómo obtener
medicamentos de acceso limitado.
v

Abreviatura Definición Descripción
MO Compra por Correo Estos medicamentos están disponibles
en una farmacia de compra por correo de
la red de Health Net, así como en otras
farmacias de la red.
NT
Fuera del Costo de
Desembolso Real
Health Net cubre algunos medicamentos
que los Centros de Servicios de Medicare
y Medicaid (CMS) excluyen de la cobertura
conforme a la Parte D. La cantidad pagada
por estos medicamentos no se considerará
para sus costos de desembolso reales
(TrOOP) ni para el Límite de Cobertura
Inicial.
PA Autorización Previa Algunos medicamentos requieren
autorización previa por cuestiones de
cobertura, eficacia o seguridad. Esto
significa que usted, su médico u otra
persona que receta deben solicitar la
aprobación de Health Net antes de recibir la
cobertura del medicamento.
QL Límite de Cantidad Para ciertos medicamentos, Health Net
limita la cantidad del medicamento que
cubrirá. Por ejemplo, proporciona 2 píldoras
por día por receta de ZOCOR (simvastatina)
40 MG. Esto puede agregarse a un
suministro estándar de un mes o de tres
meses.
RX/OTC
Medicamentos que
Requieren Receta
Médica y de Venta
Libre
Ciertos medicamentos se encuentran
disponibles tanto en forma de medicamento
que requiere receta médica como en
forma de venta libre. Salvo algunos tipos
de insulinas y suministros para insulina, los
planes Medicare Parte D de Health Net sólo
cubren los medicamentos que requieren
receta médica.
ST Terapia Escalonada En algunos casos, Health Net requiere
que usted pruebe primero determinados
medicamentos para tratar su condición
médica antes de cubrir otro medicamento
para esa condición.
Por ejemplo, si tanto el Medicamento A
como el Medicamento B tratan su condición
médica, Health Net posiblemente no
cubra el Medicamento B, a menos que
usted pruebe primero el Medicamento
A. Si el Medicamento A no es eficaz para
usted, entonces Health Net cubrirá el
Medicamento B.
Puede solicitar a Health Net que haga una excepción a estas restricciones o limitaciones.
Consulte la siguiente sección.
vi

¿Cómo solicito una excepción al
formulario de Medicare Parte D de
Health Net?
Puede solicitar a Health Net que haga una
excepción a nuestras reglas de cobertura.
Existen varios tipos de excepciones que
usted puede solicitar.
• Nos puede pedir que cubramos su
medicamento aun cuando el mismo no
se encuentre en el formulario.
– Si otorgamos su solicitud de cubrir
un medicamento que no está en el
formulario, el medicamento estará
disponible mediante el co-pago o
coseguro del Nivel 3 (medicamentos
de marca no preferidos). El
medicamento no es elegible para
una excepción de pago en un nivel
inferior.
• Puede pedirnos que anulemos las
restricciones o limitaciones de cobertura
con respecto a su medicamento.
Por ejemplo, para determinados
medicamentos, Health Net puede
limitar la cantidad del medicamento que
se cubrirá. Si su medicamento tiene un
límite de cantidad, puede pedirnos que
anulemos dicho límite y cubramos más.
• Puede solicitarnos que hagamos una
excepción y cubramos su medicamento
en un nivel inferior.
– Si su medicamento está en el
Nivel 3 (medicamentos de marca
no preferidos) o en el Nivel 4
(medicamentos inyectables), puede
solicitarnos una excepción para que
lo cubramos mediante el co-pago o
coseguro del Nivel 2 (medicamentos
de marca preferidos).
– Los medicamentos del Nivel 2
(medicamentos de marca preferidos)
y del Nivel 5 (nivel de especialidades)
no son elegibles para una excepción
de pago en un nivel inferior.
Generalmente, Health Net sólo
aprobará su solicitud de excepción si
los medicamentos alternativos o las
restricciones de utilización no fuesen tan
eficaces en el tratamiento de su condición,
o bien, si le ocasionaran efectos médicos
perjudiciales.
Usted puede comunicarse con nosotros
para solicitar una excepción. Al solicitar
una excepción, exigimos una declaración
de su médico u otra persona que receta
que respalde su solicitud. Generalmente,
debemos tomar nuestra decisión dentro
de las 72 horas de haber recibido la
declaración de respaldo de su médico u
otra persona que receta. Usted, su médico
u otra persona que receta pueden solicitar
una excepción acelerada (rápida) si creen
que su salud podría verse gravemente
perjudicada al esperar las 72 horas para
obtener una decisión. Si se otorga su
solicitud de excepción acelerada, debemos
informarle de la decisión en un lapso de
24 horas como máximo después de haber
recibido la declaración de respaldo de
su médico u otra persona que recetó el
medicamento.
vii

Descripciones de los niveles del formulario
Para determinar cuánto pagará por un medicamento, consulte las abreviaturas de la
tabla a continuación, que aparecen en las columnas Nivel de Medicamentos de Marca y
Nivel de Medicamentos Genéricos del formulario. El nivel de co-pago o coseguro que
usted pagará se muestra en la columna Co-pago/Coseguro. Si no conoce su co-pago o
coseguro para cada nivel, consulte su Resumen de Beneficios o EOC.
viii
Abreviatura Co-pago/Coseguro Descripción
1 Co-pago o coseguro
del Nivel 1
2 Co-pago o coseguro
del Nivel 2
3 Co-pago o coseguro
del Nivel 3
4 Co-pago o coseguro
del Nivel 4
5 Co-pago o coseguro
del Nivel 5
NF
Fuera del formulario:
Si Health Net aprueba
una solicitud de
excepción para un
medicamento fuera
del formulario, se
aplicará el co-pago
o coseguro del nivel
de medicamentos de
marca no preferidos
(Nivel 3).
Medicamentos genéricos preferidos.
Todos los medicamentos genéricos
preferidos cubiertos (los de la Parte D y los
que no pertenecen a la Parte D).
Medicamentos de marca preferidos.
Todos los medicamentos de marca
preferidos cubiertos (los de la Parte D y los
que no pertenecen a la Parte D).
Los medicamentos de este nivel no son
elegibles para excepciones de pago en un
nivel inferior.
Medicamentos de marca no preferidos.
Todos los medicamentos de marca no
preferidos cubiertos (los de la Parte D y los
que no pertenecen a la Parte D).
Medicamentos inyectables.
Incluye los medicamentos inyectables que
no alcanzan el umbral mínimo de costos
establecido por los CMS y requerido
para ubicarse en el Nivel 5 (nivel de
especialidades).
Todos los medicamentos cubiertos (los de
la Parte D y los que no pertenecen a la
Parte D).
Nivel de especialidades.
Incluye los medicamentos de costo elevado.
Todos los medicamentos del nivel de
especialidades cubiertos (los de la Parte D y
los que no pertenecen a la Parte D).
Los medicamentos de este nivel no son
elegibles para excepciones de pago en un
nivel inferior.
Medicamentos que no están cubiertos
en el formulario de Medicare Parte D de
Health Net. Usted puede solicitar una
excepción por parte de Health Net para
que cubra estos medicamentos. Para
obtener información sobre cómo solicitar
una excepción, consulte la sección “¿Cómo
solicito una excepción al formulario de
Medicare Parte D de Health Net?”.

¿Cómo utilizo el formulario?
Hay dos maneras de buscar su
medicamento en el formulario:
Condición médica
El formulario comienza en la página 1.
Los medicamentos de este formulario se
agrupan en categorías según el tipo de
condición médica que traten. Por ejemplo,
los medicamentos utilizados para tratar la
depresión se enumeran bajo la categoría
ANTIDEPRESIVOS.
Lista alfabética
Si no está seguro de la categoría bajo la
que se enumera su medicamento, debe
buscarlo en el índice que aparece al final
de este folleto. El índice proporciona una
lista alfabética de todos los medicamentos
incluidos en este documento. Tanto
los medicamentos de marca como
los medicamentos genéricos están
enumerados en el índice. Busque allí y
encuentre su medicamento. Junto a su
medicamento, verá el número de página
en la que puede encontrar la información
sobre la cobertura. Consulte la página
que aparece en el índice y busque el
nombre de su medicamento en la primera
columna de la lista.
¿Cómo leo el formulario?
Si tiene dificultades para encontrar un
medicamento, consulte el índice al final
de este folleto.
Medicamentos de marca y genéricos
Health Net cubre tanto los medicamentos
de marca como los medicamentos
genéricos. Un medicamento genérico
es aprobado por la FDA por contener
los mismos ingredientes activos que el
medicamento de marca. Por lo general,
los medicamentos genéricos cuestan
menos que los medicamentos de marca.
El nombre de cada medicamento puede
encontrarse en la primera columna. Los
medicamentos de marca están en letras
mayúsculas (por ejemplo: ZOCOR) y los
medicamentos genéricos están en letras
minúsculas (por ejemplo: simvastatina).
Cuando hay un medicamento de marca
con un equivalente genérico disponible,
los medicamentos se enumerarán en la
misma línea con el medicamento genérico
entre paréntesis, por ejemplo: ZOCOR
(simvastatina).
Estado del nivel
El estado del nivel se muestra a la
derecha del nombre del medicamento.
Generalmente, cuando hay un
medicamento de marca con un
equivalente genérico disponible, el
medicamento de marca puede estar en el
nivel de medicamentos no preferidos, o
bien, es posible que no se encuentre en el
formulario.
ix

Límites
La información de la columna Límites le indica si existen limitaciones o restricciones
para un medicamento. Si desea obtener una descripción completa de las abreviaturas
que se encuentran en la columna Límites, consulte la tabla Abreviaturas, que comienza
en la página v.
Nota: Ejemplo únicamente
BRAND DRUG (generic drug) Brand Tier Generic Tier Limits
Therapeutic Category Name
Therapeutic Class Name -
Brand name
(generic name)
3 1
B/D, MO,
PA, QL
Brand name 2 LA, ST
Medicamento de marca
únicamente; ningún
genérico disponible
Ejemplo de
abreviaturas;
Consulte
las páginas
v y vi para
obtener una
descripción
completa de
las abreviaturas
x
Programa de transición de Health Net
Conforme al programa de transición de
Health Net, los afiliados obtienen acceso
a medicamentos fuera del formulario.
Esto incluye los medicamentos de la
Parte D que no están en el formulario
de Medicare Parte D de Health Net,
así como los medicamentos que están
en el formulario con una limitación o
restricción (no basada en la seguridad).
El programa de transición está diseñado
para garantizar la continuidad de la
atención para los afiliados nuevos, para
los afiliados existentes que pueden estar
sujetos a cambios en el formulario y para
los afiliados que experimentan un cambio
en el nivel de atención. El programa
también permite que los afiliados que se
encuentran en centros de atención a largo
plazo tengan acceso a un suministro de
medicamentos temporal de transición.
Elegibilidad inicial y para renovación
Si usted es un afiliado nuevo, puede
estar tomando medicamentos que no
se encuentran en el formulario, o bien,
puede estar tomando medicamentos
que se encuentran en el formulario,
pero tienen restricciones o limitaciones.
Por ejemplo, posiblemente necesite que
le proporcionemos una autorización
previa antes de poder surtir su receta.
En estos casos, le recomendamos que
hable con su médico u otra persona que
receta para decidir si debe cambiar sus
medicamentos por medicamentos que
cubramos o solicitar una excepción para
que le cubramos los que toma. Mientras
habla con su médico u otra persona
que receta para determinar la forma de
proceder correcta para usted, en ciertos
casos, podemos cubrir sus medicamentos
durante los primeros 90 días de haberse
afiliado a nuestro plan. Cubriremos un
suministro temporal de transición para
30 días por única vez (a menos que
tenga una receta hecha para menos días)
cuando vaya a una farmacia de la red. Si
su receta está hecha para un suministro
de transición de menos de 30 días, se
cubrirán las repeticiones de recetas hasta
alcanzar el total de un suministro de 30
días. Esto también se puede aplicar si
usted es un afiliado que renueva contrato
y experimenta un cambio en el formulario
al comienzo del año de contrato.
Si usted es un afiliado nuevo y reside
en un centro de atención a largo plazo,

cubriremos un suministro temporal de
transición para 34 días (a menos que
tenga una receta hecha para menos
días). Le permitiremos repetir su receta
hasta que le hayamos proporcionado un
suministro de transición para 102 días (a
menos que tenga una receta hecha para
menos días).
Suministro de emergencia
Si reside en un centro de atención a largo
plazo, y han transcurrido los primeros
90 días de su afiliación a nuestro plan, y
necesita medicamentos que no están en el
formulario o que están en el formulario
con ciertas limitaciones o restricciones
(no basadas en la seguridad), cubriremos
un suministro de emergencia de sus
medicamentos para un período de
hasta 34 días (a menos que tenga una
receta hecha para menos días) mientras
solicita una excepción. Si su receta está
hecha para un suministro de transición
de menos de 34 días, se cubrirán las
repeticiones de recetas hasta alcanzar el
total de un suministro de 34 días.
Cambios en el nivel de atención
Si experimenta un cambio en el nivel
de atención, cubriremos un suministro
de transición de sus medicamentos. Un
cambio en el nivel de atención ocurre
cuando se le da de alta de un hospital o
se le traslada desde o hacia un centro de
atención a largo plazo.
varias recetas hasta alcanzar el total de
un suministro de 34 días.
Entendemos que hay otras
circunstancias en las que se puede
otorgar un suministro adicional. Estas
situaciones se manejan según cada
caso mediante la comunicación entre la
farmacia que despacha el medicamento
y Health Net.
Para obtener más información
Para obtener información más detallada
sobre su cobertura de medicamentos que
requieren receta médica de Health Net,
consulte su EOC y demás documentos
del plan.
Si tiene preguntas sobre Health Net,
llame a Servicio al Cliente al número de
teléfono gratuito que aparece al comienzo
de este folleto, o bien, visite
www.healthnet.com/medicare.
Si tiene preguntas generales acerca
de la cobertura de medicamentos que
requieren receta médica de Medicare,
llame a Medicare al 1-800-MEDICARE
(1-800-633-4227), las 24 horas del día,
los 7 días de la semana. Los usuarios
de TTY/TDD deben llamar al
1-877-486-2048. O bien,
visite www.medicare.gov.
• Si se traslada de un centro de atención
a largo plazo u hospital a su hogar y
necesita un suministro de transición,
cubriremos un suministro de 30 días.
Si su receta está hecha para menos
días, permitiremos que se surtan varias
recetas hasta alcanzar el total de un
suministro de 30 días.
• Si se traslada de su hogar o de un
hospital a un centro de atención a
largo plazo y necesita un suministro de
transición, cubriremos un suministro
de 34 días. Si su receta está hecha para
menos días, permitiremos que se surtan
xi

DRUG NAME
Drug
Tier Requirements/
Limits
ADHD/ANTI-NARCOLEPSY/ANTI-
OBESITY/ANOREXIANTS - Drugs to Treat
ADHD, Sleep and Eating Disorders
Amphetamines
adderall 1
ADDERALL XR (Use
Amphetamine-
Dextroamphetamine)
amphetaminedextroamphetamine
DEXEDRINE (Use
Dextroamphetamine
Sulfate)
dextroamphetamine sulfate
cp24 or 10 mg, 15 mg, 5
mg
dextroamphetamine sulfate
soln or 5 mg/5ml
dextroamphetamine sulfate
tabs or 10 mg, 5 mg
procentra 1
VYVANSE 20 MG 3
VYVANSE 30 MG 3
VYVANSE 40 MG, 50 MG,
60 MG, 70 MG
zenzedi 1
Anti-Obesity Agents
XENICAL 3
3
1
3
1
1
1
3
MO
MO
MO
MO
MO
MO
MO
MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
PA; MO
Attention-Deficit/Hyperactivity Disorder
INTUNIV 3
AL; MO
STRATTERA 10 MG 2
STRATTERA 100 MG, 60
MG, 80 MG
STRATTERA 18 MG 2
STRATTERA 25 MG 2
2
QL(10 ea
daily); MO
QL(1 ea daily);
MO
QL(5 ea daily);
MO
QL(4 ea daily);
MO
Drug
DRUG NAME
Tier Requirements/
Limits
STRATTERA 40 MG 2
QL(2 ea daily);
MO
Stimulants - Misc.
CONCERTA (Use
Methylphenidate HCl)
DAYTRANA 3
dexmethylphenidate hcl 1
FOCALIN (Use
Dexmethylphenidate HCl)
FOCALIN XR (Use
Dexmethylphenidate HCl)
METADATE CD (Use
Methylphenidate HCl)
METHYLIN CHEW 10 MG,
2.5 MG, 5 MG
METHYLIN SOLN 10
MG/5ML, 5 MG/5ML (Use
Methylphenidate HCl)
methylphenidate hcl cp24
or 20 mg, 30 mg, 40 mg
methylphenidate hcl cpcr or
10 mg, 20 mg, 30 mg, 40
mg, 50 mg, 60 mg
methylphenidate hcl er 1
methylphenidate hcl soln or
10 mg/5ml, 5 mg/5ml
methylphenidate hcl tabs or
10 mg, 20 mg, 5 mg
methylphenidate hcl tbcr or
18 mg, 20 mg, 27 mg, 36
mg, 54 mg
modafinil 100 mg 1
modafinil 200 mg 5
NUVIGIL 2
PROVIGIL 100 MG (Use
Modafinil)
PROVIGIL 200 MG (Use
Modafinil)
QUILLIVANT XR 3
3
3
3
3
2
3
1
1
1
1
1
3
5
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA; MO
PA; MO
PA; MO
PA; MO
PA; MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
1

DRUG NAME
RITALIN (Use
Methylphenidate HCl)
RITALIN LA (Use
Methylphenidate HCl)
RITALIN SR (Use
Methylphenidate HCl)
Drug
Tier Requirements/
Limits
3
MO
3
3
MO
MO
AMINOGLYCOSIDES - Drugs to Treat Bacterial
Infections
Aminoglycosides
amikacin sulfate soln ij 1
gm/4ml, 500 mg/2ml
gentamicin in saline 0.8-0.9
%, mg/ml
gentamicin in saline 0.9-1
%, mg/ml, 0.9-1.2 %,
mg/ml, 0.9-1.6 %, mg/ml
gentamicin sulfate soln ij
10 mg/ml, 40 mg/ml
gentamicin sulfate soln iv
10 mg/ml
gentamicin sulfate/0.9%
sodium chloride
isotonic gentamicin 4
kanamycin sulfate soln ij
333 mg/ml
neomycin sulfate tabs or
500 mg
paromomycin sulfate 1
streptomycin sulfate solr im
1 gm
TOBI (Use Tobramycin) 5
TOBI PODHALER 5
tobramycin nebu in 300
mg/5ml
tobramycin sulfate soln ij
1.2 gm/30ml, 40 mg/ml, 80
mg/2ml
tobramycin sulfate soln ij
10 mg/ml, 40 mg/ml
tobramycin sulfate solr ij
1.2 gm
4
4
4
4
4
4
4
1
4
5
4
4
4
MO
MO
MO
MO
MO
MO
MO
B/D
B/D
MO
DRUG NAME
tobramycin sulfate/sodium
chloride
Drug
Tier Requirements/
Limits
ANALGESICS - ANTI-INFLAMMATORY - Drugs
to Treat Pain, Swelling, Muscle and Joint
Conditions
Anti-TNF-alpha - Monoclonoal Antibodies
HUMIRA 5
PA
HUMIRA PEN 5
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS
STARTER
SIMPONI 5
SIMPONI ARIA 5
4
5
5
PA
PA
PA
PA
PA
Antirheumatic - Enzyme Inhibitors
XELJANZ 5
PA
Antirheumatic Antimetabolites
RHEUMATREX 2
Interleukin-1 Blockers
ARCALYST 5
MO
LA
Interleukin-1 Receptor Antagonist (IL-1Ra)
KINERET 5
PA
Interleukin-1beta Blockers
ILARIS 5
LA
Interleukin-6 Receptor Inhibitors
ACTEMRA 5
PA
Nonsteroidal Anti-inflammatory Agents
ANAPROX (Use Naproxen
Sodium)
3
MO
ANAPROX DS (Use
Naproxen Sodium)
3
MO
ARTHROTEC 50 (Use
Diclofenac w/ Misoprostol)
3
MO
ARTHROTEC 75 (Use
MO
Diclofenac w/ Misoprostol)
3
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
2

DRUG NAME
CATAFLAM (Use
Diclofenac Potassium)
CELEBREX 2
CLINORIL (Use Sulindac) 3
DAYPRO (Use Oxaprozin) 3
diclofenac potassium 1
diclofenac sodium tb24 or
100 mg
diclofenac sodium tbec or
25 mg, 50 mg, 75 mg
diclofenac w/ misoprostol 1
DUEXIS 3
EC-NAPROSYN (Use
Naproxen)
etodolac caps or 200 mg,
300 mg
etodolac tabs or 400 mg,
500 mg
etodolac tb24 or 400 mg,
500 mg, 600 mg
FELDENE (Use
Piroxicam)
fenoprofen calcium tabs or
600 mg
flurbiprofen tabs or 100 mg,
50 mg
ibuprofen susp or 100
mg/5ml
ibuprofen tabs or 400 mg 1
ibuprofen tabs or 600 mg 1
ibuprofen tabs or 800 mg 1
INDOCIN 2
indomethacin caps or 25
mg, 50 mg
indomethacin cpcr or 75
mg
Drug
Tier Requirements/
Limits
3
MO
1
1
3
1
1
1
3
1
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
RX/OTC; MO
QL(8 ea daily);
MO
QL(5 ea daily);
MO
QL(4 ea daily);
MO
MO
MO
MO
DRUG NAME
ketoprofen caps or 50 mg,
75 mg
ketoprofen er 1
ketorolac tromethamine
soln ij 15 mg/ml, 30 mg/ml
ketorolac tromethamine
soln ij 300 mg/10ml
ketorolac tromethamine
soln im 30 mg/ml, 60
mg/2ml
ketorolac tromethamine
tabs or 10 mg
meclofenamate sodium
caps or 100 mg, 50 mg
mefenamic acid caps or
250 mg
meloxicam susp or 7.5
mg/5ml
meloxicam tabs or 15 mg,
7.5 mg
MOBIC (Use Meloxicam) 3
nabumetone 1
NALFON 3
NAPRELAN 3
NAPRELAN 375 MG 2
NAPRELAN 500 MG, 750
MG
NAPROSYN (Use
Naproxen)
naproxen sodium tabs or
275 mg, 550 mg
naproxen susp or 125
mg/5ml
naproxen tabs or 250 mg,
375 mg, 500 mg
naproxen tbec or 375 mg,
500 mg
oxaprozin 1
piroxicam caps or 10 mg,
20 mg
Drug
Tier Requirements/
Limits
1
MO
4
4
4
1
1
1
1
1
3
3
1
1
1
1
1
MO
PA; AL; MO
AL
PA; AL; MO
PA; AL; MO
MO
MO
MO
MO
MO
MO
500 MG & 750
MG Pack
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
3

DRUG NAME
PONSTEL (Use
Mefenamic Acid)
SPRIX 3
sulindac tabs or 150 mg,
200 mg
tolmetin sodium 1
VIMOVO 3
VOLTAREN-XR (Use
Diclofenac Sodium)
ZIPSOR 3
Pyrimidine Synthesis Inhibitors
ARAVA (Use Leflunomide) 3
leflunomide 1
Drug
Tier Requirements/
Limits
3
MO
1
3
PA; AL; MO
MO
MO
MO
MO
MO
MO
MO
Selective Costimulation Modulators
ORENCIA 5
PA
Soluble Tumor Necrosis Factor Receptor
ENBREL 5
PA
ENBREL SURECLICK 5
PA
ANALGESICS - NonNarcotic - Drugs to Treat
Pain, Muscle and Joint Conditions
Analgesics Other
clonidine hcl (analgesia)
100 mcg/ml
clonidine hcl (analgesia)
500 mcg/ml
DURACLON 100 MCG/ML
(Use Clonidine HCl
(Analgesia))
DURACLON 500 MCG/ML
(Use Clonidine HCl
(Analgesia))
4
4
4
4
MO
MO
Analgesics-Peptide Channel Blockers
PRIALT 5
Salicylates
diflunisal tabs or 500 mg 1
MO
DRUG NAME
Drug
Tier Requirements/
Limits
ANALGESICS - OPIOID - Drugs to Treat Pain,
Muscle and Joint Conditions
Opioid Agonists
ABSTRAL 100 MCG 3
ABSTRAL 200 MCG 5
ABSTRAL 300 MCG, 400
MCG, 600 MCG, 800 MCG
ACTIQ 1200 MCG, 1600
MCG, 400 MCG, 600 MCG
(Use Fentanyl Citrate)
ACTIQ 200 MCG (Use
Fentanyl Citrate)
ACTIQ 800 MCG (Use
Fentanyl Citrate)
AVINZA 120 MG 2
AVINZA 30 MG 2
AVINZA 45 MG 2
AVINZA 60 MG 2
AVINZA 75 MG 2
AVINZA 90 MG 2
codeine sulfate 1
DEMEROL 4
DILAUDID LIQD OR 1
MG/ML (Use
Hydromorphone HCl)
DILAUDID SOLN IJ 1
MG/ML, 2 MG/ML, 4
MG/ML (Use
Hydromorphone HCl)
DILAUDID TABS OR 2
MG, 4 MG, 8 MG (Use
Hydromorphone HCl)
DILAUDID-HP SOLN 10
MG/ML (Use
Hydromorphone HCl)
DILAUDID-HP SOLR 250
MG
5
5
5
3
2
4
3
QL(6 ea daily)
QL(6 ea daily)
QL(4 ea daily)
PA; QL(4 ea
daily); MO
PA; QL(6 ea
daily); MO
PA; QL(4 ea
daily); MO
QL(13 ea
daily); MO
QL(53 ea
daily); MO
QL(35 ea
daily); MO
QL(26 ea
daily); MO
QL(21 ea
daily); MO
QL(17 ea
daily); MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
4
4
MO
MO
MO
MO
4

DRUG NAME
DOLOPHINE (Use
Methadone HCl)
DOLOPHINE HCL (Use
Methadone HCl)
DURAGESIC (Use
Fentanyl)
EXALGO 3
fentanyl 1
fentanyl citrate lpop bu
1200 mcg, 1600 mcg, 400
mcg, 600 mcg
fentanyl citrate lpop bu 200
mcg
fentanyl citrate lpop bu 800
mcg
fentanyl citrate soln ij 0.05
mg/ml
FENTORA 100 MCG, 200
MCG
FENTORA 400 MCG, 600
MCG, 800 MCG
hydromorphone hcl liqd or
1 mg/ml
hydromorphone hcl soln ij 1
mg/ml, 10 mg/ml, 2 mg/ml,
4 mg/ml, 50 mg/5ml, 500
mg/50ml
hydromorphone hcl soln ij
10 mg/ml, 50 mg/5ml
hydromorphone hcl tabs or
2 mg, 4 mg, 8 mg
INFUMORPH 200 4
INFUMORPH 500 4
KADIAN 10 MG, 200 MG
(Use Morphine Sulfate)
KADIAN 100 MG, 20 MG,
30 MG, 50 MG, 60 MG, 80
MG (Use Morphine Sulfate)
KADIAN 130 MG, 150 MG 3
KADIAN 40 MG, 70 MG 3
Drug
Tier Requirements/
Limits
3
MO
3
3
5
5
1
4
5
5
1
4
4
1
2
3
MO
QL(0.67 ea
daily); MO
MO
QL(0.67 ea
daily); MO
PA; QL(4 ea
daily); MO
PA; QL(6 ea
daily); MO
PA; QL(4 ea
daily); MO
MO
PA; QL(6 ea
daily); MO
PA; QL(4 ea
daily); MO
MO
MO
MO
MO
MO
MO
MO
PA
PA; MO
Drug
DRUG NAME
Tier Requirements/
Limits
LAZANDA 100 MCG/ACT 5
PA; MO
LAZANDA 400 MCG/ACT 5
levorphanol tartrate tabs or
2 mg
methadone hcl conc or 10
mg/ml
METHADONE HCL SOLN
IJ 10 MG/ML
methadone hcl soln or 10
mg/5ml, 5 mg/5ml
methadone hcl tabs or 10
mg, 5 mg
methadone hcl tbso or 40
mg
methadose 1
methadose sugar-free 1
morphine sulfate cp24 or
10 mg, 100 mg, 20 mg, 30
mg, 50 mg, 60 mg, 80 mg
morphine sulfate soln ij 0.5
mg/ml, 1 mg/ml
MORPHINE SULFATE
SOLN IJ 2 MG/ML
morphine sulfate soln iv 1
mg/ml
MORPHINE SULFATE
SOLN IV 10 MG/ML, 15
MG/ML, 150 MG/30ML, 2
MG/ML, 4 MG/ML, 8
MG/ML
morphine sulfate soln or 10
mg/5ml, 100 mg/5ml, 20
mg/5ml, 20 mg/ml
morphine sulfate tabs or 15
mg, 30 mg
morphine sulfate tbcr or
100 mg, 15 mg, 200 mg, 30
mg, 60 mg
MS CONTIN (Use
Morphine Sulfate)
NUCYNTA 2
NUCYNTA ER 2
1
1
4
1
1
1
1
4
4
4
4
1
1
1
3
PA
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
5

DRUG NAME
ONSOLIS 1200 MCG, 400
MCG, 600 MCG, 800 MCG
ONSOLIS 200 MCG 5
OPANA ER 2
OPANA ER (CRUSH
RESISTANT) 10 MG, 20
MG, 30 MG, 40 MG, 5 MG
OPANA ER (CRUSH
RESISTANT) 15 MG, 7.5
MG
OPANA SOLN IJ 1 MG/ML 4
OPANA TABS OR 10 MG,
5 MG (Use Oxymorphone
HCl)
ORAMORPH SR 3
OXECTA 3
oxycodone hcl caps or 5
mg
oxycodone hcl conc or 20
mg/ml
oxycodone hcl soln or 5
mg/5ml
oxycodone hcl tabs or 10
mg, 15 mg, 20 mg, 30 mg,
5 mg
OXYCONTIN 2
oxymorphone hcl 1
ROXICODONE 15 MG, 30
MG (Use Oxycodone HCl)
ROXICODONE 5 MG (Use
Oxycodone HCl)
Drug
Tier Requirements/
Limits
5
PA; QL(4 ea
daily); LA
PA; QL(6 ea
daily); LA
MO
2
2
3
1
1
1
1
3
NF
RYBIX ODT 3
RYZOLT (Use Tramadol
HCl)
SUBLIMAZE (Use
Fentanyl Citrate)
SUBSYS 100 MCG, 1200
MCG, 1600 MCG, 600
MCG
3
4
5
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
DRUG NAME
SUBSYS 200 MCG, 400
MCG, 800 MCG
tramadol hcl tabs or 50 mg 1
tramadol hcl tb24 or 100
mg, 200 mg, 300 mg
ULTRAM (Use Tramadol
HCl)
ULTRAM ER (Use
Tramadol HCl)
Opioid Combinations
acetaminophen w/ codeine
soln 6.65-12-120 %,
mg/5ml, 7-12-120 %,
mg/5ml, 7.4-12-120 %,
mg/5ml
acetaminophen w/ codeine
tabs 15-300 mg, 30-300
mg, 60-300 mg
acetaminophen/caffeine/dih
ydrocodeine bitartrate
ASPIRIN-CAFFEINE-
DIHYDROCODEINE
butalbital-acetaminophencaffeine
w/ codeine 30-40-
50-300 mg
butalbital-acetaminophencaffeine
w/ codeine 30-40-
50-325 mg
butalbital-aspirin-caffeine
w/cod
capital/codeine 1
cocet 1
cocet plus 1
FIORICET/CODEINE 30-
40-50-300 MG (Use
Butalbital-Acetaminophen-
Caffeine w/ Codeine)
FIORICET/CODEINE 30-
40-50-325 MG (Use
Butalbital-Acetaminophen-
Caffeine w/ Codeine)
Drug
Tier Requirements/
Limits
5
PA; MO
1
3
3
1
1
1
3
1
1
1
3
3
QL(8 ea daily);
MO
MO
QL(8 ea daily);
MO
MO
QL(166 ml
daily); MO
QL(13 ea
daily); MO
QL(5 ea daily)
MO
QL(13 ea
daily); MO
QL(12 ea
daily); MO
MO
QL(166 ml
daily); MO
QL(6 ea daily)
QL(6 ea daily)
QL(13 ea
daily); MO
QL(12 ea
daily); MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
6

DRUG NAME
FIORINAL/CODEINE #3
(Use Butalbital-Aspirin-
Caffeine w/Cod)
hycet 1
hydrocodone
bitartrate/acetaminophen
hydrocodoneacetaminophen
caps 5-500
mg
hydrocodoneacetaminophen
soln 2.5-
6.7-108 %, mg/5ml, 5-6.7-
217 %, mg/10ml, 6.7-7.5-
325 %, mg/15ml, 7-7.5-325
%, mg/15ml, 7.5-8.6-325
%, mg/15ml
hydrocodoneacetaminophen
soln 7-7.5-
500 %, mg/15ml, 7.5-500
mg/15ml
hydrocodoneacetaminophen
tabs 10-
300 mg, 5-300 mg, 7.5-300
mg
hydrocodoneacetaminophen
tabs 10-
325 mg, 5-325 mg, 7.5-325
mg
hydrocodoneacetaminophen
tabs 10-
500 mg, 2.5-500 mg, 5-500
mg, 7.5-500 mg
hydrocodoneacetaminophen
tabs 10-
650 mg, 10-660 mg, 7.5-
650 mg
hydrocodoneacetaminophen
tabs 10-
750 mg, 7.5-750 mg
hydrocodone-ibuprofen 1
hydrocodone/acetaminoph
en
ibudone 1
lorcet 10/650 1
Drug
Tier Requirements/
Limits
MO
3
1
1
1
1
1
1
1
1
1
1
QL(184 ml
daily); MO
QL(12 ea daily)
QL(8 ea daily);
MO
QL(184 ml
daily); MO
QL(120 ml
daily); MO
QL(13 ea
daily); MO
QL(12 ea
daily); MO
QL(8 ea daily);
MO
QL(6 ea daily);
MO
QL(5 ea daily);
MO
MO
QL(184 ml
daily); MO
MO
QL(6 ea daily);
MO
DRUG NAME
Drug
Tier Requirements/
Limits
lorcet plus 1
QL(6 ea daily);
MO
lortab elix 7-7.5-500 %,
mg/15ml
1
QL(120 ml
daily); MO
lortab tabs 10-500 mg, 5-
1
QL(8 ea daily);
500 mg, 7.5-500 mg
magnacet 10-400 mg, 5-
400 mg
magnacet 7.5-400 mg 1
maxidone 1
norco 1
oxycodone w/
acetaminophen caps 5-500
mg
oxycodone w/
acetaminophen tabs 10-
325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
oxycodone w/
acetaminophen tabs 10-
650 mg
oxycodone w/
acetaminophen tabs 7.5-
500 mg
oxycodone-aspirin 1
oxycodone-ibuprofen 1
percocet 10-325 mg, 2.5-
325 mg, 5-325 mg, 7.5-325
mg
percocet 10-650 mg 1
percocet 7.5-500 mg 1
PERCODAN (Use
Oxycodone-Aspirin)
primlev 1
reprexain 1
roxicet 1
1
1
1
1
1
1
3
MO
QL(10 ea
daily); MO
QL(10 ea daily)
QL(5 ea daily);
MO
QL(12 ea
daily); MO
QL(8 ea daily);
MO
QL(12 ea
daily); MO
QL(6 ea daily);
MO
QL(8 ea daily);
MO
MO
MO
QL(12 ea
daily); MO
QL(6 ea daily);
MO
QL(8 ea daily);
MO
MO
QL(13 ea
daily); MO
MO
QL(61 ml
daily); MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
7

Drug
DRUG NAME
Tier Requirements/
Limits
SYNALGOS-DC 3
MO
tramadol-acetaminophen 1
trezix 1
tylenol/codeine #3 1
tylenol/codeine #4 1
tylox 1
ULTRACET (Use
Tramadol-Acetaminophen)
vicodin 1
vicodin es 1
VICOPROFEN (Use
Hydrocodone-Ibuprofen)
xodol 1
zamicet 1
zolvit 1
zydone 1
Opioid Partial Agonists
BUPRENEX (Use
Buprenorphine HCl)
buprenorphine hcl soln ij
0.3 mg/ml
buprenorphine hcl subl sl 2
mg, 8 mg
buprenorphine hclnaloxone
hcl dihydrate
butorphanol tartrate soln ij
1 mg/ml, 2 mg/ml
butorphanol tartrate soln na
10 mg/ml
BUTRANS 10 MCG/HR 2
BUTRANS 15 MCG/HR 2
3
3
4
4
1
1
4
1
QL(12 ea
daily); MO
QL(11 ea
daily); MO
QL(13 ea
daily); MO
QL(13 ea
daily); MO
QL(8 ea daily);
MO
QL(12 ea
daily); MO
QL(8 ea daily);
MO
QL(5 ea daily);
MO
MO
QL(13 ea
daily); MO
QL(184 ml
daily); MO
QL(200 ml
daily); MO
QL(10 ea
daily); MO
MO
MO
PA; MO
PA; MO
MO
MO
QL(0.29 ea
daily); MO
QL(0.19 ea
daily); MO
DRUG NAME
Drug
Tier Requirements/
Limits
BUTRANS 20 MCG/HR 2
QL(0.15 ea
daily); MO
BUTRANS 5 MCG/HR 2
QL(0.58 ea
daily); MO
nalbuphine hcl soln ij 10
mg/ml, 20 mg/ml
4
MO
SUBOXONE (Use
PA; MO
Buprenorphine HCl-
Naloxone HCl Dihydrate)
3
SUBUTEX (Use
Buprenorphine HCl)
3
PA; MO
TALWIN 4
AL
ZUBSOLV 3
PA
ANDROGENS-ANABOLIC - Drugs to Regulate
Hormones
Anabolic Steroids
OXANDRIN (Use
Oxandrolone)
oxandrolone tabs or 10 mg,
2.5 mg
Androgens
ANDRODERM 2
MG/24HR, 4 MG/24HR, 5
MG/24HR
ANDRODERM 2.5
MG/24HR
ANDROGEL 2
ANDROGEL PUMP 2
androxy 1
AXIRON 3
danazol caps or 100 mg,
200 mg, 50 mg
DELATESTRYL (Use
Testosterone Enanthate)
depo-testosterone 4
FORTESTA 3
STRIANT 3
3
1
2
2
1
4
MO
MO
GL; MO
GL
GL; MO
GL; MO
MO
GL; MO
MO
MO
MO
GL; MO
GL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
8

Drug
DRUG NAME
Tier Requirements/
Limits
TESTIM 2
GL; MO
testopel 1
testosterone cypionate oil
im 100 mg/ml, 200 mg/ml
testosterone enanthate oil
im 200 mg/ml
4
4
GL
MO
MO
ANORECTAL AGENTS - Rectal Drugs to Treat
Pain, Swelling and Itching
Intrarectal Steroids
CORTENEMA (Use
Hydrocortisone
(Intrarectal))
NF
CORTIFOAM 3
hydrocortisone (intrarectal) 1
Rectal Combinations
proctofoam hc 1
Rectal Steroids
anusol-hc crea 2.5 % 1
hydrocortisone (rectal) 1
PROCTOCORT CREA 1 %
(Use Hydrocortisone
(Rectal))
Vasodilating Agents
RECTIV 2
3
MO
MO
MO
MO
MO
MO
MO
MO
ANTHELMINTICS - Drugs to Treat Worm
Infections
Anthelmintics
ALBENZA 3
BILTRICIDE 2
STROMECTOL 3
MO
MO
MO
ANTI-INFECTIVE AGENTS - MISC. - Drugs to
Treat Bacterial Infections
Anti-infective Agents - Misc.
DRUG NAME
AZACTAM 1 GM (Use
Aztreonam)
AZACTAM 2 GM (Use
Aztreonam)
AZACTAMIN ISO-
OSMOTIC DEXTROSE
aztreonam 1 gm 4
aztreonam 2 gm 4
CAYSTON 5
colistimethate sodium solr ij
150 mg
COLY-MYCIN M (Use
Colistimethate Sodium)
FLAGYL CAPS 375 MG 3
FLAGYL ER 3
FLAGYL TABS 250 MG
(Use Metronidazole)
FLAGYL TABS 500 MG
(Use Metronidazole)
METRO IV 4
metronidazole caps or 375
mg
metronidazole in nacl 4
metronidazole tabs or 250
mg
metronidazole tabs or 500
mg
NEBUPENT 2
PENTAM 300 4
PRIMSOL 2
tinidazole tabs or 250 mg,
500 mg
trimethoprim tabs or 100
mg
VANCOCIN HCL (Use
Vancomycin HCl)
Drug
Tier Requirements/
Limits
4
MO
4
4
4
4
3
3
1
1
1
1
1
5
MO
LA
MO
MO
QL(10 ea
daily); MO
MO
QL(16 ea
daily); MO
QL(8 ea daily);
MO
QL(10 ea
daily); MO
MO
QL(16 ea
daily); MO
QL(8 ea daily);
MO
MO; B/D
MO
MO
MO
MO
PA; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
9

DRUG NAME
vancomycin hcl caps or
125 mg, 250 mg
VANCOMYCIN HCL IN
DEXTROSE
vancomycin hcl solr iv 10
gm, 5000 mg, 750 mg
vancomycin hcl solr iv 1000
mg, 500 mg
XIFAXAN 200 MG 3
XIFAXAN 550 MG 5
Drug
Tier Requirements/
Limits
5
PA; MO
4
4
4
B/D
B/D
MO; B/D
MO
MO
DRUG NAME
PRIMAXIN IV (Use
Imipenem-Cilastatin)
Chloramphenicols
chloramphenicol sodium
succinate
Cyclic Lipopeptides
CUBICIN 5
Glycylcyclines
TYGACIL 4
Drug
Tier Requirements/
Limits
3
MO
4
MO; B/D
Anti-infective Misc. - Combinations
BACTRIM (Use
MO
Sulfamethoxazole-
3
Trimethoprim)
BACTRIM DS (Use
MO
Sulfamethoxazole-
3
Trimethoprim)
SEPTRA DS (Use
MO
Sulfamethoxazole-
3
Trimethoprim)
sulfamethoxazoletrimethoprim
1
MO
sulfamethoxazoletrimethoprim
soln iv 80-400
mg/5ml
4
MO
Antiprotozoal Agents
ALINIA 3
MEPRON 5
Carbapenems
DORIBAX 250 MG 5
DORIBAX 500 MG 4
imipenem-cilastatin 1
INVANZ IJ 4
INVANZ IV 4
meropenem 4
MERREM (Use
Meropenem)
4
MO
MO
MO
MO
MO
MO
Leprostatics
dapsone tabs or 100 mg,
25 mg
Lincosamides
CLEOCIN (Use
Clindamycin HCl)
CLEOCIN IN D5W (Use
Clindamycin Phosphate in
D5W)
cleocin pediatric granules 1
CLEOCIN PHOSPHATE IJ
300 MG/2ML, 9 GM/60ML
(Use Clindamycin
Phosphate)
CLEOCIN PHOSPHATE IJ
600 MG/4ML, 900 MG/6ML
(Use Clindamycin
Phosphate)
CLEOCIN PHOSPHATE IV
150 MG/ML, 600 MG/4ML
(Use Clindamycin
Phosphate)
clindamycin hcl caps or 150
mg, 300 mg, 75 mg
clindamycin palmitate
hydrochloride
clindamycin phosphate in
d5w
clindamycin phosphate soln
ij 150 mg/ml, 300 mg/2ml,
9000 mg/60ml
clindamycin phosphate soln
ij 600 mg/4ml, 900 mg/6ml
1
3
4
4
4
4
1
1
4
4
4
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
10

DRUG NAME
clindamycin phosphate
soln iv 150 mg/ml
LINCOCIN 4
Oxazolidinones
ZYVOX SOLN IV 2 MG/ML 5
ZYVOX SUSR OR 100
MG/5ML
ZYVOX TABS OR 600 MG 5
Polymyxins
polymyxin b sulfate solr ij
500000 unit
Streptogramins
SYNERCID 4
Drug
Tier Requirements/
Limits
4
5
4
MO
MO
MO
ANTIANGINAL AGENTS - Drugs to Treat Chest
Pain
Antianginals-Other
RANEXA 3
Nitrates
DILATRATE SR 2
imdur 1
ISORDIL TITRADOSE 40
MG
ISORDIL TITRADOSE 5
MG (Use Isosorbide
Dinitrate)
isosorbide dinitrate subl sl
2.5 mg, 5 mg
isosorbide dinitrate tabs or
10 mg, 20 mg, 30 mg, 5 mg
isosorbide dinitrate tbcr or
40 mg
isosorbide mononitrate 1
MONOKET (Use
Isosorbide Mononitrate)
nitro-bid 1
2
3
1
1
1
3
PA; MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
NITRO-DUR 0.1 MG/HR,
0.2 MG/HR, 0.4 MG/HR,
0.6 MG/HR (Use
Nitroglycerin)
NITRO-DUR 0.3 MG/HR,
0.8 MG/HR
nitroglycerin in d5w 4
NITROGLYCERIN IN
DEXTROSE 5% (Use
Nitroglycerin in D5W)
NITROGLYCERIN
LINGUAL
nitroglycerin pt24 td 0.1
mg/hr, 0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr
nitroglycerin soln iv 5
mg/ml
nitroglycerin soln tl 0.4
mg/spray
NITROLINGUAL
PUMPSPRAY (Use
Nitroglycerin)
NITROMIST 2
NITROSTAT 2
Drug
Tier Requirements/
Limits
MO
3
2
4
2
1
4
1
3
MO
MO
MO
MO
MO
MO
MO
ANTIANXIETY AGENTS - Drugs to Treat
Anxiety
Antianxiety Agents - Misc.
buspirone hcl tabs or 10
mg, 15 mg, 30 mg, 5 mg,
7.5 mg
hydroxyzine hcl soln im 25
mg/ml, 50 mg/ml
hydroxyzine hcl soln or 10
mg/5ml
hydroxyzine hcl syrp or 10
mg/5ml
hydroxyzine hcl tabs or 10
mg, 25 mg, 50 mg
hydroxyzine pamoate caps
or 100 mg, 25 mg, 50 mg
meprobamate 1
VISTARIL (Use
Hydroxyzine Pamoate)
1
4
1
1
1
1
3
MO
MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
11

DRUG NAME
Benzodiazepines
alprazolam intensol 1
alprazolam tabs or 0.25
mg, 0.5 mg, 1 mg, 2 mg
alprazolam tb24 or 0.5 mg,
1 mg, 2 mg, 3 mg
alprazolam tbdp or 0.25
mg, 0.5 mg, 1 mg, 2 mg
ATIVAN SOLN IJ 2 MG/ML
(Use Lorazepam)
ATIVAN SOLN IJ 4 MG/ML
(Use Lorazepam)
ATIVAN TABS OR 0.5 MG,
1 MG, 2 MG (Use
Lorazepam)
clorazepate dipotassium 1
diazepam intensol 1
diazepam soln ij 5 mg/ml 1
diazepam soln or 1 mg/ml 1
diazepam tabs or 10 mg, 2
mg, 5 mg
lorazepam conc or 2 mg/ml 1
lorazepam intensol 1
lorazepam soln ij 2 mg/ml,
20 mg/10ml
lorazepam soln ij 4 mg/ml 1
lorazepam tabs or 0.5 mg,
1 mg, 2 mg
NIRAVAM (Use
Alprazolam)
TRANXENE T (Use
Clorazepate Dipotassium)
VALIUM (Use Diazepam) 3
XANAX (Use Alprazolam) 3
XANAX XR (Use
Alprazolam)
Drug
Tier Requirements/
Limits
1
1
1
3
3
3
1
1
1
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
Drug
Tier Requirements/
Limits
ANTIARRHYTHMICS - Drugs to treat abnormal
heart rhythms
Antiarrhythmics - Misc.
ADENOCARD 6 MG/2ML
(Use Adenosine)
adenosine soln iv 6 mg/2ml 4
Antiarrhythmics Type I-A
disopyramide phosphate
caps or 100 mg, 150 mg
NORPACE (Use
Disopyramide Phosphate)
NORPACE CR 3
quinidine gluconate tbcr or
324 mg
quinidine sulfate 1
quinidine sulfate er 1
Antiarrhythmics Type I-B
lidocaine hcl (cardiac) 4
lidocaine hcl soln iv 10
mg/ml
lidocaine in d5w 4-5 %,
mg/ml
mexiletine hcl 1
XYLOCAINE IV 20 MG/ML
(Use Lidocaine HCl
(Cardiac))
Antiarrhythmics Type I-C
flecainide acetate 100 mg 1
flecainide acetate 150 mg 1
flecainide acetate 50 mg 1
propafenone hcl 1
RYTHMOL (Use
Propafenone HCl)
RYTHMOL SR (Use
Propafenone HCl)
4
1
3
1
4
4
4
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(6 ea daily);
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
12

DRUG NAME
TAMBOCOR 100 MG (Use
Flecainide Acetate)
TAMBOCOR 150 MG (Use
Flecainide Acetate)
TAMBOCOR 50 MG (Use
Flecainide Acetate)
Antiarrhythmics Type III
amiodarone hcl soln iv 150
mg/3ml, 50 mg/ml, 900
mg/18ml
amiodarone hcl tabs or 100
mg, 200 mg, 400 mg
CORDARONE (Use
Amiodarone HCl)
MULTAQ 2
TIKOSYN 3
Drug
Tier Requirements/
Limits
3
QL(3 ea daily);
MO
3
QL(2 ea daily);
MO
3
QL(6 ea daily);
MO
4
1
3
MO
MO
MO
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS - Drugs to Treat Lung Conditions
Anti-Inflammatory Agents
cromolyn sodium nebu in
20 mg/2ml
1
MO; B/D
Antiasthmatic - Monoclonal Antibodies
XOLAIR 5
PA; LA
Bronchodilators - Anticholinergics
ATROVENT HFA 3
QL(0.86 gm
daily); MO
ipratropium bromide soln in
0.02 %
1
MO; B/D
SPIRIVA HANDIHALER 2
QL(1 ea daily);
MO
TUDORZA PRESSAIR 2
QL(0.04 ea
daily); MO
Leukotriene Modulators
ACCOLATE (Use
Zafirlukast)
montelukast sodium 1
SINGULAIR (Use
Montelukast Sodium)
zafirlukast 1
3
2
MO
QL(1 ea daily);
MO
QL(1 ea daily);
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
ZYFLO CR 3
MO
Selective Phosphodiesterase 4 (PDE4)
DALIRESP 3
MO
Steroid Inhalants
ALVESCO 3
ASMANEX 120 METERED
DOSES
ASMANEX 14 METERED
DOSES
ASMANEX 30 METERED
DOSES 110 MCG/INH
ASMANEX 30 METERED
DOSES 220 MCG/INH
ASMANEX 60 METERED
DOSES
ASMANEX 7 METERED
DOSES
budesonide (inhalation)
0.25 mg/2ml
budesonide (inhalation) 0.5
mg/2ml
FLOVENT DISKUS 100
MCG/BLIST
FLOVENT DISKUS 250
MCG/BLIST
FLOVENT DISKUS 50
MCG/BLIST
FLOVENT HFA 110
MCG/ACT, 220 MCG/ACT
FLOVENT HFA 44
MCG/ACT
PULMICORT 0.25 MG/2ML
(Use Budesonide
(Inhalation))
PULMICORT 0.5 MG/2ML
(Use Budesonide
(Inhalation))
PULMICORT 1 MG/2ML 2
PULMICORT FLEXHALER
180 MCG/ACT
PULMICORT FLEXHALER
90 MCG/ACT
2
2
2
2
2
2
1
1
2
2
2
2
2
3
3
3
3
MO
QL(0.04 ea
daily); MO
QL(0.29 ea
daily); MO
QL(0.04 ea
daily); MO
QL(0.14 ea
daily); MO
QL(0.07 ea
daily); MO
QL(0.14 ea
daily); MO
QL(8 ml daily);
MO; B/D
QL(4 ml daily);
MO; B/D
QL(20 ea
daily); MO
QL(8 ea daily);
MO
QL(40 ea
daily); MO
QL(0.8 gm
daily); MO
QL(0.36 gm
daily); MO
QL(8 ml daily);
MO; B/D
QL(4 ml daily);
MO; B/D
QL(2 ml daily);
MO; B/D
QL(0.07 ea
daily); MO
QL(0.27 ea
daily); MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
13

Drug
DRUG NAME
Tier Requirements/
Limits
QVAR 2
QL(0.87 gm
daily); MO
Sympathomimetics
ACCUNEB (Use Albuterol
Sulfate)
ADVAIR DISKUS 2
ADVAIR HFA 2
albuterol sulfate nebu in
0.083 %, 0.5 %, 0.63
mg/3ml, 1.25 mg/3ml
albuterol sulfate syrp or 2
mg/5ml
albuterol sulfate tabs or 2
mg, 4 mg
albuterol sulfate tb12 or 4
mg, 8 mg
ARCAPTA NEOHALER 3
BREO ELLIPTA 2
BROVANA 3
COMBIVENT 3
COMBIVENT RESPIMAT 3
DULERA 2
DUONEB (Use
Ipratropium-Albuterol)
epinephrine hcl 4
FORADIL AEROLIZER 2
ipratropium-albuterol 1
ISUPREL 4
levalbuterol hcl nebu in
0.31 mg/3ml, 0.63 mg/3ml,
1.25 mg/0.5ml, 1.25
mg/3ml
MAXAIR AUTOHALER 2
3
1
1
1
1
3
1
MO; B/D
MO
QL(4 gm daily);
MO
MO; B/D
MO
MO
MO
QL(1 ea daily);
MO
QL(2 ea daily);
MO
MO; B/D
MO
QL(0.2 gm
daily); MO
QL(4 gm daily);
MO
MO; B/D
MO
QL(2 ea daily);
MO
MO; B/D
MO
MO; B/D
MO
DRUG NAME
metaproterenol sulfate syrp
or 10 mg/5ml
metaproterenol sulfate tabs
or 10 mg, 20 mg
PERFOROMIST 3
PROAIR HFA 2
PROVENTIL HFA 2
SEREVENT DISKUS 2
SYMBICORT 3
terbutaline sulfate soln ij 1
mg/ml
terbutaline sulfate tabs or
2.5 mg, 5 mg
VENTOLIN HFA 3
vospire er 1
XOPENEX (Use
Levalbuterol HCl)
XOPENEX
CONCENTRATE (Use
Levalbuterol HCl)
XOPENEX HFA 3
Xanthines
aminophylline 4
elixophyllin 1
LUFYLLIN 3
theophylline 1
theophylline er 1
theophylline in dextrose 4
THEOPHYLLINE/D5W 4
Drug
Tier Requirements/
Limits
1
MO
1
4
1
3
3
MO
QL(4 ml daily);
MO; B/D
MO
MO
QL(2 ea daily);
MO
QL(4 gm daily);
MO
MO
MO
MO
MO; B/D
MO; B/D
MO
MO
MO
MO
MO
MO
ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
14

DRUG NAME
COUMADIN SOLR IV 5
MG
COUMADIN TABS OR 1
MG, 10 MG, 2 MG, 2.5
MG, 3 MG, 4 MG, 5 MG, 6
MG, 7.5 MG (Use Warfarin
Sodium)
warfarin sodium tabs or 1
mg, 10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5
mg
Direct Factor Xa Inhibitors
ELIQUIS 3
XARELTO 2
Drug
Tier Requirements/
Limits
4
MO
3
1
MO
MO
MO
MO
Heparins And Heparinoid-Like Agents
ARIXTRA (Use
Fondaparinux Sodium)
4
MO
enoxaparin sodium 4
MO
fondaparinux sodium 4
FRAGMIN 4
heparin (porcine) in sodium
chloride
heparin sod (porcine) in
d5w
heparin sodium (porcine)
soln ij 1000 unit/ml, 10000
unit/ml, 20000 unit/ml,
5000 unit/0.5ml, 5000
unit/ml
HEPARIN SODIUM SOLN
IJ 2500 UNIT/ML
HEPARIN SODIUM SOLN
IV 2000 UNIT/ML
HEPARIN SODIUM/D5W
(Use Heparin Sod
(Porcine) in D5W)
HEPARIN SODIUM/NACL
0.45%
4
4
4
4
4
4
4
MO
MO
B/D
B/D
MO; B/D
B/D
B/D
B/D
B/D
DRUG NAME
HEPARIN
SODIUM/SODIUM
CHLORIDE 0.9% (Use
Heparin (Porcine) in
Sodium Chloride)
LOVENOX (Use
Enoxaparin Sodium)
Thrombin Inhibitors
argatroban 100 mg/ml 5
PRADAXA 2
Drug
Tier Requirements/
Limits
B/D
4
4
MO
MO
MO
ANTICONVULSANTS - Drugs to Treat Seizures
Anticonvulsants - Benzodiazepines
clonazepam tabs or 0.5 mg 1
QL(40 ea
daily); MO
clonazepam tabs or 1 mg 1
QL(20 ea
daily); MO
clonazepam tabs or 2 mg 1
QL(10 ea
daily); MO
clonazepam tbdp or 0.125 MO
mg, 0.25 mg, 0.5 mg, 1 mg,
2 mg
1
DIASTAT ACUDIAL 3
MO
DIASTAT PEDIATRIC 3
DIAZEPAM GEL RE 10
MG, 2.5 MG, 20 MG
KLONOPIN 0.5 MG (Use
Clonazepam)
KLONOPIN 1 MG (Use
Clonazepam)
KLONOPIN 2 MG (Use
Clonazepam)
ONFI 3
Anticonvulsants - Misc.
BANZEL 2
carbamazepine chew or
100 mg
carbamazepine cp12 or
100 mg, 200 mg, 300 mg
carbamazepine susp or
100 mg/5ml
3
3
3
3
1
MO
MO
QL(40 ea
daily); MO
QL(20 ea
daily); MO
QL(10 ea
daily); MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
15
1
1
MO
MO
MO
MO

DRUG NAME
carbamazepine tabs or 200
mg
carbamazepine tb12 or 200
mg, 400 mg
CARBATROL (Use
Carbamazepine)
gabapentin caps or 100
mg, 300 mg, 400 mg
gabapentin soln or 250
mg/5ml
gabapentin tabs or 600 mg,
800 mg
KEPPRA SOLN IV 500
MG/5ML (Use
Levetiracetam)
KEPPRA SOLN OR 100
MG/ML (Use
Levetiracetam)
KEPPRA TABS OR 1000
MG, 250 MG, 500 MG, 750
MG (Use Levetiracetam)
KEPPRA XR (Use
Levetiracetam)
LAMICTAL (Use
Lamotrigine)
LAMICTAL CHEWABLE
DISPERSIBLE (Use
Lamotrigine)
LAMICTAL ODT 3
LAMICTAL STARTER/NOT
TAKING
CARBAMAZEPINE
LAMICTAL
STARTER/TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE
LAMICTAL
STARTER/TAKING
VALPROATE
LAMICTAL XR (Use
Lamotrigine)
lamotrigine 1
levetiracetam soln iv 500
mg/5ml
Drug
Tier Requirements/
Limits
1
MO
1
3
1
1
1
4
3
3
3
3
3
3
3
3
3
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
LEVETIRACETAM SOLN
IV 500-820 MG/100ML,
540-1500 MG/100ML, 750-
1000 MG/100ML
levetiracetam soln or 100
mg/ml, 500 mg/5ml
levetiracetam tabs or 1000
mg, 250 mg, 500 mg, 750
mg
levetiracetam tb24 or 500
mg, 750 mg
LYRICA CAPS 100 MG 2
LYRICA CAPS 150 MG 2
LYRICA CAPS 200 MG 2
LYRICA CAPS 225 MG,
300 MG
LYRICA CAPS 25 MG 2
LYRICA CAPS 50 MG 2
LYRICA CAPS 75 MG 2
LYRICA SOLN 20 MG/ML 2
MYSOLINE (Use
Primidone)
NEURONTIN (Use
Gabapentin)
oxcarbazepine 1
POTIGA 200 MG 5
POTIGA 300 MG 5
POTIGA 400 MG 5
POTIGA 50 MG 5
primidone tabs or 250 mg,
50 mg
TEGRETOL (Use
Carbamazepine)
TEGRETOL-XR 100 MG 2
Drug
Tier Requirements/
Limits
4
1
1
1
2
3
3
1
3
MO
MO
MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(24 ea
daily); MO
QL(12 ea
daily); MO
QL(8 ea daily);
MO
QL(30 ml
daily); MO
MO
MO
MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(3 ea daily)
QL(24 ea
daily); MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
16

DRUG NAME
TEGRETOL-XR 200 MG,
400 MG (Use
Carbamazepine)
TOPAMAX (Use
Topiramate)
TOPAMAX SPRINKLE
(Use Topiramate)
topiramate cpsp or 15 mg,
25 mg
topiramate tabs or 100 mg,
200 mg, 25 mg, 50 mg
TRILEPTAL (Use
Oxcarbazepine)
VIMPAT SOLN IV 200
MG/20ML
VIMPAT SOLN OR 10
MG/ML
VIMPAT TABS OR 100
MG, 150 MG, 200 MG, 50
MG
ZONEGRAN (Use
Zonisamide)
zonisamide 1
Carbamates
felbamate 1
FELBATOL (Use
Felbamate)
GABA Modulators
GABITRIL (Use Tiagabine
HCl)
SABRIL 5
tiagabine hcl 1
Hydantoins
CEREBYX 100 MG
PE/2ML (Use Fosphenytoin
Sodium)
CEREBYX 500 MG
PE/10ML (Use
Fosphenytoin Sodium)
dilantin caps 100 mg, 30
mg
Drug
Tier Requirements/
Limits
MO
3
3
3
1
1
3
4
2
2
3
3
3
4
4
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
LA
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
dilantin infatabs 1
MO
DILANTIN SUSP 125
MG/5ML (Use Phenytoin)
fosphenytoin sodium 100
mg pe/2ml
fosphenytoin sodium 500
mg pe/10ml
PEGANONE 3
phenytek 1
phenytoin chew or 50 mg 1
phenytoin sodium extended 1
phenytoin sodium soln ij 50
mg/ml
phenytoin susp or 125
mg/5ml
Succinimides
CELONTIN 3
ethosuximide caps or 250
mg
ethosuximide soln or 250
mg/5ml
ZARONTIN CAPS 250 MG
(Use Ethosuximide)
zarontin soln 250 mg/5ml 1
Valproic Acid
DEPACON (Use Valproate
Sodium)
DEPAKENE (Use
Valproate Sodium)
DEPAKENE (Use Valproic
Acid)
DEPAKOTE (Use
Divalproex Sodium)
DEPAKOTE ER (Use
Divalproex Sodium)
DEPAKOTE SPRINKLES
(Use Divalproex Sodium)
divalproex sodium 1
3
4
4
4
1
1
1
3
4
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
17

Drug
DRUG NAME
Tier Requirements/
Limits
STAVZOR 3
MO
valproate sodium soln iv
100 mg/ml, 500 mg/5ml
valproate sodium soln or
250 mg/5ml
valproate sodium syrp or
250 mg/5ml
valproic acid caps or 250
mg
4
1
1
1
MO
MO
MO
MO
ANTIDEPRESSANTS - Drugs to Treat
Depression
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine tabs 15 mg, 30
mg, 45 mg
1
MO
mirtazapine tabs 7.5 mg 1
mirtazapine tbdp 15 mg, 30
mg, 45 mg
REMERON (Use
Mirtazapine)
REMERON SOLTAB (Use
Mirtazapine)
Antidepressants - Misc.
APLENZIN 174 MG 3
APLENZIN 348 MG, 522
MG
bupropion hcl tabs or 100
mg
bupropion hcl tabs or 75
mg
bupropion hcl tb12 or 100
mg
bupropion hcl tb12 or 150
mg, 200 mg
bupropion hcl tb24 or 150
mg
bupropion hcl tb24 or 300
mg
FORFIVO XL 3
maprotiline hcl 1
WELLBUTRIN 100 MG
(Use Bupropion HCl)
1
3
3
3
1
1
1
1
1
1
3
MO
MO
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
QL(4.5 ea
daily); MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
QL(1 ea daily);
MO
MO
QL(4.5 ea
daily); MO
DRUG NAME
WELLBUTRIN 75 MG (Use
Bupropion HCl)
WELLBUTRIN SR 100 MG
(Use Bupropion HCl)
WELLBUTRIN SR 150 MG,
200 MG (Use Bupropion
HCl)
WELLBUTRIN XL 150 MG
(Use Bupropion HCl)
WELLBUTRIN XL 300 MG
(Use Bupropion HCl)
Modified Cyclics
nefazodone hcl 1
OLEPTRO 3
trazodone hcl tabs or 100
mg, 150 mg, 300 mg, 50
mg
VIIBRYD 3
Drug
Tier Requirements/
Limits
3
QL(6 ea daily);
MO
3
QL(4 ea daily);
MO
QL(2 ea daily);
3 MO
3
3
1
QL(3 ea daily);
MO
QL(1 ea daily);
MO
MO
MO
MO
MO
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM 3
MO
MARPLAN 3
NARDIL (Use Phenelzine
Sulfate)
PARNATE (Use
Tranylcypromine Sulfate)
phenelzine sulfate tabs or
15 mg
tranylcypromine sulfate 1
3
3
1
MO
MO
MO
MO
MO
Selective Serotonin Reuptake Inhibitors
CELEXA 10 MG (Use
QL(4 ea daily);
Citalopram Hydrobromide)
3
MO
CELEXA 20 MG (Use
Citalopram Hydrobromide)
3
QL(2 ea daily);
MO
CELEXA 40 MG (Use
Citalopram Hydrobromide)
3
QL(1 ea daily);
MO
citalopram hydrobromide
soln 10 mg/5ml
1
QL(20 ml
daily); MO
citalopram hydrobromide
1
QL(4 ea daily);
tabs 10 mg
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
18

DRUG NAME
citalopram hydrobromide
tabs 20 mg
citalopram hydrobromide
tabs 40 mg
escitalopram oxalate 1
fluoxetine hcl caps or 10
mg, 20 mg, 40 mg
fluoxetine hcl cpdr or 90
mg
fluoxetine hcl soln or 20
mg/5ml
fluoxetine hcl tabs or 10
mg, 20 mg
FLUOXETINE HCL TABS
OR 60 MG
fluvoxamine maleate 1
LEXAPRO (Use
Escitalopram Oxalate)
LUVOX CR (Use
Fluvoxamine Maleate)
paroxetine hcl 1
PAXIL (Use Paroxetine
HCl)
PAXIL CR (Use
Paroxetine HCl)
PEXEVA 3
PROZAC (Use Fluoxetine
HCl)
PROZAC WEEKLY (Use
Fluoxetine HCl)
sertraline hcl conc or 20
mg/ml
sertraline hcl tabs or 100
mg, 25 mg, 50 mg
ZOLOFT (Use Sertraline
HCl)
Drug
Tier Requirements/
Limits
1
QL(2 ea daily);
MO
1
QL(1 ea daily);
MO
MO
1
1
1
1
3
3
3
3
3
3
3
1
1
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA 2
MO
DESVENLAFAXINE ER 3
EFFEXOR XR 150 MG
(Use Venlafaxine HCl)
3
MO
QL(1 ea daily);
MO
DRUG NAME
EFFEXOR XR 37.5 MG
(Use Venlafaxine HCl)
EFFEXOR XR 75 MG (Use
Venlafaxine HCl)
KHEDEZLA 3
PRISTIQ 3
venlafaxine hcl cp24 150
mg
venlafaxine hcl cp24 37.5
mg
venlafaxine hcl cp24 75 mg 1
VENLAFAXINE HCL ER
150 MG (Use Venlafaxine
HCl)
venlafaxine hcl er 225 mg 1
venlafaxine hcl er 37.5 mg 1
venlafaxine hcl er 75 mg 1
venlafaxine hcl tabs 100
mg
venlafaxine hcl tabs 25 mg 1
venlafaxine hcl tabs 37.5
mg
venlafaxine hcl tabs 50 mg 1
venlafaxine hcl tabs 75 mg 1
venlafaxine hcl tb24 150
mg
venlafaxine hcl tb24 37.5
mg
venlafaxine hcl tb24 75 mg 1
Tricyclic Agents
amitriptyline hcl tabs or 10
mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
amoxapine 1
Drug
Tier Requirements/
Limits
3
QL(6 ea daily);
MO
3
QL(3 ea daily);
MO
MO
1
1
3
1
1
1
1
1
MO
QL(1 ea daily);
MO
QL(6 ea daily);
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
QL(1 ea daily);
MO
QL(6 ea daily);
MO
QL(3 ea daily);
MO
QL(3.5 ea
daily); MO
QL(15 ea
daily); MO
QL(10 ea
daily); MO
QL(7.5 ea
daily); MO
QL(5 ea daily);
MO
QL(1 ea daily);
MO
QL(6 ea daily);
MO
QL(3 ea daily);
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
19
MO
MO

DRUG NAME
ANAFRANIL (Use
Clomipramine HCl)
clomipramine hcl caps or
25 mg, 50 mg, 75 mg
desipramine hcl tabs or 10
mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
doxepin hcl caps or 10 mg,
100 mg, 150 mg, 25 mg, 50
mg, 75 mg
doxepin hcl conc or 10
mg/ml
imipramine hcl tabs or 10
mg, 25 mg, 50 mg
imipramine pamoate 1
NORPRAMIN (Use
Desipramine HCl)
nortriptyline hcl caps or 10
mg, 25 mg, 50 mg, 75 mg
nortriptyline hcl soln or 10
mg/5ml
PAMELOR (Use
Nortriptyline HCl)
protriptyline hcl 1
SURMONTIL 3
tofranil 1
TOFRANIL-PM (Use
Imipramine Pamoate)
trimipramine maleate caps
or 100 mg, 25 mg, 50 mg
vivactil 1
Drug
Tier Requirements/
Limits
3
AL; MO
1
1
1
1
1
3
1
1
3
3
1
AL; MO
MO
MO
MO
AL; MO
AL; MO
MO
MO
MO
MO
MO
AL; MO
AL; MO
AL; MO
AL; MO
MO
ANTIDIABETICS - Drugs to Regulate Blood
Sugar
Alpha-Glucosidase Inhibitors
acarbose 1
GLYSET 3
PRECOSE (Use
Acarbose)
Antidiabetic - Amylin Analogs
3
QL(3 ea daily);
MO
QL(3 ea daily);
MO
QL(3 ea daily);
MO
DRUG NAME
Drug
Tier Requirements/
Limits
SYMLINPEN 120 4
QL(0.4 ml
daily); MO
SYMLINPEN 60 4
QL(0.4 ml
daily); MO
Antidiabetic Combinations
ACTOPLUS MET (Use
Pioglitazone HCl-Metformin
HCl)
ACTOPLUS MET XR 15-
1000 MG
ACTOPLUS MET XR 30-
1000 MG
DUETACT (Use
Pioglitazone HCl-
Glimepiride)
glipizide-metformin hcl 2.5-
250 mg
glipizide-metformin hcl 2.5-
500 mg, 5-500 mg
GLUCOVANCE (Use
Glyburide-Metformin)
glyburide-metformin 1
JANUMET 2
JANUMET XR 100-1000
MG
JANUMET XR 50-1000
MG, 50-500 MG
JENTADUETO 2
JUVISYNC 10-100 MG, 20-
100 MG, 40-100 MG
JUVISYNC 10-50 MG, 20-
50 MG
JUVISYNC 40-50 MG 2
KAZANO 2
KOMBIGLYZE XR 2.5-
1000 MG
KOMBIGLYZE XR 5-1000
MG, 5-500 MG
METAGLIP (Use Glipizide-
Metformin HCl)
2
2
2
2
1
1
3
2
2
2
2
2
2
3
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(1 ea daily);
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
AL; MO
AL; MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(2 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(2 ea daily)
QL(1 ea daily)
QL(2 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(8 ea daily);
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
20

DRUG NAME
OSENI 12.5-15 MG, 12.5-
30 MG, 12.5-45 MG
OSENI 15-25 MG, 25-30
MG, 25-45 MG
pioglitazone hcl-glimepiride 1
pioglitazone hcl-metformin
hcl
PRANDIMET 3
Biguanides
FORTAMET 1000 MG
(Use Metformin HCl)
FORTAMET 500 MG (Use
Metformin HCl)
GLUCOPHAGE 1000 MG
(Use Metformin HCl)
GLUCOPHAGE 500 MG
(Use Metformin HCl)
GLUCOPHAGE 850 MG
(Use Metformin HCl)
GLUCOPHAGE XR 500
MG (Use Metformin HCl)
GLUCOPHAGE XR 750
MG (Use Metformin HCl)
GLUMETZA 1000 MG 3
GLUMETZA 500 MG 3
metformin hcl tabs or 1000
mg
metformin hcl tabs or 500
mg
metformin hcl tabs or 850
mg
metformin hcl tb24 or 1000
mg, 750 mg
metformin hcl tb24 or 500
mg
metformin hcl tb24 or 500
mg
RIOMET 2
Diabetic Other
Drug
Tier Requirements/
Limits
2
QL(2 ea daily);
MO
2
QL(1 ea daily);
MO
QL(1 ea daily);
MO
1
QL(3 ea daily);
MO
QL(5 ea daily);
MO
3
3
3
3
3
3
3
1
1
1
1
1
1
QL(2 ea daily);
MO
QL(5 ea daily);
MO; Osmotic
QL(2.5 ea
daily); MO
QL(5 ea daily);
MO
QL(3 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(2.5 ea
daily); MO
QL(5 ea daily);
MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(5 ea daily);
MO; Osmotic
QL(25.5 ml
daily); MO
Drug
DRUG NAME
Tier Requirements/
Limits
GLUCAGEN 2
MO
GLUCAGEN HYPOKIT 2
glucagon emergency kit 1
KORLYM 5
PROGLYCEM 3
MO
MO
PA; QL(4 ea
daily)
MO
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
JANUVIA 100 MG 2
QL(1 ea daily);
MO
JANUVIA 25 MG 2
QL(4 ea daily);
MO
JANUVIA 50 MG 2
QL(2 ea daily);
MO
NESINA 2
QL(1 ea daily);
MO
ONGLYZA 2.5 MG 2
QL(2 ea daily);
MO
ONGLYZA 5 MG 2
QL(1 ea daily);
MO
TRADJENTA 2
QL(1 ea daily);
MO
Incretin Mimetic Agents (GLP-1 Receptor
BYDUREON 4
PA; QL(0.15 ea
daily); MO
BYETTA 10 MCG/0.04ML 4
PA; QL(4.8 ml
daily); MO
BYETTA 5 MCG/0.02ML 4
PA; QL(2.4 ml
daily); MO
VICTOZA 4
PA; QL(0.3 ml
daily); MO
Insulin Sensitizing Agents
ACTOS (Use Pioglitazone
HCl)
pioglitazone hcl 1
Insulin
APIDRA 3
APIDRA SOLOSTAR 3
2
QL(1 ea daily);
MO
QL(1 ea daily);
MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
21

DRUG NAME
Drug
Tier Requirements/
Limits
HUMALOG 2
QL(1.5 ml
daily); MO
HUMALOG KWIKPEN 2
QL(1.5 ml
daily); MO
HUMALOG MIX 50/50 2
QL(1.5 ml
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25 2
HUMALOG MIX 75/25
KWIKPEN
HUMULIN 70/30 2
HUMULIN 70/30 PEN 2
HUMULIN N 2
HUMULIN N U-100 PEN 2
HUMULIN R 2
HUMULIN R U-500
(CONCENTRATED)
LANTUS 2
LANTUS SOLOSTAR 2
LEVEMIR 2
LEVEMIR FLEXPEN 2
NOVOLIN 70/30 3
NOVOLIN 70/30 RELION 3
NOVOLIN N 3
NOVOLIN N RELION 3
NOVOLIN R 3
NOVOLIN R RELION 3
NOVOLOG 3
2
2
2
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
DRUG NAME
Drug
Tier Requirements/
Limits
NOVOLOG FLEXPEN 3
QL(1.5 ml
daily); MO
NOVOLOG MIX 70/30 3
QL(1.5 ml
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
NOVOLOG PENFILL 3
Meglitinide Analogues
nateglinide 1
PRANDIN 0.5 MG, 1 MG
(Use Repaglinide)
PRANDIN 2 MG (Use
Repaglinide)
repaglinide 0.5 mg, 1 mg 1
repaglinide 2 mg 1
STARLIX (Use
Nateglinide)
3
2
2
3
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(3 ea daily);
MO
QL(4 ea daily);
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(8 ea daily);
MO
QL(3 ea daily);
MO
Sodium-Glucose Co-Transporter 2 (SGLT2)
INVOKANA 100 MG 2
QL(2 ea daily);
MO
INVOKANA 300 MG 2
QL(1 ea daily);
MO
Sulfonylureas
AMARYL (Use
Glimepiride)
chlorpropamide 1
DIABETA 3
glimepiride 1
glipizide tabs or 10 mg, 5
mg
glipizide tb24 or 10 mg, 2.5
mg, 5 mg
GLUCOTROL (Use
Glipizide)
GLUCOTROL XL (Use
Glipizide)
glyburide micronized 1
3
1
1
3
3
QL(2 ea daily);
MO
PA; QL(2 ea
daily); AL; MO
AL; MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
AL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
22

DRUG NAME
glyburide tabs or 1.25 mg,
2.5 mg, 5 mg
GLYNASE (Use Glyburide
Micronized)
tolazamide 1
tolbutamide 1
Drug
Tier Requirements/
Limits
1
AL; MO
3
AL; MO
MO
MO
ANTIDIARRHEALS - Drugs to Treat Diarrhea
Antidiarrheal - Chloride Channel Antagonists
FULYZAQ 3
PA; QL(2 ea
daily); MO
Antiperistaltic Agents
diphenoxylate w/ atropine 1
diphenoxylate/atropine 1
LOMOTIL (Use
Diphenoxylate w/ Atropine)
loperamide hcl caps or 2
mg
MOTOFEN 3
3
1
MO
MO
MO
RX/OTC; MO
MO
ANTIDOTES - Drugs to Treat Overdose or
Toxicity
Antidotes - Chelating Agents
CHEMET 3
EXJADE 125 MG 3
EXJADE 250 MG, 500 MG 5
FERRIPROX 5
Antidotes
acetylcysteine (antidote) 1
ANTIZOL (Use
Fomepizole)
deferoxamine mesylate 5
DESFERAL (Use
Deferoxamine Mesylate)
fomepizole 4
4
5
MO
LA
LA
PA; LA
B/D
B/D
DRUG NAME
Benzodiazepine Antagonists
flumazenil 4
ROMAZICON (Use
Flumazenil)
Opioid Antagonists
naloxone hcl soln ij 0.4
mg/ml, 1 mg/ml
naltrexone hcl tabs or 50
mg
revia 1
VIVITROL 5
Drug
Tier Requirements/
Limits
4
4
1
MO
MO
ANTIEMETICS - Drugs to Treat Nausea and
Vomiting
5-HT3 Receptor Antagonists
ALOXI 4
granisetron hcl soln iv 0.1
mg/ml, 1 mg/ml, 4 mg/4ml
granisetron hcl tabs or 1
mg
granisol 1
ondansetron 1
ondansetron hcl and
dextrose
ondansetron hcl soln ij 4
mg/2ml, 40 mg/20ml
ONDANSETRON HCL
SOLN IV 32-450 MG/50ML
ondansetron hcl soln or 4
mg/5ml
ondansetron hcl tabs or 24
mg, 4 mg, 8 mg
ONDANSETRON
HCL/DEXTROSE
SANCUSO 3
ZOFRAN ODT (Use
Ondansetron)
ZOFRAN SOLN IJ 40
MG/20ML (Use
Ondansetron HCl)
4
1
4
4
4
1
1
4
3
4
MO
MO
MO; B/D
MO; B/D
MO; B/D
MO
MO; B/D
MO; B/D
MO
MO; B/D
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
23

DRUG NAME
ZOFRAN SOLN OR 4
MG/5ML (Use
Ondansetron HCl)
ZOFRAN TABS OR 4 MG,
8 MG (Use Ondansetron
HCl)
ZUPLENZ 3
Antiemetics - Anticholinergic
ANTIVERT 12.5 MG, 25
MG (Use Meclizine HCl)
3
ANTIVERT 50 MG 3
dimenhydrinate soln ij 50
mg/ml
meclizine hcl tabs or 12.5
mg, 25 mg
TIGAN CAPS OR 300 MG
(Use Trimethobenzamide
HCl)
TIGAN SOLN IM 100
MG/ML (Use
Trimethobenzamide HCl)
trimethobenzamide hcl
caps or 300 mg
trimethobenzamide hcl soln
im 100 mg/ml
Antiemetics - Miscellaneous
CESAMET 3
dronabinol 1
MARINOL (Use
Dronabinol)
Drug
Tier Requirements/
Limits
MO; B/D
3
3
4
1
3
4
1
4
3
MO; B/D
MO; B/D
RX/OTC; MO
RX/OTC; MO
PA; AL; MO
MO
PA; AL; MO
MO
MO; B/D
MO; B/D
MO; B/D
Substance P/Neurokinin 1 (NK1) Receptor
EMEND CAPS OR , 125 MO; B/D
MG, 80 MG
3
EMEND CAPS OR 40 MG 3
MO
EMEND SOLR IV 150 MG 4
MO
ANTIFUNGALS - Drugs to Treat Fungal
Infections
Antifungal - Glucan Synthesis Inhibitors
CANCIDAS 50 MG 5
Drug
DRUG NAME
Tier Requirements/
Limits
CANCIDAS 70 MG 5
MO
ERAXIS 4
MYCAMINE 5
Antifungals
ABELCET 5
AMBISOME 5
AMPHOTEC 4
amphotericin b solr ij 50 mg 4
ANCOBON 250 MG (Use
Flucytosine)
ANCOBON 500 MG (Use
Flucytosine)
flucytosine 250 mg 1
flucytosine 500 mg 1
grifulvin v 1
GRIS-PEG (Use
Griseofulvin Ultramicrosize)
griseofulvin microsize 1
griseofulvin ultramicrosize 1
LAMISIL PACK 125 MG,
187.5 MG
LAMISIL TABS 250 MG
(Use Terbinafine HCl)
nystatin tabs or 500000 unit 1
terbinafine hcl tabs or 250
mg
Imidazole-Related Antifungals
DIFLUCAN (Use
Fluconazole)
3
fluconazole in dextrose 4
fluconazole in nacl 0.9-100
%, mg/50ml, 0.9-200 %,
mg/100ml
3
3
2
2
3
1
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA; MO
PA; MO
MO
PA; MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
24

DRUG NAME
fluconazole in nacl 0.9-400
%, mg/200ml
fluconazole susr or 10
mg/ml, 40 mg/ml
fluconazole tabs or 100
mg, 150 mg, 200 mg, 50
mg
itraconazole caps or 100
mg
ketoconazole tabs or 200
mg
NOXAFIL 5
ONMEL 3
SPORANOX (Use
Itraconazole)
SPORANOX PULSEPAK
(Use Itraconazole)
VFEND (Use
Voriconazole)
VFEND IV (Use
Voriconazole)
voriconazole solr iv 200 mg 4
voriconazole susr or 40
mg/ml
voriconazole tabs or 200
mg, 50 mg
Drug
Tier Requirements/
Limits
4
MO
1
1
1
1
3
3
5
4
5
5
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
ANTIHISTAMINES - Drugs to Treat Allergies
Antihistamines - Ethanolamines
carbinoxamine maleate
soln or 4 mg/5ml
1
AL; MO
carbinoxamine maleate
tabs or 4 mg
1
MO
clemastine fumarate syrp
or 0.67 mg/5ml
1
AL; MO
clemastine fumarate tabs
or 2.68 mg
1
AL; MO
diphenhydramine hcl caps
or 50 mg
1
PA; AL;
RX/OTC; MO
diphenhydramine hcl elix or
12.5 mg/5ml
1
RX/OTC
diphenhydramine hcl soln ij MO
4
50 mg/ml
Drug
DRUG NAME
Tier Requirements/
Limits
palgic 1
AL; MO
Antihistamines - Non-Sedating
cetirizine hcl syrp 1 mg/ml,
5 mg/5ml
1
CLARINEX (Use
Desloratadine)
3
CLARINEX REDITABS
(Use Desloratadine)
3
desloratadine 1
levocetirizine
dihydrochloride
XYZAL (Use Levocetirizine
Dihydrochloride)
1
3
RX/OTC; MO
MO
MO
MO
MO
MO
Antihistamines - Phenothiazines
phenergan 4
MO
promethazine hcl soln ij 25
mg/ml, 50 mg/ml
promethazine hcl soln or
6.25 mg/5ml
promethazine hcl supp re
12.5 mg, 25 mg
promethazine hcl syrp or
6.25 mg/5ml
promethazine hcl tabs or
12.5 mg, 25 mg, 50 mg
promethegan 1
Antihistamines - Piperidines
cyproheptadine hcl syrp or
2 mg/5ml
1
cyproheptadine hcl tabs or
4 mg
1
4
1
1
1
1
MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
ANTIHYPERLIPIDEMICS - Drugs to Treat High
Cholesterol
Antihyperlipidemics - Combinations
LIPTRUZET 2
MO
VYTORIN 10-10 MG 2
VYTORIN 10-20 MG 2
QL(8 ea daily);
MO
QL(4 ea daily);
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
25

DRUG NAME
Drug
Tier Requirements/
Limits
VYTORIN 10-40 MG 2
QL(2 ea daily);
MO
VYTORIN 10-80 MG 2
PA; QL(1 ea
daily); MO
Antihyperlipidemics - Misc.
KYNAMRO 5
LOVAZA 2
VASCEPA 3
Bile Acid Sequestrants
cholestyramine light 1
cholestyramine pack or 4
gm
cholestyramine powd or 4
gm/dose
COLESTID (Use
Colestipol HCl)
COLESTID FLAVORED
(Use Colestipol HCl)
colestipol hcl 1
questran light 1
questran pack 4 gm 1
questran powd 4 gm/dose 1
WELCHOL 3
Fibric Acid Derivatives
ANTARA 130 MG, 43 MG
(Use Fenofibrate
Micronized)
ANTARA 30 MG 3
ANTARA 90 MG 3
choline fenofibrate 1
fenofibrate 1
fenofibrate micronized 1
1
1
3
3
3
PA
MO
MO
MO
MO
MO; Powder
Canister
MO
MO
MO
MO
MO
MO; Powder
Canister
MO
MO
QL(3 ea daily)
QL(1 ea daily)
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
fenofibric acid 1
MO
FENOGLIDE 3
FIBRICOR (Use Fenofibric
Acid)
gemfibrozil tabs or 600 mg 1
LIPOFEN 3
lofibra 1
LOPID (Use Gemfibrozil) 3
TRICOR (Use Fenofibrate) 2
TRIGLIDE 160 MG 3
TRIGLIDE 50 MG 3
TRILIPIX (Use Choline
Fenofibrate)
HMG CoA Reductase Inhibitors
ADVICOR 3
ALTOPREV 3
atorvastatin calcium 1
CRESTOR 3
fluvastatin sodium 1
LESCOL (Use Fluvastatin
Sodium)
LESCOL XL 3
LIPITOR (Use Atorvastatin
Calcium)
LIVALO 3
lovastatin 1
MEVACOR (Use
Lovastatin)
PRAVACHOL (Use
Pravastatin Sodium)
3
2
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
ST; MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
26

Drug
DRUG NAME
Tier Requirements/
Limits
pravastatin sodium 1
MO
SIMCOR 20-1000 MG, 20-
500 MG, 20-750 MG
SIMCOR 40-1000 MG, 40-
500 MG
simvastatin tabs or 10 mg 1
simvastatin tabs or 20 mg 1
simvastatin tabs or 40 mg 1
simvastatin tabs or 5 mg 1
simvastatin tabs or 80 mg 1
ZOCOR 10 MG (Use
Simvastatin)
ZOCOR 20 MG (Use
Simvastatin)
ZOCOR 40 MG (Use
Simvastatin)
ZOCOR 5 MG (Use
Simvastatin)
ZOCOR 80 MG (Use
Simvastatin)
2
2
3
3
3
3
3
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO
QL(1 ea daily);
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO
QL(1 ea daily);
MO
Intestinal Cholesterol Absorption Inhibitors
ZETIA 2
MO
Microsomal Triglyceride Transfer Protein
JUXTAPID 10 MG 5
PA; QL(6 ea
daily)
JUXTAPID 20 MG 5
PA; QL(3 ea
daily)
JUXTAPID 5 MG 5
PA; QL(12 ea
daily)
Nicotinic Acid Derivatives
niacin (antihyperlipidemic) 1
niacor 1
NIASPAN (Use Niacin
(Antihyperlipidemic))
2
MO
MO
MO
ANTIHYPERTENSIVES - Drugs to Treat High
Blood Pressure
DRUG NAME
ACE Inhibitors
ACCUPRIL (Use Quinapril
HCl)
ACEON 2 MG (Use
Perindopril Erbumine)
ACEON 4 MG (Use
Perindopril Erbumine)
ACEON 8 MG (Use
Perindopril Erbumine)
ALTACE (Use Ramipril) 3
benazepril hcl tabs or 10
mg, 20 mg, 40 mg, 5 mg
captopril tabs or 100 mg,
12.5 mg, 25 mg, 50 mg
enalapril maleate tabs or
10 mg
enalapril maleate tabs or
2.5 mg
enalapril maleate tabs or
20 mg
enalapril maleate tabs or 5
mg
enalaprilat 4
fosinopril sodium 1
lisinopril tabs or 10 mg, 2.5
mg, 20 mg, 30 mg, 40 mg,
5 mg
LOTENSIN (Use
Benazepril HCl)
MAVIK (Use Trandolapril) 3
moexipril hcl 1
perindopril erbumine 2 mg 1
perindopril erbumine 4 mg 1
perindopril erbumine 8 mg 1
PRINIVIL (Use Lisinopril) 3
quinapril hcl 1
Drug
Tier Requirements/
Limits
3
3
3
3
1
1
1
1
1
1
1
3
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
MO
MO
MO
QL(4 ea daily);
MO
QL(16 ea
daily); MO
QL(2 ea daily);
MO
QL(8 ea daily);
MO
MO
MO
MO
MO
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
27

Drug
DRUG NAME
Tier Requirements/
Limits
ramipril 1
MO
trandolapril 1
UNIVASC (Use Moexipril
HCl)
VASOTEC 10 MG (Use
Enalapril Maleate)
VASOTEC 2.5 MG (Use
Enalapril Maleate)
VASOTEC 20 MG (Use
Enalapril Maleate)
VASOTEC 5 MG (Use
Enalapril Maleate)
ZESTRIL (Use Lisinopril) 3
Agents for Pheochromocytoma
DEMSER 5
DIBENZYLINE 3
phentolamine mesylate solr
ij 5 mg
3
3
3
3
3
4
MO
MO
QL(4 ea daily);
MO
QL(16 ea
daily); MO
QL(2 ea daily);
MO
QL(8 ea daily);
MO
MO
MO
MO
MO
Angiotensin II Receptor Antagonists
ATACAND (Use
Candesartan Cilexetil)
3
MO
AVAPRO (Use Irbesartan) 3
MO
BENICAR 2
candesartan cilexetil 1
COZAAR (Use Losartan
Potassium)
DIOVAN 2
EDARBI 3
eprosartan mesylate 1
irbesartan 1
losartan potassium 1
MICARDIS 3
TEVETEN 400 MG 3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
TEVETEN 600 MG (Use
Eprosartan Mesylate)
Antiadrenergic Antihypertensives
CARDURA (Use
Doxazosin Mesylate)
3
MO
CATAPRES (Use
Clonidine HCl)
3
MO
CATAPRES-TTS-1 (Use
Clonidine HCl)
3
MO
CATAPRES-TTS-2 (Use
Clonidine HCl)
3
MO
CATAPRES-TTS-3 (Use
Clonidine HCl)
3
MO
clonidine hcl ptwk td 0.1
MO
mg/24hr, 0.2 mg/24hr, 0.3
mg/24hr
1
clonidine hcl tabs or 0.1
mg, 0.2 mg, 0.3 mg
1
MO
doxazosin mesylate 1
MO
guanfacine hcl 1
methyldopa tabs or 250
mg, 500 mg
methyldopate hcl 4
MINIPRESS (Use
Prazosin HCl)
prazosin hcl 1
reserpine tabs or 0.1 mg,
0.25 mg
TENEX (Use Guanfacine
HCl)
terazosin hcl 1
Drug
Tier Requirements/
Limits
3
MO
1
3
1
3
AL; MO
MO
MO
MO
MO
AL; MO
MO
Antihypertensive Combinations
ACCURETIC (Use
MO
Quinapril-
3
Hydrochlorothiazide)
amlodipine besylatebenazepril
hcl
1
MO
AMTURNIDE 2
MO
ATACAND HCT (Use
Candesartan Cilexetil-
Hydrochlorothiazide)
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
3
MO
28

Drug
DRUG NAME
Tier Requirements/
Limits
atenolol & chlorthalidone 1
MO
AVALIDE (Use Irbesartan-
Hydrochlorothiazide)
AZOR 2
benazepril &
hydrochlorothiazide
BENICAR HCT 2
bisoprolol &
hydrochlorothiazide
candesartan cilexetilhydrochlorothiazide
captopril/hydrochlorothiazid
e
clorpres 1
CORZIDE (Use Nadolol &
Bendroflumethiazide)
DIOVAN HCT (Use
Valsartan-
Hydrochlorothiazide)
DUTOPROL 3
EDARBYCLOR 3
enalapril maleate &
hydrochlorothiazide
EXFORGE 2
EXFORGE HCT 2
3
1
1
1
1
3
2
1
1
3
1
1
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
LOTENSIN HCT (Use
Benazepril &
Hydrochlorothiazide)
LOTREL (Use Amlodipine
Besylate-Benazepril HCl)
methyldopa/hydrochlorothia
zide
metoprolol &
hydrochlorothiazide
metoprolol/hydrochlorothiaz
ide
MICARDIS HCT 3
fosinopril sodium &
hydrochlorothiazide
HYZAAR (Use Losartan
Potassium &
Hydrochlorothiazide)
irbesartanhydrochlorothiazide
lisinopril &
hydrochlorothiazide
LOPRESSOR HCT (Use
Metoprolol &
Hydrochlorothiazide)
losartan potassium &
hydrochlorothiazide
moexiprilhydrochlorothiazide
nadolol &
bendroflumethiazide
PRINZIDE (Use Lisinopril
& Hydrochlorothiazide)
propranolol/hydrochlorothia
zide
quinaprilhydrochlorothiazide
TARKA 3
TEKAMLO 2
TEKTURNA HCT 2
TENORETIC 100 (Use
Atenolol & Chlorthalidone)
TENORETIC 50 (Use
Atenolol & Chlorthalidone)
TEVETEN HCT 3
TRIBENZOR 2
TWYNSTA 3
UNIRETIC (Use Moexipril-
Hydrochlorothiazide)
valsartanhydrochlorothiazide
VALTURNA 2
Drug
Tier Requirements/
Limits
MO
3
3
1
1
1
1
1
3
1
1
3
3
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
29

DRUG NAME
VASERETIC (Use
Enalapril Maleate &
Hydrochlorothiazide)
ZESTORETIC (Use
Lisinopril &
Hydrochlorothiazide)
ZIAC (Use Bisoprolol &
Hydrochlorothiazide)
Direct Renin Inhibitors
TEKTURNA 2
Drug
Tier Requirements/
Limits
MO
3
3
3
MO
MO
MO
Selective Aldosterone Receptor Antagonists
eplerenone 1
MO
INSPRA (Use Eplerenone) 3
Vasodilators
hydralazine hcl soln ij 20
mg/ml
hydralazine hcl tabs or 10
mg, 100 mg, 25 mg, 50 mg
minoxidil tabs or 10 mg, 2.5
mg
4
1
1
MO
MO
MO
ANTIMALARIALS - Drugs to Treat Malaria
(Parasitic Infections)
Antimalarial Combinations
atovaquone-proguanil hcl 1
ATOVAQUONE/PROGUA
NIL HCL
COARTEM 2
MALARONE (Use
Atovaquone-Proguanil HCl)
Antimalarials
ARALEN (Use
Chloroquine Phosphate)
chloroquine phosphate
tabs or 250 mg, 500 mg
3
3
NF
DARAPRIM 2
hydroxychloroquine sulfate
tabs or 200 mg
mefloquine hcl 1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
PLAQUENIL (Use
Hydroxychloroquine
Sulfate)
primaquine phosphate tabs
or 26.3 mg
QUALAQUIN (Use Quinine
Sulfate)
quinine sulfate caps or 324
mg
Drug
Tier Requirements/
Limits
MO
3
1
2
1
MO
PA; MO
PA; MO
ANTIMYASTHENIC/CHOLINERGIC AGENTS
Antimyasthenic/Cholinergic Agents
MESTINON SYRP 60
MG/5ML
2
MO
MESTINON TABS 60 MG MO
(Use Pyridostigmine
Bromide)
3
MESTINON TIMESPAN 2
MO
MYTELASE 2
pyridostigmine bromide
tabs or 60 mg
REGONOL 4
1
MO
ANTIMYCOBACTERIAL AGENTS - Drugs to
Treat Tuberculosis (Bacterial Infections)
Anti TB Combinations
isoniazid & rifampin 1
rifamate 1
RIFATER 3
Antimycobacterial Agents
CAPASTAT SULFATE 4
cycloserine 1
ethambutol hcl tabs or 100
mg, 400 mg
isoniazid soln ij 100 mg/ml 4
isoniazid syrp or 50 mg/5ml 1
isoniazid tabs or 100 mg,
300 mg
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
1
1
MO
MO
MO
MO
MO
MO
MO
30

DRUG NAME
MYAMBUTOL 100 MG
(Use Ethambutol HCl)
MYAMBUTOL 400 MG
(Use Ethambutol HCl)
MYCOBUTIN 3
paser 1
PRIFTIN 3
pyrazinamide tabs or 500
mg
rifadin caps or 150 mg 1
RIFADIN CAPS OR 300
MG (Use Rifampin)
RIFADIN SOLR IV 600 MG
(Use Rifampin)
rifampin caps or 150 mg 1
rifampin caps or 300 mg 1
rifampin solr iv 600 mg 4
seromycin 1
SIRTURO 5
TRECATOR 3
Drug
Tier Requirements/
Limits
NF
MO
3
1
3
4
MO
MO
MO
MO
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
MO
MO
MO
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES - Drugs to Treat Cancer
Alkylating Agents
ALKERAN (Use Melphalan
HCl)
BICNU 4
BUSULFEX 4
carboplatin soln iv 150
mg/15ml, 600 mg/60ml
carboplatin soln iv 450
mg/45ml
carboplatin soln iv 50
mg/5ml
CEENU 10 MG (Use
Lomustine)
4
1
1
4
2
MO
MO
MO
DRUG NAME
CEENU 100 MG, 40 MG
(Use Lomustine)
cisplatin soln iv 100
mg/100ml, 200 mg/200ml,
50 mg/50ml
cyclophosphamide solr ij 1
gm, 500 mg
cyclophosphamide solr ij 2
gm
cyclophosphamide tabs or
25 mg, 50 mg
ELOXATIN 100 MG/20ML,
50 MG/10ML (Use
Oxaliplatin)
ELOXATIN 200 MG/40ML 5
HEXALEN 5
IFEX (Use Ifosfamide) 4
IFOSFAMIDE 4
ifosfamide 4
LEUKERAN 2
lomustine 1
melphalan hcl 4
MUSTARGEN 4
oxaliplatin soln 100
mg/20ml, 50 mg/10ml
oxaliplatin solr 100 mg, 50
mg
TEMODAR 5
thiotepa solr ij 15 mg 4
TREANDA 5
ZANOSAR 4
Antimetabolites
ALIMTA 100 MG 5
Drug
Tier Requirements/
Limits
2
4
4
4
1
5
5
4
MO
MO; B/D
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
31

Drug
DRUG NAME
Tier Requirements/
Limits
ALIMTA 500 MG 5
MO
ARRANON 5
azacitidine 5
cladribine 4
CLOLAR 4
cytarabine soln 100 mg/ml 4
cytarabine soln 20 mg/ml 4
CYTARABINE SOLR 1 GM 4
cytarabine solr 1 gm, 500
mg
cytarabine solr 100 mg 4
DACOGEN (Use
Decitabine)
decitabine 5
FLUDARA (Use
Fludarabine Phosphate)
fludarabine phosphate soln
50 mg/2ml
fludarabine phosphate solr
50 mg
fluorouracil soln iv 1
gm/20ml
fluorouracil soln iv 2.5
gm/50ml, 5 gm/100ml, 500
mg/10ml
FOLOTYN 5
GEMCITABINE 5
gemcitabine hcl 1 gm, 200
mg
gemcitabine hcl 2 gm 5
GEMZAR (Use
Gemcitabine HCl)
LEUSTATIN (Use
Cladribine)
4
5
4
4
1
4
4
5
5
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
mercaptopurine tabs or 50
mg
methotrexate sodium soln ij
1 gm/40ml, 100 mg/4ml,
200 mg/8ml, 25 mg/ml, 250
mg/10ml, 50 mg/2ml
methotrexate sodium solr ij
1 gm
methotrexate sodium tabs
or 2.5 mg
PURINETHOL (Use
Mercaptopurine)
TABLOID 2
trexall 1
VIDAZA (Use Azacitidine) 5
Drug
Tier Requirements/
Limits
1
MO
4
4
1
3
MO
MO
MO
MO
MO
MO
Antineoplastic - Angiogenesis Inhibitors
AVASTIN 5
ZALTRAP 5
Antineoplastic - Antibodies
ARZERRA 5
CAMPATH 5
ERBITUX 5
HERCEPTIN 5
KADCYLA 5
PERJETA 5
RITUXAN 5
VECTIBIX 5
YERVOY 5
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE 5
LA
Antineoplastic - Hormonal and Related Agents
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
32

Drug
DRUG NAME
Tier Requirements/
Limits
anastrozole tabs or 1 mg 1
MO
ARIMIDEX (Use
Anastrozole)
AROMASIN (Use
Exemestane)
bicalutamide 1
CASODEX (Use
Bicalutamide)
DEPO-PROVERA 4
ELIGARD 4
EMCYT 3
exemestane 1
FARESTON 2
FASLODEX 5
FEMARA (Use Letrozole) 3
FIRMAGON 120 MG 5
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
megestrol acetate susp or
40 mg/ml, 400 mg/10ml
megestrol acetate tabs or
20 mg, 40 mg
NILANDRON 3
SOLTAMOX 3
tamoxifen citrate tabs or 10
mg, 20 mg
TRELSTAR DEPOT 4
TRELSTAR DEPOT
MIXJECT
TRELSTAR LA 4
TRELSTAR LA MIXJECT 4
TRELSTAR MIXJECT 5
VANTAS 5
XTANDI 5
ZOLADEX 10.8 MG 5
Drug
Tier Requirements/
Limits
1
AL; MO
1
1
4
MO
MO
MO
MO
PA
FIRMAGON 80 MG 4
flutamide 1
letrozole 1
leuprolide acetate kit ij 1
mg/0.2ml
LUPRON DEPOT 11.25
MG, 22.5 MG
LUPRON DEPOT 3.75 MG 4
LUPRON DEPOT 30 MG 5
LUPRON DEPOT 45 MG 5
LUPRON DEPOT 7.5 MG 5
LYSODREN 2
MEGACE ORAL (Use
Megestrol Acetate)
4
5
3
MO
MO
MO
AL; MO
ZOLADEX 3.6 MG 4
ZYTIGA 5
Antineoplastic - Immunomodulators
POMALYST 5
Antineoplastic Antibiotics
adriamycin 4
bleomycin sulfate 15 unit 4
bleomycin sulfate 30 unit 4
cerubidine 4
COSMEGEN (Use
Dactinomycin)
dactinomycin 4
daunorubicin hcl 4
4
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
33

DRUG NAME
DAUNOXOME 4
DOXIL (Use Doxorubicin
HCl Liposomal)
doxorubicin hcl liposomal 5
doxorubicin hcl soln 2
mg/ml
doxorubicin hcl solr 10 mg 4
doxorubicin hcl solr 50 mg 4
ELLENCE (Use Epirubicin
HCl)
epirubicin hcl soln 200
mg/100ml, 50 mg/25ml
EPIRUBICIN HCL SOLR
50 MG
IDAMYCIN PFS (Use
Idarubicin HCl)
idarubicin hcl 4
mitomycin solr iv 20 mg, 40
mg, 5 mg
mitoxantrone hcl 4
mitoxantrone hcl 25
mg/12.5ml (2 mg/ml)
Antineoplastic Enzyme Inhibitors
AFINITOR 5
AFINITOR DISPERZ 5
BOSULIF 5
CAPRELSA 5
COMETRIQ 5
COMETRIQ , 20 MG 5
GILOTRIF 5
GLEEVEC 2
INLYTA 5
Drug
Tier Requirements/
Limits
5
4
4
4
4
4
4
1
MO
MO
MO
MO
MO
PA
MO
PA; LA
Drug
DRUG NAME
Tier Requirements/
Limits
IRESSA 2
LA; MO
ISTODAX 5
JAKAFI 5
MEKINIST 5
NEXAVAR 5
SPRYCEL 5
STIVARGA 5
SUTENT 5
TAFINLAR 5
TARCEVA 2
TASIGNA 5
TORISEL 5
TYKERB 5
VANDETANIB 5
VELCADE 5
VOTRIENT 5
XALKORI 5
ZELBORAF 5
ZOLINZA 5
Antineoplastic Enzymes
ELSPAR 4
ONCASPAR 4
Antineoplastics Misc.
ACTIMMUNE 5
dacarbazine solr iv 200 mg 4
LA
LA
PA
LA
LA
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
34

DRUG NAME
HYDREA (Use
Hydroxyurea)
hydroxyurea caps or 500
mg
INTRON-A 10 MU/ML 5
INTRON-A 6000000
UNIT/ML
INTRON-A W/DILUENT 10
MU
INTRON-A W/DILUENT 18
MU, 50 MU
MATULANE 5
NIPENT (Use Pentostatin) 4
pentostatin 4
Drug
Tier Requirements/
Limits
3
MO
1
4
4
5
MO
DRUG NAME
FUSILEV 4
leucovorin calcium soln iv
10 mg/ml
leucovorin calcium solr ij
100 mg, 200 mg, 350 mg
leucovorin calcium solr ij 50
mg, 500 mg
leucovorin calcium tabs or
10 mg, 15 mg, 25 mg, 5 mg
mesna 4
MESNEX SOLN IV 100
MG/ML (Use Mesna)
MESNEX TABS OR 400
MG
TOTECT 4
Drug
Tier Requirements/
Limits
4
4
4
1
4
2
MO
MO
MO
MO
MO
MO
PROLEUKIN 5
SYLATRON 5
SYNRIBO 5
TARGRETIN 5
THERACYS 4
TICE BCG 4
tretinoin (chemotherapy) 5
TRISENOX 4
UVADEX 4
Chemotherapy Adjuncts
ELITEK 5
KEPIVANCE 5
MO
MO
MO
MO
MO
Chemotherapy Rescue/Antidote Agents
amifostine crystalline 1
MO
dexrazoxane 4
ETHYOL (Use Amifostine
Crystalline)
4
MO
VORAXAZE 5
ZINECARD (Use
Dexrazoxane)
Mitotic Inhibitors
ABRAXANE 5
DOCEFREZ 5
DOCETAXEL CONC 140
MG/7ML, 20 MG/0.5ML, 80
MG/2ML
DOCETAXEL CONC 20
MG/ML, 80 MG/4ML
DOCETAXEL SOLN 160
MG/16ML, 20 MG/2ML, 80
MG/8ML
ETOPOPHOS 4
etoposide soln iv 1
gm/50ml, 20 mg/ml
etoposide soln iv 500
mg/25ml
HALAVEN 5
IXEMPRA KIT 5
JEVTANA 5
4
5
5
5
1
1
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
35

DRUG NAME
paclitaxel 100 mg/16.7ml,
30 mg/5ml, 300 mg/50ml
paclitaxel 150 mg/25ml 4
TAXOTERE 20 MG/0.5ML 5
TAXOTERE 20 MG/ML, 80
MG/4ML
vinblastine sulfate soln iv 1
mg/ml
vinblastine sulfate solr iv 10
mg
vincristine sulfate soln iv 1
mg/ml
vinorelbine tartrate 4
Topoisomerase I Inhibitors
CAMPTOSAR 100
MG/5ML, 40 MG/2ML (Use
Irinotecan HCl)
CAMPTOSAR 300
MG/15ML
HYCAMTIN (Use
Topotecan HCl)
irinotecan hcl 100 mg/5ml,
40 mg/2ml
irinotecan hcl 500 mg/25ml 4
TOPOTECAN HCL SOLN
4 MG/4ML
topotecan hcl solr 4 mg 5
Drug
Tier Requirements/
Limits
4
MO
5
4
4
4
4
4
5
4
5
MO
MO
MO
MO
MO
MO
MO
MO
ANTIPARKINSON AGENTS - Drugs to Treat
Parkinson's Disease
Antiparkinson Adjuvants
LODOSYN 3
MO
Antiparkinson Anticholinergics
benztropine mesylate soln
ij 1 mg/ml
4
benztropine mesylate tabs
or 0.5 mg, 1 mg, 2 mg
1
AL; MO
COGENTIN (Use
Benztropine Mesylate)
4
trihexyphenidyl hcl 1
AL; MO
DRUG NAME
Antiparkinson COMT Inhibitors
COMTAN (Use
Entacapone)
2
entacapone 1
Antiparkinson Dopaminergics
amantadine hcl caps or 100
mg
1
amantadine hcl syrp or 50
mg/5ml
1
amantadine hcl tabs or 100
mg
1
APOKYN 5
bromocriptine mesylate
caps or 5 mg
bromocriptine mesylate
tabs or 2.5 mg
carbidopa-levodopa 1
CARBIDOPA/LEVODOPA/
ENTACAPONE
MIRAPEX (Use
Pramipexole
Dihydrochloride)
MIRAPEX ER 3
NEUPRO 3
parcopa 1
PARLODEL (Use
Bromocriptine Mesylate)
pramipexole
dihydrochloride
REQUIP (Use Ropinirole
Hydrochloride)
REQUIP XL (Use
Ropinirole Hydrochloride)
ropinirole hydrochloride 1
SINEMET (Use
Carbidopa-Levodopa)
SINEMET CR (Use
Carbidopa-Levodopa)
STALEVO 100 2
Drug
Tier Requirements/
Limits
1
1
2
3
3
1
3
3
3
3
QL(8 ea daily);
MO
QL(8 ea daily);
MO
MO
MO
MO
LA
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
36

Drug
DRUG NAME
Tier Requirements/
Limits
STALEVO 125 2
MO
STALEVO 150 2
STALEVO 200 2
STALEVO 50 2
STALEVO 75 2
MO
MO
MO
MO
Antiparkinson Monoamine Oxidase Inhibitors
AZILECT 2
MO
ELDEPRYL (Use
Selegiline HCl)
selegiline hcl caps or 5 mg 1
selegiline hcl tabs or 5 mg 1
ZELAPAR 3
3
MO
MO
MO
MO
ANTIPSYCHOTICS/ANTIMANIC AGENTS -
Drugs to Treat Mood Disorders
Antimanic Agents
LITHIUM CARBONATE
CAPS OR 150 MG (Use
Lithium Carbonate)
lithium carbonate caps or
150 mg, 300 mg, 600 mg
lithium carbonate tabs or
300 mg
lithium carbonate tbcr or
300 mg, 450 mg
lithium citrate soln or 8
meq/5ml
LITHOBID (Use Lithium
Carbonate)
Antipsychotics - Misc.
EQUETRO 3
GEODON CAPS OR 20
MG, 40 MG, 60 MG, 80
MG (Use Ziprasidone HCl)
GEODON SOLR IM 20 MG 4
LATUDA 120 MG 3
3
1
1
1
1
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(1 ea daily);
MO
DRUG NAME
Drug
Tier Requirements/
Limits
LATUDA 20 MG 3
QL(8 ea daily);
MO
LATUDA 40 MG 3
QL(4 ea daily);
MO
LATUDA 60 MG 3
QL(2.67 ea
daily); MO
LATUDA 80 MG 3
QL(2 ea daily);
MO
ziprasidone hcl 1
MO
Benzisoxazoles
FANAPT 3
FANAPT TITRATION
PACK
INVEGA 1.5 MG 3
INVEGA 3 MG 3
INVEGA 6 MG 3
INVEGA 9 MG 3
INVEGA SUSTENNA 4
RISPERDAL (Use
Risperidone)
RISPERDAL CONSTA
12.5 MG
RISPERDAL CONSTA 25
MG
RISPERDAL CONSTA
37.5 MG, 50 MG
RISPERDAL M-TAB (Use
Risperidone)
risperidone 1
Butyrophenones
HALDOL (Use Haloperidol
Lactate)
HALDOL DECANOATE
100 (Use Haloperidol
Decanoate)
HALDOL DECANOATE 50
(Use Haloperidol
Decanoate)
3
3
4
4
5
3
4
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
MO
MO
QL(0.29 ea
daily); MO
QL(0.15 ea
daily); MO
QL(0.08 ea
daily); MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
37
4
4
MO
MO
MO
MO

Drug
DRUG NAME
Tier Requirements/
Limits
haloperidol 1
MO
haloperidol decanoate 4
haloperidol lactate conc or
2 mg/ml
haloperidol lactate soln ij 5
mg/ml
Dibenzapines
clozapine 1
CLOZAPINE ODT 3
CLOZARIL (Use
Clozapine)
FAZACLO 3
loxapine succinate caps or
10 mg, 25 mg, 5 mg, 50 mg
loxitane 1
olanzapine solr im 10 mg 4
olanzapine tabs or 10 mg,
15 mg, 2.5 mg, 20 mg, 5
mg, 7.5 mg
olanzapine tbdp or 10 mg,
15 mg, 20 mg, 5 mg
quetiapine fumarate 1
SAPHRIS 10 MG 3
SAPHRIS 5 MG 3
SEROQUEL (Use
Quetiapine Fumarate)
SEROQUEL XR 3
ZYPREXA SOLR IM 10
MG (Use Olanzapine)
ZYPREXA TABS OR 10
MG, 15 MG, 2.5 MG, 20
MG, 5 MG, 7.5 MG (Use
Olanzapine)
ZYPREXA ZYDIS (Use
Olanzapine)
Phenothiazines
1
4
3
1
1
1
3
4
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
MO
MO
MO
MO
MO
DRUG NAME
chlorpromazine hcl soln ij
25 mg/ml
chlorpromazine hcl tabs or
10 mg, 100 mg, 200 mg, 25
mg, 50 mg
fluphenazine decanoate
soln ij 25 mg/ml
fluphenazine hcl conc or 5
mg/ml
fluphenazine hcl elix or 2.5
mg/5ml
fluphenazine hcl soln ij 2.5
mg/ml
fluphenazine hcl tabs or 1
mg, 10 mg, 2.5 mg, 5 mg
perphenazine tabs or 16
mg, 2 mg, 4 mg, 8 mg
prochlorperazine 1
prochlorperazine edisylate
soln ij 5 mg/ml
prochlorperazine maleate
tabs or 10 mg, 5 mg
thioridazine hcl tabs or 10
mg, 100 mg, 25 mg, 50 mg
trifluoperazine hcl tabs or 1
mg, 10 mg, 2 mg, 5 mg
Quinolinone Derivatives
ABILIFY DISCMELT 10
MG
ABILIFY DISCMELT 15
MG
ABILIFY MAINTENA 5
ABILIFY SOLN IM 9.75
MG/1.3ML
ABILIFY SOLN OR 1
MG/ML
ABILIFY TABS OR 10 MG 3
ABILIFY TABS OR 15 MG 3
ABILIFY TABS OR 2 MG 3
ABILIFY TABS OR 20 MG,
30 MG
Drug
Tier Requirements/
Limits
4
MO
1
4
1
1
4
1
1
4
1
1
1
3
3
4
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA; AL; MO
MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
MO
QL(4 ml daily);
MO
QL(30 ml
daily); MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(15 ea
daily); MO
QL(1 ea daily);
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
38

Drug
DRUG NAME
Tier Requirements/
Limits
ABILIFY TABS OR 5 MG 3
QL(6 ea daily);
MO
Thioxanthenes
thiothixene caps or 1 mg,
10 mg, 2 mg, 5 mg
1
MO
ANTISEPTICS & DISINFECTANTS - Drugs to
Prevent Bacterial Skin Infections
Chlorine Antiseptics
PHISOHEX 2
ANTIVIRALS - Drugs to Treat Viral Infections
Antiretrovirals
abacavir sulfate 1
APTIVUS CAPS 250 MG 2
APTIVUS SOLN 100
MG/ML
ATRIPLA 2
COMBIVIR (Use
Lamivudine-Zidovudine)
COMPLERA 5
CRIXIVAN 2
didanosine 1
EDURANT 5
EMTRIVA 2
EPIVIR HBV 2
EPIVIR SOLN 10 MG/ML 2
EPIVIR TABS 150 MG, 300
MG (Use Lamivudine)
EPZICOM 5
FUZEON 5
INTELENCE 100 MG 2
INTELENCE 200 MG 5
2
5
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
INTELENCE 25 MG 2
INVIRASE CAPS 200 MG 3
INVIRASE TABS 500 MG 5
ISENTRESS CHEW 100
MG
ISENTRESS CHEW 25 MG 3
ISENTRESS TABS 400
MG
KALETRA SOLN 42.4-100-
400 %, MG/5ML
KALETRA TABS 25-100
MG
KALETRA TABS 50-200
MG
lamivudine 1
lamivudine-zidovudine 5
LEXIVA SUSP 50 MG/ML 2
LEXIVA TABS 700 MG 5
NEVIRAPINE SUSP 50
MG/5ML
nevirapine tabs 200 mg 1
NORVIR 2
PREZISTA SUSP 100
MG/ML
PREZISTA TABS 150 MG,
600 MG, 800 MG
PREZISTA TABS 400 MG 5
PREZISTA TABS 75 MG 2
RESCRIPTOR 2
RETROVIR (Use
Zidovudine)
RETROVIR IV INFUSION 4
REYATAZ 100 MG 2
Drug
Tier Requirements/
Limits
3
5
2
3
2
2
5
5
3
MO
MO
QL(6 ea daily);
MO
QL(24 ea
daily); MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
39

DRUG NAME
REYATAZ 150 MG, 200
MG, 300 MG
SELZENTRY 2
stavudine 1
STRIBILD 5
SUSTIVA 2
TIVICAY 5
TRIZIVIR 5
TRUVADA 2
VIDEX EC (Use
Didanosine)
VIDEXPEDIATRIC 2
VIRACEPT 5
VIRAMUNE SUSP 50
MG/5ML
VIRAMUNE TABS 200 MG
(Use Nevirapine)
VIRAMUNE XR 100 MG 3
VIRAMUNE XR 400 MG 3
VIREAD POWD 40
MG/GM
VIREAD TABS 150 MG,
300 MG
VIREAD TABS 200 MG,
250 MG
ZERIT (Use Stavudine) 3
ZIAGEN (Use Abacavir
Sulfate)
zidovudine 1
CMV Agents
cidofovir 5
CYTOVENE (Use
Ganciclovir Sodium)
Drug
Tier Requirements/
Limits
5
MO
3
2
3
5
5
5
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
foscarnet sodium 4
ganciclovir sodium 4
VALCYTE 5
VISTIDE (Use Cidofovir) 5
Hepatitis Agents
adefovir dipivoxil 5
BARACLUDE 2
COPEGUS (Use Ribavirin
(Hepatitis C))
HEPSERA (Use Adefovir
Dipivoxil)
INCIVEK 5
INFERGEN 5
PEG-INTRON 5
PEG-INTRON REDIPEN 5
PEG-INTRON REDIPEN
PAK 4
PEGASYS 5
PEGASYS PROCLICK 5
REBETOL CAPS 200 MG
(Use Ribavirin (Hepatitis
C))
REBETOL SOLN 40
MG/ML
ribavirin (hepatitis c) 1
TYZEKA 5
VICTRELIS 5
Herpes Agents
acyclovir caps or 200 mg 1
acyclovir sodium soln 50
mg/ml
Drug
Tier Requirements/
Limits
3
5
5
5
2
4
MO
MO
MO
MO
MO
PA
PA
MO
PA
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
40

DRUG NAME
acyclovir sodium solr 1000
mg
acyclovir sodium solr 500
mg
acyclovir susp or 200
mg/5ml
acyclovir tabs or 400 mg,
800 mg
famciclovir 1
FAMVIR (Use Famciclovir) 3
valacyclovir hcl tabs or 1
gm, 1000 mg, 500 mg
VALTREX (Use
Valacyclovir HCl)
ZOVIRAX CAPS OR 200
MG (Use Acyclovir)
ZOVIRAX SUSP OR 200
MG/5ML (Use Acyclovir)
ZOVIRAX TABS OR 400
MG, 800 MG (Use
Acyclovir)
Influenza Agents
FLUMADINE (Use
Rimantadine
Hydrochloride)
RELENZA DISKHALER 3
rimantadine hydrochloride 1
TAMIFLU CAPS 30 MG, 45
MG
TAMIFLU CAPS 75 MG 2
TAMIFLU SUSR 6 MG/ML 3
Drug
Tier Requirements/
Limits
4
4
1
1
1
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
ASSORTED CLASSES - Miscellaneous Drugs
Chelating Agents
DEPEN TITRATABS 3
SYPRINE 5
Enzymes
XIAFLEX 5
MO
MO
DRUG NAME
Immunomodulators
REVLIMID 10 MG, 15 MG,
25 MG, 5 MG
REVLIMID 2.5 MG 5
THALOMID 2
Immunosuppressive Agents
ASTAGRAF XL 0.5 MG, 1
MG
3
ASTAGRAF XL 5 MG 3
ATGAM 4
azasan 1
azathioprine sodium 4
azathioprine tabs or 50 mg 1
CELLCEPT CAPS 250 MG
(Use Mycophenolate
Mofetil)
CELLCEPT
INTRAVENOUS
CELLCEPT SUSR 200
MG/ML
CELLCEPT TABS 500 MG
(Use Mycophenolate
Mofetil)
cyclosporine caps or 100
mg, 25 mg
cyclosporine modified 1
cyclosporine modified (for
microemulsion)
cyclosporine soln iv 50
mg/ml
IMURAN (Use
Azathioprine)
mycophenolate mofetil 1
MYFORTIC 3
NEORAL (Use
Cyclosporine Modified (For
Microemulsion))
Drug
Tier Requirements/
Limits
5
3
4
2
3
1
1
4
3
3
LA
MO; B/D
B/D
B/D
MO; B/D
B/D
MO; B/D
MO; B/D
B/D
MO; B/D
MO; B/D
MO; B/D
MO; B/D
MO; B/D
B/D
MO; B/D
MO; B/D
MO; B/D
MO; B/D
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
41

Drug
DRUG NAME
Tier Requirements/
Limits
NULOJIX 5
MO; B/D
PROGRAF CAPS OR 0.5
MG, 1 MG (Use
Tacrolimus)
PROGRAF CAPS OR 5
MG (Use Tacrolimus)
PROGRAF SOLN IV 5
MG/ML
RAPAMUNE SOLN 1
MG/ML
RAPAMUNE TABS 0.5 MG 2
RAPAMUNE TABS 1 MG 2
RAPAMUNE TABS 2 MG 2
SANDIMMUNE CAPS OR
100 MG, 25 MG (Use
Cyclosporine)
SANDIMMUNE SOLN IV
50 MG/ML (Use
Cyclosporine)
SANDIMMUNE SOLN OR
100 MG/ML
SIMULECT 5
tacrolimus caps or 0.5 mg,
1 mg
tacrolimus caps or 5 mg 5
THYMOGLOBULIN 2
ZORTRESS 0.25 MG 2
ZORTRESS 0.5 MG, 0.75
MG
Irrigation Solutions
irrigation solutions,
physiological
lactated ringer's (irrigation) 1
PHYSIOSOL IRRIGATION
PH 7.4
ringer's irrigation 1
3
5
4
2
3
4
3
1
5
1
3
MO; B/D
MO; B/D
B/D
QL(40 ml
daily); MO; B/D
QL(80 ea
daily); MO; B/D
QL(40 ea
daily); MO; B/D
QL(20 ea
daily); MO; B/D
MO; B/D
B/D
MO; B/D
B/D
MO; B/D
MO; B/D
B/D
MO; B/D
MO; B/D
Drug
DRUG NAME
Tier Requirements/
Limits
water for irrigation, sterile 1
MO
Peritoneal Dialysis Solutions
DIANEAL PD-2/1.5%
DEXTROSE
5
DIANEAL PD-2/2.5%
DEXTROSE
5
DIANEAL PD-2/4.25%
DEXTROSE
5
Potassium Removing Resins
KAYEXALATE (Use
Sodium Polystyrene 3
Sulfonate)
sodium polystyrene
sulfonate powd or
1
sodium polystyrene
sulfonate susp or 15 1
gm/60ml
sps 1
B/D
B/D
B/D
MO
MO
MO
MO
Systemic Lupus Erythematosus Agents
BENLYSTA 5
BETA BLOCKERS - Drugs to Treat High Blood
Pressure
Alpha-Beta Blockers
carvedilol 12.5 mg 1
carvedilol 25 mg 1
carvedilol 3.125 mg 1
carvedilol 6.25 mg 1
COREG 12.5 MG (Use
Carvedilol)
COREG 25 MG (Use
Carvedilol)
COREG 3.125 MG (Use
Carvedilol)
COREG 6.25 MG (Use
Carvedilol)
COREG CR 10 MG 3
3
3
3
3
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO
QL(8 ea daily);
MO
QL(8 ea daily);
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
42

DRUG NAME
Drug
Tier Requirements/
Limits
COREG CR 20 MG 3
QL(4 ea daily);
MO
COREG CR 40 MG 3
QL(2 ea daily);
MO
COREG CR 80 MG 3
QL(1 ea daily);
MO
labetalol hcl soln iv 5 mg/ml 4
labetalol hcl tabs or 100
mg, 200 mg, 300 mg
TRANDATE (Use
Labetalol HCl)
Beta Blockers Cardio-Selective
acebutolol hcl caps or 200
mg, 400 mg
1
atenolol tabs or 100 mg, 25
mg, 50 mg
1
betaxolol hcl 1
bisoprolol fumarate 1
BYSTOLIC 3
KERLONE (Use Betaxolol
HCl)
LOPRESSOR SOLN IV 1
MG/ML (Use Metoprolol
Tartrate)
LOPRESSOR TABS OR
100 MG, 50 MG (Use
Metoprolol Tartrate)
metoprolol succinate 1
metoprolol tartrate soln iv 1
mg/ml, 5 mg/5ml
metoprolol tartrate tabs or
100 mg, 25 mg, 50 mg
SECTRAL (Use Acebutolol
HCl)
TENORMIN (Use Atenolol) 3
TOPROL XL (Use
Metoprolol Succinate)
ZEBETA (Use Bisoprolol
Fumarate)
Beta Blockers Non-Selective
1
3
3
4
3
4
1
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
BETAPACE (Use Sotalol
HCl)
BETAPACE AF (Use
Sotalol HCl (AFIB/AFL))
CORGARD (Use Nadolol) 3
INDERAL LA (Use
Propranolol HCl)
LEVATOL 3
nadolol tabs or 20 mg, 40
mg, 80 mg
pindolol 1
propranolol hcl cp24 or 120
mg, 160 mg, 60 mg, 80 mg
propranolol hcl soln iv 1
mg/ml
propranolol hcl soln or 20
mg/5ml, 40 mg/5ml
propranolol hcl tabs or 10
mg, 20 mg, 40 mg, 60 mg,
80 mg
sotalol hcl 1
sotalol hcl (afib/afl) 1
timolol maleate tabs or 10
mg
timolol maleate tabs or 20
mg
timolol maleate tabs or 5
mg
Drug
Tier Requirements/
Limits
3
MO
3
3
1
1
4
1
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(6 ea daily);
MO
QL(3 ea daily);
MO
QL(12 ea
daily); MO
BIOLOGICALS MISC - Drugs to Treat Low
Enzymes
Biologicals Misc
ADAGEN 5
CALCIUM CHANNEL BLOCKERS - Drugs to
Treat High Blood Pressure
Calcium Channel Blockers
ADALAT CC (Use
Nifedipine)
amlodipine besylate tabs or
10 mg
3
1
MO
QL(1 ea daily);
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
43

DRUG NAME
amlodipine besylate tabs or
2.5 mg
amlodipine besylate tabs or
5 mg
CALAN (Use Verapamil
HCl)
CALAN SR (Use
Verapamil HCl)
CARDENE I.V. (Use
Nicardipine HCl)
CARDENE SR 30 MG, 60
MG
CARDIZEM (Use
Diltiazem HCl)
CARDIZEM CD (Use
Diltiazem HCl Coated
Beads)
CARDIZEM LA 120 MG 2
CARDIZEM LA 180 MG,
240 MG, 300 MG, 360 MG,
420 MG (Use Diltiazem
HCl Coated Beads)
COVERA-HS 3
dilacor xr 1
diltiazem hcl coated beads 1
diltiazem hcl cp12 or 120
mg, 60 mg, 90 mg
diltiazem hcl cp24 or 120
mg, 180 mg, 240 mg
diltiazem hcl extended
release beads
diltiazem hcl soln iv 125
mg/25ml, 25 mg/5ml, 50
mg/10ml
diltiazem hcl solr iv 100 mg 4
diltiazem hcl tabs or 120
mg, 30 mg, 60 mg, 90 mg
DYNACIRC CR 3
felodipine 1
ISOPTIN SR (Use
Verapamil HCl)
Drug
Tier Requirements/
Limits
1
QL(4 ea daily);
MO
1
QL(2 ea daily);
MO
3
MO
3
4
3
3
3
3
1
1
1
4
1
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
isradipine 1
MO
nicardipine hcl caps or 20
mg, 30 mg
nicardipine hcl soln iv 2.5
mg/ml
nifedipine caps or 20 mg 1
nifedipine tb24 or 30 mg,
60 mg, 90 mg
nimodipine caps or 30 mg 1
nisoldipine 1
NORVASC 10 MG (Use
Amlodipine Besylate)
NORVASC 2.5 MG (Use
Amlodipine Besylate)
NORVASC 5 MG (Use
Amlodipine Besylate)
NYMALIZE 5
PROCARDIA XL (Use
Nifedipine)
SULAR (Use Nisoldipine) 3
TIAZAC (Use Diltiazem
HCl Extended Release
Beads)
verapamil hcl cp24 or 100
mg, 120 mg, 180 mg, 200
mg, 240 mg, 300 mg, 360
mg
verapamil hcl soln iv 2.5
mg/ml
verapamil hcl tabs or 120
mg, 40 mg, 80 mg
verapamil hcl tbcr or 120
mg, 180 mg, 240 mg
VERELAN (Use Verapamil
HCl)
VERELAN PM (Use
Verapamil HCl)
1
4
1
3
3
3
3
3
1
4
1
1
3
3
MO
MO
MO
MO
MO
QL(1 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
CARDIOTONICS - Drugs to Treat Heart Failure
and Abnormal Heart Rhythm
Cardiac Glycosides
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
44

Drug
DRUG NAME
Tier Requirements/
Limits
digoxin soln ij 0.25 mg/ml 4
MO
digoxin soln or 0.05 mg/ml 1
digoxin tabs or 0.125 mg,
0.25 mg
LANOXIN PEDIATRIC 4
LANOXIN SOLN IJ 0.25
MG/ML (Use Digoxin)
LANOXIN TABS OR 0.125
MG, 0.25 MG (Use
Digoxin)
Phosphodiesterase Inhibitors
milrinone lactate 4
1
4
3
MO
MO
MO
MO
CARDIOVASCULAR AGENTS - MISC. - Drugs
to Treat Heart and Circulation Conditions
Cardiovascular Agents Misc. - Combinations
AMLODIPINE
MO
BESYLATE/ATORVASTAT 3
IN CALCIUM
BIDIL 3
MO
CADUET 3
Impotence Agents
CIALIS 3
Prostaglandin Vasodilators
epoprostenol sodium 5
FLOLAN (Use
Epoprostenol Sodium)
REMODULIN 5
TYVASO 5
TYVASO REFILL 5
TYVASO STARTER 5
VELETRI 5
VENTAVIS 10 MCG/ML 2
5
MO
MO
B/D
B/D
LA; B/D
B/D
B/D
B/D
B/D
LA; B/D
Drug
DRUG NAME
Tier Requirements/
Limits
VENTAVIS 20 MCG/ML 2
B/D
Pulmonary Hypertension - Endothelin
LETAIRIS 5
LA
TRACLEER 5
LA
Pulmonary Hypertension - Phosphodiesterase
ADCIRCA 5
REVATIO (Use Sildenafil
Citrate (Pulmonary
Hypertension))
sildenafil citrate (pulmonary
hypertension)
5
5
PA
PA
CEPHALOSPORINS - Drugs to Treat Bacterial
Infections
Cephalosporins - 1st Generation
cefadroxil 1
MO
cefazolin sodium soln iv 1-5
%, gm
cefazolin sodium solr ij 1
gm, 10 gm, 500 mg
cefazolin sodium solr ij 20
gm
cefazolin sodium solr iv 1
gm
CEFAZOLIN
SODIUM/DEXTROSE
cephalexin 1
KEFLEX (Use Cephalexin) 3
4
4
4
4
4
MO
MO
MO
Cephalosporins - 2nd Generation
cefaclor caps 250 mg, 500
mg
1
MO
cefaclor er 1
MO
cefaclor susr 125 mg/5ml,
250 mg/5ml, 375 mg/5ml
cefotetan 4
CEFOTETAN/DEXTROSE 4
1
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
45

DRUG NAME
cefoxitin sodium ij 10 gm 4
cefoxitin sodium iv 1 gm, 2
gm
CEFOXITIN SODIUM IV 1-
4 %, GM, 2-2.2 %, GM
cefprozil 1
CEFTIN (Use Cefuroxime
Axetil)
cefuroxime axetil 1
cefuroxime sodium ij 1.5
gm, 7.5 gm
cefuroxime sodium ij 750
mg
cefuroxime sodium iv 1.5
gm, 7.5 gm
CEFUROXIME/DEXTROS
E
mefoxin 5
ZINACEF IJ 1.5 GM, 7.5
GM (Use Cefuroxime
Sodium)
ZINACEF IJ 750 MG (Use
Cefuroxime Sodium)
ZINACEF IV 1.5 GM, 750
MG (Use Cefuroxime
Sodium)
ZINACEFIN ISO-
OSMOTIC DEXTROSE
ZINACEFIN ISO-
OSMOTIC DILUENT
Drug
Tier Requirements/
Limits
4
4
3
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
Cephalosporins - 3rd Generation
CEDAX CAPS 400 MG 3
QL(1 ea daily);
MO
CEDAX SUSR 180
MG/5ML
3
QL(11 ml
daily); MO
CEDAX SUSR 90 MG/5ML 3
QL(22 ml daily)
cefdinir 1
cefotaxime sodium ij 1 gm,
10 gm, 2 gm
cefotaxime sodium ij 500
mg
4
4
MO
MO
DRUG NAME
cefotaxime sodium iv 1 gm,
2 gm
cefpodoxime proxetil 1
ceftazidime solr ij 1 gm, 2
gm, 500 mg
ceftazidime solr ij 6 gm 4
ceftazidime solr iv 1 gm, 2
gm
CEFTAZIDIME/DEXTROS
E
CEFTIBUTEN CAPS 400
MG
CEFTIBUTEN SUSR 180
MG/5ML
ceftriaxone in iso-osmotic
dextrose 20 mg/ml
ceftriaxone in iso-osmotic
dextrose 40 mg/ml
ceftriaxone sodium solr ij 1
gm
ceftriaxone sodium solr ij 2
gm
ceftriaxone sodium solr ij
250 mg
ceftriaxone sodium solr ij
500 mg
ceftriaxone sodium solr iv 1
gm
ceftriaxone sodium solr iv
10 gm
ceftriaxone sodium solr iv 2
gm
CEFTRIAXONE/DEXTROS
E 1-3.74 %, GM
CEFTRIAXONE/DEXTROS
E 2-2.22 %, GM
CLAFORAN IJ 1 GM, 10
GM, 2 GM (Use
Cefotaxime Sodium)
CLAFORAN IJ 500 MG
(Use Cefotaxime Sodium)
CLAFORAN IV 1 GM, 2
GM
CLAFORAN/D5W 4
Drug
Tier Requirements/
Limits
4
4
4
4
3
3
4
4
4
1
4
4
4
4
4
4
4
4
4
4
MO
MO
QL(1 ea daily);
MO
QL(11 ml
daily); MO
QL(200 ml
daily)
QL(100 ml
daily)
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO
QL(8 ea daily);
MO
QL(4 ea daily)
MO
QL(2 ea daily);
MO
QL(4 ea daily)
QL(2 ea daily)
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
46

DRUG NAME
FORTAZ SOLN IV 1-5 %,
GM/50ML, 2-5 %,
GM/50ML
FORTAZ SOLR IJ 1 GM, 2
GM, 500 MG (Use
Ceftazidime)
FORTAZ SOLR IJ 6 GM
(Use Ceftazidime)
FORTAZ SOLR IV 1 GM, 2
GM (Use Ceftazidime)
rocephin 1 gm 4
rocephin 500 mg 4
SUPRAX CAPS 400 MG 3
suprax susr 100 mg/5ml,
200 mg/5ml
SUPRAX SUSR 500
MG/5ML
suprax tabs 400 mg 1
Cephalosporins - 4th Generation
CEFEPIME 4
cefepime hcl 4
MAXIPIME (Use Cefepime
HCl)
Cephalosporins - 5th Generation
TEFLARO 4
Drug
Tier Requirements/
Limits
4
4
4
4
1
3
4
MO
QL(4 ea daily);
MO
QL(8 ea daily);
MO
MO
MO
MO
MO
CONTRACEPTIVES - Drugs to Prevent
Pregnancy
Combination Contraceptives - Oral
amethyst 1
MO
BEYAZ 3
BREVICON-28 (Use
Norethindrone & Eth
Estradiol)
CYCLESSA (Use
Desogestrel-Ethinyl
Estradiol (Triphasic))
3
3
MO
MO
MO
DRUG NAME
DESOGEN (Use
Desogestrel & Ethinyl
Estradiol)
desogestrel & ethinyl
estradiol
desogestrel-ethinyl
estradiol (biphasic)
desogestrel-ethinyl
estradiol (triphasic)
drospirenone-ethinyl
estradiol
ESTROSTEP FE (Use
Norethindrone Acetate-
Ethinyl Estradiol-Fe)
ethynodiol diacet & eth
estrad
FEMCON FE (Use
Norethindrone & Ethinyl
Estradiol-Fe)
GENERESS FE 3
levonorgestrel & eth
estradiol
levonorgestrel-eth estradiol
(triphasic)
levonorgestrel-ethinyl
estradiol (91-day)
LO LOESTRIN FE 3
LO/OVRAL-28 (Use
Norgestrel & Ethinyl
Estradiol)
loestrin 1.5/30-21 1
loestrin 1/20-21 1
LOESTRIN 24 FE 3
loestrin fe 1.5/30 1
loestrin fe 1/20 1
LOSEASONIQUE (Use
Levonorgestrel-Ethinyl
Estradiol (91-Day))
MINASTRIN 24 FE 3
Drug
Tier Requirements/
Limits
MO
3
1
1
1
1
3
1
3
1
1
1
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
47

Drug
DRUG NAME
Tier Requirements/
Limits
mircette 1
MO
MODICON (Use
Norethindrone & Eth
Estradiol)
NATAZIA 3
necon 10/11-28 1
NORDETTE-28 (Use
Levonorgestrel & Eth
Estradiol)
norethin acet & estrad-fe 1
norethindrone & eth
estradiol
norethindrone & ethinyl
estradiol-fe
norethindrone & mestranol 1
norethindrone acet & eth
estra
norethindrone acetateethinyl
estradiol-fe
norethindrone-eth estradiol
(triphasic)
norgestimate-ethinyl
estradiol
norgestimate-ethinyl
estradiol (triphasic)
norgestrel & ethinyl
estradiol
NORINYL 1+35 (Use
Norethindrone & Eth
Estradiol)
NORINYL 1+50 3
ogestrel 1
ORTHO TRI-CYCLEN
(Use Norgestimate-Ethinyl
Estradiol (Triphasic))
ORTHO TRI-CYCLEN LO 2
ORTHO-CEPT (Use
Desogestrel & Ethinyl
Estradiol)
3
3
1
1
1
1
1
1
1
1
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
ORTHO-CYCLEN (Use
Norgestimate-Ethinyl
Estradiol)
ORTHO-NOVUM 1/35
(Use Norethindrone & Eth
Estradiol)
ORTHO-NOVUM 7/7/7
(Use Norethindrone-Eth
Estradiol (Triphasic))
ovcon-35 1
OVCON-50 28 2
QUARTETTE 3
SAFYRAL 3
SEASONALE (Use
Levonorgestrel-Ethinyl
Estradiol (91-Day))
SEASONIQUE (Use
Levonorgestrel-Ethinyl
Estradiol (91-Day))
TRI-NORINYL 28 (Use
Norethindrone-Eth
Estradiol (Triphasic))
YASMIN 28 (Use
Drospirenone-Ethinyl
Estradiol)
YAZ (Use Drospirenone-
Ethinyl Estradiol)
zovia 1/50e 1
Drug
Tier Requirements/
Limits
MO
3
3
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Combination Contraceptives - Transdermal
ORTHO EVRA 2
MO
Combination Contraceptives - Vaginal
NUVARING 2
MO
Emergency Contraceptives
ELLA 3
levonorgestrel (emergency
oc) 0.75 mg
levonorgestrel (emergency
oc) 1.5 mg
1
1
RX/OTC
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
48

DRUG NAME
PLAN B (Use
Levonorgestrel
(Emergency OC))
PLAN B ONE-STEP (Use
Levonorgestrel
(Emergency OC))
Progestin Contraceptives - Implants
IMPLANON 4
NEXPLANON 4
Drug
Tier Requirements/
Limits
3
3
RX/OTC
Progestin Contraceptives - Injectable
DEPO-PROVERA
MO
CONTRACEPTIVE (Use
Medroxyprogesterone
4
Acetate (Contraceptive))
DEPO-SUBQ PROVERA
104
4
MO
medroxyprogesterone
acetate (contraceptive)
4
MO
Progestin Contraceptives - Oral
NOR-QD (Use
MO
Norethindrone
3
(Contraceptive))
norethindrone
(contraceptive)
1
MO
ORTHO MICRONOR (Use
Norethindrone
(Contraceptive))
3
MO
CORTICOSTEROIDS - Steroid Hormone Drugs
to Treat Systemic Swelling Conditions
Glucocorticosteroids
ARISTOSPAN INTRA-
ARTICULAR
betamethasone sod
phosphate & acetate
budesonide cp24 or 3 mg 1
CELESTONE 3
CELESTONE-SOLUSPAN
(Use Betamethasone Sod
Phosphate & Acetate)
CORTEF (Use
Hydrocortisone)
2
4
4
3
MO
MO
MO
MO
MO
DRUG NAME
cortisone acetate tabs or
25 mg
DEPO-MEDROL (Use
Methylprednisolone
Acetate)
dexamethasone elix or 0.5
mg/5ml
dexamethasone intensol 1
dexamethasone sodium
phosphate soln ij 10 mg/ml,
4 mg/ml
dexamethasone soln or 0.5
mg/5ml
dexamethasone tabs or 0.5
mg, 0.75 mg, 1 mg, 1.5 mg,
2 mg, 4 mg, 6 mg
dexpak 10 day 1
dexpak 13 day 1
dexpak 6 day 1
ENTOCORT EC (Use
Budesonide)
FLO-PRED 3
hydrocortisone sod
succinate
hydrocortisone tabs or 10
mg, 20 mg, 5 mg
KENALOG-10 4
KENALOG-40 4
MEDROL 16 MG, 32 MG, 4
MG, 8 MG (Use
Methylprednisolone)
MEDROL 2 MG 2
MEDROL DOSEPAK (Use
Methylprednisolone)
methylprednisolone acetate
susp ij 40 mg/ml, 80 mg/ml
methylprednisolone sod
succ
methylprednisolone tabs or
16 mg, 32 mg, 4 mg, 8 mg
Drug
Tier Requirements/
Limits
1
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
49
4
1
4
1
1
3
4
1
3
3
4
4
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO

Drug
DRUG NAME
Tier Requirements/
Limits
millipred 1
MO
millipred dp 1
orapred 1
ORAPRED ODT 3
PEDIAPRED (Use
Prednisolone Sodium
Phosphate)
prednisolone sodium
phosphate soln or 15
mg/5ml, 5 mg/5ml, 6.7
mg/5ml
prednisolone sodium
phosphate soln or 25
mg/5ml
prednisolone soln or 15
mg/5ml
prednisone intensol 1
prednisone soln or 5
mg/5ml
prednisone tabs or 1 mg,
10 mg, 2.5 mg, 20 mg, 5
mg, 50 mg
RAYOS 3
SOLU-CORTEF 100 MG,
250 MG, 500 MG (Use
Hydrocortisone Sod
Succinate)
SOLU-CORTEF 1000 MG 4
SOLU-MEDROL 1000 MG,
125 MG, 40 MG, 500 MG
(Use Methylprednisolone
Sod Succ)
SOLU-MEDROL 2 GM 4
UCERIS 5
veripred 20 1
Mineralocorticoids
fludrocortisone acetate
tabs or 0.1 mg
3
1
1
1
1
1
4
4
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
Drug
Tier Requirements/
Limits
COUGH/COLD/ALLERGY - Drugs to Treat
Cough, Cold and Allergy Symptoms
Antitussives
benzonatate 1
TESSALON (Use
Benzonatate)
TESSALON PERLES (Use
Benzonatate)
NF
3
MO; NT
MO; NT
MO; NT
Cough/Cold/Allergy Combinations
CLARINEX-D 12 HOUR 3
MO
CLARINEX-D 24 HOUR 3
hydrocodone polistirexchlorpheniramine
polistirex
phenyleph-promethazine w/
cod
promethazine &
phenylephrine
promethazine vc/codeine 1
SEMPREX-D 3
TUSSIONEX
PENNKINETIC
EXTENDED RELEASE
(Use Hydrocodone
Polistirex-Chlorpheniramine
Polistirex)
ZUTRIPRO 3
Mucolytics
acetylcysteine soln in 10 %,
20 %
1
1
1
3
1
MO
MO; NT
MO; NT
PA; AL; MO
MO; NT
MO
MO; NT
MO; NT
MO; B/D
DERMATOLOGICALS - Drugs to Treat Skin
Conditions
Acne Products
ABSORICA 3
ACANYA 3
adapalene 1
AKNE-MYCIN 3
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
50

Drug
DRUG NAME
Tier Requirements/
Limits
ATRALIN 3
MO
AZELEX 3
BENZACLIN (Use
Clindamycin Phosphate-
Benzoyl Peroxide)
BENZACLIN WITH PUMP
(Use Clindamycin
Phosphate-Benzoyl
Peroxide)
BENZAMYCIN (Use
Benzoyl Peroxide-
Erythromycin)
benzoyl peroxideerythromycin
CLEOCIN-T (Use
Clindamycin Phosphate
(Topical))
CLINDAGEL 3
clindamycin phosphate
(topical)
clindamycin phosphatebenzoyl
peroxide
clindamycin phosphatebenzoyl
peroxide
(refrigerate)
DIFFERIN (Use
Adapalene)
DUAC (Use Clindamycin
Phosphate-Benzoyl
Peroxide (Refrigerate))
EPIDUO 3
erythromycin (acne aid) 1
erythromycin gel ex 2 % 1
EVOCLIN (Use
Clindamycin Phosphate
(Topical))
FABIOR 3
isotretinoin caps or 10 mg,
20 mg, 30 mg, 40 mg
3
3
3
1
3
1
1
1
3
3
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(1.67 gm
daily); MO
DRUG NAME
KLARON (Use
Sulfacetamide Sodium
(Acne))
RETIN-A (Use Tretinoin) 3
RETIN-A MICRO (Use
Tretinoin Microsphere)
RETIN-A MICRO PUMP
(Use Tretinoin
Microsphere)
sulfacetamide sodium
(acne)
tretinoin crea ex 0.025 %,
0.05 %, 0.1 %
tretinoin gel ex 0.01 %,
0.025 %
tretinoin microsphere 1
VELTIN 3
ZIANA 3
Drug
Tier Requirements/
Limits
MO
3
3
3
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
Anti-inflammatory Agents - Topical
PENNSAID 3
MO
VOLTAREN 3
Antibiotics - Topical
ALTABAX 3
MO
MO
BACTROBAN (Use
MO
Mupirocin Calcium
3
(Topical))
BACTROBAN (Use
Mupirocin)
3
MO
CORTISPORIN CREA EX
0.5-0.5-10000 %, UNIT/GM 2 MO
CORTISPORIN OINT EX MO
0.5-1-400-5000 %,
UNIT/GM
2
gentamicin sulfate (topical) 1
MO
gentamicin sulfate crea ex
0.1 %
gentamicin sulfate oint ex
0.1 %
1
1
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
51

Drug
DRUG NAME
Tier Requirements/
Limits
mupirocin calcium (topical) 1
MO
mupirocin oint ex 2 % 1
Antifungals - Topical
ciclopirox 1
ciclopirox olamine crea ex
0.77 %
ciclopirox olamine susp ex
0.77 %
clotrimazole (topical) 1
econazole nitrate 1
ERTACZO 3
EXELDERM 3
EXTINA (Use
Ketoconazole (Topical))
ketoconazole (topical) 1
LOPROX (Use Ciclopirox) 3
LOPROX SHAMPOO (Use
Ciclopirox)
MENTAX 2
NAFTIN 3
NIZORAL (Use
Ketoconazole (Topical))
nystatin (topical) 1
nystatin-triamcinolone 1
nystatin/triamcinolone 1
OXISTAT 3
VUSION 3
XOLEGEL 3
1
1
3
3
3
MO
MO
MO
MO
RX/OTC; MO
MO
MO
MO
MO
MO
MO
MO
RX/OTC; MO
MO
MO
MO
MO
MO
MO
MO
MO
Antineoplastic or Premalignant Lesion Agents
CARAC 2
MO
DRUG NAME
EFUDEX (Use Fluorouracil
(Topical))
FLUOROPLEX 2
fluorouracil (topical) 1
PANRETIN 2
PICATO 5
SOLARAZE 2
TARGRETIN 5
Antipruritics - Topical
PRUDOXIN 3
ZONALON 3
Antipsoriatics
8-MOP 2
acitretin 5
calcipotriene 1
CALCITRIOL OINT EX 3
MCG/GM
DOVONEX (Use
Calcipotriene)
DOVONEX SCALP (Use
Calcipotriene)
OXSORALEN ULTRA 2
SORIATANE (Use
Acitretin)
SORILUX 3
STELARA 5
TAZORAC 2
VECTICAL 2
Antiseborrheic Products
selenium sulfide lotn ex 2.5
%
Drug
Tier Requirements/
Limits
3
MO
2
2
3
5
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
52

DRUG NAME
SELSUN SHAMPOO (Use
Selenium Sulfide)
Antivirals - Topical
acyclovir topical 1
DENAVIR 2
XERESE 3
ZOVIRAX CREA EX 5 % 2
ZOVIRAX OINT EX 5 %
(Use Acyclovir Topical)
Burn Products
mafenide acetate pack ex 5
%
SILVADENE (Use Silver
Sulfadiazine)
silver sulfadiazine crea ex
1 %
SULFAMYLON (Use
Mafenide Acetate)
Corticosteroids - Topical
aclovate 1
ala scalp 1
alclometasone dipropionate 1
amcinonide 1
apexicon e 1
betamethasone
dipropionate (topical)
betamethasone
dipropionate augmented
betamethasone valerate
crea ex 0.1 %
betamethasone valerate
foam ex 0.12 %
betamethasone valerate
lotn ex 0.1 %
betamethasone valerate
oint ex 0.1 %
CAPEX 3
Drug
Tier Requirements/
Limits
3
MO
2
1
3
1
3
1
1
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
carmol-hc 1
MO
clobetasol propionate crea
ex 0.05 %
clobetasol propionate
emollient base
clobetasol propionate foam
ex 0.05 %
clobetasol propionate gel
ex 0.05 %
clobetasol propionate lotn
ex 0.05 %
clobetasol propionate oint
ex 0.05 %
clobetasol propionate sham
ex 0.05 %
clobetasol propionate soln
ex 0.05 %
CLOBEX (Use Clobetasol
Propionate)
CLODERM 3
CLODERM PUMP 3
CORDRAN 3
CORDRAN SP 3
CORDRAN TAPE 3
CUTIVATE (Use
Fluticasone Propionate)
DERMA-SMOOTHE/FS
BODY (Use Fluocinolone
Acetonide)
DERMA-SMOOTHE/FS
BODY OIL (Use
Fluocinolone Acetonide)
DERMA-SMOOTHE/FS
SCALP (Use Fluocinolone
Acetonide)
DERMA-SMOOTHE/FS
SCALP OIL (Use
Fluocinolone Acetonide)
DERMATOP (Use
Prednicarbate)
DESONATE 3
1
1
1
1
1
1
1
1
3
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
53

Drug
DRUG NAME
Tier Requirements/
Limits
desonide crea ex 0.05 % 1
MO
desonide lotn ex 0.05 % 1
desonide oint ex 0.05 % 1
DESOWEN CREA (Use
Desonide)
desowen lotn 1
desowen oint 1
desoximetasone crea ex
0.05 %, 0.25 %
desoximetasone gel ex
0.05 %
DESOXIMETASONE OINT
EX 0.05 %
desoximetasone oint ex
0.25 %
diflorasone diacetate crea
ex 0.05 %
diflorasone diacetate oint
ex 0.05 %
DIPROLENE (Use
Betamethasone
Dipropionate Augmented)
DIPROLENE AF (Use
Betamethasone
Dipropionate Augmented)
ELOCON (Use
Mometasone Furoate)
epifoam 1
fluocinolone acetonide crea
ex 0.01 %, 0.025 %
fluocinolone acetonide oil
ex 0.01 %
fluocinolone acetonide oint
ex 0.025 %
fluocinolone acetonide soln
ex 0.01 %
fluocinonide crea ex 0.05
%
fluocinonide emulsified
base
3
1
1
3
1
1
1
3
3
3
1
1
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
fluocinonide gel ex 0.05 % 1
MO
fluocinonide oint ex 0.05 % 1
fluocinonide soln ex 0.05 % 1
fluticasone propionate crea
ex 0.05 %
fluticasone propionate lotn
ex 0.05 %
fluticasone propionate oint
ex 0.005 %
halobetasol propionate 1
halobetasol propionate &
ammonium lactate
HALOG 3
hydrocortisone (topical)
crea 1 %
hydrocortisone (topical)
crea 2.5 %
hydrocortisone (topical) lotn
2 %, 2.5 %
hydrocortisone (topical) oint
1 %
hydrocortisone (topical) oint
2.5 %
hydrocortisone butyrate
crea ex 0.1 %
hydrocortisone butyrate
oint ex 0.1 %
hydrocortisone butyrate
soln ex 0.1 %
hydrocortisone valerate 1
KENALOG 2
LOCOID (Use
Hydrocortisone Butyrate)
LOCOID LIPOCREAM 2
LUXIQ (Use
Betamethasone Valerate)
mometasone furoate crea
ex 0.1 %
1
1
1
1
1
1
1
1
1
1
1
1
3
3
1
MO
MO
MO
MO
MO
MO
MO
MO
RX/OTC; MO
MO
MO
RX/OTC; MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
54

DRUG NAME
mometasone furoate oint
ex 0.1 %
mometasone furoate soln
ex 0.1 %
OLUX (Use Clobetasol
Propionate)
PANDEL 3
pramosone crea 1-1 % 1
pramosone lotn 1-1 %, 1-
2.5 %
prednicarbate 1
synalar crea 0.025 % 1
synalar oint 0.025 % 1
SYNALAR SOLN 0.01 %
(Use Fluocinolone
Acetonide)
TACLONEX 3
TEMOVATE (Use
Clobetasol Propionate)
TEMOVATE E (Use
Clobetasol Propionate
Emollient Base)
TEXACORT 3
topicort crea 0.05 %, 0.25
%
topicort gel 0.05 % 1
TOPICORT LIQD 0.25 % 3
TOPICORT OINT 0.05 % 3
topicort oint 0.25 % 1
triamcinolone acetonide
(topical)
triamcinolone acetonide in
absorbase
triamcinolone acetonide
oint ex 0.5 %
trianex 1
Drug
Tier Requirements/
Limits
1
MO
1
3
1
3
3
3
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
ULTRAVATE (Use
Halobetasol Propionate)
ULTRAVATE PAC 3
ULTRAVATE PAC (Use
Halobetasol Propionate &
Ammonium Lactate)
urea-hc acetate 1
VANOS 3
VERDESO 3
WESTCORT (Use
Hydrocortisone Valerate)
Emollients
LAC-HYDRIN (Use Lactic
Acid (Ammonium Lactate))
lactic acid (ammonium
lactate) crea 12 %
lactic acid (ammonium
lactate) lotn 12 %
Enzymes - Topical
SANTYL 2
Drug
Tier Requirements/
Limits
3
MO
3
3
3
1
1
Cream
MO
MO
MO
MO
MO
RX/OTC; MO
RX/OTC; MO
RX/OTC; MO
MO
Immunomodulating Agents - Topical
ALDARA (Use Imiquimod) 3
MO
imiquimod crea ex 5 % 1
ZYCLARA 3
ZYCLARA PUMP 3
MO
MO
MO
Immunosuppressive Agents - Topical
ELIDEL 3
MO
PROTOPIC 2
Keratolytic/Antimitotic Agents
CONDYLOX GEL 2
CONDYLOX SOLN (Use
Podofilox)
podofilox soln ex 0.5 % 1
3
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
55

DRUG NAME
Local Anesthetics - Topical
EMLA (Use Lidocaine-
Prilocaine)
lidocaine hcl gel ex 2 % 1
lidocaine hcl soln ex 4 % 1
lidocaine oint ex 5 % 1
lidocaine ptch ex 5 % 1
lidocaine-prilocaine 1
LIDODERM (Use
Lidocaine)
SYNERA 3
XYLOCAINE EX 4 % (Use
Lidocaine HCl)
XYLOCAINE JELLY (Use
Lidocaine HCl)
Drug
Tier Requirements/
Limits
3
2
3
3
MO; B/D
RX/OTC; MO
MO
MO
MO
MO; B/D
MO
MO
MO
Pigmenting-Depigmenting Agents
OXSORALEN 3
MO
Rosacea Agents
FINACEA 3
METROCREAM (Use
Metronidazole (Topical))
METROGEL (Use
Metronidazole (Topical))
METROLOTION (Use
Metronidazole (Topical))
metronidazole (topical) 1
ORACEA 3
Scabicides & Pediculicides
elimite 1
EURAX 2
malathion lotn ex 0.5 % 1
OVIDE (Use Malathion) 3
3
2
3
RX/OTC; MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
permethrin crea ex 5 % 1
MO
SKLICE 3
ULESFIA 3
Wound Care Products
REGRANEX 5
DIAGNOSTIC PRODUCTS
Diagnostic Tests
ADVANCED DNA
MEDICATED
COLLECTION
2
MO
MO
MO
B;NT
DIGESTIVE AIDS - Drugs to Treat Low
Digestive Enzymes
Digestive Enzymes
CREON 2
PANCREAZE 2
PANCRELIPASE 2
PERTZYE 3
SUCRAID 2
ULTRESA 3
VIOKACE 3
ZENPEP 2
MO
MO
MO
MO
LA
MO
MO
MO
DIURETICS - Drugs to Treat Heart, Circulation
Conditions and Blood Pressure
Carbonic Anhydrase Inhibitors
acetazolamide cp12 or 500
mg
1
acetazolamide sodium 4
acetazolamide tabs or 125
mg, 250 mg
DIAMOX (Use
Acetazolamide)
methazolamide tabs or 25
mg, 50 mg
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
1
3
1
MO
MO
MO
MO
56

Drug
DRUG NAME
Tier Requirements/
Limits
neptazane 1
MO
Diuretic Combinations
ALDACTAZIDE 25-25 MG
(Use Spironolactone &
Hydrochlorothiazide)
ALDACTAZIDE 50-50 MG 2
amiloride &
hydrochlorothiazide
DYAZIDE (Use
Triamterene &
Hydrochlorothiazide)
MAXZIDE (Use
Triamterene &
Hydrochlorothiazide)
MAXZIDE-25 (Use
Triamterene &
Hydrochlorothiazide)
spironolactone &
hydrochlorothiazide
triamterene &
hydrochlorothiazide
triamterene/hydrochlorothia
zide
Loop Diuretics
bumetanide soln ij 0.25
mg/ml
bumetanide tabs or 0.5 mg,
1 mg, 2 mg
DEMADEX (Use
Torsemide)
EDECRIN 3
furosemide soln ij 10 mg/ml 4
furosemide soln or 10
mg/ml, 8 mg/ml
furosemide tabs or 20 mg,
40 mg, 80 mg
LASIX (Use Furosemide) 3
torsemide soln iv 20
mg/2ml, 50 mg/5ml
torsemide tabs or 10 mg,
100 mg, 20 mg, 5 mg
3
1
3
3
3
1
1
1
4
1
3
1
1
4
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
Osmotic Diuretics
mannitol soln iv 25 % 4
Potassium Sparing Diuretics
ALDACTONE (Use
Spironolactone)
3
amiloride hcl tabs or 5 mg 1
DYRENIUM 3
MIDAMOR (Use Amiloride
HCl)
spironolactone tabs or 100
mg, 25 mg, 50 mg
Drug
Tier Requirements/
Limits
3
1
MO
MO
MO
MO
MO
MO
Thiazides and Thiazide-Like Diuretics
chlorothiazide 1
MO
chlorothiazide sodium 4
chlorthalidone 25 mg, 50
mg
DIURIL 2
hydrochlorothiazide caps or
12.5 mg
hydrochlorothiazide tabs or
12.5 mg, 25 mg, 50 mg
indapamide tabs or 1.25
mg, 2.5 mg
methyclothiazide tabs or 5
mg
metolazone 1
MICROZIDE (Use
Hydrochlorothiazide)
SODIUM DIURIL (Use
Chlorothiazide Sodium)
THALITONE 2
ZAROXOLYN (Use
Metolazone)
1
1
1
1
1
3
4
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
ENDOCRINE AND METABOLIC AGENTS -
MISC. - Drugs to Treat Bone Disease and
Regulate Hormones
Bone Density Regulators
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
57

DRUG NAME
Drug
Tier Requirements/
Limits
ACTONEL 150 MG 2
QL(0.04 ea
daily,93 day(s)
limit); MO
ACTONEL 30 MG, 5 MG 2
QL(1 ea daily);
MO
ACTONEL 35 MG 2
QL(0.15 ea
daily); MO
alendronate sodium 10 mg,
1
QL(1 ea daily);
40 mg, 5 mg
alendronate sodium 35 mg,
70 mg
ATELVIA 2
BINOSTO 3
BONIVA SOLN IV 3
MG/3ML
BONIVA TABS OR 150
MG (Use Ibandronate
Sodium)
calcitonin (salmon) 1
FORTEO 2
FORTICAL 3
FOSAMAX (Use
Alendronate Sodium)
FOSAMAX PLUS D 3
ibandronate sodium 1
MIACALCIN IJ 200
UNIT/ML
MIACALCIN NA 200
UNIT/ACT (Use Calcitonin
(Salmon))
pamidronate disodium 4
PROLIA 4
RECLAST (Use Zoledronic
Acid)
1
4
3
3
4
3
4
MO
QL(0.15 ea
daily); MO
QL(0.15 ea
daily); MO
MO
QL(0.04 ml
daily,90 day(s)
limit); MO; B/D
QL(0.034 ea
daily,90 day(s)
limit); MO; B/D
MO
QL(0.11 ml
daily)
MO
QL(0.15 ea
daily); MO
QL(0.15 ea
daily); MO
QL(0.034 ea
daily,90 day(s)
limit); MO; B/D
MO; B/D
MO
MO; B/D
QL(0.28 ml
daily,365
day(s) limit)
DRUG NAME
XGEVA 5
zoledronic acid conc 4
mg/5ml
zoledronic acid soln 5
mg/100ml
ZOLEDRONIC ACID SOLR
4 MG
ZOMETA (Use Zoledronic
Acid)
Corticotropin
ACTHAR HP 5
Fertility Regulators
chorionic gonadotropin solr
im 10000 unit
Drug
Tier Requirements/
Limits
QL(0.061 ml
daily)
5
4
5
5
4
QL(0.28 ml
daily,365
day(s) limit)
Growth Hormone Receptor Antagonists
SOMAVERT 5
LA
Growth Hormone Releasing Hormones (GHRH)
EGRIFTA 5
Growth Hormones
GENOTROPIN 12 MG 5
GENOTROPIN 5 MG 4
GENOTROPIN MINIQUICK
0.2 MG, 0.4 MG, 0.6 MG
4
GENOTROPIN MINIQUICK
0.8 MG, 1 MG, 1.2 MG, 1.4
MG, 1.6 MG, 1.8 MG, 2 MG 5
HUMATROPE 12 MG, 24
MG, 5 MG
5
HUMATROPE 6 MG 4
HUMATROPE COMBO
PACK
NORDITROPIN FLEXPRO
10 MG/1.5ML, 5 MG/1.5ML
NORDITROPIN FLEXPRO
15 MG/1.5ML
NORDITROPIN
NORDIFLEX PEN
5
4
5
5
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
58

DRUG NAME
NUTROPIN 5
NUTROPIN AQ 5
NUTROPIN AQ NUSPIN
10
NUTROPIN AQ NUSPIN
20
NUTROPIN AQ PEN 5
OMNITROPE SOLN 10
MG/1.5ML, 5 MG/1.5ML
OMNITROPE SOLR 5.8
MG
SAIZEN 5
SAIZEN CLICK.EASY 5
SEROSTIM 5
TEV-TROPIN 4
ZORBTIVE 5
Hormone Receptor Modulators
EVISTA 2
Drug
Tier Requirements/
Limits
5
5
4
5
LA
QL(1 ea daily);
MO
Insulin-Like Growth Factors (Somatomedins)
INCRELEX 4
LA
LHRH/GnRH Agonist Analog Pituitary
LUPRON DEPOT-PED
11.25 MG, 15 MG
4
LUPRON DEPOT-PED
11.25 MG, 30 MG
5
3 Month Kit
LUPRON DEPOT-PED 7.5
MG
5
SYNAREL 5
MO
Metabolic Modifiers
ALDURAZYME 5
BUPHENYL (Use Sodium
Phenylbutyrate)
CALCIJEX (Use Calcitriol) 4
5
LA
B/D
DRUG NAME
calcitriol caps or 0.25 mcg,
0.5 mcg
calcitriol soln iv 1 mcg/ml 4
calcitriol soln or 1 mcg/ml 1
CARNITOR SF (Use
Levocarnitine (Metabolic
Modifiers))
CARNITOR SOLN IV 200
MG/ML (Use Levocarnitine
(Metabolic Modifiers))
CARNITOR SOLN OR 1
GM/10ML (Use
Levocarnitine (Metabolic
Modifiers))
CARNITOR TABS OR 330
MG (Use Levocarnitine
(Metabolic Modifiers))
CYSTADANE 3
ELAPRASE 5
FABRAZYME 35 MG 5
FABRAZYME 5 MG 5
HECTOROL CAPS OR 0.5
MCG, 1 MCG, 2.5 MCG
HECTOROL SOLN IV 2
MCG/ML, 4 MCG/2ML
KUVAN 5
levocarnitine (metabolic
modifiers) soln iv 200
mg/ml
levocarnitine (metabolic
modifiers) soln or 1
gm/10ml
levocarnitine (metabolic
modifiers) tabs or 330 mg
LUMIZYME 5
MYOZYME 5
NAGLAZYME 5
Drug
Tier Requirements/
Limits
1
MO; B/D
3
4
3
3
3
4
4
1
1
B/D
MO; B/D
MO; B/D
MO; B/D
MO; B/D
MO; B/D
LA
LA
MO; B/D
MO; B/D
LA
MO; B/D
MO; B/D
MO; B/D
LA
LA
LA
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
59

Drug
DRUG NAME
Tier Requirements/
Limits
ORFADIN 2
LA
paricalcitol 1
ROCALTROL (Use
Calcitriol)
SENSIPAR 2
sodium phenylbutyrate or 3
gm/tsp
ZEMPLAR CAPS OR 1
MCG, 2 MCG, 4 MCG (Use
Paricalcitol)
ZEMPLAR SOLN IV 2
MCG/ML, 5 MCG/ML
Posterior Pituitary Hormones
DDAVP SOLN IJ 4
MCG/ML (Use
4
Desmopressin Acetate)
DDAVP SOLN NA 0.01 %
(Use Desmopressin 3
Acetate Refrigerated)
DDAVP SOLN NA 0.01 %
(Use Desmopressin 3
Acetate Spray)
DDAVP TABS OR 0.1 MG,
0.2 MG (Use
3
Desmopressin Acetate)
desmopressin acetate
refrigerated
1
desmopressin acetate soln
ij 4 mcg/ml
4
desmopressin acetate
spray
1
desmopressin acetate
spray refrigerated
1
desmopressin acetate tabs
or 0.1 mg, 0.2 mg
1
STIMATE 3
Prolactin Inhibitors
cabergoline 1
Somatostatic Agents
3
5
2
4
MO; B/D
MO; B/D
MO; B/D
MO; B/D
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
octreotide acetate 100
mcg/ml, 1000 mcg/5ml, 200
mcg/ml, 50 mcg/ml
octreotide acetate 1000
mcg/ml, 500 mcg/ml
SANDOSTATIN 100
MCG/ML, 200 MCG/ML, 50
MCG/ML (Use Octreotide
Acetate)
SANDOSTATIN 1000
MCG/ML, 500 MCG/ML
(Use Octreotide Acetate)
SANDOSTATIN LAR
DEPOT
SIGNIFOR 5
SOMATULINE DEPOT 5
Vasopressin Receptor Antagonists
SAMSCA 5
VAPRISOL 4
ESTROGENS - Hormone
Replacement/Modifying Drugs
Estrogen Combinations
ACTIVELLA (Use Estradiol
& Norethindrone Acetate)
ANGELIQ 3
CLIMARA PRO 3
COMBIPATCH 3
estradiol & norethindrone
acetate
FEMHRT 1/5 (Use
Norethindrone Acetate-
Ethinyl Estradiol)
FEMHRT LOW DOSE 3
norethindrone acetateethinyl
estradiol
prefest 1
PREMPHASE 2
Drug
Tier Requirements/
Limits
4
5
4
5
5
3
1
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
60

Drug
DRUG NAME
Tier Requirements/
Limits
PREMPRO 2
PA; AL; MO
Estrogens
ALORA 3
CENESTIN 3
CLIMARA (Use Estradiol) 3
DELESTROGEN (Use
Estradiol Valerate)
DEPO-ESTRADIOL 4
DIVIGEL 3
ELESTRIN 3
ENJUVIA 0.3 MG, 0.45
MG, 0.9 MG, 1.25 MG
ENJUVIA 0.625 MG 3
estrace 1
estradiol ptwk td 0.025
mg/24hr, 0.05 mg/24hr,
0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
estradiol tabs or 0.5 mg, 1
mg, 2 mg
estradiol valerate oil im 10
mg/ml, 20 mg/ml, 40 mg/ml
estropipate tabs or 0.75
mg, 1.5 mg, 3 mg
EVAMIST 3
FEMTRACE 3
menest 1
MENOSTAR 3
MINIVELLE 3
PREMARIN SOLR IJ 25
MG
4
3
1
1
4
1
4
MO
PA; AL; MO
MO
MO
MO
MO
MO
PA; AL; MO
AL
MO
MO
MO
MO
AL; MO
MO
PA; AL; MO
MO
MO
MO
DRUG NAME
PREMARIN TABS OR 0.3
MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
VIVELLE-DOT 3
Drug
Tier Requirements/
Limits
PA; AL; MO
2
MO
FLUOROQUINOLONES - Drugs to Treat
Bacterial Infections
Fluoroquinolones
AVELOX ABC PACK 3
AVELOX SOLN IV 0.8-400
%, MG/250ML
AVELOX TABS OR 400
MG
CIPRO I.V.-IN D5W 5-200
%, MG/100ML (Use
Ciprofloxacin in D5W)
CIPRO I.V.-IN D5W 5-400
%, MG/200ML (Use
Ciprofloxacin in D5W)
CIPRO SUSR 5
GM/100ML, 500 MG/5ML
CIPRO TABS 250 MG, 500
MG (Use Ciprofloxacin
HCl)
CIPRO XR (Use
Ciprofloxacin-Ciprofloxacin
HCl)
ciprofloxacin hcl tabs or
100 mg, 250 mg, 500 mg,
750 mg
ciprofloxacin in d5w 5-200
%, mg/100ml
ciprofloxacin in d5w 5-400
%, mg/200ml
ciprofloxacin soln iv 200
mg/20ml, 400 mg/40ml
ciprofloxacin-ciprofloxacin
hcl
FACTIVE 3
LEVAQUIN SOLN IV 5-250
%, MG/50ML, 5-500 %,
MG/100ML (Use
Levofloxacin in D5W)
4
3
4
4
2
3
3
1
4
4
4
1
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
61

DRUG NAME
LEVAQUIN SOLN IV 5-750
%, MG/150ML (Use
Levofloxacin in D5W)
LEVAQUIN SOLN OR 25
MG/ML (Use Levofloxacin)
LEVAQUIN TABS OR 250
MG, 500 MG, 750 MG (Use
Levofloxacin)
levofloxacin in d5w 5-250
%, mg/50ml, 5-500 %,
mg/100ml
levofloxacin in d5w 5-750
%, mg/150ml
levofloxacin soln iv 25
mg/ml
levofloxacin soln or 25
mg/ml
levofloxacin tabs or 250
mg, 500 mg, 750 mg
NOROXIN 3
Drug
Tier Requirements/
Limits
MO
4
3
3
4
4
4
1
1
MO
MO
MO
MO
MO
MO
GASTROINTESTINAL AGENTS - MISC. -
Miscellaneous Gastrointestinal Drugs
Gallstone Solubilizing Agents
ACTIGALL (Use Ursodiol) 3
chenodal 5
URSO 250 (Use Ursodiol) 3
URSO FORTE (Use
Ursodiol)
ursodiol caps or 300 mg 1
ursodiol tabs or 250 mg,
500 mg
3
1
MO
MO
MO
MO
MO
Gastrointestinal Antiallergy Agents
cromolyn sodium
(mastocytosis)
1
MO
GASTROCROM (Use
Cromolyn Sodium
(Mastocytosis))
3
MO
Gastrointestinal Chloride Channel Activators
AMITIZA 2
MO
Gastrointestinal Stimulants
DRUG NAME
metoclopramide hcl soln ij
5 mg/ml
metoclopramide hcl soln or
10 mg/10ml, 5 mg/5ml
metoclopramide hcl tabs or
10 mg, 5 mg
METOZOLV ODT 10 MG 3
METOZOLV ODT 5 MG 3
REGLAN SOLN IJ 5
MG/ML (Use
Metoclopramide HCl)
REGLAN TABS OR 10
MG, 5 MG (Use
Metoclopramide HCl)
Inflammatory Bowel Agents
APRISO 2
ASACOL 2
ASACOL HD 2
AZULFIDINE (Use
Sulfasalazine)
AZULFIDINE EN-TABS
(Use Sulfasalazine)
balsalazide disodium 1
CANASA 2
CIMZIA 5
CIMZIA STARTER KIT 5
COLAZAL (Use
Balsalazide Disodium)
DELZICOL 2
DIPENTUM 3
GIAZO 3
LIALDA 2
mesalamine enem re 4 gm 1
Drug
Tier Requirements/
Limits
4
MO
1
1
4
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
PA
MO
MO
MO
ST; QL(6 ea
daily); MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
62

Drug
DRUG NAME
Tier Requirements/
Limits
mesalamine w/ cleanser 1
MO
PENTASA 3
REMICADE 5
ROWASA (Use
Mesalamine w/ Cleanser)
sulfasalazine tabs or 500
mg
sulfasalazine tbec or 500
mg
Intestinal Acidifiers
lactulose (encephalopathy) 1
3
1
1
MO
PA
MO
MO
MO
MO
Irritable Bowel Syndrome (IBS) Agents
LINZESS 3
MO
LOTRONEX 2
MO
Peripheral Opioid Receptor Antagonists
RELISTOR 4
MO
Phosphate Binder Agents
calcium acetate (phosphate
binder)
eliphos 1
FOSRENOL 2
PHOSLO (Use Calcium
Acetate (Phosphate
Binder))
PHOSLYRA 3
RENVELA 2
1
3
MO
MO
MO
MO
MO
MO
Short Bowel Syndrome (SBS) Agents
GATTEX 5
PA
GENITOURINARY AGENTS -
MISCELLANEOUS - Miscellaneous Drugs to
Treat Reproductive Organs and Urinary
System
Alkalinizers
DRUG NAME
potassium citrate
(alkalinizer)
UROCIT-K 10 (Use
Potassium Citrate
(Alkalinizer))
UROCIT-K 5 (Use
Potassium Citrate
(Alkalinizer))
Cystinosis Agents
Drug
Tier Requirements/
Limits
1
MO
NF
NF
CYSTAGON 3
PROCYSBI 3
Genitourinary Irrigants
acetic acid ir 0.25 % 1
neomycin/polymyxin b gu 1
NEOSPORIN GU
IRRIGANT (Use
Neomycin/Polymyxin B
GU)
sodium chloride (gu
irrigant)
SORBITOL SOLN IR 3 %,
3.3 %
sorbitol-mannitol 1
Interstitial Cystitis Agents
ELMIRON 3
RIMSO-50 3
Prostatic Hypertrophy Agents
alfuzosin hcl 1
AVODART 2
CARDURA XL 3
finasteride tabs or 5 mg 1
FLOMAX (Use Tamsulosin
HCl)
JALYN 2
3
1
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
GL; MO
MO
GL; MO
MO
GL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
63

DRUG NAME
PROSCAR (Use
Finasteride)
RAPAFLO 3
tamsulosin hcl 1
UROXATRAL (Use
Alfuzosin HCl)
Drug
Tier Requirements/
Limits
3
GL; MO
3
MO
MO
MO
GOUT AGENTS - Drugs to Treat Gout
Gout Agent Combinations
colchicine w/ probenecid 1
Gout Agents
allopurinol sodium 4
allopurinol tabs or 100 mg 1
allopurinol tabs or 300 mg 1
ALOPRIM (Use Allopurinol
Sodium)
COLCRYS 2
KRYSTEXXA 5
ULORIC 2
ZYLOPRIM 100 MG (Use
Allopurinol)
ZYLOPRIM 300 MG (Use
Allopurinol)
Uricosurics
probenecid tabs or 500 mg 1
4
3
3
MO
QL(8 ea daily);
MO
QL(2 ea daily);
MO
MO
MO
QL(8 ea daily);
MO
QL(2 ea daily);
MO
MO
HEMATOLOGICAL AGENTS - MISC. - Drugs to
Treat Blood Disorders
Antihemophilic Products
KCENTRA 2
B;NT
Bradykinin B2 Receptor Antagonists
FIRAZYR 5
Complement Inhibitors
BERINERT 5
Drug
DRUG NAME
Tier Requirements/
Limits
CINRYZE 5
LA
Hematorheologic Agents
pentoxifylline tbcr or 400
mg
TRENTAL (Use
Pentoxifylline)
Platelet Aggregation Inhibitors
AGGRENOX 2
AGRYLIN (Use Anagrelide
HCl)
anagrelide hcl 1
BRILINTA 2
cilostazol 1
clopidogrel bisulfate 300
mg
clopidogrel bisulfate 75 mg 1
dipyridamole tabs or 25
mg, 50 mg, 75 mg
EFFIENT 2
PERSANTINE (Use
Dipyridamole)
PLAVIX 300 MG (Use
Clopidogrel Bisulfate)
PLAVIX 75 MG (Use
Clopidogrel Bisulfate)
PLETAL (Use Cilostazol) 3
ticlopidine hcl 1
1
3
3
1
1
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
PA; AL; MO
MO
PA; AL; MO
MO
MO
MO
HEMATOPOIETIC AGENTS - Drugs to Treat
Blood Disorders
Agents for Gaucher Disease
CEREZYME 200 UNIT 5
CEREZYME 400 UNIT 5
ELELYSO 5
VPRIV 5
LA
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
64

Drug
DRUG NAME
Tier Requirements/
Limits
ZAVESCA 5
LA
Agents for Sickle Cell Anemia
DROXIA 3
Hematopoietic Growth Factors
ARANESP ALBUMIN
FREE 100 MCG/0.5ML,
100 MCG/ML, 25
MCG/0.42ML, 25 MCG/ML, 4
40 MCG/0.4ML, 40
MCG/ML, 60 MCG/0.3ML,
60 MCG/ML
ARANESP ALBUMIN
FREE 150 MCG/0.3ML,
150 MCG/0.75ML, 200
5
MCG/0.4ML, 200 MCG/ML,
300 MCG/0.6ML, 300
MCG/ML, 500 MCG/ML
EPOGEN 4
LEUKINE 5
NEULASTA 5
NEUMEGA 5
NEUPOGEN 5
NPLATE 5
PROCRIT 10000 UNIT/ML,
2000 UNIT/ML, 3000
UNIT/ML, 4000 UNIT/ML
PROCRIT 20000 UNIT/ML,
40000 UNIT/ML
PROMACTA 12.5 MG 5
PROMACTA 25 MG 5
PROMACTA 50 MG 5
PROMACTA 75 MG 5
Stem Cell Mobilizers
MOZOBIL 5
2
5
MO
PA; B/D
PA; B/D
PA; B/D
PA
PA
PA
PA
PA; B/D
PA; B/D
QL(8 ea daily)
QL(4 ea daily);
LA
QL(2 ea daily);
LA
QL(1 ea daily);
LA
DRUG NAME
Drug
Tier Requirements/
Limits
HEMOSTATICS - Drugs to Stop Bleeding/Treat
Blood Disorders
Hemostatics - Systemic
AMICAR (Use
Aminocaproic Acid)
aminocaproic acid tabs or
500 mg
CYKLOKAPRON (Use
Tranexamic Acid)
LYSTEDA (Use
Tranexamic Acid)
tranexamic acid soln iv 100
mg/ml
tranexamic acid tabs or 650
mg
3
1
3
3
1
1
MO
MO
MO
MO
MO
MO
HYPNOTICS - Drugs to Help Sleep
Barbiturate Hypnotics
nembutal 4
nembutal sodium 4
phenobarbital elix or 20
mg/5ml
phenobarbital sodium soln
ij 130 mg/ml
PHENOBARBITAL
SODIUM SOLN IJ 65
MG/ML
phenobarbital soln or 20
mg/5ml
phenobarbital tabs or 100
mg, 15 mg, 16.2 mg, 30
mg, 32.4 mg, 60 mg
PHENOBARBITAL TABS
OR 64.8 MG, 97.2 MG
Hypnotics - Tricyclic Agents
SILENOR 2
Non-Barbiturate Hypnotics
AMBIEN 10 MG (Use
Zolpidem Tartrate)
AMBIEN 5 MG (Use
Zolpidem Tartrate)
1
4
4
1
1
3
3
3
PA; AL
PA; AL
PA; AL; MO
PA; AL; MO
AL; MO
AL; MO
MO
QL(1 ea daily);
AL; MO
QL(2 ea daily);
AL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
65

DRUG NAME
AMBIEN CR 12.5 MG (Use
Zolpidem Tartrate)
AMBIEN CR 6.25 MG (Use
Zolpidem Tartrate)
DORAL 3
EDLUAR 3
INTERMEZZO 3
LUNESTA 3
midazolam hcl soln ij 10
mg/10ml, 2 mg/2ml, 5
mg/ml
midazolam hcl soln ij 10
mg/2ml, 25 mg/5ml, 5
mg/5ml, 5 mg/ml, 50
mg/10ml
midazolam hcl syrp or 2
mg/ml
QUAZEPAM 3
SONATA (Use Zaleplon) 3
zaleplon 1
zolpidem tartrate tabs 10
mg
zolpidem tartrate tabs 5 mg 1
zolpidem tartrate tbcr 12.5
mg
zolpidem tartrate tbcr 6.25
mg
ZOLPIMIST 3
Drug
Tier Requirements/
Limits
3
QL(1 ea daily);
AL; MO
3
QL(2 ea daily);
AL; MO
MO
4
4
1
1
1
1
AL; MO
PA; MO
AL; MO
MO
MO
MO
AL; MO
AL; MO
QL(1 ea daily);
AL; MO
QL(2 ea daily);
AL; MO
QL(1 ea daily);
AL; MO
QL(2 ea daily);
AL; MO
AL; MO
Selective Melatonin Receptor Agonists
ROZEREM 3
MO
LAXATIVES - Bowel Treatment Drugs
Laxative Combinations
COLYTE-FLAVOR PACKS
2.82-5.53-6.36-21.5-227.1
GM
3
DRUG NAME
COLYTE-FLAVOR PACKS
2.98-5.84-6.72-22.72-240
GM (Use PEG 3350-KCl-
Sod Bicarb-Sod Chloride-
Sod Sulfate)
GOLYTELY (Use PEG
3350-KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate)
HALFLYTELY BOWEL
PREP/FLAVOR PACKS
MOVIPREP 3
NULYTELY/FLAVOR
PACKS (Use PEG 3350-
Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
peg 3350-kcl-sod bicarbsod
chloride-sod sulfate
peg 3350-potassium
chloride-sod bicarbonatesod
chloride
PREPOPIK 3
SUPREP BOWEL PREP 3
Laxatives - Miscellaneous
lactulose soln or 10
gm/15ml, 20 gm/30ml
polyethylene glycol 3350
pack or
polyethylene glycol 3350
powd or
Saline Laxatives
OSMOPREP 3
VISICOL 3
Drug
Tier Requirements/
Limits
MO
3
3
2
3
1
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
RX/OTC; MO
RX/OTC; MO
MO
MO
LOCAL ANESTHETICS-Parenteral - Drugs for
Numbing
Local Anesthetic Combinations
bupivacaine w/ epinephrine
0.1-0.1-0.5-1 %, :200000,
mg/ml, 0.1-0.5-1-1 %,
:200000, mg/ml, 0.5-0.5-1 4
%, :200000, mg/ml, 0.5-1
%, :200000, 0.5-1-1 %,
:200000, mg
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
66

DRUG NAME
bupivacaine w/ epinephrine
0.1-0.25-1 %, :200000,
mg/ml, 0.1-0.25-1-1 %,
:200000, mg/ml, 0.25-1 %,
:200000, 0.25-1-1 %,
:200000, mg/ml
lidocaine w/ epinephrine
0.5-1 %, :200000, 0.5-1-1.5
%, :200000, mg/ml, 0.5-1-2
%, :200000, mg/ml, 1-1.5
%, :200000, 1-2 %, :50000
lidocaine w/ epinephrine
0.5-1-1-1 %, :100000,
mg/ml, 0.5-1-1-2 %,
:100000, mg/ml, 1-2 %,
:100000
MARCAINE/EPINEPHRIN
E 0.25-0.5-1 %, :200000,
MG/ML, 0.25-0.5-1-1 %,
:200000, MG/ML (Use
Bupivacaine w/
Epinephrine)
MARCAINE/EPINEPHRIN
E 0.5-0.5-1 %, :200000,
MG/ML, 0.5-0.5-1-1 %,
:200000, MG/ML (Use
Bupivacaine w/
Epinephrine)
sensorcainempf/epinephrine
XYLOCAINE-
MPF/EPINEPHRINE (Use
Lidocaine w/ Epinephrine)
XYLOCAINE/EPINEPHRIN
E 0.5-1 %, :200000 (Use
Lidocaine w/ Epinephrine)
XYLOCAINE/EPINEPHRIN
E 0.5-1-1-1 %, :100000,
MG/ML, 0.5-1-1-2 %,
:100000, MG/ML (Use
Lidocaine w/ Epinephrine)
Local Anesthetics - Amides
bupivacaine hcl soln ij 0.25
%, 0.5 %
bupivacaine hcl soln ij 0.5
%, 0.75 %
bupivacaine in dextrose 4
Drug
Tier Requirements/
Limits
4
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
DRUG NAME
CARBOCAINE 1 % (Use
Mepivacaine HCl)
CARBOCAINE 1.5 %, 2 %
(Use Mepivacaine HCl)
lidocaine hcl (local anesth.)
0.5 %, 1.5 %
lidocaine hcl (local anesth.)
1 %, 2 %, 4 %
lidocaine hcl/dextrose 4
MARCAINE 0.25 %, 0.5 %
(Use Bupivacaine HCl)
MARCAINE 0.5 % (Use
Bupivacaine HCl)
MARCAINE SPINAL (Use
Bupivacaine in Dextrose)
MARCAINE W/O EPI (Use
Bupivacaine HCl)
mepivacaine hcl soln ij 1 % 4
mepivacaine hcl soln ij 1.5
%, 2 %, 3 %
NAROPIN 4
XYLOCAINE IJ 0.5 % (Use
Lidocaine HCl (Local
Anesth.))
XYLOCAINE IJ 1 %, 2 %
(Use Lidocaine HCl (Local
Anesth.))
XYLOCAINE-MPF 0.5 %,
1.5 % (Use Lidocaine HCl
(Local Anesth.))
XYLOCAINE-MPF 1 %, 2
%, 4 % (Use Lidocaine HCl
(Local Anesth.))
Local Anesthetics - Esters
chloroprocaine hcl 4
NESACAINE (Use
Chloroprocaine HCl)
NESACAINE-MPF (Use
Chloroprocaine HCl)
Drug
Tier Requirements/
Limits
4
MO
4
4
4
4
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MACROLIDES - Drugs to Treat Bacterial
Infections
Azithromycin
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
67

Drug
DRUG NAME
Tier Requirements/
Limits
azithromycin pack or 1 gm 1
MO
azithromycin solr iv 500 mg 4
azithromycin susr or 100
mg/5ml, 200 mg/5ml
azithromycin tabs or 250
mg, 500 mg, 600 mg
ZITHROMAX PACK OR 1
GM
ZITHROMAX SOLR IV 500
MG (Use Azithromycin)
ZITHROMAX SUSR OR
100 MG/5ML, 200 MG/5ML
(Use Azithromycin)
ZITHROMAX TABS OR
250 MG, 500 MG, 600 MG
(Use Azithromycin)
ZITHROMAX TRI-PAK
(Use Azithromycin)
ZITHROMAX Z-PAK (Use
Azithromycin)
ZMAX 3
Clarithromycin
BIAXIN (Use
Clarithromycin)
BIAXIN XL (Use
Clarithromycin)
BIAXIN XL PAC (Use
Clarithromycin)
clarithromycin susr or 125
mg/5ml, 250 mg/5ml
clarithromycin tabs or 250
mg, 500 mg
clarithromycin tb24 or 500
mg
Erythromycins
e.e.s. 400 1
E.E.S. GRANULES 3
ery-tab 250 mg 1
ery-tab 333 mg 1
1
1
2
4
3
3
3
3
3
3
3
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(10 ea
daily); MO
QL(100 ml
daily); MO
QL(16 ea
daily); MO
QL(12 ea
daily); MO
DRUG NAME
Drug
Tier Requirements/
Limits
ery-tab 500 mg 1
QL(8 ea daily);
MO
ERYPED 200 3
QL(100 ml
ERYPED 400 3
ERYTHROCIN
LACTOBIONATE
erythrocin lactobionate 4
erythrocin stearate 1
erythromycin base cpep or
250 mg
erythromycin base tabs or
250 mg
erythromycin base tabs or
500 mg
erythromycin cpep or 250
mg
erythromycin
ethylsuccinate tabs or 400
mg
erythromycin lactobionate 4
PCE 333 MG 3
PCE 500 MG 3
Fidaxomicin
DIFICID 5
MEDICAL DEVICES
Bandages-Dressings-Tape
gauze pads 2"x2" 1
Parenteral Therapy Supplies
1ST TIER UNIFINE
PENTIPS29GX12MM
2
1ST TIER UNIFINE
PENTIPSPLUS/ORIGINAL/ 2
29GX12MM
AURORA PEN NEEDLES
2
29GX12MM
4
1
1
1
1
1
daily); MO
QL(50 ml
daily); MO
QL(16 ea
daily); MO
QL(16 ea
daily); MO
QL(16 ea
daily); MO
QL(8 ea daily);
MO
QL(16 ea
daily); MO
QL(10 ea
daily); MO
QL(12 ea
daily); MO
QL(8 ea daily);
MO
MO
RX/OTC; MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
68

Drug
DRUG NAME
Tier Requirements/
Limits
AUTOPEN 3
RX/OTC; MO
BD AUTOSHIELD 29G X
1/2"
BD AUTOSHIELD 29G X
3/16"
BD AUTOSHIELD 29G X
5/16"
BD AUTOSHIELD DUO
30G X 3/16"
BD INSULIN SYRINGE
ULTRAFINE/U-
100/0.3ML/31G X 15/64"
BD INSULIN SYRINGE
ULTRAFINE/U-
100/0.5ML/31G X 15/64"
BD INSULIN SYRINGE
ULTRAFINE/U-
100/1ML/31G X 15/64"
BD PEN 3
BD PEN MINI 3
BD PEN
NEEDLE/ULTRAFINE/29G
X 12.7MM
BD PEN
NEEDLE/ULTRAFINE/29G
X1/2" 12.7MM
CAREONE UNIFINE
PENTIPS 29GX12MM
DRUG MART UNIFINE
PENTIPS29G X 12MM
DUANE READE UNIFINE
PENTIPS 29G X 12MM
EASY TOUCH 32GX5MM 2
EASY TOUCH 32GX6MM 2
2
2
2
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
RX/OTC; MO
RX/OTC; MO
MO
MO
MO
MO
MO
MO
MO
EASY TOUCH PEN
NEEDLES 29GX1/2"
2
MO
EXEL INSULIN PEN
NEEDLES29GX1/2" 12MM 2 MO
GLOBAL EASE INJECT
PEN NEEDLES
29GX12MM
2
MO
DRUG NAME
H-E-B INCONTROL PEN
NEEDLES 29GX12MM
HEALTHWISE PEN
NEEDLES 29GX12MM
HEALTHY ACCENTS
UNIFINE PENTIPS PEN
NEEDLES 29GX12MM
HUMAPEN LUXURA HD 3
INSULIN
SYRINGE/0.3ML/29G X 1"
INSUPEN SENSITIVE
32GX6MM
INSUPEN SENSITIVE
32GX8MM
INSUPEN ULTRAFIN
29GX12MM
INSUPEN ULTRAFIN
30GX8MM
KROGER PEN NEEDLES
29G X12MM
LITETOUCH PEN
NEEDLES 29GX12.7MM
LIVE BETTER PEN
NEEDLES 29G X 12MM
MEDICINE SHOPPE PEN
NEEDLES 29G X 12MM
MEIJER PEN NEEDLES
29G X12MM
NOVOFINE 30GX8MM 2
NOVOFINE 32GX6MM 2
NOVOFINE AUTOCOVER
30GX8MM
NOVOPEN 3 INSULIN
DELIVERY SYSTEM
NOVOPEN 3 PENMATE 3
NOVOPEN JR (GREEN) 3
NOVOPEN JR (YELLOW) 3
NOVOTWIST 30GX8MM 2
NOVOTWIST 32GX5MM 2
Drug
Tier Requirements/
Limits
2
MO
2
2
2
2
2
2
2
2
2
2
2
2
2
3
MO
MO
RX/OTC; MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
RX/OTC; MO
RX/OTC; MO
RX/OTC; MO
RX/OTC; MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
69

DRUG NAME
PC UNIFINE PENTIPS
29G X1/2"
PEN NEEDLES 29G X
12MM
PEN NEEDLES 29GX1/2" 2
PEN NEEDLES 30GX5/16" 2
PREFERRED PLUS
UNIFINE PENTIPS 29G X
12MM
PRODIGY INSULIN PEN
NEEDLES/29G X 1/2"
PX PEN NEEDLE
29GX12MM
QC PEN NEEDLES 29G X
12MM
RELION PEN NEEDLES
29GX12MM
SHOPKO UNIFINE
PENTIPS PEN
NEEDLES/ORIGINAL/29G
X12MM
SURE COMFORT PEN
NEEDLES29GX1/2"
12.7MM
SURE COMFORT PEN
NEEDLES30GX5/16"
SHORT
SURE-FINE PEN
NEEDLES 29GX1/2"
12.7MM
TODAYS HEALTH
ORIGINAL PEN NEEDLES
29G X 1/2"
ULTICARE ORIGINAL
PEN NEEDLES ULTI-FINE
ULTICARE PEN
NEEDLES/29GX 12.7MM
ULTRA-THIN II PEN
NEEDLE/29G X 1/2"
ULTRA-THIN II PEN
NEEDLES 29GX1/2"
UNIFINE PENTIPS
29GX12MM
UNIFINE PENTIPS PLUS
29GX12MM
Drug
Tier Requirements/
Limits
2
MO
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
VALUMARK PEN
NEEDLES 29GX12MM
VIDA MIA UNIFINE
PENTIPSORIGINAL
29GX12MM
Drug
Tier Requirements/
Limits
2
MO
2
MO
MIGRAINE PRODUCTS - Drugs to Treat
Migraine Headaches
Migraine Combinations
cafergot 1
migergot 1
TREXIMET 3
Migraine Products - NSAIDs
CAMBIA 3
Migraine Products
D.H.E. 45 (Use
Dihydroergotamine
Mesylate)
dihydroergotamine
mesylate soln ij 1 mg/ml
DIHYDROERGOTAMINE
MESYLATE SOLN NA 4
MG/ML
MIGRANAL 3
Serotonin Agonists
ALSUMA 4
AMERGE (Use Naratriptan
HCl)
AXERT 3
FROVA 3
IMITREX SOLN NA 20
MG/ACT (Use Sumatriptan)
IMITREX SOLN NA 5
MG/ACT (Use Sumatriptan)
IMITREX SOLN SC 6
MG/0.5ML (Use
Sumatriptan Succinate)
4
4
3
3
3
3
4
MO
MO
MO
MO
MO
MO
MO
MO
QL(0.14 ml
daily); MO
QL(0.3 ea
daily); MO
QL(0.4 ea
daily); MO
QL(0.6 ea
daily); MO
QL(0.4 ea
daily); MO
QL(0.6 ea
daily); MO
QL(0.14 ml
daily); MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
70

DRUG NAME
IMITREX STATDOSE
REFILL (Use Sumatriptan
Succinate)
IMITREX STATDOSE
SYSTEM (Use
Sumatriptan Succinate)
IMITREX TABS OR 100
MG, 25 MG, 50 MG (Use
Sumatriptan Succinate)
MAXALT (Use Rizatriptan
Benzoate)
MAXALT-MLT (Use
Rizatriptan Benzoate)
naratriptan hcl 1
RELPAX 3
rizatriptan benzoate 1
sumatriptan 20 mg/act 1
sumatriptan 5 mg/act 1
sumatriptan succinate soln
sc 4 mg/0.5ml, 6 mg/0.5ml
sumatriptan succinate tabs
or 100 mg, 25 mg, 50 mg
SUMAVEL DOSEPRO 4
zolmitriptan 1
ZOMIG (Use Zolmitriptan) 3
ZOMIG NASAL SPRAY 3
ZOMIG ZMT (Use
Zolmitriptan)
MINERALS & ELECTROLYTES
Bicarbonates
sodium acetate 2 meq/ml 4
sodium bicarbonate soln iv
7.5 %
sodium bicarbonate soln iv
8.4 %
Drug
Tier Requirements/
Limits
QL(0.14 ml
4 daily); MO
4
3
3
3
4
1
3
4
4
QL(0.14 ml
daily); MO
MO
QL(0.4 ea
daily); MO
QL(0.4 ea
daily); MO
QL(0.3 ea
daily); MO
QL(0.2 ea
daily); MO
QL(0.4 ea
daily); MO
QL(0.4 ea
daily); MO
QL(0.6 ea
daily); MO
QL(0.14 ml
daily); MO
MO
QL(0.14 ml
daily); MO
QL(0.2 ea
daily); MO
QL(0.2 ea
daily); MO
QL(0.2 ea
daily); MO
QL(0.2 ea
daily); MO
MO
DRUG NAME
SODIUM LACTATE IV 167
MEQ/L, 5 MEQ/ML
Calcium
calcium chloride (dihydrate) 4
Chloride
ammonium chloride soln iv
5 meq/ml
Electrolyte Mixtures
DEXTROSE 10%/NACL
0.45%
DEXTROSE
5%/ELECTROLYTE #48
VIAFLEX
DEXTROSE 10%/NACL
0.2%
DEXTROSE 5%/NACL
0.225%
DEXTROSE 5%/NACL
0.3%
dextrose in lactated ringers 4
dextrose w/ sodium
chloride 0.2-5 %, 0.33-5 %,
0.45-2.5 %, 0.45-5 %
dextrose w/ sodium
chloride 0.9-5 %
electrolyte-m in dextrose 4
IONOSOL-B/DEXTROSE
5%
IONOSOL-MB/DEXTROSE
5%
isolyte-h/dextrose 5% 4
isolyte-p/dextrose 5% 4
isolyte-s 4
isolyte-s ph 7.4 4
KCL 0.15%/D5W/LR 4
KCL 0.15%/D5W/NACL
0.225%
Drug
Tier Requirements/
Limits
4
4
4
4
4
4
4
4
4
4
4
4
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
71

DRUG NAME
KCL 0.15%/D5W/NACL
0.9% (Use Potassium
Chloride in Dextrose &
Sodium Chloride)
kcl 0.3%/d5w/lr iv lac ring 4
KCL 0.3%/D5W/NACL
0.9%
lactated ringer's 4
NORMOSOL -R 4
NORMOSOL-R 4
NORMOSOL-R IN D5W 4
parenteral electrolytes conc
0.225-0.25-1-1.475-1.75-
1.75 meq/ml, 0.25-0.25-
0.4-1.25-1.68-2.03-2.03
meq, meq/ml, 0.25-0.25-
0.4-1.25-1.68-2.03-2.03
meq/ml
parenteral electrolytes soln
4.5-5-20-29.5-35-35
meq/20ml
PLASMA-LYTE A 4
PLASMA-LYTE-148 4
PLASMA-LYTE-56/D5W 4
POTASSIUM CHLORIDE
0.15%/NACL 0.45%
VIAFLEX (Use Potassium
Chloride in NaCl)
POTASSIUM CHLORIDE
0.15%/NACL 0.9% (Use
Potassium Chloride in
NaCl)
POTASSIUM CHLORIDE
0.3%/NACL 0.9% (Use
Potassium Chloride in
NaCl)
potassium chloride in d5w
lactated ringers
potassium chloride in
dextrose
Drug
Tier Requirements/
Limits
4
4
4
4
4
4
4
4
4
MO
B/D
B/D
MO
DRUG NAME
potassium chloride in
dextrose & sodium chloride
potassium chloride in nacl
0.45-20 %, meq/l, 0.9-40
%, meq/l
potassium chloride in nacl
0.9-20 %, meq/l
ringer's 4
Fluoride
sodium fluoride tabs or 1
mg
Magnesium
MAGNESIUM SULFATE IN
D5W
MAGNESIUM SULFATE
SOLN IJ 40 MG/ML, 80
MG/ML
magnesium sulfate soln ij
50 %
Phosphate
sodium phosphate 4
Potassium
K-TABS (Use Potassium
Chloride)
klor-con m15 1
MICRO-K (Use Potassium
Chloride)
potassium acetate soln iv 2
meq/ml
potassium chloride cpcr or
10 meq, 8 meq
potassium chloride liqd or
10 %, 20 %
potassium chloride
microencapsulated crystals
cr
potassium chloride soln iv
0.4 meq/ml, 10 meq/100ml,
2 meq/ml
POTASSIUM CHLORIDE
SOLN IV 10 MEQ/100ML,
20 MEQ/50ML (Use
Potassium Chloride)
Drug
Tier Requirements/
Limits
4
4
4
1
4
4
4
3
3
4
1
1
1
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
72

DRUG NAME
potassium chloride soln iv
10 meq/50ml, 20
meq/100ml, 30 meq/100ml,
40 meq/100ml
POTASSIUM CHLORIDE
SOLN IV 10 MEQ/50ML,
20 MEQ/100ML, 30
MEQ/100ML, 40
MEQ/100ML (Use
Potassium Chloride)
potassium chloride soln or
10 %
potassium chloride tbcr or
10 meq, 8 meq
Sodium
sodium chloride soln ij 2.5
meq/ml
sodium chloride soln iv
0.45 %
sodium chloride soln iv 0.9
%, 3 %, 5 %
Drug
Tier Requirements/
Limits
4
4
1
1
4
4
4
MO
MO
MO
MO
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
lidocaine hcl (mouth-throat) 1
Anti-infectives - Throat
clotrimazole lozg mt 10 mg 1
clotrimazole troc mt 10 mg 1
nystatin (mouth-throat) 1
ORAVIG 3
Antiseptics - Mouth/Throat
chlorhexidine gluconate
(mouth-throat)
PERIDEX (Use
Chlorhexidine Gluconate
(Mouth-Throat))
Steroids - Mouth/Throat
triamcinolone acetonide
(mouth)
Throat Products - Misc.
1
3
1
MO
MO
MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
cevimeline hcl 1
MO
EVOXAC (Use Cevimeline
HCl)
pilocarpine hcl (oral) 1
SALAGEN (Use
Pilocarpine HCl (Oral))
MULTIVITAMINS
Prenatal Vitamins
prenatabs obn 1
3
3
MO
MO
MO
MUSCULOSKELETAL THERAPY AGENTS -
Drugs to Treat Spasms
Central Muscle Relaxants
AMRIX 3
baclofen tabs or 10 mg 1
baclofen tabs or 20 mg 1
carisoprodol tabs or 250
mg, 350 mg
chlorzoxazone tabs or 500
mg
cyclobenzaprine hcl cp24
or 15 mg, 30 mg
cyclobenzaprine hcl tabs or
10 mg, 5 mg, 7.5 mg
fexmid 1
FLEXERIL (Use
Cyclobenzaprine HCl)
LIORESAL INTRATHECAL
0.05 MG/ML
LIORESAL INTRATHECAL
10 MG/20ML, 10 MG/5ML,
40 MG/20ML
metaxalone 1
methocarbamol tabs or 500
mg, 750 mg
orphenadrine citrate tb12 or
100 mg
1
1
1
1
3
4
4
1
1
PA; AL; MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
PA; AL; MO
PA; AL; MO
PA; AL; MO
AL; MO
AL; MO
AL; MO
MO; B/D
PA; AL; MO
AL; MO
PA; AL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
73

DRUG NAME
PARAFON FORTE DSC
(Use Chlorzoxazone)
ROBAXIN SOLN IJ 100
MG/ML
ROBAXIN TABS OR 500
MG (Use Methocarbamol)
ROBAXIN-750 (Use
Methocarbamol)
SKELAXIN (Use
Metaxalone)
SOMA (Use Carisoprodol) 3
tizanidine hcl caps or 2 mg 1
tizanidine hcl caps or 4 mg 1
tizanidine hcl caps or 6 mg 1
tizanidine hcl tabs or 2 mg 1
tizanidine hcl tabs or 4 mg 1
ZANAFLEX CAPS 2 MG
(Use Tizanidine HCl)
ZANAFLEX CAPS 4 MG
(Use Tizanidine HCl)
ZANAFLEX CAPS 6 MG
(Use Tizanidine HCl)
ZANAFLEX TABS 4 MG
(Use Tizanidine HCl)
Direct Muscle Relaxants
DANTRIUM (Use
Dantrolene Sodium)
dantrolene sodium caps or
100 mg, 25 mg, 50 mg
Muscle Relaxant Combinations
carisoprodol w/ aspirin 1
carisoprodol w/ aspirin &
codeine
orphenadrine compound ds 1
orphenadrine w/ aspirin &
caff
Drug
Tier Requirements/
Limits
3
PA; AL; MO
4
3
3
3
3
3
3
3
3
1
1
1
AL; MO
AL; MO
PA; AL; MO
PA; AL; MO
QL(18 ea
daily); MO
QL(9 ea daily);
MO
QL(6 ea daily);
MO
QL(18 ea
daily); MO
QL(9 ea daily);
MO
QL(18 ea
daily); MO
QL(9 ea daily);
MO
QL(6 ea daily);
MO
QL(9 ea daily);
MO
MO
MO
PA; AL; MO
PA; AL; MO
PA; AL
AL
NASAL AGENTS - SYSTEMIC AND TOPICAL -
Drugs to treat the Nose or Sinus
DRUG NAME
Nasal Agent Combinations
DYMISTA 3
Nasal Anti-infectives
BACTROBAN NASAL 3
Nasal Antiallergy
ASTELIN (Use Azelastine
HCl)
ASTEPRO 2
azelastine hcl 1
PATANASE 3
Nasal Anticholinergics
ATROVENT (Use
Ipratropium Bromide
(Nasal))
ipratropium bromide (nasal) 1
Nasal Steroids
BECONASE AQ 3
FLONASE (Use
Fluticasone Propionate
(Nasal))
flunisolide 1
flunisolide (nasal) 1
fluticasone propionate
(nasal)
NASACORT AQ (Use
Triamcinolone Acetonide
(Nasal))
NASONEX 2
OMNARIS 3
QNASL 3
RHINOCORT AQUA 3
triamcinolone acetonide
(nasal)
Drug
Tier Requirements/
Limits
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
3
3
3
1
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
74

Drug
DRUG NAME
Tier Requirements/
Limits
VERAMYST 3
MO
ZETONNA 3
Sympathomimetic Decongestants
tyzine 1
tyzine pediatric nasal drops 1
MO
NEUROMUSCULAR AGENTS - Drugs to
Relax/Paralyze Muscles
ALS Agents
RILUTEK (Use Riluzole) 5
riluzole 5
MO
MO
Neuromuscular Blocking Agent - Neurotoxins
BOTOX 100 UNIT 4
PA
BOTOX 200 UNIT 5
XEOMIN 4
PA
Nondepolarizing Muscle Relaxants
vecuronium bromide 10 mg 4
NUTRIENTS
Carbohydrates
dextrose soln iv 10 %, 50
%, 70 %
dextrose soln iv 5 % 4
Lipids
fat emulsion 4
INTRALIPID (Use Fat
Emulsion)
LIPOSYN II (Use Fat
Emulsion)
LIPOSYN III (Use Fat
Emulsion)
Proteins
amino acid electrolyte
infusion
4
4
4
4
4
B/D
MO; B/D
B/D
B/D
B/D
B/D
B/D
Drug
DRUG NAME
Tier Requirements/
Limits
amino acid infusion 4
B/D
AMINOSYN 4
AMINOSYN
7%/ELECTROLYTES
aminosyn ii 4
AMINOSYN II (Use Amino
Acid Infusion)
AMINOSYN M 4
AMINOSYN-HBC 4
AMINOSYN-PF 4
AMINOSYN-PF 7% 4
AMINOSYN-RF 4
CLINIMIX
2.75%/DEXTROSE 5%
CLINIMIX
4.25%/DEXTROSE 10%
CLINIMIX
4.25%/DEXTROSE 20%
CLINIMIX
4.25%/DEXTROSE 25%
CLINIMIX
4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE
15%
CLINIMIX 5%/DEXTROSE
20%
CLINIMIX 5%/DEXTROSE
25%
CLINIMIX E
2.75%/DEXTROSE 10%
CLINIMIX E
2.75%/DEXTROSE 5%
CLINIMIX E
4.25%/DEXTROSE 25%
CLINIMIX E
4.25%/DEXTROSE 5%
CLINIMIX E
5%/DEXTROSE 15%
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
75

DRUG NAME
CLINIMIX E
5%/DEXTROSE 20%
CLINIMIX E
5%/DEXTROSE 25%
FREAMINE HBC 6.9% 4
FREAMINE III 4
FREAMINE III 3% 4
hepatasol 4
NEPHRAMINE 4
premasol 4
PROCALAMINE 4
PROSOL 4
travasol 4
TROPHAMINE (Use
Amino Acid Infusion)
Drug
Tier Requirements/
Limits
4
B/D
4
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
OPHTHALMIC AGENTS - Drugs to Treat the
Eye
Beta-blockers - Ophthalmic
BETAGAN (Use
Levobunolol HCl)
betaxolol hcl 1
betaxolol hcl (ophth) 1
BETIMOL 2
BETOPTIC-S 2
carteolol hcl (ophth) 1
COMBIGAN 3
COSOPT (Use
Dorzolamide HCl-Timolol
Maleate)
COSOPT PF 3
dorzolamide hcl-timolol
maleate
3
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
ISTALOL 2
MO
levobunolol hcl 1
metipranolol 1
OPTIPRANOLOL (Use
Metipranolol)
timolol maleate (ophth) 1
TIMOPTIC (Use Timolol
Maleate (Ophth))
TIMOPTIC OCUDOSE 3
TIMOPTIC-XE (Use
Timolol Maleate (Ophth))
Cycloplegic Mydriatics
cyclogyl 1
cyclopentolate hcl soln op 1
%, 2 %
mydriacyl 1
tropicamide soln op 0.5 %,
1 %
Miotics
ISOPTO CARPINE (Use
Pilocarpine HCl)
PHOSPHOLINE IODIDE 3
pilocarpine hcl soln op 1 %,
2 %, 4 %
PILOPINE HS 2
3
3
3
1
1
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Ophthalmic - Angiogenesis Inhibitors
EYLEA 5
LUCENTIS 5
Ophthalmic Adrenergic Agents
ALPHAGAN P 0.1 % 2
ALPHAGAN P 0.15 % (Use
Brimonidine Tartrate)
apraclonidine hcl 1
3
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
76

Drug
DRUG NAME
Tier Requirements/
Limits
brimonidine tartrate 1
MO
IOPIDINE (Use
Apraclonidine HCl)
NF
SIMBRINZA 3
Ophthalmic Anti-infectives
AZASITE 3
bacitracin oint op 500
unit/gm
bacitracin-polymyxin b
(ophth)
BESIVANCE 3
BETADINE OPHTHALMIC
PREP
BLEPH-10 (Use
Sulfacetamide Sodium
(Ophth))
CILOXAN OINT 2
CILOXAN SOLN (Use
Ciprofloxacin HCl (Ophth))
ciprofloxacin hcl (ophth) 1
erythromycin (ophth) 1
garamycin 1
gatifloxacin (ophth) 1
gentamicin sulfate (ophth) 1
levofloxacin (ophth) 1
MOXEZA 2
NATACYN 2
neomycin-polymy-gramicid 1
neosporin 1
OCUFLOX (Use Ofloxacin
(Ophth))
1
1
3
3
3
1
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
ofloxacin (ophth) 1
MO
polymyxin b-trimethoprim 1
POLYTRIM (Use
Polymyxin B-Trimethoprim)
sulfacetamide sodium
(ophth)
sulfacetamide sodium oint
op 10 %
tobramycin sulfate (ophth) 1
TOBREX OINT 2
TOBREX SOLN (Use
Tobramycin Sulfate
(Ophth))
trifluridine soln op 1 % 1
VIGAMOX 2
VIROPTIC (Use
Trifluridine)
ZIRGAN 3
ZYMAXID (Use
Gatifloxacin (Ophth))
Ophthalmic Decongestants
naphazoline hcl soln op 0.1
%
3
1
1
3
3
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Ophthalmic Immunomodulators
RESTASIS 2
MO
Ophthalmic Local Anesthetics
alcaine 1
proparacaine hcl soln op
0.5 %
Ophthalmic Steroids
ALREX 3
neomycin-bacitracin znpolymyxin
bacitracin-poly-neomycinhc
BLEPHAMIDE 2
blephamide s.o.p. 1
1
1
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
77

DRUG NAME
dexamethasone sodium
phosphate (ophth)
DUREZOL 2
FLAREX 2
fluorometholone (ophth) 1
FML 2
FML FORTE 2
FML LIQUIFILM (Use
Fluorometholone (Ophth))
LOTEMAX GEL 3
LOTEMAX OINT 3
LOTEMAX SUSP 2
MAXIDEX 3
MAXITROL (Use
Neomycin-Polymy-
Dexameth)
neomycin-polymydexameth
neomycin/polymyxin/hydro
cortisone
OMNIPRED (Use
Prednisolone Acetate
(Ophth))
PRED FORTE (Use
Prednisolone Acetate
(Ophth))
PRED MILD 2
PRED-G 3
PRED-G S.O.P. 3
prednisolone acetate
(ophth)
prednisolone sodium
phosphate soln op 1 %
sulfacetamide sodprednisolone
Drug
Tier Requirements/
Limits
1
MO
3
3
1
1
3
3
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
TOBRADEX (Use
Tobramycin-
Dexamethasone)
TOBRADEX ST 3
tobramycindexamethasone
TRIESENCE 4
VEXOL 3
ZYLET 2
Ophthalmics - Misc.
ACULAR (Use Ketorolac
Tromethamine (Ophth))
ACULAR LS (Use
Ketorolac Tromethamine
(Ophth))
ACUVAIL 3
ALOCRIL 3
ALOMIDE 3
azelastine hcl (ophth) 1
AZOPT 2
BEPREVE 3
BROMDAY 3
bromfenac 1
cromolyn sodium (ophth) 1
CYSTARAN 3
diclofenac sodium (ophth) 1
dorzolamide hcl 1
ELESTAT (Use Epinastine
HCl (Ophth))
EMADINE 3
epinastine hcl (ophth) 1
Drug
Tier Requirements/
Limits
MO
3
1
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(2.15 ml
daily)
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
78

Drug
DRUG NAME
Tier Requirements/
Limits
flurbiprofen sodium 1
MO
ILEVRO 2
ketorolac tromethamine
(ophth)
LASTACAFT 3
NEVANAC 2
OCUFEN (Use
Flurbiprofen Sodium)
OPTIVAR (Use Azelastine
HCl (Ophth))
PATADAY 2
PATANOL 3
PROLENSA 3
TRUSOPT (Use
Dorzolamide HCl)
VOLTAREN (Use
Diclofenac Sodium
(Ophth))
Prostaglandins - Ophthalmic
latanoprost 1
LUMIGAN 0.01 % 2
LUMIGAN 0.03 % 2
RESCULA 3
TRAVATAN Z 3
travoprost 1
XALATAN (Use
Latanoprost)
ZIOPTAN 3
1
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
OTIC AGENTS - Drugs to Treat the Ear
Otic Agents - Miscellaneous
acetic acid (otic) 1
MO
DRUG NAME
acetic acid/aluminum
acetate
Otic Anti-infectives
ofloxacin (otic) 1
Otic Combinations
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 3
CORTISPORIN SOLN OT
0.1-1-3.5-10000 %,
MG/ML, UNIT/ML (Use
Neomycin-Polymyxin-HC
(Otic))
CORTISPORIN-TC 3
neomycin-polymyxin-hc
(otic)
Otic Steroids
DERMOTIC (Use
Fluocinolone Acetonide
(Otic))
fluocinolone acetonide
(otic)
hydrocortisone w/acetic
acid
VOSOL HC (Use
Hydrocortisone w/Acetic
Acid)
Drug
Tier Requirements/
Limits
1
MO
3
1
3
1
1
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
OXYTOCICS - Drugs to Prevent/Control Uterine
Bleeding
Oxytocics
METHERGINE TABS OR
0.2 MG (Use
Methylergonovine Maleate)
methylergonovine maleate
tabs or 0.2 mg
3
1
MO
MO
PASSIVE IMMUNIZING AGENTS - Antibody
Drugs to Treat Low Immune System
Immune Serums
BIVIGAM 5
B/D
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
79

DRUG NAME
CARIMUNE
NANOFILTERED
FLEBOGAMMA 5
FLEBOGAMMA DIF 5
GAMASTAN S/D 4
GAMMAGARD LIQUID 5
GAMMAGARD S/D 10 GM,
5 GM
GAMMAGARD S/D 2.5 GM 2
GAMMAGARD S/D IGA
LESS THAN 1MCG/ML
GAMMAKED 5
GAMMAPLEX 5
GAMUNEX 5
GAMUNEX-C 5
HEPAGAM B 4
HIZENTRA 4
HYPERHEP B S/D 4
NABI-HB 4
OCTAGAM 5
PRIVIGEN 5
VARIZIG 5
Monoclonal Antibodies
SYNAGIS 5
Drug
Tier Requirements/
Limits
5
B/D
5
5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PENICILLINS - Drugs to Treat Bacterial
Infections
Aminopenicillins
amoxicillin 1
ampicillin caps 250 mg,
500 mg
1
MO
MO
DRUG NAME
ampicillin sodium solr ij 1
gm, 2 gm, 500 mg
ampicillin sodium solr ij 10
gm, 125 mg, 250 mg
ampicillin sodium solr iv 1
gm, 10 gm, 2 gm
ampicillin susr 125 mg/5ml 1
ampicillin susr 250 mg/5ml 1
MOXATAG 3
Natural Penicillins
BICILLIN L-A 4
penicillin g potassium 4
PENICILLIN G
POTASSIUM IN ISO-
OSMOTIC DEXTROSE
penicillin g procaine 4
penicillin g sodium 4
penicillin v potassium 1
pfizerpen-g 4
PFIZERPEN-G (Use
Penicillin G Potassium)
Penicillin Combinations
amoxicillin & pot
clavulanate
ampicillin & sulbactam
sodium ij 0.5-1 gm, 5-10
gm
ampicillin & sulbactam
sodium ij 1-2 gm
ampicillin & sulbactam
sodium iv 0.5-1 gm, 1-2
gm, 5-10 gm
AMPICILLIN-SULBACTAM 4
AUGMENTIN ES-600 (Use
Amoxicillin & Pot
Clavulanate)
Drug
Tier Requirements/
Limits
4
MO
4
4
4
4
1
4
4
4
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
80

DRUG NAME
AUGMENTIN SUSR 31.25-
125 MG/5ML
AUGMENTIN SUSR 62.5-
250 MG/5ML (Use
Amoxicillin & Pot
Clavulanate)
AUGMENTIN TABS 125-
500 MG, 125-875 MG (Use
Amoxicillin & Pot
Clavulanate)
AUGMENTIN XR (Use
Amoxicillin & Pot
Clavulanate)
BICILLIN C-R 0.01-0.1-
300000-300000 %,
UNIT/ML
BICILLIN C-R 0.01-0.1-
300000-900000 %,
UNIT/2ML
piperacillin sodiumtazobactam
sodium 0.25-2
gm, 4.5-36 gm
piperacillin sodiumtazobactam
sodium 0.375-
3 gm, 0.5-4 gm
ticarcillin & pot clavulanate 4
TIMENTIN 4
UNASYN ADD-VANTAGE
(Use Ampicillin &
Sulbactam Sodium)
UNASYN BULK PACK
(Use Ampicillin &
Sulbactam Sodium)
UNASYN IJ 0.5-1 GM (Use
Ampicillin & Sulbactam
Sodium)
UNASYN IJ 1-2 GM (Use
Ampicillin & Sulbactam
Sodium)
UNASYN IV 0.5-1 GM (Use
Ampicillin & Sulbactam
Sodium)
Drug
Tier Requirements/
Limits
2
MO
3
3
3
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
DRUG NAME
ZOSYN SOLN 0.25-0.5-2-5
%, GM/50ML, MG/50ML,
0.375-0.75-3-5 %,
GM/50ML, MG/50ML, 0.5-
1-4-5 %, GM/100ML,
MG/100ML
ZOSYN SOLR 0.25-0.5-2
GM, MG, 4.5-36 GM (Use
Piperacillin Sodium-
Tazobactam Sodium)
ZOSYN SOLR 0.375-0.75-
3 GM, MG, 0.5-1-4 GM,
MG (Use Piperacillin
Sodium-Tazobactam
Sodium)
Drug
Tier Requirements/
Limits
4
4
4
MO
Penicillinase-Resistant Penicillins
BACTOCILL IN
DEXTROSE 1 GM/50ML
4
BACTOCILL IN
DEXTROSE 2 GM/50ML
5
dicloxacillin sodium 1
MO
nafcillin sodium 4
NAFCILLIN SODIUM 4
NALLPEN ISO-OSMOTIC
IN DEXTROSE
NALLPEN/DEXTROSE 4
oxacillin sodium 1 gm 4
oxacillin sodium 10 gm 5
oxacillin sodium 2 gm 5
PROGESTINS - Hormone
Replacement/Modifying Drugs
Progestins
aygestin 1
MAKENA 5
medroxyprogesterone
acetate tabs or 10 mg, 2.5
mg, 5 mg
MEGACE ES 3
4
1
MO
MO
MO
AL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
81

DRUG NAME
norethindrone acetate tabs
or 5 mg
progesterone micronized
caps or 100 mg, 200 mg
PROMETRIUM (Use
Progesterone Micronized)
PROVERA (Use
Medroxyprogesterone
Acetate)
Drug
Tier Requirements/
Limits
1
MO
1
3
3
MO
MO
MO
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC. - Drugs to Treat Mental and
Emotional Conditions
Agents for Chemical Dependency
acamprosate calcium 1
MO
antabuse 1
CAMPRAL (Use
Acamprosate Calcium)
disulfiram tabs or 250 mg,
500 mg
Anti-Cataplectic Agents
XYREM 5
Antidementia Agents
ARICEPT 10 MG, 5 MG
(Use Donepezil
Hydrochloride)
ARICEPT 23 MG (Use
Donepezil Hydrochloride)
ARICEPT ODT (Use
Donepezil Hydrochloride)
donepezil hydrochloride 1
EXELON CAPS OR 1.5
MG, 3 MG, 4.5 MG, 6 MG
(Use Rivastigmine Tartrate)
EXELON PT24 TD 13.3
MG/24HR, 4.6 MG/24HR,
9.5 MG/24HR
EXELON SOLN OR 2
MG/ML
galantamine hydrobromide 1
NAMENDA 3
2
1
3
2
3
3
2
2
MO
MO
MO
LA
MO
MO
MO
MO
MO
MO
MO
MO
MO
DRUG NAME
NAMENDA TITRATION
PAK
NAMENDA XR 14 MG 3
NAMENDA XR 21 MG, 28
MG
NAMENDA XR 7 MG 3
NAMENDA XR TITRATION
PACK
RAZADYNE (Use
Galantamine
Hydrobromide)
RAZADYNE ER (Use
Galantamine
Hydrobromide)
rivastigmine tartrate 1
Drug
Tier Requirements/
Limits
3
MO
3
3
3
3
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(4 ea daily);
MO
MO
MO
MO
MO
Combination Psychotherapeutics
chlordiazepoxide/amitriptyli
ne
1
MO
perphenazine/amitriptyline 1
MO
Fibromyalgia Agents
SAVELLA 3
SAVELLA TITRATION
PACK
Movement Disorder Drug Therapy
XENAZINE 5
LA
Multiple Sclerosis Agents
AMPYRA 5
AUBAGIO 5
AVONEX 5
AVONEX PEN 5
BETASERON 5
COPAXONE 5
EXTAVIA 5
3
PA; MO
PA; MO
PA
PA
PA
PA
PA
PA
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
82

Drug
DRUG NAME
Tier Requirements/
Limits
GILENYA 5
PA
REBIF 5
REBIF REBIDOSE 5
REBIF REBIDOSE
TITRATIONPACK
REBIF TITRATION PACK 5
TECFIDERA 5
TECFIDERA STARTER
PACK
TYSABRI 5
5
5
PA
PA
PA
PA
PA
PA
PA
Postherpetic Neuralgia (PHN) Agents
GRALISE 3
MO
GRALISE STARTER 3
MO
Pseudobulbar Affect (PBA) Agents
NUEDEXTA 2
MO
Psychotherapeutic and Neurological Agents -
ORAP 3
MO
Restless Leg Syndrome (RLS) Agents
HORIZANT 3
MO
Smoking Deterrents
bupropion hcl (smoking
deterrent)
CHANTIX 3
CHANTIX CONTINUING
MONTHPAK
CHANTIX STARTING
MONTH PAK
NICOTROL INHALER 3
NICOTROL NS 2
ZYBAN (Use Bupropion
HCl (Smoking Deterrent))
1
3
3
3
QL(2 ea daily);
MO
PA; MO
PA; MO
PA; MO
QL(17 ea
daily); MO
MO
QL(2 ea daily);
MO
DRUG NAME
Drug
Tier Requirements/
Limits
RESPIRATORY AGENTS - MISC. - Drugs to
Treat Lung Conditions
Alpha-Proteinase Inhibitor (Human)
ARALAST NP 1000 MG,
400 MG
5
LA
ARALAST NP 500 MG 2
LA
ARALAST NP 800 MG 5
GLASSIA 4
PROLASTIN 5
PROLASTIN-C 5
ZEMAIRA 5
Cystic Fibrosis Agents
KALYDECO 5
PULMOZYME 2
LA
LA
LA
LA
PA
B/D
SULFONAMIDES - Drugs to Treat Bacterial
Infections
Sulfonamides
sulfadiazine tabs or 500 mg 1
MO
TETRACYCLINES - Drugs to Treat Bacterial
Infections
Tetracyclines
adoxa 1
demeclocycline hcl tabs or
150 mg, 300 mg
DORYX (Use Doxycycline
Hyclate)
doxycycline (monohydrate) 1
doxycycline hyclate caps or
100 mg, 50 mg
doxycycline hyclate solr iv
100 mg
doxycycline hyclate tabs or
100 mg, 20 mg
doxycycline hyclate tbec or
100 mg, 150 mg, 75 mg
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
83
1
3
1
4
1
1
MO
MO
MO
MO
MO
MO
MO
MO

Drug
DRUG NAME
Tier Requirements/
Limits
dynacin 1
MO
MINOCIN CAPS OR 100
MG, 50 MG (Use
Minocycline HCl)
MINOCIN SOLR IV 100
MG
minocycline hcl caps or
100 mg, 50 mg, 75 mg
minocycline hcl tabs or 100
mg, 50 mg, 75 mg
minocycline hcl tb24 or 135
mg, 45 mg, 90 mg
MONODOX (Use
Doxycycline
(Monohydrate))
SOLODYN 3
tetracycline hcl caps or 250
mg, 500 mg
VIBRAMYCIN CAPS 100
MG (Use Doxycycline
Hyclate)
VIBRAMYCIN SUSR 25
MG/5ML (Use Doxycycline
(Monohydrate))
VIBRAMYCIN SYRP 50
MG/5ML
3
4
1
1
1
3
1
3
3
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
THYROID AGENTS - Drugs to Regulate
Thyroid Hormones
Antithyroid Agents
methimazole tabs or 10
mg, 5 mg
propylthiouracil tabs or 50
mg
tapazole 1
Thyroid Hormones
CYTOMEL (Use
Liothyronine Sodium)
levothyroxine sodium tabs
or 100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg,
175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
1
1
3
1
MO
MO
MO
MO
MO
DRUG NAME
liothyronine sodium soln iv
10 mcg/ml
liothyronine sodium tabs or
25 mcg, 5 mcg, 50 mcg
SYNTHROID (Use
Levothyroxine Sodium)
TRIOSTAT (Use
Liothyronine Sodium)
TOXOIDS
Toxoid Combinations
ADACEL 4
BOOSTRIX 4
DAPTACEL 4
DECAVAC 4
DIPHTHERIA/TETANUS
TOXOID PEDIATRIC
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
INFANRIX 4
KINRIX 4
PEDIARIX 4
PENTACEL 4
TENIVAC 4
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT
TRIPEDIA 4
Toxoids
TETANUS TOXOID
ADSORBED
Drug
Tier Requirements/
Limits
4
1
3
4
4
4
4
4
MO
MO
B/D
B/D
B/D
B/D
ULCER DRUGS - Drugs to Treat Bowel,
Intestine and Stomach Conditions
Antispasmodics
ATROPINE SULFATE
SOLN IJ 0.05 MG/ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
4
84

DRUG NAME
atropine sulfate soln ij 0.1
mg/ml
BENTYL CAPS OR 10 MG
(Use Dicyclomine HCl)
BENTYL SOLN IM 10
MG/ML
BENTYL SYRP OR 10
MG/5ML (Use Dicyclomine
HCl)
BENTYL TABS OR 20 MG
(Use Dicyclomine HCl)
CANTIL 3
CUVPOSA 2
dicyclomine hcl caps 10 mg 1
dicyclomine hcl soln 10
mg/5ml
dicyclomine hcl tabs 20 mg 1
glycopyrrolate soln ij 0.2
mg/ml, 0.4 mg/2ml, 1
mg/5ml, 4 mg/20ml
glycopyrrolate tabs or 1
mg, 2 mg
methscopolamine bromide
tabs or 2.5 mg, 5 mg
PAMINE (Use
Methscopolamine Bromide)
PAMINE FORTE (Use
Methscopolamine Bromide)
propantheline bromide tabs
or 15 mg
ROBINUL FORTE (Use
Glycopyrrolate)
ROBINUL SOLN IJ 0.2
MG/ML, 0.4 MG/2ML, 1
MG/5ML, 4 MG/20ML (Use
Glycopyrrolate)
ROBINUL TABS OR 1 MG
(Use Glycopyrrolate)
H-2 Antagonists
AXID (Use Nizatidine) 3
cimetidine hcl 1
Drug
Tier Requirements/
Limits
4
3
4
3
3
1
4
1
1
3
3
1
3
4
3
PA; AL; MO
PA; AL; MO
PA; AL; MO
MO
MO
PA; AL; MO
MO
PA; AL; MO
MO
MO
MO
MO
MO
PA; AL; MO
MO
MO
MO
MO
MO
Drug
DRUG NAME
Tier Requirements/
Limits
cimetidine tabs or 200 mg 1
RX/OTC; MO
cimetidine tabs or 300 mg,
400 mg, 800 mg
famotidine premixed 4
famotidine soln iv 10 mg/ml 4
famotidine susr or 40
mg/5ml
famotidine tabs or 20 mg 1
famotidine tabs or 40 mg 1
nizatidine 1
PEPCID SUSR 40 MG/5ML
(Use Famotidine)
PEPCID TABS 20 MG (Use
Famotidine)
PEPCID TABS 40 MG (Use
Famotidine)
ranitidine hcl caps or 150
mg, 300 mg
ranitidine hcl soln ij 150
mg/6ml, 50 mg/2ml
ranitidine hcl soln ij 25
mg/ml
ranitidine hcl syrp or 15
mg/ml, 150 mg/10ml, 75
mg/5ml
ranitidine hcl tabs or 150
mg
ranitidine hcl tabs or 300
mg
ZANTAC SOLN IJ 25
MG/ML (Use Ranitidine
HCl)
ZANTAC SOLN IJ 25
MG/ML (Use Ranitidine
HCl)
ZANTAC SOLN IV 0.45-50
%, MG/50ML
ZANTAC SYRP OR 15
MG/ML (Use Ranitidine
HCl)
1
1
3
3
3
1
4
4
1
1
1
4
4
4
3
MO
MO
MO
RX/OTC; MO
MO
MO
MO
RX/OTC; MO
MO
MO
MO
MO
RX/OTC; MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
85

DRUG NAME
ZANTAC TABS OR 150
MG (Use Ranitidine HCl)
ZANTAC TABS OR 300
MG (Use Ranitidine HCl)
ZANTAC TBEF OR 25 MG 2
Misc. Anti-Ulcer
CARAFATE (Use
Sucralfate)
sucralfate tabs or 1 gm 1
Proton Pump Inhibitors
ACIPHEX (Use
Rabeprazole Sodium)
DEXILANT 3
lansoprazole cpdr or 15 mg 1
lansoprazole cpdr or 30 mg 1
lansoprazole tbdp or 15
mg, 30 mg
NEXIUM 3
NEXIUM I.V. 20 MG 4
NEXIUM I.V. 40 MG 4
omeprazole cpdr or 10 mg,
20 mg, 40 mg
pantoprazole sodium solr iv
40 mg
pantoprazole sodium tbec
or 20 mg, 40 mg
PREVACID 15 MG (Use
Lansoprazole)
PREVACID 30 MG (Use
Lansoprazole)
PREVACID SOLUTAB 3
PRILOSEC CPDR 10 MG,
20 MG, 40 MG (Use
Omeprazole)
PRILOSEC PACK 10 MG,
2.5 MG
PROTONIX PACK OR 40
MG
Drug
Tier Requirements/
Limits
3
RX/OTC; MO
3
3
2
1
1
4
1
3
3
3
3
3
MO
MO
MO
MO
ST; QL(1 ea
daily); MO
RX/OTC; MO
MO
MO
ST; QL(1 ea
daily); MO
MO
MO
MO
RX/OTC; MO
MO
MO
MO
ST; MO
MO
DRUG NAME
PROTONIX SOLR IV 40
MG (Use Pantoprazole
Sodium)
PROTONIX TBEC OR 20
MG, 40 MG (Use
Pantoprazole Sodium)
rabeprazole sodium 1
Ulcer Drugs - Prostaglandins
CYTOTEC (Use
Misoprostol)
3
misoprostol tabs or 100
mcg, 200 mcg
1
Ulcer Therapy Combinations
amoxicillin-clarithromycin
w/ lansoprazole
1
HELIDAC 3
omeprazole-sodium
bicarbonate 20-1100 mg
omeprazole-sodium
bicarbonate 40-1100 mg
PREVPAC (Use
Amoxicillin-Clarithromycin
w/ Lansoprazole)
PYLERA 3
ZEGERID CAPS 20-1100
MG (Use Omeprazole-
Sodium Bicarbonate)
ZEGERID CAPS 40-1100
MG (Use Omeprazole-
Sodium Bicarbonate)
ZEGERID PACK 20-1680
MG
ZEGERID PACK 40-1680
MG
Drug
Tier Requirements/
Limits
4
3
1
1
3
3
3
3
3
MO
MO
MO
MO
MO
MO
ST; RX/OTC;
MO
ST; MO
MO
MO
ST; RX/OTC;
MO
ST; MO
ST; MO
MO
URINARY ANTI-INFECTIVES - Drugs to Treat
Bladder/Kidney Infections
Urinary Anti-infectives
FURADANTIN (Use
Nitrofurantoin)
HIPREX (Use
Methenamine Hippurate)
3
3
PA; AL; MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
MO
86

DRUG NAME
MACROBID (Use
Nitrofurantoin Monohyd
Macro)
MACRODANTIN 100 MG,
50 MG (Use Nitrofurantoin
Macrocrystal)
MACRODANTIN 25 MG 2
methenamine hippurate 1
nitrofurantoin macrocrystal
caps or 100 mg, 50 mg
nitrofurantoin monohyd
macro
nitrofurantoin susp or 25
mg/5ml
Drug
Tier Requirements/
Limits
MO
3
3
1
1
1
PA; AL; MO
PA; AL; MO
MO
PA; AL; MO
MO
PA; AL; MO
URINARY ANTISPASMODICS - Drugs to Treat
Miscellaneous Bladder Spasms
Urinary Antispasmodic - Antimuscarinics
DETROL (Use Tolterodine
Tartrate)
2
MO
DETROL LA 2
MO
DITROPAN XL (Use
Oxybutynin Chloride)
ENABLEX 2
GELNIQUE 3
oxybutynin chloride 1
OXYTROL 3
SANCTURA (Use
Trospium Chloride)
SANCTURA XR (Use
Trospium Chloride)
tolterodine tartrate 1
TOVIAZ 2
trospium chloride 1
VESICARE 2
3
3
3
MO
MO
MO
MO
RX/OTC; MO
MO
MO
MO
MO
MO
MO
Urinary Antispasmodics - Beta-3 Adrenergic
Drug
DRUG NAME
Tier Requirements/
Limits
MYRBETRIQ 3
MO
Urinary Antispasmodics - Cholinergic
bethanechol chloride 1
MO
urecholine 1
MO
Urinary Antispasmodics - Direct Muscle
flavoxate hcl 1
MO
VACCINES
Bacterial Vaccines
ACTHIB 4
HIBERIX 4
MENACTRA 4
MENOMUNE-A/C/Y/W-135 4
MENVEO 4
PEDVAX HIB 4
TYPHIM VI 4
Mixed Vaccine Combinations
COMVAX 4
Viral Vaccines
CERVARIX 4
ENGERIX-B 4
FLUARIX QUADRIVALENT
2013-2014
FLUMIST
QUADRIVALENT
FLUZONE
QUADRIVALENT 2013-
2014
GARDASIL 4
HAVRIX 4
4
2
4
B/D
B;NT
B;NT
B;NT
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
87

DRUG NAME
IMOVAX RABIES
(H.D.C.V.)
IPOL INACTIVATED IPV 4
IXIARO 4
M-M-R II W/DILUENT 10
DOSE
MEDICAL PROVIDER EZ
FLU SHOT PF 2012-2013
MEDICAL PROVIDER EZ
FLU SHOT PF 2013-2014
PROQUAD 4
RABAVERT 4
RECOMBIVAX HB 4
ROTARIX 3
ROTATEQ 2
TWINRIX 4
VAQTA 4
VARIVAX 4
YF-VAX 4
ZOSTAVAX 4
Drug
Tier Requirements/
Limits
4
B/D
4
5
5
B;NT
B;NT
B/D
B/D
VAGINAL PRODUCTS - Drugs to Treat Vaginal
Infections and Low Hormones
Vaginal Anti-infectives
CLEOCIN (Use
Clindamycin Phosphate
Vaginal)
clindamycin phosphate
vaginal
METROGEL-VAGINAL
(Use Metronidazole
Vaginal)
metronidazole vaginal 1
miconazole 3 1
3
1
3
MO
MO
MO
MO
MO
DRUG NAME
nystatin vaginal 1
TERAZOL 3 (Use
Terconazole Vaginal)
TERAZOL 7 (Use
Terconazole Vaginal)
terconazole vaginal 1
Vaginal Estrogens
estrace 1
ESTRING 3
FEMRING 3
PREMARIN CREA VA
0.625 MG/GM
VAGIFEM 3
Vaginal Progestins
CRINONE 3
ENDOMETRIN 3
Drug
Tier Requirements/
Limits
3
3
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
VASOPRESSORS - Drugs to Treat Heart and
Circulation Conditions
Anaphylaxis Therapy Agents
ADRENACLICK 2
AUVI-Q 2
EPINEPHRINE DEVI IJ
0.15 MG/0.15ML, 0.3
MG/0.3ML
EPIPEN 2-PAK 2
EPIPEN-JR 2-PAK 2
TWINJECT 2
Vasopressors
dobutamine hcl 4
dobutamine in d5w 4
2
MO
MO
MO
MO
MO
MO
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
88

DRUG NAME
DOBUTAMINE/DEXTROS
E 5% (Use Dobutamine in
D5W)
dopamine hcl 4
Drug
Tier Requirements/
Limits
4
dopamine in d5w 4
midodrine hcl 1
phenylephrine hcl soln ij 10
mg/ml
VITAMINS
Oil Soluble Vitamins
DRISDOL CAPS 50000
UNIT (Use Ergocalciferol)
ergocalciferol caps or
50000 unit
MEPHYTON 3
1
3
1
MO
MO
MO; NT
MO; NT
MO; NT
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B=Medicare Part B B/D=Medicare Part B vs. Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order NT=Non-TrOOP PA=Prior Authorization
QL=Quantity Limit RX/OTC=Prescription & Over-The-Counter ST=Step Therapy
89

Index
1ST TIER UNIFINE
PENTIPS29GX12MM
1ST TIER UNIFINE
68
PENTIPSPLUS/ORIGINAL/29GX
12MM 68
8-MOP 52
abacavir sulfate 39
ABELCET 24
ABILIFY 1 MG/ML 38
ABILIFY 10 MG 38
ABILIFY 15 MG 38
ABILIFY 2 MG 38
ABILIFY 20 MG, 30 MG 38
ABILIFY 5 MG 39
ABILIFY 9.75 MG/1.3ML 38
ABILIFY DISCMELT 10 MG 38
ABILIFY DISCMELT 15 MG 38
ABILIFY MAINTENA 38
ABRAXANE 35
ABSORICA 50
ABSTRAL 100 MCG 4
ABSTRAL 200 MCG 4
ABSTRAL 300 MCG, 400 MCG,
600 MCG, 800 MCG 4
acamprosate calcium 82
ACANYA 50
acarbose 20
ACCOLATE 13
ACCUNEB 14
ACCUPRIL 27
ACCURETIC 28
acebutolol hcl 200 mg, 400 mg 43
ACEON 2 MG 27
ACEON 4 MG 27
ACEON 8 MG 27
acetaminophen w/ codeine 15-
300 mg, 30-300 mg, 60-300 mg 6
acetaminophen w/ codeine 6.65-
12-120 %, mg/5ml, 7-12-120 %,
mg/5ml, 7.4-12-120 %, mg/5ml 6
acetaminophen/caffeine/dihydroc
odeine bitartrate
acetazolamide 125 mg, 250
6
mg 56
acetazolamide 500 mg 56
acetazolamide sodium 56
acetic acid (otic) 79
acetic acid 0.25 % 63
acetic acid/aluminum acetate 79
acetylcysteine (antidote) 23
acetylcysteine 10 %, 20 % 50
ACIPHEX 86
acitretin 52
aclovate 53
ACTEMRA 2
ACTHAR HP 58
ACTHIB 87
ACTIGALL 62
ACTIMMUNE 34
ACTIQ 1200 MCG, 1600 MCG,
400 MCG, 600 MCG 4
ACTIQ 200 MCG 4
ACTIQ 800 MCG 4
ACTIVELLA 60
ACTONEL 150 MG 58
ACTONEL 30 MG, 5 MG 58
ACTONEL 35 MG 58
ACTOPLUS MET 20
ACTOPLUS MET XR 15-1000
MG 20
ACTOPLUS MET XR 30-1000
MG 20
ACTOS 21
ACULAR 78
ACULAR LS 78
ACUVAIL 78
acyclovir 200 mg 40
acyclovir 200 mg/5ml 41
acyclovir 400 mg, 800 mg 41
acyclovir sodium 1000 mg 41
acyclovir sodium 50 mg/ml 40
acyclovir sodium 500 mg 41
acyclovir topical 53
ADACEL 84
ADAGEN 43
ADALAT CC 43
adapalene 50
ADCIRCA 45
adderall 1
ADDERALL XR 1
adefovir dipivoxil 40
ADENOCARD 6 MG/2ML 12
adenosine 6 mg/2ml 12
adoxa 83
ADRENACLICK 88
adriamycin 33
ADVAIR DISKUS 14
ADVAIR HFA 14
ADVANCED DNA MEDICATED
COLLECTION 56
ADVICOR 26
AFINITOR 34
AFINITOR DISPERZ 34
AGGRENOX 64
AGRYLIN 64
AKNE-MYCIN 50
ala scalp 53
ALBENZA 9
albuterol sulfate 0.083 %, 0.5 %,
0.63 mg/3ml, 1.25 mg/3ml 14
albuterol sulfate 2 mg, 4 mg 14
albuterol sulfate 2 mg/5ml 14
albuterol sulfate 4 mg, 8 mg 14
alcaine 77
alclometasone dipropionate 53
ALDACTAZIDE 25-25 MG 57
ALDACTAZIDE 50-50 MG 57
ALDACTONE 57
ALDARA 55
ALDURAZYME 59
alendronate sodium 10 mg, 40
mg, 5 mg 58
alendronate sodium 35 mg, 70
mg 58
alfuzosin hcl 63
ALIMTA 100 MG 31
ALIMTA 500 MG 32
ALINIA 10
ALKERAN 31
allopurinol 100 mg 64
allopurinol 300 mg 64
allopurinol sodium 64
ALOCRIL 78
ALOMIDE 78
ALOPRIM 64
ALORA 61
ALOXI 23
ALPHAGAN P 0.1 % 76
ALPHAGAN P 0.15 % 76
alprazolam 0.25 mg, 0.5 mg, 1
mg, 2 mg 12
alprazolam 0.5 mg, 1 mg, 2 mg, 3
mg 12
alprazolam intensol 12
ALREX 77
ALSUMA 70
Index 1

ALTABAX 51
ALTACE 27
ALTOPREV 26
ALVESCO 13
amantadine hcl 100 mg 36
amantadine hcl 50 mg/5ml 36
AMARYL 22
AMBIEN 10 MG 65
AMBIEN 5 MG 65
AMBIEN CR 12.5 MG 66
AMBIEN CR 6.25 MG 66
AMBISOME 24
amcinonide 53
AMERGE 70
amethyst 47
AMICAR 65
amifostine crystalline 35
amikacin sulfate 1 gm/4ml, 500
mg/2ml
amiloride &
2
hydrochlorothiazide 57
amiloride hcl 5 mg 57
amino acid electrolyte infusion 75
amino acid infusion 75
aminocaproic acid 500 mg 65
aminophylline 14
AMINOSYN 75
AMINOSYN
7%/ELECTROLYTES 75
aminosyn ii 75
AMINOSYN II 75
AMINOSYN M 75
AMINOSYN-HBC 75
AMINOSYN-PF 75
AMINOSYN-PF 7% 75
AMINOSYN-RF 75
amiodarone hcl 100 mg, 200 mg,
400 mg 13
amiodarone hcl 150 mg/3ml, 50
mg/ml, 900 mg/18ml 13
AMITIZA 62
amitriptyline hcl 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg 19
amlodipine besylate 10 mg 43
amlodipine besylate 2.5 mg 44
amlodipine besylate 5 mg 44
amlodipine besylate-benazepril
hcl 28
AMLODIPINE
BESYLATE/ATORVASTATIN
CALCIUM
ammonium chloride 5
45
meq/ml 71
amoxapine 19
amoxicillin 80
amoxicillin & pot clavulanate 80
amoxicillin-clarithromycin w/
lansoprazole
amphetaminedextroamphetamine
86
1
AMPHOTEC 24
amphotericin b 50 mg 24
ampicillin & sulbactam sodium
0.5-1 gm, 1-2 gm, 5-10 gm 80
ampicillin & sulbactam sodium
0.5-1 gm, 5-10 gm 80
ampicillin & sulbactam sodium
1-2 gm 80
ampicillin 125 mg/5ml 80
ampicillin 250 mg, 500 mg 80
ampicillin 250 mg/5ml 80
ampicillin sodium 1 gm, 10 gm,
2 gm 80
ampicillin sodium 1 gm, 2 gm,
500 mg 80
ampicillin sodium 10 gm, 125
mg, 250 mg 80
AMPICILLIN-SULBACTAM 80
AMPYRA 82
AMRIX 73
AMTURNIDE 28
ANAFRANIL 20
anagrelide hcl 64
ANAPROX 2
ANAPROX DS 2
anastrozole 1 mg 33
ANCOBON 250 MG 24
ANCOBON 500 MG 24
ANDRODERM 2 MG/24HR, 4
MG/24HR, 5 MG/24HR 8
ANDRODERM 2.5 MG/24HR 8
ANDROGEL 8
ANDROGEL PUMP 8
androxy 8
ANGELIQ 60
antabuse 82
ANTARA 130 MG, 43 MG 26
ANTARA 30 MG 26
ANTARA 90 MG 26
ANTIVERT 12.5 MG, 25 MG 24
ANTIVERT 50 MG 24
ANTIZOL 23
anusol-hc 2.5 % 9
apexicon e 53
APIDRA 21
APIDRA SOLOSTAR 21
APLENZIN 174 MG 18
APLENZIN 348 MG, 522 MG 18
APOKYN 36
apraclonidine hcl 76
APRISO 62
APTIVUS 100 MG/ML 39
APTIVUS 250 MG 39
ARALAST NP 1000 MG, 400
MG 83
ARALAST NP 500 MG 83
ARALAST NP 800 MG 83
ARALEN 30
ARANESP ALBUMIN FREE 100
MCG/0.5ML, 100 MCG/ML, 25
MCG/0.42ML, 25 MCG/ML, 40
MCG/0.4ML, 40 MCG/ML, 60
MCG/0.3ML, 60 MCG/ML 65
ARANESP ALBUMIN FREE 150
MCG/0.3ML, 150 MCG/0.75ML,
200 MCG/0.4ML, 200 MCG/ML,
300 MCG/0.6ML, 300 MCG/ML,
500 MCG/ML 65
ARAVA 4
ARCALYST 2
ARCAPTA NEOHALER 14
argatroban 100 mg/ml 15
ARICEPT 10 MG, 5 MG 82
ARICEPT 23 MG 82
ARICEPT ODT 82
ARIMIDEX 33
ARISTOSPAN INTRA-
ARTICULAR 49
ARIXTRA 15
AROMASIN 33
ARRANON 32
ARTHROTEC 50 2
ARTHROTEC 75 2
ARZERRA 32
ASACOL 62
ASACOL HD 62
ASMANEX 120 METERED
DOSES 13
Index 2

ASMANEX 14 METERED
DOSES
ASMANEX 30 METERED
13
DOSES 110 MCG/INH
ASMANEX 30 METERED
13
DOSES 220 MCG/INH
ASMANEX 60 METERED
13
DOSES
ASMANEX 7 METERED
13
DOSES
ASPIRIN-CAFFEINE-
13
DIHYDROCODEINE 6
ASTAGRAF XL 0.5 MG, 1 MG 41
ASTAGRAF XL 5 MG 41
ASTELIN 74
ASTEPRO 74
ATACAND 28
ATACAND HCT 28
ATELVIA 58
atenolol & chlorthalidone 29
atenolol 100 mg, 25 mg, 50 mg43
ATGAM 41
ATIVAN 0.5 MG, 1 MG, 2 MG 12
ATIVAN 2 MG/ML 12
ATIVAN 4 MG/ML 12
atorvastatin calcium 26
atovaquone-proguanil hcl 30
ATOVAQUONE/PROGUANIL
HCL 30
ATRALIN 51
ATRIPLA 39
ATROPINE SULFATE 0.05
MG/ML 84
atropine sulfate 0.1 mg/ml 85
ATROVENT 74
ATROVENT HFA 13
AUBAGIO 82
AUGMENTIN 125-500 MG, 125-
875 MG
AUGMENTIN 31.25-125
81
MG/5ML
AUGMENTIN 62.5-250
81
MG/5ML 81
AUGMENTIN ES-600 80
AUGMENTIN XR 81
AURORA PEN NEEDLES
29GX12MM 68
AUTOPEN 69
AUVI-Q 88
AVALIDE 29
AVAPRO 28
AVASTIN 32
AVELOX 0.8-400 %,
MG/250ML 61
AVELOX 400 MG 61
AVELOX ABC PACK 61
AVINZA 120 MG 4
AVINZA 30 MG 4
AVINZA 45 MG 4
AVINZA 60 MG 4
AVINZA 75 MG 4
AVINZA 90 MG 4
AVODART 63
AVONEX 82
AVONEX PEN 82
AXERT 70
AXID 85
AXIRON 8
aygestin 81
azacitidine 32
AZACTAM 1 GM 9
AZACTAM 2 GM 9
AZACTAMIN ISO-OSMOTIC
DEXTROSE 9
azasan 41
AZASITE 77
azathioprine 50 mg 41
azathioprine sodium 41
azelastine hcl 74
azelastine hcl (ophth) 78
AZELEX 51
AZILECT 37
azithromycin 1 gm 68
azithromycin 100 mg/5ml, 200
mg/5ml 68
azithromycin 250 mg, 500 mg,
600 mg 68
azithromycin 500 mg 68
AZOPT 78
AZOR 29
aztreonam 1 gm 9
aztreonam 2 gm 9
AZULFIDINE 62
AZULFIDINE EN-TABS 62
bacitracin 500 unit/gm 77
bacitracin-poly-neomycin-hc 77
bacitracin-polymyxin b
(ophth) 77
baclofen 10 mg 73
baclofen 20 mg 73
BACTOCILL IN DEXTROSE 1
GM/50ML 81
BACTOCILL IN DEXTROSE 2
GM/50ML 81
BACTRIM 10
BACTRIM DS 10
BACTROBAN 51
BACTROBAN NASAL 74
balsalazide disodium 62
BANZEL 15
BARACLUDE 40
BD AUTOSHIELD 29G X 1/2" 69
BD AUTOSHIELD 29G X 3/16" 69
BD AUTOSHIELD 29G X 5/16" 69
BD AUTOSHIELD DUO 30G X
3/16"
BD INSULIN SYRINGE
69
ULTRAFINE/U-100/0.3ML/31G X
15/64"
BD INSULIN SYRINGE
69
ULTRAFINE/U-100/0.5ML/31G X
15/64"
BD INSULIN SYRINGE
69
ULTRAFINE/U-100/1ML/31G X
15/64" 69
BD PEN 69
BD PEN MINI 69
BD PEN
NEEDLE/ULTRAFINE/29G X
12.7MM
BD PEN
69
NEEDLE/ULTRAFINE/29GX1/2"
12.7MM 69
BECONASE AQ 74
benazepril &
hydrochlorothiazide 29
benazepril hcl 10 mg, 20 mg, 40
mg, 5 mg 27
BENICAR 28
BENICAR HCT 29
BENLYSTA 42
BENTYL 10 MG 85
BENTYL 10 MG/5ML 85
BENTYL 10 MG/ML 85
BENTYL 20 MG 85
BENZACLIN 51
BENZACLIN WITH PUMP 51
BENZAMYCIN 51
benzonatate 50
benzoyl peroxide-erythromycin 51
Index 3

enztropine mesylate 0.5 mg, 1
mg, 2 mg 36
benztropine mesylate 1 mg/ml 36
BEPREVE 78
BERINERT 64
BESIVANCE 77
BETADINE OPHTHALMIC
PREP 77
BETAGAN 76
betamethasone dipropionate
(topical)
betamethasone dipropionate
53
augmented 53
betamethasone sod phosphate &
acetate 49
betamethasone valerate 0.1 % 53
betamethasone valerate 0.12
% 53
BETAPACE 43
BETAPACE AF 43
BETASERON 82
betaxolol hcl 43
betaxolol hcl (ophth) 76
bethanechol chloride 87
BETIMOL 76
BETOPTIC-S 76
BEYAZ 47
BIAXIN 68
BIAXIN XL 68
BIAXIN XL PAC 68
bicalutamide 33
BICILLIN C-R 0.01-0.1-300000-
300000 %, UNIT/ML 81
BICILLIN C-R 0.01-0.1-300000-
900000 %, UNIT/2ML 81
BICILLIN L-A 80
BICNU 31
BIDIL 45
BILTRICIDE 9
BINOSTO 58
bisoprolol &
hydrochlorothiazide 29
bisoprolol fumarate 43
BIVIGAM 79
bleomycin sulfate 15 unit 33
bleomycin sulfate 30 unit 33
BLEPH-10 77
BLEPHAMIDE 77
blephamide s.o.p. 77
BONIVA 150 MG 58
BONIVA 3 MG/3ML 58
BOOSTRIX 84
BOSULIF 34
BOTOX 100 UNIT 75
BOTOX 200 UNIT 75
BREO ELLIPTA 14
BREVICON-28 47
BRILINTA 64
brimonidine tartrate 77
BROMDAY 78
bromfenac 78
bromocriptine mesylate 2.5
mg 36
bromocriptine mesylate 5 mg 36
BROVANA 14
budesonide (inhalation) 0.25
mg/2ml
budesonide (inhalation) 0.5
13
mg/2ml 13
budesonide 3 mg 49
bumetanide 0.25 mg/ml 57
bumetanide 0.5 mg, 1 mg, 2
mg 57
BUPHENYL 59
bupivacaine hcl 0.25 %, 0.5
%
bupivacaine hcl 0.5 %, 0.75
67
% 67
bupivacaine in dextrose 67
bupivacaine w/ epinephrine 0.1-
0.1-0.5-1 %, :200000, mg/ml,
0.1-0.5-1-1 %, :200000, mg/ml,
0.5-0.5-1 %, :200000, mg/ml,
0.5-1 %, :200000, 0.5-1-1 %,
:200000, mg 66
bupivacaine w/ epinephrine 0.1-
0.25-1 %, :200000, mg/ml, 0.1-
0.25-1-1 %, :200000, mg/ml,
0.25-1 %, :200000, 0.25-1-1 %,
:200000, mg/ml 67
BUPRENEX 8
buprenorphine hcl 0.3 mg/ml 8
buprenorphine hcl 2 mg, 8 mg 8
buprenorphine hcl-naloxone hcl
dihydrate
bupropion hcl (smoking
8
deterrent) 83
bupropion hcl 100 mg 18
bupropion hcl 150 mg 18
bupropion hcl 150 mg, 200
mg 18
bupropion hcl 300 mg 18
bupropion hcl 75 mg 18
buspirone hcl 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg 11
BUSULFEX 31
butalbital-acetaminophencaffeine
w/ codeine 30-40-50-300
mg
butalbital-acetaminophencaffeine
6
w/ codeine 30-40-50-325
mg 6
butalbital-aspirin-caffeine w/cod 6
butorphanol tartrate 1 mg/ml, 2
mg/ml 8
butorphanol tartrate 10 mg/ml 8
BUTRANS 10 MCG/HR 8
BUTRANS 15 MCG/HR 8
BUTRANS 20 MCG/HR 8
BUTRANS 5 MCG/HR 8
BYDUREON 21
BYETTA 10 MCG/0.04ML 21
BYETTA 5 MCG/0.02ML 21
BYSTOLIC 43
cabergoline 60
CADUET 45
cafergot 70
CALAN 44
CALAN SR 44
CALCIJEX 59
calcipotriene 52
calcitonin (salmon) 58
calcitriol 0.25 mcg, 0.5 mcg 59
calcitriol 1 mcg/ml 59
CALCITRIOL 3 MCG/GM 52
calcium acetate (phosphate
binder) 63
calcium chloride (dihydrate) 71
CAMBIA 70
CAMPATH 32
CAMPRAL 82
CAMPTOSAR 100 MG/5ML, 40
MG/2ML 36
CAMPTOSAR 300 MG/15ML 36
CANASA 62
CANCIDAS 50 MG 24
CANCIDAS 70 MG 24
candesartan cilexetil 28
candesartan cilexetilhydrochlorothiazide
29
CANTIL 85
CAPASTAT SULFATE 30
Index 4

CAPEX 53
capital/codeine 6
CAPRELSA 34
captopril 100 mg, 12.5 mg, 25
mg, 50 mg 27
captopril/hydrochlorothiazide 29
CARAC 52
CARAFATE 86
carbamazepine 100 mg 15
carbamazepine 100 mg, 200 mg,
300 mg 15
carbamazepine 100 mg/5ml 15
carbamazepine 200 mg 16
carbamazepine 200 mg, 400
mg 16
CARBATROL 16
carbidopa-levodopa 36
CARBIDOPA/LEVODOPA/ENTA
CAPONE 36
carbinoxamine maleate 4 mg 25
carbinoxamine maleate 4
mg/5ml 25
CARBOCAINE 1 % 67
CARBOCAINE 1.5 %, 2 % 67
carboplatin 150 mg/15ml, 600
mg/60ml 31
carboplatin 450 mg/45ml 31
carboplatin 50 mg/5ml 31
CARDENE I.V. 44
CARDENE SR 30 MG, 60 MG 44
CARDIZEM 44
CARDIZEM CD 44
CARDIZEM LA 120 MG 44
CARDIZEM LA 180 MG, 240 MG,
300 MG, 360 MG, 420 MG 44
CARDURA 28
CARDURA XL 63
CAREONE UNIFINE PENTIPS
29GX12MM 69
CARIMUNE NANOFILTERED 80
carisoprodol 250 mg, 350 mg 73
carisoprodol w/ aspirin 74
carisoprodol w/ aspirin &
codeine 74
carmol-hc 53
CARNITOR 1 GM/10ML 59
CARNITOR 200 MG/ML 59
CARNITOR 330 MG 59
CARNITOR SF 59
carteolol hcl (ophth) 76
carvedilol 12.5 mg 42
carvedilol 25 mg 42
carvedilol 3.125 mg 42
carvedilol 6.25 mg 42
CASODEX 33
CATAFLAM 3
CATAPRES 28
CATAPRES-TTS-1 28
CATAPRES-TTS-2 28
CATAPRES-TTS-3 28
CAYSTON 9
CEDAX 180 MG/5ML 46
CEDAX 400 MG 46
CEDAX 90 MG/5ML 46
CEENU 10 MG 31
CEENU 100 MG, 40 MG 31
cefaclor 125 mg/5ml, 250
mg/5ml, 375 mg/5ml 45
cefaclor 250 mg, 500 mg 45
cefaclor er 45
cefadroxil 45
cefazolin sodium 1 gm 45
cefazolin sodium 1 gm, 10 gm,
500 mg 45
cefazolin sodium 1-5 %, gm 45
cefazolin sodium 20 gm 45
CEFAZOLIN
SODIUM/DEXTROSE 45
cefdinir 46
CEFEPIME 47
cefepime hcl 47
cefotaxime sodium 1 gm, 10
gm, 2 gm
cefotaxime sodium 1 gm, 2
46
gm 46
cefotaxime sodium 500 mg 46
cefotetan 45
CEFOTETAN/DEXTROSE 45
cefoxitin sodium 1 gm, 2 gm 46
CEFOXITIN SODIUM 1-4 %,
GM, 2-2.2 %, GM 46
cefoxitin sodium 10 gm 46
cefpodoxime proxetil 46
cefprozil 46
ceftazidime 1 gm, 2 gm 46
ceftazidime 1 gm, 2 gm, 500
mg 46
ceftazidime 6 gm 46
CEFTAZIDIME/DEXTROSE 46
CEFTIBUTEN 180 MG/5ML 46
CEFTIBUTEN 400 MG 46
CEFTIN 46
ceftriaxone in iso-osmotic
dextrose 20 mg/ml
ceftriaxone in iso-osmotic
46
dextrose 40 mg/ml 46
ceftriaxone sodium 1 gm 46
ceftriaxone sodium 10 gm 46
ceftriaxone sodium 2 gm 46
ceftriaxone sodium 250 mg 46
ceftriaxone sodium 500 mg 46
CEFTRIAXONE/DEXTROSE 1-
3.74 %, GM 46
CEFTRIAXONE/DEXTROSE 2-
2.22 %, GM 46
cefuroxime axetil 46
cefuroxime sodium 1.5 gm, 7.5
gm 46
cefuroxime sodium 750 mg 46
CEFUROXIME/DEXTROSE 46
CELEBREX 3
CELESTONE 49
CELESTONE-SOLUSPAN 49
CELEXA 10 MG 18
CELEXA 20 MG 18
CELEXA 40 MG 18
CELLCEPT 200 MG/ML 41
CELLCEPT 250 MG 41
CELLCEPT 500 MG 41
CELLCEPT INTRAVENOUS 41
CELONTIN 17
CENESTIN 61
cephalexin 45
CEREBYX 100 MG PE/2ML 17
CEREBYX 500 MG PE/10ML 17
CEREZYME 200 UNIT 64
CEREZYME 400 UNIT 64
cerubidine 33
CERVARIX 87
CESAMET 24
cetirizine hcl 1 mg/ml, 5
mg/5ml 25
cevimeline hcl 73
CHANTIX 83
CHANTIX CONTINUING
MONTHPAK 83
CHANTIX STARTING MONTH
PAK 83
CHEMET 23
Index 5

chenodal 62
chloramphenicol sodium
succinate 10
chlordiazepoxide/amitriptyline 82
chlorhexidine gluconate (mouththroat)
73
chloroprocaine hcl 67
chloroquine phosphate 250 mg,
500 mg 30
chlorothiazide 57
chlorothiazide sodium 57
chlorpromazine hcl 10 mg, 100
mg, 200 mg, 25 mg, 50 mg 38
chlorpromazine hcl 25 mg/ml 38
chlorpropamide 22
chlorthalidone 25 mg, 50 mg 57
chlorzoxazone 500 mg 73
cholestyramine 4 gm 26
cholestyramine 4 gm/dose 26
cholestyramine light 26
choline fenofibrate 26
chorionic gonadotropin 10000
unit 58
CIALIS 45
ciclopirox 52
ciclopirox olamine 0.77 % 52
cidofovir 40
cilostazol 64
CILOXAN 77
cimetidine 200 mg 85
cimetidine 300 mg, 400 mg, 800
mg 85
cimetidine hcl 85
CIMZIA 62
CIMZIA STARTER KIT 62
CINRYZE 64
CIPRO 250 MG, 500 MG 61
CIPRO 5 GM/100ML, 500
MG/5ML 61
CIPRO HC 79
CIPRO I.V.-IN D5W 5-200 %,
MG/100ML
CIPRO I.V.-IN D5W 5-400 %,
61
MG/200ML 61
CIPRO XR 61
CIPRODEX 79
ciprofloxacin 200 mg/20ml, 400
mg/40ml 61
ciprofloxacin hcl (ophth) 77
ciprofloxacin hcl 100 mg, 250 mg,
500 mg, 750 mg 61
ciprofloxacin in d5w 5-200 %,
mg/100ml 61
ciprofloxacin in d5w 5-400 %,
mg/200ml 61
ciprofloxacin-ciprofloxacin hcl61
cisplatin 100 mg/100ml, 200
mg/200ml, 50 mg/50ml
citalopram hydrobromide 10
31
mg
citalopram hydrobromide 10
18
mg/5ml
citalopram hydrobromide 20
18
mg
citalopram hydrobromide 40
19
mg 19
cladribine 32
CLAFORAN 1 GM, 10 GM, 2
GM 46
CLAFORAN 1 GM, 2 GM 46
CLAFORAN 500 MG 46
CLAFORAN/D5W 46
CLARINEX 25
CLARINEX REDITABS 25
CLARINEX-D 12 HOUR 50
CLARINEX-D 24 HOUR 50
clarithromycin 125 mg/5ml, 250
mg/5ml
clarithromycin 250 mg, 500
68
mg 68
clarithromycin 500 mg 68
clemastine fumarate 0.67
mg/5ml 25
clemastine fumarate 2.68 mg 25
CLEOCIN 10
CLEOCIN IN D5W 10
cleocin pediatric granules 10
CLEOCIN PHOSPHATE 150
MG/ML, 600 MG/4ML 10
CLEOCIN PHOSPHATE 300
MG/2ML, 9 GM/60ML 10
CLEOCIN PHOSPHATE 600
MG/4ML, 900 MG/6ML 10
CLEOCIN-T 51
CLIMARA 61
CLIMARA PRO 60
CLINDAGEL 51
clindamycin hcl 150 mg, 300
mg, 75 mg
clindamycin palmitate
10
hydrochloride
clindamycin phosphate
10
(topical)
clindamycin phosphate 150
51
mg/ml 11
clindamycin phosphate 150
mg/ml, 300 mg/2ml, 9000
mg/60ml
clindamycin phosphate 600
10
mg/4ml, 900 mg/6ml 10
clindamycin phosphate in d5w 10
clindamycin phosphate vaginal 88
clindamycin phosphate-benzoyl
peroxide 51
clindamycin phosphate-benzoyl
peroxide (refrigerate)
CLINIMIX 2.75%/DEXTROSE
51
5%
CLINIMIX 4.25%/DEXTROSE
75
10%
CLINIMIX 4.25%/DEXTROSE
75
20%
CLINIMIX 4.25%/DEXTROSE
75
25%
CLINIMIX 4.25%/DEXTROSE
75
5%
CLINIMIX 5%/DEXTROSE
75
15%
CLINIMIX 5%/DEXTROSE
75
20%
CLINIMIX 5%/DEXTROSE
75
25% 75
CLINIMIX E 2.75%/DEXTROSE
10% 75
CLINIMIX E 2.75%/DEXTROSE
5% 75
CLINIMIX E 4.25%/DEXTROSE
25% 75
CLINIMIX E 4.25%/DEXTROSE
5%
CLINIMIX E 5%/DEXTROSE
75
15%
CLINIMIX E 5%/DEXTROSE
75
20%
CLINIMIX E 5%/DEXTROSE
76
25% 76
CLINORIL 3
clobetasol propionate 0.05 % 53
clobetasol propionate emollient
base 53
CLOBEX 53
CLODERM 53
CLODERM PUMP 53
CLOLAR 32
clomipramine hcl 25 mg, 50 mg,
75 mg 20
clonazepam 0.125 mg, 0.25 mg,
0.5 mg, 1 mg, 2 mg 15
clonazepam 0.5 mg 15
clonazepam 1 mg 15
clonazepam 2 mg 15
Index 6

clonidine hcl (analgesia) 100
mcg/ml
clonidine hcl (analgesia) 500
4
mcg/ml 4
clonidine hcl 0.1 mg, 0.2 mg, 0.3
mg
clonidine hcl 0.1 mg/24hr, 0.2
28
mg/24hr, 0.3 mg/24hr 28
clopidogrel bisulfate 300 mg 64
clopidogrel bisulfate 75 mg 64
clorazepate dipotassium 12
clorpres 29
clotrimazole (topical) 52
clotrimazole 10 mg 73
clozapine 38
CLOZAPINE ODT 38
CLOZARIL 38
COARTEM 30
cocet 6
cocet plus 6
codeine sulfate 4
COGENTIN 36
COLAZAL 62
colchicine w/ probenecid 64
COLCRYS 64
COLESTID 26
COLESTID FLAVORED 26
colestipol hcl 26
colistimethate sodium 150 mg 9
COLY-MYCIN M 9
COLY-MYCIN S 79
COLYTE-FLAVOR PACKS 2.82-
5.53-6.36-21.5-227.1 GM 66
COLYTE-FLAVOR PACKS 2.98-
5.84-6.72-22.72-240 GM 66
COMBIGAN 76
COMBIPATCH 60
COMBIVENT 14
COMBIVENT RESPIMAT 14
COMBIVIR 39
COMETRIQ 34
COMETRIQ , 20 MG 34
COMPLERA 39
COMTAN 36
COMVAX 87
CONCERTA 1
CONDYLOX 55
COPAXONE 82
COPEGUS 40
CORDARONE 13
CORDRAN 53
CORDRAN SP 53
CORDRAN TAPE 53
COREG 12.5 MG 42
COREG 25 MG 42
COREG 3.125 MG 42
COREG 6.25 MG 42
COREG CR 10 MG 42
COREG CR 20 MG 43
COREG CR 40 MG 43
COREG CR 80 MG 43
CORGARD 43
CORTEF 49
CORTENEMA 9
CORTIFOAM 9
cortisone acetate 25 mg 49
CORTISPORIN 0.1-1-3.5-
10000 %, MG/ML, UNIT/ML 79
CORTISPORIN 0.5-0.5-10000
%, UNIT/GM 51
CORTISPORIN 0.5-1-400-5000
%, UNIT/GM 51
CORTISPORIN-TC 79
CORZIDE 29
COSMEGEN 33
COSOPT 76
COSOPT PF 76
COUMADIN 1 MG, 10 MG, 2
MG, 2.5 MG, 3 MG, 4 MG, 5
MG, 6 MG, 7.5 MG 15
COUMADIN 5 MG 15
COVERA-HS 44
COZAAR 28
CREON 56
CRESTOR 26
CRINONE 88
CRIXIVAN 39
cromolyn sodium
(mastocytosis) 62
cromolyn sodium (ophth) 78
cromolyn sodium 20 mg/2ml 13
CUBICIN 10
CUTIVATE 53
CUVPOSA 85
CYCLESSA 47
cyclobenzaprine hcl 10 mg, 5
mg, 7.5 mg 73
cyclobenzaprine hcl 15 mg, 30
mg 73
cyclogyl 76
cyclopentolate hcl 1 %, 2 % 76
cyclophosphamide 1 gm, 500
mg 31
cyclophosphamide 2 gm 31
cyclophosphamide 25 mg, 50
mg 31
cycloserine 30
cyclosporine 100 mg, 25 mg 41
cyclosporine 50 mg/ml 41
cyclosporine modified 41
cyclosporine modified (for
microemulsion) 41
CYKLOKAPRON 65
CYMBALTA 19
cyproheptadine hcl 2 mg/5ml 25
cyproheptadine hcl 4 mg 25
CYSTADANE 59
CYSTAGON 63
CYSTARAN 78
CYTARABINE 1 GM 32
cytarabine 1 gm, 500 mg 32
cytarabine 100 mg 32
cytarabine 100 mg/ml 32
cytarabine 20 mg/ml 32
CYTOMEL 84
CYTOTEC 86
CYTOVENE 40
D.H.E. 45 70
dacarbazine 200 mg 34
DACOGEN 32
dactinomycin 33
DALIRESP 13
danazol 100 mg, 200 mg, 50 mg8
DANTRIUM 74
dantrolene sodium 100 mg, 25
mg, 50 mg 74
dapsone 100 mg, 25 mg 10
DAPTACEL 84
DARAPRIM 30
daunorubicin hcl 33
DAUNOXOME 34
DAYPRO 3
DAYTRANA 1
DDAVP 0.01 % 60
DDAVP 0.1 MG, 0.2 MG 60
Index 7

DDAVP 4 MCG/ML 60
DECAVAC 84
decitabine 32
deferoxamine mesylate 23
DELATESTRYL 8
DELESTROGEN 61
DELZICOL 62
DEMADEX 57
demeclocycline hcl 150 mg, 300
mg 83
DEMEROL 4
DEMSER 28
DENAVIR 53
DEPACON 17
DEPAKENE 17
DEPAKOTE 17
DEPAKOTE ER 17
DEPAKOTE SPRINKLES 17
DEPEN TITRATABS 41
DEPO-ESTRADIOL 61
DEPO-MEDROL 49
DEPO-PROVERA 33
DEPO-PROVERA
CONTRACEPTIVE 49
DEPO-SUBQ PROVERA 104 49
depo-testosterone 8
DERMA-SMOOTHE/FS BODY 53
DERMA-SMOOTHE/FS BODY
OIL
DERMA-SMOOTHE/FS
53
SCALP 53
DERMA-SMOOTHE/FS SCALP
OIL 53
DERMATOP 53
DERMOTIC 79
DESFERAL 23
desipramine hcl 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg 20
desloratadine 25
desmopressin acetate 0.1 mg,
0.2 mg
desmopressin acetate 4
60
mcg/ml
desmopressin acetate
60
refrigerated 60
desmopressin acetate spray 60
desmopressin acetate spray
refrigerated 60
DESOGEN 47
desogestrel & ethinyl estradiol 47
desogestrel-ethinyl estradiol
(biphasic)
desogestrel-ethinyl estradiol
47
(triphasic) 47
DESONATE 53
desonide 0.05 % 54
DESOWEN 54
desowen 54
desoximetasone 0.05 % 54
DESOXIMETASONE 0.05 % 54
desoximetasone 0.05 %, 0.25
% 54
desoximetasone 0.25 % 54
DESVENLAFAXINE ER 19
DETROL 87
DETROL LA 87
dexamethasone 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2 mg, 4 mg,
6 mg 49
dexamethasone 0.5 mg/5ml 49
dexamethasone intensol 49
dexamethasone sodium
phosphate (ophth)
dexamethasone sodium
78
phosphate 10 mg/ml, 4
mg/ml 49
DEXEDRINE 1
DEXILANT 86
dexmethylphenidate hcl 1
dexpak 10 day 49
dexpak 13 day 49
dexpak 6 day 49
dexrazoxane 35
dextroamphetamine sulfate 10
mg, 15 mg, 5 mg 1
dextroamphetamine sulfate 10
mg, 5 mg
dextroamphetamine sulfate 5
1
mg/5ml
DEXTROSE 10%/NACL
1
0.45%
DEXTROSE
71
5%/ELECTROLYTE #48
VIAFLEX 71
dextrose 10 %, 50 %, 70 % 75
DEXTROSE 10%/NACL
0.2% 71
dextrose 5 % 75
DEXTROSE 5%/NACL
0.225% 71
DEXTROSE 5%/NACL 0.3% 71
dextrose in lactated ringers 71
dextrose w/ sodium chloride 0.2-5
%, 0.33-5 %, 0.45-2.5 %, 0.45-5
% 71
dextrose w/ sodium chloride 0.9-5
% 71
DIABETA 22
DIAMOX 56
DIANEAL PD-2/1.5%
DEXTROSE
DIANEAL PD-2/2.5%
42
DEXTROSE
DIANEAL PD-2/4.25%
42
DEXTROSE 42
DIASTAT ACUDIAL 15
DIASTAT PEDIATRIC 15
diazepam 1 mg/ml 12
diazepam 10 mg, 2 mg, 5 mg 12
DIAZEPAM 10 MG, 2.5 MG, 20
MG 15
diazepam 5 mg/ml 12
diazepam intensol 12
DIBENZYLINE 28
diclofenac potassium 3
diclofenac sodium (ophth) 78
diclofenac sodium 100 mg 3
diclofenac sodium 25 mg, 50 mg,
75 mg 3
diclofenac w/ misoprostol 3
dicloxacillin sodium 81
dicyclomine hcl 10 mg 85
dicyclomine hcl 10 mg/5ml 85
dicyclomine hcl 20 mg 85
didanosine 39
DIFFERIN 51
DIFICID 68
diflorasone diacetate 0.05 % 54
DIFLUCAN 24
diflunisal 500 mg 4
digoxin 0.05 mg/ml 45
digoxin 0.125 mg, 0.25 mg 45
digoxin 0.25 mg/ml 45
dihydroergotamine mesylate 1
mg/ml
DIHYDROERGOTAMINE
70
MESYLATE 4 MG/ML 70
dilacor xr 44
dilantin 100 mg, 30 mg 17
DILANTIN 125 MG/5ML 17
dilantin infatabs 17
DILATRATE SR 11
Index 8

DILAUDID 1 MG/ML 4
DILAUDID 1 MG/ML, 2 MG/ML, 4
MG/ML 4
DILAUDID 2 MG, 4 MG, 8 MG 4
DILAUDID-HP 10 MG/ML 4
DILAUDID-HP 250 MG 4
diltiazem hcl 100 mg 44
diltiazem hcl 120 mg, 180 mg,
240 mg 44
diltiazem hcl 120 mg, 30 mg, 60
mg, 90 mg 44
diltiazem hcl 120 mg, 60 mg, 90
mg
diltiazem hcl 125 mg/25ml, 25
44
mg/5ml, 50 mg/10ml 44
diltiazem hcl coated beads 44
diltiazem hcl extended release
beads 44
dimenhydrinate 50 mg/ml 24
DIOVAN 28
DIOVAN HCT 29
DIPENTUM 62
diphenhydramine hcl 12.5
mg/5ml 25
diphenhydramine hcl 50 mg 25
diphenhydramine hcl 50 mg/ml 25
diphenoxylate w/ atropine 23
diphenoxylate/atropine 23
DIPHTHERIA/TETANUS
TOXOID PEDIATRIC
DIPHTHERIA/TETANUS
84
TOXOIDS ADSORBED
PEDIATRIC 84
DIPROLENE 54
DIPROLENE AF 54
dipyridamole 25 mg, 50 mg, 75
mg 64
disopyramide phosphate 100 mg,
150 mg 12
disulfiram 250 mg, 500 mg 82
DITROPAN XL 87
DIURIL 57
divalproex sodium 17
DIVIGEL 61
dobutamine hcl 88
dobutamine in d5w 88
DOBUTAMINE/DEXTROSE
5% 89
DOCEFREZ 35
DOCETAXEL 140 MG/7ML, 20
MG/0.5ML, 80 MG/2ML 35
DOCETAXEL 160 MG/16ML, 20
MG/2ML, 80 MG/8ML 35
DOCETAXEL 20 MG/ML, 80
MG/4ML 35
DOLOPHINE 5
DOLOPHINE HCL 5
donepezil hydrochloride 82
dopamine hcl 89
dopamine in d5w 89
DORAL 66
DORIBAX 250 MG 10
DORIBAX 500 MG 10
DORYX 83
dorzolamide hcl 78
dorzolamide hcl-timolol
maleate 76
DOVONEX 52
DOVONEX SCALP 52
doxazosin mesylate 28
doxepin hcl 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75
mg 20
doxepin hcl 10 mg/ml 20
DOXIL 34
doxorubicin hcl 10 mg 34
doxorubicin hcl 2 mg/ml 34
doxorubicin hcl 50 mg 34
doxorubicin hcl liposomal 34
doxycycline (monohydrate) 83
doxycycline hyclate 100 mg 83
doxycycline hyclate 100 mg,
150 mg, 75 mg 83
doxycycline hyclate 100 mg, 20
mg 83
doxycycline hyclate 100 mg, 50
mg 83
DRISDOL 50000 UNIT 89
dronabinol 24
drospirenone-ethinyl
estradiol 47
DROXIA 65
DRUG MART UNIFINE
PENTIPS29G X 12MM 69
DUAC 51
DUANE READE UNIFINE
PENTIPS 29G X 12MM 69
DUETACT 20
DUEXIS 3
DULERA 14
DUONEB 14
DURACLON 100 MCG/ML 4
DURACLON 500 MCG/ML 4
DURAGESIC 5
DUREZOL 78
DUTOPROL 29
DYAZIDE 57
DYMISTA 74
dynacin 84
DYNACIRC CR 44
DYRENIUM 57
e.e.s. 400 68
E.E.S. GRANULES 68
EASY TOUCH 32GX5MM 69
EASY TOUCH 32GX6MM 69
EASY TOUCH PEN NEEDLES
29GX1/2" 69
EC-NAPROSYN 3
econazole nitrate 52
EDARBI 28
EDARBYCLOR 29
EDECRIN 57
EDLUAR 66
EDURANT 39
EFFEXOR XR 150 MG 19
EFFEXOR XR 37.5 MG 19
EFFEXOR XR 75 MG 19
EFFIENT 64
EFUDEX 52
EGRIFTA 58
ELAPRASE 59
ELDEPRYL 37
electrolyte-m in dextrose 71
ELELYSO 64
ELESTAT 78
ELESTRIN 61
ELIDEL 55
ELIGARD 33
elimite 56
eliphos 63
ELIQUIS 15
ELITEK 35
elixophyllin 14
ELLA 48
ELLENCE 34
ELMIRON 63
ELOCON 54
ELOXATIN 100 MG/20ML, 50
MG/10ML 31
ELOXATIN 200 MG/40ML 31
Index 9

ELSPAR 34
EMADINE 78
EMCYT 33
EMEND , 125 MG, 80 MG 24
EMEND 150 MG 24
EMEND 40 MG 24
EMLA 56
EMSAM 18
EMTRIVA 39
ENABLEX 87
enalapril maleate &
hydrochlorothiazide 29
enalapril maleate 10 mg 27
enalapril maleate 2.5 mg 27
enalapril maleate 20 mg 27
enalapril maleate 5 mg 27
enalaprilat 27
ENBREL 4
ENBREL SURECLICK 4
ENDOMETRIN 88
ENGERIX-B 87
ENJUVIA 0.3 MG, 0.45 MG, 0.9
MG, 1.25 MG 61
ENJUVIA 0.625 MG 61
enoxaparin sodium 15
entacapone 36
ENTOCORT EC 49
EPIDUO 51
epifoam 54
epinastine hcl (ophth) 78
EPINEPHRINE 0.15 MG/0.15ML,
0.3 MG/0.3ML 88
epinephrine hcl 14
EPIPEN 2-PAK 88
EPIPEN-JR 2-PAK 88
epirubicin hcl 200 mg/100ml, 50
mg/25ml 34
EPIRUBICIN HCL 50 MG 34
EPIVIR 10 MG/ML 39
EPIVIR 150 MG, 300 MG 39
EPIVIR HBV 39
eplerenone 30
EPOGEN 65
epoprostenol sodium 45
eprosartan mesylate 28
EPZICOM 39
EQUETRO 37
ERAXIS 24
ERBITUX 32
ergocalciferol 50000 unit 89
ERIVEDGE 32
ERTACZO 52
ery-tab 250 mg 68
ery-tab 333 mg 68
ery-tab 500 mg 68
ERYPED 200 68
ERYPED 400 68
ERYTHROCIN
LACTOBIONATE 68
erythrocin lactobionate 68
erythrocin stearate 68
erythromycin (acne aid) 51
erythromycin (ophth) 77
erythromycin 2 % 51
erythromycin 250 mg 68
erythromycin base 250 mg 68
erythromycin base 500 mg 68
erythromycin ethylsuccinate
400 mg 68
erythromycin lactobionate 68
escitalopram oxalate 19
estrace 61
estradiol & norethindrone
acetate 60
estradiol 0.025 mg/24hr, 0.05
mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr 61
estradiol 0.5 mg, 1 mg, 2 mg 61
estradiol valerate 10 mg/ml, 20
mg/ml, 40 mg/ml 61
ESTRING 88
estropipate 0.75 mg, 1.5 mg, 3
mg 61
ESTROSTEP FE 47
ethambutol hcl 100 mg, 400
mg 30
ethosuximide 250 mg 17
ethosuximide 250 mg/5ml 17
ethynodiol diacet & eth
estrad 47
ETHYOL 35
etodolac 200 mg, 300 mg 3
etodolac 400 mg, 500 mg 3
etodolac 400 mg, 500 mg, 600
mg 3
ETOPOPHOS 35
etoposide 1 gm/50ml, 20
mg/ml 35
etoposide 500 mg/25ml 35
EURAX 56
EVAMIST 61
EVISTA 59
EVOCLIN 51
EVOXAC 73
EXALGO 5
EXEL INSULIN PEN
NEEDLES29GX1/2" 12MM 69
EXELDERM 52
EXELON 1.5 MG, 3 MG, 4.5 MG,
6 MG
EXELON 13.3 MG/24HR, 4.6
82
MG/24HR, 9.5 MG/24HR 82
EXELON 2 MG/ML 82
exemestane 33
EXFORGE 29
EXFORGE HCT 29
EXJADE 125 MG 23
EXJADE 250 MG, 500 MG 23
EXTAVIA 82
EXTINA 52
EYLEA 76
FABIOR 51
FABRAZYME 35 MG 59
FABRAZYME 5 MG 59
FACTIVE 61
famciclovir 41
famotidine 10 mg/ml 85
famotidine 20 mg 85
famotidine 40 mg 85
famotidine 40 mg/5ml 85
famotidine premixed 85
FAMVIR 41
FANAPT 37
FANAPT TITRATION PACK 37
FARESTON 33
FASLODEX 33
fat emulsion 75
FAZACLO 38
felbamate 17
FELBATOL 17
FELDENE 3
felodipine 44
FEMARA 33
FEMCON FE 47
FEMHRT 1/5 60
Index 10

FEMHRT LOW DOSE 60
FEMRING 88
FEMTRACE 61
fenofibrate 26
fenofibrate micronized 26
fenofibric acid 26
FENOGLIDE 26
fenoprofen calcium 600 mg 3
fentanyl 5
fentanyl citrate 0.05 mg/ml 5
fentanyl citrate 1200 mcg, 1600
mcg, 400 mcg, 600 mcg 5
fentanyl citrate 200 mcg 5
fentanyl citrate 800 mcg 5
FENTORA 100 MCG, 200 MCG 5
FENTORA 400 MCG, 600 MCG,
800 MCG 5
FERRIPROX 23
fexmid 73
FIBRICOR 26
FINACEA 56
finasteride 5 mg 63
FIORICET/CODEINE 30-40-50-
300 MG 6
FIORICET/CODEINE 30-40-50-
325 MG 6
FIORINAL/CODEINE #3 7
FIRAZYR 64
FIRMAGON 120 MG 33
FIRMAGON 80 MG 33
FLAGYL 250 MG 9
FLAGYL 375 MG 9
FLAGYL 500 MG 9
FLAGYL ER 9
FLAREX 78
flavoxate hcl 87
FLEBOGAMMA 80
FLEBOGAMMA DIF 80
flecainide acetate 100 mg 12
flecainide acetate 150 mg 12
flecainide acetate 50 mg 12
FLEXERIL 73
FLO-PRED 49
FLOLAN 45
FLOMAX 63
FLONASE 74
FLOVENT DISKUS 100
MCG/BLIST 13
FLOVENT DISKUS 250
MCG/BLIST
FLOVENT DISKUS 50
13
MCG/BLIST 13
FLOVENT HFA 110 MCG/ACT,
220 MCG/ACT
FLOVENT HFA 44
13
MCG/ACT
FLUARIX QUADRIVALENT
13
2013-2014
fluconazole 10 mg/ml, 40
87
mg/ml 25
fluconazole 100 mg, 150 mg,
200 mg, 50 mg 25
fluconazole in dextrose 24
fluconazole in nacl 0.9-100 %,
mg/50ml, 0.9-200 %,
mg/100ml 24
fluconazole in nacl 0.9-400 %,
mg/200ml 25
flucytosine 250 mg 24
flucytosine 500 mg 24
FLUDARA 32
fludarabine phosphate 50 mg32
fludarabine phosphate 50
mg/2ml
fludrocortisone acetate 0.1
32
mg 50
FLUMADINE 41
flumazenil 23
FLUMIST QUADRIVALENT 87
flunisolide 74
flunisolide (nasal) 74
fluocinolone acetonide (otic) 79
fluocinolone acetonide 0.01
% 54
fluocinolone acetonide 0.01 %,
0.025 % 54
fluocinolone acetonide 0.025
% 54
fluocinonide 0.05 % 54
fluocinonide emulsified base 54
fluorometholone (ophth) 78
FLUOROPLEX 52
fluorouracil (topical) 52
fluorouracil 1 gm/20ml 32
fluorouracil 2.5 gm/50ml, 5
gm/100ml, 500 mg/10ml 32
fluoxetine hcl 10 mg, 20 mg 19
fluoxetine hcl 10 mg, 20 mg, 40
mg 19
fluoxetine hcl 20 mg/5ml 19
FLUOXETINE HCL 60 MG 19
fluoxetine hcl 90 mg 19
fluphenazine decanoate 25
mg/ml
fluphenazine hcl 1 mg, 10 mg,
38
2.5 mg, 5 mg 38
fluphenazine hcl 2.5 mg/5ml 38
fluphenazine hcl 2.5 mg/ml 38
fluphenazine hcl 5 mg/ml 38
flurbiprofen 100 mg, 50 mg 3
flurbiprofen sodium 79
flutamide 33
fluticasone propionate (nasal) 74
fluticasone propionate 0.005 % 54
fluticasone propionate 0.05 % 54
fluvastatin sodium 26
fluvoxamine maleate 19
FLUZONE QUADRIVALENT
2013-2014 87
FML 78
FML FORTE 78
FML LIQUIFILM 78
FOCALIN 1
FOCALIN XR 1
FOLOTYN 32
fomepizole 23
fondaparinux sodium 15
FORADIL AEROLIZER 14
FORFIVO XL 18
FORTAMET 1000 MG 21
FORTAMET 500 MG 21
FORTAZ 1 GM, 2 GM 47
FORTAZ 1 GM, 2 GM, 500 MG47
FORTAZ 1-5 %, GM/50ML, 2-5
%, GM/50ML 47
FORTAZ 6 GM 47
FORTEO 58
FORTESTA 8
FORTICAL 58
FOSAMAX 58
FOSAMAX PLUS D 58
foscarnet sodium 40
fosinopril sodium 27
fosinopril sodium &
hydrochlorothiazide
fosphenytoin sodium 100 mg
29
pe/2ml
fosphenytoin sodium 500 mg
17
pe/10ml 17
FOSRENOL 63
FRAGMIN 15
Index 11

FREAMINE HBC 6.9% 76
FREAMINE III 76
FREAMINE III 3% 76
FROVA 70
FULYZAQ 23
FURADANTIN 86
furosemide 10 mg/ml 57
furosemide 10 mg/ml, 8 mg/ml 57
furosemide 20 mg, 40 mg, 80
mg 57
FUSILEV 35
FUZEON 39
gabapentin 100 mg, 300 mg, 400
mg 16
gabapentin 250 mg/5ml 16
gabapentin 600 mg, 800 mg 16
GABITRIL 17
galantamine hydrobromide 82
GAMASTAN S/D 80
GAMMAGARD LIQUID 80
GAMMAGARD S/D 10 GM, 5
GM 80
GAMMAGARD S/D 2.5 GM 80
GAMMAGARD S/D IGA LESS
THAN 1MCG/ML 80
GAMMAKED 80
GAMMAPLEX 80
GAMUNEX 80
GAMUNEX-C 80
ganciclovir sodium 40
garamycin 77
GARDASIL 87
GASTROCROM 62
gatifloxacin (ophth) 77
GATTEX 63
gauze pads 2"x2" 68
GELNIQUE 87
GEMCITABINE 32
gemcitabine hcl 1 gm, 200 mg 32
gemcitabine hcl 2 gm 32
gemfibrozil 600 mg 26
GEMZAR 32
GENERESS FE 47
GENOTROPIN 12 MG 58
GENOTROPIN 5 MG 58
GENOTROPIN MINIQUICK 0.2
MG, 0.4 MG, 0.6 MG 58
GENOTROPIN MINIQUICK 0.8
MG, 1 MG, 1.2 MG, 1.4 MG,
1.6 MG, 1.8 MG, 2 MG 58
gentamicin in saline 0.8-0.9 %,
mg/ml
gentamicin in saline 0.9-1 %,
2
mg/ml, 0.9-1.2 %, mg/ml, 0.9-
1.6 %, mg/ml 2
gentamicin sulfate (ophth) 77
gentamicin sulfate (topical) 51
gentamicin sulfate 0.1 % 51
gentamicin sulfate 10 mg/ml 2
gentamicin sulfate 10 mg/ml, 40
mg/ml 2
gentamicin sulfate/0.9% sodium
chloride 2
GEODON 20 MG 37
GEODON 20 MG, 40 MG, 60
MG, 80 MG 37
GIAZO 62
GILENYA 83
GILOTRIF 34
GLASSIA 83
GLEEVEC 34
glimepiride 22
glipizide 10 mg, 2.5 mg, 5
mg 22
glipizide 10 mg, 5 mg 22
glipizide-metformin hcl 2.5-250
mg 20
glipizide-metformin hcl 2.5-500
mg, 5-500 mg 20
GLOBAL EASE INJECT PEN
NEEDLES 29GX12MM 69
GLUCAGEN 21
GLUCAGEN HYPOKIT 21
glucagon emergency kit 21
GLUCOPHAGE 1000 MG 21
GLUCOPHAGE 500 MG 21
GLUCOPHAGE 850 MG 21
GLUCOPHAGE XR 500 MG 21
GLUCOPHAGE XR 750 MG 21
GLUCOTROL 22
GLUCOTROL XL 22
GLUCOVANCE 20
GLUMETZA 1000 MG 21
GLUMETZA 500 MG 21
glyburide 1.25 mg, 2.5 mg, 5
mg 23
glyburide micronized 22
glyburide-metformin 20
glycopyrrolate 0.2 mg/ml, 0.4
mg/2ml, 1 mg/5ml, 4 mg/20ml 85
glycopyrrolate 1 mg, 2 mg 85
GLYNASE 23
GLYSET 20
GOLYTELY 66
GRALISE 83
GRALISE STARTER 83
granisetron hcl 0.1 mg/ml, 1
mg/ml, 4 mg/4ml 23
granisetron hcl 1 mg 23
granisol 23
grifulvin v 24
GRIS-PEG 24
griseofulvin microsize 24
griseofulvin ultramicrosize 24
guanfacine hcl 28
H-E-B INCONTROL PEN
NEEDLES 29GX12MM 69
HALAVEN 35
HALDOL 37
HALDOL DECANOATE 100 37
HALDOL DECANOATE 50 37
HALFLYTELY BOWEL
PREP/FLAVOR PACKS 66
halobetasol propionate 54
halobetasol propionate &
ammonium lactate 54
HALOG 54
haloperidol 38
haloperidol decanoate 38
haloperidol lactate 2 mg/ml 38
haloperidol lactate 5 mg/ml 38
HAVRIX 87
HEALTHWISE PEN NEEDLES
29GX12MM 69
HEALTHY ACCENTS UNIFINE
PENTIPS PEN NEEDLES
29GX12MM 69
HECTOROL 0.5 MCG, 1 MCG,
2.5 MCG
HECTOROL 2 MCG/ML, 4
59
MCG/2ML 59
HELIDAC 86
HEPAGAM B 80
heparin (porcine) in sodium
chloride 15
heparin sod (porcine) in d5w 15
heparin sodium (porcine) 1000
unit/ml, 10000 unit/ml, 20000
unit/ml, 5000 unit/0.5ml, 5000
unit/ml 15
Index 12

HEPARIN SODIUM 2000
UNIT/ML
HEPARIN SODIUM 2500
15
UNIT/ML 15
HEPARIN SODIUM/D5W 15
HEPARIN SODIUM/NACL
0.45%
HEPARIN SODIUM/SODIUM
15
CHLORIDE 0.9% 15
hepatasol 76
HEPSERA 40
HERCEPTIN 32
HEXALEN 31
HIBERIX 87
HIPREX 86
HIZENTRA 80
HORIZANT 83
HUMALOG 22
HUMALOG KWIKPEN 22
HUMALOG MIX 50/50 22
HUMALOG MIX 50/50
KWIKPEN 22
HUMALOG MIX 75/25 22
HUMALOG MIX 75/25
KWIKPEN 22
HUMAPEN LUXURA HD 69
HUMATROPE 12 MG, 24 MG, 5
MG 58
HUMATROPE 6 MG 58
HUMATROPE COMBO PACK 58
HUMIRA 2
HUMIRA PEN 2
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS
2
STARTER 2
HUMULIN 70/30 22
HUMULIN 70/30 PEN 22
HUMULIN N 22
HUMULIN N U-100 PEN 22
HUMULIN R 22
HUMULIN R U-500
(CONCENTRATED) 22
HYCAMTIN 36
hycet 7
hydralazine hcl 10 mg, 100 mg,
25 mg, 50 mg 30
hydralazine hcl 20 mg/ml 30
HYDREA 35
hydrochlorothiazide 12.5 mg 57
hydrochlorothiazide 12.5 mg,
25 mg, 50 mg 57
hydrocodone
bitartrate/acetaminophen 7
hydrocodone polistirexchlorpheniramine
polistirex 50
hydrocodone-acetaminophen
10-300 mg, 5-300 mg, 7.5-300
mg 7
hydrocodone-acetaminophen
10-325 mg, 5-325 mg, 7.5-325
mg 7
hydrocodone-acetaminophen
10-500 mg, 2.5-500 mg, 5-500
mg, 7.5-500 mg 7
hydrocodone-acetaminophen
10-650 mg, 10-660 mg, 7.5-650
mg 7
hydrocodone-acetaminophen
10-750 mg, 7.5-750 mg 7
hydrocodone-acetaminophen
2.5-6.7-108 %, mg/5ml, 5-6.7-
217 %, mg/10ml, 6.7-7.5-325
%, mg/15ml, 7-7.5-325 %,
mg/15ml, 7.5-8.6-325 %,
mg/15ml 7
hydrocodone-acetaminophen 5-
500 mg 7
hydrocodone-acetaminophen 7-
7.5-500 %, mg/15ml, 7.5-500
mg/15ml 7
hydrocodone-ibuprofen 7
hydrocodone/acetaminophen 7
hydrocortisone (intrarectal) 9
hydrocortisone (rectal) 9
hydrocortisone (topical) 1 % 54
hydrocortisone (topical) 2 %,
2.5 % 54
hydrocortisone (topical) 2.5
% 54
hydrocortisone 10 mg, 20 mg, 5
mg 49
hydrocortisone butyrate 0.1
% 54
hydrocortisone sod succinate49
hydrocortisone valerate 54
hydrocortisone w/acetic acid 79
hydromorphone hcl 1 mg/ml 5
hydromorphone hcl 1 mg/ml, 10
mg/ml, 2 mg/ml, 4 mg/ml, 50
mg/5ml, 500 mg/50ml 5
hydromorphone hcl 10 mg/ml,
50 mg/5ml 5
hydromorphone hcl 2 mg, 4 mg,
8 mg 5
hydroxychloroquine sulfate 200
mg 30
hydroxyurea 500 mg 35
hydroxyzine hcl 10 mg, 25 mg, 50
mg 11
hydroxyzine hcl 10 mg/5ml 11
hydroxyzine hcl 25 mg/ml, 50
mg/ml 11
hydroxyzine pamoate 100 mg, 25
mg, 50 mg 11
HYPERHEP B S/D 80
HYZAAR 29
ibandronate sodium 58
ibudone 7
ibuprofen 100 mg/5ml 3
ibuprofen 400 mg 3
ibuprofen 600 mg 3
ibuprofen 800 mg 3
IDAMYCIN PFS 34
idarubicin hcl 34
IFEX 31
IFOSFAMIDE 31
ifosfamide 31
ILARIS 2
ILEVRO 79
imdur 11
imipenem-cilastatin 10
imipramine hcl 10 mg, 25 mg, 50
mg 20
imipramine pamoate 20
imiquimod 5 % 55
IMITREX 100 MG, 25 MG, 50
MG 71
IMITREX 20 MG/ACT 70
IMITREX 5 MG/ACT 70
IMITREX 6 MG/0.5ML 70
IMITREX STATDOSE REFILL 71
IMITREX STATDOSE
SYSTEM 71
IMOVAX RABIES (H.D.C.V.) 88
IMPLANON 49
IMURAN 41
INCIVEK 40
INCRELEX 59
indapamide 1.25 mg, 2.5 mg 57
INDERAL LA 43
INDOCIN 3
indomethacin 25 mg, 50 mg 3
indomethacin 75 mg 3
INFANRIX 84
INFERGEN 40
Index 13

INFUMORPH 200 5
INFUMORPH 500 5
INLYTA 34
INSPRA 30
INSULIN SYRINGE/0.3ML/29G X
1"
INSUPEN SENSITIVE
69
32GX6MM
INSUPEN SENSITIVE
69
32GX8MM
INSUPEN ULTRAFIN
69
29GX12MM
INSUPEN ULTRAFIN
69
30GX8MM 69
INTELENCE 100 MG 39
INTELENCE 200 MG 39
INTELENCE 25 MG 39
INTERMEZZO 66
INTRALIPID 75
INTRON-A 10 MU/ML 35
INTRON-A 6000000 UNIT/ML 35
INTRON-A W/DILUENT 10 MU35
INTRON-A W/DILUENT 18 MU,
50 MU 35
INTUNIV 1
INVANZ 10
INVEGA 1.5 MG 37
INVEGA 3 MG 37
INVEGA 6 MG 37
INVEGA 9 MG 37
INVEGA SUSTENNA 37
INVIRASE 200 MG 39
INVIRASE 500 MG 39
INVOKANA 100 MG 22
INVOKANA 300 MG 22
IONOSOL-B/DEXTROSE 5% 71
IONOSOL-MB/DEXTROSE
5% 71
IOPIDINE 77
IPOL INACTIVATED IPV 88
ipratropium bromide (nasal) 74
ipratropium bromide 0.02 % 13
ipratropium-albuterol 14
irbesartan 28
irbesartan-hydrochlorothiazide 29
IRESSA 34
irinotecan hcl 100 mg/5ml, 40
mg/2ml 36
irinotecan hcl 500 mg/25ml 36
irrigation solutions,
physiological 42
ISENTRESS 100 MG 39
ISENTRESS 25 MG 39
ISENTRESS 400 MG 39
isolyte-h/dextrose 5% 71
isolyte-p/dextrose 5% 71
isolyte-s 71
isolyte-s ph 7.4 71
isoniazid & rifampin 30
isoniazid 100 mg, 300 mg 30
isoniazid 100 mg/ml 30
isoniazid 50 mg/5ml 30
ISOPTIN SR 44
ISOPTO CARPINE 76
ISORDIL TITRADOSE 40
MG 11
ISORDIL TITRADOSE 5 MG 11
isosorbide dinitrate 10 mg, 20
mg, 30 mg, 5 mg 11
isosorbide dinitrate 2.5 mg, 5
mg 11
isosorbide dinitrate 40 mg 11
isosorbide mononitrate 11
isotonic gentamicin 2
isotretinoin 10 mg, 20 mg, 30
mg, 40 mg 51
isradipine 44
ISTALOL 76
ISTODAX 34
ISUPREL 14
itraconazole 100 mg 25
IXEMPRA KIT 35
IXIARO 88
JAKAFI 34
JALYN 63
JANUMET 20
JANUMET XR 100-1000 MG 20
JANUMET XR 50-1000 MG,
50-500 MG 20
JANUVIA 100 MG 21
JANUVIA 25 MG 21
JANUVIA 50 MG 21
JENTADUETO 20
JEVTANA 35
JUVISYNC 10-100 MG, 20-100
MG, 40-100 MG 20
JUVISYNC 10-50 MG, 20-50
MG 20
JUVISYNC 40-50 MG 20
JUXTAPID 10 MG 27
JUXTAPID 20 MG 27
JUXTAPID 5 MG 27
K-TABS 72
KADCYLA 32
KADIAN 10 MG, 200 MG 5
KADIAN 100 MG, 20 MG, 30 MG,
50 MG, 60 MG, 80 MG 5
KADIAN 130 MG, 150 MG 5
KADIAN 40 MG, 70 MG 5
KALETRA 25-100 MG 39
KALETRA 42.4-100-400 %,
MG/5ML 39
KALETRA 50-200 MG 39
KALYDECO 83
kanamycin sulfate 333 mg/ml 2
KAYEXALATE 42
KAZANO 20
KCENTRA 64
KCL 0.15%/D5W/LR 71
KCL 0.15%/D5W/NACL
0.225% 71
KCL 0.15%/D5W/NACL 0.9% 72
kcl 0.3%/d5w/lr iv lac ring 72
KCL 0.3%/D5W/NACL 0.9% 72
KEFLEX 45
KENALOG 54
KENALOG-10 49
KENALOG-40 49
KEPIVANCE 35
KEPPRA 100 MG/ML 16
KEPPRA 1000 MG, 250 MG, 500
MG, 750 MG 16
KEPPRA 500 MG/5ML 16
KEPPRA XR 16
KERLONE 43
ketoconazole (topical) 52
ketoconazole 200 mg 25
ketoprofen 50 mg, 75 mg 3
ketoprofen er 3
ketorolac tromethamine
(ophth) 79
ketorolac tromethamine 10 mg 3
ketorolac tromethamine 15
mg/ml, 30 mg/ml
ketorolac tromethamine 30
3
mg/ml, 60 mg/2ml
ketorolac tromethamine 300
3
mg/10ml 3
KHEDEZLA 19
Index 14

KINERET 2
KINRIX 84
KLARON 51
KLONOPIN 0.5 MG 15
KLONOPIN 1 MG 15
KLONOPIN 2 MG 15
klor-con m15 72
KOMBIGLYZE XR 2.5-1000
MG 20
KOMBIGLYZE XR 5-1000 MG, 5-
500 MG 20
KORLYM 21
KROGER PEN NEEDLES 29G
X12MM 69
KRYSTEXXA 64
KUVAN 59
KYNAMRO 26
labetalol hcl 100 mg, 200 mg,
300 mg 43
labetalol hcl 5 mg/ml 43
LAC-HYDRIN 55
lactated ringer's 72
lactated ringer's (irrigation) 42
lactic acid (ammonium lactate) 12
% 55
lactulose (encephalopathy) 63
lactulose 10 gm/15ml, 20
gm/30ml 66
LAMICTAL 16
LAMICTAL CHEWABLE
DISPERSIBLE 16
LAMICTAL ODT 16
LAMICTAL STARTER/NOT
TAKING CARBAMAZEPINE 16
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING
VALPROATE 16
LAMICTAL STARTER/TAKING
VALPROATE 16
LAMICTAL XR 16
LAMISIL 125 MG, 187.5 MG 24
LAMISIL 250 MG 24
lamivudine 39
lamivudine-zidovudine 39
lamotrigine 16
LANOXIN 0.125 MG, 0.25 MG 45
LANOXIN 0.25 MG/ML 45
LANOXIN PEDIATRIC 45
lansoprazole 15 mg 86
lansoprazole 15 mg, 30 mg 86
lansoprazole 30 mg 86
LANTUS 22
LANTUS SOLOSTAR 22
LASIX 57
LASTACAFT 79
latanoprost 79
LATUDA 120 MG 37
LATUDA 20 MG 37
LATUDA 40 MG 37
LATUDA 60 MG 37
LATUDA 80 MG 37
LAZANDA 100 MCG/ACT 5
LAZANDA 400 MCG/ACT 5
leflunomide 4
LESCOL 26
LESCOL XL 26
LETAIRIS 45
letrozole 33
leucovorin calcium 10 mg, 15
mg, 25 mg, 5 mg 35
leucovorin calcium 10 mg/ml 35
leucovorin calcium 100 mg, 200
mg, 350 mg 35
leucovorin calcium 50 mg, 500
mg 35
LEUKERAN 31
LEUKINE 65
leuprolide acetate 1
mg/0.2ml 33
LEUSTATIN 32
levalbuterol hcl 0.31 mg/3ml,
0.63 mg/3ml, 1.25 mg/0.5ml,
1.25 mg/3ml 14
LEVAQUIN 25 MG/ML 62
LEVAQUIN 250 MG, 500 MG,
750 MG
LEVAQUIN 5-250 %,
62
MG/50ML, 5-500 %,
MG/100ML
LEVAQUIN 5-750 %,
61
MG/150ML 62
LEVATOL 43
LEVEMIR 22
LEVEMIR FLEXPEN 22
levetiracetam 100 mg/ml, 500
mg/5ml
levetiracetam 1000 mg, 250
16
mg, 500 mg, 750 mg
levetiracetam 500 mg, 750
16
mg 16
levetiracetam 500 mg/5ml 16
LEVETIRACETAM 500-820
MG/100ML, 540-1500
MG/100ML, 750-1000
MG/100ML 16
levobunolol hcl 76
levocarnitine (metabolic
modifiers) 1 gm/10ml
levocarnitine (metabolic
59
modifiers) 200 mg/ml
levocarnitine (metabolic
59
modifiers) 330 mg 59
levocetirizine dihydrochloride 25
levofloxacin (ophth) 77
levofloxacin 25 mg/ml 62
levofloxacin 250 mg, 500 mg, 750
mg
levofloxacin in d5w 5-250 %,
62
mg/50ml, 5-500 %, mg/100ml
levofloxacin in d5w 5-750 %,
62
mg/150ml 62
levonorgestrel & eth estradiol 47
levonorgestrel (emergency oc)
0.75 mg 48
levonorgestrel (emergency oc)
1.5 mg
levonorgestrel-eth estradiol
48
(triphasic) 47
levonorgestrel-ethinyl estradiol
(91-day) 47
levorphanol tartrate 2 mg 5
levothyroxine sodium 100 mcg,
112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg,
300 mcg, 50 mcg, 75 mcg, 88
mcg 84
LEXAPRO 19
LEXIVA 50 MG/ML 39
LEXIVA 700 MG 39
LIALDA 62
lidocaine 5 % 56
lidocaine hcl (cardiac) 12
lidocaine hcl (local anesth.) 0.5
%, 1.5 % 67
lidocaine hcl (local anesth.) 1 %,
2 %, 4 % 67
lidocaine hcl (mouth-throat) 73
lidocaine hcl 10 mg/ml 12
lidocaine hcl 2 % 56
lidocaine hcl 4 % 56
lidocaine hcl/dextrose 67
lidocaine in d5w 4-5 %, mg/ml 12
Index 15

lidocaine w/ epinephrine 0.5-1 %,
:200000, 0.5-1-1.5 %, :200000,
mg/ml, 0.5-1-2 %, :200000,
mg/ml, 1-1.5 %, :200000, 1-2 %,
:50000 67
lidocaine w/ epinephrine 0.5-1-1-
1 %, :100000, mg/ml, 0.5-1-1-2
%, :100000, mg/ml, 1-2 %,
:100000 67
lidocaine-prilocaine 56
LIDODERM 56
LINCOCIN 11
LINZESS 63
LIORESAL INTRATHECAL 0.05
MG/ML 73
LIORESAL INTRATHECAL 10
MG/20ML, 10 MG/5ML, 40
MG/20ML 73
liothyronine sodium 10 mcg/ml 84
liothyronine sodium 25 mcg, 5
mcg, 50 mcg 84
LIPITOR 26
LIPOFEN 26
LIPOSYN II 75
LIPOSYN III 75
LIPTRUZET 25
lisinopril & hydrochlorothiazide 29
lisinopril 10 mg, 2.5 mg, 20 mg,
30 mg, 40 mg, 5 mg
LITETOUCH PEN NEEDLES
27
29GX12.7MM
LITHIUM CARBONATE 150
69
MG 37
lithium carbonate 150 mg, 300
mg, 600 mg 37
lithium carbonate 300 mg 37
lithium carbonate 300 mg, 450
mg 37
lithium citrate 8 meq/5ml 37
LITHOBID 37
LIVALO 26
LIVE BETTER PEN NEEDLES
29G X 12MM 69
LO LOESTRIN FE 47
LO/OVRAL-28 47
LOCOID 54
LOCOID LIPOCREAM 54
LODOSYN 36
loestrin 1.5/30-21 47
loestrin 1/20-21 47
LOESTRIN 24 FE 47
loestrin fe 1.5/30 47
loestrin fe 1/20 47
lofibra 26
LOMOTIL 23
lomustine 31
loperamide hcl 2 mg 23
LOPID 26
LOPRESSOR 1 MG/ML 43
LOPRESSOR 100 MG, 50
MG 43
LOPRESSOR HCT 29
LOPROX 52
LOPROX SHAMPOO 52
lorazepam 0.5 mg, 1 mg, 2
mg 12
lorazepam 2 mg/ml 12
lorazepam 2 mg/ml, 20
mg/10ml 12
lorazepam 4 mg/ml 12
lorazepam intensol 12
lorcet 10/650 7
lorcet plus 7
lortab 10-500 mg, 5-500 mg,
7.5-500 mg 7
lortab 7-7.5-500 %, mg/15ml 7
losartan potassium 28
losartan potassium &
hydrochlorothiazide 29
LOSEASONIQUE 47
LOTEMAX 78
LOTENSIN 27
LOTENSIN HCT 29
LOTREL 29
LOTRONEX 63
lovastatin 26
LOVAZA 26
LOVENOX 15
loxapine succinate 10 mg, 25
mg, 5 mg, 50 mg 38
loxitane 38
LUCENTIS 76
LUFYLLIN 14
LUMIGAN 0.01 % 79
LUMIGAN 0.03 % 79
LUMIZYME 59
LUNESTA 66
LUPRON DEPOT 11.25 MG,
22.5 MG 33
LUPRON DEPOT 3.75 MG 33
LUPRON DEPOT 30 MG 33
LUPRON DEPOT 45 MG 33
LUPRON DEPOT 7.5 MG 33
LUPRON DEPOT-PED 11.25
MG, 15 MG
LUPRON DEPOT-PED 11.25
59
MG, 30 MG 59
LUPRON DEPOT-PED 7.5 MG59
LUVOX CR 19
LUXIQ 54
LYRICA 100 MG 16
LYRICA 150 MG 16
LYRICA 20 MG/ML 16
LYRICA 200 MG 16
LYRICA 225 MG, 300 MG 16
LYRICA 25 MG 16
LYRICA 50 MG 16
LYRICA 75 MG 16
LYSODREN 33
LYSTEDA 65
M-M-R II W/DILUENT 10
DOSE 88
MACROBID 87
MACRODANTIN 100 MG, 50
MG 87
MACRODANTIN 25 MG 87
mafenide acetate 5 % 53
magnacet 10-400 mg, 5-400 mg 7
magnacet 7.5-400 mg 7
MAGNESIUM SULFATE 40
MG/ML, 80 MG/ML 72
magnesium sulfate 50 % 72
MAGNESIUM SULFATE IN
D5W 72
MAKENA 81
MALARONE 30
malathion 0.5 % 56
mannitol 25 % 57
maprotiline hcl 18
MARCAINE 0.25 %, 0.5 % 67
MARCAINE 0.5 % 67
MARCAINE SPINAL 67
MARCAINE W/O EPI 67
MARCAINE/EPINEPHRINE 0.25-
0.5-1 %, :200000, MG/ML, 0.25-
0.5-1-1 %, :200000, MG/ML 67
MARCAINE/EPINEPHRINE 0.5-
0.5-1 %, :200000, MG/ML, 0.5-
0.5-1-1 %, :200000, MG/ML 67
MARINOL 24
MARPLAN 18
Index 16

MATULANE 35
MAVIK 27
MAXAIR AUTOHALER 14
MAXALT 71
MAXALT-MLT 71
MAXIDEX 78
maxidone 7
MAXIPIME 47
MAXITROL 78
MAXZIDE 57
MAXZIDE-25 57
meclizine hcl 12.5 mg, 25 mg 24
meclofenamate sodium 100 mg,
50 mg
MEDICAL PROVIDER EZ FLU
3
SHOT PF 2012-2013 88
MEDICAL PROVIDER EZ FLU
SHOT PF 2013-2014
MEDICINE SHOPPE PEN
88
NEEDLES 29G X 12MM 69
MEDROL 16 MG, 32 MG, 4 MG,
8 MG 49
MEDROL 2 MG 49
MEDROL DOSEPAK 49
medroxyprogesterone acetate
(contraceptive) 49
medroxyprogesterone acetate 10
mg, 2.5 mg, 5 mg 81
mefenamic acid 250 mg 3
mefloquine hcl 30
mefoxin 46
MEGACE ES 81
MEGACE ORAL 33
megestrol acetate 20 mg, 40
mg 33
megestrol acetate 40 mg/ml, 400
mg/10ml
MEIJER PEN NEEDLES 29G
33
X12MM 69
MEKINIST 34
meloxicam 15 mg, 7.5 mg 3
meloxicam 7.5 mg/5ml 3
melphalan hcl 31
MENACTRA 87
menest 61
MENOMUNE-A/C/Y/W-135 87
MENOSTAR 61
MENTAX 52
MENVEO 87
MEPHYTON 89
mepivacaine hcl 1 % 67
mepivacaine hcl 1.5 %, 2 %, 3
% 67
meprobamate 11
MEPRON 10
mercaptopurine 50 mg 32
meropenem 10
MERREM 10
mesalamine 4 gm 62
mesalamine w/ cleanser 63
mesna 35
MESNEX 100 MG/ML 35
MESNEX 400 MG 35
MESTINON 60 MG 30
MESTINON 60 MG/5ML 30
MESTINON TIMESPAN 30
METADATE CD 1
METAGLIP 20
metaproterenol sulfate 10 mg,
20 mg
metaproterenol sulfate 10
14
mg/5ml 14
metaxalone 73
metformin hcl 1000 mg 21
metformin hcl 1000 mg, 750
mg 21
metformin hcl 500 mg 21
metformin hcl 850 mg 21
methadone hcl 10 mg, 5 mg 5
methadone hcl 10 mg/5ml, 5
mg/5ml 5
methadone hcl 10 mg/ml 5
METHADONE HCL 10
MG/ML 5
methadone hcl 40 mg 5
methadose 5
methadose sugar-free 5
methazolamide 25 mg, 50
mg 56
methenamine hippurate 87
METHERGINE 0.2 MG 79
methimazole 10 mg, 5 mg 84
methocarbamol 500 mg, 750
mg 73
methotrexate sodium 1 gm 32
methotrexate sodium 1
gm/40ml, 100 mg/4ml, 200
mg/8ml, 25 mg/ml, 250
mg/10ml, 50 mg/2ml 32
methotrexate sodium 2.5 mg 32
methscopolamine bromide 2.5
mg, 5 mg 85
methyclothiazide 5 mg 57
methyldopa 250 mg, 500 mg 28
methyldopa/hydrochlorothiazide 2
9
methyldopate hcl 28
methylergonovine maleate 0.2
mg
METHYLIN 10 MG, 2.5 MG, 5
79
MG
METHYLIN 10 MG/5ML, 5
1
MG/5ML
methylphenidate hcl 10 mg, 20
1
mg, 30 mg, 40 mg, 50 mg, 60
mg
methylphenidate hcl 10 mg, 20
1
mg, 5 mg 1
methylphenidate hcl 10 mg/5ml, 5
mg/5ml
methylphenidate hcl 18 mg, 20
1
mg, 27 mg, 36 mg, 54 mg
methylphenidate hcl 20 mg, 30
1
mg, 40 mg 1
methylphenidate hcl er 1
methylprednisolone 16 mg, 32
mg, 4 mg, 8 mg 49
methylprednisolone acetate 40
mg/ml, 80 mg/ml 49
methylprednisolone sod succ 49
metipranolol 76
metoclopramide hcl 10 mg, 5
mg 62
metoclopramide hcl 10 mg/10ml,
5 mg/5ml 62
metoclopramide hcl 5 mg/ml 62
metolazone 57
metoprolol &
hydrochlorothiazide 29
metoprolol succinate 43
metoprolol tartrate 1 mg/ml, 5
mg/5ml 43
metoprolol tartrate 100 mg, 25
mg, 50 mg 43
metoprolol/hydrochlorothiazide 29
METOZOLV ODT 10 MG 62
METOZOLV ODT 5 MG 62
METRO IV 9
METROCREAM 56
METROGEL 56
METROGEL-VAGINAL 88
METROLOTION 56
metronidazole (topical) 56
metronidazole 250 mg 9
metronidazole 375 mg 9
metronidazole 500 mg 9
Index 17

metronidazole in nacl 9
metronidazole vaginal 88
MEVACOR 26
mexiletine hcl 12
MIACALCIN 200 UNIT/ACT 58
MIACALCIN 200 UNIT/ML 58
MICARDIS 28
MICARDIS HCT 29
miconazole 3 88
MICRO-K 72
MICROZIDE 57
MIDAMOR 57
midazolam hcl 10 mg/10ml, 2
mg/2ml, 5 mg/ml
midazolam hcl 10 mg/2ml, 25
66
mg/5ml, 5 mg/5ml, 5 mg/ml, 50
mg/10ml 66
midazolam hcl 2 mg/ml 66
midodrine hcl 89
migergot 70
MIGRANAL 70
millipred 50
millipred dp 50
milrinone lactate 45
MINASTRIN 24 FE 47
MINIPRESS 28
MINIVELLE 61
MINOCIN 100 MG 84
MINOCIN 100 MG, 50 MG 84
minocycline hcl 100 mg, 50 mg,
75 mg 84
minocycline hcl 135 mg, 45 mg,
90 mg 84
minoxidil 10 mg, 2.5 mg 30
MIRAPEX 36
MIRAPEX ER 36
mircette 48
mirtazapine 15 mg, 30 mg, 45
mg 18
mirtazapine 7.5 mg 18
misoprostol 100 mcg, 200 mcg 86
mitomycin 20 mg, 40 mg, 5 mg 34
mitoxantrone hcl 34
mitoxantrone hcl 25 MG/12.5ML
(2 mg/ml) 34
MOBIC 3
modafinil 100 mg 1
modafinil 200 mg 1
MODICON 48
moexipril hcl 27
moexipril-hydrochlorothiazide29
mometasone furoate 0.1 % 54
MONODOX 84
MONOKET 11
montelukast sodium 13
morphine sulfate 0.5 mg/ml, 1
mg/ml 5
morphine sulfate 1 mg/ml 5
morphine sulfate 10 mg, 100
mg, 20 mg, 30 mg, 50 mg, 60
mg, 80 mg
morphine sulfate 10 mg/5ml,
5
100 mg/5ml, 20 mg/5ml, 20
mg/ml
MORPHINE SULFATE 10
5
MG/ML, 15 MG/ML, 150
MG/30ML, 2 MG/ML, 4 MG/ML,
8 MG/ML
morphine sulfate 100 mg, 15
5
mg, 200 mg, 30 mg, 60 mg
morphine sulfate 15 mg, 30
5
mg
MORPHINE SULFATE 2
5
MG/ML 5
MOTOFEN 23
MOVIPREP 66
MOXATAG 80
MOXEZA 77
MOZOBIL 65
MS CONTIN 5
MULTAQ 13
mupirocin 2 % 52
mupirocin calcium (topical) 52
MUSTARGEN 31
MYAMBUTOL 100 MG 31
MYAMBUTOL 400 MG 31
MYCAMINE 24
MYCOBUTIN 31
mycophenolate mofetil 41
mydriacyl 76
MYFORTIC 41
MYOZYME 59
MYRBETRIQ 87
MYSOLINE 16
MYTELASE 30
NABI-HB 80
nabumetone 3
nadolol &
bendroflumethiazide 29
nadolol 20 mg, 40 mg, 80 mg 43
nafcillin sodium 81
NAFCILLIN SODIUM 81
NAFTIN 52
NAGLAZYME 59
nalbuphine hcl 10 mg/ml, 20
mg/ml 8
NALFON 3
NALLPEN ISO-OSMOTIC IN
DEXTROSE 81
NALLPEN/DEXTROSE 81
naloxone hcl 0.4 mg/ml, 1
mg/ml 23
naltrexone hcl 50 mg 23
NAMENDA 82
NAMENDA TITRATION PAK 82
NAMENDA XR 14 MG 82
NAMENDA XR 21 MG, 28 MG 82
NAMENDA XR 7 MG 82
NAMENDA XR TITRATION
PACK 82
naphazoline hcl 0.1 % 77
NAPRELAN 3
NAPRELAN 375 MG 3
NAPRELAN 500 MG, 750 MG 3
NAPROSYN 3
naproxen 125 mg/5ml 3
naproxen 250 mg, 375 mg, 500
mg 3
naproxen 375 mg, 500 mg 3
naproxen sodium 275 mg, 550
mg 3
naratriptan hcl 71
NARDIL 18
NAROPIN 67
NASACORT AQ 74
NASONEX 74
NATACYN 77
NATAZIA 48
nateglinide 22
NEBUPENT 9
necon 10/11-28 48
nefazodone hcl 18
nembutal 65
nembutal sodium 65
neomycin sulfate 500 mg 2
neomycin-bacitracin znpolymyxin
77
neomycin-polymy-dexameth 78
Index 18

neomycin-polymy-gramicid 77
neomycin-polymyxin-hc (otic) 79
neomycin/polymyxin b gu 63
neomycin/polymyxin/hydrocortiso
ne 78
NEORAL 41
neosporin 77
NEOSPORIN GU IRRIGANT 63
NEPHRAMINE 76
neptazane 57
NESACAINE 67
NESACAINE-MPF 67
NESINA 21
NEULASTA 65
NEUMEGA 65
NEUPOGEN 65
NEUPRO 36
NEURONTIN 16
NEVANAC 79
nevirapine 200 mg 39
NEVIRAPINE 50 MG/5ML 39
NEXAVAR 34
NEXIUM 86
NEXIUM I.V. 20 MG 86
NEXIUM I.V. 40 MG 86
NEXPLANON 49
niacin (antihyperlipidemic) 27
niacor 27
NIASPAN 27
nicardipine hcl 2.5 mg/ml 44
nicardipine hcl 20 mg, 30 mg 44
NICOTROL INHALER 83
NICOTROL NS 83
nifedipine 20 mg 44
nifedipine 30 mg, 60 mg, 90
mg 44
NILANDRON 33
nimodipine 30 mg 44
NIPENT 35
NIRAVAM 12
nisoldipine 44
nitro-bid 11
NITRO-DUR 0.1 MG/HR, 0.2
MG/HR, 0.4 MG/HR, 0.6
MG/HR
NITRO-DUR 0.3 MG/HR, 0.8
11
MG/HR 11
nitrofurantoin 25 mg/5ml 87
nitrofurantoin macrocrystal 100
mg, 50 mg
nitrofurantoin monohyd
87
macro
nitroglycerin 0.1 mg/hr, 0.2
87
mg/hr, 0.4 mg/hr, 0.6 mg/hr 11
nitroglycerin 0.4 mg/spray 11
nitroglycerin 5 mg/ml 11
nitroglycerin in d5w 11
NITROGLYCERIN IN
DEXTROSE 5% 11
NITROGLYCERIN LINGUAL 11
NITROLINGUAL
PUMPSPRAY 11
NITROMIST 11
NITROSTAT 11
nizatidine 85
NIZORAL 52
NOR-QD 49
norco 7
NORDETTE-28 48
NORDITROPIN FLEXPRO 10
MG/1.5ML, 5 MG/1.5ML 58
NORDITROPIN FLEXPRO 15
MG/1.5ML 58
NORDITROPIN NORDIFLEX
PEN 58
norethin acet & estrad-fe 48
norethindrone & eth estradiol 48
norethindrone & ethinyl
estradiol-fe 48
norethindrone & mestranol 48
norethindrone
(contraceptive)
norethindrone acet & eth
49
estra 48
norethindrone acetate 5 mg 82
norethindrone acetate-ethinyl
estradiol 60
norethindrone acetate-ethinyl
estradiol-fe
norethindrone-eth estradiol
48
(triphasic)
norgestimate-ethinyl
48
estradiol 48
norgestimate-ethinyl estradiol
(triphasic) 48
norgestrel & ethinyl estradiol 48
NORINYL 1+35 48
NORINYL 1+50 48
NORMOSOL -R 72
NORMOSOL-R 72
NORMOSOL-R IN D5W 72
NOROXIN 62
NORPACE 12
NORPACE CR 12
NORPRAMIN 20
nortriptyline hcl 10 mg, 25 mg, 50
mg, 75 mg 20
nortriptyline hcl 10 mg/5ml 20
NORVASC 10 MG 44
NORVASC 2.5 MG 44
NORVASC 5 MG 44
NORVIR 39
NOVOFINE 30GX8MM 69
NOVOFINE 32GX6MM 69
NOVOFINE AUTOCOVER
30GX8MM 69
NOVOLIN 70/30 22
NOVOLIN 70/30 RELION 22
NOVOLIN N 22
NOVOLIN N RELION 22
NOVOLIN R 22
NOVOLIN R RELION 22
NOVOLOG 22
NOVOLOG FLEXPEN 22
NOVOLOG MIX 70/30 22
NOVOLOG MIX 70/30
PREFILLED FLEXPEN 22
NOVOLOG PENFILL 22
NOVOPEN 3 INSULIN
DELIVERY SYSTEM 69
NOVOPEN 3 PENMATE 69
NOVOPEN JR (GREEN) 69
NOVOPEN JR (YELLOW) 69
NOVOTWIST 30GX8MM 69
NOVOTWIST 32GX5MM 69
NOXAFIL 25
NPLATE 65
NUCYNTA 5
NUCYNTA ER 5
NUEDEXTA 83
NULOJIX 42
NULYTELY/FLAVOR PACKS 66
NUTROPIN 59
NUTROPIN AQ 59
NUTROPIN AQ NUSPIN 10 59
NUTROPIN AQ NUSPIN 20 59
NUTROPIN AQ PEN 59
NUVARING 48
NUVIGIL 1
Index 19

NYMALIZE 44
nystatin (mouth-throat) 73
nystatin (topical) 52
nystatin 500000 unit 24
nystatin vaginal 88
nystatin-triamcinolone 52
nystatin/triamcinolone 52
OCTAGAM 80
octreotide acetate 100 mcg/ml,
1000 mcg/5ml, 200 mcg/ml, 50
mcg/ml 60
octreotide acetate 1000 mcg/ml,
500 mcg/ml 60
OCUFEN 79
OCUFLOX 77
ofloxacin (ophth) 77
ofloxacin (otic) 79
ogestrel 48
olanzapine 10 mg 38
olanzapine 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg 38
olanzapine 10 mg, 15 mg, 20 mg,
5 mg 38
OLEPTRO 18
OLUX 55
omeprazole 10 mg, 20 mg, 40
mg 86
omeprazole-sodium bicarbonate
20-1100 mg 86
omeprazole-sodium bicarbonate
40-1100 mg 86
OMNARIS 74
OMNIPRED 78
OMNITROPE 10 MG/1.5ML, 5
MG/1.5ML 59
OMNITROPE 5.8 MG 59
ONCASPAR 34
ondansetron 23
ondansetron hcl 24 mg, 4 mg, 8
mg 23
ONDANSETRON HCL 32-450
MG/50ML
ondansetron hcl 4 mg/2ml, 40
23
mg/20ml 23
ondansetron hcl 4 mg/5ml 23
ondansetron hcl and dextrose 23
ONDANSETRON
HCL/DEXTROSE 23
ONFI 15
ONGLYZA 2.5 MG 21
ONGLYZA 5 MG 21
ONMEL 25
ONSOLIS 1200 MCG, 400
MCG, 600 MCG, 800 MCG 6
ONSOLIS 200 MCG 6
OPANA 1 MG/ML 6
OPANA 10 MG, 5 MG 6
OPANA ER 6
OPANA ER (CRUSH
RESISTANT) 10 MG, 20 MG,
30 MG, 40 MG, 5 MG
OPANA ER (CRUSH
6
RESISTANT) 15 MG, 7.5 MG 6
OPTIPRANOLOL 76
OPTIVAR 79
ORACEA 56
ORAMORPH SR 6
ORAP 83
orapred 50
ORAPRED ODT 50
ORAVIG 73
ORENCIA 4
ORFADIN 60
orphenadrine citrate 100 mg 73
orphenadrine compound ds 74
orphenadrine w/ aspirin &
caff 74
ORTHO EVRA 48
ORTHO MICRONOR 49
ORTHO TRI-CYCLEN 48
ORTHO TRI-CYCLEN LO 48
ORTHO-CEPT 48
ORTHO-CYCLEN 48
ORTHO-NOVUM 1/35 48
ORTHO-NOVUM 7/7/7 48
OSENI 12.5-15 MG, 12.5-30
MG, 12.5-45 MG 21
OSENI 15-25 MG, 25-30 MG,
25-45 MG 21
OSMOPREP 66
ovcon-35 48
OVCON-50 28 48
OVIDE 56
oxacillin sodium 1 gm 81
oxacillin sodium 10 gm 81
oxacillin sodium 2 gm 81
oxaliplatin 100 mg, 50 mg 31
oxaliplatin 100 mg/20ml, 50
mg/10ml 31
OXANDRIN 8
oxandrolone 10 mg, 2.5 mg 8
oxaprozin 3
oxcarbazepine 16
OXECTA 6
OXISTAT 52
OXSORALEN 56
OXSORALEN ULTRA 52
oxybutynin chloride 87
oxycodone hcl 10 mg, 15 mg, 20
mg, 30 mg, 5 mg 6
oxycodone hcl 20 mg/ml 6
oxycodone hcl 5 mg 6
oxycodone hcl 5 mg/5ml 6
oxycodone w/ acetaminophen 10-
325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg 7
oxycodone w/ acetaminophen 10-
650 mg 7
oxycodone w/ acetaminophen 5-
500 mg
oxycodone w/ acetaminophen
7
7.5-500 mg 7
oxycodone-aspirin 7
oxycodone-ibuprofen 7
OXYCONTIN 6
oxymorphone hcl 6
OXYTROL 87
paclitaxel 100 mg/16.7ml, 30
mg/5ml, 300 mg/50ml 36
paclitaxel 150 mg/25ml 36
palgic 25
PAMELOR 20
pamidronate disodium 58
PAMINE 85
PAMINE FORTE 85
PANCREAZE 56
PANCRELIPASE 56
PANDEL 55
PANRETIN 52
pantoprazole sodium 20 mg, 40
mg 86
pantoprazole sodium 40 mg 86
PARAFON FORTE DSC 74
parcopa 36
parenteral electrolytes 0.225-
0.25-1-1.475-1.75-1.75 meq/ml,
0.25-0.25-0.4-1.25-1.68-2.03-
2.03 meq, meq/ml, 0.25-0.25-0.4-
1.25-1.68-2.03-2.03 meq/ml 72
parenteral electrolytes 4.5-5-20-
29.5-35-35 meq/20ml 72
paricalcitol 60
Index 20

PARLODEL 36
PARNATE 18
paromomycin sulfate 2
paroxetine hcl 19
paser 31
PATADAY 79
PATANASE 74
PATANOL 79
PAXIL 19
PAXIL CR 19
PC UNIFINE PENTIPS 29G
X1/2" 70
PCE 333 MG 68
PCE 500 MG 68
PEDIAPRED 50
PEDIARIX 84
PEDVAX HIB 87
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate 66
peg 3350-potassium chloride-sod
bicarbonate-sod chloride 66
PEG-INTRON 40
PEG-INTRON REDIPEN 40
PEG-INTRON REDIPEN PAK
4 40
PEGANONE 17
PEGASYS 40
PEGASYS PROCLICK 40
PEN NEEDLES 29G X 12MM 70
PEN NEEDLES 29GX1/2" 70
PEN NEEDLES 30GX5/16" 70
penicillin g potassium 80
PENICILLIN G POTASSIUM IN
ISO-OSMOTIC DEXTROSE 80
penicillin g procaine 80
penicillin g sodium 80
penicillin v potassium 80
PENNSAID 51
PENTACEL 84
PENTAM 300 9
PENTASA 63
pentostatin 35
pentoxifylline 400 mg 64
PEPCID 20 MG 85
PEPCID 40 MG 85
PEPCID 40 MG/5ML 85
percocet 10-325 mg, 2.5-325 mg,
5-325 mg, 7.5-325 mg 7
percocet 10-650 mg 7
percocet 7.5-500 mg 7
PERCODAN 7
PERFOROMIST 14
PERIDEX 73
perindopril erbumine 2 mg 27
perindopril erbumine 4 mg 27
perindopril erbumine 8 mg 27
PERJETA 32
permethrin 5 % 56
perphenazine 16 mg, 2 mg, 4
mg, 8 mg 38
perphenazine/amitriptyline 82
PERSANTINE 64
PERTZYE 56
PEXEVA 19
pfizerpen-g 80
PFIZERPEN-G 80
phenelzine sulfate 15 mg 18
phenergan 25
phenobarbital 100 mg, 15 mg,
16.2 mg, 30 mg, 32.4 mg, 60
mg 65
phenobarbital 20 mg/5ml 65
PHENOBARBITAL 64.8 MG,
97.2 MG
phenobarbital sodium 130
65
mg/ml 65
PHENOBARBITAL SODIUM 65
MG/ML 65
phentolamine mesylate 5 mg 28
phenyleph-promethazine w/
cod 50
phenylephrine hcl 10 mg/ml 89
phenytek 17
phenytoin 125 mg/5ml 17
phenytoin 50 mg 17
phenytoin sodium 50 mg/ml 17
phenytoin sodium extended 17
PHISOHEX 39
PHOSLO 63
PHOSLYRA 63
PHOSPHOLINE IODIDE 76
PHYSIOSOL IRRIGATION PH
7.4 42
PICATO 52
pilocarpine hcl (oral) 73
pilocarpine hcl 1 %, 2 %, 4 %76
PILOPINE HS 76
pindolol 43
pioglitazone hcl 21
pioglitazone hcl-glimepiride 21
pioglitazone hcl-metformin hcl 21
piperacillin sodium-tazobactam
sodium 0.25-2 gm, 4.5-36 gm 81
piperacillin sodium-tazobactam
sodium 0.375-3 gm, 0.5-4 gm 81
piroxicam 10 mg, 20 mg 3
PLAN B 49
PLAN B ONE-STEP 49
PLAQUENIL 30
PLASMA-LYTE A 72
PLASMA-LYTE-148 72
PLASMA-LYTE-56/D5W 72
PLAVIX 300 MG 64
PLAVIX 75 MG 64
PLETAL 64
podofilox 0.5 % 55
polyethylene glycol 3350 66
polymyxin b sulfate 500000
unit 11
polymyxin b-trimethoprim 77
POLYTRIM 77
POMALYST 33
PONSTEL 4
potassium acetate 2 meq/ml 72
POTASSIUM CHLORIDE
0.15%/NACL 0.45% VIAFLEX 72
POTASSIUM CHLORIDE
0.15%/NACL 0.9%
POTASSIUM CHLORIDE
72
0.3%/NACL 0.9% 72
potassium chloride 0.4 meq/ml,
10 meq/100ml, 2 meq/ml 72
potassium chloride 10 % 73
potassium chloride 10 %, 20 % 72
potassium chloride 10 meq, 8
meq
POTASSIUM CHLORIDE 10
72
MEQ/100ML, 20 MEQ/50ML 72
potassium chloride 10 meq/50ml,
20 meq/100ml, 30 meq/100ml, 40
meq/100ml
POTASSIUM CHLORIDE 10
73
MEQ/50ML, 20 MEQ/100ML, 30
MEQ/100ML, 40 MEQ/100ML 73
potassium chloride in d5w
lactated ringers 72
potassium chloride in dextrose 72
potassium chloride in dextrose &
sodium chloride 72
potassium chloride in nacl 0.45-
20 %, meq/l, 0.9-40 %, meq/l 72
Index 21

potassium chloride in nacl 0.9-20
%, meq/l
potassium chloride
72
microencapsulated crystals cr 72
potassium citrate (alkalinizer) 63
POTIGA 200 MG 16
POTIGA 300 MG 16
POTIGA 400 MG 16
POTIGA 50 MG 16
PRADAXA 15
pramipexole dihydrochloride 36
pramosone 1-1 % 55
pramosone 1-1 %, 1-2.5 % 55
PRANDIMET 21
PRANDIN 0.5 MG, 1 MG 22
PRANDIN 2 MG 22
PRAVACHOL 26
pravastatin sodium 27
prazosin hcl 28
PRECOSE 20
PRED FORTE 78
PRED MILD 78
PRED-G 78
PRED-G S.O.P. 78
prednicarbate 55
prednisolone 15 mg/5ml 50
prednisolone acetate (ophth) 78
prednisolone sodium phosphate
1 % 78
prednisolone sodium phosphate
15 mg/5ml, 5 mg/5ml, 6.7
mg/5ml 50
prednisolone sodium phosphate
25 mg/5ml 50
prednisone 1 mg, 10 mg, 2.5 mg,
20 mg, 5 mg, 50 mg 50
prednisone 5 mg/5ml 50
prednisone intensol 50
PREFERRED PLUS UNIFINE
PENTIPS 29G X 12MM 70
prefest 60
PREMARIN 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25 MG 61
PREMARIN 0.625 MG/GM 88
PREMARIN 25 MG 61
premasol 76
PREMPHASE 60
PREMPRO 61
prenatabs obn 73
PREPOPIK 66
PREVACID 15 MG 86
PREVACID 30 MG 86
PREVACID SOLUTAB 86
PREVPAC 86
PREZISTA 100 MG/ML 39
PREZISTA 150 MG, 600 MG,
800 MG 39
PREZISTA 400 MG 39
PREZISTA 75 MG 39
PRIALT 4
PRIFTIN 31
PRILOSEC 10 MG, 2.5 MG 86
PRILOSEC 10 MG, 20 MG, 40
MG
primaquine phosphate 26.3
86
mg 30
PRIMAXIN IV 10
primidone 250 mg, 50 mg 16
primlev 7
PRIMSOL 9
PRINIVIL 27
PRINZIDE 29
PRISTIQ 19
PRIVIGEN 80
PROAIR HFA 14
probenecid 500 mg 64
PROCALAMINE 76
PROCARDIA XL 44
procentra 1
prochlorperazine 38
prochlorperazine edisylate 5
mg/ml 38
prochlorperazine maleate 10
mg, 5 mg
PROCRIT 10000 UNIT/ML,
38
2000 UNIT/ML, 3000 UNIT/ML,
4000 UNIT/ML
PROCRIT 20000 UNIT/ML,
65
40000 UNIT/ML 65
PROCTOCORT 1 % 9
proctofoam hc 9
PROCYSBI 63
PRODIGY INSULIN PEN
NEEDLES/29G X 1/2" 70
progesterone micronized 100
mg, 200 mg 82
PROGLYCEM 21
PROGRAF 0.5 MG, 1 MG 42
PROGRAF 5 MG 42
PROGRAF 5 MG/ML 42
PROLASTIN 83
PROLASTIN-C 83
PROLENSA 79
PROLEUKIN 35
PROLIA 58
PROMACTA 12.5 MG 65
PROMACTA 25 MG 65
PROMACTA 50 MG 65
PROMACTA 75 MG 65
promethazine & phenylephrine 50
promethazine hcl 12.5 mg, 25
mg
promethazine hcl 12.5 mg, 25
25
mg, 50 mg 25
promethazine hcl 25 mg/ml, 50
mg/ml 25
promethazine hcl 6.25 mg/5ml 25
promethazine vc/codeine 50
promethegan 25
PROMETRIUM 82
propafenone hcl 12
propantheline bromide 15 mg 85
proparacaine hcl 0.5 % 77
propranolol hcl 1 mg/ml 43
propranolol hcl 10 mg, 20 mg, 40
mg, 60 mg, 80 mg 43
propranolol hcl 120 mg, 160 mg,
60 mg, 80 mg
propranolol hcl 20 mg/5ml, 40
43
mg/5ml 43
propranolol/hydrochlorothiazide 2
9
propylthiouracil 50 mg 84
PROQUAD 88
PROSCAR 64
PROSOL 76
PROTONIX 20 MG, 40 MG 86
PROTONIX 40 MG 86
PROTOPIC 55
protriptyline hcl 20
PROVENTIL HFA 14
PROVERA 82
PROVIGIL 100 MG 1
PROVIGIL 200 MG 1
PROZAC 19
PROZAC WEEKLY 19
PRUDOXIN 52
PULMICORT 0.25 MG/2ML 13
PULMICORT 0.5 MG/2ML 13
Index 22

PULMICORT 1 MG/2ML 13
PULMICORT FLEXHALER 180
MCG/ACT 13
PULMICORT FLEXHALER 90
MCG/ACT 13
PULMOZYME 83
PURINETHOL 32
PX PEN NEEDLE 29GX12MM 70
PYLERA 86
pyrazinamide 500 mg 31
pyridostigmine bromide 60 mg 30
QC PEN NEEDLES 29G X
12MM 70
QNASL 74
QUALAQUIN 30
QUARTETTE 48
QUAZEPAM 66
questran 4 gm 26
questran 4 gm/dose 26
questran light 26
quetiapine fumarate 38
QUILLIVANT XR 1
quinapril hcl 27
quinapril-hydrochlorothiazide 29
quinidine gluconate 324 mg 12
quinidine sulfate 12
quinidine sulfate er 12
quinine sulfate 324 mg 30
QVAR 14
RABAVERT 88
rabeprazole sodium 86
ramipril 28
RANEXA 11
ranitidine hcl 15 mg/ml, 150
mg/10ml, 75 mg/5ml 85
ranitidine hcl 150 mg 85
ranitidine hcl 150 mg, 300 mg 85
ranitidine hcl 150 mg/6ml, 50
mg/2ml 85
ranitidine hcl 25 mg/ml 85
ranitidine hcl 300 mg 85
RAPAFLO 64
RAPAMUNE 0.5 MG 42
RAPAMUNE 1 MG 42
RAPAMUNE 1 MG/ML 42
RAPAMUNE 2 MG 42
RAYOS 50
RAZADYNE 82
RAZADYNE ER 82
REBETOL 200 MG 40
REBETOL 40 MG/ML 40
REBIF 83
REBIF REBIDOSE 83
REBIF REBIDOSE
TITRATIONPACK 83
REBIF TITRATION PACK 83
RECLAST 58
RECOMBIVAX HB 88
RECTIV 9
REGLAN 10 MG, 5 MG 62
REGLAN 5 MG/ML 62
REGONOL 30
REGRANEX 56
RELENZA DISKHALER 41
RELION PEN NEEDLES
29GX12MM 70
RELISTOR 63
RELPAX 71
REMERON 18
REMERON SOLTAB 18
REMICADE 63
REMODULIN 45
RENVELA 63
repaglinide 0.5 mg, 1 mg 22
repaglinide 2 mg 22
reprexain 7
REQUIP 36
REQUIP XL 36
RESCRIPTOR 39
RESCULA 79
reserpine 0.1 mg, 0.25 mg 28
RESTASIS 77
RETIN-A 51
RETIN-A MICRO 51
RETIN-A MICRO PUMP 51
RETROVIR 39
RETROVIR IV INFUSION 39
REVATIO 45
revia 23
REVLIMID 10 MG, 15 MG, 25
MG, 5 MG 41
REVLIMID 2.5 MG 41
REYATAZ 100 MG 39
REYATAZ 150 MG, 200 MG,
300 MG 40
RHEUMATREX 2
RHINOCORT AQUA 74
ribavirin (hepatitis c) 40
rifadin 150 mg 31
RIFADIN 300 MG 31
RIFADIN 600 MG 31
rifamate 30
rifampin 150 mg 31
rifampin 300 mg 31
rifampin 600 mg 31
RIFATER 30
RILUTEK 75
riluzole 75
rimantadine hydrochloride 41
RIMSO-50 63
ringer's 72
ringer's irrigation 42
RIOMET 21
RISPERDAL 37
RISPERDAL CONSTA 12.5
MG 37
RISPERDAL CONSTA 25 MG 37
RISPERDAL CONSTA 37.5 MG,
50 MG 37
RISPERDAL M-TAB 37
risperidone 37
RITALIN 2
RITALIN LA 2
RITALIN SR 2
RITUXAN 32
rivastigmine tartrate 82
rizatriptan benzoate 71
ROBAXIN 100 MG/ML 74
ROBAXIN 500 MG 74
ROBAXIN-750 74
ROBINUL 0.2 MG/ML, 0.4
MG/2ML, 1 MG/5ML, 4
MG/20ML 85
ROBINUL 1 MG 85
ROBINUL FORTE 85
ROCALTROL 60
rocephin 1 gm 47
rocephin 500 mg 47
ROMAZICON 23
ropinirole hydrochloride 36
ROTARIX 88
ROTATEQ 88
ROWASA 63
roxicet 7
Index 23

ROXICODONE 15 MG, 30 MG 6
ROXICODONE 5 MG 6
ROZEREM 66
RYBIX ODT 6
RYTHMOL 12
RYTHMOL SR 12
RYZOLT 6
SABRIL 17
SAFYRAL 48
SAIZEN 59
SAIZEN CLICK.EASY 59
SALAGEN 73
SAMSCA 60
SANCTURA 87
SANCTURA XR 87
SANCUSO 23
SANDIMMUNE 100 MG, 25
MG 42
SANDIMMUNE 100 MG/ML 42
SANDIMMUNE 50 MG/ML 42
SANDOSTATIN 100 MCG/ML,
200 MCG/ML, 50 MCG/ML 60
SANDOSTATIN 1000 MCG/ML,
500 MCG/ML 60
SANDOSTATIN LAR DEPOT 60
SANTYL 55
SAPHRIS 10 MG 38
SAPHRIS 5 MG 38
SAVELLA 82
SAVELLA TITRATION PACK 82
SEASONALE 48
SEASONIQUE 48
SECTRAL 43
selegiline hcl 5 mg 37
selenium sulfide 2.5 % 52
SELSUN SHAMPOO 53
SELZENTRY 40
SEMPREX-D 50
SENSIPAR 60
sensorcaine-mpf/epinephrine 67
SEPTRA DS 10
SEREVENT DISKUS 14
seromycin 31
SEROQUEL 38
SEROQUEL XR 38
SEROSTIM 59
sertraline hcl 100 mg, 25 mg, 50
mg 19
sertraline hcl 20 mg/ml 19
SHOPKO UNIFINE PENTIPS
PEN
NEEDLES/ORIGINAL/29GX12
MM 70
SIGNIFOR 60
sildenafil citrate (pulmonary
hypertension) 45
SILENOR 65
SILVADENE 53
silver sulfadiazine 1 % 53
SIMBRINZA 77
SIMCOR 20-1000 MG, 20-500
MG, 20-750 MG 27
SIMCOR 40-1000 MG, 40-500
MG 27
SIMPONI 2
SIMPONI ARIA 2
SIMULECT 42
simvastatin 10 mg 27
simvastatin 20 mg 27
simvastatin 40 mg 27
simvastatin 5 mg 27
simvastatin 80 mg 27
SINEMET 36
SINEMET CR 36
SINGULAIR 13
SIRTURO 31
SKELAXIN 74
SKLICE 56
sodium acetate 2 meq/ml 71
sodium bicarbonate 7.5 % 71
sodium bicarbonate 8.4 % 71
sodium chloride (gu irrigant) 63
sodium chloride 0.45 % 73
sodium chloride 0.9 %, 3 %, 5
% 73
sodium chloride 2.5 meq/ml 73
SODIUM DIURIL 57
sodium fluoride 1 mg 72
SODIUM LACTATE 167
MEQ/L, 5 MEQ/ML
sodium phenylbutyrate 3
71
gm/tsp 60
sodium phosphate 72
sodium polystyrene sulfonate42
sodium polystyrene sulfonate
15 gm/60ml 42
SOLARAZE 52
SOLODYN 84
SOLTAMOX 33
SOLU-CORTEF 100 MG, 250
MG, 500 MG 50
SOLU-CORTEF 1000 MG 50
SOLU-MEDROL 1000 MG, 125
MG, 40 MG, 500 MG 50
SOLU-MEDROL 2 GM 50
SOMA 74
SOMATULINE DEPOT 60
SOMAVERT 58
SONATA 66
SORBITOL 3 %, 3.3 % 63
sorbitol-mannitol 63
SORIATANE 52
SORILUX 52
sotalol hcl 43
sotalol hcl (afib/afl) 43
SPIRIVA HANDIHALER 13
spironolactone &
hydrochlorothiazide 57
spironolactone 100 mg, 25 mg,
50 mg 57
SPORANOX 25
SPORANOX PULSEPAK 25
SPRIX 4
SPRYCEL 34
sps 42
STALEVO 100 36
STALEVO 125 37
STALEVO 150 37
STALEVO 200 37
STALEVO 50 37
STALEVO 75 37
STARLIX 22
stavudine 40
STAVZOR 18
STELARA 52
STIMATE 60
STIVARGA 34
STRATTERA 10 MG 1
STRATTERA 100 MG, 60 MG,
80 MG 1
STRATTERA 18 MG 1
STRATTERA 25 MG 1
STRATTERA 40 MG 1
streptomycin sulfate 1 gm 2
STRIANT 8
STRIBILD 40
Index 24

STROMECTOL 9
SUBLIMAZE 6
SUBOXONE 8
SUBSYS 100 MCG, 1200 MCG,
1600 MCG, 600 MCG
SUBSYS 200 MCG, 400 MCG,
6
800 MCG 6
SUBUTEX 8
SUCRAID 56
sucralfate 1 gm 86
SULAR 44
sulfacetamide sodprednisolone
78
sulfacetamide sodium (acne) 51
sulfacetamide sodium (ophth) 77
sulfacetamide sodium 10 % 77
sulfadiazine 500 mg 83
sulfamethoxazole-trimethoprim 10
sulfamethoxazole-trimethoprim
SOLN IV 80-400 MG/5ML 10
SULFAMYLON 53
sulfasalazine 500 mg 63
sulindac 150 mg, 200 mg 4
sumatriptan 20 mg/act 71
sumatriptan 5 mg/act 71
sumatriptan succinate 100 mg,
25 mg, 50 mg
sumatriptan succinate 4
71
mg/0.5ml, 6 mg/0.5ml 71
SUMAVEL DOSEPRO 71
suprax 100 mg/5ml, 200
mg/5ml 47
SUPRAX 400 MG 47
suprax 400 mg 47
SUPRAX 500 MG/5ML 47
SUPREP BOWEL PREP 66
SURE COMFORT PEN
NEEDLES29GX1/2" 12.7MM
SURE COMFORT PEN
70
NEEDLES30GX5/16" SHORT 70
SURE-FINE PEN NEEDLES
29GX1/2" 12.7MM 70
SURMONTIL 20
SUSTIVA 40
SUTENT 34
SYLATRON 35
SYMBICORT 14
SYMLINPEN 120 20
SYMLINPEN 60 20
SYNAGIS 80
SYNALAR 0.01 % 55
synalar 0.025 % 55
SYNALGOS-DC 8
SYNAREL 59
SYNERA 56
SYNERCID 11
SYNRIBO 35
SYNTHROID 84
SYPRINE 41
TABLOID 32
TACLONEX 55
tacrolimus 0.5 mg, 1 mg 42
tacrolimus 5 mg 42
TAFINLAR 34
TALWIN 8
TAMBOCOR 100 MG 13
TAMBOCOR 150 MG 13
TAMBOCOR 50 MG 13
TAMIFLU 30 MG, 45 MG 41
TAMIFLU 6 MG/ML 41
TAMIFLU 75 MG 41
tamoxifen citrate 10 mg, 20
mg 33
tamsulosin hcl 64
tapazole 84
TARCEVA 34
TARGRETIN 35
TARKA 29
TASIGNA 34
TAXOTERE 20 MG/0.5ML 36
TAXOTERE 20 MG/ML, 80
MG/4ML 36
TAZORAC 52
TECFIDERA 83
TECFIDERA STARTER
PACK 83
TEFLARO 47
TEGRETOL 16
TEGRETOL-XR 100 MG 16
TEGRETOL-XR 200 MG, 400
MG 17
TEKAMLO 29
TEKTURNA 30
TEKTURNA HCT 29
TEMODAR 31
TEMOVATE 55
TEMOVATE E 55
TENEX 28
TENIVAC 84
TENORETIC 100 29
TENORETIC 50 29
TENORMIN 43
TERAZOL 3 88
TERAZOL 7 88
terazosin hcl 28
terbinafine hcl 250 mg 24
terbutaline sulfate 1 mg/ml 14
terbutaline sulfate 2.5 mg, 5
mg 14
terconazole vaginal 88
TESSALON 50
TESSALON PERLES 50
TESTIM 9
testopel 9
testosterone cypionate 100
mg/ml, 200 mg/ml
testosterone enanthate 200
9
mg/ml
TETANUS TOXOID
9
ADSORBED
TETANUS/DIPHTHERIA
84
TOXOIDS-ADSORBED
ADULT
tetracycline hcl 250 mg, 500
84
mg 84
TEV-TROPIN 59
TEVETEN 400 MG 28
TEVETEN 600 MG 28
TEVETEN HCT 29
TEXACORT 55
THALITONE 57
THALOMID 41
theophylline 14
theophylline er 14
theophylline in dextrose 14
THEOPHYLLINE/D5W 14
THERACYS 35
thioridazine hcl 10 mg, 100 mg,
25 mg, 50 mg 38
thiotepa 15 mg 31
thiothixene 1 mg, 10 mg, 2 mg, 5
mg 39
THYMOGLOBULIN 42
tiagabine hcl 17
TIAZAC 44
ticarcillin & pot clavulanate 81
TICE BCG 35
ticlopidine hcl 64
TIGAN 100 MG/ML 24
Index 25

TIGAN 300 MG 24
TIKOSYN 13
TIMENTIN 81
timolol maleate (ophth) 76
timolol maleate 10 mg 43
timolol maleate 20 mg 43
timolol maleate 5 mg 43
TIMOPTIC 76
TIMOPTIC OCUDOSE 76
TIMOPTIC-XE 76
tinidazole 250 mg, 500 mg 9
TIVICAY 40
tizanidine hcl 2 mg 74
tizanidine hcl 4 mg 74
tizanidine hcl 6 mg 74
TOBI 2
TOBI PODHALER 2
TOBRADEX 78
TOBRADEX ST 78
tobramycin 300 mg/5ml 2
tobramycin sulfate (ophth) 77
tobramycin sulfate 1.2 gm 2
tobramycin sulfate 1.2 gm/30ml,
40 mg/ml, 80 mg/2ml 2
tobramycin sulfate 10 mg/ml, 40
mg/ml
tobramycin sulfate/sodium
2
chloride 2
tobramycin-dexamethasone 78
TOBREX 77
TODAYS HEALTH ORIGINAL
PEN NEEDLES 29G X 1/2" 70
tofranil 20
TOFRANIL-PM 20
tolazamide 23
tolbutamide 23
tolmetin sodium 4
tolterodine tartrate 87
TOPAMAX 17
TOPAMAX SPRINKLE 17
topicort 0.05 % 55
TOPICORT 0.05 % 55
topicort 0.05 %, 0.25 % 55
TOPICORT 0.25 % 55
topicort 0.25 % 55
topiramate 100 mg, 200 mg, 25
mg, 50 mg 17
topiramate 15 mg, 25 mg 17
topotecan hcl 4 mg 36
TOPOTECAN HCL 4
MG/4ML 36
TOPROL XL 43
TORISEL 34
torsemide 10 mg, 100 mg, 20
mg, 5 mg
torsemide 20 mg/2ml, 50
57
mg/5ml 57
TOTECT 35
TOVIAZ 87
TRACLEER 45
TRADJENTA 21
tramadol hcl 100 mg, 200 mg,
300 mg 6
tramadol hcl 50 mg 6
tramadol-acetaminophen 8
TRANDATE 43
trandolapril 28
tranexamic acid 100 mg/ml 65
tranexamic acid 650 mg 65
TRANXENE T 12
tranylcypromine sulfate 18
travasol 76
TRAVATAN Z 79
travoprost 79
trazodone hcl 100 mg, 150 mg,
300 mg, 50 mg 18
TREANDA 31
TRECATOR 31
TRELSTAR DEPOT 33
TRELSTAR DEPOT
MIXJECT 33
TRELSTAR LA 33
TRELSTAR LA MIXJECT 33
TRELSTAR MIXJECT 33
TRENTAL 64
tretinoin (chemotherapy) 35
tretinoin 0.01 %, 0.025 % 51
tretinoin 0.025 %, 0.05 %, 0.1
% 51
tretinoin microsphere 51
trexall 32
TREXIMET 70
trezix 8
TRI-NORINYL 28 48
triamcinolone acetonide
(mouth)
triamcinolone acetonide
73
(nasal) 74
triamcinolone acetonide
(topical) 55
triamcinolone acetonide 0.5 % 55
triamcinolone acetonide in
absorbase
triamterene &
55
hydrochlorothiazide 57
triamterene/hydrochlorothiazide 5
7
trianex 55
TRIBENZOR 29
TRICOR 26
TRIESENCE 78
trifluoperazine hcl 1 mg, 10 mg, 2
mg, 5 mg 38
trifluridine 1 % 77
TRIGLIDE 160 MG 26
TRIGLIDE 50 MG 26
trihexyphenidyl hcl 36
TRILEPTAL 17
TRILIPIX 26
trimethobenzamide hcl 100
mg/ml 24
trimethobenzamide hcl 300 mg 24
trimethoprim 100 mg 9
trimipramine maleate 100 mg, 25
mg, 50 mg 20
TRIOSTAT 84
TRIPEDIA 84
TRISENOX 35
TRIZIVIR 40
TROPHAMINE 76
tropicamide 0.5 %, 1 % 76
trospium chloride 87
TRUSOPT 79
TRUVADA 40
TUDORZA PRESSAIR 13
TUSSIONEX PENNKINETIC
EXTENDED RELEASE 50
TWINJECT 88
TWINRIX 88
TWYNSTA 29
TYGACIL 10
TYKERB 34
tylenol/codeine #3 8
tylenol/codeine #4 8
tylox 8
TYPHIM VI 87
TYSABRI 83
TYVASO 45
Index 26

TYVASO REFILL 45
TYVASO STARTER 45
TYZEKA 40
tyzine 75
tyzine pediatric nasal drops 75
UCERIS 50
ULESFIA 56
ULORIC 64
ULTICARE ORIGINAL PEN
NEEDLES ULTI-FINE
ULTICARE PEN
70
NEEDLES/29GX 12.7MM
ULTRA-THIN II PEN
70
NEEDLE/29G X 1/2" 70
ULTRA-THIN II PEN NEEDLES
29GX1/2" 70
ULTRACET 8
ULTRAM 6
ULTRAM ER 6
ULTRAVATE 55
ULTRAVATE PAC 55
ULTRESA 56
UNASYN 0.5-1 GM 81
UNASYN 1-2 GM 81
UNASYN ADD-VANTAGE 81
UNASYN BULK PACK 81
UNIFINE PENTIPS
29GX12MM
UNIFINE PENTIPS PLUS
70
29GX12MM 70
UNIRETIC 29
UNIVASC 28
urea-hc acetate 55
urecholine 87
UROCIT-K 10 63
UROCIT-K 5 63
UROXATRAL 64
URSO 250 62
URSO FORTE 62
ursodiol 250 mg, 500 mg 62
ursodiol 300 mg 62
UVADEX 35
VAGIFEM 88
valacyclovir hcl 1 gm, 1000 mg,
500 mg 41
VALCYTE 40
VALIUM 12
valproate sodium 100 mg/ml, 500
mg/5ml 18
valproate sodium 250 mg/5ml 18
valproic acid 250 mg 18
valsartanhydrochlorothiazide
29
VALTREX 41
VALTURNA 29
VALUMARK PEN NEEDLES
29GX12MM 70
VANCOCIN HCL 9
vancomycin hcl 10 gm, 5000
mg, 750 mg 10
vancomycin hcl 1000 mg, 500
mg 10
vancomycin hcl 125 mg, 250
mg
VANCOMYCIN HCL IN
10
DEXTROSE 10
VANDETANIB 34
VANOS 55
VANTAS 33
VAPRISOL 60
VAQTA 88
VARIVAX 88
VARIZIG 80
VASCEPA 26
VASERETIC 30
VASOTEC 10 MG 28
VASOTEC 2.5 MG 28
VASOTEC 20 MG 28
VASOTEC 5 MG 28
VECTIBIX 32
VECTICAL 52
vecuronium bromide 10 mg 75
VELCADE 34
VELETRI 45
VELTIN 51
venlafaxine hcl 100 mg 19
venlafaxine hcl 150 mg 19
venlafaxine hcl 25 mg 19
venlafaxine hcl 37.5 mg 19
venlafaxine hcl 50 mg 19
venlafaxine hcl 75 mg 19
VENLAFAXINE HCL ER 150
MG 19
venlafaxine hcl er 225 mg 19
venlafaxine hcl er 37.5 mg 19
venlafaxine hcl er 75 mg 19
VENTAVIS 10 MCG/ML 45
VENTAVIS 20 MCG/ML 45
VENTOLIN HFA 14
VERAMYST 75
verapamil hcl 100 mg, 120 mg,
180 mg, 200 mg, 240 mg, 300
mg, 360 mg 44
verapamil hcl 120 mg, 180 mg,
240 mg 44
verapamil hcl 120 mg, 40 mg, 80
mg 44
verapamil hcl 2.5 mg/ml 44
VERDESO 55
VERELAN 44
VERELAN PM 44
veripred 20 50
VESICARE 87
VEXOL 78
VFEND 25
VFEND IV 25
VIBRAMYCIN 100 MG 84
VIBRAMYCIN 25 MG/5ML 84
VIBRAMYCIN 50 MG/5ML 84
vicodin 8
vicodin es 8
VICOPROFEN 8
VICTOZA 21
VICTRELIS 40
VIDA MIA UNIFINE
PENTIPSORIGINAL
29GX12MM 70
VIDAZA 32
VIDEX EC 40
VIDEXPEDIATRIC 40
VIGAMOX 77
VIIBRYD 18
VIMOVO 4
VIMPAT 10 MG/ML 17
VIMPAT 100 MG, 150 MG, 200
MG, 50 MG 17
VIMPAT 200 MG/20ML 17
vinblastine sulfate 1 mg/ml 36
vinblastine sulfate 10 mg 36
vincristine sulfate 1 mg/ml 36
vinorelbine tartrate 36
VIOKACE 56
VIRACEPT 40
VIRAMUNE 200 MG 40
VIRAMUNE 50 MG/5ML 40
VIRAMUNE XR 100 MG 40
VIRAMUNE XR 400 MG 40
VIREAD 150 MG, 300 MG 40
Index 27

VIREAD 200 MG, 250 MG 40
VIREAD 40 MG/GM 40
VIROPTIC 77
VISICOL 66
VISTARIL 11
VISTIDE 40
vivactil 20
VIVELLE-DOT 61
VIVITROL 23
VOLTAREN 51
VOLTAREN-XR 4
VORAXAZE 35
voriconazole 200 mg 25
voriconazole 200 mg, 50 mg 25
voriconazole 40 mg/ml 25
VOSOL HC 79
vospire er 14
VOTRIENT 34
VPRIV 64
VUSION 52
VYTORIN 10-10 MG 25
VYTORIN 10-20 MG 25
VYTORIN 10-40 MG 26
VYTORIN 10-80 MG 26
VYVANSE 20 MG 1
VYVANSE 30 MG 1
VYVANSE 40 MG, 50 MG, 60
MG, 70 MG 1
warfarin sodium 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6
mg, 7.5 mg 15
water for irrigation, sterile 42
WELCHOL 26
WELLBUTRIN 100 MG 18
WELLBUTRIN 75 MG 18
WELLBUTRIN SR 100 MG 18
WELLBUTRIN SR 150 MG, 200
MG 18
WELLBUTRIN XL 150 MG 18
WELLBUTRIN XL 300 MG 18
WESTCORT 55
XALATAN 79
XALKORI 34
XANAX 12
XANAX XR 12
XARELTO 15
XELJANZ 2
XENAZINE 82
XENICAL 1
XEOMIN 75
XERESE 53
XGEVA 58
XIAFLEX 41
XIFAXAN 200 MG 10
XIFAXAN 550 MG 10
xodol 8
XOLAIR 13
XOLEGEL 52
XOPENEX 14
XOPENEX CONCENTRATE 14
XOPENEX HFA 14
XTANDI 33
XYLOCAINE 0.5 % 67
XYLOCAINE 1 %, 2 % 67
XYLOCAINE 20 MG/ML 12
XYLOCAINE 4 % 56
XYLOCAINE JELLY 56
XYLOCAINE-MPF 0.5 %, 1.5
% 67
XYLOCAINE-MPF 1 %, 2 %, 4
%
XYLOCAINE-
67
MPF/EPINEPHRINE 67
XYLOCAINE/EPINEPHRINE
0.5-1 %, :200000 67
XYLOCAINE/EPINEPHRINE
0.5-1-1-1 %, :100000, MG/ML,
0.5-1-1-2 %, :100000,
MG/ML 67
XYREM 82
XYZAL 25
YASMIN 28 48
YAZ 48
YERVOY 32
YF-VAX 88
zafirlukast 13
zaleplon 66
ZALTRAP 32
zamicet 8
ZANAFLEX 2 MG 74
ZANAFLEX 4 MG 74
ZANAFLEX 6 MG 74
ZANOSAR 31
ZANTAC 0.45-50 %,
MG/50ML 85
ZANTAC 15 MG/ML 85
ZANTAC 150 MG 86
ZANTAC 25 MG 86
ZANTAC 25 MG/ML 85
ZANTAC 300 MG 86
ZARONTIN 250 MG 17
zarontin 250 mg/5ml 17
ZAROXOLYN 57
ZAVESCA 65
ZEBETA 43
ZEGERID 20-1100 MG 86
ZEGERID 20-1680 MG 86
ZEGERID 40-1100 MG 86
ZEGERID 40-1680 MG 86
ZELAPAR 37
ZELBORAF 34
ZEMAIRA 83
ZEMPLAR 1 MCG, 2 MCG, 4
MCG
ZEMPLAR 2 MCG/ML, 5
60
MCG/ML 60
ZENPEP 56
zenzedi 1
ZERIT 40
ZESTORETIC 30
ZESTRIL 28
ZETIA 27
ZETONNA 75
ZIAC 30
ZIAGEN 40
ZIANA 51
zidovudine 40
ZINACEF 1.5 GM, 7.5 GM 46
ZINACEF 1.5 GM, 750 MG 46
ZINACEF 750 MG 46
ZINACEFIN ISO-OSMOTIC
DEXTROSE
ZINACEFIN ISO-OSMOTIC
46
DILUENT 46
ZINECARD 35
ZIOPTAN 79
ziprasidone hcl 37
ZIPSOR 4
ZIRGAN 77
ZITHROMAX 1 GM 68
ZITHROMAX 100 MG/5ML, 200
MG/5ML 68
ZITHROMAX 250 MG, 500 MG,
600 MG 68
ZITHROMAX 500 MG 68
ZITHROMAX TRI-PAK 68
Index 28

ZITHROMAX Z-PAK 68
ZMAX 68
ZOCOR 10 MG 27
ZOCOR 20 MG 27
ZOCOR 40 MG 27
ZOCOR 5 MG 27
ZOCOR 80 MG 27
ZOFRAN 4 MG, 8 MG 24
ZOFRAN 4 MG/5ML 24
ZOFRAN 40 MG/20ML 23
ZOFRAN ODT 23
ZOLADEX 10.8 MG 33
ZOLADEX 3.6 MG 33
ZOLEDRONIC ACID 4 MG 58
zoledronic acid 4 mg/5ml 58
zoledronic acid 5 mg/100ml 58
ZOLINZA 34
zolmitriptan 71
ZOLOFT 19
zolpidem tartrate 10 mg 66
zolpidem tartrate 12.5 mg 66
zolpidem tartrate 5 mg 66
zolpidem tartrate 6.25 mg 66
ZOLPIMIST 66
zolvit 8
ZOMETA 58
ZOMIG 71
ZOMIG NASAL SPRAY 71
ZOMIG ZMT 71
ZONALON 52
ZONEGRAN 17
zonisamide 17
ZORBTIVE 59
ZORTRESS 0.25 MG 42
ZORTRESS 0.5 MG, 0.75 MG 42
ZOSTAVAX 88
ZOSYN 0.25-0.5-2 GM, MG, 4.5-
36 GM
ZOSYN 0.25-0.5-2-5 %,
81
GM/50ML, MG/50ML, 0.375-
0.75-3-5 %, GM/50ML,
MG/50ML, 0.5-1-4-5 %,
GM/100ML, MG/100ML 81
ZOSYN 0.375-0.75-3 GM, MG,
0.5-1-4 GM, MG 81
zovia 1/50e 48
ZOVIRAX 200 MG 41
ZOVIRAX 200 MG/5ML 41
ZOVIRAX 400 MG, 800 MG 41
ZOVIRAX 5 % 53
ZUBSOLV 8
ZUPLENZ 24
ZUTRIPRO 50
ZYBAN 83
ZYCLARA 55
ZYCLARA PUMP 55
zydone 8
ZYFLO CR 13
ZYLET 78
ZYLOPRIM 100 MG 64
ZYLOPRIM 300 MG 64
ZYMAXID 77
ZYPREXA 10 MG 38
ZYPREXA 10 MG, 15 MG, 2.5
MG, 20 MG, 5 MG, 7.5 MG 38
ZYPREXA ZYDIS 38
ZYTIGA 33
ZYVOX 100 MG/5ML 11
ZYVOX 2 MG/ML 11
ZYVOX 600 MG 11
Index 29