2018 comprehensive formulary - kaiser permanente · 2017-09-01 · 2018 formulary that was covered...

Y0043_N00005930_Final03 approved HPMS Approved Formulary File Submission 00017154, Version 8

Kaiser Permanente

2018 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 09/01/17. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniormedrx.

Kaiser Permanente Regions

CALIFORNIA REGIONS Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)

Member Service Contact Center 1-800-443-0815 TTY 711

COLORADO REGION Kaiser Permanente Senior Advantage (HMO)

Member Services 1-800-476-2167 TTY 711

GEORGIA REGION Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP)


HAWAII REGION Kaiser Permanente Senior Advantage (HMO)


MID-ATLANTIC STATES REGION (District of Columbia, Maryland, and Virginia) Kaiser Permanente Medicare Plus (Cost) and Kaiser Permanente Medicare Advantage (HMO)


NORTHWEST REGION Kaiser Permanente Senior Advantage (HMO)

Membership Services 1-877-221-8221 TTY 711

http://kp.org/seniormedrx

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.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Kaiser Permanente. When it refers to “plan” or “our plan,” it means Kaiser Permanente Senior Advantage, Kaiser Permanente Medicare Advantage, or Kaiser Permanente Medicare Plus, depending upon the region in which you are enrolled.

This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 2018. For an updated formulary, please visit our website at kp.org/seniormedrx or call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change on January 1 of each year, and for group members, at other times in accord with your group’s contract with us.

In California, Maryland and the District of Columbia, Kaiser Permanente is an HMO plan and a Cost plan with a Medicare contract. In Hawaii, Oregon, Washington, Colorado, and Georgia, Kaiser Permanente is an HMO plan with a Medicare contract. In Virginia, Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

This document is available for free in Spanish and Chinese. Please call the Member Services number listed on the front and back covers.

Este documento está disponible de forma gratuita en español y chino. Por favor llame al número de Servicios a los Miembros que aparece en la portada y la contraportada.

本文件有西班牙文版和中文版可供免費索取。請致電封面和封底所列的會員服務電話號碼。


Kaiser Permanente 2018 Comprehensive Formulary • 1

What is the Kaiser Permanente Formulary? A formulary is a list of covered drugs selected by Kaiser Permanente 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. Our plan will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a Kaiser Permanente network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Our plan covers all drugs that can be included in a Medicare Part D prescription drug plan according to Medicare requirements. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. Can the formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 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, or add prior authorization, 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 (FDA) 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 January 1, 2018. To get updated information about the drugs covered by our plan, please call us. Contact information for your Kaiser Permanente Region appears on the front and back cover pages. In the event of a midyear non-maintenance formulary change, we will provide details in the Medicare Part D Explanation of Benefits that we send you or Provision of Notice posted at kp.org/seniormedrx. How do I use the formulary? There are two ways to find your drug within the formulary: Medical condition The formulary begins on page 6. 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


2 • Kaiser Permanente 2018 Comprehensive Formulary

under the category, “Cardiovascular Drugs”. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. 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 62. The index provides an alphabetical list of all of the drugs included in this document. Preferred generic and generic drugs, preferred brand-name and nonpreferred brand-name drugs, specialty-tier drugs, and injectable vaccines 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? Our plan 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 and specialty-tier drugs. Cost sharing for preferred generic drugs may be different than for generic drugs. Please see your Evidence of Coverage for more information. What are brand-name drugs? Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand-name drug expires, other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same

active ingredient(s) at lower prices. Cost sharing for preferred brand-name drugs may be different than for nonpreferred brand-name drugs. Please see your Evidence of Coverage for more information. What are specialty-tier drugs? Specialty-tier drugs are very high-cost drugs approved by the FDA that are on our formulary. What are injectable Part D vaccines? Part D vaccines are certain injectable vaccines that are covered under Medicare Part D (for example, Zostavax for shingles, Adacel for Diphtheria, Tetanus, and Pertussis, which are approved by the FDA). 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: Our plan may require you or your network provider to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, we may not cover the drug.


Note: If your prescription has more than one refill remaining, you can only get one refill at a time, unless authorized because you will be away from our service area for an extended period of time. For certain drugs, we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive. Also, if there is a shortage in the marketplace, we may fill your prescription for a limited quantity. You can find out if your drug has any additional requirements or limits by looking on the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Kaiser Permanente formulary?” on this page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included on this formulary (list of covered drugs), you should first check our Kaiser Permanente 2018 Comprehensive Formulary at kp.org/seniormedrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered.

Our plan covers all Medicare Part D drugs. In the rare case that your Medicare Part D prescription drug is not on our Kaiser Permanente 2018 Comprehensive Formulary, you have two options:

• You can ask your network provider to prescribe a similar drug that is included on our formulary.

• You can ask us to make an exception and cover your drug. See the next section for information about how to request an exception.

How do I request an exception to the Kaiser Permanente Formulary? You can ask us 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 a drug even if it may not be on our Kaiser Permanente 2018 Comprehensive Formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a Part D formulary drug at a lower cost-sharing level if this drug is not on the specialty tier (Tier 5), subject to our tiering exception process. If approved this would lower the amount you may pay for your drug.



• You can ask us to waive coverage restrictions or limits on your drug. For example, if your drug requires prior authorization, you can ask us to waive the prior authorization requirement for your Part D drug.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition 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 request a formulary, tiering or utilization restriction exception you should submit a statement from your network provider supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your network provider 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 a supporting statement from your network provider or other prescriber. Please note: You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS). You cannot get an exception for drugs that are excluded under Medicare Part D. Please refer to your Evidence of Coverage for more information about requesting exceptions, including the appeals process.

What do I do before I can talk to my network provider about changing my drugs or requesting an exception? In rare cases, you might be taking Medicare Part D 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 network provider 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 network provider 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 Part D drugs that may not be on our formulary or if your ability to get your drugs is limited, we 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, we may cover an additional refill, as medically necessary. After you have used these refills, we will not pay for these drugs. 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 up to a 98-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 written for fewer days) while you pursue a formulary exception. As a current member of our plan, if you have a covered inpatient stay in the hospital or in a skilled nursing facility, the drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug coverage. When you are discharged home or to a custodial level of care at a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy may be covered under your Medicare Part D coverage. Since your drug coverage is different depending on the setting where you obtain the drug, it is possible that a drug you were taking that was covered under your medical benefit might not be covered by Medicare Part D (for example, over-the-counter drugs, or cough medicine). If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage).

For more information For more detailed information about your Kaiser Permanente prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. 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 users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

http://www.medicare.gov/


Kaiser Permanente’s Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the index that begins on page 62. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., ALBENZA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The second column, “Drug Tier,” will indicate what tier number the drug is in: Tier 1 – Preferred generic drugs Tier 2 – Generic drugs Tier 3 – Preferred brand-name drugs Tier 4 – Nonpreferred brand-name drugs Tier 5 – Specialty-tier drugs Tier 6 – Injectable Part D vaccines Generally, the cost sharing you will pay for your drugs depends on your coverage stage, the type of network pharmacy where you purchase your drugs, and your drug’s cost-sharing tier on our formulary. Please refer to your Evidence of Coverage for the details about your Medicare Part D prescription drug coverage, including your cost-sharing amounts. Note: If your coverage is through an employer-sponsored group plan (including a union or trust fund), you may have different drug benefits and cost sharing, and you may have coverage for other drugs that are not covered by Medicare Part D (non-Part D drugs). The amount you pay for non-Part D drugs does not count toward your total out-of-pocket expenditures, and if you are receiving Extra Help to pay for your Medicare Part D prescription drugs, you will not receive any Extra Help to pay for non-Part D drugs. Please check with your group benefits administrator or see your Evidence of Coverage. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region.


MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/refill or by phone or mobile app, which may lower your costs for a three-month supply. Please contact us 10 days before your refills run out. Generally, you should receive them within 10 days. If not, please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance. Additional drugs may be available for mail order. Not all drugs can be mailed; restrictions and limitations apply. For more information, please visit kp.org/seniormedrx or call the appropriate regional phone number below. Region

Mail-Order Contact Numbers (TTY 711)

California

Kaiser Permanente Mail Order Pharmacy Northern CA – 1-888-218-6245 Monday through Friday, 8 a.m. to 6 p.m. Southern CA – 1-866-206-2983 Monday through Friday, 7 a.m. to 7 p.m.

Colorado

Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday, 8 a.m. to 6 p.m.

Georgia

Kaiser Permanente Refill Pharmacy 770-434-2008 or toll free 1-888-662-4579 Seven days a week, 24 hours

Hawaii

Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday, 8:30 a.m. to 5 p.m.

Mid-Atlantic States

Kaiser Permanente Mid-Atlantic Automated Refill Center 703-466-4900 or toll-free 1-800-733-6345 Monday through Friday, 7 a.m. to 6 p.m., Saturday, 8:30 a.m. to 4 p.m.

Northwest

Kaiser Permanente Mail Order Pharmacy 1-800-548-9809 Monday through Friday, 8 a.m. to 4:30 p.m.

NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste.

PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.

http://kp.org/refillhttp://kp.org/seniormedrx

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 8 • Kaiser Permanente 2018 Comprehensive Formulary

Drug Name Drug Tier Requirements/

Limits ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA 3 BILTRICIDE 3 ivermectin 2 mebendazole 2 STROMECTOL 4 ANTIBACTERIALS amikacin sulfate soln 500 mg/2ml 2 HI

amoxicillin 2 amoxicillin & pot clavulanate 2

ampicillin 2 ampicillin sodium solr 1 gm 2 HI

ampicillin sodium solr 10 gm 2 HI

ampicillin sodium solr 125 mg 2 HI

ampicillin-sulbactam sodium solr 1.5 (1-0.5) gm

2 HI

ampicillin-sulbactam sodium solr 15 (10-5) gm 2 HI

ampicillin-sulbactam sodium solr 3 (2-1) gm 2 HI

AUGMENTIN 3 AVELOX 4 AVELOX SOLN 400 MG/250ML 3 HI

AVYCAZ SOLR 2.5 (2-0.5) GM 4 HI

AZACTAM IN DEXTROSE SOLN 1 GM

3 HI

AZACTAM IN DEXTROSE SOLN 2 GM

3 HI

azithromycin 2 MO AZITHROMYCIN PACK 1 GM 3 MO

azithromycin solr 500 mg 2 HI aztreonam solr 1 gm 2 HI AZULFIDINE 4


Limits AZULFIDINE EN-TABS 4 bacitracin 2 BACTOCILL IN DEXTROSE SOLN 1 GM/50ML

3 HI

BACTOCILL IN DEXTROSE SOLN 2 GM/50ML

3 HI

BACTRIM 4 MO BACTRIM DS 4 MO BETHKIS 5 PA BICILLIN C-R 4 BICILLIN C-R 900/300 4 BICILLIN L-A 3 CAYSTON 5 LD,NDS cefaclor 2 cefaclor monohydrate 2 cefadroxil 2 cefazolin sodium solr 1 gm 2 HI

cefazolin sodium solr 10 gm 2 HI

cefazolin sodium solr 500 mg 2 HI

cefdinir 2 cefepime hcl solr 1 gm 2 HI cefepime hcl solr 2 gm 2 HI cefixime 2 cefotaxime sodium solr 1 gm 2 HI

cefotaxime sodium solr 2 gm 2 HI

cefotaxime sodium solr 500 mg 2 HI

cefotetan disodium solr 1 gm 2 HI

cefotetan disodium solr 2 gm 2 HI

cefoxitin sodium solr 1 gm 2 HI



You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.



Limits CEFOXITIN SODIUM-DEXTROSE SOLR 1-4 GM-%

3 HI

CEFOXITIN SODIUM-DEXTROSE SOLR 2-2.2 GM-%

3 HI

cefpodoxime proxetil 2 cefprozil 2 CEFTAZIDIME AND DEXTROSE SOLR 1 GM/50ML

3 HI

CEFTAZIDIME AND DEXTROSE SOLR 2 GM/50ML

3 HI

ceftazidime solr 1 gm 2 HI ceftazidime solr 2 gm 2 HI ceftazidime solr 6 gm 2 HI CEFTIN 3 ceftriaxone sodium solr 1 gm 2 HI

ceftriaxone sodium solr 10 gm 2 HI

ceftriaxone sodium solr 2 gm 2 HI

ceftriaxone sodium solr 250 mg 2 HI

ceftriaxone sodium solr 500 mg 2 HI

cefuroxime axetil 2 cefuroxime sodium solr 1.5 gm 2 HI

cefuroxime sodium solr 7.5 gm 2 HI

cefuroxime sodium solr 750 mg 2 HI

CEFUROXIME-DEXTROSE SOLR 1.5-2.9 GM-%

3 HI

cephalexin 2 chloramphenicol sod succinate solr 1 gm 2 HI

CIPRO 4 CIPRO IN D5W SOLN 400 MG/200ML 4 HI

ciprofloxacin 2 ciprofloxacin hcl 2


Limits ciprofloxacin in d5w soln 200 mg/100ml 2 HI

ciprofloxacin soln 400 mg/40ml 2 HI

ciprofloxacin-ciprofloxacin hcl 2

clarithromycin 2 CLEOCIN 4 CLEOCIN IN D5W SOLN 300 MG/50ML 3 HI

CLEOCIN IN D5W SOLN 600 MG/50ML 3 HI

CLEOCIN IN D5W SOLN 900 MG/50ML 3 HI

CLEOCIN PHOSPHATE SOLN 900 MG/6ML 4 HI

clindamycin hcl 2 clindamycin palmitate hydrochloride 2

clindamycin phosphate in d5w soln 300 mg/50ml 2 HI



clindamycin phosphate soln 300 mg/2ml 2 HI



colistimethate sodium solr 150 mg 2 HI

CUBICIN SOLR 500 MG 5 HI DALVANCE SOLR 500 MG 5 HI

daptomycin solr 500 mg 2 HI demeclocycline hcl 2 dicloxacillin sodium 2 DIFICID 5 NDS DORIBAX SOLR 500 MG 4 HI

DORYX 4 MO DORYX MPC 4 MO doxy 100 solr 100 mg 2 HI



Limits doxycycline (monohydrate) 2 MO

doxycycline hyclate 2 MO E.E.S. GRANULES 4 ERYPED 200 4 ERYPED 400 4 erythrocin lactobionate solr 500 mg 2 HI

erythromycin base 2 MO erythromycin ethylsuccinate 2

erythromycin stearate 2 FORTAZ SOLR 1 GM 3 HI FORTAZ SOLR 2 GM 3 HI FORTAZ SOLR 6 GM 4 HI gentamicin in saline soln 0.8-0.9 mg/ml-% 2 HI

gentamicin in saline soln 1-0.9 mg/ml-% 2 HI

gentamicin in saline soln 1.2-0.9 mg/ml-% 2 HI

gentamicin in saline soln 1.6-0.9 mg/ml-% 2 HI

gentamicin sulfate soln 10 mg/ml 2 HI

gentamicin sulfate soln 40 mg/ml 2 HI

imipenem-cilastatin solr 250 mg 2 HI

imipenem-cilastatin solr 500 mg 2 HI

INVANZ SOLR 1 GM 3 HI KITABIS PAK 5 PA LEVAQUIN 4 levofloxacin 2 levofloxacin in d5w soln 500 mg/100ml 2 HI

levofloxacin in d5w soln 750 mg/150ml 2 HI

levofloxacin soln 25 mg/ml 2 HI

LINCOCIN SOLN 300 MG/ML 4 HI

lincomycin hcl soln 300 mg/ml 2 HI

linezolid 2 NDS


Limits LINEZOLID IN SODIUM CHLORIDE SOLN 600-0.9 MG/300ML-%

4 HI

linezolid soln 600 mg/300ml 2 HI

MAXIPIME SOLR 1 GM 4 HI MAXIPIME SOLR 2 GM 4 HI meropenem solr 500 mg 2 HI MERREM SOLR 500 MG 4 HI

MINOCIN 4 MO minocycline hcl 2 MO moxifloxacin hcl 2 MOXIFLOXACIN HCL SOLN 400 MG/250ML 4 HI

NAFCILLIN SODIUM IN DEXTROSE SOLN 1 GM/50ML

3 HI

NAFCILLIN SODIUM IN DEXTROSE SOLN 2 GM/100ML

3 HI

nafcillin sodium solr 1 gm 2 HI

nafcillin sodium solr 10 gm 2 HI

neomycin sulfate 2 ofloxacin 2 ORBACTIV SOLR 400 MG 5 HI

oxacillin sodium solr 10 gm 2 HI

oxacillin sodium solr 2 gm 2 HI

PCE 4 PENICILLIN G POT IN DEXTROSE SOLN 20000 UNIT/ML

3 HI

PENICILLIN G POT IN DEXTROSE SOLN 40000 UNIT/ML

3 HI

PENICILLIN G POT IN DEXTROSE SOLN 60000 UNIT/ML

3 HI

penicillin g potassium solr 5000000 unit 2 HI

penicillin g procaine 2




Limits penicillin g sodium solr 5000000 unit 2 HI

penicillin v potassium 2 piperacillin sod-tazobactam so solr 3.375 (3-0.375) gm

2 HI

piperacillin sod-tazobactam so solr 4.5 (4-0.5) gm

2 HI

piperacillin sod-tazobactam so solr 40.5 (36-4.5) gm

2 HI

polymyxin b sulfate solr 500000 unit 2 HI

PRIMAXIN IV SOLR 250-250 MG 4 HI

PRIMAXIN IV SOLR 500-500 MG 4 HI

SIVEXTRO 5 NDS SIVEXTRO SOLR 200 MG 5 HI

SOLODYN 4 MO streptomycin sulfate 2 sulfadiazine 2 sulfamethoxazole-trimethoprim 2 MO

sulfamethoxazole-trimethoprim soln 400-80 mg/5ml

2 HI

sulfasalazine 2 SUPRAX 4 SYNERCID SOLR 150-350 MG 3 HI

tazicef solr 1 gm 2 HI tazicef solr 2 gm 2 HI tazicef solr 6 gm 2 HI TEFLARO SOLR 400 MG 4 HI

TEFLARO SOLR 600 MG 4 HI

tetracycline hcl 2 MO TIGECYCLINE SOLR 50 MG 4 HI

TOBI 5 PA TOBI PODHALER 5 tobramycin 2 PA


Limits tobramycin sulfate soln 10 mg/ml 2 HI

tobramycin sulfate soln 80 mg/2ml 2 HI

TYGACIL SOLR 50 MG 4 HI UNASYN SOLR 15 (10-5) GM 4 HI

UNASYN SOLR 3 (2-1) GM 4 HI

VANCOCIN HCL 5 NDS vancomycin hcl 2 VANCOMYCIN HCL IN DEXTROSE SOLN 1-5 GM/200ML-%

3 HI

VANCOMYCIN HCL IN DEXTROSE SOLN 500-5 MG/100ML-%

3 HI

vancomycin hcl solr 10 gm 2 HI

vancomycin hcl solr 1000 mg 2 HI

vancomycin hcl solr 500 mg 2 HI

VIBRAMYCIN 4 MO XIFAXAN 4 NDS ZERBAXA SOLR 1.5 (1-0.5) GM 4 HI

ZINACEF IN STERILE WATER SOLN 1.5 GM 3 HI

ZINACEF SOLR 1.5 GM 4 HI ZINACEF SOLR 7.5 GM 4 HI ZINACEF SOLR 750 MG 4 HI ZITHROMAX PACK 1 GM 4 MO

ZITHROMAX SOLR 500 MG 4 HI

ZITHROMAX SUSR 100 MG/5ML 4 MO

ZITHROMAX SUSR 200 MG/5ML 4 MO

ZITHROMAX TABS 250 MG 4 MO





Limits ZITHROMAX TRI-PAK TABS 500 MG 4 MO

ZITHROMAX Z-PAK TABS 250 MG 4 MO

ZMAX SUSR 2 GM 4 MO ZOSYN SOLN 2-0.25 GM/50ML 4 HI

ZOSYN SOLN 3-0.375 GM/50ML 4 HI

ZOSYN SOLR 40.5 (36-4.5) GM 4 HI

ZYVOX 5 NDS ZYVOX SOLN 200 MG/100ML 5 HI

ZYVOX SOLN 600 MG/300ML 5 HI

ANTIFUNGALS ABELCET SUSP 5 MG/ML 4 HI

AMBISOME SUSR 50 MG 5 HI

amphotericin b solr 50 mg 2 HI

ANCOBON 5 NDS CANCIDAS SOLR 50 MG 5 HI

CANCIDAS SOLR 70 MG 5 HI

CRESEMBA 5 NDS CRESEMBA SOLR 372 MG 5 HI

DIFLUCAN 4 ERAXIS SOLR 100 MG 4 HI ERAXIS SOLR 50 MG 4 HI fluconazole 2 fluconazole in sodium chloride soln 200-0.9 mg/100ml-%

2 HI

fluconazole in sodium chloride soln 400-0.9 mg/200ml-%

2 HI

FLUCYTOSINE 5 NDS GRIS-PEG 4 griseofulvin microsize 2 griseofulvin ultramicrosize 2


Limits itraconazole 2 ketoconazole 2 LAMISIL 4 MYCAMINE SOLR 100 MG 4 HI

MYCAMINE SOLR 50 MG 4 HI

NOXAFIL 5 NDS nystatin 2 nystatin (mouth-throat) 2 ONMEL TABS 200 MG 4 SPORANOX CAPS 100 MG 4

SPORANOX SOLN 10 MG/ML 3

terbinafine hcl 2 VFEND IV SOLR 200 MG 4 HI

VFEND SUSR 40 MG/ML 5 NDS

VFEND TABS 200 MG 5 NDS VFEND TABS 50 MG 5 NDS voriconazole 2 voriconazole solr 200 mg 2 HI ANTIMYCOBACTERIALS aminosalicylic acid 2 MO CAPASTAT SULFATE SOLR 1 GM 3 HI

dapsone 2 MO ethambutol hcl 2 MO isoniazid 2 MO isoniazid & rifampin 2 MO MYAMBUTOL 4 MO MYCOBUTIN 4 MO PRIFTIN 4 MO pyrazinamide 2 MO rifabutin 2 MO RIFADIN 4 MO rifampin 2 MO rifampin solr 600 mg 2 HI RIFATER 4 MO SIRTURO 5 NDS TRECATOR 4 MO ANTIPROTOZOALS ALINIA 4




Limits atovaquone 2 NDS atovaquone-proguanil hcl 2

chloroquine phosphate 2 COARTEM 3 DARAPRIM 3 FLAGYL 4 hydroxychloroquine sulfate 2 MO

IMPAVIDO 5 NDS MALARONE 4 mefloquine hcl 2 MEPRON 5 NDS METRO SOLN 500-0.74 MG/100ML-% 3 HI

metronidazole 2 metronidazole in nacl soln 500-0.79 mg/100ml-%

2 HI

NEBUPENT SOLR 300 MG 3 PA

paromomycin sulfate 2 PENTAM SOLR 300 MG 4 PLAQUENIL 4 MO primaquine phosphate 2 QUALAQUIN 4 NDS quinine sulfate 2 NDS TINDAMAX 4 tinidazole 2 ANTIVIRALS abacavir sulfate 2 MO abacavir sulfate-lamivudine 2 MO

abacavir sulfate-lamivudine-zidovudine 2 MO

acyclovir 2 MO acyclovir sodium soln 50 mg/ml 2 HI

adefovir dipivoxil 2 NDS APTIVUS 3 MO ATRIPLA 3 MO BARACLUDE SOLN 0.05 MG/ML 3 MO

BARACLUDE TABS 0.5 MG 5


Limits BARACLUDE TABS 1 MG 5

cidofovir soln 75 mg/ml 2 HI COMBIVIR 4 MO COMPLERA 3 MO COPEGUS 4 MO CRIXIVAN 3 MO CYTOVENE SOLR 500 MG 4 HI

DAKLINZA 5 PA,NDS DESCOVY 3 MO didanosine 2 MO EDURANT 3 MO EMTRIVA 3 MO entecavir 2 MO EPCLUSA 5 PA,NDS EPIVIR HBV SOLN 5 MG/ML 3 MO

EPIVIR HBV TABS 100 MG 4 MO

EPIVIR SOLN 10 MG/ML 3 MO

EPIVIR TABS 150 MG 4 MO EPIVIR TABS 300 MG 4 MO EPZICOM 4 MO EVOTAZ 4 MO famciclovir 2 MO FLUMADINE 4 MO FUZEON 3 NDS ganciclovir sodium solr 500 mg 2 HI

GENVOYA 3 MO HARVONI 5 PA,NDS HEPSERA 5 NDS INFERGEN 5 NDS INTELENCE 3 MO INVIRASE 3 MO ISENTRESS 3 MO ISENTRESS HD 3 MO KALETRA 3 MO lamivudine 2 MO lamivudine (hbv) 2 MO lamivudine-zidovudine 2 MO LEXIVA SUSP 50 MG/ML 4 MO



Limits LEXIVA TABS 700 MG 3 MO lopinavir-ritonavir 2 MO MAVYRET 5 PA,NDS nevirapine 2 MO NORVIR 3 MO ODEFSEY 3 MO OLYSIO 5 PA,NDS oseltamivir phosphate 2 MO PEG-INTRON 5 NDS PEG-INTRON REDIPEN 5 NDS PEG-INTRON REDIPEN PAK 4 5 NDS

PEGASYS 5 NDS PEGASYS PROCLICK 5 NDS PEGINTRON 5 NDS PLEGRIDY 5 NDS PLEGRIDY STARTER PACK 5 NDS

PREZCOBIX 3 MO PREZISTA 3 MO RAPIVAB SOLN 200 MG/20ML 5 HI

REBETOL 4 MO RELENZA DISKHALER 3 MO RESCRIPTOR 3 MO RETROVIR CAPS 100 MG 4 MO

RETROVIR SOLN 10 MG/ML 3 HI

RETROVIR SYRP 50 MG/5ML 4 MO

REYATAZ 3 MO ribavirin (hepatitis c) 2 MO rimantadine hydrochloride 2 MO

SELZENTRY 3 MO SOVALDI 5 PA,NDS stavudine 2 MO STRIBILD 3 MO SUSTIVA CAPS 200 MG 3 MO SUSTIVA CAPS 50 MG 3 MO SUSTIVA TABS 600 MG 4 MO SYNAGIS 5 NDS TAMIFLU 4 MO TECHNIVIE 5 PA,NDS


Limits TIVICAY 3 MO TRIUMEQ 3 MO TRIZIVIR 4 MO TRUVADA TABS 100-150 MG 4 MO

TRUVADA TABS 133-200 MG 4 MO



TYBOST 3 MO TYZEKA 4 NDS valacyclovir hcl 2 MO VALCYTE SOLR 50 MG/ML 3 NDS

VALCYTE TABS 450 MG 5 NDS

valganciclovir hcl 2 NDS VALTREX 4 MO VEMLIDY 5 NDS VICTRELIS 5 NDS VIDEX EC CPDR 125 MG 4 MO

VIDEX EC CPDR 200 MG 4 MO



VIDEX SOLR 2 GM 3 MO VIEKIRA PAK 5 PA,NDS VIEKIRA XR 5 PA,NDS VIRACEPT 3 MO VIRAMUNE 4 MO VIRAMUNE XR 4 MO VIRAZOLE 3 MO VIREAD POWD 40 MG/GM 3 MO

VIREAD TABS 150 MG 3 MO VIREAD TABS 200 MG 4 MO VIREAD TABS 250 MG 4 MO VIREAD TABS 300 MG 4 MO VISTIDE SOLN 75 MG/ML 5 HI

VOSEVI 5 PA,NDS




Limits ZEPATIER 5 PA,NDS ZERIT 4 MO ZIAGEN SOLN 20 MG/ML 3 MO

ZIAGEN TABS 300 MG 4 MO zidovudine 2 MO ZOVIRAX 4 MO URINARY ANTI-INFECTIVES FURADANTIN 4 HIPREX 4 MACROBID 4 MACRODANTIN 4 methenamine hippurate 2 MONUROL 4 nitrofurantoin 2 nitrofurantoin macrocrystal 2

nitrofurantoin monohyd macro 2

PRIMSOL 3 MO trimethoprim 2 MO ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate 2 cetirizine hcl 2 CLARINEX 4 CLARINEX-D 12 HOUR 4 clemastine fumarate 2 cyproheptadine hcl 2 desloratadine 2 diphenhydramine hcl 2 KARBINAL ER 4 levocetirizine dihydrochloride 2

promethazine & phenylephrine 2

promethazine hcl 2 SEMPREX-D 4 XYZAL 4 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE 3 adrucil soln 500 mg/10ml 2 HI AFINITOR 5 NDS AFINITOR DISPERZ 5 NDS


Limits ALECENSA 5 NDS ALIMTA 3 ALKERAN SOLR 50 MG 4 ALUNBRIG 5 NDS anastrozole 2 ARIMIDEX 4 AROMASIN 4 ARRANON 4 ARZERRA 5 NDS AVASTIN 3 azacitidine 2 BAVENCIO 5 NDS BCG VACCINE 3 BELEODAQ 5 NDS BENDEKA SOLN 100 MG/4ML 5 NDS

BEXAROTENE 5 NDS bicalutamide 2 BICNU 3 bleomycin sulfate 2 BLINCYTO 5 NDS BOSULIF 5 NDS busulfan 2 BUSULFEX 4 CABOMETYX 5 NDS CAMPTOSAR 4 CAPRELSA 3 LD,NDS carboplatin 2 CASODEX 4 cisplatin 2 cladribine 2 clofarabine 2 CLOLAR 4 COMETRIQ (100 MG DAILY DOSE) 5 LD,NDS

COMETRIQ (140 MG DAILY DOSE) 5 LD,NDS

COMETRIQ (60 MG DAILY DOSE) 5 LD,NDS

COSMEGEN 4 COTELLIC 5 NDS CYCLOPHOSPHAMIDE 4 PA CYRAMZA 5 NDS cytarabine 2 dacarbazine 2



Limits DACOGEN 4 DARZALEX 5 NDS daunorubicin hcl 2 decitabine 2 DOCETAXEL (NON-ALCOHOL) SOLN 160 MG/8ML

5 NDS

DOCETAXEL (NON-ALCOHOL) SOLN 20 MG/ML

5 NDS

DOCETAXEL (NON-ALCOHOL) SOLN 80 MG/4ML

5 NDS

DOCETAXEL CONC 20 MG/0.5ML 3

DOCETAXEL CONC 80 MG/2ML 3

DOCETAXEL CONC 80 MG/4ML 4

DOCETAXEL SOLN 80 MG/8ML 4

DOXIL 4 doxorubicin hcl 2 doxorubicin hcl liposomal 2 DROXIA 4 ELIGARD KIT 22.5 MG 4 ELIGARD KIT 30 MG 4 ELIGARD KIT 45 MG 4 ELIGARD KIT 7.5 MG 4 ELLENCE 4 ELSPAR 3 EMCYT 3 NDS EMPLICITI 5 NDS epirubicin hcl 2 ERBITUX 3 ERIVEDGE 5 NDS ERWINAZE 4 ETOPOPHOS 4 etoposide 2 EVOMELA SOLR 50 MG 5 NDS exemestane 2 FARESTON 4 FARYDAK 5 LD,NDS FASLODEX 5 NDS FEMARA 4 FIRMAGON 4


Limits fludarabine phosphate 2 fluorouracil soln 2.5 gm/50ml 2 HI

flutamide 2 FOLOTYN 4 GAZYVA 5 NDS gemcitabine hcl 2 GEMZAR 4 GILOTRIF 5 NDS GLEEVEC 5 NDS GLEOSTINE CAPS 10 MG 3

GLEOSTINE CAPS 100 MG 3



HALAVEN 4 HERCEPTIN SOLR 150 MG 5 NDS

HERCEPTIN SOLR 440 MG 3 NDS

HEXALEN 5 NDS HYCAMTIN 4 HYDREA 4 hydroxyurea 2 IBRANCE 5 NDS ICLUSIG 5 LD,NDS IDAMYCIN PFS 4 idarubicin hcl 2 IDHIFA 5 NDS IFEX 3 ifosfamide 2 imatinib mesylate 2 NDS IMBRUVICA 5 NDS IMFINZI 5 NDS INLYTA 5 NDS INTRON A 5 NDS IRESSA 5 NDS irinotecan hcl 2 ISTODAX 3 ISTODAX (OVERFILL) 3 IXEMPRA KIT 5 NDS JAKAFI 5 NDS




Limits JEVTANA 4 KADCYLA 5 NDS KEYTRUDA 5 NDS KISQALI 200 DOSE TABS 200 MG 5 NDS

KISQALI 400 DOSE TABS 200 MG 5 NDS

KISQALI 600 DOSE TABS 200 MG 5 NDS

KISQALI FEMARA 200 DOSE TBPK 200 & 2.5 MG

5 NDS


5 NDS


5 NDS

KYPROLIS 5 NDS LARTRUVO 5 NDS LENVIMA 10 MG DAILY DOSE 5 LD,NDS

LENVIMA 14 MG DAILY DOSE 5 LD,NDS





letrozole 2 LEUKERAN 3 leuprolide acetate 2 LOMUSTINE CAPS 10 MG 3

LOMUSTINE CAPS 100 MG 3

LOMUSTINE CAPS 40 MG 3

LONSURF 5 NDS LUPANETA PACK 4 LUPRON DEPOT (1-MONTH) KIT 3.75 MG 3


Limits LUPRON DEPOT (1-MONTH) KIT 7.5 MG 3

LUPRON DEPOT (3-MONTH) KIT 11.25 MG 3

LUPRON DEPOT (3-MONTH) KIT 22.5 MG 3

LUPRON DEPOT (4-MONTH) KIT 30 MG 3

LUPRON DEPOT (6-MONTH) KIT 45 MG 3

LUPRON DEPOT-PED (1-MONTH) 3

LUPRON DEPOT-PED (3-MONTH) 3

LYNPARZA 5 NDS LYSODREN 3 NDS MARQIBO 5 NDS MATULANE 5 NDS MEGACE ORAL 4 megestrol acetate 2 MEKINIST 5 NDS melphalan hcl 2 mercaptopurine 2 methotrexate sodium 2 PA mitomycin 2 mitoxantrone hcl 2 MUSTARGEN 3 NERLYNX 5 NDS NEXAVAR 5 NDS NILANDRON 4 nilutamide 2 NINLARO 5 NDS NIPENT 4 ODOMZO 5 NDS ONCASPAR 3 ONIVYDE 5 NDS OPDIVO 5 NDS oxaliplatin 2 paclitaxel 2 PERJETA 5 NDS POMALYST 5 NDS PORTRAZZA 5 NDS PROLEUKIN 5 NDS PURIXAN 5 NDS REVLIMID 5 NDS



Limits RHEUMATREX 4 RITUXAN 3 RITUXAN HYCELA 5 RUBRACA 5 NDS RYDAPT 5 NDS SOLTAMOX 4 SPRYCEL 5 NDS STIVARGA 5 NDS SUTENT 5 NDS SYLATRON 4 SYLVANT 5 NDS SYNRIBO 5 NDS TABLOID 3 TAFINLAR 5 NDS TAGRISSO 5 NDS tamoxifen citrate 2 TARCEVA 5 NDS TARGRETIN 5 NDS TASIGNA 5 NDS TAXOTERE CONC 80 MG/4ML 4

TECENTRIQ 5 NDS TENIPOSIDE 3 TEPADINA 5 NDS THALOMID 5 NDS thiotepa 2 TICE BCG 3 topotecan hcl 2 TORISEL 3 TREANDA SOLR 100 MG 4

TRELSTAR MIXJECT 4 tretinoin (chemotherapy) 2 NDS TRISENOX 3 TYKERB 5 NDS UNITUXIN 5 NDS UVADEX 4 VALSTAR 3 VANTAS 3 VECTIBIX 4 VELCADE 4 VENCLEXTA STARTING PACK TBPK 10 & 50 & 100 MG

5 NDS


Limits VENCLEXTA TABS 10 MG 4 NDS

VENCLEXTA TABS 100 MG 5 NDS

VENCLEXTA TABS 50 MG 4 NDS

VIDAZA 4 vinblastine sulfate 2 vincristine sulfate 2 vinorelbine tartrate 2 VOTRIENT 5 NDS XALKORI 5 NDS XATMEP 5 PA,NDS XTANDI 5 NDS YERVOY 3 YONDELIS 5 NDS ZALTRAP 5 NDS ZANOSAR 3 ZEJULA 5 NDS ZELBORAF 5 NDS ZOLINZA 5 NDS ZYDELIG 5 NDS ZYKADIA 5 NDS ZYTIGA 5 NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA 4 MO atropine sulfate 2 MO ATROPINE SULFATE 4 MO ATROVENT HFA 3 MO BENTYL 4 MO BEVESPI AEROSPHERE 4 MO

CUVPOSA SOLN 1 MG/5ML 3 MO

dicyclomine hcl 2 MO glycopyrrolate 2 MO INCRUSE ELLIPTA 4 MO ipratropium bromide 1 PA,MO ipratropium bromide (nasal) 2 MO

methscopolamine bromide 2 MO

propantheline bromide 2 MO ROBINUL TABS 1 MG 4 MO




Limits ROBINUL-FORTE TABS 2 MG 4 MO

SPIRIVA HANDIHALER CAPS 18 MCG 4 MO

SPIRIVA RESPIMAT AERS 1.25 MCG/ACT 4 MO

SPIRIVA RESPIMAT AERS 2.5 MCG/ACT 3 MO

STIOLTO RESPIMAT 3 MO TUDORZA PRESSAIR 4 MO AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX 3 MO CHANTIX CONTINUING MONTH PAK 3 MO

CHANTIX STARTING MONTH PAK 3 MO

NICOTROL INHA 10 MG 3 MO NICOTROL NS SOLN 10 MG/ML 4 MO

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS ARICEPT 4 MO bethanechol chloride 2 MO cevimeline hcl 2 MO donepezil hydrochloride 2 MO EVOXAC 4 MO EXELON 4 MO galantamine hydrobromide 2 MO

GUANIDINE HCL 4 MO MESTINON SYRP 60 MG/5ML 3 MO

MESTINON TABS 60 MG 4 MO

MESTINON TBCR 180 MG 4 MO

pilocarpine hcl (oral) 2 MO pyridostigmine bromide 2 MO RAZADYNE 4 MO RAZADYNE ER 4 MO REGONOL SOLN 10 MG/2ML 3 HI,MO

rivastigmine 2 MO rivastigmine tartrate 2 MO SALAGEN 4 MO SKELETAL MUSCLE RELAXANTS


Limits AMRIX 4 PA baclofen 2 MO carisoprodol 2 PA,NDS carisoprodol w/ aspirin 2 PA,NDS carisoprodol w/ aspirin & codeine 2 PA,NDS

chlorzoxazone 2 cyclobenzaprine hcl 2 PA DANTRIUM 4 dantrolene sodium 2 GABLOFEN SOLN 10000 MCG/20ML 3 PA

GABLOFEN SOLN 20000 MCG/20ML 3 PA

GABLOFEN SOLN 40000 MCG/20ML 3 PA

GABLOFEN SOSY 50 MCG/ML 3 PA

LIORESAL SOLN 0.05 MG/ML 4 PA

LIORESAL SOLN 10 MG/20ML 4 PA



metaxalone 2 methocarbamol 2 orphenadrine citrate 2 SKELAXIN 4 SOMA 4 PA,NDS tizanidine hcl 2 ZANAFLEX 4 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl 2 MO D.H.E. 45 SOLN 1 MG/ML 5 NDS

DIBENZYLINE 5 NDS dihydroergotamine mesylate 2 NDS

ergoloid mesylates 2 MO FLOMAX 4 MO MIGRANAL SOLN 4 MG/ML 3 NDS



Limits PHENOXYBENZAMINE HCL 5 NDS

RAPAFLO 4 MO tamsulosin hcl 2 MO UROXATRAL 4 MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADRENALIN SOLN 1 MG/ML 4

ADVAIR DISKUS 4 MO ADVAIR HFA 4 MO AIRDUO RESPICLICK 113/14 4 MO

AIRDUO RESPICLICK 232/14 4 MO

AIRDUO RESPICLICK 55/14 4 MO

albuterol sulfate er tb12 4 mg 2 MO

albuterol sulfate er tb12 8 mg 2 MO

albuterol sulfate nebu (2.5 mg/3ml) 0.083% 1 PA,MO

albuterol sulfate nebu (5 mg/ml) 0.5% 1 PA,MO,NDS

albuterol sulfate nebu 0.63 mg/3ml 2 PA,MO

albuterol sulfate nebu 1.25 mg/3ml 2 PA,MO

albuterol sulfate syrp 2 mg/5ml 2 MO

albuterol sulfate tabs 2 mg 2 MO

albuterol sulfate tabs 4 mg 2 MO

ARCAPTA NEOHALER 4 MO AUVI-Q SOAJ 0.15 MG/0.15ML 5 NDS

AUVI-Q SOAJ 0.3 MG/0.3ML 5 NDS

BROVANA 4 PA,MO COMBIVENT RESPIMAT AERS 20-100 MCG/ACT

3 MO

DUONEB SOLN 0.5-2.5 (3) MG/3ML 4 PA,MO


Limits epinephrine (anaphylaxis) 2

EPINEPHRINE SOAJ 0.15 MG/0.3ML 4

EPINEPHRINE SOAJ 0.3 MG/0.3ML 4

EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML 3

fluticasone-salmeterol 2 MO ipratropium-albuterol 2 PA,MO levalbuterol hcl 2 PA,MO levalbuterol tartrate 2 MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 2 MO midodrine hcl 2 MO NORTHERA 5 NDS PERFOROMIST 4 PA,MO PROAIR HFA 4 MO PROAIR RESPICLICK 4 MO PROVENTIL HFA 4 MO SEREVENT DISKUS 3 MO STRIVERDI RESPIMAT 3 MO terbutaline sulfate 2 MO VENTOLIN HFA 4 MO XOPENEX 4 PA,MO XOPENEX CONCENTRATE 4 PA,MO

XOPENEX HFA 4 MO BLOOD FORMATION, COAGULATION, AND THROMBOSIS BLOOD FORMATION MODIFIERS BERINERT KIT 500 UNIT 5 HI

CINRYZE SOLR 500 UNIT 5 HI

FIRAZYR 5 NDS RUCONEST SOLR 2100 UNIT 5 HI

COAGULANTS AND ANTICOAGULANTS AGGRENOX 4 MO AGRYLIN 4 MO AMICAR 3 MO anagrelide hcl 2 MO ARGATROBAN SOLN 125 MG/125ML 4 HI




Limits argatroban soln 250 mg/2.5ml 2 HI

ARIXTRA SOLN 10 MG/0.8ML 5 NDS

ARIXTRA SOLN 2.5 MG/0.5ML 4 NDS

ARIXTRA SOLN 5 MG/0.4ML 5 NDS

ARIXTRA SOLN 7.5 MG/0.6ML 5 NDS

aspirin-dipyridamole 2 MO BRILINTA 3 MO cilostazol 2 MO clopidogrel bisulfate 2 MO COUMADIN 4 MO CYKLOKAPRON SOLN 1000 MG/10ML 4 HI

DURLAZA 4 MO EFFIENT 4 MO ELIQUIS 4 MO enoxaparin sodium 2 NDS fondaparinux sodium 2 NDS FONDAPARINUX SODIUM SOLN 10 MG/0.8ML

5 NDS

FONDAPARINUX SODIUM SOLN 5 MG/0.4ML

5 NDS

FONDAPARINUX SODIUM SOLN 7.5 MG/0.6ML

5 NDS

FRAGMIN 4 NDS heparin (porcine) in d5w soln 40-5 unit/ml-% 2 HI

heparin (porcine) in d5w soln 50-5 unit/ml-% 2 HI

HEPARIN SOD (PORCINE) IN D5W SOLN 100 UNIT/ML

4 HI

heparin sodium (porcine) 2 heparin sodium (porcine) soln 1000 unit/ml 2 HI

heparin sodium (porcine) soln 5000 unit/ml 2 HI

INTEGRILIN SOLN 20 MG/10ML 4 HI


Limits INTEGRILIN SOLN 75 MG/100ML 4 HI

LOVENOX 3 NDS LYSTEDA 4 MO pentoxifylline 2 MO PLAVIX 4 MO PRADAXA 3 MO SAVAYSA 4 MO tranexamic acid 2 MO tranexamic acid soln 1000 mg/10ml 2 HI

warfarin sodium 1 MO XARELTO 4 MO XARELTO STARTER PACK 4 MO

YOSPRALA 4 MO ZONTIVITY 4 MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) 4 PA,NDS

EPOGEN 3 PA,NDS GRANIX 5 NDS LEUKINE SOLR 250 MCG 3 HI

MIRCERA 4 PA MOZOBIL 4 NEULASTA 5 NDS NEULASTA ONPRO 5 NDS NEUMEGA 5 NDS NEUPOGEN 5 NDS NPLATE 4 NDS PROCRIT 3 PA,NDS PROMACTA 5 NDS ZARXIO 5 NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA 4 MO CARDURA XL 4 MO DEMSER 4 MO doxazosin mesylate 2 MO MINIPRESS 4 MO prazosin hcl 2 MO terazosin hcl 2 MO ANTILIPEMIC AGENTS ALTOPREV 4 MO



Limits ANTARA 4 MO atorvastatin calcium 1 MO cholestyramine 2 MO cholestyramine light 2 MO choline fenofibrate 2 MO COLESTID 4 MO colestipol hcl 2 MO CRESTOR 4 MO ezetimibe 2 MO ezetimibe-simvastatin 2 MO fenofibrate 2 MO FENOFIBRATE 4 MO fenofibrate micronized 2 MO fenofibric acid 2 MO FENOFIBRIC ACID 4 MO FENOGLIDE 4 MO FIBRICOR 4 MO fluvastatin sodium 2 MO gemfibrozil 2 MO JUXTAPID 5 PA,LD,NDS KYNAMRO 5 PA,LD,NDS LESCOL XL 4 MO LIPITOR 4 MO LIPOFEN 4 MO LIVALO 4 MO LOPID 4 MO lovastatin 1 MO LOVAZA 4 MO niacin (antihyperlipidemic) 2 MO

NIASPAN 4 MO omega-3-acid ethyl esters 2 MO

PRALUENT 5 PA,NDS PRAVACHOL 4 MO pravastatin sodium 2 MO REPATHA 5 PA,NDS REPATHA PUSHTRONEX SYSTEM

5 PA,NDS

REPATHA SURECLICK 5 PA,NDS rosuvastatin calcium 2 MO simvastatin 1 MO TRICOR 4 MO TRIGLIDE 4 MO


Limits TRILIPIX 4 MO VASCEPA 4 MO VYTORIN 4 MO WELCHOL 4 MO ZETIA 4 MO ZOCOR 4 MO CALCIUM-CHANNEL BLOCKING AGENTS ADALAT CC 4 MO amlodipine besylate 1 MO amlodipine besylate-atorvastatin calcium 2 MO

amlodipine besylate-benazepril hcl 2 MO

amlodipine besylate-olmesartan medoxomil 2 MO

amlodipine besylate-valsartan 2 MO

amlodipine-valsartan-hydrochlorothiazide 2 MO

AZOR 4 MO CADUET 4 MO CALAN 4 MO CALAN SR 4 MO CARDENE IV SOLN 20-0.86 MG/200ML-% 3 HI

CARDENE IV SOLN 40-0.83 MG/200ML-% 3 HI

CARDIZEM 4 MO CARDIZEM CD 4 MO CARDIZEM LA 4 MO CLEVIPREX EMUL 0.5 MG/ML 3 HI

diltiazem hcl 2 MO diltiazem hcl coated beads 2 MO

diltiazem hcl extended release beads 2 MO

diltiazem hcl soln 50 mg/10ml 2 HI

diltiazem hcl solr 100 mg 2 HI EXFORGE 4 MO EXFORGE HCT 4 MO felodipine 2 MO isradipine 2 MO LOTREL 4 MO nicardipine hcl 2 MO




Limits nicardipine hcl soln 2.5 mg/ml 2 HI

nifedipine 2 MO nimodipine 2 MO nisoldipine 2 MO NORVASC 4 MO olmesartan medoxomil-amlodipine-hydrochlorothiazide

2 MO

PROCARDIA 4 MO PROCARDIA XL 4 MO SULAR 4 MO TARKA 4 MO telmisartan-amlodipine 2 MO TIAZAC 4 MO trandolapril-verapamil hcl 2 MO TRIBENZOR 4 MO TWYNSTA 4 MO verapamil hcl 2 MO verapamil hcl soln 2.5 mg/ml 2 HI

VERELAN 4 MO VERELAN PM 4 MO CARDIAC DRUGS amiodarone hcl 2 MO amiodarone hcl soln 150 mg/3ml 2 HI

CORLANOR 4 MO digoxin 2 MO DIGOXIN SOLN 0.05 MG/ML 3 MO

disopyramide phosphate 2 MO dofetilide 2 MO flecainide acetate 2 MO LANOXIN PEDIATRIC SOLN 0.1 MG/ML 3

LANOXIN SOLN 0.25 MG/ML 4

LANOXIN TABS 125 MCG 4 MO

LANOXIN TABS 187.5 MCG 4 MO

LANOXIN TABS 250 MCG 4 MO

LANOXIN TABS 62.5 MCG 4 MO


Limits mexiletine hcl 2 MO MULTAQ 4 MO NEXTERONE SOLN 150-4.21 MG/100ML-% 4 HI

NEXTERONE SOLN 360-4.14 MG/200ML-% 4 HI

NORPACE CAPS 100 MG 4 MO

NORPACE CAPS 150 MG 4 MO

NORPACE CR CP12 100 MG 3 MO

NORPACE CR CP12 150 MG 3 MO

procainamide hcl 2 propafenone hcl 2 MO quinidine gluconate 2 MO QUINIDINE GLUCONATE 3 MO

quinidine sulfate 2 MO RANEXA 4 MO RYTHMOL SR 4 MO TIKOSYN 4 MO HYPOTENSIVE AGENTS CATAPRES 4 MO CATAPRES-TTS-1 4 MO CATAPRES-TTS-2 4 MO CATAPRES-TTS-3 4 MO clonidine hcl 2 MO clonidine hcl (adhd) 2 MO guanfacine hcl 2 MO hydralazine hcl soln 20 mg/ml 2

hydralazine hcl tabs 10 mg 1 MO




KAPVAY 4 MO mecamylamine hcl 2 NDS methyldopa 2 MO methyldopa & hydrochlorothiazide 2 MO



Limits methyldopate hcl soln 250 mg/5ml 2 HI

minoxidil 2 MO RESERPINE 3 MO RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ACCUPRIL 4 MO ACCURETIC 4 MO ALDACTAZIDE 4 MO ALDACTONE 4 MO ALTACE 4 MO ATACAND 4 MO ATACAND HCT 4 MO AVALIDE 4 MO AVAPRO 4 MO benazepril & hydrochlorothiazide 2 MO

benazepril hcl 1 MO BENICAR 4 MO BENICAR HCT 4 MO BYVALSON 4 MO candesartan cilexetil 2 MO candesartan cilexetil-hydrochlorothiazide 2 MO

captopril 2 MO captopril & hydrochlorothiazide 2 MO

COZAAR 4 MO DIOVAN 4 MO DIOVAN HCT 4 MO EDARBI 4 MO EDARBYCLOR 4 MO enalapril maleate 2 MO enalapril maleate & hydrochlorothiazide 2 MO

ENTRESTO 3 MO eplerenone 2 MO eprosartan mesylate 2 MO fosinopril sodium 2 MO fosinopril sodium & hydrochlorothiazide 2 MO

HYZAAR 4 MO INSPRA 4 MO irbesartan 2 MO


Limits irbesartan-hydrochlorothiazide 2 MO

lisinopril & hydrochlorothiazide 1 MO

lisinopril tabs 10 mg 1 MO lisinopril tabs 2.5 mg 1 MO lisinopril tabs 20 mg 1 MO lisinopril tabs 30 mg 2 MO lisinopril tabs 40 mg 1 MO lisinopril tabs 5 mg 1 MO losartan potassium 1 MO losartan potassium & hydrochlorothiazide 2 MO

LOTENSIN 4 MO MAVIK 4 MO MICARDIS 4 MO MICARDIS HCT 4 MO moexipril hcl 2 MO moexipril-hydrochlorothiazide 2 MO

olmesartan medoxomil 2 MO olmesartan medoxomil-hydrochlorothiazide 2 MO

perindopril erbumine 2 MO PRINIVIL 4 MO QBRELIS 4 MO quinapril hcl 2 MO quinapril-hydrochlorothiazide 2 MO

ramipril 2 MO spironolactone & hydrochlorothiazide 2 MO

spironolactone tabs 100 mg 2 MO



TEKTURNA 4 MO TEKTURNA HCT 4 MO telmisartan 2 MO telmisartan-hydrochlorothiazide 2 MO

trandolapril 2 MO valsartan 2 MO




Limits valsartan-hydrochlorothiazide 2 MO

VASERETIC 4 MO VASOTEC 4 MO ZESTORETIC 4 MO ZESTRIL 4 MO VASODILATING AGENTS ADCIRCA 5 PA,NDS BIDIL 4 MO CIALIS 4 PA,NDS dipyridamole 2 MO GONITRO PACK 400 MCG 4 MO

ISORDIL TITRADOSE 4 MO isosorbide dinitrate 2 MO isosorbide mononitrate er tb24 120 mg 2 MO

isosorbide mononitrate er tb24 30 mg 1 MO

isosorbide mononitrate er tb24 60 mg 1 MO

isosorbide mononitrate tabs 10 mg 2 MO

isosorbide mononitrate tabs 20 mg 2 MO

NITRO-DUR PT24 0.1 MG/HR 4 MO






nitroglycerin 2 MO nitroglycerin soln 5 mg/ml 2 HI

NITROMIST AERS 400 MCG/SPRAY 4 MO

NITROSTAT SUBL 0.3 MG 4 MO

NITROSTAT SUBL 0.4 MG 4 MO


Limits NITROSTAT SUBL 0.6 MG 4 MO

REVATIO SOLN 10 MG/12.5ML 5 HI

REVATIO SUSR 10 MG/ML 4 PA,NDS

REVATIO TABS 20 MG 5 PA,NDS sildenafil citrate (pulmonary hypertension)

2 PA,MO

sildenafil citrate soln 10 mg/12.5ml 2 HI

ß-ADRENERGIC BLOCKING AGENTS acebutolol hcl 2 MO atenolol 1 MO atenolol & chlorthalidone 2 MO BETAPACE AF 4 MO betaxolol hcl 2 MO bisoprolol & hydrochlorothiazide 1 MO

bisoprolol fumarate 2 MO BYSTOLIC 4 MO carvedilol 1 MO COREG 4 MO COREG CR 4 MO CORGARD 4 MO CORZIDE 4 MO DUTOPROL 4 MO INDERAL LA 4 MO INNOPRAN XL 4 MO labetalol hcl 2 MO labetalol hcl soln 5 mg/ml 2 HI

LOPRESSOR 4 MO LOPRESSOR HCT 4 MO metoprolol & hydrochlorothiazide 2 MO

metoprolol succinate 2 MO metoprolol tartrate soct 5 mg/5ml 2 HI

metoprolol tartrate soln 5 mg/5ml 2 HI

metoprolol tartrate tabs 100 mg 1 MO

metoprolol tartrate tabs 25 mg 1 MO



Limits metoprolol tartrate tabs 50 mg 1 MO

nadolol & bendroflumethiazide 2 MO

nadolol tabs 20 mg 1 MO nadolol tabs 40 mg 1 MO nadolol tabs 80 mg 2 MO pindolol 2 MO propranolol & hydrochlorothiazide 2 MO

propranolol hcl er cp24 120 mg 2 MO




propranolol hcl soln 1 mg/ml 2 HI

propranolol hcl soln 20 mg/5ml 2 MO

propranolol hcl soln 40 mg/5ml 2 MO

propranolol hcl tabs 10 mg 1 MO





sotalol hcl 2 MO sotalol hcl (afib/afl) 2 MO SOTYLIZE 4 MO TENORETIC 100 4 MO TENORETIC 50 4 MO TENORMIN 4 MO timolol maleate 2 MO TOPROL XL 4 MO ZIAC 4 MO CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS disulfiram 2 MO


Limits ANALGESICS AND ANTIPYRETICS ABSTRAL SUBL 100 MCG 4 PA,NDS

ABSTRAL SUBL 200 MCG 4 PA,NDS





acetaminophen w/ codeine 2 NDS

acetaminophen-caff-dihydrocod 2 NDS

ACTIQ LPOP 1200 MCG 5 PA,NDS ACTIQ LPOP 1600 MCG 5 PA,NDS ACTIQ LPOP 200 MCG 4 PA,NDS ACTIQ LPOP 400 MCG 5 PA,NDS ACTIQ LPOP 600 MCG 5 PA,NDS ACTIQ LPOP 800 MCG 5 PA,NDS ANAPROX DS 4 ARTHROTEC 4 ARYMO ER TBEA 15 MG 4 NDS

ARYMO ER TBEA 30 MG 4 NDS

ARYMO ER TBEA 60 MG 5 NDS

AVINZA 4 NDS BELBUCA 4 NDS buprenorphine 2 NDS butalbital-acetaminophen 2 butalbital-acetaminophen-caffeine 2

butalbital-acetaminophen-caffeine w/ codeine

2 NDS

butalbital-aspirin-caffeine 2 butalbital-aspirin-caffeine w/cod 2 NDS

butorphanol tartrate 2 NDS BUTRANS 4 NDS CELEBREX 4




Limits celecoxib 2 codeine sulfate 2 NDS CODEINE SULFATE 3 NDS CONZIP 4 NDS DAYPRO 4 DEMEROL INJ 4 PA,NDS DEMEROL TABS 4 NDS diclofenac potassium 2 diclofenac sodium 2 diclofenac w/ misoprostol 2 diflunisal 2 DILAUDID 4 NDS DOLOPHINE TABS 10 MG 4 NDS

DOLOPHINE TABS 5 MG 4 NDS

DUEXIS 4 DURAGESIC-100 4 NDS DURAGESIC-12 4 NDS DURAGESIC-25 4 NDS DURAGESIC-50 4 NDS DURAGESIC-75 4 NDS EC-NAPROSYN 4 EMBEDA 4 NDS etodolac 2 EXALGO 4 NDS FELDENE 4 NDS fenoprofen calcium 2 FENOPROFEN CALCIUM 4

fentanyl 2 NDS fentanyl citrate LPOP 2 PA,NDS FENTANYL CITRATE LPOP 1200 MCG 5 PA,NDS

FENTANYL CITRATE LPOP 1600 MCG 5 PA,NDS




FENTORA TABS 100 MCG 4 PA,NDS



Limits FENTORA TABS 400 MCG 4 PA,NDS



FIORINAL 4 FIORINAL/CODEINE #3 4 NDS flurbiprofen 2 GRALISE 4 GRALISE STARTER 4 hydrocodone-acetaminophen 2 NDS

hydrocodone-ibuprofen 2 NDS hydromorphone hcl 2 NDS HYSINGLA ER 4 PA,NDS ibuprofen 2 ILARIS 5 NDS ILARIS (150MG DELIVERED) 5 NDS

INDOCIN 4 indomethacin 2 KADIAN CP24 10 MG 4 NDS KADIAN CP24 100 MG 4 NDS KADIAN CP24 20 MG 4 NDS KADIAN CP24 200 MG 4 NDS KADIAN CP24 30 MG 4 NDS KADIAN CP24 40 MG 4 NDS KADIAN CP24 50 MG 4 NDS KADIAN CP24 60 MG 4 NDS KADIAN CP24 80 MG 4 NDS ketoprofen 2 ketorolac tromethamine 2 LAZANDA SOLN 100 MCG/ACT 4 PA,NDS

LAZANDA SOLN 300 MCG/ACT 4 PA,NDS

LAZANDA SOLN 400 MCG/ACT 4 PA,NDS

levorphanol tartrate 2 NDS meclofenamate sodium 2 mefenamic acid 2 meloxicam 2 meperidine hcl 2 PA,NDS methadone hcl 2 NDS



Limits METHADONE HCL SOLN 10 MG/ML 3 NDS

MOBIC 4 morphine sulfate 2 NDS MORPHINE SULFATE (PF) SOLN 10 MG/ML 4 HI

MORPHINE SULFATE (PF) SOLN 2 MG/ML 4 HI



morphine sulfate beads 2 NDS MORPHINE SULFATE TABS 15 MG 3 NDS

MORPHINE SULFATE TABS 30 MG 3 NDS

MS CONTIN TBCR 100 MG 4 NDS





nabumetone 2 nalbuphine hcl 2 NDS NAPRELAN 4 NAPROSYN 4 naproxen 2 naproxen sodium 2 NUCYNTA 4 NDS NUCYNTA ER 4 NDS OPANA 4 NDS OPANA ER 4 PA,NDS oxaprozin 2 oxycodone hcl 2 NDS oxycodone w/ acetaminophen 2 NDS

oxycodone-aspirin 2 NDS oxycodone-ibuprofen 2 NDS OXYCONTIN 4 NDS oxymorphone hcl 2 NDS pentazocine w/ naloxone 2 NDS


Limits PERCODAN 4 NDS piroxicam 2 NDS PONSTEL 4 ROXICODONE 4 NDS SUBSYS 4 PA,NDS sulindac 2 SYNALGOS-DC 4 NDS TALWIN 4 NDS TIVORBEX 4 tolmetin sodium 2 tramadol hcl 2 NDS tramadol-acetaminophen 2 NDS ULTRACET 4 NDS ULTRAM 4 NDS ULTRAM ER 4 NDS VICOPROFEN 4 NDS VIMOVO 4 NDS VIVLODEX 4 XARTEMIS XR 4 NDS XTAMPZA ER 4 NDS ZIPSOR 4 ZOHYDRO ER 4 PA,NDS ZORVOLEX 4 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS ADDERALL XR CP24 10 MG 3 NDS

ADDERALL XR CP24 15 MG 3 NDS





ADZENYS XR-ODT 4 NDS amphetamine sulfate 2 NDS amphetamine-dextroamphetamine 2 NDS

APTENSIO XR CP24 10 MG 3 NDS





Limits APTENSIO XR CP24 20 MG 3 NDS





armodafinil 2 PA CONCERTA TBCR 18 MG 3 NDS

CONCERTA TBCR 27 MG 3 NDS



COTEMPLA XR-ODT 4 NDS DAYTRANA 4 NDS DESOXYN 4 PA,NDS DEXEDRINE 4 NDS dexmethylphenidate hcl 2 NDS dextroamphetamine sulfate 2 NDS

DYANAVEL XR 4 NDS FOCALIN 4 NDS FOCALIN XR 4 NDS METADATE CD CPCR 10 MG 4 NDS

METADATE CD CPCR 20 MG 4 NDS





methamphetamine hcl 2 PA,NDS METHYLIN CHEW 10 MG 4 NDS

METHYLIN CHEW 2.5 MG 4 NDS


Limits METHYLIN CHEW 5 MG 4 NDS METHYLIN SOLN 10 MG/5ML 4 NDS

METHYLIN SOLN 5 MG/5ML 4 NDS

methylphenidate hcl 2 NDS modafinil 2 PA,NDS MYDAYIS CP24 12.5 MG 4 NDS

MYDAYIS CP24 25 MG 4 NDS MYDAYIS CP24 37.5 MG 4 NDS

MYDAYIS CP24 50 MG 4 NDS NUVIGIL 4 PA PROVIGIL 4 PA,NDS QUILLICHEW ER CHER 20 MG 4 NDS

QUILLICHEW ER CHER 30 MG 4 NDS

QUILLICHEW ER CHER 40 MG 4 NDS

QUILLIVANT XR SUSR 25 MG/5ML 4 NDS

RITALIN LA CP24 10 MG 4 NDS





RITALIN TABS 10 MG 4 NDS RITALIN TABS 20 MG 4 NDS RITALIN TABS 5 MG 4 NDS VYVANSE CAPS 10 MG 3 NDS VYVANSE CAPS 20 MG 3 NDS VYVANSE CAPS 30 MG 3 NDS VYVANSE CAPS 40 MG 3 NDS VYVANSE CAPS 50 MG 3 NDS VYVANSE CAPS 60 MG 3 NDS VYVANSE CAPS 70 MG 3 NDS VYVANSE CHEW 10 MG 4 NDS



Limits VYVANSE CHEW 20 MG 4 NDS

VYVANSE CHEW 30 MG 4 NDS




ANTICONVULSANTS APTIOM 4 MO BANZEL SUSP 40 MG/ML 3 MO

BANZEL TABS 200 MG 5 NDS BANZEL TABS 400 MG 5 NDS BRIVIACT SOLN 10 MG/ML 5 NDS

BRIVIACT SOLN 50 MG/5ML 4 HI

BRIVIACT TABS 10 MG 5 NDS BRIVIACT TABS 100 MG 5 NDS

BRIVIACT TABS 25 MG 5 NDS BRIVIACT TABS 50 MG 5 NDS BRIVIACT TABS 75 MG 5 NDS carbamazepine 2 MO CARBATROL 4 MO CELONTIN 3 MO CEREBYX 4 clonazepam 2 NDS DEPACON SOLN 100 MG/ML 4 HI

DEPAKENE 4 MO DEPAKOTE 4 MO DEPAKOTE ER 4 MO DEPAKOTE SPRINKLES 4 MO

DIASTAT ACUDIAL 3 NDS DIASTAT PEDIATRIC 3 NDS diazepam (anticonvulsant) 2 NDS

DILANTIN 4 MO divalproex sodium 2 MO EQUETRO 4 MO ethosuximide 2 MO


Limits felbamate 2 MO FELBATOL 5 NDS fosphenytoin sodium 2 FYCOMPA SUSP 0.5 MG/ML 5 NDS

FYCOMPA TABS 10 MG 4 FYCOMPA TABS 12 MG 4 FYCOMPA TABS 2 MG 4 FYCOMPA TABS 4 MG 4 FYCOMPA TABS 6 MG 4 FYCOMPA TABS 8 MG 4 gabapentin 2 MO GABITRIL 4 MO HORIZANT 4 MO KEPPRA SOLN 100 MG/ML 4 MO

KEPPRA TABS 1000 MG 4 MO

KEPPRA TABS 250 MG 4 MO KEPPRA TABS 500 MG 4 MO KEPPRA TABS 750 MG 4 MO KEPPRA XR TB24 500 MG 4 MO

KEPPRA XR TB24 750 MG 4 MO

KLONOPIN 4 NDS LAMICTAL CHEW 25 MG 4 MO

LAMICTAL CHEW 5 MG 4 MO LAMICTAL ODT TBDP 100 MG 4 MO

LAMICTAL ODT TBDP 200 MG 4 MO



LAMICTAL STARTER KIT 25 (35) MG 3 MO

LAMICTAL STARTER KIT 25 (42)-100 (7) MG 3 MO

LAMICTAL STARTER KIT 25 (84)-100(14) MG 3 MO

LAMICTAL TABS 100 MG 4 MO




Limits LAMICTAL TABS 150 MG 4 MO

LAMICTAL TABS 200 MG 4 MO

LAMICTAL TABS 25 MG 4 MO LAMICTAL XR KIT 25 & 50 & 100 MG 4 MO

LAMICTAL XR KIT 25 (21)-50 (7) MG 4 MO

LAMICTAL XR KIT 50 & 100 & 200 MG 4 MO

LAMICTAL XR TB24 100 MG 4 MO






lamotrigine 2 MO levetiracetam 2 MO levetiracetam in nacl soln 1000 mg/100ml 2 HI

levetiracetam in nacl soln 1500 mg/100ml 2 HI

levetiracetam in nacl soln 500 mg/100ml 2 HI

levetiracetam soln 500 mg/5ml 2 HI

LYRICA 4 MO MAGNESIUM SULFATE SOLN 2 GM/50ML 3 HI

MAGNESIUM SULFATE SOLN 20 GM/500ML 3 HI



magnesium sulfate soln 50 % 2 HI

MYSOLINE 4 MO NEURONTIN 4 MO


Limits ONFI 4 MO oxcarbazepine 2 MO OXTELLAR XR 4 MO PEGANONE 4 MO phenytoin 2 MO phenytoin sodium 2 phenytoin sodium extended 2 MO

primidone 2 MO QUDEXY XR 4 MO SABRIL 5 LD,NDS SPRITAM TB3D 1000 MG 4 NDS

SPRITAM TB3D 250 MG 4 MO SPRITAM TB3D 500 MG 4 MO SPRITAM TB3D 750 MG 5 NDS TEGRETOL 4 MO TEGRETOL-XR 4 MO tiagabine hcl 2 MO TOPAMAX 4 MO TOPAMAX SPRINKLE 4 MO topiramate 2 MO TRILEPTAL 4 MO TROKENDI XR 4 MO valproate sodium 2 MO valproate sodium soln 100 mg/ml 2 HI

valproic acid 2 MO VIMPAT SOLN 10 MG/ML 4

VIMPAT SOLN 200 MG/20ML 4 HI

VIMPAT TABS 100 MG 5 VIMPAT TABS 150 MG 5 VIMPAT TABS 200 MG 5 VIMPAT TABS 50 MG 4 ZARONTIN 4 MO ZONEGRAN 4 MO zonisamide 2 MO ANTIMIGRAINE AGENTS almotriptan malate 2 AMERGE 4 AXERT 4 CAMBIA 4 ergotamine w/ caffeine 2



Limits FROVA 4 frovatriptan succinate 2 IMITREX 4 IMITREX STATDOSE REFILL 4

MAXALT 4 MAXALT-MLT 4 naratriptan hcl 2 ONZETRA XSAIL 4 RELPAX 4 rizatriptan benzoate 2 sumatriptan 2 sumatriptan succinate 2 SUMAVEL DOSEPRO 4 TREXIMET 4 ZEMBRACE SYMTOUCH 4

zolmitriptan 2 ZOMIG 4 ZOMIG ZMT 4 ANTIPARKINSONIAN AGENTS amantadine hcl 2 MO APOKYN 5 NDS AZILECT 4 MO benztropine mesylate 2 MO bromocriptine mesylate 2 MO cabergoline 2 MO carbidopa 2 MO carbidopa-levodopa 2 MO carbidopa-levodopa-entacapone 2 MO

COGENTIN 4 COMTAN 4 MO DUOPA 4 LD ELDEPRYL 4 MO EMSAM 4 MO entacapone 2 MO LODOSYN 4 MO MIRAPEX 4 MO MIRAPEX ER 4 MO NEUPRO 4 MO PARLODEL 4 MO pramipexole dihydrochloride 2 MO

rasagiline mesylate 2 MO


Limits REQUIP 4 MO REQUIP XL 4 MO ropinirole hydrochloride 2 MO RYTARY 4 MO selegiline hcl 2 MO SINEMET 4 MO SINEMET CR 4 MO STALEVO 100 4 MO STALEVO 125 4 MO STALEVO 150 4 MO STALEVO 200 4 MO STALEVO 50 4 MO STALEVO 75 4 MO TASMAR 4 MO tolcapone 2 MO trihexyphenidyl hcl 2 MO ZELAPAR 4 MO ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam 2 NDS AMBIEN 4 NDS AMBIEN CR 4 NDS ATIVAN 4 NDS BELSOMRA 4 buspirone hcl 2 BUTISOL SODIUM 4 chlordiazepoxide hcl 2 NDS clorazepate dipotassium 2 NDS diazepam 2 NDS DIAZEPAM 4 NDS EDLUAR 4 NDS estazolam 2 NDS eszopiclone 2 NDS flurazepam hcl 2 NDS HALCION 4 NDS HETLIOZ 5 PA,NDS hydroxyzine hcl 2 hydroxyzine pamoate 2 INTERMEZZO 4 NDS lorazepam 2 NDS LUNESTA 4 NDS meprobamate 2 midazolam hcl 2 NDS oxazepam 2 NDS phenobarbital 2 PHENOBARBITAL 4




Limits QUAZEPAM 4 NDS RESTORIL 4 NDS ROZEREM 4 SILENOR 4 SONATA 4 NDS temazepam 2 NDS TRANXENE-T 4 NDS triazolam 2 NDS VALIUM 4 NDS VISTARIL 4 XANAX 4 NDS XANAX XR 4 NDS zaleplon 2 NDS zolpidem tartrate 2 NDS ZOLPIMIST 4 NDS CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS acamprosate calcium 2 MO atomoxetine hcl 2 MO AUSTEDO 5 LD,NDS guanfacine hcl (adhd) 2 MO INGREZZA 5 NDS INTUNIV 4 MO memantine hcl 2 MO NAMENDA 4 MO NAMENDA TITRATION PAK 4 MO

NAMENDA XR 4 MO NAMENDA XR TITRATION PACK 4 MO

NAMZARIC 4 MO,NDS NUEDEXTA 3 NDS RADICAVA 5 NDS RILUTEK 5 NDS riluzole 2 MO SAVELLA 3 MO SAVELLA TITRATION PACK 3 MO

STRATTERA 4 MO TETRABENAZINE 5 NDS XENAZINE 5 NDS XYREM 5 LD,NDS MULTIPLE SCLEROSIS AGENTS AMPYRA 5 NDS AUBAGIO 5 PA,NDS


Limits AVONEX 5 NDS AVONEX PEN 5 NDS AVONEX PREFILLED 5 NDS BETASERON KIT 0.3 MG 5 NDS

COPAXONE 5 NDS EXTAVIA KIT 0.3 MG 3 NDS GILENYA 5 NDS glatiramer acetate 2 NDS LEMTRADA SOLN 12 MG/1.2ML 5 HI

OCREVUS SOLN 300 MG/10ML 5 HI

REBIF 5 NDS REBIF REBIDOSE 5 NDS REBIF REBIDOSE TITRATION PACK 5 NDS

REBIF TITRATION PACK 5 NDS

TECFIDERA 5 NDS TYSABRI CONC 300 MG/15ML 5 PA,HI

ZINBRYTA 5 LD,NDS OPIATE ANTAGONISTS BUNAVAIL 4 PA,NDS BUPRENEX 4 PA,NDS buprenorphine hcl 2 PA,NDS buprenorphine hcl-naloxone hcl dihydrate 2 PA,NDS

EVZIO SOAJ 0.4 MG/0.4ML 4

EVZIO SOAJ 2 MG/0.4ML 5 NDS

naloxone hcl 2 naltrexone hcl 2 NARCAN LIQD 4 MG/0.1ML 3

SUBOXONE 4 PA,NDS VIVITROL 4 NDS ZUBSOLV 4 PA,NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY 4 MO ABILIFY MAINTENA 4 amitriptyline hcl 2 MO amoxapine 2 MO ANAFRANIL 4 MO



Limits APLENZIN 4 MO aripiprazole 2 MO ARISTADA 5 NDS BRISDELLE 4 MO bupropion hcl 2 MO bupropion hcl (smoking deterrent) 2 MO

CELEXA 4 MO chlordiazepoxide-amitriptyline 2

chlorpromazine hcl 2 MO citalopram hydrobromide soln 10 mg/5ml 2 MO

citalopram hydrobromide tabs 10 mg 2 MO



clomipramine hcl 2 MO clozapine 2 NDS CLOZARIL 4 NDS CYMBALTA 4 MO desipramine hcl 2 MO DESVENLAFAXINE ER 4 MO desvenlafaxine succinate 2 MO doxepin hcl 2 MO duloxetine hcl 2 MO EFFEXOR XR 4 MO escitalopram oxalate 2 MO FANAPT 4 MO FANAPT TITRATION PACK 4 MO

FAZACLO 4 NDS FETZIMA 4 MO FETZIMA TITRATION 4 MO FLUOXETINE HCL 4 MO fluoxetine hcl caps 10 mg 1 MO

fluoxetine hcl caps 20 mg 1 MO

fluoxetine hcl caps 40 mg 1 MO

fluoxetine hcl cpdr 90 mg 2 MO fluoxetine hcl soln 20 mg/5ml 2 MO


Limits fluoxetine hcl tabs 10 mg 2 MO fluoxetine hcl tabs 20 mg 2 MO fluphenazine decanoate 2 fluphenazine hcl 2 MO fluvoxamine maleate 2 MO FORFIVO XL 4 MO GEODON 3 MO GEODON 4 MO HALDOL 4 HALDOL DECANOATE 4 haloperidol 2 MO haloperidol decanoate 2 haloperidol lactate 2 MO imipramine hcl 2 MO imipramine pamoate 2 MO INVEGA 4 MO INVEGA SUSTENNA 4 NDS INVEGA TRINZA 4 KHEDEZLA 4 MO LATUDA 5 NDS LEXAPRO 4 MO LITHIUM 3 MO lithium carbonate 2 MO LITHOBID 4 MO loxapine succinate 2 MO maprotiline hcl 2 MO MARPLAN 4 MO mirtazapine 2 MO molindone hcl 2 MO NARDIL 4 MO nefazodone hcl 2 MO NORPRAMIN 4 MO nortriptyline hcl 2 MO NUPLAZID 5 NDS olanzapine 2 MO olanzapine-fluoxetine hcl 2 MO ORAP 4 MO paliperidone 2 MO PAMELOR 4 MO PARNATE 4 MO paroxetine hcl er tb24 12.5 mg 2 MO

paroxetine hcl er tb24 25 mg 2 MO




Limits paroxetine hcl er tb24 37.5 mg 2 MO

paroxetine hcl tabs 10 mg 1 MO




PAXIL 4 MO PAXIL CR 4 MO perphenazine 2 MO perphenazine-amitriptyline 2 MO

PEXEVA 4 MO phenelzine sulfate 2 MO pimozide 2 MO PRISTIQ 4 MO prochlorperazine 2 MO prochlorperazine edisylate 2

prochlorperazine maleate 2

protriptyline hcl 2 MO PROZAC 4 MO PROZAC WEEKLY 4 MO quetiapine fumarate 2 MO REMERON 4 MO REMERON SOLTAB 4 MO REXULTI 4 NDS RISPERDAL 4 MO RISPERDAL CONSTA 4 NDS RISPERDAL M-TAB 4 MO risperidone 2 MO SAPHRIS 5 NDS SARAFEM 4 MO SEROQUEL 4 MO SEROQUEL XR 4 MO sertraline hcl 2 MO SURMONTIL 4 MO SYMBYAX 4 MO thioridazine hcl 2 MO thiothixene 2 MO tranylcypromine sulfate 2 MO


Limits trazodone hcl tabs 100 mg 1 MO

trazodone hcl tabs 150 mg 1 MO



trifluoperazine hcl 2 MO trimipramine maleate 2 MO TRINTELLIX 4 MO venlafaxine hcl 2 MO VERSACLOZ 4 NDS VIIBRYD 4 MO VIIBRYD STARTER PACK 4 MO

VRAYLAR CAPS 1.5 MG 5 NDS

VRAYLAR CAPS 3 MG 5 NDS VRAYLAR CAPS 4.5 MG 5 NDS

VRAYLAR CAPS 6 MG 5 NDS VRAYLAR CPPK 1.5 & 3 MG 4 NDS

WELLBUTRIN SR 4 MO WELLBUTRIN XL 4 MO ziprasidone hcl 2 MO ZOLOFT 4 MO ZYBAN 4 MO ZYPREXA 4 MO ZYPREXA RELPREVV 4 ZYPREXA ZYDIS 4 MO DIABETIC SUPPLIES DIABETIC SUPPLIES alcohol swabs 2 MO gauze pads & dressings 2 MO insulin pen needle 2 MO insulin syringe/needle u-100 2 MO

ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS potassium citrate (alkalinizer) 2 MO

SODIUM LACTATE SOLN 5 MEQ/ML 4 HI



Limits UROCIT-K 10 4 MO UROCIT-K 15 4 MO UROCIT-K 5 4 MO AMMONIA DETOXICANTS BUPHENYL 5 NDS CARBAGLU 4 LD lactulose 2 MO lactulose (encephalopathy) 2 MO

LITHOSTAT 4 MO RAVICTI 5 NDS sodium phenylbutyrate 2 NDS CALORIC AGENTS AMINOSYN II SOLN 10 % 4 HI

AMINOSYN II SOLN 15 % 4 HI

AMINOSYN II SOLN 7 % 4 HI AMINOSYN II SOLN 8.5 % 4 HI

aminosyn ii/electrolytes soln 8.5 % 2 HI

AMINOSYN-HBC SOLN 7 % 4 HI

AMINOSYN-PF SOLN 10 % 4 HI

AMINOSYN-PF SOLN 7 % 4 HI

AMINOSYN-RF SOLN 5.2 % 4 HI

AMINOSYN/ELECTROLYTES SOLN 7 % 4 HI

aminosyn/electrolytes soln 8.5 % 2 HI

CLINIMIX E/DEXTROSE (2.75/10) SOLN 2.75 % 3 HI





CLINIMIX E/DEXTROSE (5/15) SOLN 5 % 3 HI


Limits CLINIMIX E/DEXTROSE (5/20) SOLN 5 % 3 HI

CLINIMIX E/DEXTROSE (5/25) SOLN 5 % 3 HI

CLINIMIX/DEXTROSE (2.75/5) SOLN 2.75 % 3 HI





CLINIMIX/DEXTROSE (5/15) SOLN 5 % 3 HI



clinisol sf soln 15 % 2 HI dextrose soln 10 % 2 HI dextrose soln 5 % 2 HI FREAMINE HBC SOLN 6.9 % 4 HI

HEPATAMINE SOLN 8 % 4 HI

intralipid emul 20 % 2 HI INTRALIPID EMUL 30 % 4 HI LIPOSYN III EMUL 10 % 3 HI NEPHRAMINE SOLN 5.4 % 3 HI

nutrilipid emul 20 % 2 HI plenamine soln 15 % 2 HI premasol soln 10 % 2 HI premasol soln 6 % 2 HI PROCALAMINE SOLN 3 % 3 HI

PROSOL SOLN 20 % 4 HI TRAVASOL SOLN 10 % 4 HI TROPHAMINE SOLN 10 % 3 HI

TROPHAMINE SOLN 6 % 3 HI

DIURETICS




Limits amiloride & hydrochlorothiazide 1 MO

amiloride hcl 2 MO bumetanide 2 MO chlorothiazide 2 MO chlorothiazide sodium solr 500 mg 2 HI

chlorthalidone 2 MO DEMADEX 4 MO DIURIL 3 MO DYAZIDE 4 MO DYRENIUM 3 MO EDECRIN 3 MO ethacrynate sodium solr 50 mg 2 HI

ethacrynic acid 2 MO furosemide soln 10 mg/ml 2 HI,MO

furosemide soln 8 mg/ml 2 MO furosemide tabs 20 mg 1 MO furosemide tabs 40 mg 1 MO furosemide tabs 80 mg 1 MO hydrochlorothiazide caps 12.5 mg 2 MO

hydrochlorothiazide tabs 12.5 mg 1 MO

hydrochlorothiazide tabs 25 mg 1 MO

hydrochlorothiazide tabs 50 mg 1 MO

indapamide 1 MO LASIX 4 MO MAXZIDE 4 MO MAXZIDE-25 4 MO methyclothiazide 2 MO metolazone 2 MO MICROZIDE 4 MO SAMSCA 4 NDS SODIUM DIURIL SOLR 500 MG 4 HI

SODIUM EDECRIN SOLR 50 MG 3 HI

torsemide 2 MO triamterene-hctz caps 37.5-25 mg 2 MO


Limits triamterene-hctz caps 50-25 mg 2 MO

triamterene-hctz tabs 37.5-25 mg 1 MO

triamterene-hctz tabs 75-50 mg 1 MO

ION-REMOVING AGENTS AURYXIA 4 MO FOSRENOL CHEW 1000 MG 4 MO

FOSRENOL CHEW 500 MG 4 MO

FOSRENOL CHEW 750 MG 4 MO

FOSRENOL PACK 1000 MG 5 NDS

FOSRENOL PACK 750 MG 5 NDS

KAYEXALATE 4 MO RENAGEL 3 MO RENVELA 3 MO sevelamer carbonate 2 MO sodium polystyrene sulfonate 2 MO

VELPHORO 5 NDS VELTASSA 4 NDS IRRIGATING SOLUTIONS irrigation solutions, physiological 2 MO

lactated ringer's (irrigation) 2 MO

ringer's irrigation 2 MO sodium chloride (gu irrigant) 2 MO

water for irrigation, sterile 2 MO

REPLACEMENT PREPARATIONS calcium acetate (phosphate binder) 2 MO

DEXTROSE 5%/ELECTROLYTE #48 SOLN

3 HI

dextrose in lactated ringers soln 5 % 2 HI

DEXTROSE-NACL SOLN 10-0.2 % 3 HI



Limits DEXTROSE-NACL SOLN 10-0.45 % 3 HI

dextrose-nacl soln 2.5-0.45 % 2 HI

dextrose-nacl soln 5-0.2 % 2 HI

DEXTROSE-NACL SOLN 5-0.225 % 4 HI




IONOSOL-MB IN D5W SOLN 4 HI

ISOLYTE-P IN D5W SOLN 4 HI

ISOLYTE-S SOLN 4 HI K-TAB TBCR 10 MEQ 3 MO K-TAB TBCR 20 MEQ 4 MO K-TAB TBCR 8 MEQ 4 MO kcl in dextrose-nacl soln 10-5-0.45 meq/l-%-% 2 HI

kcl in dextrose-nacl soln 20-5-0.2 meq/l-%-% 2 HI






KCL IN DEXTROSE-NACL SOLN 40-5-0.9 MEQ/L-%-%

3 HI

KCL-LACTATED RINGERS-D5W SOLN 20 MEQ/L

3 HI

lactated ringers soln 2 HI,MO MAGNESIUM SULFATE IN D5W SOLN 1-5 GM/100ML-%

3 HI


Limits NORMOSOL-M IN D5W SOLN 4 HI

NORMOSOL-R IN D5W SOLN 4 HI

NORMOSOL-R PH 7.4 SOLN 4 HI

PHOSLYRA 3 MO PLASMA-LYTE 148 SOLN 3 HI

PLASMA-LYTE A SOLN 3 HI PLASMA-LYTE-56 IN D5W SOLN 3 HI

potassium chloride 2 MO potassium chloride in dextrose soln 20-5 meq/l-%

2 HI

potassium chloride in dextrose soln 40-5 meq/l-%

2 HI

potassium chloride in nacl soln 20-0.45 meq/l-%

2 HI

potassium chloride in nacl soln 20-0.9 meq/l-% 2 HI

potassium chloride in nacl soln 40-0.9 meq/l-% 2 HI

potassium chloride microencapsulated crystals cr

2 MO

potassium chloride soln 10 meq/100ml 2 HI

potassium chloride soln 2 meq/ml 2 HI



POTASSIUM CHLORIDE SOLN 40 MEQ/15ML (20%)

4 MO

ringers soln 2 HI sodium chloride soln 0.45 % 2 HI

sodium chloride soln 0.9 % 2 HI,MO




Limits sodium chloride soln 2.5 meq/ml 2 HI

sodium chloride soln 3 % 2 HI sodium chloride soln 5 % 2 HI tpn electrolytes soln 2 HI ZINC TRACE METAL SOLN 1 MG/ML 3 HI

URICOSURIC AGENTS colchicine w/ probenecid 2 MO probenecid 2 MO ZURAMPIC 4 MO ENZYMES ENZYMES ADAGEN 3 LD ALDURAZYME SOLN 2.9 MG/5ML 3 HI

CERDELGA 5 NDS CEREZYME SOLR 400 UNIT 5 HI

ELAPRASE SOLN 6 MG/3ML 5 HI

ELELYSO SOLR 200 UNIT 5 HI

ELITEK SOLR 1.5 MG 3 HI ELITEK SOLR 7.5 MG 4 HI FABRAZYME SOLR 35 MG 5 HI

FABRAZYME SOLR 5 MG 5 HI

KANUMA SOLN 20 MG/10ML 5 HI

LUMIZYME SOLR 50 MG 5 HI

MYOZYME SOLR 50 MG 5 HI

NAGLAZYME SOLN 1 MG/ML 5 HI

PULMOZYME 5 PA,NDS STRENSIQ 5 LD,NDS SUCRAID 4 LD VIMIZIM SOLN 5 MG/5ML 5 HI

VPRIV SOLR 400 UNIT 5 HI ZAVESCA 5 LD,NDS


Limits EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE 4 bacitracin (ophthalmic) 2 bacitracin-polymyxin b (ophth) 2

BESIVANCE 4 BLEPH-10 4 chlorhexidine gluconate (mouth-throat) 2

CILOXAN OINT 0.3 % 3 CILOXAN SOLN 0.3 % 4 ciprofloxacin hcl (ophth) 2 erythromycin (ophth) 2 gatifloxacin (ophth) 2 gentamicin sulfate (ophth) 2

levofloxacin (ophth) 2 MOXEZA 4 NATACYN 3 neomycin-bacitracin zn-polymyxin 2

neomycin-polymyxin-gramicidin 2

OCUFLOX 4 ofloxacin (ophth) 2 ofloxacin (otic) 2 OTOVEL 4 polymyxin b-trimethoprim 2 POLYTRIM 4 sulfacetamide sodium (ophth) 2

tobramycin (ophth) 2 TOBREX OINT 0.3 % 3 TOBREX SOLN 0.3 % 4 trifluridine 2 VIGAMOX 4 VIROPTIC 4 ZIRGAN 4 ZYMAXID 4 ANTI-INFLAMMATORY AGENTS ACULAR 4 MO ACULAR LS 4 MO ACUVAIL 4 MO



Limits ALREX 4 MO bacitracin-poly-neomycin-hc 2 MO

BECONASE AQ 4 MO BLEPHAMIDE 3 MO bromfenac sodium (ophth) 2 MO

budesonide (nasal) 2 MO CIPRO HC 4 MO CIPRODEX 3 MO COLY-MYCIN S 3 MO CORTISPORIN-TC 3 MO dexamethasone sodium phosphate (ophth) 2 MO

diclofenac sodium (ophth) 2 MO

DUREZOL 4 MO FLAREX 4 MO flunisolide (nasal) 2 MO fluocinolone acetonide (otic) 2 MO

fluorometholone (ophth) 2 MO flurbiprofen sodium 2 MO fluticasone propionate (nasal) 2 MO

FML FORTE SUSP 0.25 % 3 MO

FML LIQUIFILM SUSP 0.1 % 4 MO

FML OINT 0.1 % 3 MO hydrocortisone w/acetic acid 2 MO

ILEVRO 4 MO ketorolac tromethamine (ophth) 2 MO

LOTEMAX 4 MO MAXIDEX 4 MO MAXITROL 4 MO mometasone furoate (nasal) 2 MO

NASONEX 4 MO neomycin-polymy-dexameth 2 MO

neomycin-polymyxin-hc (ophth) 2 MO


Limits neomycin-polymyxin-hc (otic) 2 MO

NEVANAC 4 MO OCUFEN 4 MO OMNARIS 4 MO OMNIPRED SUSP 1 % 4 MO PRED FORTE SUSP 1 % 4 MO

PRED MILD SUSP 0.12 % 3 MO

PRED-G 3 MO PRED-G S.O.P. 3 MO prednisolone acetate (ophth) 2 MO

prednisolone sodium phosphate (ophth) 2 MO

PROLENSA 4 MO QNASL 4 MO QNASL CHILDRENS 4 MO RESTASIS 3 MO sulfacetamide sod-prednisolone 2 MO

TOBRADEX OINT 0.3-0.1 % 3 MO

TOBRADEX ST SUSP 0.3-0.05 % 4 MO

TOBRADEX SUSP 0.3-0.1 % 4 MO

tobramycin-dexamethasone 2 MO

triamcinolone acetonide (nasal) 2 MO

VEXOL 3 MO XIIDRA 4 ZETONNA 4 MO ZYLET 4 MO ANTIALLERGIC AGENTS ALOCRIL 4 MO ALOMIDE 4 MO ASTEPRO 4 MO azelastine hcl 2 MO azelastine hcl (ophth) 2 MO BEPREVE 4 MO cromolyn sodium (ophth) 2 MO DYMISTA 4 MO ELESTAT 4 MO




Limits EMADINE 4 MO ep

2018 comprehensive formulary - kaiser permanente · 2017-09-01 · 2018 formulary that was covered...

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