2013 united healthcare formulary.pdf

00013509G, 11 Y0066_120911_110211

Inside Drug tiers and drug payment stages Complete list of drugs by category Requirements and limits Index of covered drugs

Please read: This document contains information about thedrugs covered bythis plan.

Note to existing members: This complete list of drugs has changed since last year. Please review this document to make sure it still contains the drugs you take.

FormularyComprehensive

(Complete list of covered drugs)

UnitedHealthcare Group Medicare Advantage Plan

2013

about this complete drug listThis is a complete list of prescription drugs that are covered by the UnitedHealthcare Group Medicare Advantage Plan, insured through UnitedHealthcare, for the 2013 plan year. It is called the Comprehensive Formulary (drug list) and includes all of the drugs covered by the plan.

For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your drug is covered:

1. See if your drug is included in this complete drug list.2. Visit the plan website at www.UHCRetiree.com. You can use online tools to look up your drugs. The information is updated on a regular basis.

3. Call Customer Service at the number located on the back of your ID card. Customer Service can look up your drugs and let you know if they are covered.

For more informationPlease take the time to review your Evidence of Coverage and any other 2013 plan materials you have received. These materials give more detailed information about your drug coverage in the plan.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1800MEDICARE (18006334227), 24 hours a day, 7 days a week. TTY/TDD users should call 18774862048. Or visit www.medicare.gov.

Questions?If you have questions, were here to help.

CallCustomerService at the number located on the back of your ID card.

Or visit www.UHCRetiree.com

online toolsVisit www.UHCRetiree.com to

Look up your drugs and see what you could save with lower-cost drugs

View your cost and benefits summary Track your payment status and claims history

12013 Complete drug list

The plan is designed to help you manage your prescription drug costs. An important part of this is giving you choices so you and your doctor can choose the best course of treatment for you.

A formulary is a list of the drugs covered by a Medicare Advantage prescription drug plan 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. The plan will generally cover the drugs listed in the formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

With your doctors help, you can use this drug list as a tool to choose the drugs that work best for you and to find lower-cost drugs if needed.

using the drug listThere are two ways to find your prescription drugs in this complete drug list:

1. Alphabetical list (index): Turn to the Index of covered drugs section, which begins on page 62, to see the list of drug names in alphabetical order.

2. Medical condition: Turn to the Covered drugs by category section, which begins on page 8, to look for drug names based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the Cardiovascular Drugs category and look under Cholesterol Control Drugs.

Is it a generic or brand name drug?The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin).

More information about your drugSome drugs have requirements or limits. Please see the Requirements and limits section on page 4 for more information on drugs you may use.

This document is a complete list of covered drugs. If your drug is not included in this drug list, the plan may still cover it. Contact Customer Service to ask if its covered, or go to www.UHCRetiree.com to look it up online. If you learn that the plan does not cover your drug, you have two options:

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

2. You can ask the plan to make an exception and cover your drug. See the Coverage decisions section on page 5 for information about how to request an exception.

2Drug tiers and drug payment stagesThe amount you pay for a covered drug will depend on:

Your drug payment stage. The plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the stage youre in.

The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may have a different copay or coinsurance amount. The chart below shows the differences between the tiers.

For more information about drug payment stages and copay or coinsurance amounts for each tier, please refer to the plans Evidence of Coverage (EOC).

If you qualify for extra helpIf you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for extra help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider). Please read it to find out what your costs are. You can also contact Customer Service.

Drug Tier Includes

Tier 1: Preferredgeneric

Most genericdrugs.

Tier 2: Preferred brand

Many common brand name drugs, called preferred brands, and some higher-cost generic drugs.

Tier 3: Non-preferred brand

Non-preferred generic and non-preferred brand name drugs.

Tier 4: Specialty tier

Unique and/or very high-cost drugs.

3Generic drugsThe plan covers both brand name and generic drugs. The Food and Drug Administration (FDA) requires a generic drug to have the same active ingredient as the brand name drug. Using generic drugs, whether preferred or non-preferred, may save you money on your copays or coinsurance and may help you stay out of the coverage gap if you have one.

VaccinesThe plan covers a number of Part D vaccines. Our coverage may include the cost of both the vaccine medication and the administration of the vaccine shot. Some vaccines, like those for the flu and pneumonia, may be covered by Medicare Part B (doctor and outpatient health care).

For the best coverage, the plan recommends that you get vaccines at a network pharmacy if your state allows it. The administration fee likely will be lower at a network pharmacy than at your doctors office. If you get your vaccines at your doctors office, you will pay the entire cost of the vaccine and administration fee to your doctor.

Please see your Evidence of Coverage for more information about vaccines and their costs.

To make sure a recommended vaccine is covered, call Customer Service at the number located on the back of your ID card.

4requirements and limitsSome of the plans drugs have requirements or limits to help ensure safe, effective and affordable use. If your drug has any requirements or limits, there will be a code(s) in the Requirements & Limits column of the drug list starting on page 8. The codes and what they mean are shown below.

You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug. See the Coverage decisions section on the next page or your Evidence of Coverage to learn more.

If you do not get prior approval from the plan for a drug with a requirement or limit, you may be responsible for paying the full cost of the drug.

B/D Medicare Part B or Part DDepending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescriptiondrugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure its correctly covered byMedicare.

la Limited accessDrugs are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that cant be done at a network pharmacy.

Pa Prior authorizationThe plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you dont get approval, the plan may not cover the drug.

ST Step therapyThere are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover thisdrug.

For more information about requirements and limits, call Customer Service at the number located on the back of your ID card.

5 Generally, the plan will only approve your request for an exception if the alternative drugs included in the plans formulary, the lower-tiered drug or additional utilization restrictions would not be effective in treating your condition and/or would cause you to have adverse medical effects.

Asking for a coverage decisionYou (or your authorized representative) and your doctor can ask for an initial coverage decision by calling Customer Service at the number located on the back of your ID card.

When you are requesting a formulary, tiering or utilization restriction exception, your prescriber or physician should submit a statement supporting your request.

See your Evidence of Coverage for more information.

Receiving a coverage decisionGenerally, the plan will make a coverage decision within 72 hours after receiving your prescribing physicians statement. You can request an expedited, or fast, decision if you or your doctor believe your health requires it. If the plan agrees to a fast decision, you will receive a decision within 24 hours after the plan receives your prescribers or prescribing physicians supporting statement.

Coverage decisionsAt times you may need to ask for drug coverage thats not normally provided by the plan. When you do, the plan will consider your request and respond with a coverage decision (coverage determination).

Examples of coverage decisions you may ask for include:

Asking the plan to pay you back for the cost of a drug you bought at an out-of-network pharmacy. Asking for an exception to the plans coverage rules.

How to request an exceptionYou can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

You can ask the plan to cover your drug even if it is not on the formulary (formulary exception).

You can ask the plan to waive coverage restrictions or limits on your drug (utilization exception).

You can ask the plan to provide a higher level of coverage for your drug (tier exception). If your drug is in the non-preferred tier/the highest tier subject to the tiering exceptions

process, you can ask the plan to cover it at the cost-sharing amount that applies to drugs in the preferred tier/lowest tier subject to the tiering exception 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 in the plans formulary, you may not ask us to provide a higher level of coverage for the drug. Tiering exceptions are not available for drugs in the specialty tier.

6Drug list changesThe plan recognizes that drug list stability is very important to you. That is why the plan tries to make as few changes to the drug list as possible during the plan year. From time to time, drug list changes may be necessary for safety or other reasons.

The drug list may change throughout the year when the plan:

Adds a new drug. Removes a drug. Changes the requirements or limits for a drug. Moves a drug to a lower-cost tier. Moves a drug to a higher-cost tier.

If the FDA declares a drug to be unsafe or the drugs manufacturer removes the drug from the market, the plan will immediately remove the drug from the drug list and inform affected members. If a drug moves to a higher-cost tier or undergoes some other change, the plan will inform affected members at least 60 days before the change 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.

Generally, if you are taking a drug on the 2013 drug list that was covered at the beginning of the year, the plan will not remove the drug from the drug list or move a drug to a higher tier during the 2013 coverage year except when a new, less expensive generic equivalent drug becomes available (for example, the brand name drug moves to a higher tier and the less expensive drug is on the lower tier), or when new information about the safety or effectiveness of a drug is released.

Other types of changes, such as removing a drug from the drug list, 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. It is important that you have continued access for the remainder of the coverage year to the list of drugs that were available when you chose the plan, except for cases in which you can save additional money or your safety is a concern.

If there are changes to the drug list such as regular or necessary updates, members may see information in the Explanation of Benefits statement, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The plan website also has updated information.

7Transition supply process New or continuing membersAs a new or continuing member in the plan, you may be taking drugs that are not on the formulary. Or you may be taking a drug that is on the formulary but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers, or request a formulary exception so that the plan will cover the drug you take. While you talk to your doctor to determine the right course of action for you, the plan may cover your drug in certain cases during the first 90 days you are a member of the plan.

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

Long-term care facility residentsIf youre a resident of a long-term care facility, the plan will allow you to refill your prescription until we have provided you with a 91-day transition supply of the drug consistent with dispensing increment (unless your prescription is for fewer days). The plan will also cover one or more refills for the first 90 days of your membership. If you need a drug thats not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of your plan membership, the plan will cover a 31-day emergency supply of the drug (unless your prescription is for fewer days) while you request a formulary exception.

Other transitionsYou may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug thats not on the drug list, or if its difficult for you to get your drugs, you are required to use the plans exception process. You may ask for a one-time emergency supply of up to 31 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception.

For more informationFor more detailed information about the plans prescription drug coverage, pleasereview your Evidence of Coverage and other plan materials.

If you have questions, please call CustomerService at the number located onthe back of your ID card.

Or visit www.UHCRetiree.com

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1800MEDICARE (18006334227), 24 hours a day, 7 days a week. TTY/TDD users should call 18774862048. Or visit www.medicare.gov.

8Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug PA = Prior authorization ST = Step therapy

Drug Name Drug TierRequirements

&Limits

Diflunisal 1Duexis 3 STEC-Naprosyn 3Etodolac (200mg Capsule, Tablet)

1

Etodolac ER 1Feldene 3Fenoprofen Calcium 1Flector 3Flurbiprofen 1Ibuprofen (Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet)

1

Indocin (Suspension) 3Indomethacin (Capsule) 2Indomethacin ER 2Ketoprofen 2Ketoprofen ER 2Ketorolac Tromethamine (Tablet)

2


&Limits

Analgesics Drugs to Treat Pain, Inflammation and Muscle and Joint Conditions

Analgesics, Other Miscellaneous AnalgesicsGralise 3 STGralise Starter 3 STNonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory DrugsAnaprox 3Anaprox DS 3Arthrotec 3Cambia 3Cataflam 3Celebrex 2Clinoril 3Daypro 3Diclofenac Potassium 1Diclofenac Sodium DR 1Diclofenac Sodium ER 1

Covered drugs by categoryThis Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by the plan. It is current as of January 1, 2013.

The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information in the Requirements & Limits column tells you if the plan has any special requirements for coverage of your drug.

If you have trouble finding your drug in the list, turn to the Index of covered drugs section that begins on page 62. If your prescription is not in this complete formulary, please visit www.UHCRetiree.com or call Customer Service at the number located on the back of your ID card, for additional help.

9Drug Name Drug TierRequirements

&Limits

Ketorolac Tromethamine (15mg/ml Injection, 30mg/ml Injection)

2 PA

Meclofenamate Sodium 2Mefenamic Acid 2Meloxicam 1Mobic 3Nabumetone 2Nalfon 3Naprelan (750mg Tablet Extended Release 24 Hour)

3

Naprosyn 3Naproxen 1Naproxen DR 1Naproxen Sodium (275mg Tablet, 550mg Tablet)

1

Oxaprozin 1Oxycodone/Ibuprofen 2Piroxicam 2Ponstel 3Sprix 3 PASulindac 1Tolmetin Sodium 2Treximet 3 STVoltaren-XR 3Zipsor 3 STOpioid Analgesics, Long-Acting Opioid Pain RelieversAstramorph 2Avinza 2Dolophine 3Dolophine HCl 3Duragesic (12mcg/Hr Patch 72 Hour, 25mcg/Hr Patch 72 Hour, 50mcg/Hr Patch 72 Hour)

3 ST


&Limits

Duragesic (100mcg/Hr Patch 72 Hour, 75mcg/Hr Patch 72 Hour)

4 ST

Duramorph 2Exalgo 2Fentanyl (Patch) 2Kadian (100mg Capsule Extended Release 24 Hour, 10mg Capsule Extended Release 24 Hour, 20mg Capsule Extended Release 24 Hour, 30mg Capsule Extended Release 24 Hour, 50mg Capsule Extended Release 24 Hour, 60mg Capsule Extended Release 24 Hour, 80mg Capsule Extended Release 24 Hour)

3

Kadian (200mg Capsule Extended Release 24 Hour)

4

Levorphanol Tartrate 2Methadone HCl (Concentrate, Oral Solution, Tablet)

2

Methadone HCl (Injection) 3

Methadose (Tablet) 2Morphine Sulfate (Oral Solution, Tablet)

2

Morphine Sulfate ER 2

10

Bold type = Brand name drug B/D=MedicarePartBorPartD LA = Limited access drug PA = Prior authorization ST = Step therapy


&Limits

MS Contin (100mg Tablet Extended Release 12 Hour, 15mg Tablet Extended Release 12 Hour, 30mg Tablet Extended Release 12 Hour, 60mg Tablet Extended Release 12 Hour)

3

MS Contin (200mg Tablet Extended Release 12 Hour)

4

Nucynta ER 2Opana ER (Crush Resistant) 2

Oxycontin 2Oxymorphone HCl ER 2Ryzolt 3 STTramadol HCl ER (Tablet Extended Release 24 Hour)

3

Ultram ER 3Opioid Analgesics, Short-Acting Opioid Pain RelieversAbstral (100mcg Tablet Sublingual) 3 PA

Abstral (200mcg Tablet Sublingual, 300mcg Tablet Sublingual, 400mcg Tablet Sublingual, 600mcg Tablet Sublingual, 800mcg Tablet Sublingual)

4 PA


&Limits

Acetaminophen/Caffeine/Dihydrocodeine Bitartrate

2

Acetaminophen/Codeine 1Actiq 4 PAButalbital/Aspirin/Caffeine/Codeine

2

Butorphanol Tartrate 2Capital/Codeine 3Carisoprodol/Aspirin/Codeine

3

Co-Gesic 2Codeine Sulfate (Tablet) 1Demerol (50mg/ml Injection) 3

Demerol (Tablet) 3 STDilaudid 3Dilaudid-5 3Dilaudid-HP (10mg/ml Injection) 3

Endocet 2Endodan 1Fentanyl Citrate Oral Transmucosal

4 PA

Fentora 4 PAFiorinal/Codeine 3Hycet 3

11


&Limits

Hydrocodone/Acetaminophen (Oral Solution, 300mg; 10mg Tablet, 300mg; 5mg Tablet, 300mg; 7.5mg Tablet, 325mg; 10mg Tablet, 325mg; 5mg Tablet, 325mg; 7.5mg Tablet, 500mg; 10mg Tablet, 500mg; 2.5mg Tablet, 500mg; 5mg Tablet, 500mg; 7.5mg Tablet, 650mg; 10mg Tablet, 650mg; 7.5mg Tablet, 660mg; 10mg Tablet, 750mg; 10mg Tablet, 750mg; 7.5mg Tablet)

2

Hydrocodone/Ibuprofen 2Hydromorphone HCl (500mg/50ml Injection, Tablet)

2

Lazanda 3 PALorcet 3Lortab 3Magnacet 3Maxidone 3Meperidine HCl (100mg/ml Injection, 25mg/ml Injection, 50mg/ml Injection)

3

Meperidine HCl (Oral Solution, Tablet)

3 ST

Nalbuphine HCl 2Norco 3Nucynta 3 PAOnsolis 4 PAOpana (Tablet) 3Oxecta 3 PA


&Limits

Oxycodone HCl (Capsule, Concentrate, 15mg Tablet, 30mg Tablet, 5mg Tablet)

2

Oxycodone/Acetaminophen

2

Oxycodone/Aspirin 1Oxymorphone HCl 2Pentazocine/Acetaminophen

3 ST

Pentazocine/Naloxone HCl 3 STPercocet 3Percodan 3Reprexain 3Roxicet (500mg; 5mg Tablet)

2

Roxicet (Oral Solution) 3Roxicodone 3Stagesic 2Synalgos-DC 3Talwin 3Tramadol HCl 1Tramadol HCl/Acetaminophen

1

Tylenol/Codeine 3Tylox 3Ultracet 3Ultram 3Vicodin 3Vicodin ES 3Vicodin HP 3Vicoprofen 3Xodol (300mg; 10mg Tablet, 300mg; 7.5mg Tablet)

3

Zamicet 3Zydone 3

12



&Limits

Anesthetics Drugs for Numbing

Local AnestheticsEmla 3 B/DLidocaine (Ointment) 2 B/DLidocaine HCl (External Solution)

2

Lidocaine HCl (0.5% Injection, 1% Injection)

2 B/D

Lidocaine HCl (Gel) 2Lidocaine Viscous 2Lidocaine/Prilocaine (Cream)

2 B/D

Lidoderm 2Synera 3 B/DXylocaine (External Solution) 3

Xylocaine (1% Injection) 3 B/D

Anti-Inflammatory Agents

Nonsteroidal Anti-Inflammatory Drugs Pain/Anti-Inflammatory DrugsNaprelan (375mg Tablet Extended Release 24 Hour, 500mg Tablet Extended Release 24 Hour)

3

Antibacterials Drugs to Treat Bacterial Infections

Aminoglycosides AntibioticsAmikacin Sulfate (500mg/2ml Injection, 50mg/ml Injection)

2

Gentak (Ointment) 1


&Limits

Gentamicin Sulfate (Cream, Injection, 0.1% Ointment, Ophthalmic Solution)

1

Gentamicin Sulfate/NaCl (1.2mg/ml; 0.9% Injection, 1.6mg/ml; 0.9% Injection, 1mg/ml; 0.9% Injection)

1

Gentamicin Sulfate/NaCl (0.9mg/ml; 0.9% Injection, 1.4mg/ml; 0.9% Injection)

2

Isotonic Gentamicin (0.8mg/ml; 0.9% Injection)

1

Kanamycin Sulfate 2Neomycin Sulfate 1Neomycin/Polymyxin B Sulfates

2

Paromomycin Sulfate 2Streptomycin Sulfate 3Tobi 4 B/DTobramycin Sulfate (Ophthalmic Solution)

1

Tobramycin Sulfate (10mg/ml Injection, 80mg/2ml Injection)

2

Tobramycin Sulfate/Sodium Chloride

2

Tobrex (Ointment) 2Tobrex (Ophthalmic Solution) 3

Antibacterials, Other AntibioticsAltabax 3Baciim 1

13


&Limits

Bacitracin (Injection, Ophthalmic Ointment)

1

Bacitracin/Polymyxin B 1Bactroban 3Bactroban Nasal 3Chloramphenicol Sodium Succinate 2

Cleocin 3Cleocin Galaxy 3Cleocin in D5W 3Cleocin Phosphate (900mg/6ml Injection) 3

Clindamycin HCl (150mg Capsule, 300mg Capsule)

1

Clindamycin Phosphate (Cream)

1

Clindamycin Phosphate Add-Vantage

2

Colistimethate Sodium 3Coly-Mycin M 3 STCortisporin (Cream, Ointment) 3

Cubicin 4 B/DFlagyl 3Flagyl ER 3Furadantin 3Hiprex 3Lincocin 3Macrobid 3Macrodantin (100mg Capsule, 25mg Capsule) 3

Methenamine Hippurate 2MetroCream 3MetroGel 3MetroGel-Vaginal 3Metrolotion 3Metronidazole 2


&Limits

Metronidazole in NaCl 0.79%

2

Metronidazole Vaginal 1Monurol 3Mupirocin 1Neomycin/Bacitracin/Polymyxin

1

Neomycin/Polymyxin/Gramicidin

1

Neosporin 3Nitrofurantoin 2Nitrofurantoin Macrocrystalline (50mg Capsule)

2

Nitrofurantoin Monohydrate 2Phisohex 3Polymyxin B Sulfate 2Polytrim 3Prevpac 3Primsol 3Silvadene 3Silver Sulfadiazine 1SSD 1Sulfamylon 3Synercid 4Thermazene 1Trimethoprim 1Trimethoprim Sulfate/Polymyxin B Sulfate

1

Tygacil 3Vancocin HCl 4 PAVancomycin HCl (1000mg Injection, 10gm Injection, 500mg Injection)

2 B/D

Vancomycin HCl (125mg Capsule) 4 PA

14



&Limits

Vancomycin HCl (250mg Capsule)

4 PA

Vandazole 1Vibativ (250mg Injection) 3Xifaxan (200mg Tablet) 3Xifaxan (550mg Tablet) 4Zyvox 4 PABeta-Lactam, Cephalosporins AntibioticsCedax (Capsule) 3Cefaclor 1Cefaclor ER 1Cefadroxil 1Cefazolin Sodium (10gm Injection, 1gm Injection, 1gm; 5% Injection, 500mg Injection)

2

Cefdinir 2Cefepime (1gm Injection, 2gm Injection)

2

Cefotaxime Sodium (10gm Injection, 1gm Injection, 2gm Injection)

2

Cefoxitin Sodium/Dextrose 2

Cefoxitin Sodium 2Cefpodoxime Proxetil 2Cefprozil 2Ceftazidime (1gm Injection, 2gm Injection, 6gm Injection)

2

Ceftazidime/Dextrose 2Ceftin 3


&Limits

Ceftriaxone Sodium 2Cefuroxime Axetil (Tablet) 1Cefuroxime Sodium (1.5gm Injection, 7.5gm Injection, 750mg Injection)

1

Cephalexin 1Claforan 3Fortaz (1gm/50ml; 5% Injection, 2gm Injection, 2gm/50ml; 5% Injection, 6gm Injection)

3

Keflex (250mg Capsule, 500mg Capsule) 3

Rocephin (500mg Injection) 3

Spectracef 3Suprax 2Teflaro 3Zinacef 3Zinacef in Iso-Osmotic Dextrose 3

Zinacef in Iso-Osmotic Diluent 3

Beta-Lactam, Other AntibioticsAzactam (2gm Injection) 2

Azactam in Iso-Osmotic Dextrose 3

Aztreonam (1gm Injection) 2Cayston 4 PACefotetan 3

15


&Limits

Doribax (500mg Injection) 3

Imipenem/Cilastatin 2Invanz 3Meropenem (500mg Injection)

2

Merrem (500mg Injection) 3

Primaxin 3Beta-Lactam, Penicillins AntibioticsAmoxicillin 1Amoxicillin/Potassium Clavulanate

1

Amoxicillin/Potassium Clavulanate ER

1

Ampicillin 2Ampicillin Sodium (10gm Injection, 125mg Injection, 1gm Injection)

2

Ampicillin-Sulbactam (10gm; 5gm Injection, 2gm; 1gm Injection)

2

Bactocill in Dextrose (1gm/50ml Injection) 3

Bactocill in Dextrose (2gm/50ml Injection) 4

Bicillin C-R 3Bicillin L-A 3Dicloxacillin Sodium 1Moxatag 3Nafcillin Sodium (10gm Injection, 1gm Injection)

2

Nallpen/Dextrose (1gm/50ml Injection) 3

Oxacillin Sodium (10gm Injection, 1gm Injection)

3

Penicillin G Potassium (5mu Injection)

3


&Limits

Penicillin G Potassium in Iso-Osmotic Dextrose 2

Penicillin G Procaine 3Penicillin G Sodium 3Penicillin V Potassium 1Pfizerpen-G (20mu Injection) 3

Piperacillin Sodium/Tazobactam Sodium (3gm; 0.375gm Injection, 4gm; 0.5gm Injection)

2

Timentin (0.1gm; 3gm Injection) 3

Unasyn (2gm; 1gm Injection) 3

Unasyn Bulk Pack 3Zosyn (3gm; 0.375gm Injection, 5%; 2gm/50ml; 0.25gm/50ml Injection, 5%; 3gm/50ml; 0.375gm/50ml Injection)

3

Macrolides AntibioticsAkne-Mycin 3Azasite 2Azithromycin (500mg Injection, Suspension Reconstituted, Tablet)

1

Biaxin 3Biaxin XL 3Biaxin XL PAC 3Clarithromycin 2Clarithromycin ER 2Dificid 4 PAE.E.S. 400 1E.E.S. Granules 2Ery 1Ery-Tab 2Eryped 2

16



&Limits

Erythrocin Lactobionate (500mg Injection) 3

Erythrocin Stearate 3Erythromycin (External Solution, Gel, Ointment)

1

Erythromycin Base 1Erythromycin Ethylsuccinate

1

Ketek 3 PAPCE 3Zithromax (Injection, Suspension Reconstituted, Tablet)

3

Zithromax Tri-Pak 3Zithromax Z-Pak 3Zmax 3Quinolones AntibioticsAvelox (Tablet) 2Avelox (Injection) 3Avelox ABC Pack 2Besivance 2Ciloxan 3Cipro 3Cipro HC 3Cipro IV (200mg/100ml; 5% Injection) 3

Ciprodex 2Ciprofloxacin (400mg/40ml Injection)

1

Ciprofloxacin ER 2Ciprofloxacin HCl 1Factive 3


&Limits

Levaquin (5%; 750mg/150ml Injection, Oral Solution, Tablet)

3

Levofloxacin 2Levofloxacin in D5W (5%; 500mg/100ml Injection)

2

Moxeza 2Noroxin 3Ocuflox 3Ofloxacin 2Vigamox 2Zymaxid 2Sulfonamides AntibioticsBactrim 3Bactrim DS 3Bleph-10 3Septra DS 3Sodium Sulfacetamide (Ophthalmic Solution)

1

Sulfacetamide Sodium (Ointment)

1

Sulfadiazine 2Sulfamethoxazole/Trimethoprim

1

Sulfamethoxazole/Trimethoprim DS

1

Tetracyclines AntibioticsDemeclocycline HCl 2Doryx 3Doxycycline (75mg Capsule)

2

17


&Limits

Doxycycline Hyclate (Capsule, Injection, Tablet, 100mg Tablet Delayed Release, 75mg Tablet Delayed Release)

2

Doxycycline Hyclate (150mg Tablet Delayed Release)

3

Doxycycline Monohydrate (150mg Tablet, 50mg Tablet, 75mg Tablet)

2

Dynacin 3Minocin (Capsule) 3Minocycline HCl (Capsule) 1Minocycline HCl (Tablet) 3Minocycline HCl ER 3Monodox 3Oracea 3Solodyn 3Tetracycline HCl 1Vibramycin 3

Anticonvulsants Drugs to Treat Seizures

Anticonvulsants, Other Seizure Control DrugsKeppra (Oral Solution, Tablet) 3

Keppra XR 3Levetiracetam (500mg/5ml Injection, Oral Solution, Tablet)

1

Levetiracetam ER 2Phenobarbital (Elixir, 16.2mg Tablet, 30mg Tablet, 32.4mg Tablet, 64.8mg Tablet, 97.2mg Tablet)

1 PA

Potiga 3


&Limits

Calcium Channel Modifying Agents Seizure Control DrugsCelontin 3Ethosuximide 2Lyrica 2Zarontin 3Zonegran 3Zonisamide 1Gamma-Aminobutyric Acid (GABA) Augmenting Agents Seizure Control DrugsClonazepam 1Clonazepam ODT 3Clorazepate Dipotassium 1Depacon 3Depakene 3Depakote 3Depakote ER 3Depakote Sprinkles 3Diazepam (Gel) 3Divalproex Sodium 1Divalproex Sodium DR 1Divalproex Sodium ER 1Gabapentin 1Gabitril 3Horizant 3 STKlonopin 3Mysoline 3Neurontin 3Onfi 3 PAPrimidone 1Sabril 4 PAStavzor 3Tranxene T 3Valproate Sodium (100mg/ml injection)

2

Valproic Acid 1

18



&Limits

Glutamate Reducing Agents Seizure Control DrugsFelbamate (Tablet) 3Felbamate (Suspension) 4Felbatol (Tablet) 3Felbatol (Suspension) 4Lamictal (Tablet) 3Lamictal Chewable Dispersible 3

Lamictal ODT (Tablet Dispersible) 3

Lamictal Starter Kit 3Lamictal XR (Kit, 100mg Tablet Extended Release 24 Hour, 200mg Tablet Extended Release 24 Hour, 250mg Tablet Extended Release 24 Hour, 25mg Tablet Extended Release 24 Hour, 50mg Tablet Extended Release 24 Hour)

3

Lamotrigine (Tablet) 1Lamotrigine (Tablet Chewable)

2

Topamax 3Topamax Sprinkle 3Topiramate 1Sodium Channel Agents Seizure Control DrugsBanzel 3Carbamazepine 2


&Limits

Carbamazepine ER (Capsule Extended Release 12 Hour)

2

Carbatrol 3Dilantin 2Dilantin Infatabs 2Epitol 2Equetro 3Fosphenytoin Sodium (100mg pe/2ml Injection)

2

Oxcarbazepine 2Peganone 3Phenytek 1Phenytoin 1Phenytoin Sodium 1Phenytoin Sodium Extended

1

Tegretol 2Tegretol-XR 2Trileptal 3Vimpat (Oral Solution, Tablet) 3

Vimpat (Injection) 3 PA

Antidementia Agents Drugs to Treat Alzheimers Disease and Dementia

Antidementia Agents, OtherErgoloid Mesylates 2Cholinesterase Inhibitors Alzheimers Disease and Dementia DrugsAricept (23mg Tablet) 2Aricept (10mg Tablet, 5mg Tablet) 3

19


&Limits

Aricept ODT 3Donepezil HCl 1Exelon (Capsule, Oral Solution) 3

Exelon (Patch 24 Hour) 3 STGalantamine Hydrobromide 2Razadyne 3Razadyne ER 3Rivastigmine Tartrate 2N-methyl-D-aspartate (NMDA) Receptor Antagonists Alzheimers Disease and Dementia DrugsNamenda 2Namenda Titration Pak 2

Antidepressants Drugs to Treat Depression

Antidepressants, Other AntidepressantsAplenzin 3Budeprion SR 1Bupropion HCl 1Bupropion HCl SR 1Bupropion XL 1Maprotiline HCl 1Mirtazapine 1Mirtazapine ODT (30mg Tablet Dispersible, 45mg Tablet Dispersible)

1

Nefazodone HCl 1Oleptro 3Remeron 3Remeron Soltab 3Trazodone HCl 1Wellbutrin 3Wellbutrin SR 3Wellbutrin XL 3


&Limits

Monoamine Oxidase Inhibitors AntidepressantsEmsam 3 STMarplan 3Nardil 2Parnate 3Phenelzine Sulfate 1Selegiline HCl 2Tranylcypromine Sulfate 2Zelapar 3Serotonin/Norepinephrine Reuptake Inhibitors AntidepressantsCelexa 3Citalopram Hydrobromide (Tablet)

1

Citalopram Hydrobromide (Oral Solution)

2

Cymbalta 2Effexor XR 3Escitalopram Oxalate 1Fluoxetine DR 3Fluoxetine HCl (Capsule, Oral Solution, 10mg Tablet, 20mg Tablet)

1

Fluvoxamine Maleate 1Lexapro 3Luvox CR 3Paroxetine HCl 1Paroxetine HCl ER 3Paxil 3Paxil CR 3Pexeva 3Pristiq 3 PAProzac 3Prozac Weekly 3Sarafem 3 STSertraline HCl (Tablet) 1

20



&Limits

Sertraline HCl (Concentrate)

2

Venlafaxine HCl 2Venlafaxine HCl ER (Capsule Extended Release 24 Hour)

1

Venlafaxine HCl ER (225mg Tablet Extended Release 24 Hour)

3

Venlafaxine HCl ER (150mg Tablet Extended Release 24 Hour, 37.5mg Tablet Extended Release 24 Hour, 75mg Tablet Extended Release 24 Hour)

3

Viibryd 3 STZoloft 3Tricyclics AntidepressantsAmitriptyline HCl 1Amoxapine 1Anafranil 3Clomipramine HCl 1Desipramine HCl 2Doxepin HCl 1Imipramine HCl 1Imipramine Pamoate 2Norpramin 3Nortriptyline HCl 1Pamelor 4 STPerphenazine/Amitriptyline 1Protriptyline HCl 2


&Limits

Surmontil 3Tofranil 3Tofranil-PM 3Trimipramine Maleate 2Vivactil 3

Antidotes, Deterrents, and Toxicologic Agents Drugs for Overdose or Deterrents

Alcohol Deterrents/Anti-Craving Antidotes/Deterrents/ProtectantsAntabuse 2Campral 3Disulfiram 2Naltrexone HCl 2Revia 3Vivitrol 4Opioid Antagonists Antidotes/Deterrents/ProtectantsBuprenex 3Buprenorphine HCl 2Butrans 3 PANaloxone HCl (1mg/ml Injection)

2

Suboxone 3Smoking Cessation Agents DeterrentsBuproban 1Chantix 3Chantix Pak 3Nicotrol Inhaler 3Nicotrol NS 2Zyban 3

21


&Limits

Antiemetics Drugs to Treat Nausea and Vomiting

Antiemetics, Other Nausea and Vomiting DrugsAntivert 3Meclizine HCl 1Tigan 3 PATrimethobenzamide HCl (Capsule)

3 PA

Emetogenic Therapy Adjuncts Nausea and Vomiting DrugsAloxi 3Anzemet (Injection) 3Anzemet (50mg Tablet) 3 B/DAnzemet (100mg Tablet) 4 B/DCesamet 4 B/D, PADronabinol (2.5mg Capsule, 5mg Capsule)

2 B/D, PA

Dronabinol (10mg Capsule) 4 B/D, PAEmend (Capsule) 2 B/D, PAGranisetron HCl (0.1mg/ml Injection, 1mg/ml Injection)

2

Granisetron HCl (Tablet) 2 B/DGranisol 2 B/DMarinol (2.5mg Capsule) 3 B/D, PAMarinol (10mg Capsule, 5mg Capsule) 4 B/D, PA

Ondansetron HCl (Tablet) 1 B/DOndansetron HCl (4mg/2ml Injection)

2

Ondansetron HCl (Oral Solution)

2 B/D

Ondansetron ODT 1 B/DSancuso 4Zofran (Oral Solution, Tablet) 4 B/D, PA


&Limits

Zofran (Injection) 4 STZofran ODT 4 B/D, PAZuplenz 3 B/D

Antifungals Drugs to Treat Fungal Infections

Antifungals Fungal Infection DrugsAbelcet 4 B/DAmBisome 4 B/DAmphotec (50mg Injection) 3 B/D

Amphotericin B 2 B/DAncobon 4Cancidas 4Ciclopirox 2Ciclopirox Nail Lacquer 2Ciclopirox Olamine 2Clotrimazole (External Cream, External Solution, Troche)

1

Clotrimazole/Betamethasone Dipropionate

1

Diflucan 3Econazole Nitrate 1Eraxis (100mg Injection) 4Ertaczo 3Exelderm 3Extina 3Fluconazole 1Fluconazole in Dextrose (56mg/ml; 400mg/200ml Injection)

1

Flucytosine 4Gris-Peg 3Griseofulvin Microsize 2Itraconazole 2 PA

22



&Limits

Ketoconazole (Cream, Shampoo, Tablet)

1

Ketoconazole (Foam) 3Lamisil (Packet, Tablet) 3Loprox 3Loprox Shampoo 3Lotrisone 3Mentax 3Miconazole 3 1Mycamine 4Naftin (1% Cream, Gel) 3Natacyn 2Nizoral 3Noxafil 4Nyamyc 1Nystatin (Cream, Ointment, 100000unit/gm Powder, Suspension, Tablet)

1

Nystatin/Triamcinolone 1Nystop 1Oxistat 3Pedi-Dri 1Sporanox (Oral Solution) 3 PASporanox (Capsule) 4 PASporanox Pulsepak 3 PATerazol 3Terbinafine HCl (Tablet) 1Terconazole (0.4% Cream, Suppository)

1

Vfend (Suspension Reconstituted) 4

Vfend (Tablet) 4 ST


&Limits

Vfend IV 3Voriconazole (Tablet) 4Zazole (Cream) 1

Antigout Agents Drugs to Treat Gout

Antigout Agents Gout DrugsAllopurinol (Tablet) 1Allopurinol Sodium (Injection)

1

Aloprim 3Colcrys 2Probenecid 1Probenecid/Colchicine 1Uloric 2 STZyloprim 3

Antimigraine Agents Drugs to Treat Migraines

Ergot Alkaloids Migraine DrugsDihydroergotamine Mesylate

2

Ergotamine Tartrate/Caffeine

2

Migergot 2Migranal 3Serotonin (5-HT) 1b/1d Receptor Agonists Migraine DrugsAmerge 3Axert 3 STFrova 3 STImitrex 3Imitrex Statdose Refill 3Maxalt 2

23


&Limits

Maxalt-MLT 2Naratriptan HCl 1Relpax 3 STSumatriptan Succinate (Tablet)

1

Sumatriptan Succinate (6mg/0.5ml Injection)

2

Zomig 3 STZomig ZMT 3 ST

Antimyasthenic Agents Drugs to Treat Myasthenia Gravis

Parasympathomimetics Myasthenia Gravis DrugsMestinon 3Mestinon Timespan 3Mytelase 3Pyridostigmine Bromide 1Regonol 1

Antimycobacterials Drugs to Treat Infections

Antimycobacterials, Other Miscellaneous Anti-InfectivesDapsone 2Mycobutin 3Antituberculars Tuberculosis DrugsCapastat Sulfate 3Ethambutol HCl 2Isoniazid 2Paser 3Priftin 3Rifadin 3Rifamate 3Rifampin (Capsule) 2Rifampin (Injection) 3Rifater 3Seromycin 3Trecator 3


&Limits

Antineoplastics Drugs to Treat Cancer

Alkylating Agents Chemotherapy AgentsAlkeran (Injection) 3BiCNU 3Busulfex 4CeeNU 3Cyclophosphamide (Tablet) 2 B/DDacarbazine (200mg Injection)

2

Hexalen 4 PAIfex (3gm Injection) 3Ifosfamide (1gm Injection) 2Leukeran 2Matulane 4Melphalan HCl 4Mustargen 4Thiotepa 3Treanda (100mg Injection) 4 PA

Zanosar 4Antiangiogenic Agents Chemotherapy AgentsCaprelsa 4 PARevlimid (10mg Capsule, 15mg Capsule, 25mg Capsule, 5mg Capsule)

4 PA, LA

Thalomid 4 PAAntiestrogens/Modifiers Chemotherapy AgentsEmcyt 3 PAFareston 3Faslodex 4Tamoxifen Citrate 1

24



&Limits

Antimetabolites Chemotherapy AgentsCladribine 2 B/DClolar 4Cytarabine (500mg Injection)

2 B/D

Cytarabine Aqueous (20mg/ml Injection)

1 B/D

Cytarabine Aqueous (100mg/ml Injection)

2 B/D

Droxia 3Elitek (1.5mg Injection) 4Fluorouracil (500mg/10ml Injection)

2 B/D

Folotyn (40mg/2ml Injection) 4 PA

Gemcitabine HCl (1gm Injection)

4

Gemzar (1gm Injection) 4Hydrea 3Hydroxyurea 1Mercaptopurine 2Nipent 4 STPentostatin 4Purinethol 3Tabloid 3 PAAntineoplastics, Other Chemotherapy AgentsAbraxane 4 PAAdriamycin (2mg/ml Injection)

2 B/D

Alimta (500mg Injection) 4 PAAmifostine 4


&Limits

Arranon 4Bleomycin Sulfate (30unit Injection)

2 B/D

Camptosar (100mg/5ml Injection) 3 ST

Carboplatin (150mg/15ml Injection)

2

Cerubidine 3Cisplatin (100mg/100ml Injection)

2

Cosmegen 3Dacogen 4Daunorubicin HCl (5mg/ml Injection)

1

Dexrazoxane (500mg Injection)

4 PA

Docefrez 4Docetaxel (80mg/4ml Injection, 80mg/8ml Injection)

4

Doxil 4 B/DDoxorubicin HCl (2mg/ml Injection)

2 B/D

Ellence (200mg/100ml Injection) 4 ST

Eloxatin (100mg/20ml Injection) 4

Elspar 3Epirubicin HCl (50mg/25ml Injection)

2

Erivedge 4 PAEthyol 4 ST

25


&Limits

Fludarabine Phosphate (50mg Injection)

4

Fusilev 4Halaven 4 PAIdamycin PFS (20mg/20ml Injection) 4 ST

Idarubicin HCl (10mg/10ml Injection)

4

Irinotecan (100mg/5ml Injection)

2

Istodax 4 PAIxempra Kit (45mg Injection) 4

Jakafi 4 PAJevtana 4 PALeucovorin Calcium (100mg Injection, 350mg Injection, Tablet)

2

Menest 2Mesna 2Mesnex 3Mitomycin (20mg Injection)

2

Mitoxantrone HCl 2 PAOntak 4 PAOxaliplatin (100mg/20ml Injection)

4

Paclitaxel (300mg/50ml Injection)

2

Picato 3Proleukin 4 PASylatron 4 PATaxotere (80mg/4ml Injection) 4

Trisenox 3 PAVelcade 4 PAVidaza 4 PAVinblastine Sulfate (10mg Injection)

2 B/D


&Limits

Vincasar PFS 2 B/DVincristine Sulfate 2 B/DVinorelbine Tartrate (50mg/5ml Injection)

2

Zinecard (250mg Injection) 4 PA

Zolinza 4 PAZytiga 4 PAAromatase Inhibitors, 3rd Generation Chemotherapy AgentsAnastrozole 1Arimidex 3Aromasin 3Exemestane 2Femara 3Letrozole 1Enzyme Inhibitors Chemotherapy AgentsEtopophos 4Etoposide (Injection) 2Hycamtin (Injection) 4Toposar 2Topotecan HCl (4mg Injection)

4

Molecular Target Inhibitors Chemotherapy AgentsAfinitor 4 PAGleevec 4 PAInlyta 4 PANexavar 4 PASprycel 4 PASutent 4 PATarceva 4 PATasigna 4 PATykerb 4 PAVotrient 4 PAXalkori 4 PAZelboraf 4 PA

26



&Limits

Monoclonal Antibodies Chemotherapy AgentsArzerra 4 PAAvastin (100mg/4ml Injection) 4 PA

Campath 4 PAErbitux (100mg/50ml Injection) 4 PA

Herceptin 4 PARituxan 4 PAVectibix (100mg/5ml Injection) 4 PA

Yervoy (50mg/10ml Injection) 4 PA

Retinoids Chemotherapy AgentsPanretin 4 PATargretin 4 PATretinoin (Capsule) 4

Antiparasitics Drugs to Treat Parasitic Infections

Anthelmintics Worm Infection DrugsAlbenza 2Biltricide 2Stromectol 2Antiprotozoals Protozoal Infection DrugsAlinia 3Atovaquone/Proguanil HCl (250mg; 100mg Tablet)

2

Chloroquine Phosphate 2Coartem 3Daraprim 2


&Limits

Hydroxychloroquine Sulfate 1Malarone 3Mefloquine HCl 1Mepron 4Nebupent 3 B/DPentam 300 3Plaquenil 3Primaquine Phosphate 3Qualaquin 3 PAPediculicides/Scabicides Scabies and Lice DrugsEurax 3Lindane 2Malathion 2Ovide 3Permethrin (Cream) 1Ulesfia 3

Antiparkinson Agents Drugs to Treat Parkinsons Disease

Anticholinergics Parkinsons Disease DrugsBenztropine Mesylate 1Cogentin 3Trihexyphenidyl HCl 1Antiparkinson Agents Parkinsons Disease DrugsComtan 2Tasmar 4

27


&Limits

Dopamine Agonists Parkinsons Disease DrugsApokyn 4Bromocriptine Mesylate 2Mirapex 3Mirapex ER 3Parlodel 3Pramipexole Dihydrochloride

2

Requip 3Requip XL 3Ropinirole ER 3Ropinirole HCl 1Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors Parkinsons Disease DrugsCarbidopa/Levodopa 1Carbidopa/Levodopa ER 1Carbidopa/Levodopa ODT

1

Lodosyn 3Parcopa 3Sinemet 3Sinemet CR 3Stalevo 2Monoamine Oxidase B (MAO-B) Inhibitors Parkinsons Disease DrugsAzilect 2Eldepryl 3

Antipsychotics Drugs to Treat Mood Disorders

1st Generation/Typical Mood Disorder DrugsChlorpromazine HCl 1Compro 1Fluphenazine Decanoate 2Fluphenazine HCl 1


&Limits

Haldol 3Haldol Decanoate 3Haloperidol 1Haloperidol Decanoate 1Haloperidol Lactate 1Loxapine Succinate 1Loxitane 3Orap 2Perphenazine 1Prochlorperazine 1Prochlorperazine Edisylate 2Prochlorperazine Maleate 1Thioridazine HCl 2Thiothixene 1Trifluoperazine HCl 12nd Generation/Atypical Mood Disorder DrugsAbilify 3Abilify Discmelt 3Fanapt 3 STFanapt Titration Pack 3 STGeodon 3Invega 3 STInvega Sustenna (39mg/0.25ml Injection, 78mg/0.5ml Injection)

3

Invega Sustenna (117mg/0.75ml Injection, 156mg/ml Injection, 234mg/1.5ml Injection)

4

Latuda 3Olanzapine 2Olanzapine ODT 2Quetiapine Fumarate 1Risperdal 3

28



&Limits

Risperdal Consta (12.5mg Injection, 25mg Injection)

3

Risperdal Consta (37.5mg Injection, 50mg Injection)

4

Risperdal M-Tab 3Risperidone (Tablet) 1Risperidone (Oral Solution) 2Risperidone ODT 2Saphris 2Seroquel 3Seroquel XR 2Ziprasidone HCl (Capsule) 3Zyprexa 3Zyprexa Zydis 3Treatment-Resistant Mood Disorder DrugsClozapine 2Clozaril 3Fazaclo 2

Antispasticity Agents Drugs to Treat Spasms

Antispasticity Agents Muscle Spasm DrugsBaclofen 1Dantrium 3Dantrolene Sodium (Capsule)

2


&Limits

Gablofen (10000mcg/20ml Injection, 50mcg/ml Injection)

2 B/D, PA

Gablofen (40000mcg/20ml Injection)

4 B/D, PA

Lioresal Intrathecal (0.05mg/ml Injection, 10mg/20ml Injection)

2 B/D, PA

Lioresal Intrathecal (10mg/5ml Injection) 4 B/D, PA

Tizanidine HCl (Tablet) 1Tizanidine HCl (Capsule) 3Zanaflex 3

Antivirals Drugs to Treat Viral Infections

Anti-Cytomegalovirus (CMV) Agents Miscellaneous Antiviral DrugsCytovene 3 B/DFoscarnet Sodium 2 B/DGanciclovir (Capsule) 3Ganciclovir (Injection) 3 B/DValcyte 4Vistide 4Zirgan 3Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors HIV DrugsAtripla 4Complera 4Edurant 4Intelence (100mg Tablet, 200mg Tablet) 4

29


&Limits

Nevirapine (Tablet) 2Rescriptor 3Sustiva 3Viramune (Tablet) 2Viramune (Suspension) 3Viramune XR 2Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors HIV DrugsCombivir 4Didanosine 2Emtriva 3Epivir (Oral Solution) 2Epivir (Tablet) 3Epivir HBV 2Epzicom 4Lamivudine 2Lamivudine/Zidovudine 4Retrovir 3Retrovir IV Infusion 3Stavudine (Capsule) 2Trizivir 4Truvada 4Videx EC 3Videx Pediatric (2gm Oral Solution) 3

Viread 4Zerit 3Ziagen 3Zidovudine 2Anti-HIV Agents, Other HIV DrugsFuzeon 4Isentress 4Selzentry 4


&Limits

Anti-HIV Agents, Protease Inhibitors HIV DrugsAptivus 4Crixivan 2Invirase (Capsule) 3Invirase (Tablet) 4Kaletra (100mg; 25mg Tablet) 3

Kaletra (Oral Solution, 200mg; 50mg Tablet) 4

Lexiva (Suspension) 3Lexiva (Tablet) 4Norvir 3Prezista (150mg Tablet, 75mg Tablet) 3

Prezista (400mg Tablet, 600mg Tablet) 4

Reyataz (100mg Capsule) 2

Reyataz (150mg Capsule, 200mg Capsule, 300mg Capsule)

4

Viracept 4Anti-Influenza Agents Flu DrugsAmantadine HCl 1Relenza Diskhaler 3Rimantadine HCl 1Tamiflu 2Antihepatitis Agents Hepatitis DrugsBaraclude (Oral Solution) 3

Baraclude (Tablet) 4Copegus 4 PAHepsera 4Incivek 4 PAInfergen (15mcg/0.5ml Injection) 4 PA

30



&Limits

Intron-A (10mu/0.2ml Injection, 3mu/0.2ml Injection, 6000000unit/ml Injection)

3 PA

Intron-A (5mu/0.2ml Injection) 4 PA

Intron-A W/Diluent (10mu Injection) 4 PA

Peg-Intron (50mcg/0.5ml Injection) 4 PA

Peg-Intron Redipen 4 PAPegasys 4 PAPegasys Proclick (135mcg/0.5ml Injection) 4 PA

Rebetol (Oral Solution) 3 PARebetol (Capsule) 4 PARibapak (Tablet) 4 PARibasphere (Capsule, 200mg Tablet)

2 PA

Ribasphere (400mg Tablet, 600mg Tablet)

4 PA

Ribavirin 2 PATyzeka 4Victrelis 4 PAAntiherpetic Agents Herpes DrugsAcyclovir 1Acyclovir Sodium (500mg Injection)

1 B/D

Denavir 3Famciclovir 2Famvir 3Trifluridine 2Valacyclovir HCl 2


&Limits

Valtrex 2Viroptic 3Xerese 3Zovirax 3

Anxiolytics Drugs to Treat Anxiety

Anxiolytics, Other Anxiety DrugsAlprazolam 1Alprazolam ER (0.5mg Tablet Extended Release 24 Hour)

3

Alprazolam Intensol 3Alprazolam ODT 3Alprazolam XR (1mg Tablet Extended Release 24 Hour, 2mg Tablet Extended Release 24 Hour, 3mg Tablet Extended Release 24 Hour)

3

Ativan (Tablet) 3Buspirone HCl 1Chlordiazepoxide HCl 1Chlordiazepoxide/Amitriptyline

1

Diazepam (Oral Solution, Tablet)

1

Diazepam Intensol 1Estazolam 3Lorazepam (Tablet) 1Lorazepam Intensol 1Meprobamate 3 PANiravam 3

31


&Limits

Oxazepam 3Valium 3Xanax 3Xanax XR 3

Bipolar Agents Drugs to Treat Mood Disorders

Bipolar Agents Mood Disorder DrugsSymbyax 3Mood Stabilizers Mood Disorder DrugsLithium Carbonate 1Lithium Carbonate ER 1Lithium Citrate 1Lithobid 2

Blood Glucose Regulators Drugs to Regulate Blood Sugar

Antidiabetic Agents Diabetic DrugsAcarbose 1Actoplus Met 2Actoplus Met XR 3Actos 2Amaryl 3Avandamet 3 PAAvandaryl 3 PAAvandia 3 PABydureon 3Byetta 2Chlorpropamide 3 STCycloset 3 PADiabeta 3Duetact 2Fortamet 3 STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide/Metformin HCl 1


&Limits

Glucophage 3Glucophage XR 3Glucotrol 3Glucotrol XL 3Glucovance (2.5mg; 500mg Tablet, 5mg; 500mg Tablet)

3

Glumetza (500mg Tablet Extended Release 24 Hour)

3

Glyburide 1Glyburide Micronized 1Glyburide/Metformin HCl 1Glynase 3Glyset 3Janumet 2Janumet XR 3 STJanuvia 2Jentadueto 3 STJuvisync 3 STKombiglyze XR 2Metformin HCl 1Metformin HCl ER (500mg Tablet Extended Release 24 Hour, 750mg Tablet Extended Release 24 Hour)

1

Nateglinide 2Onglyza 2Prandimet 3Prandin 3Precose 3Riomet 3Starlix 3Symlinpen 120 3 PASymlinpen 60 3 PATolazamide 1Tolbutamide 1

32



&Limits

Tradjenta 3 STVictoza 2Glycemic Agents Diabetic DrugsClinimix 4.25%/Dextrose 20%

3 B/D

Clinimix 5%/Dextrose 15% 3 B/D

Clinimix 5%/Dextrose 20% 3 B/D

Clinimix E 2.75%/Dextrose 10% 3 B/D




Clinimix E 5%/Dextrose 15% 3 B/D

Clinimix E 5%/Dextrose 25% 3 B/D

Dextrose 10%/NaCl 0.45% 2

Dextrose 10% Flex Container

2

Dextrose 10%/NaCl 0.2%

2

Dextrose 2.5%/Sodium Chloride 0.45%

2

Dextrose 5% 2Dextrose 5%/NaCl 0.2% 2Dextrose 5%/NaCl 0.225% 2


&Limits


2


2

Dextrose 5%/NaCl 0.9% 2Glucagen Hypokit 3Glucagon Emergency Kit 2

Ionosol-B/Dextrose 5% 3Ionosol-MB/Dextrose 5% 3

KCl 0.075%/D5W/NaCl 0.45%

2

KCl 0.15%/D5W/LR 2KCl 0.15%/D5W/NaCl 0.2%

2

KCl 0.15%/D5W/NaCl 0.225%

2

KCl 0.15%/D5W/NaCl 0.9%

2

KCl 0.3%/D5W/NaCl 0.45%

2

KCl 0.3%/D5W/NaCl 0.9%

2

Normosol-R in D5W 2Potassium Chloride 0.15%/D5W/NaCl 0.33%

2

Potassium Chloride 0.15%/D5W/ NaCl 0.45% Viaflex

2

Potassium Chloride 0.22%/D5W/ NaCl 0.45%

2

Proglycem 3

33


&Limits

Insulins Diabetic DrugsHumalog (Vial) 2Humalog Kwikpen 2Humulin (Vial) 2Humulin Pen 2Lantus 2Lantus Solostar 2Levemir 2Levemir Flexpen 2Novolin (Vial) 2Novolog (Vial) 2Novolog Flexpen 2

Blood Products/Modifiers/Volume Expanders Drugs to Treat Blood Disorders

Anticoagulants Blood ThinnersArgatroban (100mg/ml Injection) 4

Argatroban (125mg/125ml; 0.9% Injection)

4

Arixtra (2.5mg/0.5ml Injection) 3

Arixtra (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection)

4

Coumadin (Tablet) 2Coumadin (Injection) 3Enoxaparin Sodium (30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection)

3

Enoxaparin Sodium (100mg/ml Injection, 120mg/0.8ml Injection, 150mg/ml Injection)

4


&Limits

Fondaparinux Sodium (2.5mg/0.5ml Injection)

3

Fondaparinux Sodium (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection)

4

Fragmin (25000unit/ml Injection, 2500unit/0.2ml Injection, 5000unit/0.2ml Injection)

3

Fragmin (10000unit/ml Injection, 12500unit/0.5ml Injection, 15000unit/0.6ml Injection, 18000unt/0.72ml Injection, 7500unit/0.3ml Injection)

4

Heparin Sodium (10000unit/ml Injection, 1000unit/ml Injection, 20000unit/ml Injection, 5000unit/ml Injection)

2

Heparin Sodium/D5W (5%; 40unit/ml Injection)

2

Heparin Sodium/NaCl (100unit/ml; 0.45% Injection, 50unit/ml; 0.45% Injection)

2

Heparin Sodium/NaCl 0.9% Premix

2

Jantoven 1Lovenox (300mg/3ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection)

3

34



&Limits

Lovenox (100mg/ml Injection, 120mg/0.8ml Injection, 150mg/ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection)

4

Pradaxa 2 PAWarfarin Sodium 1Xarelto 2 PABlood Formation Modifiers Blood Formation DrugsAgrylin 3Anagrelide Hydrochloride 1Aranesp Albumin Free (100mcg/0.5ml Injection, 100mcg/ml Injection, 25mcg/0.42ml Injection, 25mcg/ml Injection, 40mcg/0.4ml Injection, 40mcg/ml Injection, 60mcg/0.3ml Injection, 60mcg/ml Injection)

3 B/D, PA

Aranesp Albumin Free (150mcg/0.3ml Injection, 200mcg/0.4ml Injection, 200mcg/ml Injection, 300mcg/0.6ml Injection, 300mcg/ml Injection, 500mcg/ml Injection)

4 B/D, PA

Epogen 3 B/D, PALeukine 4 PAMozobil 4 PANeulasta 4 PANeumega 2 PA


&Limits

Neupogen (300mcg/0.5ml Injection, 480mcg/0.8ml Injection, 480mcg/1.6ml Injection)

4 PA

Procrit (10000unit/ml Injection, 2000unit/ml Injection, 3000unit/ml Injection, 4000unit/ml Injection)

3 B/D, PA

Procrit (20000unit/ml Injection, 40000unit/ml Injection)

4 B/D, PA

Promacta 4 PABlood Products/Modifiers/Volume ExpandersCinryze 4 PACoagulants Blood Clotting DrugsCyklokapron 2Tranexamic Acid 2Platelet Modifying Agents Platelet Modifying DrugsAggrenox 2Brilinta 3 PACilostazol 1Clopidogrel 1Dipyridamole (Tablet) 1 PAEffient 3 PAPersantine 3 PAPlavix 3Pletal 3Ticlopidine HCl 2

35


&Limits

Cardiovascular Agents Drugs to Treat Heart and Circulation Conditions

Alpha-Adrenergic Agonists Blood Pressure DrugsCatapres 3Catapres-TTS 3Clonidine HCl (Tablet) 1Clonidine HCl (Patch Weekly)

2

Clorpres 3Guanfacine HCl 1Methyldopa 1Methyldopa/Hydrochlorothiazide

1

Methyldopate HCl 1Midodrine HCl 2Tenex 3Alpha-Adrenergic Blocking Agents Blood Pressure DrugsCardura XL 3Dibenzyline 3Minipress 3Prazosin HCl 1Reserpine 1Angiotensin II Receptor Antagonists Blood Pressure DrugsAtacand 3 STAtacand HCT 3 STAvalide 3Avapro 3Benicar 2Benicar HCT 2Cozaar 3Diovan 2Diovan HCT 2Edarbi 3Edarbyclor 3


&Limits

Eprosartan Mesylate 3Hyzaar 3Irbesartan 1Irbesartan/Hydrochlorothiazide

1

Losartan Potassium 1Losartan Potassium/Hydrochlorothiazide

1

Micardis 3Micardis HCT 3Teveten 3Teveten HCT 3 STAngiotensin-Converting Enzyme (ACE) Inhibitors Blood Pressure DrugsAccupril 3Accuretic 3Aceon 3Altace 3Benazepril HCl 1Benazepril HCl/Hydrochlorothiazide

1

Captopril 1Captopril/Hydrochlorothiazide

1

Enalapril Maleate 1Enalapril Maleate/Hydrochlorothiazide

1

Fosinopril Sodium 1Fosinopril Sodium/Hydrochlorothiazide

1

Lisinopril 1Lisinopril/Hydrochlorothiazide

1

Lotensin 3Lotensin HCT 3Mavik 3Moexipril HCl 2

36



&Limits

Moexipril/Hydrochlorothiazide

2

Perindopril Erbumine 1Prinivil 3Prinzide 3Quinapril HCl 1Quinapril/Hydrochlorothiazide

1

Ramipril 1Tarka 3Trandolapril 1Uniretic 3Univasc 3Vaseretic 3Vasotec 3Zestoretic 3Zestril 3Antiarrhythmics Heart Regulation DrugsAmiodarone HCl (50mg/ml Injection, Tablet)

1

Betapace (120mg Tablet, 160mg Tablet) 3

Betapace AF (80mg Tablet) 3

Cordarone 3Disopyramide Phosphate 1Flecainide Acetate 1Mexiletine HCl 1Multaq 2Norpace 3Norpace CR 3


&Limits

Pacerone (200mg Tablet) 1Pacerone (100mg Tablet, 400mg Tablet) 3

Procainamide HCl 2Propafenone HCl 1Propafenone HCl ER 2Quinidine Gluconate 3Quinidine Gluconate ER 1Quinidine Sulfate 1Quinidine Sulfate ER 1Rythmol 3Rythmol SR 3Sorine 1Sotalol HCl (Tablet) 1Sotalol HCl (Injection) 2Tikosyn 3Beta-Adrenergic Blocking Agents Blood Pressure DrugsAcebutolol HCl 1Atenolol 1Atenolol/Chlorthalidone 1Betaxolol HCl (20mg Tablet)

1

Bisoprolol Fumarate 1Bisoprolol Fumarate/Hydrochlorothiazide

1

Bystolic 2Carvedilol 1Coreg 3Coreg CR 3 STCorgard 3

37


&Limits

Corzide 3Inderal LA 3Innopran XL 3Labetalol HCl 1Levatol 3Lopressor 3Lopressor HCT 3Metoprolol Succinate ER 2Metoprolol Tartrate (Tablet) 1Metoprolol Tartrate (Injection)

2

Metoprolol/Hydrochlorothiazide

2

Nadolol 2Nadolol/Bendroflumethiazide

2

Pindolol 1Propranolol HCl 1Propranolol HCl ER 1Propranolol/Hydrochlorothiazide

1

Sectral 3Tenoretic 3Tenormin 3Timolol Maleate (Tablet) 1Toprol XL 3Trandate (100mg Tablet, 200mg Tablet) 3

Zebeta 3Ziac 3Calcium Channel Blocking Agents Blood Pressure DrugsAdalat CC 3Afeditab CR 1Amlodipine Besylate 1Amlodipine Besylate/Benazepril HCl

3


&Limits

Azor 2Caduet 3 STCalan 3Calan SR 3Cardizem 3Cardizem CD 3Cardizem LA 3Cartia XT 1Covera-HS 3Dilacor XR 3Dilt-CD (120mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

1

Dilt-XR (180mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour)

1

Diltiazem CD (120mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

1

Diltiazem HCl (100mg Injection, 50mg/10ml Injection, Tablet)

1

Diltiazem HCl ER (Capsule Extended Release 12 Hour, 180mg Capsule Extended Release 24 Hour, 360mg Capsule Extended Release 24 Hour)

1

Dynacirc CR 3Exforge 2Exforge HCT 2

38



&Limits

Felodipine ER 2Isradipine 2Lotrel 3Matzim LA 3Nicardipine HCl 1Nifediac CC (90mg Tablet Extended Release 24 Hour)

1

Nifedical XL 1Nifedipine (Capsule) 2Nifedipine ER 1Nimodipine 3Nisoldipine 2Nisoldipine ER 2Norvasc 3Procardia 3Procardia XL 3Sular 3 STTaztia XT 1Tiazac 3Tribenzor 2Twynsta 3Verapamil HCl (Tablet) 1Verapamil HCl (Injection) 2Verapamil HCl ER (Tablet Extended Release)

1

Verapamil HCl ER (Capsule Extended Release 24 Hour)

2

Verelan 3Verelan PM 3


&Limits

Cardiovascular Agents, Other Miscellaneous Cardiac DrugsAmturnide 3 STDemser 4Digoxin 1Lanoxin (0.25mg/ml Injection, Tablet) 2

Lanoxin (0.1mg/ml Injection) 3

Pentoxifylline ER 1Ranexa 2 STTekamlo 3 STTekturna 2 STTekturna HCT 2 STTrental 3Valturna 3 STDiuretics, Carbonic Anhydrase Inhibitors Cardiac DrugsAcetazolamide Sodium 2Diuretics, Loop Cardiac DrugsBumetanide 1Demadex (10mg Tablet, 20mg Tablet, 5mg Tablet)

3

Edecrin 3Furosemide 1Lasix 3Torsemide (20mg/2ml Injection, Tablet)

1

39


&Limits

Diuretics, Potassium-Sparing Cardiac DrugsAldactazide 3Aldactone 3Amiloride HCl 1Amiloride/Hydrochlorothiazide

1

Dyazide 3Dyrenium 3Eplerenone 2Inspra 3Maxzide 3Spironolactone 1Spironolactone/Hydrochlorothiazide

1

Triamterene/Hydrochlorothiazide

1

Diuretics, Thiazide Cardiac DrugsChlorothiazide 1Chlorothiazide Sodium 1Chlorthalidone (25mg Tablet, 50mg Tablet)

1

Diuril 3Diuril IV 3Hydrochlorothiazide 1Indapamide 1Methyclothiazide 1Metolazone 1Microzide 3Thalitone 3Dyslipidemics, Fibric Acid Derivatives Cholesterol Control DrugsAntara 2Fenofibrate 1Fenofibrate Micronized 1Fenoglide 3 STFibricor 3 ST


&Limits

Gemfibrozil 1Lipofen 3 STLofibra 3Lopid 3Tricor 2Trilipix 2Dyslipidemics, HMG CoA Reductase Inhibitors Cholesterol Control DrugsAdvicor 3 STAltoprev 3 STAtorvastatin Calcium 1Crestor 2Fluvastatin 3 STLescol 3 STLescol XL 3 STLipitor 3Livalo 3Lovastatin 1Mevacor 3Pravachol 3Pravastatin Sodium 1Simcor (1000mg; 40mg Tablet Extended Release 24 Hour, 500mg; 20mg Tablet Extended Release 24 Hour, 500mg; 40mg Tablet Extended Release 24 Hour, 750mg; 20mg Tablet Extended Release 24 Hour)

3 ST

Simvastatin 1Zocor 3Dyslipidemics, Other Miscellaneous Cholesterol Control DrugsCholestyramine Light (Packet)

1

Colestid (Granules, Tablet) 3

40



&Limits

Colestipol HCl (Tablet) 1Colestipol HCl (Granules) 2Lovaza 3Niaspan 2Prevalite (Powder) 1Questran (Packet) 3Vytorin 3Welchol 2Zetia 2Vasodilators, Direct-Acting Arterial Chest Pain DrugsHydralazine HCl 1Minoxidil (Tablet) 1Vasodilators, Direct-Acting Arterial/Venous Chest Pain DrugsDilatrate SR 3Isordil Titradose 3Isosorbide Dinitrate 1Isosorbide Dinitrate ER 1Isosorbide Mononitrate (20mg Tablet)

1

Isosorbide Mononitrate ER 1Minitran 1Monoket 3Nitro-Bid 3Nitroglycerin (Injection, Patch)

1

Nitrolingual Pumpspray 3Nitromist 3Nitrostat 2Rectiv 3


&Limits

Central Nervous System Agents Drugs to Treat Nerve Conditions

Attention Deficit Hyperactivity Disorder Agents, Amphetamines ADHD DrugsAdderall XR 3Amphetamine/Dextroamphetamine (Tablet)

2

Desoxyn 3Dexedrine 3Dextroamphetamine Sulfate (5mg Tablet)

1

Dextroamphetamine Sulfate (10mg Tablet)

2

Dextroamphetamine Sulfate ER

2

Methamphetamine HCl 2Vyvanse 3Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines ADHD DrugsConcerta 3Daytrana 3Dexmethylphenidate HCl 2Focalin 3Focalin XR 3Intuniv 3Kapvay 3Metadate CD 3Metadate ER 1Methylin 3Methylphenidate HCl 2

41


&Limits

Methylphenidate HCl ER (20mg Tablet Extended Release)

1

Methylphenidate HCl ER (Capsule Extended Release 24 Hour)

2

Ritalin 3Ritalin LA 3Ritalin SR 3Strattera 3 STCentral Nervous System, Other Miscellaneous Central Nervous System DrugsButalbital/Acetaminophen/Caffeine/Codeine

2

Fioricet/Codeine 3Nuedexta 2 PARilutek 2Xenazine 4 PAFibromyalgia Agents Fibromyalgia DrugsSavella 2Savella Titration Pack 2Multiple Sclerosis Agents Multiple Sclerosis DrugsAmpyra 4 PACopaxone 4 PAGilenya 4 PA

Dental And Oral Agents Drugs to Treat Mouth and Throat Conditions

Dental and Oral AgentsChlorhexidine Gluconate Oral Rinse

1

Evoxac 3 STKepivance 4Periogard 1Pilocarpine HCl (Tablet) 2Salagen 3Triamcinolone in Orabase 1


&Limits

Dermatological Agents Drugs to Treat Skin Conditions

Dermatological Agents Skin Agents8-MOP 3Acanya 3 STAczone 3Adapalene 2Aldara 3Amevive 4 PAAmmonium Lactate 1Amnesteem 2Atralin 3 PAAvita (Cream) 1 PAAvita (Gel) 2 PAAzelex 3Benzamycin 3Calcipotriene 2Carac 3Claravis 2Cleocin-T 3Clindacin PAC 3Clindagel 3Clindamycin Phosphate (External Solution, Foam, Gel, Lotion, Swab)

2

Clindamycin/Benzoyl Peroxide (5%; 1% Gel)

2

Condylox (Gel) 3Differin 3Dovonex 3Dovonex Scalp 3Efudex 3Elidel 3 STEpiduo 3 STErythromycin/Benzoyl Peroxide

1

Evoclin 3

42



&Limits

Finacea 2Fluoroplex 3Fluorouracil (Cream) 2Imiquimod 3Klaron 3LAC-Hydrin 3Laclotion 1Oxsoralen 3 PAOxsoralen Ultra 4 PAPennsaid 3Podofilox 2Protopic 3 STRegranex 4 PARetin-A 3 PARetin-A Micro 3 PASantyl 3Selenium Sulfide (Lotion) 1Solaraze 3 PASoriatane 4Sorilux 3Stelara 4 PASulfacetamide Sodium (Suspension)

2

Taclonex 3Taclonex Scalp 3Tazorac 3 PATretin-X (Kit) 3 PATretinoin (Cream, Gel) 2 PAUvadex 3Vectical 3Veltin 3 PA


&Limits

Veregen 3Voltaren (Gel) 2Ziana 3 PAZonalon 3Zyclara 2

Enzyme Replacements/Modifiers Drugs to Treat Enzyme Deficiency

Enzyme Replacements/Modifiers Enzyme Replacement/Modifying DrugsAdagen 4Aldurazyme 4Buphenyl 4Carbaglu 4Cerezyme (200unit Injection) 4 PA

Creon 2Cystadane 4Cystagon 3Elaprase 4Fabrazyme (35mg Injection) 4

Kuvan 4Lumizyme 4Myozyme 4Naglazyme 4Orfadin 4Pancreaze 3Sucraid 4Vpriv 4 PAZavesca 4Zenpep 2

43


&Limits

Gastrointestinal Agents Drugs to Treat Bowel, Intestine and Stomach Conditions

Antispasmodics, Gastrointestinal Bowel Treatment DrugsAtropine Sulfate (0.05mg/ml Injection, 0.1mg/ml Injection)

1 PA

Bentyl 3 PACantil 3Cuvposa 3Dicyclomine HCl (Capsule, Oral Solution, Tablet)

1 PA

Glycopyrrolate 2Helidac 3Methscopolamine Bromide 2Pamine 3Pamine Forte 3Propantheline Bromide 1Robinul (Tablet) 3Robinul Forte 3Gastrointestinal Agents, Other Miscellaneous Gastrointestinal DrugsActigall 3Cromolyn Sodium (Concentrate)

2

Diphenoxylate/Atropine 1 PAGastrocrom 3Halflytely Bowel Prep/Flavor Packs 2

Lomotil 3Loperamide HCl (Capsule) 1Metoclopramide HCl 1Metozolv ODT 3 STMotofen 3OsmoPrep 3


&Limits

Pylera 3Reglan 3Relistor (12mg/0.6ml Injection) 3 PA

Urso 3Ursodiol 2Histamine2 (H2) Blocking Agents Ulcer and Stomach Acid DrugsAxid (Oral Solution) 3Cimetidine 1Cimetidine HCl 1Famotidine (Injection, Suspension Reconstituted, 20mg Tablet, 40mg Tablet)

1

Famotidine Premixed 2Nizatidine 1Pepcid 3Ranitidine HCl (Capsule, 150mg/6ml Injection, Syrup, Tablet)

1

Zantac 3Irritable Bowel Syndrome Agents Bowel Treatment DrugsAmitiza 2 STLotronex 4 PALaxatives Bowel Treatment DrugsColyte-Flavor Packs (240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm Oral Solution)

3

Enulose 1Gavilyte-C 1Gavilyte-G 1Gavilyte-N/Flavor Pack 1Golytely 3Lactulose 1MoviPrep 3

44



&Limits

Nulytely/Flavor Packs 2Polyethylene Glycol 3350 (Powder)

1

Suprep Bowel Prep 3Trilyte 1Protectants Ulcer and Stomach Acid DrugsCarafate 3Cytotec 3Misoprostol (200mcg Tablet)

1

Sucralfate 1Proton Pump Inhibitors Ulcer and Stomach Acid DrugsAciphex 3 STDexilant 3Lansoprazole 3 STNexium 2Nexium I.V. 3Omeprazole (Capsule Delayed Release)

1

Omeprazole/Sodium Bicarbonate

2

Pantoprazole Sodium 1Prevacid 3 STPrevacid Solutab 3 STPrilosec (Capsule Delayed Release) 3 ST

Protonix (Injection) 3Protonix (Packet, Tablet Delayed Release) 3 ST

Vimovo 2Zegerid 3 ST


&Limits

Genitourinary Agents Drugs to Treat Bladder, Genital and Kidney Conditions

Antispasmodics, Urinary Bladder Control DrugsDetrol 3 STDetrol LA 3 STDitropan XL 3Enablex 3 STFlavoxate HCl 2Gelnique (10% Gel) 2Oxybutynin Chloride 1Oxybutynin Chloride ER 2Oxytrol 2Sanctura 3Sanctura XR 3Toviaz 2 STTrospium Chloride 2Vesicare 2Benign Prostatic Hypertrophy Agents Prostate Enlargement DrugsAlfuzosin HCl ER 2Avodart 2Cardura 3Doxazosin Mesylate 1Finasteride (Tablet) 1Flomax 3Jalyn 3 STProscar 3Rapaflo 2Tamsulosin HCl 1

45


&Limits

Terazosin HCl 1Uroxatral 3Genitourinary Agents, Other Miscellaneous Bladder, Genital, and Kidney Conditions DrugsBethanechol Chloride 1Cialis (2.5mg Tablet, 5mg Tablet) 3 PA

Elmiron 3Urecholine 3Phosphate Binders Phosphate-Removing AgentsFosrenol 4Renagel 2 STRenvela 2

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Drugs to Regulate Hormones

Glucocorticoids/Mineralocorticoids Anti-Inflammatory DrugsA-Hydrocort 2Aclovate 3Ala Scalp 3Ala-Cort 2Alclometasone Dipropionate

1

Amcinonide 1Anusol-HC (Cream) 3Augmented Betamethasone Dipropionate (Cream, Lotion, Ointment)

1

Betamethasone Dipropionate

1

Betamethasone Valerate 1Capex 3Carmol-HC 3Celestone 3


&Limits

Clobetasol Propionate (External Solution, Gel, Lotion, Ointment, Shampoo)

1

Clobetasol Propionate (Foam)

2

Clobetasol Propionate E 1Clobex 3Cloderm Pump 3Cordran 3Cordran Tape 3Cortef 3Cortifoam 3Cortisone Acetate 1Cutivate 3Depo-Medrol 3Derma-Smoothe/FS 3Dermatop 3Desonate 3Desonide 1Desowen (Cream, Lotion) 3

Desoximetasone (Cream, Gel, 0.25% Ointment)

2

Dexamethasone (Elixir, Tablet)

1

Dexamethasone Intensol 1Dexamethasone Sodium Phosphate (4mg/ml Injection)

1

Dexpak 13 Day 3Diflorasone Diacetate 1Diprolene 3Diprolene AF 3Elocon 3Flo-Pred 3Fludrocortisone Acetate 1

46



&Limits

Fluocinolone Acetonide (Cream, External Solution, Ointment)

1

Fluocinolone Acetonide Body Oil

1

Fluocinonide (External Solution, Gel, Ointment)

1

Fluocinonide-E 1Fluticasone Propionate (Cream, Lotion, Ointment)

1

Halobetasol Propionate 2Halog 3Hydrocortisone (1% Cream, 2.5% Cream, 2.5% Lotion, 1% Ointment, 2.5% Ointment, Tablet)

2

Hydrocortisone Valerate 2Kenalog 3Locoid (External Solution, Lotion, Ointment)

3

Locoid Lipocream 3Lokara 1Luxiq 3Medrol (16mg Tablet, 32mg Tablet, 4mg Tablet, 8mg Tablet)

3

Medrol Dosepak 3Methylprednisolone (Tablet)

1

Methylprednisolone Acetate (Injection)

2

Methylprednisolone Dose Pack

1


&Limits

Methylprednisolone Sodium Succinate (Injection)

2

Millipred (Oral Solution) 3Mometasone Furoate 1Olux-E 3Orapred 3Orapred ODT (15mg Tablet Dispersible, 30mg Tablet Dispersible)

3

Pandel 3Prednicarbate 1Prednisolone Sodium Phosphate (Oral Solution)

1

Prednisone 1Prednisone Intensol 1Proctocream HC 2Solu-Cortef (100mg Injection, 250mg Injection)

3

Solu-Medrol (125mg Injection, 2gm Injection, 40mg Injection, 500mg Injection)

3

Temovate 3Topicort (Cream, Gel, 0.25% Ointment) 3

Triamcinolone Acetonide (Cream, Lotion, Ointment)

1

Triderm 1U-Cort 1Ultravate 3

47


&Limits

Vanos 3Verdeso 3Veripred 20 3Westcort 3

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormone Replacement/Modifying DrugsChorionic Gonadotropin 2 PADDAVP (Nasal Solution, Tablet) 3

DDAVP (Injection) 4 STDesmopressin Acetate 2Egrifta 4 PAGenotropin 4 PAGenotropin Miniquick (0.2mg Injection) 3 PA

Genotropin Miniquick (0.4mg Injection, 0.6mg Injection, 0.8mg Injection, 1.2mg Injection, 1.4mg Injection, 1.6mg Injection, 1.8mg Injection, 1mg Injection, 2mg Injection)

4 PA

Humatrope 4 PAIncrelex 4 PANorditropin Flexpro 4 PANorditropin Nordiflex Pen 4 PA

Nutropin 4 PANutropin AQ 4 PAOmnitrope (10mg/1.5ml Injection, 5mg/1.5ml Injection)

3 PA


&Limits

Omnitrope (5.8mg Injection) 4 PA

Pregnyl W/Diluent Benzyl Alcohol/NaCl

2 PA

Saizen 4 PASerostim 4 PAStimate 3Tev-Tropin 3 PAZorbtive 4 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Drugs to Regulate Hormones

Anabolic Steroids Hormone Replacement/Modifying DrugsOxandrolone (2.5mg Tablet)

2 PA

Oxandrolone (10mg Tablet) 4 PAAndrogens Hormone Replacement/Modifying DrugsAndrogel (50mg/5gm Gel) 2

Androgel Pump (1.62% Gel) 2

Androxy 2Axiron 3 PADanazol 2Delatestryl 3Depo-Testosterone 3Fortesta 3 PAMethitest 3Striant 3 PATestim 3 PATestosterone Cypionate 2Testosterone Enanthate 2Testred 3

48



&Limits

Estrogens Hormone Replacement/Modifying DrugsActivella 3Alora 3Amethia 1Amethyst 1Angeliq (0.5mg; 1mg Tablet) 3

Apri 1Aranelle 1Aviane 1Balziva 1Beyaz 3Brevicon 3Briellyn 1Cenestin 3Climara 3Climara Pro 3Combipatch 3Cryselle 1Cyclafem 1/35 1Cyclafem 7/7/7 1Cyclessa 3Delestrogen 3Depo-Estradiol 3Desogen 3Divigel (1mg/gm Gel) 3Elestrin 3Emoquette 1Enjuvia 2Enpresse 1


&Limits

Estrace 3Estradiol 1Estradiol Valerate 2Estradiol/Norethindrone Acetate (1mg; 0.5mg Tablet)

1

Estring 3Estropipate 1Estrostep Fe 3Evamist 3Femcon Fe 3Femhrt 1/5 3Femhrt Low Dose 3Femring 3Femtrace 3Gianvi 1Introvale 1Jinteli 1Junel 1Junel Fe 1Kariva 1Kelnor 1Leena 1Lessina 1Levora 1Lo Loestrin Fe 3Lo/Ovral 3Loestrin Fe (20mcg; 75mg; 1mg Tablet) 3

LoSeasonique 3Low-Ogestrel 1

49


&Limits

Lutera 1Lybrel 3Marlissa 1Menostar 3Microgestin 1Microgestin Fe 1Modicon 3Mononessa 1Necon 1Nordette 3Norinyl (35mcg; 1mg Tablet) 3

Nortrel 1Nuvaring 2Ocella 1Ogestrel 1Orsythia 1Ortho Evra 3Ortho Tri-Cyclen 3Ortho Tri-Cyclen Lo 3Ortho-Cept 3Ortho-Cyclen 3Ortho-Novum 7/7/7 3Ovcon-35 3Ovcon-50 28 3Portia 1Prefest 3Premarin (Cream, Tablet) 2

Premarin (Injection) 3Premphase 2Prempro 2Previfem 1Quasense 1Reclipsen 1Safyral 3


&Limits

Seasonale 3Seasonique 3Sprintec 1Sronyx 1Tri-Legest Fe 1Tri-Norinyl 3Tri-Previfem 1Tri-Sprintec 1Trinessa 1Trivora 1Vagifem 3Velivet 1Vestura 1Vivelle-Dot 2Yasmin 3Yaz 3Zeosa 1Zovia 1Progesterone Hormone Replacement/Modifying DrugsElla 3Progestins Hormone Replacement/Modifying DrugsAygestin 3Camila 1Crinone 3Depo-Provera 3Depo-SubQ Provera 104 3Endometrin 3Errin 1Jolivette 1Medroxyprogesterone Acetate

1

Megace ES 3Megace Oral 3Megestrol Acetate 1

50



&Limits

Next Choice 1Nor-QD 3Nora-BE 1Norethindrone Acetate 1Ortho Micronor 3Progesterone (Capsule) 1Prometrium 3Provera 3Selective Estrogen Receptor Modifying Agents Hormone Replacement/Modifying DrugsEvista 2

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Drugs to Replace Thyroid Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Thyroid Replacement DrugsCytomel 3Levothroid 2Levothyroxine Sodium (Tablet)

1

Levoxyl 2Liothyronine Sodium 1Synthroid 2Tirosint 3


&Limits

Unithroid (100mcg Tablet, 112mcg Tablet, 125mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet)

1

Hormonal Agents, Suppressant (Adrenal) Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Adrenal) Hormone SuppressantsLysodren 2

Hormonal Agents, Suppressant (Parathyroid) Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Parathyroid) Hormone SuppressantsSensipar (30mg Tablet) 2Sensipar (60mg Tablet, 90mg Tablet) 4

Hormonal Agents, Suppressant (Pituitary) Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Pituitary) Hormone SuppressantsCabergoline 2Eligard 3Firmagon (80mg Injection) 3 PA

Firmagon (120mg Injection) 4 PA

51


&Limits

Leuprolide Acetate 2Lupron Depot (3.75mg Injection) 3

Lupron Depot (22.5mg Injection, 30mg Injection, 45mg Injection, 7.5mg Injection)

4

Lupron Depot-PED (11.25mg Injection 3 Month)

3

Lupron Depot-PED (11.25mg Injection 1 Month, 15mg Injection 1 Month)

4

Octreotide Acetate (100mcg/ml Injection, 50mcg/ml Injection)

3 PA

Octreotide Acetate (1000mcg/ml Injection, 200mcg/ml Injection, 500mcg/ml Injection)

4 PA

Sandostatin 4 PASandostatin LAR Depot 4 PASomatuline Depot 4 PASomavert 4 PASynarel 4 PATrelstar Depot 4Trelstar LA 4Trelstar Mixject 4

Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Drugs to Regulate Hormones

Antiandrogens Hormone SuppressantsBicalutamide 1Casodex 3Flutamide 2Nilandron 3


&Limits

Hormonal Agents, Suppressant (Thyroid) Drugs to Suppress Thyroid Hormones

Antithyroid Agents Thyroid Suppressing DrugsMethimazole 1Propylthiouracil 1Tapazole 3

Immunological Agents Drugs that Stimulate or Suppress the Immune System

Immune Suppressants Immune System DrugsAzasan 3Azathioprine 1Azathioprine Sodium 2Benlysta (120mg Injection) 4 PA

Cellcept (Capsule) 3 B/D, PACellcept (Suspension Reconstituted, Tablet) 4 B/D, PA

Cellcept Intravenous 3 B/D, PACimzia 4 PACyclosporine 2 B/DCyclosporine Modified (100mg Capsule)

1 B/D

Cyclosporine Modified (50mg Capsule, Oral Solution)

2 B/D

Enbrel 4 PAGengraf 2 B/DHumira 4 PAHumira Starter Kit 4 PAImuran 3Kineret 4 PAMethotrexate (Tablet) 1

52



&Limits

Methotrexate Sodium (25mg/ml Injection)

1

Methotrexate Sodium (1gm Injection)

2

Mycophenolate Mofetil 2 B/D, PAMyfortic (180mg Tablet Delayed Release) 3 B/D

Myfortic (360mg Tablet Delayed Release) 4 B/D

Neoral 3 B/DNulojix 4 B/D, PAOrencia 4 PAPrograf (0.5mg Capsule, 1mg Capsule, Injection) 3 B/D, PA

Prograf (5mg Capsule) 4 B/D, PARapamune (0.5mg Tablet) 3 B/D

Rapamune (Oral Solution, 1mg Tablet, 2mg Tablet)

4 B/D

Remicade 4 PARheumatrex 3Sandimmune 3 B/DSimponi 4 PATacrolimus (0.5mg Capsule, 1mg Capsule)

2 B/D, PA

Tacrolimus (5mg Capsule) 4 B/D, PATorisel 4Trexall 3Zortress (0.25mg Tablet) 3 B/D, PAZortress (0.5mg Tablet, 0.75mg Tablet) 4 B/D, PA


&Limits

Immunizing Agents, Passive Immune System DrugsAtgam 4 B/DCarimune Nanofiltered (3gm Injection) 4 B/D, PA

Gammagard Liquid 4 B/D, PAGammaplex (10gm/200ml Injection) 4 B/D, PA

Gamunex-C (1gm/10ml Injection) 4 B/D, PA

Hizentra (1gm/5ml Injection) 4 B/D, PA

Privigen (20gm/200ml Injection) 4 B/D, PA

Thymoglobulin 4 B/DImmunomodulators Immune System DrugsActemra (200mg/10ml Injection) 4 PA

Actimmune 4Arava 3Arcalyst 4 PAAvonex 4 PABetaseron 4 PAExtavia 3 PAIlaris 4 PALeflunomide 1Rebif 4 PARebif Titration Pack 4 PARidaura 3Simulect (20mg Injection) 4 B/D

53


&Limits

Synagis (50mg/0.5ml Injection) 4

Tysabri 4 PA, LAVaccinesActHIB 2Adacel 2Boostrix 2Cervarix 3Comvax 2Daptacel 2Decavac 2Engerix-B 2 B/DGardasil 2Havrix 2Infanrix 2IPOL 2Ixiaro 2M-M-R II 2Menactra 2Menomune-A/C/Y/W-135 2

Menveo 2Pedvax HIB 2ProQuad 2Rabavert 2Recombivax HB (10mcg/ml Injection, 40mcg/ml Injection)

2 B/D

RotaTeq 2Tetanus/Diphtheria Toxoids-Adsorbed Adult

2

Twinrix 2Typhim Vi 2Vaqta (25unit/0.5ml Injection) 2

Varivax 2


&Limits

YF-Vax 2Zostavax 3

Inflammatory Bowel Disease Agents Drugs to Treat Inflammatory Bowel Disease

Aminosalicylates Inflammatory Bowel Disease DrugsApriso 2Asacol 3Asacol HD 3 PABalsalazide Disodium 2Canasa 2Colazal 3Dipentum 3Lialda 3Mesalamine (Kit) 2Pentasa 3sfRowasa 4Glucocorticoids Inflammatory Bowel Disease DrugsBudesonide (Capsule Extended Release 24 Hour)

2

Colocort 2Entocort EC 3Hydrocortisone (Enema) 2Millipred (Tablet) 3Sulfonamides Inflammatory Bowel Disease DrugsAzulfidine 3Azulfidine EN-Tabs 3Sulfasalazine (Tablet) 1Sulfazine EC 1

54



&Limits

Metabolic Bone Disease Agents Drugs to Treat Bone Conditions

Metabolic Bone Disease Agents Osteoporosis (Bone Loss) DrugsActonel 3Alendronate Sodium 1Atelvia 3Boniva (Tablet) 3Boniva (Injection) 3 B/DCalcijex 3 B/DCalcitonin-Salmon 2Calcitriol (Capsule, Injection, Oral Solution)

1 B/D

Didronel 3Etidronate Disodium 2Forteo 3 B/D, PAFortical 2Fosamax (70mg Tablet) 3Fosamax Plus D 3 STHectorol 2 B/DIbandronate Sodium 2Miacalcin (Nasal Solution) 3

Miacalcin (Injection) 3 B/D, PAPamidronate Disodium (30mg/10ml Injection, 90mg/10ml Injection)

2 B/D

Pamidronate Disodium (6mg/ml Injection)

3 B/D

Prolia 3 PAReclast 3 PA


&Limits

Rocaltrol 3 B/DSkelid 3Xgeva 4 PAZemplar 2 B/DZometa 4

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAlcohol Preps (Pad) 1Botox (100unit Injection) 3 PACarnitor 3 B/DFerriprox 4 PAFirazyr 4 PAFomepizole 4Gauze Pads 2Insulin Syringes, Needles 2

Intralipid (1.7%; 30% Injection) 3 B/D

Intralipid (2.25%; 20% Injection)

3 B/D

Lactated Ringers Irrigation 2Levocarnitine 2 B/DLiposyn III (1.2%; 2.5%; 10% Injection, 1.2%; 2.5%; 20% Injection)

3 B/D

Methergine 2Methylergonovine Maleate (Tablet)

1

Physiolyte 3Physiosol Irrigation 3Ringers Irrigation 2

55


&Limits

Sodium Chloride 0.9% (Irrigation Solution)

1

Sterile Water Irrigation 2Xeomin (50unit Injection) 3 PA

Ophthalmic Agents Drugs to Treat Eye Conditions

Ophthalmic Agents, Other Miscellaneous Eye DrugsAK-Con 1Alcaine 3Mydriacyl 3Proparacaine HCl 1Restasis 2Tropicamide 1Ophthalmic Anti-Allergy Agents Allergy, Infection and Inflammation DrugsAlocril 3Alomide 3Azelastine HCl (Ophthalmic Solution)

2

Bepreve 3Cromolyn Sodium (Ophthalmic Solution)

1

Elestat 3Emadine 3Epinastine HCl 2Lastacaft 2Optivar 3 STPataday 3Patanol 2Ophthalmic Anti-Inflammatories Allergy, Infection and Inflammation DrugsAcular 2Acular LS 2Acuvail 3 PAAlrex 2


&Limits

Blephamide 2Blephamide S.O.P. 2Bromday 3Bromfenac 2Dexamethasone Sodium Phosphate (Ophthalmic Solution)

1

Diclofenac Sodium (Ophthalmic Solution)

1

Durezol 2Flarex 2Flurbiprofen Sodium 1FML 2FML Forte 2FML Liquifilm 3Ketorolac Tromethamine (Ophthalmic Solution)

2

Lotemax 2Maxidex 3Maxitrol 3Neomycin/Polymyxin/Bacitracin/Hydrocortisone

1

Neomycin/Polymyxin/Dexamethasone

1

Neomycin/Polymyxin/Hydrocortisone (Ophthalmic Suspension)

1

Nevanac 2Ocufen 3Omnipred 3Pred Forte 3Pred Mild 2Pred-G 2Pred-G S.O.P. 2Prednisolone Acetate 1

56



&Limits

Prednisolone Sodium Phosphate (Ophthalmic Solution)

1

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

1

Tobradex (Ointment) 2Tobradex (Suspension) 3Tobradex ST 3Tobramycin/Dexamethasone

2

Vexol 3Voltaren (Ophthalmic Solution) 3

Zylet 2Ophthalmic Antiglaucoma Agents Glaucoma DrugsAcetazolamide 1Acetazolamide ER 2Alphagan P 2Apraclonidine 2Azopt 2Betagan 3Betaxolol HCl (Ophthalmic Solution)

1

Betimol 3Betoptic-S 3Brimonidine Tartrate 1Carteolol HCl 1Combigan 2Cosopt 3Diamox 3


&Limits

Dorzolamide HCl 1Dorzolamide HCl/Timolol Maleate

1

Iopidine 3Isopto Carpine 3Istalol 3Levobunolol HCl (0.5% Ophthalmic Solution)

1

Methazolamide 1Metipranolol 1Optipranolol 3Phospholine Iodide 2Pilopine HS 2Timolol Maleate (Gel Forming Solution, Ophthalmic Solution)

1

Timoptic Ocudose 3Timoptic-XE 3Trusopt 3Ophthalmic Prostaglandin and Prostamide Analogs Glaucoma DrugsLatanoprost 1Lumigan 2Travatan Z 2Xalatan 3 STZioptan 3 ST

Otic Agents Drugs to Treat Ear Conditions

Otic Agents Ear DrugsAcetasol HC 2Acetic Acid 1

57


&Limits

Coly-Mycin S 3Cortisporin (Solution, Suspensi

2013 united healthcare formulary.pdf

Documents

drug tiers

drug listthere

complete drug listthis

prescription drug costs

plan materials

plan year

bythis plan

plan rules