2013 formulary (list of covered drugs)
TRANSCRIPT
ODS AdvantageComprehensive Formulary
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
Benefi ciaries must use network pharmacies to access their prescription drug benefi t. Benefi ts, formulary, pharmacy network, premium and/or copayments/coinsurance may change onJanuary 1, 2014.
To receive this document in an alternate format or language, please contact Pharmacy Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacifi c time, seven days a week.
www.odscompanies.com/odsadvantage
2013 Formulary (List of covered drugs)
H3813-003H3813-006
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�Combined Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC)
�Comprehensive Formulary (if applicable)
�Provider and/or Pharmacy Directory (if applicable)
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I
ODS Advantage Comprehensive Formulary
2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014. ODS Advantage PPORX plan is a PPO plan with a Medicare contract. To receive document in an alternate format or language, please contact Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week.
Formulary ID 00013384, Version 5 H3813_1085PPORXS13A
File & Use (09/11/2012)
II
What is the ODS Advantage Formulary?
A formulary is a list of covered drugs selected by ODS Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. ODS Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a ODS Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 2012. To get updated information about the drugs covered by ODS Advantage, please visit our Web site at www.odscompanies.com/odsadvantage or call Customer Service at 1-888-786-7509, from 7 am to 8 pm, Pacific time, seven days a week. (TTY/TDD users should call 711.) How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiac Drugs. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
III
Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1 (at the back of this booklet). The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs? ODS Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: ODS Advantage requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from ODS Advantage before you fill your prescriptions. If you don’t get approval, ODS Advantage may not cover the drug.
• Quantity Limits: For certain drugs, ODS Advantage limits the amount of the drug that ODS Advantage will cover. For example, ODS Advantage provides 9 tablets in 28 days per prescription for sumatriptan (Imitrex) tablets. This may be in addition to a standard one month or three month supply.
• Step Therapy: In some cases, ODS Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, ODS Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, ODS Advantage will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at www.odscompanies.com/odsadvantage. You can ask ODS Advantage to make an exception to these restrictions or limits. See the section, “How do I request an exception to the ODS Advantage formulary?” on page IV for information about how to request an exception.
IV
What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that ODS Advantage does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by ODS Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by ODS Advantage.
• You can ask ODS Advantage to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the ODS Advantage Formulary? You can ask ODS Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, ODS Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in one of our non-preferred/highest tiers subject to the tiering exceptions process tier (Tier 2 or Tier 4), you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred/lowest tier subject to the tiering exceptions process tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the tier designated as the high-cost/unique drug tier (Specialty tier – Tier 5).
Generally, ODS Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s
V
supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
If you have a level of care change, (going into or coming out of a skilled nursing facility or long term care home) we will provide you with a 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
For more information For more detailed information about your ODS Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about ODS Advantage, please call Customer Service at 1-888-786-7509, 7 am to 8 pm, Pacific time, seven days a week. (TTY/TDD users should call 711.) Or visit www.odscompanies.com/odsadvantage.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.
VI
ODS Advantage Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by ODS Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ASMANEX) and generic drugs are listed in lower-case italics (e.g., sumatriptan). The information in the Requirements/Limits column tells you if ODS Advantage has any special requirements for coverage of your drug.
o LA – This prescription may be available only at certain pharmacies. For more information call
Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
o PA for Ages 65 and Older; May be High Risk Medication – The Centers for Medicare and Medicaid Services (CMS) considers this medication to be of high risk for patients 65 years old or older. Please contact your provider for more information.
o PA – Prior authorization is required for these drugs. This means you or your provider will need to get approval from ODS Advantage before you can fill your prescription. If you don’t get approval, ODS Advantage may not cover the drug. See page IV for how to request an exception. If you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
o PA for Part B vs Part D Only - This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. If you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
o PA for ESRD only – These drugs are also prescribed for members who have End-Stage Renal
Disease (ESRD). If you have ESRD then you may need to receive these drugs from your dialysis facility. If you don’t have ESRD, see page IV for how to request an exception. If you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
o QL – These drugs have a quantity limit. This means you will receive a limited amount of these drugs unless you or your provider asks for an exception to the quantity limit. See page IV for how to request an exception. The maximum dosage allowed for the drug is noted first, then the days supply (e.g., sumatriptan tablets QL 9 in 28 days, this means a maximum of 9 tablets are allowed within 28 days). If you need help asking for an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
VII
o Rx Product Only - This drug is now available as a generic over-the-counter (OTC) medication. OTC products are not covered under your Part D benefit. The prescription strength is only covered under your Part D benefit. If you have questions please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
o ST – These drugs require you to first try certain other drugs to treat your medical condition
before we will cover this drug. See page IV for how to request an exception. If you need help asking for an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week. (TTY users should call 711.)
Below is your cost sharing by plan and tier.
ODS Advantage PPORX ODS Advantage PPORX Select
Deductible $120.00 $120.00 Drug Tier up to a 31-day
supply up to a 93-day
supply up to a 31-day
supply up to a 93-day
supply Tier 1 $5.00 $15.00 $5.00 $15.00 Tier 2 $33.00 $99.00 $33.00 $99.00 Tier 3 $41.00 $123.00 $41.00 $123.00 Tier 4 50% 50% 50% 50% Tier 5 30% drugs on this tier
are limited to a 31-day supply
30% drugs on this tier are limited to a 31-
day supply
1
Drug Name Drug
Tier Requirements/Limits
Adrenals Adrenals
ADVAIR DISKUS 3 QL: 62 in
31 days
ADVAIR HFA 3 QL: 12 in
28 days
AEROBID-M 4 QL: 14 in
25 days
A-HYDROCORT 4 PA (PA for Part B vs
Part D Only)
ALVESCO 4 QL: 12.2
in 25
days
ASMANEX 4 QL: 1 in
14 days
aer pow ba:
220mcg(60)
ASMANEX 4 QL: 1 in
25 days
aer pow ba:
110mcg(30),
220mcg120
ASMANEX 4 QL: 1 in
7 days
aer pow ba:
220mcg(30)
betamet acet/betamet na
ph
(Celestone) 1 PA (PA for Part B vs
Part D Only)
budesonide (Entocort EC) 2 capdr & er
cortisone acetate (Cortisone Acetate) 1 PA (PA for Part B vs
Part D Only)
dexamethasone acetate (Dexamethasone Acetate) 1 PA (PA for Part B vs
Part D Only)
dexamethasone sod
phosphate
(Dexamethasone Sod Phosphate) 1 PA vial: 10mg/ml, (PA
for Part B vs Part D
Only)
dexamethasone sod
phosphate
(Dexamethasone Sod Phosphate) 1 PA vial: 4mg/ml, (PA
for Part B vs Part D
Only)
dexamethasone (Dexamethasone) 1 PA elixir, tablet, (PA
for Part B vs Part D
Only)
dexamethasone (Dexamethasone) 1 PA tab ds pk, (PA for
Part B vs Part D
Only)
DULERA 3 QL: 13 in
28 days
2
Drug Name Drug
Tier Requirements/Limits
FLOVENT DISKUS 3 QL: 120
in 30
days
disk w/dev: 250mcg
FLOVENT DISKUS 3 QL: 60 in
30 days
disk w/dev: 50mcg,
100mcg
FLOVENT HFA 3 QL: 12 in
28 days
aer w/adap: 110mcg
FLOVENT HFA 3 QL: 21.2
in 28
days
aer w/adap: 44mcg
FLOVENT HFA 3 QL: 24 in
28 days
aer w/adap: 220mcg
fludrocortisone acetate (Fludrocortisone Acetate) 1
hydrocortisone sod
succinate
(Hydrocortisone Sod Succinate) 1 PA (PA for Part B vs
Part D Only)
hydrocortisone (Cortef) 1 PA (PA for Part B vs
Part D Only)
methylprednisolone
acetate
(Depo-medrol) 1 PA (PA for Part B vs
Part D Only)
methylprednisolone sod
succ
(Solu-medrol) 1 PA vial: 1000mg, (PA
for Part B vs Part D
Only)
methylprednisolone sod
succ
(Solu-medrol) 1 PA vial: 125mg/2ml,
(PA for Part B vs
Part D Only)
methylprednisolone (Medrol) 1 PA (PA for Part B vs
Part D Only)
prednisolone acetate (Prednisolone Acetate) 1 PA (PA for Part B vs
Part D Only)
prednisolone sod
phosphate
(Orapred) 1 PA (PA for Part B vs
Part D Only)
prednisolone (Prednisolone) 1 PA (PA for Part B vs
Part D Only)
PREDNISONE
INTENSOL
4 PA (PA for Part B vs
Part D Only)
prednisone (Prednisone) 1 PA solution, tablet,
(PA for Part B vs
Part D Only)
prednisone (Prednisone) 1 PA tab ds pk, (PA for
Part B vs Part D
Only)
3
Drug Name Drug
Tier Requirements/Limits
QVAR 3 QL: 17.4
in 25
days
SOLU-CORTEF (PF) 4 PA (PA for Part B vs
Part D Only)
SOLU-MEDROL (PF) 4 PA vial: 40mg/ml, (PA
for Part B vs Part D
Only)
SYMBICORT 4 ST, QL:
11 in 25
days
triamcinolone acetonide (Kenalog-40) 1 PA (PA for Part B vs
Part D Only)
VERIPRED 20 1 PA (PA for Part B vs
Part D Only)
Alpha-Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents
doxazosin mesylate (Cardura) 1
prazosin hcl (Minipress) 1
terazosin hcl (Hytrin) 1
Ammonia Detoxicants Ammonia Detoxicants
BUPHENYL 3
CARBAGLU 5
lactulose (Lactulose) 1 solution
lactulose (Lactulose) 1 syrup
LITHOSTAT 3
Analgesics and Antipyretics Analgesics And Antipyretics, Miscellaneous
acetaminophen/phenyltolx
cit
(Staflex) 1
ACUFLEX 4
FLEXTRA PLUS 4
mg sal/acetaminophn/p-
tlox/caf
(Durabac Forte) 1
OFIRMEV 4
RELAGESIC 4 liquid
sal-amide/acetamin/p-tlox/
caff
(Durabac) 1
sal-amide/acetaminophn/
p-tlox
(Asp) 1
4
Drug Name Drug
Tier Requirements/Limits
salicylamide/
acetaminophen
(Salicylamide/acetaminophen) 1
Nonsteroidal Anti-inflammatory Agents
CALDOLOR 4
CELEBREX 3 ST, QL:
62 in 31
days
choline sal/mag salicylate (Choline Sal/mag Salicylate) 1
diclofenac potassium (Cataflam) 1
diclofenac sodium (Voltaren) 1
diflunisal (Diflunisal) 1
etodolac (Etodolac) 1 capsule: 200mg;
tablet
etodolac (Etodolac) 1 capsule: 300mg
etodolac (Etodolac) 2 tab er 24h
fenoprofen calcium (Fenoprofen Calcium) 1
FLECTOR 4 ST
flurbiprofen (Ansaid) 1
ibuprofen (Motrin) 1
indomethacin sodium
trihydrate
(Indocin I.v.) 1 (May be High Risk
Med for Ages 65
and Older)
indomethacin (Indocin SR) 2 capsule er, (May be
High Risk Med for
Ages 65 and Older)
indomethacin (Indomethacin) 1 capsule, (May be
High Risk Med for
Ages 65 and Older)
ketoprofen (Ketoprofen) 1 capsule
ketoprofen (Ketoprofen) 2 cap24h pel
ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 20 in
31 days
vial: 60mg/2ml
ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 40 in
31 days
vial: 15mg/ml
ketorolac tromethamine (Toradol) 1 QL: 20 in
31 days
cartridge: 30mg/ml
ketorolac tromethamine (Toradol) 1 QL: 40 in
31 days
cartridge: 15mg/ml
LEVACET 4
magnesium salicylate (Magnesium Salicylate) 1
meclofenamate sodium (Meclofenamate Sodium) 2
mefenamic acid (Ponstel) 2
meloxicam (Mobic) 1
5
Drug Name Drug
Tier Requirements/Limits
nabumetone (Relafen) 1
naproxen sodium (Anaprox) 1
naproxen (Naprosyn) 1
oxaprozin (Oxaprozin) 1
piroxicam (Feldene) 1
salsalate (Salflex) 1
SOLARAZE 4
sulindac (Clinoril) 1
tolmetin sodium (Tolmetin Sodium) 2
VOLTAREN 3 ST gel (gram),
(Topical Gel)
Opiate Agonists
acetaminophen with
codeine
(Tylenol-codeine No.3) 1 QL: 180
in 30
days
tablet: 300mg-60mg
acetaminophen with
codeine
(Tylenol-codeine No.3) 1 QL: 180
in 30
days
tablet: 650mg-
30mg, 650mg-60mg
acetaminophen with
codeine
(Tylenol-codeine No.3) 1 QL: 360
in 30
days
tablet: 300mg-
15mg, 300mg-30mg
codeine phos/
acetaminophen
(Codeine Phos/acetaminophen) 1 QL: 2500
in 30
days
codeine phosphate (Codeine Phosphate) 1 (Injection)
codeine sulfate (Codeine Sulfate) 1 QL: 180
in 30
days
CODEINE SULFATE 1 QL: 1800
in 30
days
dhcodeine bt/
acetaminophn/caff
(Dhcodeine Bt/acetaminophn/
caff)
1 QL: 300
in 30
days
capsule
dhcodeine bt/
acetaminophn/caff
(Panlor SS) 1 QL: 150
in 30
days
tablet
fentanyl citrate (Actiq) 5 PA, QL:
120 in 30
days
fentanyl (Duragesic) 2 PA, QL:
10 in 30
days
patch td72: 12mcg/
hr, 25mcg/hr,
50mcg/hr, 75mcg/hr
6
Drug Name Drug
Tier Requirements/Limits
fentanyl (Duragesic) 2 PA, QL:
20 in 30
days
patch td72: 100mcg/
hr
hydrocodone bit/
acetaminophen
(Hycet) 1 QL: 2025
in 30
days
solution: 10-300/15
hydrocodone bit/
acetaminophen
(Hycet) 1 QL: 2700
in 30
days
solution: 5-163/7.5
hydrocodone bit/
acetaminophen
(Hycet) 1 QL: 2700
in 30
days
solution: 7.5-325/
15, 7.5-500/15
hydrocodone bit/
acetaminophen
(Vicodin) 1 QL: 150
in 30
days
tablet: 7.5-750mg,
10-750mg
hydrocodone bit/
acetaminophen
(Vicodin) 1 QL: 180
in 30
days
tablet: 7.5-650mg,
10-660mg, 10mg-
650mg
hydrocodone bit/
acetaminophen
(Vicodin) 1 QL: 240
in 30
days
capsule, tablet: 2.5-
500mg, 5mg-
500mg, 7.5-500mg,
10mg-500mg
hydrocodone bit/
acetaminophen
(Vicodin) 1 QL: 360
in 30
days
tablet: 2.5-325mg
hydrocodone bit/
acetaminophen
(Vicodin) 1 QL: 360
in 30
days
tablet: 5mg-325mg,
7.5-325mg, 10mg-
325mg
hydrocodone bit/
acetaminophen
(Vicodin) 1 QL: 390
in 30
days
tablet: 5mg-300mg,
7.5-300mg, 10mg-
300mg
hydrocodone/ibuprofen (Vicoprofen) 1 QL: 150
in 30
days
hydromorphone hcl (Dilaudid) 1 QL: 180
in 30
days
tablet: 2mg, 4mg
hydromorphone hcl (Dilaudid) 1 QL: 240
in 30
days
tablet: 8mg
hydromorphone hcl (Dilaudid) 2 vial
7
Drug Name Drug
Tier Requirements/Limits
hydromorphone hcl (Dilaudid-5) 1 QL: 1200
in 30
days
liquid
hydromorphone hcl/pf (Hydromorphone HCl/PF) 2 ampul, disp syrin
hydromorphone hcl/pf (Hydromorphone HCl/PF) 2 vial
ibuprofen/oxycodone hcl (Combunox) 1 QL: 28 in
30 days
KADIAN 3 ST, QL:
60 in 30
days
cap er pel: 10mg
KADIAN 5 ST, QL:
120 in 30
days
cap er pel: 200mg
levorphanol tartrate (Levo-dromoran) 2 QL: 180
in 30
days
methadone hcl (Methadone HCl) 1 vial
methadone hcl (Methadone HCl) 1 QL: 1800
in 30
days
oral conc, solution
methadone hcl (Methadose) 1 QL: 360
in 30
days
tablet
methadone hcl (Methadose) 1 QL: 90 in
30 days
tablet sol
morphine sulfate in 0.9 %
nacl
(Morphine Sulfate In 0.9 %
NaCl)
1
morphine sulfate (Kadian) 2 ST, QL:
60 in 30
days
cap er pel: 20mg,
30mg, 50mg, 60mg,
80mg
morphine sulfate (Kadian) 5 ST, QL:
60 in 30
days
cap er pel: 100mg
morphine sulfate (Morphine Sulfate) 1 disp syrin, pen
injctr, supp.rect, vial
morphine sulfate (MS Contin) 1 QL: 120
in 30
days
tablet er: 30mg,
60mg, 100mg
morphine sulfate (MS Contin) 1 QL: 180
in 30
days
tablet, tablet er:
15mg, 200mg
8
Drug Name Drug
Tier Requirements/Limits
morphine sulfate (MSIR) 1 QL: 200
in 30
days
solution: 100mg/
5ml
morphine sulfate (MSIR) 1 QL: 300
in 30
days
solution: 20mg/5ml
morphine sulfate (MSIR) 1 QL: 700
in 30
days
solution: 10mg/5ml
morphine sulfate/d5w (Morphine Sulfate/D5W) 1
morphine sulfate/pf (Morphine Sulfate/PF) 1 pca vial, vial: 25mg/
ml
morphine sulfate/pf (Morphine Sulfate/PF) 1 vial: 0.5mg/ml,
1mg/ml
NUCYNTA ER 3 QL: 60 in
30 days
NUCYNTA 3 QL: 181
in 30
days
oxycodone hcl (Oxycodone HCl) 1 QL: 120
in 30
days
tab er 12h: 80mg
oxycodone hcl (Oxycodone HCl) 1 QL: 1300
in 30
days
solution
oxycodone hcl (Oxycodone HCl) 1 QL: 60 in
30 days
tab er 12h: 10mg,
20mg, 40mg
oxycodone hcl (Roxicodone) 1 QL: 180
in 30
days
capsule, oral conc,
tablet: 5mg, 15mg,
30mg
oxycodone hcl (Roxicodone) 1 QL: 180
in 30
days
tablet: 10mg, 20mg
oxycodone hcl/
acetaminophen
(Oxycodone HCl/
acetaminophen)
1 QL: 1800
in 30
days
solution
oxycodone hcl/
acetaminophen
(Percocet) 1 QL: 180
in 30
days
tablet: 10mg-650mg
oxycodone hcl/
acetaminophen
(Percocet) 1 QL: 240
in 30
days
capsule, tablet:
5mg-500mg, 7.5-
500mg
9
Drug Name Drug
Tier Requirements/Limits
oxycodone hcl/
acetaminophen
(Percocet) 1 QL: 360
in 30
days
tablet: 2.5-325mg,
5mg-325mg, 7.5-
325mg, 10mg-
325mg
oxycodone hcl/aspirin (Percodan) 1 QL: 360
in 30
days
oxycodone hcl/oxycodon
ter/asa
(Oxycodone HCl/oxycodon Ter/
asa)
1 QL: 360
in 30
days
OXYCONTIN 3 QL: 120
in 30
days
tab er 12h: 80mg
OXYCONTIN 3 QL: 60 in
30 days
tab er 12h: 10mg,
15mg, 20mg, 30mg,
40mg, 60mg
oxymorphone hcl (Opana ER) 2 QL: 60 in
30 days
tab er 12h
oxymorphone hcl (Opana) 2 QL: 180
in 30
days
tablet
tramadol hcl (Ultram ER) 1 QL: 30 in
30 days
tab er 24h: 200mg,
300mg
tramadol hcl (Ultram ER) 1 QL: 90 in
30 days
tab er 24h: 100mg
tramadol hcl (Ultram) 1 QL: 240
in 30
days
tablet
tramadol hcl/
acetaminophen
(Ultracet) 1 QL: 240
in 30
days
10
Drug Name Drug
Tier Requirements/Limits
Opiate Partial Agonists
buprenorphine hcl (Buprenorphine HCl) 2 disp syrin
buprenorphine hcl (Subutex) 2 PA, QL:
20 in 30
days
tab subl: 2mg
buprenorphine hcl (Subutex) 2 PA, QL:
5 in 30
days
tab subl: 8mg
butorphanol tartrate (Butorphanol Tartrate) 2 disp syrin
butorphanol tartrate (Butorphanol Tartrate) 2 QL: 5 in
28 days
spray
nalbuphine hcl (Nalbuphine HCl) 1
SUBOXONE 4 PA, QL:
90 in 30
days
Androgens Androgens
ANADROL-50 5
ANDRODERM 4 QL: 30 in
30 days
patch td24: 2mg/
24hr, 4mg/24hr
ANDROGEL 3 QL: 150
in 30
days
gel md pmp
ANDROGEL 3 QL: 300
in 30
days
gel packet
AXIRON 3 QL: 180
in 28
days
danazol (Danocrine) 2
fluoxymesterone (Fluoxymesterone) 2
oxandrolone (Oxandrin) 2
TESTIM 4 PA, QL:
300 in 30
days
testosterone cypionate (Depo-testosterone) 1 PA
testosterone enanthate (Delatestryl) 1 PA, QL:
5 in 28
days
11
Drug Name Drug
Tier Requirements/Limits
Anorexigenics, Respiratory, Cerebral Stimulants Amphetamines
amphet asp/amphet/d-
amphet
(Adderall XR) 2 PA, QL:
30 in 30
days
cap er 24h, (PA for
Ages 65 and Older;
May be High Risk
Med)
amphet asp/amphet/d-
amphet
(Adderall) 1 PA, QL:
60 in 30
days
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
dextroamphetamine
sulfate
(Dexedrine) 2 PA, QL:
120 in 30
days
capsule er, (PA for
Ages 65 and Older;
May be High Risk
Med)
dextroamphetamine
sulfate
(Dextrostat) 1 PA, QL:
180 in 30
days
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
methamphetamine hcl (Desoxyn) 1 QL: 150
in 30
days
(May be High Risk
Med for Ages 65
and Older)
VYVANSE 4 PA, QL:
30 in 30
days
(PA for Ages 65 and
Older; May be High
Risk Med)
Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous
caffeine citrated (Cafcit) 1
caffeine/sodium benzoate (Caffeine/sodium Benzoate) 1
dexmethylphenidate hcl (Focalin) 1 PA, QL:
60 in 30
days
(PA for Ages 65 and
Older; May be High
Risk Med)
FOCALIN XR 4 PA, QL:
30 in 30
days
(PA for Ages 65 and
Older; May be High
Risk Med)
METADATE CD 4 PA, QL:
30 in 30
days
(PA for Ages 65 and
Older; May be High
Risk Med)
METHYLIN 4 PA, QL:
180 in 30
days
tab chew: 10mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
12
Drug Name Drug
Tier Requirements/Limits
METHYLIN 4 PA, QL:
90 in 30
days
tab chew: 2.5mg,
5mg, (PA for Ages
65 and Older; May
be High Risk Med)
methylphenidate hcl (Concerta) 2 PA, QL:
31 in 31
days
tab er 24, (PA for
Ages 65 and Older;
May be High Risk
Med)
methylphenidate hcl (Methylin) 1 PA, QL:
900 in 30
days
solution, (PA for
Ages 65 and Older;
May be High Risk
Med)
methylphenidate hcl (Ritalin LA) 2 PA, QL:
30 in 30
days
cpmp 50-50: 20mg,
40mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
methylphenidate hcl (Ritalin LA) 2 PA, QL:
60 in 30
days
cpmp 50-50: 30mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
methylphenidate hcl (Ritalin) 1 PA, QL:
90 in 30
days
tablet er: 10mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
methylphenidate hcl (Ritalin) 1 PA, QL:
90 in 30
days
tablet, tablet er:
20mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
NUVIGIL 4 PA, QL:
30 in 30
days
tablet: 150mg,
250mg
NUVIGIL 4 PA, QL:
90 in 30
days
tablet: 50mg
RITALIN LA 4 PA, QL:
30 in 30
days
cpmp 50-50: 10mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
13
Drug Name Drug
Tier Requirements/Limits
Anthelmintics Anthelmintics
ALBENZA 3
BILTRICIDE 4
mebendazole (Mebendazole) 1
STROMECTOL 3
Antiallergic Agents Antiallergic Agents
ALOMIDE 4
ASTEPRO 3 QL: 30 in
25 days
azelastine hcl (Astelin) 1 QL: 30 in
25 days
spray/pump
azelastine hcl (Optivar) 2 drops
BEPREVE 4 ST
epinastine hcl (Elestat) 2
PATADAY 3 ST
PATANASE 4 QL: 30.5
in 30
days
PATANOL 3 ST
Antibacterials Aminoglycosides
amikacin sulfate (Amikacin Sulfate) 1
gentamicin in nacl, iso-
osm
(Gentamicin In Nacl, Iso-osm) 1 piggyback: 60mg/
100ml, 100mg/50ml
gentamicin in nacl, iso-
osm
(Gentamicin In Nacl, Iso-osm) 1 piggyback: 60mg/
50ml, 70mg/50ml,
80mg/100ml, 80mg/
50ml, 90mg/100ml,
100mg/0.1l
gentamicin sulfate (Garamycin) 1
gentamicin sulfate/pf (Gentamicin Sulfate/PF) 1
kanamycin sulfate (Kanamycin Sulfate) 1 vial: 1g/3ml
kanamycin sulfate (Kanamycin Sulfate) 1 vial: 500mg/2ml
NEBCIN IN DEXTROSE 4
NEBCIN 4 vial: 80mg
neomycin sulfate (Neomycin Sulfate) 1 solution
neomycin sulfate (Neomycin Sulfate) 1 tablet
streptomycin sulfate (Streptomycin Sulfate) 2
TOBI 5 PA (PA for Part B vs
Part D Only)
14
Drug Name Drug
Tier Requirements/Limits
tobramycin sulfate (Nebcin) 1 vial port
tobramycin sulfate (Nebcin) 2 vial
tobramycin/sodium
chloride
(Tobramycin/sodium Chloride) 1
Antibacterials, Miscellaneous
bacitracin (Bacitracin) 2
chloramphenicol na succ (Chloramphenicol Na Succ) 1
clindamycin hcl (Cleocin HCl) 1 capsule: 150mg,
300mg
clindamycin hcl (Cleocin HCl) 1 capsule: 75mg
clindamycin palmitate hcl (Cleocin Palmitate) 2
clindamycin phosphate (Cleocin Phosphate) 1
colistin (colistimethate na) (Coly-mycin M Parenteral) 2
CUBICIN 5 PA (PA for ESRD
Only)
polymyxin b sulfate (Polymyxin B Sulfate) 1
SYNERCID 5
vancomycin hcl (Vancocin HCl) 5 capsule
vancomycin hcl (Vancomycin HCl) 2 PA vial, (PA for ESRD
Only)
vancomycin hcl/d5w (Vancomycin HCl/D5W) 2
VANCOMYCIN HCL 4
XIFAXAN 3 PA, QL:
60 in 30
days
tablet: 550mg
XIFAXAN 3 PA, QL:
9 in 30
days
tablet: 200mg
ZYVOX 5
Cephalosporins
CEDAX 4 capsule
CEDAX 4 susp recon
cefaclor (Ceclor) 1 susp recon
cefaclor (Ceclor) 2 capsule, tab er 12h
cefadroxil hydrate (Cefadroxil Hydrate) 1
cefazolin sodium (Ancef) 2
cefazolin sodium/
dextrose,iso
(Cefazolin Sodium/dextrose, Iso) 2 froz.piggy
cefazolin sodium/
dextrose,iso
(Cefazolin Sodium/dextrose, Iso) 2 piggyback
cefdinir (Omnicef) 2
cefditoren pivoxil (Spectracef) 2
cefepime hcl (Maxipime) 2
15
Drug Name Drug
Tier Requirements/Limits
CEFEPIME 3
CEFEPIME-DEXTROSE 3
cefotaxime sodium (Claforan) 1 vial: 1g, 2g, 10g
cefotaxime sodium (Claforan) 1 vial: 500mg
cefpodoxime proxetil (Cefpodoxime Proxetil) 1 susp recon: 50mg/
5ml
cefpodoxime proxetil (Vantin) 2 susp recon: 100mg/
5ml; tablet
cefprozil (Cefzil) 2
ceftazidime pentahydrate (Fortaz) 2 vial: 1g; vial port
ceftazidime pentahydrate (Fortaz) 2 vial: 2g, 6g, 500mg
CEFTAZIDIME 2
ceftriaxone na/
dextrose,iso
(Ceftriaxone Na/dextrose, Iso) 2
ceftriaxone sodium (Rocephin) 2
cefuroxime axetil (Ceftin) 1 tablet
cefuroxime axetil (Cefuroxime Axetil) 1 susp recon
cefuroxime sodium (Zinacef) 1 vial: 7.5g
cefuroxime sodium (Zinacef) 2 vial: 1.5g, 750mg
cefuroxime sodium/
dextrose,iso
(Cefuroxime Sodium/dextrose,
Iso)
1
cephalexin (Keflex) 1
SUPRAX 4
TAZICEF IN
DEXTROSE
3
Macrolides
azithromycin hydrogen
citrate
(Azithromycin Hydrogen
Citrate)
1
azithromycin (Zithromax) 1 packet
azithromycin (Zithromax) 1 susp recon, tablet,
vial
clarithromycin (Biaxin XL) 2 susp recon, tab er
24h
clarithromycin (Biaxin) 1 tablet
DIFICID 5 QL: 20 in
10 days
ery e-succ/sulfisoxazole (Pediazole) 1
ERY-TAB 1
ERYTHROCIN
LACTOBIONATE
3 vial port: 1g
ERYTHROCIN
LACTOBIONATE
3 vial port: 500mg
erythromycin base (Eryc) 1 capsule dr
16
Drug Name Drug
Tier Requirements/Limits
erythromycin base (Erythromycin Base) 1 tablet, tablet dr
erythromycin
ethylsuccinate
(Erythromycin Ethylsuccinate) 1 oral susp: 200mg/
5ml
erythromycin
ethylsuccinate
(Erythromycin Ethylsuccinate) 1 tablet
erythromycin stearate (Erythromycin Stearate) 1 tablet: 250mg
erythromycin stearate (Erythromycin Stearate) 1 tablet: 500mg
KETEK 4 ST
Miscellaneous B-lactam Antibiotics
AZACTAM-ISO-
OSMOTIC DEXTROSE
4
aztreonam (Azactam) 2
CAYSTON 5 LA
cefotetan disod/
dextrose,iso
(Cefotetan Disod/dextrose, Iso) 2
cefotetan disodium (Cefotetan Disodium) 2
cefoxitin sodium (Mefoxin) 1 vial: 10g
cefoxitin sodium (Mefoxin) 2 vial: 1g, 2g
cefoxitin sodium/
dextrose,iso
(Cefoxitin Sodium/dextrose, Iso) 1
imipenem/cilastatin
sodium
(Primaxin) 2
INVANZ 4 vial
INVANZ 4 vial port
meropenem (Merrem) 2
Penicillins
amoxicillin (Amoxil) 1 capsule, susp recon,
tab chew: 125mg,
250mg; tablet
amoxicillin (Amoxil) 1 tab chew: 200mg,
400mg
amoxicillin/potassium clav (Augmentin) 1
ampicillin sodium (Totacillin-N) 1 vial: 125mg
ampicillin sodium (Totacillin-N) 2 vial port
ampicillin sodium (Totacillin-N) 2 vial: 2g, 10g
ampicillin sodium/
sulbactam na
(Unasyn) 1 vial: 15g
ampicillin sodium/
sulbactam na
(Unasyn) 2 vial port
ampicillin sodium/
sulbactam na
(Unasyn) 2 vial: 3g
ampicillin trihydrate (Ampicillin Trihydrate) 1
BACTOCILL 4
17
Drug Name Drug
Tier Requirements/Limits
BICILLIN C-R 3
BICILLIN L-A 3
dicloxacillin sodium (Dicloxacillin Sodium) 1
nafcillin sodium (Unipen) 2 vial
nafcillin sodium (Unipen) 2 vial port
nafcillin sodium/d2.4w (Nafcillin Sodium/d2.4w) 2
oxacillin sodium (Oxacillin Sodium) 2
oxacillin sodium/
dextrose,iso
(Oxacillin Sodium/dextrose, Iso) 2
pen g pot/dextrose-water (Pen G Pot/dextrose-water) 2 froz.piggy: 1mm/
50ml
pen g pot/dextrose-water (Pen G Pot/dextrose-water) 2 froz.piggy: 2mm/
50ml, 3mm/50ml
penicillin g potassium (Penicillin G Potassium) 2
penicillin g potassium/d5w (Penicillin G Potassium/D5W) 2
penicillin g procaine (Penicillin G Procaine) 2 disp syrin: 1.2mm/
2ml
penicillin g procaine (Penicillin G Procaine) 2 disp syrin: 600000/
ml
penicillin v potassium (Veetids 500) 1
piperacillin sodium (Piperacillin Sodium) 2
piperacillin sodium/
tazobactam
(Zosyn) 2
PIPRACIL IN
DEXTROSE
4
TIMENTIN 4
ZOSYN 4 froz.piggy
18
Drug Name Drug
Tier Requirements/Limits
Quinolones
AVELOX ABC PACK 3
AVELOX IV 3
AVELOX 3
ciprofloxacin hcl (Cipro) 1
ciprofloxacin lactate (Cipro I.V.) 1
ciprofloxacin lactate/d5w (Cipro I.V.) 1
ciprofloxacin/ciprofloxa
hcl
(Cipro XR) 2
FACTIVE 4
levofloxacin (Levaquin) 1 vial
levofloxacin (Levaquin) 2 solution, tablet
levofloxacin/d5w (Levaquin) 1
nalidixic acid (Nalidixic Acid) 1
NOROXIN 4
ofloxacin (Floxin) 2
Sulfonamides (Systemic)
sulfadiazine (Sulfadiazine) 2
sulfamethoxazole/
trimethoprim
(Septra) 1
sulfasalazine (Azulfidine) 1
Tetracyclines
demeclocycline hcl (Declomycin) 2
doxycycline hyclate (Doryx) 2 tablet dr, vial
doxycycline hyclate (Vibramycin) 1 capsule
doxycycline hyclate (Vibramycin) 2 capsule dr
doxycycline hyclate (Vibra-tabs) 1 tablet
doxycycline monohydrate (Adoxa) 1 tablet: 50mg,
100mg
doxycycline monohydrate (Adoxa) 2 capsule: 75mg;
tablet: 75mg,
150mg
doxycycline monohydrate (Monodox) 2 capsule: 150mg
MINOCIN 5 vial
minocycline hcl (Dynacin) 1 capsule
minocycline hcl (Dynacin) 2 tab er 24h, tablet
tetracycline hcl (Ala-tet) 1 capsule
tetracycline hcl (Tetracycline HCl) 1 oral susp
TYGACIL 5
19
Drug Name Drug
Tier Requirements/Limits
Anticholinergic Agents Antimuscarinics/Antispasmodics
atropine sulfate (Atropine Sulfate) 1 ampul, vial
atropine sulfate (Atropine Sulfate) 1 disp syrin
ATROVENT HFA 3 QL: 25.8
in 28
days
dicyclomine hcl (Bentyl) 1 PA capsule, syrup,
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
glycopyrrolate (Robinul) 1 vial
glycopyrrolate (Robinul) 2 tablet
isopropamide/
prochlorperazine
(Isopropamide/prochlorperazine) 1
methscopolamine bromide (Pamine) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
SPIRIVA 3 QL: 30 in
30 days
Anticonvulsants Anticonvulsants, Miscellaneous
BANZEL 4
carbamazepine (Carbatrol) 2 cpmp 12hr, oral
susp
carbamazepine (Tegretol XR) 2 tab er 12h
carbamazepine (Tegretol) 1 tab chew, tablet
divalproex sodium (Depakote ER) 2 cap sprink, tab er
24h
divalproex sodium (Depakote) 1 tablet dr
felbamate (Felbatol) 2
gabapentin (Neurontin) 1 capsule
gabapentin (Neurontin) 2 solution, tablet
GABITRIL 3
LAMICTAL (BLUE) 4
LAMICTAL (ORANGE) 4
LAMICTAL ODT
(BLUE)
4
LAMICTAL ODT
(GREEN)
4
LAMICTAL ODT
(ORANGE)
4
20
Drug Name Drug
Tier Requirements/Limits
LAMICTAL ODT 4
LAMICTAL XR (BLUE) 4
LAMICTAL XR
(GREEN)
4
LAMICTAL XR
(ORANGE)
4
LAMICTAL XR 4 tab er 24: 25mg,
50mg, 100mg,
200mg, 250mg
LAMICTAL XR 4 tab er 24: 300mg
lamotrigine (Lamictal (green)) 2 tab ds pk
lamotrigine (Lamictal) 1 tablet, tb chw dsp
levetiracetam (Keppra) 1 vial
levetiracetam (Keppra) 2 solution, tab er 24h,
tablet
LYRICA 3 QL: 93 in
31 days
magnesium chloride (Magnesium Chloride) 1
magnesium sulfate (Magnesium Sulfate) 1 disp syrin
magnesium sulfate (Magnesium Sulfate) 1 infus. btl,
piggyback, vial
magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1
oxcarbazepine (Trileptal) 1 tablet
oxcarbazepine (Trileptal) 2 oral susp
POTIGA 4 QL: 270
in 30
days
tablet: 50mg
POTIGA 4 QL: 90 in
30 days
tablet: 200mg,
300mg, 400mg
SABRIL 5
TEGRETOL XR 3 tab er 12h: 100mg
topiramate (Topamax) 1 tablet
topiramate (Topamax) 2 cap sprink
TRILEPTAL 4 oral susp
valproate sodium (Depakene) 1
valproic acid (Depakene) 1
VIMPAT 4 QL: 1200
in 30
days
solution
VIMPAT 4 QL: 200
in 5 days
vial
VIMPAT 4 QL: 60 in
30 days
tablet
21
Drug Name Drug
Tier Requirements/Limits
zonisamide (Zonegran) 1
Hydantoins
DILANTIN 3 capsule: 30mg
DILANTIN 3 tab chew
fosphenytoin sodium (Cerebyx) 1
PEGANONE 3
PHENYTEK 3
phenytoin sodium
extended
(Dilantin) 1
phenytoin sodium (Phenytoin Sodium) 1 ampul
phenytoin sodium (Phenytoin Sodium) 1 disp syrin
phenytoin (Dilantin-125) 1
Succinimides
CELONTIN 3
ethosuximide (Zarontin) 1 syrup
ethosuximide (Zarontin) 2 capsule
Antidiabetic Agents Antidiabetic Agents, Miscellaneous
acarbose (Precose) 2 QL: 90 in
30 days
BYDUREON 3 ST, QL:
4 in 28
days
BYETTA 3 ST, QL:
1.2 in 28
days
pen injctr: 5mcg/
0.02
BYETTA 3 ST, QL:
2.4 in 28
days
pen injctr: 10mcg/
0.04
GLYSET 4 QL: 90 in
30 days
JANUMET XR 3 QL: 30 in
30 days
tbmp 24hr: 50mg-
500mg, 100-
1000mg
JANUMET XR 3 QL: 60 in
30 days
tbmp 24hr: 50-
1000mg
JANUMET 3 QL: 60 in
30 days
JANUVIA 3 QL: 30 in
30 days
JENTADUETO 3 QL: 60 in
30 days
22
Drug Name Drug
Tier Requirements/Limits
JUVISYNC 3 QL: 30 in
30 days
KORLYM 5 PA, QL:
112 in 28
days
metformin hcl (Fortamet) 1 QL: 60 in
30 days
tab er 24
metformin hcl (Glucophage) 1 QL: 120
in 30
days
tab er 24h: 500mg;
tablet: 500mg
metformin hcl (Glucophage) 1 QL: 60 in
30 days
tablet: 1000mg
metformin hcl (Glucophage) 1 QL: 90 in
30 days
tab er 24h: 750mg;
tablet: 850mg
nateglinide (Starlix) 2 QL: 90 in
30 days
PRANDIMET 3 QL: 150
in 30
days
PRANDIN 3 QL: 240
in 30
days
SYMLIN 4 QL: 20 in
28 days
SYMLINPEN 120 4 QL: 16.2
in 28
days
SYMLINPEN 60 4 QL: 9 in
28 days
TRADJENTA 3 QL: 30 in
30 days
VICTOZA 3-PAK 4 PA, QL:
9 in 28
days
Insulins
HUMALOG MIX 50-50 3 QL: 30 in
28 days
insuln pen
HUMALOG MIX 50-50 3 QL: 40 in
28 days
vial
HUMALOG MIX 75-25 3 QL: 30 in
28 days
insuln pen
HUMALOG MIX 75-25 3 QL: 40 in
28 days
vial
23
Drug Name Drug
Tier Requirements/Limits
HUMALOG 3 QL: 30 in
28 days
insuln pen
HUMALOG 3 QL: 40 in
28 days
vial
HUMULIN 70-30 3 QL: 30 in
28 days
insuln pen
HUMULIN 70-30 3 QL: 40 in
28 days
vial
HUMULIN N 3 QL: 30 in
28 days
insuln pen
HUMULIN N 3 QL: 40 in
28 days
vial
HUMULIN R 3 QL: 40 in
28 days
LANTUS SOLOSTAR 3 QL: 30 in
28 days
LANTUS 3 QL: 40 in
28 days
LEVEMIR 3 ST, QL:
30 in 28
days
insuln pen
LEVEMIR 3 ST, QL:
40 in 28
days
vial
NOVOLIN 70-30
INNOLET
3 QL: 30 in
28 days
NOVOLIN 70-30 3 QL: 40 in
28 days
NOVOLIN N INNOLET 3 QL: 30 in
28 days
NOVOLIN N 3 QL: 40 in
28 days
NOVOLIN R 3 QL: 30 in
28 days
insuln pen
NOVOLIN R 3 QL: 40 in
28 days
vial
NOVOLOG MIX 70-30 3 QL: 30 in
28 days
insuln pen
NOVOLOG MIX 70-30 3 QL: 40 in
28 days
vial
NOVOLOG 3 QL: 30 in
28 days
insuln pen
24
Drug Name Drug
Tier Requirements/Limits
NOVOLOG 3 QL: 40 in
28 days
vial
Sulfonylureas
glimepiride (Amaryl) 1 QL: 30 in
30 days
tablet: 1mg, 2mg
glimepiride (Amaryl) 1 QL: 60 in
30 days
tablet: 4mg
glipizide (Glucotrol XL) 1 QL: 30 in
30 days
tab er 24: 2.5mg,
5mg
glipizide (Glucotrol) 1 QL: 120
in 30
days
tablet: 10mg
glipizide (Glucotrol) 1 QL: 60 in
30 days
tab er 24: 10mg;
tablet: 5mg
glipizide/metformin hcl (Metaglip) 2 QL: 120
in 30
days
tablet: 2.5-500mg,
5mg-500mg
glipizide/metformin hcl (Metaglip) 2 QL: 60 in
30 days
tablet: 2.5-250mg
glyburide (Micronase) 1 PA, QL:
120 in 30
days
tablet: 5mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
glyburide (Micronase) 1 PA, QL:
30 in 30
days
tablet: 1.25mg,
2.5mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
glyburide,micronized (Glynase) 1 PA, QL:
30 in 30
days
tablet: 1.5mg, 3mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
glyburide,micronized (Glynase) 1 PA, QL:
60 in 30
days
tablet: 6mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
glyburide/metformin hcl (Glucovance) 1 PA, QL:
120 in 30
days
tablet: 2.5-500mg,
5mg-500mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
25
Drug Name Drug
Tier Requirements/Limits
glyburide/metformin hcl (Glucovance) 1 PA, QL:
60 in 30
days
tablet: 1.25-250mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
tolazamide (Tolazamide) 1 QL: 120
in 30
days
tablet: 250mg
tolazamide (Tolazamide) 1 QL: 60 in
30 days
tablet: 500mg
tolbutamide (Tolbutamide) 1 QL: 180
in 30
days
Thiazolidinediones
ACTOPLUS MET XR 3 QL: 60 in
30 days
ACTOPLUS MET 3 QL: 90 in
30 days
ACTOS 4 QL: 30 in
30 days
AVANDAMET 3 PA, QL:
60 in 30
days
AVANDARYL 3 PA, QL:
30 in 30
days
AVANDIA 3 PA, QL:
30 in 30
days
DUETACT 3 QL: 30 in
30 days
Antidiarrhea Agents Antidiarrhea Agents
diphenoxylate hcl/atropine (Lomotil) 1 (May be High Risk
Med for Ages 65
and Older)
loperamide hcl (Loperamide HCl) 1
paregoric (Paregoric) 2
Antiemetics 5-ht3 Receptor Antagonists
ALOXI 4
granisetron hcl (Kytril) 2 vial
26
Drug Name Drug
Tier Requirements/Limits
granisetron hcl (Kytril) 2 PA solution, tablet,
(PA for Part B vs
Part D Only)
granisetron hcl/pf (Kytril) 1
ondansetron hcl (Zofran) 1 vial
ondansetron hcl (Zofran) 1 PA tablet, (PA for Part
B vs Part D Only)
ondansetron hcl (Zofran) 2 PA solution, (PA for
Part B vs Part D
Only)
ondansetron (Zofran Odt) 1 PA (PA for Part B vs
Part D Only)
Antiemetics, Miscellaneous
CESAMET 4
dronabinol (Marinol) 2
EMEND 3 PA, QL:
1 per fill
capsule: 40mg,
125mg, (PA for
Part B vs Part D
Only)
EMEND 3 PA, QL:
2 per fill
capsule: 80mg, (PA
for Part B vs Part D
Only)
EMEND 3 PA, QL:
3 per fill
cap ds pk, (PA for
Part B vs Part D
Only)
EMEND 3 QL: 2 in
28 days
vial
Antihistamines (GI Drugs)
dimenhydrinate (Dimenhydrinate) 1
meclizine hcl (Antivert) 1
prochlorperazine edisylate (Compazine) 1
prochlorperazine maleate (Compazine) 1
Antifungal (Systemic) Antifungals, Miscellaneous
ABELCET 5 PA (PA for Part B vs
Part D Only)
amphotericin b (Amphotericin B) 2 PA (PA for Part B vs
Part D Only)
flucytosine (Ancobon) 5
griseofulvin,microsize (Grifulvin V) 1
GRIS-PEG 4
nystatin (Mycostatin) 1 powder(ea), tablet
nystatin (Nystatin) 1 powder
27
Drug Name Drug
Tier Requirements/Limits
terbinafine hcl (Lamisil) 1
triacetin (Triacetin) 1
Azoles
fluconazole in nacl,iso-
osm
(Fluconazole In Nacl,iso-osm) 1
fluconazole (Diflucan) 1
itraconazole (Sporanox) 2
ketoconazole (Nizoral) 1
NOXAFIL 5
SPORANOX 3 solution
VFEND IV 4
VFEND 5 susp recon
voriconazole (Vfend) 5 tablet
Echinocandins
CANCIDAS 5
ERAXIS (WATER
DILUENT)
5
Antiglaucoma Agents Antiglaucoma Agents
acetazolamide sodium (Acetazolamide Sodium) 1
acetazolamide (Acetazolamide) 1 tablet
acetazolamide (Diamox Sequels) 2 capsule er
ALPHAGAN P 3 drops: 0.1%
AZOPT 3
betaxolol hcl (Betaxolol HCl) 1
BETIMOL 4
BETOPTIC S 4
brimonidine tartrate (Alphagan P) 1
brimonidine tartrate (Alphagan P) 1 (Drops 0.15%)
COMBIGAN 3
dorzolamide hcl (Trusopt) 1
dorzolamide hcl/timolol
maleat
(Cosopt) 1
ISOPTO CARPINE 3 drops: 8%
ISTALOL 4
latanoprost (Xalatan) 1
levobunolol hcl (Betagan) 1 drops: 0.25%
levobunolol hcl (Betagan) 1 drops: 0.5%
LUMIGAN 3 QL: 2.5
in 25
days
methazolamide (Neptazane) 1
28
Drug Name Drug
Tier Requirements/Limits
metipranolol (Optipranolol) 1
PHOSPHOLINE IODIDE 4
pilocarpine hcl (Isopto Carpine) 1
PILOPINE HS 4
timolol maleate (Timoptic) 1
TRAVATAN Z 3 QL: 2.5
in 25
days
Antihistamines Antihistamines
carbinoxamine maleate (Palgic) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
clemastine fumarate (Clemastine Fumarate) 1 PA syrup, tablet:
2.68mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
clemastine fumarate (Clemastine Fumarate) 1 PA tablet: 1.34mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
diphenhydramine hcl (Benadryl) 1 vial
diphenhydramine hcl (Diphenhydramine HCl) 1 disp syrin
levocetirizine
dihydrochloride
(Xyzal) 2
p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 1
phenyleph/acetaminop/p-
tlox/cp
(Phenyleph/acetaminop/p-tlox/
cp)
1
phenylephrine/chlor-tan (Rynatan) 1
promethazine hcl (Promethazine HCl) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
tripelennamine hcl (Tripelennamine HCl) 1
Anti-infectives (EENT) Anti-infectives (EENT)
acetic acid (Vosol) 1
acetic acid/aluminum
acetate
(Domeboro) 1
acetic acid/hydrocortisone (Vosol HC) 2
AZASITE 4
bacitracin (Bacitracin) 1
29
Drug Name Drug
Tier Requirements/Limits
bacitracin/polymyxin b
sulfate
(Polycin-b) 1
BACTROBAN NASAL 4
BESIVANCE 4 ST
BLEPHAMIDE S.O.P. 3
BLEPHAMIDE 4
CETRAXAL 4
chlorhexidine gluconate (Peridex) 1
CILOXAN 4 oint. (g)
CIPRO HC 3
CIPRODEX 3
ciprofloxacin hcl (Ciloxan) 1
COLY-MYCIN S 4
CORTISPORIN-TC 4
cresyl ace/ben alc/
butanol/ipa
(Cresyl Ace/ben Alc/butanol/ipa) 1
doxycycline hyclate (Periostat) 1
erythromycin base (Romycin) 1
gentamicin sulfate (Garamycin) 1
levofloxacin (Quixin) 1
MOXEZA 3
NATACYN 3
neo/polymyx b sulf/
dexameth
(Maxitrol) 1
neomy sulf/bacitra/
polymyxin b
(Neomy Sulf/bacitra/polymyxin
B)
1 packet
neomy sulf/bacitra/
polymyxin b
(Neo-polycin) 1 oint. (g)
neomy sulf/bacitrac zn/
poly/hc
(Triple Antibiotic HC) 1
neomycin sulfate/dex na
ph
(Neomycin Sulfate/dex Na Ph) 1
neomycin/polymyxin b
sulf/hc
(Oticin HC) 1
neomycin/polymyxn b/
gramicidin
(Neosporin) 1
ofloxacin (Floxin) 1
polymyxin b sulfate/tmp (Polytrim) 1
sulfacetamide sodium (Sulfac) 1
sulfacetamide/
prednisolone sp
(Sulfacetamide/prednisolone Sp) 1
TOBRADEX 4 oint. (g)
30
Drug Name Drug
Tier Requirements/Limits
tobramycin sulf/
dexamethasone
(Tobradex) 1
tobramycin sulfate (Tobrex) 1
trifluridine (Viroptic) 2
VIGAMOX 3
ZIRGAN 4
ZYLET 3
ZYMAR 3
ZYMAXID 3
Anti-infectives (Skin and Mucous Membrane) Antibacterials (Skin and Mucous Membrane)
ALTABAX 4
clindamycin phos/benzoyl
perox
(Benzaclin) 2 gel (gram)
clindamycin phos/benzoyl
perox
(Duac) 2 gel er (g)
clindamycin phosphate (Cleocin T) 1
erythromycin base/ethanol (Emgel) 1
erythromycin/benzoyl
peroxide
(Benzamycin) 1
gentamicin sulfate (Gentamicin Sulfate) 1
metronidazole (Nydamax) 1 gel (gram), gel w/
appl
metronidazole (Vitazol) 2 cream (g), lotion
mupirocin (Centany) 1
neomy sulf/polymyxin b
sulfate
(Neosporin G.U. Irrigant) 1
Antifungals (Skin and Mucous Membrane)
ciclopirox olamine (Loprox) 1 suspension
ciclopirox olamine (Loprox) 2 cream (g)
ciclopirox (Penlac) 2
clotrimazole (Lotrimin) 1
clotrimazole/
betamethasone dip
(Lotrisone) 1
econazole nitrate (Spectazole) 1
EXELDERM 4
GYNAZOLE-1 3
ketoconazole (Extina) 2 foam
ketoconazole (Kuric) 1 cream (g), shampoo
LAMISIL 3
miconazole nitrate (Monistat 3) 1
31
Drug Name Drug
Tier Requirements/Limits
nystatin (Mycostatin) 1 cream (g), oint. (g),
powder
nystatin (Nystatin) 1 tablet
nystatin/triamcin (Mycogen II) 1
sod propionate/inosi/aa14/
urea
(Sod Propionate/inosi/aa14/urea) 1
sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid) 1
terconazole (Terazol 7) 1
XOLEGEL 4
Antivirals (Skin and Mucous Membrane)
DENAVIR 3
VEREGEN 4
ZOVIRAX 4
Local Anti-infectives, Miscellaneous
acetic ac/ricinoleic/
oxyquinol
(Acetic Ac/ricinoleic/oxyquinol) 1
alcohol antiseptic pads (Alcohol Antiseptic Pads) 1
AVC 3
selenium sulfide (Selenium Sulfide) 1 suspension
selenium sulfide (Selseb) 1 shampoo
silver nitrate (Silver Nitrate) 1
silver sulfadiazine (Silvadene) 1
sulfacetamide sodium (Klaron) 2
SULFAMYLON 4
Scabicides and Pediculicides
EURAX 3
lindane (Lindane) 2
malathion (Ovide) 1
permethrin (Elimite) 1
Anti-infectives (systemic), Miscellaneous Anti-infectives (systemic), Miscellaneous
FUROXONE 3
Anti-inflammatory Agents (EENT) Anti-inflammatory Agents (EENT)
ALREX 3
BECONASE AQ 4 QL: 50 in
28 days
BROMDAY 3
bromfenac sodium (Bromfenac Sodium) 2
dexamethasone sod
phosphate
(Ak-dex) 1
diclofenac sodium (Voltaren) 1
32
Drug Name Drug
Tier Requirements/Limits
DUREZOL 3
flunisolide (Nasarel) 1 QL: 50 in
25 days
fluocinolone acetonide oil (Dermotic) 1
fluorometholone (Fluorometholone) 1
flurbiprofen sodium (Ocufen) 1
fluticasone propionate (Flonase) 1 QL: 16 in
30 days
ketorolac tromethamine (Acular LS) 1 drops: 0.5%
ketorolac tromethamine (Acular LS) 2 drops: 0.4%
LOTEMAX 3
NASONEX 3 QL: 34 in
28 days
NEVANAC 3
OMNARIS 4 QL: 13 in
30 days
prednisolone acetate (Pred Forte) 1
prednisolone sod
phosphate
(Prednisol) 1
QNASL 4 QL: 8.7
in 28
days
RESTASIS 4 PA, QL:
64 in 31
days
RHINOCORT AQUA 4 QL: 17.2
in 30
days
triamcinolone acetonide (Nasacort Aq) 2 QL: 16.5
in 30
days
VERAMYST 4 QL: 10 in
30 days
ZETONNA 4 QL: 6.1
in 30
days
Anti-inflammatory Agents (GI Drugs) Anti-inflammatory Agents (GI Drugs)
APRISO 3
ASACOL HD 4
ASACOL 4
balsalazide disodium (Colazal) 2
DIPENTUM 3
33
Drug Name Drug
Tier Requirements/Limits
LIALDA 4
mesalamine w/cleansing
wipes
(Rowasa) 2
PENTASA 4
Anti-inflammatory Agents (Respiratory) Anti-inflammatory Agents (Respiratory)
ALOCRIL 4
cromolyn sodium (Cromolyn Sodium) 1 drops
cromolyn sodium (Gastrocrom) 2 solution
cromolyn sodium (Intal) 1 PA ampul-neb, (PA for
Part B vs Part D
Only)
SINGULAIR 4
zafirlukast (Accolate) 1
Anti-inflammatory Agents (Skin and Mucous) Anti-inflammatory Agents (Skin and Mucous)
alclometasone
dipropionate
(Aclovate) 1
amcinonide (Amcinonide) 1
APEXICON E 4
betamet diprop/prop gly (Diprolene AF) 1
betamethasone
dipropionate
(Betamethasone Dipropionate) 1 gel (gram)
betamethasone
dipropionate
(Del-beta) 1 cream (g), lotion,
oint. (g)
betamethasone valerate (Betamethasone Valerate) 1
clobetasol propionate (Olux) 2 foam, lotion,
shampoo
clobetasol propionate (Temovate) 1 cream (g), gel
(gram), oint. (g),
solution
CLODERM 4
CORDRAN SP 4
CORDRAN 4 lotion, med. tape
CORDRAN 4 oint. (g)
desonide (Desowen) 1 cream (g), lotion,
oint. (g): 0.05%
desoximetasone (Topicort) 2 cream (g), gel
(gram), oint. (g):
0.25%
desoximetasone (Topicort) 2 oint. (g): 0.05%
diflorasone diacetate (Psorcon) 1
34
Drug Name Drug
Tier Requirements/Limits
fluocinolone acetonide (Fluocinolone Acetonide) 1
fluocinolone/shower cap (Derma-smoothe-fs) 1
fluocinonide (Fluocinonide) 1
fluticasone propionate (Cutivate) 1 cream (g), oint. (g)
fluticasone propionate (Cutivate) 2 lotion
halobetasol propionate (Ultravate) 1
hydrocortisone acetate (Hydrocortisone Acetate) 1
hydrocortisone acetate/
aloe v
(Nuzon) 1
hydrocortisone acetate/
urea
(Carmol HC) 1
hydrocortisone butyrate (Locoid) 1
hydrocortisone valerate (Hydrocortisone Valerate) 1
hydrocortisone (Cortenema) 2 enema
hydrocortisone (Proctocort) 1 cream (g),
cream(gm), lotion,
oint. (g)
KENALOG 4 aerosol
LOCOID 4 cream (g)
mometasone furoate (Elocon) 1
prednicarbate (Dermatop) 1
triamcinolone acetonide (Triamcinolone Acetonide) 1 cream (g), lotion,
oint. (g): 0.025%,
0.1%, 0.5%; paste
(g)
triamcinolone acetonide (Triderm) 1 cream, oint. (g):
0.05%
Antilipemic Agents Antilipemic Agents, Miscellaneous
LOVAZA 3
niacin (Niacin) 1 tablet: 500mg
NIASPAN 3
ZETIA 4
Bile Acid Sequestrants
cholestyramine (with
sugar)
(Questran) 2
cholestyramine/aspartame (Questran Light) 2
colestipol hcl (Colestid) 2
WELCHOL 3
Fibric Acid Derivatives
fenofibrate (Lofibra) 1
fenofibrate,micronized (Lofibra) 1
35
Drug Name Drug
Tier Requirements/Limits
fenofibric acid (Fibricor) 1
gemfibrozil (Lopid) 1
TRICOR 4
TRILIPIX 3
HMG-CoA Reductase Inhibitors
ADVICOR 4 ST
ALTOPREV 4
amlodipine/atorvastatin (Caduet) 2
atorvastatin calcium (Lipitor) 2
CRESTOR 4 ST
fluvastatin sodium (Lescol) 2
lovastatin (Mevacor) 1
pravastatin sodium (Pravachol) 1
SIMCOR 4 tbmp 24hr: 1000-
20mg
SIMCOR 4 tbmp 24hr: 500mg-
20mg, 500mg-
40mg, 750mg-
20mg, 1000-40mg
simvastatin (Zocor) 1 QL: 30 in
30 days
Antimigraine Agents Selective Serotonin Agonists
AXERT 4 QL: 12 in
28 days
FROVA 4 QL: 18 in
28 days
naratriptan hcl (Amerge) 2 QL: 9 in
28 days
sumatriptan succinate (Imitrex) 1 QL: 9 in
28 days
tablet
sumatriptan succinate (Imitrex) 2 QL: 4 in
28 days
cartridge, vial
sumatriptan succinate (Imitrex) 2 QL: 4 in
28 days
pen injctr
sumatriptan (Imitrex) 2 QL: 12 in
28 days
spray: 20mg
sumatriptan (Imitrex) 2 QL: 18 in
28 days
spray: 5mg
ZOMIG ZMT 4 QL: 9 in
28 days
ZOMIG 4 QL: 6 in
28 days
spray
36
Drug Name Drug
Tier Requirements/Limits
ZOMIG 4 QL: 9 in
28 days
tablet
Antimycobacterials Antimycobacterials
CAPASTAT SULFATE 3
dapsone (Dapsone) 1
ethambutol hcl (Myambutol) 2
isoniazid (Isoniazid) 1
MYCOBUTIN 4
PASER 3
PRIFTIN 4
pyrazinamide (Pyrazinamide) 1
rifampin (Rifadin) 2
rifampin/isoniazid (Rifamate) 1
SEROMYCIN 4
TRECATOR 3
Antineoplastic Agents Antineoplastic Agents
ABRAXANE 5
ADCETRIS 5
AFINITOR 5 PA, QL:
28 in 28
days
ALIMTA 5
anastrozole (Arimidex) 1
ARRANON 5
ARZERRA 5 PA, QL:
80 in 30
days
AVASTIN 5
BEXXAR 5
bicalutamide (Casodex) 2
BICNU 4
bleomycin sulfate (Bleomycin Sulfate) 1 PA
BUSULFEX 5
CAMPATH 5
CAPRELSA 5 PA, QL:
30 in 30
days
tablet: 300mg
CAPRELSA 5 PA, QL:
60 in 30
days
tablet: 100mg
37
Drug Name Drug
Tier Requirements/Limits
carboplatin (Paraplatin) 2
CEENU 3
cisplatin (Cisplatin) 1
cladribine (Leustatin) 2 PA (PA for Part B vs
Part D Only)
CLOLAR 5
cyclophosphamide (Cyclophosphamide) 2 PA, ST tablet, (PA for Part
B vs Part D Only)
cyclophosphamide (Cytoxan) 2 PA vial, (PA for Part B
vs Part D Only)
cytarabine/pf (Cytarabine/PF) 1 PA (PA for Part B vs
Part D Only)
dacarbazine (Dtic-Dome IV) 1
DACOGEN 5
dactinomycin (Cosmegen) 1
daunorubicin hcl (Cerubidine) 2
DAUNOXOME 4
DOCEFREZ 5
docetaxel (Taxotere) 5 vial: 20mg/2ml,
20mg/ml(1)
docetaxel (Taxotere) 5 vial: fnl20mg/2
doxorubicin hcl liposomal (Doxil) 5 PA (PA for Part B vs
Part D Only)
doxorubicin hcl (Adriamycin RDF) 2 PA vial: 50mg
DROXIA 3
ELIGARD 4 QL: 1 in
112 days
disp syrin: 30mg
ELIGARD 4 QL: 1 in
28 days
disp syrin: 7.5mg
ELIGARD 4 QL: 1 in
84 days
disp syrin: 22.5mg
ELIGARD 5 QL: 1 in
168 days
disp syrin: 45mg
ELSPAR 3
EMCYT 3
epirubicin hcl (Ellence) 1
ERBITUX 4
ERIVEDGE 5 PA, QL:
30 in 30
days
ERWINAZE 5 PA, QL:
60 in 30
days
38
Drug Name Drug
Tier Requirements/Limits
ETOPOPHOS 4
etoposide (Etoposide) 2
exemestane (Aromasin) 2
FARESTON 5
FASLODEX 5 disp syrin: 125mg/
2.5
FASLODEX 5 disp syrin: 250mg/
5ml
FIRMAGON 4
floxuridine (FUDR) 1 PA (PA for Part B vs
Part D Only)
fludarabine phosphate (Fludara) 5
fluorouracil (Fluorouracil) 2 PA
flutamide (Flutamide) 2
FOLOTYN 5
gemcitabine hcl (Gemzar) 5 vial: 1g
gemcitabine hcl (Gemzar) 5 vial: 200mg
GLEEVEC 5 QL: 60 in
30 days
HALAVEN 5 PA, QL:
24 in 28
days
HERCEPTIN 5 PA (PA for Part B vs
Part D Only)
HEXALEN 5
hydroxyurea (Hydrea) 1
idarubicin hcl (Idamycin Pfs) 2
ifosfamide (Ifex) 2 PA (PA for Part B vs
Part D Only)
ifosfamide/mesna (Ifex-mesnex) 5 PA kit: 1g-1g, 3g-1g,
(PA for Part B vs
Part D Only)
INLYTA 5 PA, QL:
180 in 30
days
tablet: 1mg
INLYTA 5 PA, QL:
60 in 30
days
tablet: 5mg
IRESSA 5 PA, QL:
30 in 30
days
irinotecan hcl (Camptosar) 5
ISTODAX 5 PA
39
Drug Name Drug
Tier Requirements/Limits
IXEMPRA 5
JAKAFI 5 PA, QL:
60 in 30
days
JEVTANA 5
letrozole (Femara) 2
LEUKERAN 4
leuprolide acetate (Lupron) 2 QL: 2 in
28 days
LUPRON DEPOT 5 QL: 1 in
112 days
syringekit: 30mg
LUPRON DEPOT 5 QL: 1 in
168 days
syringekit: 45mg
LUPRON DEPOT 5 QL: 1 in
28 days
syringekit: 3.75mg
LUPRON DEPOT 5 QL: 1 in
84 days
syringekit:
11.25mg, 22.5mg
LUPRON DEPOT-PED 5 QL: 1 in
28 days
LYSODREN 3
MATULANE 5
MEGACE ES 3 (May be High Risk
Med for Ages 65
and Older)
megestrol acetate (Megace) 1 (May be High Risk
Med for Ages 65
and Older)
melphalan hcl (Alkeran) 5
mercaptopurine (Purinethol) 2
methotrexate sodium (Methotrexate Sodium) 1 PA, ST tablet, (PA for Part
B vs Part D Only)
methotrexate sodium (Methotrexate Sodium) 1 PA vial, (PA for Part B
vs Part D Only)
methotrexate sodium/pf (Methotrexate Sodium/PF) 1 PA (PA for Part B vs
Part D Only)
mitomycin (Mitomycin) 1 PA
mitoxantrone hcl (Novantrone) 1
MUSTARGEN 3
NEXAVAR 5 PA, QL:
120 in 30
days
NILANDRON 3
ONCASPAR 5
40
Drug Name Drug
Tier Requirements/Limits
ONTAK 5
oxaliplatin (Oxaliplatin) 5
paclitaxel (Taxol) 2
pentostatin (Nipent) 5
PROLEUKIN 5
REVLIMID 5 LA, QL:
30 in 30
days
RITUXAN 5 PA
SPRYCEL 5
SUTENT 5 PA, QL:
30 in 30
days
TABLOID 3
tamoxifen citrate (Nolvadex) 1
TARCEVA 5 PA, QL:
30 in 30
days
TARGRETIN 5
TASIGNA 5
thiotepa (Thiotepa) 2
topotecan hcl (Hycamtin) 5
TORISEL 5 PA (PA for Part B vs
Part D Only)
TREANDA 5
TRELSTAR 5 QL: 1 in
168 days
disp syrin: 22.5mg/
2ml
TRELSTAR 5 QL: 1 in
28 days
disp syrin: 3.75mg/
2ml
TRELSTAR 5 QL: 1 in
84 days
disp syrin: 11.25/
2ml
tretinoin (Tretinoin) 5
TREXALL 3 PA, ST (PA for Part B vs
Part D Only)
TRISENOX 5
TYKERB 5
VALSTAR 5
VANDETANIB 5 PA, QL:
30 in 30
days
tablet: 300mg
VANDETANIB 5 PA, QL:
60 in 30
days
tablet: 100mg
41
Drug Name Drug
Tier Requirements/Limits
VECTIBIX 5
VELCADE 5
VIDAZA 5
vinblastine sulfate (Vinblastine Sulfate) 2 PA (PA for Part B vs
Part D Only)
vincristine sulfate (Vincristine Sulfate) 1 PA (PA for Part B vs
Part D Only)
vinorelbine tartrate (Navelbine) 1
VOTRIENT 5 PA, QL:
120 in 30
days
VUMON 4
XALKORI 5 PA, QL:
60 in 30
days
YERVOY 5 PA, QL:
30 in 21
days
ZANOSAR 5
ZELBORAF 5 PA, QL:
240 in 30
days
ZOLADEX 4 QL: 1 in
28 days
implant: 3.6mg
ZOLADEX 4 QL: 1 in
84 days
implant: 10.8mg
ZOLINZA 5
ZYTIGA 5 PA, QL:
120 in 30
days
Antiparkinsonian Agents Antiparkinsonian Agents
amantadine hcl (Amantadine HCl) 1
APOKYN 5
AZILECT 3
benztropine mesylate (Benztropine Mesylate) 1 PA tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
benztropine mesylate (Cogentin) 2 PA ampul, (PA for
Ages 65 and Older;
May be High Risk
Med)
42
Drug Name Drug
Tier Requirements/Limits
bromocriptine mesylate (Parlodel) 2
cabergoline (Cabergoline) 2
carbidopa/levodopa (Sinemet 25-100) 1
COMTAN 3
pramipexole di-hcl (Mirapex) 2
ropinirole hcl (Requip XL) 2 tab er 24h
ropinirole hcl (Requip) 1 tablet
selegiline hcl (Eldepryl) 1
STALEVO 100 3
STALEVO 125 3
STALEVO 150 3
STALEVO 200 3
STALEVO 50 3
STALEVO 75 3
TASMAR 3
trihexyphenidyl hcl (Trihexyphenidyl HCl) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
43
Drug Name Drug
Tier Requirements/Limits
Antiprotozoal Agents Antiprotozoal Agents
ALINIA 4
atovaquone/proguanil hcl (Malarone) 2 tablet: 250-100mg
atovaquone/proguanil hcl (Malarone) 2 tablet: 62.5-25mg
chloroquine phosphate (Aralen Phosphate) 1
COARTEM 4
DARAPRIM 3
HALFAN 3
hydroxychloroquine
sulfate
(Plaquenil) 1
mefloquine hcl (Lariam) 1
MEPRON 5
metronidazole (Flagyl) 1
metronidazole/sodium
chloride
(Metro IV) 1
paromomycin sulfate (Paromomycin Sulfate) 1
pentamidine isethionate (Pentam 300) 1
PRIMAQUINE 3 QL: 93 in
31 days
QUALAQUIN 4 PA, QL:
42 in 30
days
tinidazole (Tindamax) 1
YODOXIN 3
Antipruritics and Local Anesthetics Antipruritics and Local Anesthetics
AMERICAINE 3
ANACAINE 3
lidocaine (Lidocaine) 1 PA (PA for ESRD
Only)
lidocaine/prilocaine (EMLA) 1 PA (PA for ESRD
Only)
LIDODERM 4
PRUDOXIN 4
ZONALON 4
Antiulcer Agents Antiulcer Agents
CARAFATE 3 oral susp
cimetidine hcl (Cimetidine HCl) 1 (Rx Product Only)
cimetidine in 0.9 % nacl (Cimetidine In 0.9 % NaCl) 1 (Rx Product Only)
cimetidine (Tagamet) 1 (Rx Product Only)
44
Drug Name Drug
Tier Requirements/Limits
famotidine in nacl,iso-
osm/pf
(Famotidine In Nacl,iso-osm/PF) 1
famotidine (Pepcid) 1 (Rx Product Only)
lansoprazole (Prevacid) 2 ST capsule dr, (Rx
Product Only)
lansoprazole (Prevacid) 2 ST tab rap dr, (Rx
Product Only)
misoprostol (Cytotec) 1 tablet: 100mcg
misoprostol (Cytotec) 1 tablet: 200mcg
nizatidine (Axid) 1 capsule
nizatidine (Axid) 2 solution
omeprazole (Prilosec) 1 capsule dr: 10mg,
20mg, 40mg, (Rx
Product Only)
omeprazole/sodium
bicarbonate
(Zegerid) 1 (Rx Product Only)
pantoprazole sodium (Protonix) 1
PROTONIX IV 4
ranitidine hcl (Zantac) 1 (Rx Product Only)
sucralfate (Carafate) 1 tablet
sucralfate (Sucralfate) 2 oral susp
Antivirals (Systemic) Antiretrovirals
APTIVUS 4 solution
APTIVUS 5 capsule
ATRIPLA 5
COMPLERA 5
CRIXIVAN 4 capsule: 100mg
CRIXIVAN 4 capsule: 200mg,
400mg
didanosine (Videx EC) 2
EDURANT 5
EMTRIVA 3
EPIVIR HBV 4
EPIVIR 4 solution
EPZICOM 5
FUZEON 5
INTELENCE 3 tablet: 25mg
INTELENCE 5 tablet: 100mg,
200mg
INVIRASE 5
ISENTRESS 5
45
Drug Name Drug
Tier Requirements/Limits
KALETRA 3 tablet: 100mg-25mg
KALETRA 5 solution, tablet:
200mg-50mg
lamivudine (Epivir) 2
lamivudine/zidovudine (Combivir) 5
LEXIVA 3 oral susp
LEXIVA 5 tablet
nevirapine (Viramune) 2 tablet
NORVIR 4
PREZISTA 3 tablet: 75mg
PREZISTA 5 tablet: 150mg,
400mg, 600mg
RESCRIPTOR 4
RETROVIR 3 vial
REYATAZ 3 capsule: 100mg
REYATAZ 5 capsule: 150mg,
200mg, 300mg
SELZENTRY 5
stavudine (Zerit) 2 capsule
stavudine (Zerit) 2 soln recon
SUSTIVA 4 capsule: 100mg
SUSTIVA 4 capsule: 50mg,
200mg; tablet
TRIZIVIR 5
TRUVADA 5
VIDEX 3
VIRACEPT 4 powder
VIRACEPT 4 tablet
VIRAMUNE XR 3
VIRAMUNE 3 oral susp
VIREAD 5
ZERIT 4 soln recon
ZIAGEN 4
zidovudine (Retrovir) 1 syrup
zidovudine (Retrovir) 2 capsule, tablet
46
Drug Name Drug
Tier Requirements/Limits
Antivirals, Miscellaneous
foscarnet sodium (Foscavir) 1 PA (PA for Part B vs
Part D Only)
RELENZA 4
rimantadine hcl (Flumadine) 1
SYNAGIS 4
TAMIFLU 3 capsule, susp recon:
6mg/ml
Hcv Protease Inhibitors
INCIVEK 5 PA, QL:
168 in 28
days
VICTRELIS 5 PA, QL:
336 in 28
days
Interferons
ALFERON N 5
INTRON A 3 PA pen ij kit: 3mm/
0.2ml; vial: 10mm/
ml
INTRON A 5 PA pen ij kit: 5mm/
0.2ml, 10mm/0.2ml;
vial: 6mmunit/ml
INTRON A 5 PA vial: 18mmunit,
50mmunit
PEGASYS PROCLICK 5 PA
PEGASYS 5 PA
PEGINTRON REDIPEN 5 PA
PEGINTRON 5 PA kit: 50mcg/0.5
PEGINTRON 5 PA kit: 80mcg/0.5,
120mcg/0.5,
150mcg/0.5
SYLATRON 5 PA, QL:
1 in 28
days
Nucleosides and Nucleotides
acyclovir sodium (Acyclovir Sodium) 1 PA (PA for Part B vs
Part D Only)
acyclovir (Zovirax) 1 capsule, tablet
acyclovir (Zovirax) 2 oral susp
BARACLUDE 4 solution
BARACLUDE 5 tablet
famciclovir (Famvir) 2
47
Drug Name Drug
Tier Requirements/Limits
ganciclovir sodium (Cytovene) 1 PA (PA for Part B vs
Part D Only)
ganciclovir (Cytovene) 2 capsule: 250mg
ganciclovir (Cytovene) 5 capsule: 500mg
HEPSERA 5
RIBATAB 5 tab ds pk: 600-
600mg
ribavirin (Copegus) 2 capsule, tablet
ribavirin (Ribatab) 5 tab ds pk: 200-
400mg
ribavirin (Ribatab) 5 tab ds pk: 400-
400mg, 600-400mg
TYZEKA 5
valacyclovir hcl (Valtrex) 2
VALCYTE 4 soln recon
VALCYTE 5 tablet
VISTIDE 5
Anxiolytics, Sedatives and Hypnotics Anxiolytics, Sedatives and Hypnotics, Miscellaneous
buspirone hcl (Buspar) 1
droperidol (Inapsine) 1
glutethimide (Glutethimide) 1
hydroxyzine hcl (Hydroxyzine HCl) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
hydroxyzine pamoate (Vistaril) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
ROZEREM 3
zaleplon (Sonata) 1 PA, QL:
90 in 365
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
zolpidem tartrate (Ambien CR) 2 PA, QL:
90 in 365
days
tab mphase, (PA/
QL for Ages 65 and
Older; May be High
Risk Med)
zolpidem tartrate (Ambien) 1 PA, QL:
90 in 365
days
tablet, (PA/QL for
Ages 65 and Older;
May be High Risk
Med)
Astringents Astringents
aluminum chloride (Drysol) 1
48
Drug Name Drug
Tier Requirements/Limits
XERAC AC 3
Benzodiazepines Benzodiazepines
alprazolam (Xanax XR) 1 QL: 30 in
30 days
tab er 24h: 0.5mg,
1mg
alprazolam (Xanax XR) 1 QL: 60 in
30 days
tab er 24h: 2mg,
3mg
alprazolam (Xanax) 1 QL: 90 in
30 days
tab rapdis, tablet
clonazepam (Klonopin) 1 QL: 300
in 30
days
tab rapdis: 2mg;
tablet: 2mg
clonazepam (Klonopin) 1 QL: 90 in
30 days
tab rapdis: 0.125mg,
0.25mg, 0.5mg,
1mg; tablet: 0.5mg,
1mg
clorazepate dipotassium (Tranxene T-tab) 1 PA, QL:
120 in 30
days
tablet: 15mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
clorazepate dipotassium (Tranxene T-tab) 1 PA, QL:
60 in 30
days
tablet: 3.75mg,
7.5mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
DIASTAT ACUDIAL 4
diazepam (Diastat) 2 kit
diazepam (Diazepam) 1 PA, QL:
1200 in
30 days
oral conc, solution,
(PA for Ages 65 and
Older; May be High
Risk Med)
diazepam (Valium) 1 PA, QL:
120 in 30
days
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
estazolam (Prosom) 1 QL: 30 in
30 days
lorazepam (Ativan) 1 QL: 2 in
30 days
disp syrin, vial
lorazepam (Ativan) 1 QL: 90 in
30 days
tablet
49
Drug Name Drug
Tier Requirements/Limits
ONFI 4 PA, QL:
60 in 30
days
oxazepam (Oxazepam) 1 QL: 120
in 30
days
temazepam (Restoril) 1 QL: 30 in
30 days
triazolam (Halcion) 1 QL: 30 in
30 days
Beta-Adrenergic Blocking Agents Beta-Adrenergic Blocking Agents
acebutolol hcl (Sectral) 1
atenolol (Tenormin) 1
atenolol/chlorthalidone (Tenoretic 100) 1
betaxolol hcl (Kerlone) 1
bisoprolol fumarate (Zebeta) 1
bisoprolol fumarate/hctz (Ziac) 1
BYSTOLIC 3
carvedilol (Coreg) 1
COREG CR 3
DUTOPROL 3
esmolol hcl (Brevibloc) 1 PA
INNOPRAN XL 4
labetalol hcl (Trandate) 1 disp syrin
labetalol hcl (Trandate) 1 tablet, vial
metoprolol succinate (Toprol XL) 1
metoprolol tartrate (Lopressor) 1
metoprolol/
hydrochlorothiazide
(Lopressor HCT) 1
nadolol (Corgard) 1
nadolol/
bendroflumethiazide
(Corzide) 1
pindolol (Pindolol) 1
propranolol hcl (Propranolol HCl) 1
propranolol/
hydrochlorothiazid
(Propranolol/hydrochlorothiazid) 1
sotalol hcl (Betapace) 1
SOTALOL HCL 4
timolol maleate (Timolol Maleate) 1
Blood Derivatives Blood Derivatives
50
Drug Name Drug
Tier Requirements/Limits
ALBUKED-25 3
ALBUKED-5 3
ALBUMIN (HUMAN) 3
ALBUMINAR-25 3
ALBUMINAR-5 3
ALBURX 3
ALBUTEIN 3
BUMINATE 3
FLEXBUMIN 3
KEDBUMIN 3
PLASBUMIN-25 3
PLASBUMIN-5 3
STERILE DILUENT 3
Calcium-Channel Blocking Agents Calcium-Channel Blocking Agents, Miscellaneous
diltiazem hcl (Cardizem CD) 1 various dosage and/
or strengths are
available
diltiazem hcl (Tiazac) 1 capsule er: 420mg
verapamil hcl (Calan) 1 cap24h pct, cap24h
pel: 120mg, 180mg,
240mg; tablet, tablet
er, vial
verapamil hcl (Verelan) 1 cap24h pel: 360mg;
disp syrin
Dihydropyridines
amlodipine besylate (Norvasc) 1
amlodipine besylate/
benazepril
(Lotrel) 2
AZOR 4 ST
CARDENE I.V. 4 piggyback
CARDENE SR 4
CLEVIPREX 4
DYNACIRC CR 4
EXFORGE HCT 3 ST
EXFORGE 3 ST
felodipine (Plendil) 1
isradipine (Dynacirc) 2
nicardipine hcl (Nicardipine HCl) 1
nifedipine (Procardia XL) 1 tab er 24, tablet er
nimodipine (Nimotop) 2
nisoldipine (Sular) 2
51
Drug Name Drug
Tier Requirements/Limits
Caloric Agents Caloric Agents
AMINO ACIDS 3 PA
AMINOSYN II 3.5% M-
DEXTROSE 5%
3 PA (PA for Part B vs
Part D Only)
AMINOSYN II 3.5%-
DEXTROSE 25%
3 PA (PA for Part B vs
Part D Only)
AMINOSYN II 3.5%-
DEXTROSE 5%
3 PA (PA for Part B vs
Part D Only)
AMINOSYN II 4.25% M-
DEXT 10%
3 PA (PA for Part B vs
Part D Only)
AMINOSYN II 4.25%-
DEXTROSE 25%
3 PA (PA for Part B vs
Part D Only)
AMINOSYN II 5% IN
25% DEXTROSE
3 PA (PA for Part B vs
Part D Only)
AMINOSYN II IN
DEXTROSE
3 PA (PA for Part B vs
Part D Only)
AMINOSYN II with
LYTES-CA-DW
3 PA iv soln: 3.5%, (PA
for Part B vs Part D
Only)
AMINOSYN II with
LYTES-CA-DW
3 PA iv soln: 4.25%, (PA
for Part B vs Part D
Only)
AMINOSYN II 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
AMINOSYN II 3 PA iv soln: 15%, (PA
for Part B vs Part D
Only)
AMINOSYN II 3 PA iv soln: 7%, (PA
for Part B vs Part D
Only)
AMINOSYN II 3 PA iv soln: 8.5%, (PA
for Part B vs Part D
Only)
AMINOSYN M 3 PA (PA for Part B vs
Part D Only)
AMINOSYN with
ELECTROLYTES
3 PA (PA for Part B vs
Part D Only)
AMINOSYN 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
52
Drug Name Drug
Tier Requirements/Limits
AMINOSYN 3 PA iv soln: 3.5%, (PA
for Part B vs Part D
Only)
AMINOSYN 3 PA iv soln: 5%, (PA
for Part B vs Part D
Only)
AMINOSYN 3 PA iv soln: 7%, (PA
for Part B vs Part D
Only)
AMINOSYN 3 PA iv soln: 8.5%, (PA
for Part B vs Part D
Only)
AMINOSYN 3 PA iv soln: 8.5%, (PA
for Part B vs Part D
Only)
AMINOSYN-HBC 3 PA (PA for Part B vs
Part D Only)
AMINOSYN-HF 3 PA (PA for Part B vs
Part D Only)
AMINOSYN-PF 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
AMINOSYN-PF 3 PA iv soln: 7%, (PA
for Part B vs Part D
Only)
AMINOSYN-RF 3 PA (PA for Part B vs
Part D Only)
BRANCHAMIN 3 PA (PA for Part B vs
Part D Only)
CLINIMIX E 3 PA iv soln: 2.75%, (PA
for Part B vs Part D
Only)
CLINIMIX E 3 PA iv soln: 4.25%, (PA
for Part B vs Part D
Only)
CLINIMIX E 3 PA iv soln: 5%, (PA
for Part B vs Part D
Only)
CLINIMIX 3 PA iv soln: 2.75%, (PA
for Part B vs Part D
Only)
53
Drug Name Drug
Tier Requirements/Limits
CLINIMIX 3 PA iv soln: 4.25%, (PA
for Part B vs Part D
Only)
CLINIMIX 3 PA iv soln: 5%, (PA
for Part B vs Part D
Only)
CLINISOL 3 PA (PA for Part B vs
Part D Only)
cysteine hcl (Cysteine HCl) 1 PA (PA for Part B vs
Part D Only)
dextrose 10 % and 0.225
% nacl
(Dextrose 10 % and 0.225 %
NaCl)
1
dextrose 10 % and 0.225
% nacl
(Dextrose 10 % and 0.225 %
NaCl)
1 iv soln
dextrose 10 % and 0.9 %
nacl
(Dextrose 10 % and 0.9 % NaCl) 1
dextrose 10%-0.5 normal
saline
(Dextrose 10%-0.5 Normal
Saline)
1
dextrose 10%-water (Dextrose 10%-water) 1 PA (PA for Part B vs
Part D Only)
dextrose 2.5 %-water (Dextrose 2.5 %-water) 1 PA (PA for Part B vs
Part D Only)
dextrose 2.5%-0.5normal
saline
(Dextrose 2.5%-0.5 Normal
Saline)
1
dextrose 20 % in water (Dextrose 20 % in Water) 1 PA (PA for Part B vs
Part D Only)
dextrose 20%-water (Dextrose 20%-water) 1 PA (PA for Part B vs
Part D Only)
dextrose 25%-water (Dextrose 25%-water) 1 PA (PA for Part B vs
Part D Only)
dextrose 40%-water (Dextrose 40%-water) 1 PA (PA for Part B vs
Part D Only)
dextrose 5 % and 0.33 %
nacl
(Dextrose 5 % and 0.33 % NaCl) 1
dextrose 5 % and 0.9 %
nacl
(Dextrose 5 % and 0.9 % NaCl) 1
dextrose 5 %-0.225 %
nacl
(Dextrose 5 %-0.225 % NaCl) 1
dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 % NaCl) 1
dextrose 5 %-water (Dextrose 5 %-water) 1
dextrose 50 % in water (Dextrose 50 % in Water) 1 PA (PA for Part B vs
Part D Only)
54
Drug Name Drug
Tier Requirements/Limits
dextrose 60 % in water (Dextrose 60 % in Water) 1 PA (PA for Part B vs
Part D Only)
dextrose 70 % in water (Dextrose 70 % in Water) 1 PA (PA for Part B vs
Part D Only)
ethyl alcohol/d5w (Ethyl Alcohol/D5W) 1
FREAMINE HBC 3 PA (PA for Part B vs
Part D Only)
FREAMINE III with
ELECTROLYTES
3 PA (PA for Part B vs
Part D Only)
FREAMINE III 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
FREAMINE III 3 PA iv soln: 8.5%, (PA
for Part B vs Part D
Only)
fructose 10% (Fructose 10%) 1 PA (PA for Part B vs
Part D Only)
HEPATAMINE 3 PA (PA for Part B vs
Part D Only)
HEPATASOL 3 PA (PA for Part B vs
Part D Only)
INTRALIPID 3 PA emulsion: 10%,
(PA for Part B vs
Part D Only)
INTRALIPID 3 PA emulsion: 20%,
30%, (PA for Part
B vs Part D Only)
LIPOSYN II 3 PA (PA for Part B vs
Part D Only)
LIPOSYN III 3 PA emulsion: 10%,
20%, (PA for Part
B vs Part D Only)
LIPOSYN III 3 PA emulsion: 30%,
(PA for Part B vs
Part D Only)
NEPHRAMINE 3 PA (PA for Part B vs
Part D Only)
NOVAMINE 3 PA (PA for Part B vs
Part D Only)
PREMASOL 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
55
Drug Name Drug
Tier Requirements/Limits
PREMASOL 3 PA iv soln: 6%, (PA
for Part B vs Part D
Only)
PROCALAMINE 3 PA (PA for Part B vs
Part D Only)
PROSOL 3 PA (PA for Part B vs
Part D Only)
QUICK MIX with LYTES 3 PA (PA for Part B vs
Part D Only)
RENAMIN 3 PA (PA for Part B vs
Part D Only)
TRAVAMULSION 3 PA (PA for Part B vs
Part D Only)
TRAVASOL W/
DEXTROSE
3 PA (PA for Part B vs
Part D Only)
TRAVASOL W/
ELECTROLYTES
3 PA iv soln.: 5.5%, (PA
for Part B vs Part D
Only)
TRAVASOL W/
ELECTROLYTES
3 PA iv soln.: 8.5%, (PA
for Part B vs Part D
Only)
TRAVASOL with
DEXTROSE
3 PA iv soln: 8.5%, (PA
for Part B vs Part D
Only)
TRAVASOL with
ELECTROLYTES
3 PA (PA for Part B vs
Part D Only)
TRAVASOL 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
TRAVASOL 3 PA iv soln: 5.5%, (PA
for Part B vs Part D
Only)
TRAVASOL 3 PA iv soln: 8.5%, (PA
for Part B vs Part D
Only)
TRAVERT IN NORMAL
SALINE
3 PA (PA for Part B vs
Part D Only)
TRAVERT 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
TRAVERT 3 PA iv soln: 5%, (PA
for Part B vs Part D
Only)
56
Drug Name Drug
Tier Requirements/Limits
TROPHAMINE 3 PA iv soln: 10%, (PA
for Part B vs Part D
Only)
TROPHAMINE 3 PA iv soln: 6%, (PA
for Part B vs Part D
Only)
Cardiac Drugs Antiarrhythmic Agents
amiodarone hcl (Amiodarone HCl) 1 disp syrin
amiodarone hcl (Cordarone) 1 tablet, vial
disopyramide phosphate (Norpace) 1 PA capsule er, (PA for
Ages 65 and Older;
May be High Risk
Med)
disopyramide phosphate (Norpace) 1 PA capsule, (PA for
Ages 65 and Older;
May be High Risk
Med)
flecainide acetate (Tambocor) 1
lidocaine hcl (Lidocaine HCl) 1
lidocaine hcl/d5w/pf (Lidocaine HCl/d5w/PF) 1 iv soln: 2mg/ml,
8mg/ml
lidocaine hcl/pf (Lidocaine HCl/PF) 1
mexiletine hcl (Mexitil) 1
MULTAQ 3
procainamide hcl (Procainamide HCl) 1 capsule, tablet sa
procainamide hcl (Procainamide HCl) 1 vial
PRONESTYL 3
propafenone hcl (Rythmol) 2
quinidine gluconate (Quinidine Gluconate) 1
quinidine sulfate (Quinidine Sulfate) 1
TIKOSYN 3
Cardiac Drugs, Miscellaneous
digoxin (Lanoxin) 1 PA, QL:
30 in 30
days
tablet, (PAfor Ages
65 and Older; May
be High Risk Med)
digoxin (Lanoxin) 1 PA ampul, (PA/QL for
Ages 65 and Older;
May be High Risk
Med)
DIGOXIN 3 PA, QL:
75 in 30
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
57
Drug Name Drug
Tier Requirements/Limits
inamrinone lactate (Inamrinone Lactate) 1 PA (PA for Part B vs
Part D Only)
milrinone lactate (Milrinone Lactate) 5 PA (PA for Part B vs
Part D Only)
milrinone lactate/d5w (Primacor in 5% Dextrose) 5 PA (PA for Part B vs
Part D Only)
RANEXA 3 QL: 120
in 30
days
tab er 12h: 500mg
RANEXA 3 QL: 60 in
30 days
tab er 12h: 1000mg
Cathartics and Laxatives Cathartics and Laxatives
AMITIZA 3 QL: 60 in
30 days
peg 3350/na sulf,bicarb,cl/
kcl
(Colyte with Flavor Packets) 1
polyethylene glycol 3350 (Polyethylene Glycol 3350) 1
sodium chloride/nahco3/
kcl/peg
(Nulytely) 1
Cell Stimulants and Proliferants Cell Stimulants and Proliferants
KEPIVANCE 5
RETIN-A MICRO 4 PA
tretinoin (Retin-A) 1 PA
Central Nervous System Agents, Miscellaneous Central Nervous System Agents, Miscellaneous
BUTISOL SODIUM 4 PA, QL:
120 in 30
days
tablet: 30mg, (May
be High Risk Med
for Ages 65 and
Older)
BUTISOL SODIUM 4 PA, QL:
473 in 30
days
elixir: 30mg/5ml,
(May be High Risk
Med for Ages 65
and Older)
BUTISOL SODIUM 4 PA, QL:
60 in 30
days
tablet: 50mg, (May
be High Risk Med
for Ages 65 and
Older)
CAMPRAL 3 tab ds pk
CAMPRAL 3 tablet dr
flumazenil (Romazicon) 1
58
Drug Name Drug
Tier Requirements/Limits
INTUNIV 4 QL: 30 in
30 days
lithium carbonate (Eskalith) 1
lithium citrate (Lithium Citrate) 1
LODOSYN 3
LUMINAL SODIUM 4 PA, QL:
2 in 30
days
disp syrin: 60mg/
ml, 130mg/ml
NAMENDA 3 QL: 360
in 30
days
solution
NAMENDA 3 QL: 49 in
28 days
tab ds pk
NAMENDA 3 QL: 62 in
31 days
tablet
NUEDEXTA 3 QL: 60 in
30 days
phenobarbital sodium (Phenobarbital Sodium) 1 PA, QL:
2 in 30
days
vial: 65mg/ml,
130mg/ml
phenobarbital (Phenobarbital) 1 PA, QL:
1500 in
30 days
elixir: 20mg/5ml,
(May be High Risk
Med for Ages 65
and Older)
phenobarbital (Phenobarbital) 1 PA, QL:
200 in 30
days
tablet: 30mg, (May
be High Risk Med
for Ages 65 and
Older)
phenobarbital (Phenobarbital) 1 PA, QL:
90 in 30
days
tablet: 15mg, 60mg,
100mg, (May be
High Risk Med for
Ages 65 and Older)
phenobarbital (Phenobarbital) 1 PA, QL:
90 in 30
days
tablet: 16.2mg,
32.4mg, 64.8mg,
97.2mg, (May be
High Risk Med for
Ages 65 and Older)
primidone (Mysoline) 1
RILUTEK 5
SAVELLA 3 QL: 60 in
30 days
STRATTERA 3
59
Drug Name Drug
Tier Requirements/Limits
XENAZINE 5 PA, QL:
112 in 28
days
XYREM 5 LA
60
Drug Name Drug
Tier Requirements/Limits
Contraceptives Contraceptives
desogestrel-ethinyl
estradiol
(Desogen) 1
desog-et estra/ethin estra (Mircette) 1
ethinyl estradiol/
drospirenone
(Yaz) 2
ethynodiol d-ethinyl
estradiol
(Demulen 1-50-21) 1
levonorgestrel (Plan B) 1
levonorgestrel-eth
estradiol
(Lybrel) 1 tablet: 0.1-0.02,
0.15-0.03, 6-5-10
levonorgestrel-eth
estradiol
(Lybrel) 2 tablet: 90-20mcg
levonorgestrel-eth
estradiol
(Seasonale) 1 QL: 91 in
84 days
tbdspk 3mo
l-norgest-eth estr/ethin
estra
(Seasonique) 2 QL: 91 in
84 days
tbdspk 3mo: 100-
20(84)
l-norgest-eth estr/ethin
estra
(Seasonique) 2 QL: 91 in
84 days
tbdspk 3mo: 150-
30(84)
noreth a-et estra/fe
fumarate
(Loestrin Fe) 1
noreth-ethinyl estradiol/
iron
(Femcon Fe) 2
norethindrone a-e
estradiol
(Loestrin) 1
norethindrone (Nor-Q-D) 1
norethindrone-ethinyl
estrad
(Ovcon-35) 1
norethindrone-mestranol (Ortho-novum) 1
norgestimate-ethinyl
estradiol
(Ortho Tri-cyclen) 1
norgestrel-ethinyl
estradiol
(Lo-ovral-28) 1
NUVARING 3 QL: 1 in
28 days
ORTHO EVRA 4 QL: 3 in
28 days
61
Drug Name Drug
Tier Requirements/Limits
Devices Devices
needles, insulin disp.,
safety
(Needles, Insulin Disp., Safety) 1
needles, insulin disposable (Needles, Insulin Disposable) 1
syring w-
ndl,disp,insul,0.3ml
(Syring W-ndl,disp,insul,0.3ml) 1
syring w-
ndl,disp,insul,0.5ml
(Syring W-ndl,disp,insul,0.5ml) 1
syringe & needle,insulin,1
ml
(Syringe & Needle,insulin,1 Ml) 1
Diuretics Diuretics, Miscellaneous
chlorothiazide (Chlorothiazide) 1
chlorthalidone (Chlorthalidone) 1
hydrochlorothiazide (Hydrochlorothiazide) 1
indapamide (Lozol) 1
methyclothiazide (Methyclothiazide) 1
metolazone (Zaroxolyn) 1
SAMSCA 5 QL: 30 in
30 days
tablet: 15mg
SAMSCA 5 QL: 60 in
30 days
tablet: 30mg
Loop Diuretics
bumetanide (Bumex) 1
furosemide (Furosemide) 1 disp syrin
furosemide (Lasix) 1 solution, tablet, vial
torsemide (Demadex) 1
Potassium-sparing Diuretics
amiloride hcl (Midamor) 1
amiloride/
hydrochlorothiazide
(Amiloride/hydrochlorothiazide) 1
DYRENIUM 4
triamterene/
hydrochlorothiazid
(Maxzide-25mg) 1
EENT Drugs, Miscellaneous EENT Drugs, Miscellaneous
apraclonidine hcl (Iopidine) 1
atropine sulfate (Isopto Atropine) 1
carteolol hcl (Carteolol HCl) 1
CYCLOGYL 3 drops: 0.5%
cyclopentolate hcl (Cyclogyl) 1 drops: 1%
62
Drug Name Drug
Tier Requirements/Limits
homatropine hbr (Isopto Homatropine) 1
IOPIDINE 4 droperette
ipratropium bromide (Atrovent) 1 QL: 15 in
10 days
spray: 42mcg
ipratropium bromide (Atrovent) 1 QL: 30 in
28 days
spray: 21mcg
ISOPTO
HOMATROPINE
3 drops: 2%
LACRISERT 3
naphazoline hcl (Albalon) 1
naphazoline hcl/antazoline (Naphazoline HCl/antazoline) 1
phenylephrine hcl (Mydfrin) 1
PROPINE 3
tropicamide (Mydral) 1
TYZINE 3 drops
TYZINE 3 spray
Enzymes Enzymes
ADAGEN 5
ALDURAZYME 5
CEREDASE 5
CEREZYME 5
ELAPRASE 5
ELITEK 5
FABRAZYME 5
KRYSTEXXA 5
LUMIZYME 5
MYOZYME 5
NAGLAZYME 5
PULMOZYME 5 PA (PA for Part B vs
Part D Only)
VPRIV 5
XIAFLEX 5 PA, QL:
1 in 28
days
63
Drug Name Drug
Tier Requirements/Limits
Estrogens and Antiestrogens Estrogens and Antiestrogens
ALORA 4 PA, QL:
8 in 28
days
(PA for Ages 65 and
Older; May be High
Risk Med)
ANGELIQ 4 PA (PA for Ages 65 and
Older; May be High
Risk Med)
CENESTIN 4 PA (PA for Ages 65 and
Older; May be High
Risk Med)
COMBIPATCH 3 PA, QL:
8 in 28
days
(PA for Ages 65 and
Older; May be High
Risk Med)
DEPO-ESTRADIOL 4 PA
ESTRACE 3 PA cream/appl
estradiol valerate (Delestrogen) 1 PA
estradiol (Climara) 1 PA, QL:
4 in 28
days
patch tdwk, (PA for
Ages 65 and Older;
May be High Risk
Med)
estradiol (Estrace) 1 PA tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
estradiol/noreth ac (Activella) 1 PA tablet: 1-0.5mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
estradiol/noreth ac (Activella) 2 PA tablet: 0.5-0.1mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
ESTRASORB 4 PA, QL:
97.44 in
28 days
(PA for Ages 65 and
Older; May be High
Risk Med)
ESTRING 4 PA, QL:
1 in 84
days
estropipate (Ogen) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
EVISTA 3
64
Drug Name Drug
Tier Requirements/Limits
FEMHRT 4 tablet: 0.5mg-2.5
FEMRING 4 PA, QL:
1 in 84
days
MENEST 4 PA (PA for Ages 65 and
Older; May be High
Risk Med)
norethind ac/ethinyl
estradiol
(Femhrt) 2
PREFEST 4 PA (PA for Ages 65 and
Older; May be High
Risk Med)
PREMARIN 3 PA (PA for Ages 65 and
Older; May be High
Risk Med)
PREMPHASE 3 PA (PA for Ages 65 and
Older; May be High
Risk Med)
PREMPRO 3 PA (PA for Ages 65 and
Older; May be High
Risk Med)
VAGIFEM 3 PA, QL:
18 in 28
days
tablet: 10mcg
VAGIFEM 3 PA, QL:
8 in 28
days
tablet: 25mcg
VIVELLE-DOT 3 PA, QL:
8 in 28
days
(PA for Ages 65 and
Older; May be High
Risk Med)
Genitourinary Smooth Muscle Relaxants Genitourinary Smooth Muscle Relaxants
DETROL LA 3
flavoxate hcl (Urispas) 2
GELNIQUE 4 QL: 30 in
30 days
gel packet
GELNIQUE 4 QL: 92 in
30 days
gel md pmp
oxybutynin chloride (Ditropan) 1
OXYTROL 4 QL: 8 in
28 days
SANCTURA XR 4
tolterodine tartrate (Detrol) 2
65
Drug Name Drug
Tier Requirements/Limits
TOVIAZ 3
trospium chloride (Sanctura) 2
VESICARE 3
GI Drugs, Miscellaneous GI Drugs, Miscellaneous
CHENODAL 5 PA, QL:
120 in 30
days
CIMZIA 5 PA, QL:
3 in 28
days
CREON 3
lipase/protease/amylase (Zenpep) 2
LOTRONEX 5
metoclopramide hcl (Metoclopramide HCl) 1 PA disp syrin, (PA for
Ages 65 and Older;
May be High Risk
Med)
metoclopramide hcl (Reglan) 1 PA solution, tablet, vial,
(PA for Ages 65 and
Older; May be High
Risk Med)
NUTRESTORE 3
PANCREAZE 4
RELISTOR 4 PA, QL:
28 in 28
days
disp syrin
RELISTOR 4 PA, QL:
28 in 28
days
vial
ursodiol (Actigall) 2
ZENPEP 3
66
Drug Name Drug
Tier Requirements/Limits
Heavy Metal Antagonists Heavy Metal Antagonists
BAL IN OIL 3
CALCIUM DISODIUM
VERSENATE
3
deferoxamine mesylate (Desferal) 1 PA
edetate disodium (Edetate Disodium) 1
ENDRATE 3
EXJADE 3 tab disper: 125mg
EXJADE 5 tab disper: 250mg,
500mg
FERRIPROX 5
GALZIN 4
na nitrite/na thiosul/amyl
nit
(Na Nitrite/na Thiosul/amyl Nit) 1
sodium thiosulfate (Sodium Thiosulfate) 2
SYPRINE 5
Hematologic Agents Anticoagulants
CEPROTIN 5
citrate-phos-dex solution (Citrate-phos-dex Solution) 1
enoxaparin sodium (Lovenox) 2 QL: 13.6
in 30
days
disp syrin: 40mg/
0.4ml
enoxaparin sodium (Lovenox) 2 QL: 18 in
30 days
disp syrin: 30mg/
0.3ml
enoxaparin sodium (Lovenox) 2 QL: 20.4
in 30
days
disp syrin: 60mg/
0.6ml
enoxaparin sodium (Lovenox) 2 QL: 27.2
in 30
days
disp syrin: 80mg/
0.8ml
enoxaparin sodium (Lovenox) 5 QL: 27.2
in 30
days
disp syrin: 120mg/
.8ml
enoxaparin sodium (Lovenox) 5 QL: 34 in
30 days
disp syrin: 150mg/
ml
enoxaparin sodium (Lovenox) 5 QL: 36 in
30 days
disp syrin: 100mg/
ml
fondaparinux sodium (Arixtra) 2 QL: 11.2
in 28
days
disp syrin: 10mg/
0.8ml
67
Drug Name Drug
Tier Requirements/Limits
fondaparinux sodium (Arixtra) 2 QL: 5.6
in 28
days
disp syrin: 5mg/
0.4ml
fondaparinux sodium (Arixtra) 2 QL: 7 in
28 days
disp syrin: 2.5mg/
0.5
fondaparinux sodium (Arixtra) 2 QL: 8.4
in 28
days
disp syrin: 7.5mg/
0.6
heparin sodium,porcine (Hep-lock) 1 PA (PA for ESRD
Only)
heparin sodium,porcine/
d5w
(Heparin Sodium, porcine/D5W) 1
heparin sodium,porcine/
ns/pf
(Heparin Sodium, porcine/ns/PF) 1
heparin sodium,porcine/pf (Hep-lock) 1 vial port
heparin sodium,porcine/pf (Hep-lock) 1 PA vial, (PA for ESRD
Only)
heparin sodium,porcine/pf (Monoject Prefill Advanced) 1 PA disp syrin, (PA for
ESRD Only)
IPRIVASK 5 PA, QL:
24 in 28
days
LOVENOX 3 QL: 36 in
30 days
vial
PRADAXA 4 PA, QL:
60 in 30
days
warfarin sodium (Coumadin) 1
XARELTO 4 PA, QL:
30 in 30
days
Hematologic Agents, Miscellaneous
aminocaproic acid (Amicar) 2 solution, tablet
aminocaproic acid (Aminocaproic Acid) 1 vial
anagrelide hcl (Agrylin) 2
LYSTEDA 4 QL: 30 in
30 days
pentoxifylline (Trental) 1
protamine sulfate (Protamine Sulfate) 1 PA (PA for ESRD
Only)
tranexamic acid (Tranexamic Acid) 2
Platelet-aggregation Inhibitors
68
Drug Name Drug
Tier Requirements/Limits
BRILINTA 4 QL: 60 in
30 days
cilostazol (Pletal) 1
clopidogrel bisulfate (Plavix) 1
EFFIENT 3 QL: 30 in
30 days
Hematopoietic Agents Hematopoietic Agents
ARANESP 3 PA, QL:
1.2 in 28
days
disp syrin: 60mcg/
0.3
ARANESP 3 PA, QL:
1.6 in 28
days
disp syrin: 40mcg/
0.4
ARANESP 3 PA, QL:
1.68 in
28 days
disp syrin: 25mcg/
0.42
ARANESP 3 PA, QL:
4 in 28
days
vial: 25mcg/ml,
40mcg/ml, 60mcg/
ml
ARANESP 5 PA, QL:
1.2 in 28
days
disp syrin: 150mcg/
0.3
ARANESP 5 PA, QL:
1.6 in 28
days
disp syrin: 200mcg/
0.4
ARANESP 5 PA, QL:
2 in 28
days
disp syrin: 100mcg/
0.5
ARANESP 5 PA, QL:
2.4 in 28
days
disp syrin: 300mcg/
0.6
ARANESP 5 PA, QL:
4 in 28
days
disp syrin: 500mcg/
ml; vial: 100mcg/
ml, 200mcg/ml,
300mcg/ml
EPOGEN 3 PA, QL:
12 in 28
days
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml, 20000/ml
EPOGEN 5 PA, QL:
6 in 28
days
vial: 40000/ml
LEUKINE 5
69
Drug Name Drug
Tier Requirements/Limits
MOZOBIL 5 PA, QL:
9.6 per
fill
NEULASTA 5
NEUMEGA 5
NEUPOGEN 5
PROCRIT 3 PA, QL:
12 in 28
days
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml
PROCRIT 5 PA, QL:
12 in 28
days
vial: 20000/ml
PROCRIT 5 PA, QL:
6 in 28
days
vial: 40000/ml
PROMACTA 5 PA, QL:
30 in 30
days
Hypotensive Agents Hypotensive Agents, Miscellaneous
clonidine hcl (Catapres) 1
clonidine hcl/
chlorthalidone
(Clonidine HCl/chlorthalidone) 2
clonidine (Catapres-TTS 3) 2 QL: 4 in
28 days
patch tdwk: 0.1mg/
24hr, 0.2mg/24hr
clonidine (Catapres-TTS 3) 2 QL: 8 in
28 days
patch tdwk: 0.3mg/
24hr
fenoldopam mesylate (Corlopam) 1 PA (PA for Part B vs
Part D Only)
guanfacine hcl (Tenex) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
hydralazine hcl (Apresoline) 1
hydralazine/
hydrochlorothiazid
(Hydralazine/
hydrochlorothiazid)
1
hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz) 1 PA, QL:
30 in 30
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
minoxidil (Minoxidil) 1
PROGLYCEM 3
reserpine (Reserpine) 1 PA, QL:
30 in 30
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
70
Drug Name Drug
Tier Requirements/Limits
reserpine/
hydrochlorothiazide
(Reserpine/hydrochlorothiazide) 1 PA, QL:
30 in 30
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
Ion-Removing Agents Ion-Removing Agents
calcium acetate (Phoslo) 2
calcium carbonate/mag
carb/fa
(Calcium Carbonate/mag Carb/
fa)
1
FOSRENOL 4
PHOSLYRA 4
RENAGEL 3
RENVELA 3 powd pack: 2.4g;
tablet
sodium polystyrene
sulfonate
(Sodium Polystyrene Sulfonate) 1
Irrigating Solutions Irrigating Solutions
acetic acid (Acetic Acid) 1
glycine (Aminoacetic Acid) 1
LACTATED RINGERS 3
mannitol/sorbitol solution (Mannitol/sorbitol Solution) 1
ringers solution (Tis-u-sol) 1
sod chloride 0.45% irrig.
soln
(Sod Chloride 0.45% Irrig. Soln) 1
sodium chloride irrig
solution
(Sodium Chloride Irrig Solution) 1
sorbitol solution (Sorbitol Solution) 1
UROLOGIC SOLUTION
G
3
water for irrigation,sterile (Water for Irrigation, Sterile) 1
Keratolytic Agents Keratolytic Agents
benzoyl peroxide
microspheres
(Neobenz Micro) 1
benzoyl peroxide (Acne Medication-5) 1 cleanser, gel (gram),
lotion, med. pad
benzoyl peroxide/aloe
vera
(Benziq) 1
benzoyl peroxide/
hydrocortison
(Benzoyl Peroxide/
hydrocortison)
1
benzoyl peroxide/urea (Zoderm) 1
potassium hydroxide (Potassium Hydroxide) 1
71
Drug Name Drug
Tier Requirements/Limits
salicylic acid (Salacyn) 1
salicylic acid/ammon lact/
aloe
(Salkera) 1
salicylic acid/ceramide
cmb #1
(Salex) 1
silver nitrate applicator (Silver Nitrate Applicator) 1
Keratoplastic Agents Keratoplastic Agents
DRITHO-SCALP 3
sulfacetamide sodium/urea (Rosula Ns) 1 med. pad
Local Anesthetics Local Anesthetics
aa/antipyrn/bcaine/
polico#1/al
(Auralgan) 2
aa/antpy/bcaine/polico/al
acet
(Aa/antpy/bcaine/polico/al Acet) 2
AKTEN 4
antipyrine/benzocaine/
glycerin
(Otra Nr) 1
benzocaine (Omedia Otic) 1
chloroprocaine hcl/pf (Nesacaine-MPF) 1
chloroxylenol/pramoxine
hcl
(Oticin) 1
cocaine hcl (Cocaine HCl) 2
lidocaine hcl (Xylocaine) 1 jel (ml), jel/pf app,
solution
lidocaine hcl (Xylocaine) 1 PA vial, (PA for ESRD
Only)
lidocaine hcl/pf (Xylocaine-MPF) 1 PA ampul, ampul luer,
(PA for ESRD
Only)
mepivacaine hcl/pf (Mepivacaine HCl/PF) 1
phenylephrine/antipy/b-
caine
(Otogesic) 1
proparacaine hcl (Ophthetic) 1
proparacaine/fluorescein
sod
(Proparacaine/fluorescein Sod) 1
tetracaine hcl/pf (Tetracaine HCl/PF) 1
XYLOCAINE 1 vial: 20mg/ml
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
72
Drug Name Drug
Tier Requirements/Limits
ACTEMRA 5 PA, QL:
40 in 30
days
ACTHAR H.P. 5 PA, QL:
35 in 28
days
ACTIMMUNE 5
ACTONEL with
CALCIUM
3 QL: 28 in
28 days
ACTONEL 3 QL: 1 in
28 days
tablet: 150mg
ACTONEL 3 QL: 31 in
31 days
tablet: 5mg, 30mg
ACTONEL 3 QL: 4 in
28 days
tablet: 35mg
alendronate sodium (Fosamax) 1 tablet: 5mg, 10mg,
40mg
alendronate sodium (Fosamax) 1 QL: 4 in
28 days
tablet: 35mg, 70mg
allopurinol sodium (Aloprim) 1
allopurinol (Zyloprim) 1
amifostine crystalline (Ethyol) 1
ammonium chloride (Ammonium Chloride) 1
AMPYRA 5 PA, QL:
60 in 30
days
ARCALYST 5
ATELVIA 4 QL: 4 in
28 days
AVODART 3
AVONEX
ADMINISTRATION
PACK
5 ST
AVONEX 5 ST
azathioprine sodium (Azathioprine Sodium) 1 PA (PA for Part B vs
Part D Only)
azathioprine (Imuran) 1 PA (PA for Part B vs
Part D Only)
BENLYSTA 5 PA, QL:
2 in 28
days
73
Drug Name Drug
Tier Requirements/Limits
BERINERT 5 PA, QL:
4 in 300
days
BETASERON 5 ST
BONIVA 3 PA, QL:
3 in 84
days
disp syrin, (PA for
ESRD Only)
BONIVA 3 QL: 31 in
31 days
tablet: 2.5mg
BOTOX 4 PA, QL:
1 in 90
days
vial: 200unit
BOTOX 4 PA, QL:
4 in 90
days
vial: 100unit
CELLCEPT 4 PA vial, (PA for Part B
vs Part D Only)
CELLCEPT 5 PA susp recon, (PA for
Part B vs Part D
Only)
CINRYZE 5 PA, QL:
20 in 28
days
citric acid/sodium citrate (Bicitra) 1
colchicine/probenecid (Colchicine/probenecid) 1
COLCRYS 3
COPAXONE 5
cyclosporine (Sandimmune) 2 PA capsule, vial, (PA
for Part B vs Part D
Only)
cyclosporine (Sandimmune) 2 PA solution, (PA for
Part B vs Part D
Only)
cyclosporine, modified (Neoral) 2 PA (PA for Part B vs
Part D Only)
CYSTADANE 4
dexrazoxane (Totect) 1
disulfiram (Antabuse) 2
DUODOTE 3
DYSPORT 4 PA, QL:
2 in 90
days
ELMIRON 3
74
Drug Name Drug
Tier Requirements/Limits
ENBREL 5 PA, QL:
7.84 in
28 days
pen injctr
ENBREL 5 PA, QL:
8 in 28
days
kit
ENBREL 5 PA, QL:
8.16 in
28 days
disp syrin
etidronate disodium (Didronel) 2
EXTAVIA 5 ST
finasteride (Proscar) 1
FIRAZYR 5
FLUORITAB 4
FLURA-DROPS 4
fomepizole (Antizol) 5
FUSILEV 5
gauze bandage (Gauze Bandage) 1
GILENYA 5 PA, QL:
28 in 28
days
GLUCAGEN 3
GLUCAGON
EMERGENCY KIT
3
gold sodium thiomalate (Myochrysine) 1
HUMIRA 5 PA, QL:
4 in 28
days
kit, pen ij kit: 40mg/
0.8ml
HUMIRA 5 PA, QL:
6 in 28
days
pen ij kit: 40mg/
0.8ml, (Starter Kit)
ibandronate sodium (Boniva) 2 QL: 1 in
28 days
ILARIS 5
KALBITOR 5
KINERET 5 PA, QL:
18.76 in
28 days
K-PHOS M.F. 3
K-PHOS NO.2 3
KUVAN 5
leflunomide (Arava) 2
leucovorin calcium (Leucovorin Calcium) 1
75
Drug Name Drug
Tier Requirements/Limits
levocarnitine (with sugar) (Carnitor) 2 PA (PA for ESRD
Only)
levocarnitine (Carnitor) 2 PA (PA for ESRD
Only)
mesna (Mesnex) 1
MESNEX 5 tablet
methylene blue (Methylene Blue) 1
methylergonovine maleate (Methergine) 1 tablet
methylergonovine maleate (Methylergonovine Maleate) 1 vial
mycophenolate mofetil (Cellcept) 2 PA (PA for Part B vs
Part D Only)
MYFORTIC 4 PA (PA for Part B vs
Part D Only)
MYOBLOC 4 PA, QL:
1 in 90
days
NPLATE 5 PA, QL:
8 in 28
days
NULOJIX 5 PA (PA for Part B vs
Part D Only)
octreotide acetate (Sandostatin) 2 vial: 50mcg/ml,
100mcg/ml,
200mcg/ml
octreotide acetate (Sandostatin) 5 vial: 500mcg/ml,
1000mcg/ml
ORENCIA 5 PA, QL:
4 in 28
days
disp syrin
ORENCIA 5 PA, QL:
4 in 28
days
vial
ORFADIN 3
pamidronate disodium (Aredia) 1 PA vial: 60mg/10ml,
90mg/10ml, (PA
for ESRD Only)
pamidronate disodium (Aredia) 2 PA vial: 30mg/10ml,
(PA for ESRD
Only)
phosphorus #1 (K-phos Neutral) 1
potassium citrate (Urocit-K) 1
potassium citrate/citric
acid
(Polycitra-k) 1
76
Drug Name Drug
Tier Requirements/Limits
PRALIDOXIME
CHLORIDE
3
probenecid (Probenecid) 1
PROGRAF 4 PA ampul, (PA for Part
B vs Part D Only)
PROLIA 4 PA, QL:
1 in 180
days
PROTOPAM CHLORIDE 4
RAPAMUNE 3 PA solution, tablet:
0.5mg, (PA for Part
B vs Part D Only)
RAPAMUNE 5 PA tablet: 1mg, 2mg,
(PA for Part B vs
Part D Only)
REBIF 5
RECLAST 4 QL: 100
in 300
days
REMICADE 5 PA
REVLIMID 5 LA, QL:
30 in 30
days
RIDAURA 4
SANDOSTATIN LAR 5
SENSIPAR 3 tablet: 30mg
SENSIPAR 5 tablet: 60mg, 90mg
SIMPONI 5 PA, QL:
0.5 in 28
days
SIMULECT 3 PA (PA for Part B vs
Part D Only)
SKELID 4
sod/pot/k cit/sod cit/cit
acid
(Polycitra-lc) 1
sodium bicarbonate (Sodium Bicarbonate) 1
sodium fluoride (Sodium Fluoride) 4 drops, tab chew
sodium lactate (Sodium Lactate) 1
SOLIRIS 5
SOMATULINE DEPOT 5 QL: 1 in
28 days
77
Drug Name Drug
Tier Requirements/Limits
STELARA 5 PA, QL:
10 in 360
days
vial
STELARA 5 PA, QL:
5 in 360
days
disp syrin
SUPPRELIN LA 5 QL: 1 in
360 days
SUPPRELIN 4
SYNAREL 5
tacrolimus (Prograf) 2 PA (PA for Part B vs
Part D Only)
THALOMID 5 QL: 60 in
30 days
TYSABRI 5 LA, PA,
QL: 15 in
28 days
ULORIC 3 ST, QL:
31 in 31
days
VANTAS 4 QL: 1 in
360 days
XEOMIN 4 PA, QL:
2 in 90
days
XGEVA 5 PA, QL:
1.7 in 28
days
ZAVESCA 5
ZOMETA 4 infus. btl
ZOMETA 4 vial
ZORTRESS 4 PA, QL:
60 in 30
days
tablet: 0.25mg, (PA
for Part B vs Part D
Only)
ZORTRESS 5 PA, QL:
60 in 30
days
tablet: 0.5mg,
0.75mg, (PA for
Part B vs Part D
Only)
Opiate Antagonists Opiate Antagonists
naloxone hcl (Naloxone HCl) 1 ampul, disp syrin:
0.4mg/ml; vial
naloxone hcl (Naloxone HCl) 1 disp syrin: 1mg/ml
78
Drug Name Drug
Tier Requirements/Limits
naltrexone hcl (Revia) 1
Parasympathomimetics (Cholinergic Agents) Parasympathomimetics (Cholinergic Agents)
ARICEPT 3 PA, QL:
31 in 31
days
tablet: 23mg
bethanechol chloride (Urecholine) 2
CHANTIX 3 PA, QL:
168 in 84
days
tablet
CHANTIX 3 PA, QL:
53 in 28
days
tab ds pk
donepezil hcl (Aricept Odt) 2 QL: 31 in
31 days
tab rapdis
donepezil hcl (Aricept) 1 QL: 31 in
31 days
tablet
EXELON 4 PA, QL:
30 in 30
days
patch td24
EXELON 4 QL: 240
in 31
days
solution
galantamine hbr (Razadyne ER) 2 QL: 30 in
30 days
cap24h pel
galantamine hbr (Razadyne) 2 QL: 200
in 30
days
solution
galantamine hbr (Razadyne) 2 QL: 60 in
30 days
tablet
MESTINON 4 syrup, tablet er
MYTELASE 3
neostigmine methylsulfate (Neostigmine Methylsulfate) 1
NICOTROL NS 4 QL: 240
in 180
days
NICOTROL 4 QL: 2016
in 365
days
physostigmine salicylate (Physostigmine Salicylate) 1
pilocarpine hcl (Salagen) 2
PROSTIGMIN 3
pyridostigmine bromide (Mestinon) 1
79
Drug Name Drug
Tier Requirements/Limits
REGONOL 4
rivastigmine tartrate (Exelon) 2 QL: 62 in
31 days
Parathyroid Parathyroid
calcitonin,salmon,syntheti
c
(Miacalcin) 2 QL: 3.7
in 28
days
FORTEO 4 QL: 3 in
28 days
FORTICAL 3 QL: 3.7
in 28
days
MIACALCIN 3 PA vial, (PA for ESRD
Only)
Pituitary Pituitary
DDAVP 3 ampul: 15mcg/ml
desmopressin acetate (DDAVP) 1 ampul
desmopressin acetate (DDAVP) 2 tablet
desmopressin acetate (Desmopressin Acetate) 2 QL: 15 in
30 days
solution
desmopressin acetate (Desmopressin Acetate) 2 QL: 15 in
30 days
spray/pump
GENOTROPIN 3 PA disp syrin: 0.2mg/
0.25
GENOTROPIN 5 PA various dosage and/
or strengths are
available
HUMATROPE 5 PA
NORDITROPIN
FLEXPRO
5 PA
NORDITROPIN
NORDIFLEX
5 PA
NORDITROPIN 5 PA
NUTROPIN AQ NUSPIN 5 PA cartridge: 10mg/2ml
NUTROPIN AQ NUSPIN 5 PA cartridge: 5mg/2ml
NUTROPIN AQ 5 PA
NUTROPIN 5 PA
OMNITROPE 3 PA cartridge: 10mg/
1.5ml
OMNITROPE 5 PA cartridge: 5mg/
1.5ml; vial
80
Drug Name Drug
Tier Requirements/Limits
SAIZEN 5 PA cartridge, vial: 5mg
SAIZEN 5 PA vial: 8.8mg
SEROSTIM 5 PA
STIMATE 4
TEV-TROPIN 3 PA
vasopressin (Pitressin) 1
ZORBTIVE 5 PA
Progestins Progestins
DEPO-PROVERA 3 QL: 10 in
28 days
vial: 400mg/ml
medroxyprogesterone
acetate
(Depo-provera) 1 QL: 1 in
84 days
disp syrin
medroxyprogesterone
acetate
(Depo-provera) 1 QL: 1 in
84 days
vial
medroxyprogesterone
acetate
(Provera) 1 tablet
norethindrone acetate (Aygestin) 1
progesterone (Progesterone In Oil) 1
progesterone,micronized (Prometrium) 1
Psychotherapeutic Agents Antidepressants
amitriptyline hcl (Amitriptyline HCl) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
amoxapine (Amoxapine) 1
bupropion hcl (Wellbutrin SR) 1
citalopram hydrobromide (Celexa) 1 solution
citalopram hydrobromide (Celexa) 1 QL: 30 in
30 days
tablet
clomipramine hcl (Anafranil) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
CYMBALTA 3 QL: 30 in
30 days
capsule dr: 30mg
CYMBALTA 3 QL: 60 in
30 days
capsule dr: 20mg,
60mg
desipramine hcl (Norpramin) 2
doxepin hcl (Doxepin HCl) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
EMSAM 4 QL: 30 in
30 days
81
Drug Name Drug
Tier Requirements/Limits
escitalopram oxalate (Lexapro) 2
fluoxetine hcl (Prozac) 1 capsule, solution,
tablet: 10mg, 20mg
fluoxetine hcl (Prozac) 2 capsule dr
fluoxetine hcl (Rapiflux) 2 tablet: 60mg
fluvoxamine maleate (Fluvoxamine Maleate) 1
imipramine hcl (Tofranil) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
imipramine pamoate (Tofranil-PM) 2 PA (PA for Ages 65 and
Older; May be High
Risk Med)
LEXAPRO 4 solution
LUVOX CR 4
maprotiline hcl (Maprotiline HCl) 1
MARPLAN 4
mirtazapine (Remeron) 1
nefazodone hcl (Nefazodone HCl) 1
nortriptyline hcl (Pamelor) 1
paroxetine hcl (Paroxetine HCl) 1 oral susp
paroxetine hcl (Paxil) 1 tab er 24h, tablet
PAXIL 4 oral susp
perphenazine/
amitriptyline hcl
(Perphenazine/amitriptyline
HCl)
1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
phenelzine sulfate (Nardil) 1
PRISTIQ ER 4 QL: 31 in
31 days
protriptyline hcl (Vivactil) 2
sertraline hcl (Zoloft) 1
SILENOR 3 QL: 30 in
30 days
SURMONTIL 4 PA (PA for Ages 65 and
Older; May be High
Risk Med)
SYMBYAX 4 QL: 30 in
30 days
tranylcypromine sulfate (Parnate) 2
trazodone hcl (Trazodone HCl) 1
trimipramine maleate (Surmontil) 2 PA (PA for Ages 65 and
Older; May be High
Risk Med)
82
Drug Name Drug
Tier Requirements/Limits
VENLAFAXINE HCL
ER
2
venlafaxine hcl (Effexor XR) 2 cap er 24h
venlafaxine hcl (Effexor) 1 tablet
VIIBRYD 4 QL: 30 in
30 days
Antipsychotic Agents
ABILIFY DISCMELT 3 ST, QL:
62 in 31
days
tab rapdis: 15mg
ABILIFY DISCMELT 3 ST, QL:
93 in 31
days
tab rapdis: 10mg
ABILIFY 3 ST, QL:
161.2 in
28 days
vial
ABILIFY 3 ST, QL:
31 in 31
days
tablet
ABILIFY 3 ST, QL:
930 in 31
days
solution
chlorpromazine hcl (Chlorpromazine HCl) 1 ampul, tablet
chlorpromazine hcl (Chlorpromazine HCl) 1 oral conc.
clozapine (Clozaril) 1 QL: 140
in 31
days
tablet: 200mg
clozapine (Clozaril) 1 QL: 279
in 31
days
tablet: 100mg
clozapine (Clozaril) 1 QL: 93 in
31 days
tablet: 25mg, 50mg
FANAPT 4 ST, QL:
60 in 30
days
tablet
FANAPT 4 ST, QL:
8 in 28
days
tab ds pk
FAZACLO 4 ST, QL:
124 in 31
days
tab rapdis: 200mg
83
Drug Name Drug
Tier Requirements/Limits
FAZACLO 4 ST, QL:
186 in 31
days
tab rapdis: 150mg
FAZACLO 4 ST, QL:
93 in 31
days
tab rapdis: 12.5mg,
25mg, 100mg
fluphenazine decanoate (Fluphenazine Decanoate) 1
fluphenazine hcl (Fluphenazine HCl) 1
GEODON 4 QL: 6 in
28 days
vial
haloperidol decanoate (Haloperidol Decanoate) 1
haloperidol lactate (Haloperidol Lactate) 1
haloperidol (Haloperidol) 1
INVEGA SUSTENNA 3 QL: 0.25
in 28
days
disp syrin: 39mg/
0.25
INVEGA SUSTENNA 3 QL: 0.5
in 28
days
disp syrin: 78mg/
0.5ml
INVEGA SUSTENNA 5 QL: 0.75
in 28
days
disp syrin: 117mg/
0.75
INVEGA SUSTENNA 5 QL: 1 in
28 days
disp syrin: 156mg/
ml
INVEGA SUSTENNA 5 QL: 1.5
in 28
days
disp syrin: 234mg/
1.5
INVEGA 4 ST, QL:
31 in 31
days
tab er 24: 1.5mg,
3mg, 9mg
INVEGA 4 ST, QL:
62 in 31
days
tab er 24: 6mg
LATUDA 4 ST, QL:
30 in 30
days
loxapine succinate (Loxitane) 1
MOBAN 4
NAVANE 4 capsule: 20mg
olanzapine (Zyprexa) 2 QL: 31 in
31 days
ORAP 4
perphenazine (Perphenazine) 1
84
Drug Name Drug
Tier Requirements/Limits
quetiapine fumarate (Seroquel) 2 QL: 93 in
31 days
RISPERDAL CONSTA 4 QL: 4 in
28 days
risperidone (Risperdal M-tab) 2 QL: 124
in 31
days
tab rapdis: 3mg,
4mg
risperidone (Risperdal M-tab) 2 QL: 62 in
31 days
tab rapdis: 0.25mg,
0.5mg, 1mg, 2mg
risperidone (Risperdal) 1 QL: 496
in 31
days
solution
risperidone (Risperdal) 1 QL: 62 in
31 days
tablet
SAPHRIS 4 ST, QL:
60 in 30
days
SEROQUEL XR 4 ST, QL:
31 in 31
days
tab er 24h: 200mg
SEROQUEL XR 4 ST, QL:
62 in 31
days
tab er 24h: 50mg,
150mg, 300mg,
400mg
thioridazine hcl (Thioridazine HCl) 1 PA oral conc., (PA for
Ages 65 and Older;
May be High Risk
Med)
thioridazine hcl (Thioridazine HCl) 1 PA tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
thiothixene (Navane) 1
trifluoperazine hcl (Trifluoperazine HCl) 1
ziprasidone hcl (Geodon) 2 QL: 62 in
31 days
ZYPREXA RELPREVV 5 QL: 2 in
28 days
ZYPREXA 4 QL: 31 in
31 days
vial
85
Drug Name Drug
Tier Requirements/Limits
Renin-Angiotensin-Aldosterone System Inhibitors Angiotensin II Receptor Antagonists
BENICAR HCT 3 ST
BENICAR 3 ST
DIOVAN HCT 4 ST
DIOVAN 4 ST
eprosartan mesylate (Teveten) 2
irbesartan (Avapro) 2
irbesartan/
hydrochlorothiazide
(Avalide) 2
losartan potassium (Cozaar) 1
losartan/
hydrochlorothiazide
(Hyzaar) 1
MICARDIS HCT 4 ST
MICARDIS 4 ST
TEVETEN HCT 4 ST
TEVETEN 4 ST tablet: 400mg
TRIBENZOR 4 ST
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl (Lotensin) 1
benazepril/
hydrochlorothiazide
(Lotensin HCT) 1
captopril (Capoten) 1
captopril/
hydrochlorothiazide
(Capozide) 1
enalapril maleate (Vasotec) 1
enalapril/
hydrochlorothiazide
(Vaseretic) 1
enalaprilat dihydrate (Enalaprilat Dihydrate) 2
fosinopril sodium (Monopril) 1
fosinopril/
hydrochlorothiazide
(Monopril HCT) 1
lisinopril (Zestril) 1
lisinopril/
hydrochlorothiazide
(Prinzide) 1
moexipril hcl (Univasc) 1
moexipril/
hydrochlorothiazide
(Uniretic) 1
perindopril erbumine (Aceon) 1
quinapril hcl (Accupril) 1
quinapril/
hydrochlorothiazide
(Accuretic) 1
86
Drug Name Drug
Tier Requirements/Limits
ramipril (Altace) 1
trandolapril (Mavik) 1
trandolapril/verapamil hcl (Trandolapril/verapamil HCl) 1
Renin-Angiotensin-Aldosterone System Inhibitors
AMTURNIDE 4 ST
eplerenone (Inspra) 2
spironolact/
hydrochlorothiazid
(Aldactazide) 1
spironolactone (Aldactone) 1
TEKAMLO 4 ST
TEKTURNA HCT 4 ST
TEKTURNA 4 ST
VALTURNA 4 ST
Replacement Preparations Replacement Preparations
0.9 % sodium chloride (0.9 % Sodium Chloride) 1
calcium chloride (Calcium Chloride) 1
calcium gluconate (Calcium Gluconate) 1 PA
dex 2.5%-half str
lact.ringers
(Dex 2.5%-half Str Lact.ringers) 1
dextrose 2.5% in half
ringers
(Dextrose 2.5% In Half Ringers) 1
dextrose 5% in ringers (Dextrose 5% In Ringers) 1
dextrose 5%-lactated
ringers
(Dextrose 5%-Lactated Ringers) 1
DEXTROSE W/
ELECTROLYTE A
3
DEXTROSE W/
ELECTROLYTE B
3
EFFER-K 4
electrolyte-48 solution/
d10w
(Electrolyte-48 Solution/d10w) 1
electrolyte-48 solution/
d5w
(Electrolyte-48 Solution/D5W) 1
electrolyte-48/fructose
10%
(Electrolyte-48/fructose 10%) 1
electrolyte-48/fructose 5% (Electrolyte-48/fructose 5%) 1
electrolyte-75 solution/
d5w
(Electrolyte-75 Solution/D5W) 1
electrolyte-75/fructose 5% (Electrolyte-75/fructose 5%) 1
electrolyte-r solution/d5w (Normosol-r and Dextrose) 1
HYPERLYTE CR 3
HYPERLYTE R 3
87
Drug Name Drug
Tier Requirements/Limits
IONOSOL B with
DEXTROSE 5%
3
IONOSOL MB-
DEXTROSE 5%
3
IONOSOL T-DEXTROSE
5%
3
ISOLYTE E 3
ISOLYTE H W/
DEXTROSE
3
ISOLYTE M W/
DEXTROSE
3
ISOLYTE P with
DEXTROSE
3
ISOLYTE S with
DEXTROSE
3
ISOLYTE S 3
LACTATED RINGERS 4
NORMOSOL-M and
DEXTROSE
3
NORMOSOL-R PH 7.4 3
NUTRILYTE II 3
NUTRILYTE 3
PLASMA-LYTE 148 3
PLASMA-LYTE 56 IN
DEXTROSE
3
PLASMA-LYTE A PH
7.4
3
PLASMA-LYTE M IN
DEXTROSE
3
pot chloride/pot bicarb/cit
ac
(K-lyte-cl) 1
potassium acetate (Potassium Acetate) 1
potassium bicarbonate/cit
ac
(K-lyte) 1
potassium chlorid/d10-
0.2%nacl
(Potassium Chlorid/d10-
0.2%NaCl)
1
potassium chlorid/d5-
0.225nacl
(Potassium Chlorid/d5-
0.225NaCl)
1 iv soln: 10meq/l,
30meq/l, 40meq/l
potassium chlorid/d5-
0.225nacl
(Potassium Chlorid/d5-
0.225NaCl)
1 iv soln: 20meq/l
potassium chloride in
0.9%nacl
(Potassium Chloride In
0.9%NaCl)
1
88
Drug Name Drug
Tier Requirements/Limits
potassium chloride (Kaochlor) 1 liquid, packet, tablet
sa
potassium chloride (K-dur) 1 capsule er,
piggyback, tab er
prt, tablet er, vial
potassium chloride/d5-
0.25ns
(Potassium Chloride/D5-0.25
NS)
1
potassium chloride/d5-
0.33nacl
(Potassium Chloride/d5-
0.33NaCl)
1
potassium chloride/d5-
0.45nacl
(Potassium Chloride/d5-
0.45NaCl)
1
potassium chloride/d5-
0.9%nacl
(Potassium Chloride/d5-
0.9%NaCl)
1
potassium chloride/d5lr (Potassium Chloride/D5 LR) 1
potassium chloride/d5w (Potassium Chloride/D5W) 1 iv soln: 10meq/l
potassium chloride/d5w (Potassium Chloride/D5W) 1 iv soln: 20meq/l,
30meq/l, 40meq/l
potassium chloride-0.45%
nacl
(Potassium Chloride-0.45%
NaCl)
1
potassium gluconate (Potassium Gluconate) 1
potassium phos,m-basic-d-
basic
(Potassium Phos,m-basic-d-
basic)
1
ringers solution (Ringers Solution) 1
sodium acetate (Sodium Acetate) 1
sodium chloride 0.45 % (Sodium Chloride 0.45 %) 1
sodium chloride 3% (Sodium Chloride 3%) 1
sodium chloride 5% (Sodium Chloride 5%) 1
sodium chloride (Sodium Chloride) 1 iv soln
sodium chloride (Sodium Chloride) 1 vial
sodium phos,m-basic-d-
basic
(Sodium Phos,m-basic-d-basic) 1
TPN ELECTROLYTES 3
TRAVERT-
ELECTROLYTE NO.1
3
TRAVERT-
ELECTROLYTE NO.2
3 iv soln: 10%
TRAVERT-
ELECTROLYTE NO.2
3 iv soln: 5%
TRAVERT-
ELECTROLYTE NO.3
3
TRAVERT-
ELECTROLYTE NO.4
3
Respiratory Tract Agents, Miscellaneous
89
Drug Name Drug
Tier Requirements/Limits
Respiratory Tract Agents, Miscellaneous
acetylcysteine (Acetylcysteine) 1 PA (PA for Part B vs
Part D Only)
aminophylline (Aminophylline) 1 liquid, tablet
aminophylline (Aminophylline) 1 vial
ARALAST 5
DALIRESP 3 ST, QL:
30 in 30
days
guaifen/theop anhyd/p-
ephed
(Guaifen/theop Anhyd/p-ephed) 1
KALYDECO 5 PA, QL:
60 in 30
days
PROLASTIN C 5
PROLASTIN 5
theophylline anhydrous (Theochron) 1 elixir, tab er 12h:
100mg, 200mg,
300mg, 450mg;
tablet er
theophylline anhydrous (Theochron) 1 solution, tab er 12h:
200mg
theophylline/d5w (Theophylline/D5W) 1
XOLAIR 5 PA, QL:
6 in 28
days
ZEMAIRA 5
90
Drug Name Drug
Tier Requirements/Limits
Sclerosing Agents Sclerosing Agents
ethanolamine oleate (Ethanolamine Oleate) 1
sodium morrhuate (Sodium Morrhuate) 1
sodium tetradecyl sulfate (Sodium Tetradecyl Sulfate) 1
Serums Serums
ANASCORP 5
ANTIVENIN
LATRODECTUS
MACTANS
3
ANTIVENIN
MICRURUS FULVIUS
5
CARIMUNE NF
NANOFILTERED
5 PA (PA for Part B vs
Part D Only)
CROFAB 5
CYTOGAM 5
DIGIBIND 3
DIGIFAB 3
FLEBOGAMMA DIF 5 PA (PA for Part B vs
Part D Only)
FLEBOGAMMA 5 PA (PA for Part B vs
Part D Only)
GAMMAGARD LIQUID 5 PA (PA for Part B vs
Part D Only)
GAMMAPLEX 5 PA (PA for Part B vs
Part D Only)
GAMUNEX-C 5 PA (PA for Part B vs
Part D Only)
HIZENTRA 5 PA (PA for Part B vs
Part D Only)
HYPERRAB S-D 3
HYPERRHO S-D 3
IMOGAM RABIES-HT 3
MICRHOGAM PLUS 3
OCTAGAM 5 PA (PA for Part B vs
Part D Only)
PRIVIGEN 5 PA (PA for Part B vs
Part D Only)
RHOGAM PLUS 3
RHOPHYLAC 3
91
Drug Name Drug
Tier Requirements/Limits
VIVAGLOBIN 5 PA (PA for Part B vs
Part D Only)
WINRHO SDF 3
Skeletal Muscle Relaxants Skeletal Muscle Relaxants
baclofen (Baclofen) 1
carisoprodol (Soma) 1 PA, QL:
120 in 30
days
tablet: 250mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
carisoprodol (Soma) 1 PA, QL:
120 in 30
days
tablet: 350mg, (PA
for Ages 65 and
Older; May be High
Risk Med)
chlorzoxazone (Parafon Forte DSC) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
chlorzoxazone/
acetaminophen
(Chlorzoxazone/acetaminophen) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
cyclobenzaprine hcl (Flexeril) 1 PA tablet: 5mg, 10mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
dantrolene sodium (Dantrium) 1 vial
dantrolene sodium (Dantrium) 2 capsule
metaxalone (Skelaxin) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
methocarbamol (Robaxin-750) 1 PA (PA for Ages 65 and
Older; May be High
Risk Med)
tizanidine hcl (Zanaflex) 1 tablet
tizanidine hcl (Zanaflex) 2 capsule
Skin and Mucous Membrane Agents, Miscellaneous Skin and Mucous Membrane Agents, Miscellaneous
8-MOP 3
adapalene (Differin) 2
AMEVIVE 5 PA, QL:
4 in 28
days
ammonium lactate (Lac-hydrin) 1
AZELEX 4
92
Drug Name Drug
Tier Requirements/Limits
calcipotriene (Calcipotriene) 1 oint. (g)
calcipotriene (Dovonex) 2 solution
calcitriol (Vectical) 2
CARAC 3
CONDYLOX 4 gel (gram)
DIFFERIN 4 gel (gram): 0.3%;
lotion
DOVONEX 3 cream
ELIDEL 3 PA
EPIDUO 4
FLUOROPLEX 3
fluorouracil (Efudex) 2 cream (g)
fluorouracil (Efudex) 2 solution
imiquimod (Aldara) 2 PA, QL:
24 in 30
days
isotretinoin (Accutane) 2
LEVULAN 3
METVIXIA 3
OXSORALEN 4
OXSORALEN-ULTRA 5
PANRETIN 5
PICATO 4 PA, QL:
2 in 56
days
gel (ea): 0.05%
PICATO 4 PA, QL:
3 in 56
days
gel (ea): 0.015%
podofilox (Condylox) 2
podophyllum resin (Pododerm) 2
PROTOPIC 4 PA
RECTIV 4 QL: 30 in
30 days
REGRANEX 4 PA, QL:
30 in 30
days
SANTYL 3
SORIATANE 5 capsule: 10mg,
17.5mg, 25mg
SORIATANE 5 capsule: 22.5mg
STELARA 5 PA, QL:
10 in 360
days
93
Drug Name Drug
Tier Requirements/Limits
TACLONEX SCALP 3
TACLONEX 2
TARGRETIN 5
TAZORAC 3
UVADEX 4
ZYCLARA 3 PA, QL:
28 in 28
days
Somatotropin Agonists and Antagonists Somatotropin Agonists and Antagonists
INCRELEX 5
SOMAVERT 5
Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents
alfuzosin hcl (Uroxatral) 2
dihydroergotamine
mesylate
(D.H.E. 45) 2
ergotamine tartrate/
caffeine
(Ergotamine Tartrate/caffeine) 1
phentolamine mesylate (Phentolamine Mesylate) 2 PA
PHENTOLAMINE
MESYLATE
2 PA
tamsulosin hcl (Flomax) 1
Sympathomimetic (Adrenergic) Agents Sympathomimetic (Adrenergic) Agents
albuterol sulfate (Accuneb) 1 PA solution, vial-neb:
0.63mg/3ml,
1.25mg/3ml, 2.5mg/
3ml, (PA for Part B
vs Part D Only)
albuterol sulfate (Proventil) 1 syrup, tablet
albuterol sulfate (Vospire ER) 2 tab er 12h
albuterol (Ventolin) 1
COMBIVENT
RESPIMAT
3 QL: 8 in
30 days
COMBIVENT 3 QL: 29.4
in 30
days
dobutamine hcl (Dobutamine HCl) 2 PA (PA for Part B vs
Part D Only)
dobutamine hcl/d5w (Dobutamine HCl/D5W) 1 PA (PA for Part B vs
Part D Only)
94
Drug Name Drug
Tier Requirements/Limits
dopamine hcl (Dopamine HCl) 1 PA (PA for Part B vs
Part D Only)
dopamine hcl/d5w (Dopamine HCl/D5W) 1 PA (PA for Part B vs
Part D Only)
ephedrine sulfate (Ephedrine Sulfate) 1
epinephrine (Adrenaclick) 2 QL: 2 in
30 days
disp syrin: 0.3mg/
0.3; pen injctr
epinephrine (Epinephrine) 1 disp syrin: 0.1mg/
ml
epinephrine/pf (Epinephrine/PF) 1
EPIPEN JR 4 QL: 2 in
30 days
EPIPEN 4 QL: 2 in
30 days
FORADIL 3 QL: 62 in
31 days
isoproterenol hcl (Isoproterenol HCl) 1
MAXAIR AUTOHALER 4 QL: 14 in
30 days
metaproterenol sulfate (Metaproterenol Sulfate) 1
midodrine hcl (Proamatine) 2
NEO-SYNEPHRINE 4
norepinephrine bit/0.9 %
nacl
(Norepinephrine Bit/0.9 %
NaCl)
1 PA (PA for Part B vs
Part D Only)
norepinephrine bitartrate (Norepinephrine Bitartrate) 1 PA (PA for Part B vs
Part D Only)
phenylephrine hcl (Phenylephrine HCl) 1
phenylephrine tannate (Phenylephrine Tannate) 1
PROAIR HFA 3 QL: 17 in
25 days
SEREVENT DISKUS 3 QL: 62 in
31 days
terbutaline sulfate (Brethine) 1
VENTOLIN HFA 4 QL: 36 in
25 days
Thyroid and Antithyroid Agents Thyroid and Antithyroid Agents
levothyroxine sodium (Levothyroxine Sodium) 2 vial
levothyroxine sodium (Synthroid) 1 tablet
liothyronine sodium (Cytomel) 1
methimazole (Tapazole) 1 tablet: 20mg
methimazole (Tapazole) 1 tablet: 5mg, 10mg
propylthiouracil (Propylthiouracil) 1
95
Drug Name Drug
Tier Requirements/Limits
Toxoids Toxoids
ADACEL 3 disp syrin
ADACEL 3 vial
BOOSTRIX 3
DAPTACEL 3
DIPHTHERIA-
TETANUS TOXOID
3
INFANRIX PF 3
INFANRIX 3
TE ANATOXAL BERNA 3 PA (PA for Part B vs
Part D Only)
TENIVAC 3
TETANUS DIPHTHERIA
TOXOIDS
3
TETANUS-DIPHTERIA-
DECAVAC
3
TRIHIBIT 3
TRIPEDIA 3
Urinary Anti-infectives Urinary Anti-infectives
methenamine mandelate (Mandelamine) 1 tablet: 500mg
methenamine mandelate (Mandelamine) 2 tablet: 1g
nitrofurantoin
macrocrystal
(Macrobid) 1 PA, QL:
90 in 365
days
(PA/QL for Ages 65
and Older; May be
High Risk Med)
trimethoprim (Trimethoprim) 1
Vaccines Vaccines
ACTHIB 3
ATTENUVAX
VACCINE with
DILUENT
3 PA (PA for Part B vs
Part D Only)
BCG VACCINE (TICE
STRAIN)
3 PA (PA for Part B vs
Part D Only)
BIOTHRAX 3
CERVARIX 4 disp syrin
CERVARIX 4 vial
COMVAX 3
ENGERIX-B 3 PA (PA for Part B vs
Part D Only)
GARDASIL 4 disp syrin
96
Drug Name Drug
Tier Requirements/Limits
GARDASIL 4 vial
HAVRIX 3 PA (PA for Part B vs
Part D Only)
IPOL 3
IXIARO 3
JE-VAX 3
KINRIX 3
MENACTRA 3 disp syrin
MENACTRA 3 vial
MENOMUNE-A-C-Y-W-
135
3
MENVEO A-C-Y-W-135-
DIP
3
MERUVAX II VACCINE
W-DILUENT
3
M-M-R II VACCINE 3
MUMPSVAX VACCINE
W-DILUENT
3
PEDIARIX 3
PEDVAXHIB 3
PENTACEL 3
PROQUAD 4
RABAVERT 3 PA (PA for Part B vs
Part D Only)
RECOMBIVAX HB 3 PA disp syrin
RECOMBIVAX HB 3 PA disp syrin, (PA for
Part B vs Part D
Only)
RECOMBIVAX HB 3 PA vial, (PA for Part B
vs Part D Only)
ROTARIX 3
ROTATEQ 3
THERACYS 3 PA (PA for Part B vs
Part D Only)
TWINRIX 3 disp syrin
TWINRIX 3 vial
TYPHIM VI 3
VAQTA 3 PA disp syrin, (PA for
Part B vs Part D
Only)
VAQTA 3 PA vial, (PA for Part B
vs Part D Only)
VARIVAX VACCINE 3
97
Drug Name Drug
Tier Requirements/Limits
YF-VAX 3
ZOSTAVAX 3
Vasodilating Agents Vasodilating Agents
ADCIRCA 5 PA, QL:
60 in 30
days
AGGRENOX 3 QL: 60 in
30 days
alprostadil (Alprostadil) 2 PA
amyl nitrite (Amyl Nitrite) 1
epoprostenol sodium
(glycine)
(Flolan) 2 PA vial: 0.5mg, (PA
for Part B vs Part D
Only)
epoprostenol sodium
(glycine)
(Flolan) 5 PA vial: 1.5mg, (PA
for Part B vs Part D
Only)
isosorbide dinitrate (Isordil) 1
isosorbide mononitrate (Imdur) 1 tab er 24h, tablet:
20mg
isosorbide mononitrate (Ismo) 1 tablet: 10mg
ISOVEX 3
LETAIRIS 5 PA, QL:
30 in 30
days
NITRO-BID 3
nitroglycerin (Nitro-dur) 1 QL: 30 in
30 days
patch td24: 0.1mg/
hr, 0.2mg/hr, 0.6mg/
hr
nitroglycerin (Nitro-dur) 1 QL: 60 in
30 days
patch td24: 0.4mg/
hr
nitroglycerin (Nitroglycerin) 1 vial
nitroglycerin (Nitrolingual) 2 spray
nitroglycerin/d5w (Nitroglycerin/D5W) 1
NITROSTAT 3
nylidrin hcl (Nylidrin HCl) 1 tablet: 12mg
papaverine hcl (Papaverine HCl) 1 PA
REMODULIN 5 PA (PA for Part B vs
Part D Only)
REVATIO 5 PA, QL:
37.5 in 1
day
vial
98
Drug Name Drug
Tier Requirements/Limits
REVATIO 5 PA, QL:
90 in 30
days
tablet
TRACLEER 5 LA, PA,
QL: 60 in
30 days
Vitamins and Minerals Vitamins and Minerals
calcitriol (Rocaltrol) 1 PA (PA for ESRD
Only)
FLUOR-A-DAY 4
fluoride/iron/vit a,c&d (Fluoride/iron/vit A,c&d) 4
FLURA 4
HECTOROL 3 PA (PA for ESRD
Only)
LOZI-FLUR 4
multivitamins with
fluoride
(Multivitamins with Fluoride) 4
ped mv a,c,d3 #21 w-
fluoride
(Ped Mv A,c,d3 #21 W-fluoride) 4
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa) 3 (All Pre-Natal
Vitamins are
Covered)
sodium fluoride (Luride) 4 drops
sodium fluoride (Luride) 4 tab chew
ZEMPLAR 4 PA (PA for ESRD
Only)
I-1
INDEX
0.9 % sodium chloride ....... 86
8-MOP................................ 91
aa/antipyrn/bcaine/polico#1/
al .................................... 71
aa/antpy/bcaine/polico/al
acet ................................. 71
ABELCET.......................... 26
ABILIFY ............................ 82
ABILIFY DISCMELT ....... 82
ABRAXANE ..................... 36
acarbose ............................. 21
acebutolol hcl ..................... 49
acetaminophen with codeine 5
acetaminophen/phenyltolx cit
.......................................... 3
acetazolamide .................... 27
acetazolamide sodium ........ 27
acetic ac/ricinoleic/oxyquinol
........................................ 31
acetic acid .................... 28, 70
acetic acid/aluminum acetate
........................................ 28
acetic acid/hydrocortisone . 28
acetylcysteine ..................... 89
ACTEMRA ........................ 72
ACTHAR H.P. ................... 72
ACTHIB ............................. 95
ACTIMMUNE ................... 72
ACTONEL ......................... 72
ACTONEL with CALCIUM
........................................ 72
ACTOPLUS MET ............. 25
ACTOPLUS MET XR ....... 25
ACTOS .............................. 25
ACUFLEX ........................... 3
acyclovir ............................. 46
acyclovir sodium ................ 46
ADACEL ........................... 95
ADAGEN ........................... 62
adapalene ........................... 91
ADCETRIS ........................ 36
ADCIRCA .......................... 97
ADVAIR DISKUS ............... 1
ADVAIR HFA ..................... 1
ADVICOR .......................... 35
AEROBID-M ....................... 1
AFINITOR ......................... 36
AGGRENOX ..................... 97
A-HYDROCORT ................. 1
AKTEN .............................. 71
ALBENZA ......................... 13
ALBUKED-25 ................... 50
ALBUKED-5 ..................... 50
ALBUMIN HUMAN ......... 50
ALBUMINAR-25 .............. 50
ALBUMINAR-5 ................ 50
ALBURX ........................... 50
ALBUTEIN ........................ 50
albuterol ............................. 93
albuterol sulfate.................. 93
alclometasone dipropionate
........................................ 33
alcohol antiseptic pads ....... 31
ALDURAZYME ................ 62
alendronate sodium ............ 72
ALFERON N...................... 46
alfuzosin hcl........................ 93
ALIMTA ............................ 36
ALINIA .............................. 43
allopurinol .......................... 72
allopurinol sodium ............. 72
ALOCRIL........................... 33
ALOMIDE ......................... 13
ALORA .............................. 63
ALOXI ............................... 25
ALPHAGAN P ................... 27
alprazolam .......................... 48
alprostadil .......................... 97
ALREX............................... 31
ALTABAX ......................... 30
ALTOPREV ....................... 35
aluminum chloride.............. 47
ALVESCO ........................... 1
amantadine hcl .................. 41
amcinonide......................... 33
AMERICAINE .................. 43
AMEVIVE ......................... 91
amifostine crystalline ......... 72
amikacin sulfate ................. 13
amiloride hcl ...................... 61
amiloride/
hydrochlorothiazide ....... 61
AMINO ACIDS ................. 51
aminocaproic acid ............. 67
aminophylline .................... 89
AMINOSYN ................ 51, 52
AMINOSYN II .................. 51
AMINOSYN II 3.5% M-
DEXTROSE 5% ............ 51
AMINOSYN II 3.5%-
DEXTROSE 25% .......... 51
AMINOSYN II 3.5%-
DEXTROSE 5% ............ 51
AMINOSYN II 4.25% M-
DEXT 10% .................... 51
AMINOSYN II 4.25%-
DEXTROSE 25% .......... 51
AMINOSYN II 5% IN 25%
DEXTROSE .................. 51
AMINOSYN II IN
DEXTROSE .................. 51
AMINOSYN II with LYTES-
CA-DW .......................... 51
AMINOSYN M ................. 51
AMINOSYN with
ELECTROLYTES ......... 51
AMINOSYN-HBC ............ 52
AMINOSYN-HF ............... 52
AMINOSYN-PF ................ 52
AMINOSYN-RF ............... 52
amiodarone hcl .................. 56
AMITIZA .......................... 57
amitriptyline hcl ................. 80
I-2
amlodipine besylate ........... 50
amlodipine besylate/
benazepril ....................... 50
amlodipine/atorvastatin ..... 35
ammonium chloride ........... 72
ammonium lactate .............. 91
amoxapine .......................... 80
amoxicillin.......................... 16
amoxicillin/potassium clav. 16
amphet asp/amphet/d-amphet
........................................ 11
amphotericin b ................... 26
ampicillin sodium ............... 16
ampicillin sodium/sulbactam
na.................................... 16
ampicillin trihydrate .......... 16
AMPYRA .......................... 72
AMTURNIDE.................... 86
amyl nitrite ......................... 97
ANACAINE ....................... 43
ANADROL-50 ................... 10
anagrelide hcl .................... 67
ANASCORP ...................... 90
anastrozole ......................... 36
ANDRODERM .................. 10
ANDROGEL...................... 10
ANGELIQ .......................... 63
antipyrine/benzocaine/
glycerin .......................... 71
ANTIVENIN
LATRODECTUS
MACTANS .................... 90
ANTIVENIN MICRURUS
FULVIUS ....................... 90
APEXICON E .................... 33
APOKYN ........................... 41
apraclonidine hcl ............... 61
APRISO ............................. 32
APTIVUS ........................... 44
ARALAST ......................... 89
ARANESP ......................... 68
ARCALYST ...................... 72
ARICEPT ........................... 78
ARRANON ........................ 36
ARZERRA ......................... 36
ASACOL ............................ 32
ASACOL HD ..................... 32
ASMANEX .......................... 1
ASTEPRO .......................... 13
ATELVIA........................... 72
atenolol ............................... 49
atenolol/chlorthalidone ...... 49
atorvastatin calcium ........... 35
atovaquone/proguanil hcl .. 43
ATRIPLA ........................... 44
atropine sulfate ............. 19, 61
ATROVENT HFA ............. 19
ATTENUVAX VACCINE
with DILUENT .............. 95
AVANDAMET .................. 25
AVANDARYL................... 25
AVANDIA ......................... 25
AVASTIN .......................... 36
AVC ................................... 31
AVELOX ........................... 18
AVELOX ABC PACK....... 18
AVELOX IV ...................... 18
AVODART ........................ 72
AVONEX ........................... 72
AVONEX
ADMINISTRATION
PACK ............................. 72
AXERT............................... 35
AXIRON ............................ 10
AZACTAM-ISO-OSMOTIC
DEXTROSE ................... 16
AZASITE ........................... 28
azathioprine ........................ 72
azathioprine sodium ........... 72
azelastine hcl ...................... 13
AZELEX ............................ 91
AZILECT ........................... 41
azithromycin ....................... 15
azithromycin hydrogen citrate
........................................ 15
AZOPT ............................... 27
AZOR ................................. 50
aztreonam ........................... 16
bacitracin ..................... 14, 28
bacitracin/polymyxin b sulfate
....................................... 29
baclofen ............................. 91
BACTOCILL ..................... 16
BACTROBAN NASAL .... 29
BAL IN OIL ...................... 66
balsalazide disodium ......... 32
BANZEL ........................... 19
BARACLUDE ................... 46
BCG VACCINE TICE
STRAIN ......................... 95
BECONASE AQ ............... 31
benazepril hcl .................... 85
benazepril/
hydrochlorothiazide ....... 85
BENICAR .......................... 85
BENICAR HCT ................. 85
BENLYSTA ...................... 72
benzocaine ......................... 71
benzoyl peroxide ................ 70
benzoyl peroxide
microspheres .................. 70
benzoyl peroxide/aloe vera 70
benzoyl peroxide/
hydrocortison ................. 70
benzoyl peroxide/urea ........ 70
benztropine mesylate ......... 41
BEPREVE ......................... 13
BERINERT ........................ 73
BESIVANCE ..................... 29
betamet acet/betamet na ph . 1
betamet diprop/prop gly .... 33
betamethasone dipropionate
....................................... 33
betamethasone valerate ..... 33
BETASERON .................... 73
betaxolol hcl ................ 27, 49
bethanechol chloride ......... 78
BETIMOL ......................... 27
BETOPTIC S ..................... 27
BEXXAR ........................... 36
bicalutamide ...................... 36
BICILLIN C-R .................. 17
I-3
BICILLIN L-A ................... 17
BICNU ............................... 36
BILTRICIDE ..................... 13
BIOTHRAX ....................... 95
bisoprolol fumarate ............ 49
bisoprolol fumarate/hctz .... 49
bleomycin sulfate ............... 36
BLEPHAMIDE .................. 29
BLEPHAMIDE S.O.P. ...... 29
BONIVA ............................ 73
BOOSTRIX........................ 95
BOTOX .............................. 73
BRANCHAMIN ................ 52
BRILINTA ......................... 68
brimonidine tartrate ........... 27
BROMDAY ....................... 31
bromfenac sodium .............. 31
bromocriptine mesylate ...... 42
budesonide ........................... 1
bumetanide ......................... 61
BUMINATE ...................... 50
BUPHENYL ........................ 3
buprenorphine hcl .............. 10
bupropion hcl ..................... 80
buspirone hcl ...................... 47
BUSULFEX ....................... 36
BUTISOL SODIUM .......... 57
butorphanol tartrate........... 10
BYDUREON ..................... 21
BYETTA ............................ 21
BYSTOLIC ........................ 49
cabergoline ........................ 42
caffeine citrated ................. 11
caffeine/sodium benzoate ... 11
calcipotriene ...................... 92
calcitonin,salmon,synthetic 79
calcitriol ....................... 92, 98
calcium acetate .................. 70
calcium carbonate/mag carb/
fa .................................... 70
calcium chloride................. 86
CALCIUM DISODIUM
VERSENATE ................ 66
calcium gluconate .............. 86
CALDOLOR ........................ 4
CAMPATH ........................ 36
CAMPRAL......................... 57
CANCIDAS ....................... 27
CAPASTAT SULFATE ..... 36
CAPRELSA ....................... 36
captopril ............................. 85
captopril/hydrochlorothiazide
........................................ 85
CARAC .............................. 92
CARAFATE ....................... 43
CARBAGLU ........................ 3
carbamazepine ................... 19
carbidopa/levodopa ............ 42
carbinoxamine maleate ...... 28
carboplatin ......................... 37
CARDENE I.V. .................. 50
CARDENE SR ................... 50
CARIMUNE NF
NANOFILTERED ......... 90
carisoprodol ....................... 91
carteolol hcl........................ 61
carvedilol ............................ 49
CAYSTON ......................... 16
CEDAX .............................. 14
CEENU............................... 37
cefaclor ............................... 14
cefadroxil hydrate .............. 14
cefazolin sodium ................. 14
cefazolin sodium/dextrose,iso
........................................ 14
cefdinir ............................... 14
cefditoren pivoxil ................ 14
CEFEPIME......................... 15
cefepime hcl ........................ 14
CEFEPIME-DEXTROSE .. 15
cefotaxime sodium .............. 15
cefotetan disod/dextrose,iso16
cefotetan disodium.............. 16
cefoxitin sodium.................. 16
cefoxitin sodium/dextrose,iso
........................................ 16
cefpodoxime proxetil .......... 15
cefprozil .............................. 15
CEFTAZIDIME................. 15
ceftazidime pentahydrate ... 15
ceftriaxone na/dextrose,iso 15
ceftriaxone sodium ............. 15
cefuroxime axetil ................ 15
cefuroxime sodium ............. 15
cefuroxime sodium/
dextrose,iso .................... 15
CELEBREX......................... 4
CELLCEPT ....................... 73
CELONTIN ....................... 21
CENESTIN ........................ 63
cephalexin .......................... 15
CEPROTIN ........................ 66
CEREDASE....................... 62
CEREZYME ...................... 62
CERVARIX ....................... 95
CESAMET......................... 26
CETRAXAL ...................... 29
CHANTIX ......................... 78
CHENODAL ..................... 65
chloramphenicol na succ ... 14
chlorhexidine gluconate .... 29
chloroprocaine hcl/pf ........ 71
chloroquine phosphate ...... 43
chlorothiazide .................... 61
chloroxylenol/pramoxine hcl
....................................... 71
chlorpromazine hcl ............ 82
chlorthalidone .................... 61
chlorzoxazone .................... 91
chlorzoxazone/acetaminophen
....................................... 91
cholestyramine (with sugar)
....................................... 34
cholestyramine/aspartame . 34
choline sal/mag salicylate ... 4
ciclopirox ........................... 30
ciclopirox olamine ............. 30
cilostazol ............................ 68
CILOXAN ......................... 29
cimetidine........................... 43
cimetidine hcl ..................... 43
cimetidine in 0.9 % nacl .... 43
I-4
CIMZIA ............................. 65
CINRYZE .......................... 73
CIPRO HC ......................... 29
CIPRODEX........................ 29
ciprofloxacin hcl .......... 18, 29
ciprofloxacin lactate .......... 18
ciprofloxacin lactate/d5w... 18
ciprofloxacin/ciprofloxa hcl
........................................ 18
cisplatin .............................. 37
citalopram hydrobromide .. 80
citrate-phos-dex solution ... 66
citric acid/sodium citrate ... 73
cladribine ........................... 37
clarithromycin .................... 15
clemastine fumarate ........... 28
CLEVIPREX...................... 50
clindamycin hcl .................. 14
clindamycin palmitate hcl .. 14
clindamycin phos/benzoyl
perox .............................. 30
clindamycin phosphate. 14, 30
CLINIMIX ................... 52, 53
CLINIMIX E ...................... 52
CLINISOL ......................... 53
clobetasol propionate......... 33
CLODERM ........................ 33
CLOLAR............................ 37
clomipramine hcl ............... 80
clonazepam ........................ 48
clonidine ............................. 69
clonidine hcl ....................... 69
clonidine hcl/chlorthalidone
........................................ 69
clopidogrel bisulfate .......... 68
clorazepate dipotassium..... 48
clotrimazole........................ 30
clotrimazole/betamethasone
dip .................................. 30
clozapine ............................ 82
COARTEM ........................ 43
cocaine hcl ......................... 71
codeine phos/acetaminophen5
codeine phosphate ................ 5
codeine sulfate ...................... 5
CODEINE SULFATE .......... 5
colchicine/probenecid ........ 73
COLCRYS ......................... 73
colestipol hcl ...................... 34
colistin (colistimethate na) . 14
COLY-MYCIN S ............... 29
COMBIGAN ...................... 27
COMBIPATCH .................. 63
COMBIVENT .................... 93
COMBIVENT RESPIMAT93
COMPLERA ...................... 44
COMTAN........................... 42
COMVAX .......................... 95
CONDYLOX ..................... 92
COPAXONE ...................... 73
CORDRAN ........................ 33
CORDRAN SP ................... 33
COREG CR ........................ 49
cortisone acetate .................. 1
CORTISPORIN-TC ........... 29
CREON .............................. 65
CRESTOR .......................... 35
cresyl ace/ben alc/butanol/ipa
........................................ 29
CRIXIVAN ........................ 44
CROFAB ............................ 90
cromolyn sodium ................ 33
CUBICIN ........................... 14
cyclobenzaprine hcl ............ 91
CYCLOGYL ...................... 61
cyclopentolate hcl ............... 61
cyclophosphamide .............. 37
cyclosporine ....................... 73
cyclosporine, modified ....... 73
CYMBALTA ..................... 80
CYSTADANE .................... 73
cysteine hcl ......................... 53
cytarabine/pf....................... 37
CYTOGAM ........................ 90
dacarbazine ........................ 37
DACOGEN ........................ 37
dactinomycin ...................... 37
DALIRESP ......................... 89
danazol............................... 10
dantrolene sodium ............. 91
dapsone .............................. 36
DAPTACEL ...................... 95
DARAPRIM ...................... 43
daunorubicin hcl ................ 37
DAUNOXOME ................. 37
DDAVP ............................. 79
deferoxamine mesylate ...... 66
demeclocycline hcl ............. 18
DENAVIR ......................... 31
DEPO-ESTRADIOL ......... 63
DEPO-PROVERA ............. 80
desipramine hcl.................. 80
desmopressin acetate ......... 79
desogestrel-ethinyl estradiol
....................................... 60
desog-et estra/ethin estra... 60
desonide ............................. 33
desoximetasone .................. 33
DETROL LA ..................... 64
dex 2.5%-half str lact.ringers
....................................... 86
dexamethasone..................... 1
dexamethasone acetate ........ 1
dexamethasone sod phosphate
................................... 1, 31
dexmethylphenidate hcl ..... 11
dexrazoxane ....................... 73
dextroamphetamine sulfate 11
dextrose 10 % and 0.225 %
nacl ................................ 53
dextrose 10 % and 0.9 % nacl
....................................... 53
dextrose 10%-0.5 normal
saline .............................. 53
dextrose 10%-water ........... 53
dextrose 2.5 %-water ......... 53
dextrose 2.5% in half ringers
....................................... 86
dextrose 2.5%-0.5normal
saline .............................. 53
dextrose 20 % in water ...... 53
dextrose 20%-water ........... 53
I-5
dextrose 25%-water ........... 53
dextrose 40%-water ........... 53
dextrose 5 % and 0.33 % nacl
........................................ 53
dextrose 5 % and 0.9 % nacl
........................................ 53
dextrose 5 %-0.225 % nacl 53
dextrose 5 %-0.45 % nacl .. 53
dextrose 5 %-water ............ 53
dextrose 5% in ringers ....... 86
dextrose 5%-lactated ringers
........................................ 86
dextrose 50 % in water ...... 53
dextrose 60 % in water ...... 54
dextrose 70 % in water ...... 54
DEXTROSE W/
ELECTROLYTE A ....... 86
DEXTROSE W/
ELECTROLYTE B ........ 86
dhcodeine bt/acetaminophn/
caff.................................... 5
DIASTAT ACUDIAL ....... 48
diazepam ............................ 48
diclofenac potassium ............ 4
diclofenac sodium .......... 4, 31
dicloxacillin sodium ........... 17
dicyclomine hcl .................. 19
didanosine .......................... 44
DIFFERIN.......................... 92
DIFICID ............................. 15
diflorasone diacetate .......... 33
diflunisal .............................. 4
DIGIBIND ......................... 90
DIGIFAB ........................... 90
digoxin................................ 56
DIGOXIN .......................... 56
dihydroergotamine mesylate
........................................ 93
DILANTIN ........................ 21
diltiazem hcl ....................... 50
dimenhydrinate .................. 26
DIOVAN ............................ 85
DIOVAN HCT ................... 85
DIPENTUM ....................... 32
diphenhydramine hcl .......... 28
diphenoxylate hcl/atropine . 25
DIPHTHERIA-TETANUS
TOXOID......................... 95
disopyramide phosphate ..... 56
disulfiram ........................... 73
divalproex sodium .............. 19
dobutamine hcl ................... 93
dobutamine hcl/d5w ........... 93
DOCEFREZ ....................... 37
docetaxel............................. 37
donepezil hcl ....................... 78
dopamine hcl ...................... 94
dopamine hcl/d5w .............. 94
dorzolamide hcl .................. 27
dorzolamide hcl/timolol
maleat ............................. 27
DOVONEX ........................ 92
doxazosin mesylate ............... 3
doxepin hcl ......................... 80
doxorubicin hcl ................... 37
doxorubicin hcl liposomal .. 37
doxycycline hyclate ...... 18, 29
doxycycline monohydrate ... 18
DRITHO-SCALP ............... 71
dronabinol .......................... 26
droperidol ........................... 47
DROXIA ............................ 37
DUETACT ......................... 25
DULERA .............................. 1
DUODOTE......................... 73
DUREZOL ......................... 32
DUTOPROL....................... 49
DYNACIRC CR ................. 50
DYRENIUM ...................... 61
DYSPORT .......................... 73
econazole nitrate ................ 30
edetate disodium ................. 66
EDURANT ......................... 44
EFFER-K ............................ 86
EFFIENT ............................ 68
ELAPRASE ........................ 62
electrolyte-48 solution/d10w
........................................ 86
electrolyte-48 solution/d5w 86
electrolyte-48/fructose 10%86
electrolyte-48/fructose 5% . 86
electrolyte-75 solution/d5w 86
electrolyte-75/fructose 5% . 86
electrolyte-r solution/d5w .. 86
ELIDEL ............................. 92
ELIGARD .......................... 37
ELITEK ............................. 62
ELMIRON ......................... 73
ELSPAR ............................ 37
EMCYT ............................. 37
EMEND ............................. 26
EMSAM............................. 80
EMTRIVA ......................... 44
enalapril maleate ............... 85
enalapril/hydrochlorothiazide
....................................... 85
enalaprilat dihydrate ......... 85
ENBREL ............................ 74
ENDRATE......................... 66
ENGERIX-B ...................... 95
enoxaparin sodium ............ 66
ephedrine sulfate................ 94
EPIDUO............................. 92
epinastine hcl ..................... 13
epinephrine ........................ 94
epinephrine/pf .................... 94
EPIPEN .............................. 94
EPIPEN JR ........................ 94
epirubicin hcl ..................... 37
EPIVIR .............................. 44
EPIVIR HBV ..................... 44
eplerenone ......................... 86
EPOGEN ........................... 68
epoprostenol sodium (glycine)
....................................... 97
eprosartan mesylate ........... 85
EPZICOM .......................... 44
ERAXIS WATER DILUENT
....................................... 27
ERBITUX .......................... 37
ergotamine tartrate/caffeine
....................................... 93
I-6
ERIVEDGE........................ 37
ERWINAZE ....................... 37
ery e-succ/sulfisoxazole ..... 15
ERY-TAB .......................... 15
ERYTHROCIN
LACTOBIONATE ......... 15
erythromycin base .. 15, 16, 29
erythromycin base/ethanol . 30
erythromycin ethylsuccinate
........................................ 16
erythromycin stearate ........ 16
erythromycin/benzoyl
peroxide.......................... 30
escitalopram oxalate .......... 81
esmolol hcl ......................... 49
estazolam............................ 48
ESTRACE .......................... 63
estradiol ............................. 63
estradiol valerate ............... 63
estradiol/noreth ac ............. 63
ESTRASORB .................... 63
ESTRING ........................... 63
estropipate.......................... 63
ethambutol hcl .................... 36
ethanolamine oleate ........... 90
ethinyl estradiol/drospirenone
........................................ 60
ethosuximide ...................... 21
ethyl alcohol/d5w ............... 54
ethynodiol d-ethinyl estradiol
........................................ 60
etidronate disodium ........... 74
etodolac ................................ 4
ETOPOPHOS .................... 38
etoposide ............................ 38
EURAX .............................. 31
EVISTA ............................. 63
EXELDERM ...................... 30
EXELON............................ 78
exemestane ......................... 38
EXFORGE ......................... 50
EXFORGE HCT ................ 50
EXJADE ............................ 66
EXTAVIA .......................... 74
FABRAZYME ................... 62
FACTIVE ........................... 18
famciclovir .......................... 46
famotidine ........................... 44
famotidine in nacl,iso-osm/pf
........................................ 44
FANAPT ............................ 82
FARESTON ....................... 38
FASLODEX ....................... 38
FAZACLO ................... 82, 83
felbamate ............................ 19
felodipine ............................ 50
FEMHRT ............................ 64
FEMRING .......................... 64
fenofibrate .......................... 34
fenofibrate,micronized........ 34
fenofibric acid .................... 35
fenoldopam mesylate .......... 69
fenoprofen calcium ............... 4
fentanyl ............................. 5, 6
fentanyl citrate...................... 5
FERRIPROX ...................... 66
finasteride ........................... 74
FIRAZYR ........................... 74
FIRMAGON....................... 38
flavoxate hcl ....................... 64
FLEBOGAMMA ............... 90
FLEBOGAMMA DIF ........ 90
flecainide acetate................ 56
FLECTOR ............................ 4
FLEXBUMIN..................... 50
FLEXTRA PLUS ................. 3
FLOVENT DISKUS ............ 2
FLOVENT HFA ................... 2
floxuridine .......................... 38
fluconazole ......................... 27
fluconazole in nacl,iso-osm 27
flucytosine........................... 26
fludarabine phosphate ........ 38
fludrocortisone acetate ......... 2
flumazenil ........................... 57
flunisolide ........................... 32
fluocinolone acetonide ....... 34
fluocinolone acetonide oil .. 32
fluocinolone/shower cap .... 34
fluocinonide ....................... 34
FLUOR-A-DAY ................ 98
fluoride/iron/vit a,c&d ....... 98
FLUORITAB ..................... 74
fluorometholone ................. 32
FLUOROPLEX ................. 92
fluorouracil .................. 38, 92
fluoxetine hcl ...................... 81
fluoxymesterone ................. 10
fluphenazine decanoate ..... 83
fluphenazine hcl ................. 83
FLURA .............................. 98
FLURA-DROPS ................ 74
flurbiprofen .......................... 4
flurbiprofen sodium ........... 32
flutamide ............................ 38
fluticasone propionate . 32, 34
fluvastatin sodium .............. 35
fluvoxamine maleate .......... 81
FOCALIN XR ................... 11
FOLOTYN......................... 38
fomepizole .......................... 74
fondaparinux sodium ... 66, 67
FORADIL .......................... 94
FORTEO ............................ 79
FORTICAL ........................ 79
foscarnet sodium ................ 46
fosinopril sodium ............... 85
fosinopril/
hydrochlorothiazide ....... 85
fosphenytoin sodium .......... 21
FOSRENOL....................... 70
FREAMINE HBC.............. 54
FREAMINE III .................. 54
FREAMINE III with
ELECTROLYTES ......... 54
FROVA .............................. 35
fructose 10% ...................... 54
furosemide ......................... 61
FUROXONE ..................... 31
FUSILEV ........................... 74
FUZEON ........................... 44
gabapentin ......................... 19
I-7
GABITRIL ......................... 19
galantamine hbr ................. 78
GALZIN ............................. 66
GAMMAGARD LIQUID .. 90
GAMMAPLEX .................. 90
GAMUNEX-C ................... 90
ganciclovir ......................... 47
ganciclovir sodium ............. 47
GARDASIL ................. 95, 96
gauze bandage ................... 74
GELNIQUE ....................... 64
gemcitabine hcl .................. 38
gemfibrozil ......................... 35
GENOTROPIN .................. 79
gentamicin in nacl, iso-osm 13
gentamicin sulfate .. 13, 29, 30
gentamicin sulfate/pf .......... 13
GEODON ........................... 83
GILENYA .......................... 74
GLEEVEC ......................... 38
glimepiride ......................... 24
glipizide .............................. 24
glipizide/metformin hcl ...... 24
GLUCAGEN...................... 74
GLUCAGON EMERGENCY
KIT ................................. 74
glutethimide........................ 47
glyburide ............................ 24
glyburide,micronized ......... 24
glyburide/metformin hcl .... 24,
25
glycine ................................ 70
glycopyrrolate .................... 19
GLYSET ............................ 21
gold sodium thiomalate ...... 74
granisetron hcl ............. 25, 26
granisetron hcl/pf ............... 26
griseofulvin,microsize ........ 26
GRIS-PEG.......................... 26
guaifen/theop anhyd/p-ephed
........................................ 89
guanfacine hcl .................... 69
GYNAZOLE-1 .................. 30
HALAVEN ........................ 38
HALFAN ............................ 43
halobetasol propionate ....... 34
haloperidol ......................... 83
haloperidol decanoate ........ 83
haloperidol lactate ............. 83
HAVRIX ............................ 96
HECTOROL....................... 98
heparin sodium,porcine ...... 67
heparin sodium,porcine/d5w
........................................ 67
heparin sodium,porcine/ns/pf
........................................ 67
heparin sodium,porcine/pf . 67
HEPATAMINE .................. 54
HEPATASOL..................... 54
HEPSERA .......................... 47
HERCEPTIN ...................... 38
HEXALEN ......................... 38
HIZENTRA ........................ 90
homatropine hbr ................. 62
HUMALOG ....................... 23
HUMALOG MIX 50-50 .... 22
HUMALOG MIX 75-25 .... 22
HUMATROPE ................... 79
HUMIRA ............................ 74
HUMULIN 70-30 ............... 23
HUMULIN N ..................... 23
HUMULIN R ..................... 23
hydralazine hcl ................... 69
hydralazine/
hydrochlorothiazid ......... 69
hydralazine/reserpin/hctz ... 69
hydrochlorothiazide ........... 61
hydrocodone bit/
acetaminophen ................. 6
hydrocodone/ibuprofen ........ 6
hydrocortisone ................ 2, 34
hydrocortisone acetate ....... 34
hydrocortisone acetate/aloe v
........................................ 34
hydrocortisone acetate/urea
........................................ 34
hydrocortisone butyrate ..... 34
hydrocortisone sod succinate
......................................... 2
hydrocortisone valerate ..... 34
hydromorphone hcl .......... 6, 7
hydromorphone hcl/pf.......... 7
hydroxychloroquine sulfate 43
hydroxyurea ....................... 38
hydroxyzine hcl .................. 47
hydroxyzine pamoate ......... 47
HYPERLYTE CR.............. 86
HYPERLYTE R ................ 86
HYPERRAB S-D .............. 90
HYPERRHO S-D .............. 90
ibandronate sodium ........... 74
ibuprofen .............................. 4
ibuprofen/oxycodone hcl ...... 7
idarubicin hcl ..................... 38
ifosfamide........................... 38
ifosfamide/mesna ............... 38
ILARIS .............................. 74
imipenem/cilastatin sodium 16
imipramine hcl ................... 81
imipramine pamoate .......... 81
imiquimod .......................... 92
IMOGAM RABIES-HT .... 90
inamrinone lactate ............. 57
INCIVEK ........................... 46
INCRELEX ....................... 93
indapamide ........................ 61
indomethacin ....................... 4
indomethacin sodium
trihydrate ......................... 4
INFANRIX ........................ 95
INFANRIX PF ................... 95
INLYTA ............................ 38
INNOPRAN XL ................ 49
INTELENCE ..................... 44
INTRALIPID ..................... 54
INTRON A ........................ 46
INTUNIV........................... 58
INVANZ ............................ 16
INVEGA ............................ 83
INVEGA SUSTENNA ...... 83
INVIRASE......................... 44
I-8
IONOSOL B with
DEXTROSE 5% ............ 87
IONOSOL MB-DEXTROSE
5% .................................. 87
IONOSOL T-DEXTROSE
5% .................................. 87
IOPIDINE .......................... 62
IPOL ................................... 96
ipratropium bromide .......... 62
IPRIVASK ......................... 67
irbesartan ........................... 85
irbesartan/
hydrochlorothiazide ....... 85
IRESSA .............................. 38
irinotecan hcl ..................... 38
ISENTRESS ....................... 44
ISOLYTE E ....................... 87
ISOLYTE H W/DEXTROSE
........................................ 87
ISOLYTE M W/DEXTROSE
........................................ 87
ISOLYTE P with
DEXTROSE ................... 87
ISOLYTE S ........................ 87
ISOLYTE S with
DEXTROSE ................... 87
isoniazid ............................. 36
isopropamide/
prochlorperazine ............ 19
isoproterenol hcl ................ 94
ISOPTO CARPINE ........... 27
ISOPTO HOMATROPINE 62
isosorbide dinitrate ............ 97
isosorbide mononitrate ...... 97
isotretinoin ......................... 92
ISOVEX ............................. 97
isradipine ........................... 50
ISTALOL ........................... 27
ISTODAX .......................... 38
itraconazole........................ 27
IXEMPRA.......................... 39
IXIARO.............................. 96
JAKAFI .............................. 39
JANUMET ......................... 21
JANUMET XR ................... 21
JANUVIA........................... 21
JENTADUETO .................. 21
JE-VAX .............................. 96
JEVTANA .......................... 39
JUVISYNC......................... 22
KADIAN .............................. 7
KALBITOR ........................ 74
KALETRA ......................... 45
KALYDECO ...................... 89
kanamycin sulfate ............... 13
KEDBUMIN ...................... 50
KENALOG......................... 34
KEPIVANCE ..................... 57
KETEK ............................... 16
ketoconazole ................. 27, 30
ketoprofen ............................. 4
ketorolac tromethamine.. 4, 32
KINERET ........................... 74
KINRIX .............................. 96
KORLYM........................... 22
K-PHOS M.F. ..................... 74
K-PHOS NO.2 .................... 74
KRYSTEXXA .................... 62
KUVAN ............................. 74
labetalol hcl ........................ 49
LACRISERT ...................... 62
LACTATED RINGERS .... 70,
87
lactulose ............................... 3
LAMICTAL BLUE ............ 19
LAMICTAL ODT .............. 20
LAMICTAL ODT BLUE... 19
LAMICTAL ODT GREEN 19
LAMICTAL ODT ORANGE
........................................ 19
LAMICTAL ORANGE...... 19
LAMICTAL XR ................. 20
LAMICTAL XR BLUE ..... 20
LAMICTAL XR GREEN .. 20
LAMICTAL XR ORANGE
........................................ 20
LAMISIL ............................ 30
lamivudine .......................... 45
lamivudine/zidovudine ....... 45
lamotrigine......................... 20
lansoprazole....................... 44
LANTUS ........................... 23
LANTUS SOLOSTAR ...... 23
latanoprost ......................... 27
LATUDA ........................... 83
leflunomide ........................ 74
LETAIRIS ......................... 97
letrozole ............................. 39
leucovorin calcium ............ 74
LEUKERAN ...................... 39
LEUKINE .......................... 68
leuprolide acetate .............. 39
LEVACET ........................... 4
LEVEMIR ......................... 23
levetiracetam ..................... 20
levobunolol hcl .................. 27
levocarnitine ...................... 75
levocarnitine (with sugar) . 75
levocetirizine dihydrochloride
....................................... 28
levofloxacin .................. 18, 29
levofloxacin/d5w ................ 18
levonorgestrel .................... 60
levonorgestrel-eth estradiol60
levorphanol tartrate ............. 7
levothyroxine sodium ......... 94
LEVULAN ........................ 92
LEXAPRO ......................... 81
LEXIVA ............................ 45
LIALDA ............................ 33
lidocaine ............................ 43
lidocaine hcl ................ 56, 71
lidocaine hcl/d5w/pf .......... 56
lidocaine hcl/pf ............ 56, 71
lidocaine/prilocaine ........... 43
LIDODERM ...................... 43
lindane ............................... 31
liothyronine sodium ........... 94
lipase/protease/amylase..... 65
LIPOSYN II ....................... 54
LIPOSYN III ..................... 54
lisinopril............................. 85
I-9
lisinopril/hydrochlorothiazide
........................................ 85
lithium carbonate ............... 58
lithium citrate ..................... 58
LITHOSTAT........................ 3
l-norgest-eth estr/ethin estra
........................................ 60
LOCOID ............................ 34
LODOSYN ........................ 58
loperamide hcl ................... 25
lorazepam ........................... 48
losartan potassium ............. 85
losartan/hydrochlorothiazide
........................................ 85
LOTEMAX ........................ 32
LOTRONEX ...................... 65
lovastatin ............................ 35
LOVAZA ........................... 34
LOVENOX ........................ 67
loxapine succinate .............. 83
LOZI-FLUR ....................... 98
LUMIGAN ......................... 27
LUMINAL SODIUM ........ 58
LUMIZYME ...................... 62
LUPRON DEPOT .............. 39
LUPRON DEPOT-PED ..... 39
LUVOX CR ....................... 81
LYRICA ............................. 20
LYSODREN ...................... 39
LYSTEDA ......................... 67
magnesium chloride ........... 20
magnesium salicylate ........... 4
magnesium sulfate .............. 20
magnesium sulfate/d5w ...... 20
malathion ........................... 31
mannitol/sorbitol solution .. 70
maprotiline hcl ................... 81
MARPLAN ........................ 81
MATULANE ..................... 39
MAXAIR AUTOHALER .. 94
mebendazole ....................... 13
meclizine hcl....................... 26
meclofenamate sodium ......... 4
medroxyprogesterone acetate
........................................ 80
mefenamic acid ..................... 4
mefloquine hcl .................... 43
MEGACE ES ..................... 39
megestrol acetate................ 39
meloxicam............................. 4
melphalan hcl ..................... 39
MENACTRA ..................... 96
MENEST ............................ 64
MENOMUNE-A-C-Y-W-135
........................................ 96
MENVEO A-C-Y-W-135-
DIP ................................. 96
mepivacaine hcl/pf.............. 71
MEPRON ........................... 43
mercaptopurine .................. 39
meropenem ......................... 16
MERUVAX II VACCINE
W-DILUENT ................. 96
mesalamine w/cleansing
wipes ............................... 33
mesna .................................. 75
MESNEX ........................... 75
MESTINON ....................... 78
METADATE CD ............... 11
metaproterenol sulfate........ 94
metaxalone ......................... 91
metformin hcl...................... 22
methadone hcl ...................... 7
methamphetamine hcl ......... 11
methazolamide .................... 27
methenamine mandelate ..... 95
methimazole ........................ 94
methocarbamol ................... 91
methotrexate sodium .......... 39
methotrexate sodium/pf ...... 39
methscopolamine bromide.. 19
methyclothiazide ................. 61
methylene blue .................... 75
methylergonovine maleate.. 75
METHYLIN ................. 11, 12
methylphenidate hcl............ 12
methylprednisolone .............. 2
methylprednisolone acetate . 2
methylprednisolone sod succ 2
metipranolol....................... 28
metoclopramide hcl ........... 65
metolazone ......................... 61
metoprolol succinate.......... 49
metoprolol tartrate ............ 49
metoprolol/
hydrochlorothiazide ....... 49
metronidazole .............. 30, 43
metronidazole/sodium
chloride .......................... 43
METVIXIA ....................... 92
mexiletine hcl ..................... 56
mg sal/acetaminophn/p-tlox/
caf .................................... 3
MIACALCIN..................... 79
MICARDIS ........................ 85
MICARDIS HCT ............... 85
miconazole nitrate ............. 30
MICRHOGAM PLUS ....... 90
midodrine hcl ..................... 94
milrinone lactate ................ 57
milrinone lactate/d5w ........ 57
MINOCIN .......................... 18
minocycline hcl .................. 18
minoxidil ............................ 69
mirtazapine ........................ 81
misoprostol ........................ 44
mitomycin........................... 39
mitoxantrone hcl ................ 39
M-M-R II VACCINE ........ 96
MOBAN ............................ 83
moexipril hcl ...................... 85
moexipril/
hydrochlorothiazide ....... 85
mometasone furoate ........... 34
morphine sulfate .............. 7, 8
morphine sulfate in 0.9 %
nacl .................................. 7
morphine sulfate/d5w .......... 8
morphine sulfate/pf .............. 8
MOXEZA .......................... 29
MOZOBIL ......................... 69
I-10
MULTAQ .......................... 56
multivitamins with fluoride 98
MUMPSVAX VACCINE W-
DILUENT ...................... 96
mupirocin ........................... 30
MUSTARGEN ................... 39
MYCOBUTIN ................... 36
mycophenolate mofetil ....... 75
MYFORTIC ....................... 75
MYOBLOC........................ 75
MYOZYME ....................... 62
MYTELASE ...................... 78
na nitrite/na thiosul/amyl nit
........................................ 66
nabumetone .......................... 5
nadolol ............................... 49
nadolol/bendroflumethiazide
........................................ 49
nafcillin sodium .................. 17
nafcillin sodium/d2.4w ....... 17
NAGLAZYME .................. 62
nalbuphine hcl .................... 10
nalidixic acid ...................... 18
naloxone hcl ....................... 77
naltrexone hcl..................... 78
NAMENDA ....................... 58
naphazoline hcl .................. 62
naphazoline hcl/antazoline 62
naproxen .............................. 5
naproxen sodium .................. 5
naratriptan hcl ................... 35
NASONEX ........................ 32
NATACYN ........................ 29
nateglinide.......................... 22
NAVANE ........................... 83
NEBCIN ............................. 13
NEBCIN IN DEXTROSE.. 13
needles, insulin disp., safety
........................................ 61
needles, insulin disposable. 61
nefazodone hcl ................... 81
neo/polymyx b sulf/dexameth
........................................ 29
neomy sulf/bacitra/polymyxin
b ...................................... 29
neomy sulf/bacitrac zn/poly/
hc .................................... 29
neomy sulf/polymyxin b
sulfate ............................. 30
neomycin sulfate ................. 13
neomycin sulfate/dex na ph 29
neomycin/polymyxin b sulf/hc
........................................ 29
neomycin/polymyxn b/
gramicidin ...................... 29
neostigmine methylsulfate .. 78
NEO-SYNEPHRINE ......... 94
NEPHRAMINE .................. 54
NEULASTA ....................... 69
NEUMEGA ........................ 69
NEUPOGEN ...................... 69
NEVANAC ........................ 32
nevirapine ........................... 45
NEXAVAR ........................ 39
niacin .................................. 34
NIASPAN........................... 34
nicardipine hcl.................... 50
NICOTROL ........................ 78
NICOTROL NS.................. 78
nifedipine ............................ 50
NILANDRON .................... 39
nimodipine .......................... 50
nisoldipine .......................... 50
NITRO-BID ....................... 97
nitrofurantoin macrocrystal
........................................ 95
nitroglycerin ....................... 97
nitroglycerin/d5w ............... 97
NITROSTAT ...................... 97
nizatidine ............................ 44
NORDITROPIN ................. 79
NORDITROPIN FLEXPRO
........................................ 79
NORDITROPIN
NORDIFLEX ................. 79
norepinephrine bit/0.9 % nacl
........................................ 94
norepinephrine bitartrate .. 94
noreth a-et estra/fe fumarate
....................................... 60
noreth-ethinyl estradiol/iron
....................................... 60
norethind ac/ethinyl estradiol
....................................... 64
norethindrone .................... 60
norethindrone acetate ........ 80
norethindrone a-e estradiol 60
norethindrone-ethinyl estrad
....................................... 60
norethindrone-mestranol ... 60
norgestimate-ethinyl estradiol
....................................... 60
norgestrel-ethinyl estradiol 60
NORMOSOL-M and
DEXTROSE .................. 87
NORMOSOL-R PH 7.4 ..... 87
NOROXIN ......................... 18
nortriptyline hcl ................. 81
NORVIR ............................ 45
NOVAMINE ..................... 54
NOVOLIN 70-30 ............... 23
NOVOLIN 70-30 INNOLET
....................................... 23
NOVOLIN N ..................... 23
NOVOLIN N INNOLET ... 23
NOVOLIN R ..................... 23
NOVOLOG ................. 23, 24
NOVOLOG MIX 70-30 .... 23
NOXAFIL .......................... 27
NPLATE ............................ 75
NUCYNTA .......................... 8
NUCYNTA ER.................... 8
NUEDEXTA ..................... 58
NULOJIX .......................... 75
NUTRESTORE ................. 65
NUTRILYTE ..................... 87
NUTRILYTE II ................. 87
NUTROPIN ....................... 79
NUTROPIN AQ ................ 79
NUTROPIN AQ NUSPIN . 79
NUVARING ...................... 60
I-11
NUVIGIL ........................... 12
nylidrin hcl ......................... 97
nystatin ......................... 26, 31
nystatin/triamcin ................ 31
OCTAGAM ....................... 90
octreotide acetate ............... 75
OFIRMEV............................ 3
ofloxacin ....................... 18, 29
olanzapine .......................... 83
omeprazole ......................... 44
omeprazole/sodium
bicarbonate .................... 44
OMNARIS ......................... 32
OMNITROPE .................... 79
ONCASPAR ...................... 39
ondansetron........................ 26
ondansetron hcl .................. 26
ONFI .................................. 49
ONTAK.............................. 40
ORAP ................................. 83
ORENCIA .......................... 75
ORFADIN .......................... 75
ORTHO EVRA .................. 60
oxacillin sodium ................. 17
oxacillin sodium/dextrose,iso
........................................ 17
oxaliplatin .......................... 40
oxandrolone ....................... 10
oxaprozin.............................. 5
oxazepam............................ 49
oxcarbazepine .................... 20
OXSORALEN ................... 92
OXSORALEN-ULTRA ..... 92
oxybutynin chloride ............ 64
oxycodone hcl....................... 8
oxycodone hcl/acetaminophen
...................................... 8, 9
oxycodone hcl/aspirin .......... 9
oxycodone hcl/oxycodon ter/
asa .................................... 9
OXYCONTIN ...................... 9
oxymorphone hcl .................. 9
OXYTROL ........................ 64
paclitaxel ............................ 40
pamidronate disodium ........ 75
PANCREAZE .................... 65
PANRETIN ........................ 92
pantoprazole sodium .......... 44
papaverine hcl .................... 97
paregoric ............................ 25
paromomycin sulfate .......... 43
paroxetine hcl ..................... 81
PASER ............................... 36
PATADAY ......................... 13
PATANASE ....................... 13
PATANOL ......................... 13
PAXIL ................................ 81
ped mv a,c,d3 #21 w-fluoride
........................................ 98
PEDIARIX ......................... 96
PEDVAXHIB ..................... 96
peg 3350/na sulf,bicarb,cl/kcl
........................................ 57
PEGANONE ...................... 21
PEGASYS .......................... 46
PEGASYS PROCLICK ..... 46
PEGINTRON ..................... 46
PEGINTRON REDIPEN ... 46
pen g pot/dextrose-water .... 17
penicillin g potassium......... 17
penicillin g potassium/d5w . 17
penicillin g procaine........... 17
penicillin v potassium ......... 17
PENTACEL ....................... 96
pentamidine isethionate...... 43
PENTASA .......................... 33
pentostatin .......................... 40
pentoxifylline ...................... 67
p-epd tan/chlor-tan ............. 28
perindopril erbumine.......... 85
permethrin .......................... 31
perphenazine ...................... 83
perphenazine/amitriptyline
hcl ................................... 81
phenelzine sulfate ............... 81
phenobarbital ..................... 58
phenobarbital sodium ......... 58
phentolamine mesylate ....... 93
PHENTOLAMINE
MESYLATE .................. 93
phenyleph/acetaminop/p-tlox/
cp ................................... 28
phenylephrine hcl ........ 62, 94
phenylephrine tannate ....... 94
phenylephrine/antipy/b-caine
....................................... 71
phenylephrine/chlor-tan .... 28
PHENYTEK ...................... 21
phenytoin ........................... 21
phenytoin sodium ............... 21
phenytoin sodium extended 21
PHOSLYRA ...................... 70
PHOSPHOLINE IODIDE . 28
phosphorus #1.................... 75
physostigmine salicylate .... 78
PICATO ............................. 92
pilocarpine hcl ............. 28, 78
PILOPINE HS ................... 28
pindolol .............................. 49
piperacillin sodium ............ 17
piperacillin sodium/
tazobactam ..................... 17
PIPRACIL IN DEXTROSE
....................................... 17
piroxicam ............................. 5
PLASBUMIN-25 ............... 50
PLASBUMIN-5 ................. 50
PLASMA-LYTE 148 ........ 87
PLASMA-LYTE 56 IN
DEXTROSE .................. 87
PLASMA-LYTE A PH 7.4 87
PLASMA-LYTE M IN
DEXTROSE .................. 87
pnv with ca,no.72/iron/fa ... 98
podofilox ............................ 92
podophyllum resin ............. 92
polyethylene glycol 3350 ... 57
polymyxin b sulfate ............ 14
polymyxin b sulfate/tmp ..... 29
pot chloride/pot bicarb/cit ac
....................................... 87
potassium acetate .............. 87
I-12
potassium bicarbonate/cit ac
........................................ 87
potassium chlorid/d10-
0.2%nacl ........................ 87
potassium chlorid/d5-
0.225nacl ........................ 87
potassium chloride ............. 88
potassium chloride in
0.9%nacl ........................ 87
potassium chloride/d5-0.25ns
........................................ 88
potassium chloride/d5-
0.33nacl .......................... 88
potassium chloride/d5-
0.45nacl .......................... 88
potassium chloride/d5-
0.9%nacl ........................ 88
potassium chloride/d5lr ..... 88
potassium chloride/d5w ..... 88
potassium chloride-0.45%
nacl ................................. 88
potassium citrate ................ 75
potassium citrate/citric acid
........................................ 75
potassium gluconate........... 88
potassium hydroxide .......... 70
potassium phos,m-basic-d-
basic ............................... 88
POTIGA ............................. 20
PRADAXA ........................ 67
PRALIDOXIME
CHLORIDE ................... 76
pramipexole di-hcl ............. 42
PRANDIMET .................... 22
PRANDIN .......................... 22
pravastatin sodium ............. 35
prazosin hcl .......................... 3
prednicarbate ..................... 34
prednisolone ......................... 2
prednisolone acetate ...... 2, 32
prednisolone sod phosphate 2,
32
prednisone ............................ 2
PREDNISONE INTENSOL 2
PREFEST ........................... 64
PREMARIN ....................... 64
PREMASOL................. 54, 55
PREMPHASE .................... 64
PREMPRO ......................... 64
PREZISTA ......................... 45
PRIFTIN ............................. 36
PRIMAQUINE ................... 43
primidone ........................... 58
PRISTIQ ER ....................... 81
PRIVIGEN ......................... 90
PROAIR HFA .................... 94
probenecid .......................... 76
procainamide hcl ................ 56
PROCALAMINE ............... 55
prochlorperazine edisylate . 26
prochlorperazine maleate .. 26
PROCRIT ........................... 69
progesterone ....................... 80
progesterone,micronized .... 80
PROGLYCEM ................... 69
PROGRAF ......................... 76
PROLASTIN ...................... 89
PROLASTIN C .................. 89
PROLEUKIN ..................... 40
PROLIA ............................. 76
PROMACTA ...................... 69
promethazine hcl ................ 28
PRONESTYL ..................... 56
propafenone hcl .................. 56
proparacaine hcl ................ 71
proparacaine/fluorescein sod
........................................ 71
PROPINE ........................... 62
propranolol hcl ................... 49
propranolol/
hydrochlorothiazid ......... 49
propylthiouracil .................. 94
PROQUAD......................... 96
PROSOL............................. 55
PROSTIGMIN ................... 78
protamine sulfate ................ 67
PROTONIX IV .................. 44
PROTOPAM CHLORIDE . 76
PROTOPIC ........................ 92
protriptyline hcl ................. 81
PRUDOXIN....................... 43
PULMOZYME .................. 62
pyrazinamide ..................... 36
pyridostigmine bromide ..... 78
QNASL .............................. 32
QUALAQUIN ................... 43
quetiapine fumarate ........... 84
QUICK MIX with LYTES 55
quinapril hcl ...................... 85
quinapril/hydrochlorothiazide
....................................... 85
quinidine gluconate ........... 56
quinidine sulfate ................ 56
QVAR .................................. 3
RABAVERT ...................... 96
ramipril .............................. 86
RANEXA........................... 57
ranitidine hcl...................... 44
RAPAMUNE ..................... 76
REBIF ................................ 76
RECLAST ......................... 76
RECOMBIVAX HB .......... 96
RECTIV ............................. 92
REGONOL ........................ 79
REGRANEX ..................... 92
RELAGESIC ....................... 3
RELENZA ......................... 46
RELISTOR ........................ 65
REMICADE ...................... 76
REMODULIN ................... 97
RENAGEL......................... 70
RENAMIN......................... 55
RENVELA......................... 70
RESCRIPTOR ................... 45
reserpine ............................ 69
reserpine/hydrochlorothiazide
....................................... 70
RESTASIS ......................... 32
RETIN-A MICRO ............. 57
RETROVIR ....................... 45
REVATIO .................... 97, 98
REVLIMID .................. 40, 76
I-13
REYATAZ ......................... 45
RHINOCORT AQUA ........ 32
RHOGAM PLUS ............... 90
RHOPHYLAC ................... 90
RIBATAB .......................... 47
ribavirin ............................. 47
RIDAURA ......................... 76
rifampin .............................. 36
rifampin/isoniazid .............. 36
RILUTEK .......................... 58
rimantadine hcl .................. 46
ringers solution ............ 70, 88
RISPERDAL CONSTA ..... 84
risperidone ......................... 84
RITALIN LA ..................... 12
RITUXAN.......................... 40
rivastigmine tartrate .......... 79
ropinirole hcl ..................... 42
ROTARIX .......................... 96
ROTATEQ ......................... 96
ROZEREM ........................ 47
SABRIL ............................. 20
SAIZEN ............................. 80
sal-amide/acetamin/p-tlox/
caff.................................... 3
sal-amide/acetaminophn/p-
tlox.................................... 3
salicylamide/acetaminophen 4
salicylic acid ...................... 71
salicylic acid/ammon lact/
aloe ................................. 71
salicylic acid/ceramide cmb
#1.................................... 71
salsalate ............................... 5
SAMSCA ........................... 61
SANCTURA XR ............... 64
SANDOSTATIN LAR....... 76
SANTYL ............................ 92
SAPHRIS ........................... 84
SAVELLA ......................... 58
selegiline hcl ...................... 42
selenium sulfide .................. 31
SELZENTRY ..................... 45
SENSIPAR ......................... 76
SEREVENT DISKUS ........ 94
SEROMYCIN .................... 36
SEROQUEL XR ................ 84
SEROSTIM ........................ 80
sertraline hcl ...................... 81
SILENOR ........................... 81
silver nitrate ....................... 31
silver nitrate applicator ...... 71
silver sulfadiazine ............... 31
SIMCOR............................. 35
SIMPONI ........................... 76
SIMULECT ........................ 76
simvastatin .......................... 35
SINGULAIR ...................... 33
SKELID .............................. 76
sod chloride 0.45% irrig. soln
........................................ 70
sod propionate/inosi/aa14/
urea................................. 31
sod/pot/k cit/sod cit/cit acid 76
sodium acetate .................... 88
sodium bicarbonate ............ 76
sodium chloride .................. 88
sodium chloride 0.45 % ...... 88
sodium chloride 3% ............ 88
sodium chloride 5% ............ 88
sodium chloride irrig solution
........................................ 70
sodium chloride/nahco3/kcl/
peg .................................. 57
sodium fluoride ............. 76, 98
sodium lactate .................... 76
sodium morrhuate .............. 90
sodium phos,m-basic-d-basic
........................................ 88
sodium polystyrene sulfonate
........................................ 70
sodium tetradecyl sulfate .... 90
sodium thiosulfate .............. 66
sodium thiosulfate/sal acid . 31
SOLARAZE ......................... 5
SOLIRIS ............................. 76
SOLU-CORTEF PF ............. 3
SOLU-MEDROL PF ............ 3
SOMATULINE DEPOT ... 76
SOMAVERT ..................... 93
sorbitol solution ................. 70
SORIATANE..................... 92
sotalol hcl .......................... 49
SOTALOL HCL ................ 49
SPIRIVA ............................ 19
spironolact/
hydrochlorothiazid......... 86
spironolactone ................... 86
SPORANOX ...................... 27
SPRYCEL .......................... 40
STALEVO 100 .................. 42
STALEVO 125 .................. 42
STALEVO 150 .................. 42
STALEVO 200 .................. 42
STALEVO 50 .................... 42
STALEVO 75 .................... 42
stavudine ............................ 45
STELARA ................... 77, 92
STERILE DILUENT ......... 50
STIMATE .......................... 80
STRATTERA .................... 58
streptomycin sulfate ........... 13
STROMECTOL................. 13
SUBOXONE ..................... 10
sucralfate ........................... 44
sulfacetamide sodium .. 29, 31
sulfacetamide sodium/urea 71
sulfacetamide/prednisolone
sp .................................... 29
sulfadiazine ........................ 18
sulfamethoxazole/
trimethoprim .................. 18
SULFAMYLON ................ 31
sulfasalazine ...................... 18
sulindac ................................ 5
sumatriptan ........................ 35
sumatriptan succinate ........ 35
SUPPRELIN ...................... 77
SUPPRELIN LA................ 77
SUPRAX ........................... 15
SURMONTIL .................... 81
SUSTIVA .......................... 45
I-14
SUTENT ............................ 40
SYLATRON ...................... 46
SYMBICORT ...................... 3
SYMBYAX........................ 81
SYMLIN ............................ 22
SYMLINPEN 120 .............. 22
SYMLINPEN 60 ................ 22
SYNAGIS .......................... 46
SYNAREL ......................... 77
SYNERCID........................ 14
SYPRINE ........................... 66
syring w-ndl,disp,insul,0.3ml
........................................ 61
syring w-ndl,disp,insul,0.5ml
........................................ 61
syringe & needle,insulin,1 ml
........................................ 61
TABLOID .......................... 40
TACLONEX ...................... 93
TACLONEX SCALP......... 93
tacrolimus .......................... 77
TAMIFLU .......................... 46
tamoxifen citrate ................ 40
tamsulosin hcl .................... 93
TARCEVA ......................... 40
TARGRETIN ............... 40, 93
TASIGNA .......................... 40
TASMAR ........................... 42
TAZICEF IN DEXTROSE 15
TAZORAC ......................... 93
TE ANATOXAL BERNA . 95
TEGRETOL XR ................ 20
TEKAMLO ........................ 86
TEKTURNA ...................... 86
TEKTURNA HCT ............. 86
temazepam.......................... 49
TENIVAC .......................... 95
terazosin hcl ......................... 3
terbinafine hcl .................... 27
terbutaline sulfate .............. 94
terconazole ......................... 31
TESTIM ............................. 10
testosterone cypionate ........ 10
testosterone enanthate ....... 10
TETANUS DIPHTHERIA
TOXOIDS ...................... 95
TETANUS-DIPHTERIA-
DECAVAC..................... 95
tetracaine hcl/pf.................. 71
tetracycline hcl ................... 18
TEVETEN .......................... 85
TEVETEN HCT ................. 85
TEV-TROPIN .................... 80
THALOMID....................... 77
theophylline anhydrous ...... 89
theophylline/d5w ................ 89
THERACYS ....................... 96
thioridazine hcl ................... 84
thiotepa ............................... 40
thiothixene .......................... 84
TIKOSYN .......................... 56
TIMENTIN......................... 17
timolol maleate ............. 28, 49
tinidazole ............................ 43
tizanidine hcl ...................... 91
TOBI................................... 13
TOBRADEX ...................... 29
tobramycin sulf/
dexamethasone ............... 30
tobramycin sulfate ........ 14, 30
tobramycin/sodium chloride
........................................ 14
tolazamide .......................... 25
tolbutamide ......................... 25
tolmetin sodium .................... 5
tolterodine tartrate ............. 64
topiramate .......................... 20
topotecan hcl ...................... 40
TORISEL ........................... 40
torsemide ............................ 61
TOVIAZ ............................. 65
TPN ELECTROLYTES ..... 88
TRACLEER ....................... 98
TRADJENTA ..................... 22
tramadol hcl ......................... 9
tramadol hcl/acetaminophen 9
trandolapril ........................ 86
trandolapril/verapamil hcl . 86
tranexamic acid ................. 67
tranylcypromine sulfate ..... 81
TRAVAMULSION ........... 55
TRAVASOL ...................... 55
TRAVASOL W/DEXTROSE
....................................... 55
TRAVASOL W/
ELECTROLYTES ......... 55
TRAVASOL with
DEXTROSE .................. 55
TRAVASOL with
ELECTROLYTES ......... 55
TRAVATAN Z .................. 28
TRAVERT ......................... 55
TRAVERT IN NORMAL
SALINE ......................... 55
TRAVERT-ELECTROLYTE
NO.1 .............................. 88
TRAVERT-ELECTROLYTE
NO.2 .............................. 88
TRAVERT-ELECTROLYTE
NO.3 .............................. 88
TRAVERT-ELECTROLYTE
NO.4 .............................. 88
trazodone hcl ..................... 81
TREANDA ........................ 40
TRECATOR ...................... 36
TRELSTAR ....................... 40
tretinoin ....................... 40, 57
TREXALL ......................... 40
triacetin .............................. 27
triamcinolone acetonide 3, 32,
34
triamterene/
hydrochlorothiazid......... 61
triazolam ............................ 49
TRIBENZOR ..................... 85
TRICOR............................. 35
trifluoperazine hcl.............. 84
trifluridine .......................... 30
trihexyphenidyl hcl ............ 42
TRIHIBIT .......................... 95
TRILEPTAL ...................... 20
TRILIPIX........................... 35
I-15
trimethoprim ...................... 95
trimipramine maleate ......... 81
TRIPEDIA ......................... 95
tripelennamine hcl ............. 28
TRISENOX ........................ 40
TRIZIVIR .......................... 45
TROPHAMINE ................. 56
tropicamide ........................ 62
trospium chloride ............... 65
TRUVADA ........................ 45
TWINRIX .......................... 96
TYGACIL .......................... 18
TYKERB............................ 40
TYPHIM VI ....................... 96
TYSABRI .......................... 77
TYZEKA............................ 47
TYZINE ............................. 62
ULORIC ............................. 77
UROLOGIC SOLUTION G
........................................ 70
ursodiol .............................. 65
UVADEX ........................... 93
VAGIFEM ......................... 64
valacyclovir hcl .................. 47
VALCYTE ......................... 47
valproate sodium ................ 20
valproic acid ...................... 20
VALSTAR ......................... 40
VALTURNA...................... 86
vancomycin hcl................... 14
VANCOMYCIN HCL ....... 14
vancomycin hcl/d5w ........... 14
VANDETANIB ................. 40
VANTAS ........................... 77
VAQTA.............................. 96
VARIVAX VACCINE ...... 96
vasopressin ......................... 80
VECTIBIX ......................... 41
VELCADE ......................... 41
venlafaxine hcl ................... 82
VENLAFAXINE HCL ER 82
VENTOLIN HFA .............. 94
VERAMYST...................... 32
verapamil hcl ...................... 50
VEREGEN ......................... 31
VERIPRED 20 ..................... 3
VESICARE ........................ 65
VFEND............................... 27
VFEND IV ......................... 27
VICTOZA 3-PAK .............. 22
VICTRELIS ....................... 46
VIDAZA............................. 41
VIDEX ............................... 45
VIGAMOX......................... 30
VIIBRYD ........................... 82
VIMPAT............................. 20
vinblastine sulfate ............... 41
vincristine sulfate ............... 41
vinorelbine tartrate ............ 41
VIRACEPT ........................ 45
VIRAMUNE ...................... 45
VIRAMUNE XR ................ 45
VIREAD ............................. 45
VISTIDE ............................ 47
VIVAGLOBIN ................... 91
VIVELLE-DOT ................. 64
VOLTAREN ........................ 5
voriconazole ....................... 27
VOTRIENT ........................ 41
VPRIV ................................ 62
VUMON ............................. 41
VYVANSE ......................... 11
warfarin sodium ................. 67
water for irrigation,sterile.. 70
WELCHOL ........................ 34
WINRHO SDF ................... 91
XALKORI .......................... 41
XARELTO ......................... 67
XENAZINE ........................ 59
XEOMIN ............................ 77
XERAC AC ........................ 48
XGEVA .............................. 77
XIAFLEX ........................... 62
XIFAXAN .......................... 14
XOLAIR ............................. 89
XOLEGEL ......................... 31
XYLOCAINE .................... 71
XYREM ............................. 59
YERVOY........................... 41
YF-VAX ............................ 97
YODOXIN......................... 43
zafirlukast .......................... 33
zaleplon .............................. 47
ZANOSAR ........................ 41
ZAVESCA ......................... 77
ZELBORAF....................... 41
ZEMAIRA ......................... 89
ZEMPLAR......................... 98
ZENPEP............................. 65
ZERIT ................................ 45
ZETIA ................................ 34
ZETONNA ........................ 32
ZIAGEN ............................ 45
zidovudine .......................... 45
ziprasidone hcl ................... 84
ZIRGAN ............................ 30
ZOLADEX ........................ 41
ZOLINZA .......................... 41
zolpidem tartrate................ 47
ZOMETA........................... 77
ZOMIG ........................ 35, 36
ZOMIG ZMT ..................... 35
ZONALON ........................ 43
zonisamide ......................... 21
ZORBTIVE ....................... 80
ZORTRESS ....................... 77
ZOSTAVAX ...................... 97
ZOSYN .............................. 17
ZOVIRAX ......................... 31
ZYCLARA ........................ 93
ZYLET............................... 30
ZYMAR ............................. 30
ZYMAXID ........................ 30
ZYPREXA ......................... 84
ZYPREXA RELPREVV ... 84
ZYTIGA ............................ 41
ZYVOX ............................. 14
902253 (9/12)
601 S.W. Second Ave. Portland, OR 97204-3156 503-265-4709 or 888-786-7509 (TTY/TDD 711)
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