2019 drug formulary - kaiser permanente · 2019 drug formulary for members covered through large...

XB0001338-50-17All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc.

Effective January 2020

2020 Drug FormularyFor members covered through large employer groups with a 1-tier or 2-tier in-network

pharmacy benefit and no out-of-network pharmacy benefit

Alliance

Core

Drug Formulary INTRODUCTION

What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost.

How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers.

How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs.

Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.

How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage.

Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions.

Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/ formulary. Non-formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug.

Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.

http://www.ghc.org/

http://www.ghc.org/

The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 45 days prior to the effective date.

What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?

Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.

Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.

Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.

High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.

Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.

Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:

• Preferred blood glucose strips:

o One Touch Verio o One Touch Ultra

http://www.kp.org/wa/pharmacy/drug-formulary

o Prodigy – prior authorization required o Contour Next – prior authorization required

o Freestyle – prior authorization required

• Disposable insulin syringes and needles

• Lancing devices and lancets

Preferred blood glucose meters are covered only when filled through mail order pharmacy.

Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.

To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.

Address: Kaiser Permanente Mail Order Pharmacy

PO Box 34383 Seattle, WA 98124-1383

Phone: 800-245-RXRX (1-800-245-7979)

Fax: 206-630-7950, or toll-free 1-800-350-1683

Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at 1-888-630- 4636 to find if you have OTC drug coverage.

Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.

Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.

If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be covered in full.

Excluded Prescription Products for Medications that have Over-The-

Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), and fluticasone propionate nasal spray (Flonase). Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage.

How do I get additional information?

Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document. The most current drug formulary is available at www.kp.org/wa/formulary.

http://www.ghc.org/

http://www.ghc.org/

9

Table of Contents

Analgesics - Drugs for Pain and Inflammation ........................................................................ 11

Analgesics - Drugs for Pain .......................................................................................................... 11

Anesthetics ....................................................................................................................................... 12

Anti-Addiction / Substance Abuse Treatment Agents........................................................... 12

Antibacterials .................................................................................................................................... 12

Anticoagulants ................................................................................................................................. 13

Anticonvulsants - Drugs for Seizures ........................................................................................ 14

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia .............................. 14

Antidepressants ............................................................................................................................... 14

Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 15

Antifungals ........................................................................................................................................ 15

Antigout Agents ............................................................................................................................... 15

Antimigraine Agents ....................................................................................................................... 16

Antimyasthenic Agents .................................................................................................................. 16

Antimycobacterials ......................................................................................................................... 16

Antineoplastics - Drugs for Cancer ............................................................................................ 16

Antiparasitics .................................................................................................................................... 17

Antiparkinson Agents ..................................................................................................................... 17

Antiplatelets ...................................................................................................................................... 17

Antipsychotics - Drugs for Mood Disorders ............................................................................ 17

Antivirals ............................................................................................................................................ 18

Anxiolytics - Drugs for Anxiety .................................................................................................... 19

Bipolar Agents - Drugs for Mood Disorders ............................................................................. 20

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......... 20

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 20

Central Nervous System Agents - Drugs for Attention Deficit Disorder ......................... 22

Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 23

Central Nervous System Agents - Miscellaneous .................................................................. 23

Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 23

Dermatological Agents - Drugs for Skin Conditions ............................................................. 23

Diabetes - Antidiabetic Agents .................................................................................................... 25

Diabetes - Glucose Monitoring .................................................................................................... 26

Diabetes - Glycemic Agents ......................................................................................................... 26

Diabetes - Insulins ........................................................................................................................... 26

Electrolytes / Minerals / Metals / Vitamins ................................................................................ 27

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 28

10

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 28

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 29

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 29

Genitourinary Agents - Drugs for Prostate Conditions ......................................................... 29

Hormonal Agents - Adrenal .......................................................................................................... 29

Hormonal Agents - Men's Health ................................................................................................. 30

Hormonal Agents - Osteoporosis ............................................................................................... 30

Hormonal Agents - Pituitary ......................................................................................................... 30

Hormonal Agents - Prostaglandins ............................................................................................ 30

Hormonal Agents - Sex Hormones and Birth Control ........................................................... 30

Hormonal Agents - Thyroid ........................................................................................................... 33

Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 33

Immunological Agents - Drugs for Vaccination ...................................................................... 34

Inflammatory Bowel Disease Agents ......................................................................................... 35

Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 35

Metabolic Bone Disease Agents - Other ................................................................................... 35

Miscellaneous Therapeutic Agents ............................................................................................ 35

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 36

Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 36

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 36

Otic Agents - Drugs for Ear Conditions ..................................................................................... 37

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 37

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions .............................................................................................................................................................. 38

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 39

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 39

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 39

Sleep Disorder Agents ................................................................................................................... 39

Index of Drugs .................................................................................................................................. 41

Effective Date: 01/01/2020 11

Drug Name Drug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

celecoxib oral 1

choline-mag trisalicylate 1

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium oral 1

diflunisal oral 1

etodolac 1

flurbiprofen oral 1

ibu 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

indomethacin er 1

indomethacin oral 1

ketorolac tromethamine injection

1

ketorolac tromethamine intramuscular

1

meclofenamate sodium oral

1

meloxicam oral 1

nabumetone oral 1

naproxen oral 1

naproxen sodium oral tablet 275 mg, 550 mg

1

piroxicam oral 1

salsalate oral 1

sulindac oral 1

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet 200 mg

1

Analgesics - Drugs for Pain

acetaminophen-codeine 1 QL

acetaminophen-codeine #2

1 QL


1 QL

Drug Name Drug Tier

Notes


1 QL

butalbital-apap-caffeine oral tablet

1

butalbital-aspirin-caffeine 1

codeine sulfate 1 QL

endocet 1 QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; QL

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1 QL

hydromorphone hcl oral 1 QL

hydromorphone hcl rectal 1

levorphanol tartrate oral 1 PA; QL

lorcet 1 QL

lorcet hd 1 QL

lorcet plus 1 QL

methadone hcl intensol 1 ST; QL

methadone hcl oral 1 ST; QL

methadose oral tablet soluble

1 ST; QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1 QL

morphine sulfate er oral tablet extended release

1 ST; QL

morphine sulfate oral 1 QL

morphine sulfate rectal 1

OXYCODONE HCL ER 2 ST; QL

oxycodone hcl oral concentrate 100 mg/5ml

1 QL

oxycodone hcl oral solution

1 QL


Drug Name Drug Tier

Notes

oxycodone hcl oral tablet 1 QL

oxycodone-acetaminophen

1 QL

oxycodone-aspirin 1 QL

OXYCONTIN 2 ST; QL

tramadol hcl ir 1 QL

tramadol-acetaminophen 1 QL

Anesthetics

glydo external gel 2 % 1

lidocaine external patch 1

lidocaine hcl external gel 2 %

1

lidocaine hcl injection solution

1

lidocaine hcl urethral/mucosal external gel

1

lidocaine-prilocaine 1

prilovix 1

prilovix ultralite 1

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium 1

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

1

bupropion hcl er (smoking det)

1

CHANTIX 2

CHANTIX CONTINUING MONTH PAK

2

CHANTIX STARTING MONTH PAK

2

disulfiram oral 1

naloxone hcl injection 1

naltrexone hcl oral 1

NARCAN 1

Drug Name Drug Tier

Notes

NICORETTE MOUTH/THROAT GUM 2 MG

2 PA

nicotine polacrilex mouth/throat

2 PA

nicotine step 1 1 PA



VIVITROL 2 QL

Antibacterials

amoxicillin 1

amoxicillin-potassium clavulanate oral

1

ampicillin 1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 250 mg, 500 mg

1

avidoxy 1

azithromycin oral 1

BICILLIN L-A 2

cefadroxil 1

cefazolin sodium injection solution reconstituted 1 gm

1

cefdinir 1

cefixime 1

cefprozil 1

ceftazidime injection solution reconstituted 1 gm

1

CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML

2

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

1

cefuroxime axetil 1

cephalexin oral capsule 250 mg, 500 mg

1


Drug Name Drug Tier

Notes

cephalexin oral suspension reconstituted

1

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)

2

ciprofloxacin hcl oral 1

ciprofloxacin oral 1

clarithromycin oral 1

clindamycin hcl oral 1

clindamycin palmitate hcl 1

clindamycin phosphate injection solution 300 mg/2ml

1

clindamycin phosphate vaginal

1

dicloxacillin sodium 1

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral tablet

1

FIRVANQ 2

gentamicin sulfate external

1

gentamicin sulfate injection solution 40 mg/ml

1

levofloxacin oral 1

linezolid oral suspension reconstituted

1 QL

linezolid oral tablet 1

methenamine hippurate 1

metronidazole oral tablet 1

metronidazole vaginal 1

minocycline hcl oral capsule

1

mondoxyne nl 1

Drug Name Drug Tier

Notes

morgidox oral 1

moxifloxacin hcl oral 1

mupirocin calcium 1

mupirocin external 1

neomycin sulfate oral 1

nitrofurantoin 1

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

okebo 1

penicillin v potassium 1

PRIMSOL 2

silver sulfadiazine external

1

SIVEXTRO ORAL 2 QL

ssd 1

sulfamethoxazole-trimethoprim oral

1

sulfatrim pediatric 1

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

2

tazicef injection solution reconstituted 1 gm

1

trimethoprim oral 1

TRIMPEX ORAL SOLUTION 50 MG/5ML

2

vancomycin hcl oral capsule

1 QL

vancomycin hcl oral solution reconstituted

1

vandazole 1

Anticoagulants

enoxaparin sodium 1 QL

fondaparinux sodium 1 QL


Drug Name Drug Tier

Notes

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml

1

heparin sodium (porcine) pf

1

jantoven 1

LOVENOX 1 QL

PRADAXA 2

warfarin sodium oral 1

XARELTO 2 PA

XARELTO STARTER PACK

2 PA

Anticonvulsants - Drugs for Seizures

carbamazepine er 1

carbamazepine oral 1

CELONTIN 2

DIASTAT PEDIATRIC 1

diazepam rectal 1

DILANTIN ORAL CAPSULE 30 MG

2

divalproex sodium er 1

divalproex sodium oral 1

epitol 1

ethosuximide oral 1

gabapentin oral 1

lamotrigine oral tablet 1

lamotrigine oral tablet chewable

1

levetiracetam er 1

levetiracetam oral 1

oxcarbazepine 1

phenobarbital oral 1

phenobarbital sodium injection solution 130 mg/ml

1

phenytoin infatabs 1

phenytoin oral 1

Drug Name Drug Tier

Notes

phenytoin sodium extended oral capsule 100 mg

1

phenytoin sodium injection

1

primidone oral 1 QL

roweepra 1

roweepra xr 1

subvenite 1

topiramate oral 1

valproate sodium oral solution 250 mg/5ml

1

valproic acid oral 1

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

donepezil hcl oral tablet 10 mg, 5 mg

1

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl oral tablet 10 mg, 5 mg

1

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1

bupropion hcl oral 1

citalopram hydrobromide 1

clomipramine hcl oral 1

desipramine hcl oral 1

doxepin hcl oral 1

duloxetine hcl oral 1

escitalopram oxalate 1


Drug Name Drug Tier

Notes

fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg

1

fluoxetine hcl oral capsule 1

fluoxetine hcl oral solution 1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

imipramine hcl oral 1

maprotiline hcl 1

mirtazapine oral 1

nortriptyline hcl oral 1

paroxetine hcl 1

PAXIL ORAL SUSPENSION

2

perphenazine-amitriptyline

1

phenelzine sulfate oral 1

protriptyline hcl 1

sertraline hcl oral 1

tranylcypromine sulfate 1

trazodone hcl oral 1

venlafaxine hcl 1

venlafaxine hcl er oral capsule extended release 24 hour

1

Antiemetics - Drugs for Nausea and Vomiting

aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg

1

compro 1

dimenhydrinate injection 1

dronabinol 1

metoclopramide hcl injection

1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

ondansetron hcl injection 1

ondansetron hcl oral 1

Drug Name Drug Tier

Notes

ondansetron odt 1

perphenazine oral 1

prochlorperazine 1

prochlorperazine edisylate injection

1

prochlorperazine maleate oral

1

Antifungals

ciclodan 1

ciclodan external cream 0.77 %

1

ciclopirox external gel 1

ciclopirox external solution

1

ciclopirox olamine external

1

clotrimazole mouth/throat 1

CRESEMBA ORAL 2 PA; QL

fluconazole oral 1

flucytosine oral 2 QL

griseofulvin microsize oral 1

griseofulvin ultramicrosize 1

itraconazole oral 1 PA

ketoconazole external cream

1

ketoconazole external shampoo

1

ketoconazole oral 1

nyamyc 1

nyata external powder 100000 unit/gm

1

nystatin external 1

nystatin mouth/throat 1

nystatin oral 1

nystatin-triamcinolone 1

nystop 1

terbinafine hcl oral 1

voriconazole oral 1 PA

Antigout Agents


Drug Name Drug Tier

Notes

allopurinol oral 1

COLCHICINE ORAL CAPSULE

2

colchicine tablet 0.6 mg oral

1

COLCHICINE TABLET 0.6 MG ORAL

2

colchicine-probenecid 1

COLCRYS 2

probenecid 1

Antimigraine Agents

dihydroergotamine mesylate injection

1 QL

dihydroergotamine mesylate nasal

1

ERGOMAR 2

ergotamine-caffeine 1

MIGERGOT 2

naratriptan hcl 1

rizatriptan benzoate 1

sumatriptan nasal 1

sumatriptan succinate oral

1

sumatriptan succinate refill

1

sumatriptan succinate subcutaneous

1

zolmitriptan oral 1

Antimyasthenic Agents

MESTINON ORAL SYRUP 60 MG/5ML

2

pyridostigmine bromide er 1

pyridostigmine bromide oral

1

Antimycobacterials

dapsone oral 1

ethambutol hcl oral 1

isoniazid oral 1

PRIFTIN 2

pyrazinamide oral 1

Drug Name Drug Tier

Notes

rifabutin 1

rifampin oral 1

Antineoplastics - Drugs for Cancer

abiraterone acetate 1 QL

AFINITOR 2 PA; QL

AFINITOR DISPERZ 2 PA; QL

anastrozole oral 1

bicalutamide 1

capecitabine 1 QL

COTELLIC 2 PA; QL

cyclophosphamide oral 1

DROXIA 2

erlotinib hcl 1 PA

etoposide oral 1 QL

exemestane 1

flutamide 1

GILOTRIF 2 PA; QL

GLEOSTINE 2

hydroxyurea oral 1

imatinib mesylate 1 QL

IMBRUVICA 2 PA; QL

IRESSA 2 PA; QL

letrozole oral 1

leucovorin calcium oral 1

LEUKERAN 2

MATULANE 2 QL

MEKINIST 2 PA; QL

melphalan 1 QL

mercaptopurine oral 1

mesna 1

MESNEX ORAL 2

MYLERAN 2 QL

NEXAVAR 2 PA

REVLIMID 2 PA; QL

RYDAPT 2 PA; QL

SPRYCEL 2 PA; QL

STIVARGA 2 PA


Drug Name Drug Tier

Notes

SUTENT 2 PA; QL

TABLOID 2

TAFINLAR 2 PA; QL

TAGRISSO 2 PA; QL

tamoxifen citrate oral 1

temozolomide 1 QL

THALOMID 2 PA; QL

tretinoin oral 1 QL

TYKERB 2 PA; QL

VENCLEXTA 2 PA; QL

VENCLEXTA STARTING PACK

2 PA; QL

VOTRIENT 2 PA; QL

XTANDI 2 PA; QL

ZELBORAF 2 PA

ZYDELIG 2 PA; QL

ZYTIGA ORAL TABLET 500 MG

2 QL

Antiparasitics

albendazole oral 1

ALINIA 2

atovaquone oral 1

chloroquine phosphate oral

1

crotan 2

DARAPRIM 2 QL

EURAX 2

hydroxychloroquine sulfate oral

1

KRINTAFEL 2

permethrin external 1

praziquantel oral 1

primaquine phosphate 1

ULESFIA 2

Antiparkinson Agents

amantadine hcl oral 1

benztropine mesylate 1

bromocriptine mesylate oral

1

Drug Name Drug Tier

Notes

carbidopa oral 1

carbidopa-levodopa er 1

carbidopa-levodopa oral tablet

1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg

1

carbidopa-levodopa-entacapone

1

DUOPA 2 PA

entacapone 1

pramipexole dihydrochloride

1

rasagiline mesylate oral 1 PA

ropinirole hcl 1

selegiline hcl oral 1

trihexyphenidyl hcl oral elixir

1

trihexyphenidyl hcl oral tablet

1

Antiplatelets

aspirin-dipyridamole er 1

BRILINTA 2

cilostazol 1

clopidogrel bisulfate oral 1

dipyridamole oral 1

prasugrel hcl 1

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA 2 QL

aripiprazole oral solution 1

aripiprazole oral tablet 1

ARISTADA 2 QL

ARISTADA INITIO 2 QL

chlorpromazine hcl injection

1

chlorpromazine hcl oral 1

clozapine oral tablet 1

fluphenazine decanoate injection

1

fluphenazine hcl 1


Drug Name Drug Tier

Notes

haloperidol decanoate intramuscular

1

haloperidol lactate 1

haloperidol oral 1

INVEGA SUSTENNA 2

INVEGA TRINZA 2 QL

loxapine succinate 1

olanzapine 1

PERSERIS 2

pimozide 1

quetiapine fumarate 1

quetiapine fumarate er 1

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG

2

risperidone oral solution 1

risperidone oral tablet 1

thiothixene 1

trifluoperazine hcl 1

ziprasidone hcl 1

ZYPREXA RELPREVV 2

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1 QL

abacavir-lamivudine-zidovudine

1 QL

acyclovir oral 1

adefovir dipivoxil 1 QL

APTIVUS ORAL CAPSULE

2 QL

atazanavir sulfate 1 QL

ATRIPLA 2 QL

BARACLUDE ORAL SOLUTION

2 QL

BIKTARVY 2 QL

CIMDUO 2 QL

Drug Name Drug Tier

Notes

COMPLERA 2 PA; QL

CRIXIVAN 2

DESCOVY 2 QL

didanosine 1

EDURANT 2

efavirenz 1

EMTRIVA 2

entecavir 1 QL

EPCLUSA 2 PA; QL

EPIVIR HBV ORAL SOLUTION

2

fosamprenavir calcium 1 QL

GENVOYA 2

HARVONI 2 PA; QL

INTELENCE 2

INTRON A 2 QL

INVIRASE ORAL CAPSULE 200 MG

2

ISENTRESS HD 2

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET CHEWABLE

2

JULUCA 2 QL

KALETRA ORAL TABLET 2

lamivudine 1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

2 PA; QL

LEXIVA ORAL SUSPENSION

2 QL

lopinavir-ritonavir 1

moderiba oral tablet 200 mg

1 QL

nevirapine er 1

nevirapine oral tablet 1

NORVIR ORAL CAPSULE 100 MG

2

NORVIR ORAL PACKET 2


Drug Name Drug Tier

Notes

NORVIR ORAL SOLUTION

2

ODEFSEY 2 QL

oseltamivir phosphate oral

1

PEGASYS 2 QL

PEGASYS PROCLICK 2 QL

PEGINTRON 2 QL

PREZCOBIX 2 QL

PREZISTA 2

REBETOL ORAL SOLUTION 40 MG/ML

2 QL

RELENZA DISKHALER 2

RESCRIPTOR 2

REYATAZ ORAL PACKET

2

ribasphere oral capsule 200 mg

1 QL

ribasphere oral tablet 200 mg

1 QL

ribavirin oral 1 QL

rimantadine hcl 1

ritonavir 1

SELZENTRY ORAL SOLUTION

2 QL

SELZENTRY ORAL TABLET 150 MG, 300 MG

2 QL

SELZENTRY ORAL TABLET 25 MG, 75 MG

2

SOFOSBUVIR-VELPATASVIR

2 PA; QL

SOVALDI ORAL TABLET 200 MG

2 PA; QL

stavudine 1

STRIBILD 2 PA; QL

SYMFI 1

SYMFI LO 1

SYMTUZA 2 QL

TAMIFLU 2

Drug Name Drug Tier

Notes

tenofovir disoproxil fumarate

1

TIVICAY 2

TRIUMEQ 2 QL

TRUVADA 2 QL

TYBOST 2 PA

valacyclovir hcl oral 1

valganciclovir hcl 1 QL

VIDEX 2

VIRACEPT 2

VIREAD ORAL POWDER 2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

VOSEVI 2 PA; QL

zidovudine 1

Anxiolytics - Drugs for Anxiety

alprazolam er 1

alprazolam oral tablet 1

alprazolam xr 1

buspirone hcl oral 1

chlordiazepoxide hcl 1

clonazepam oral 1

clorazepate dipotassium 1

diazepam injection 1

diazepam intramuscular 1

diazepam oral solution 1

diazepam oral tablet 1

hydroxyzine hcl oral 1

hydroxyzine pamoate oral 1

lorazepam injection solution 2 mg/ml

1

lorazepam intensol 1

lorazepam oral concentrate 2 mg/ml

1

lorazepam oral tablet 1

midazolam hcl injection solution 10 mg/2ml, 5 mg/ml

1


Drug Name Drug Tier

Notes

oxazepam 1

triazolam 1

Bipolar Agents - Drugs for Mood Disorders

lithium 1

lithium carbonate er 1

lithium carbonate oral 1

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

anagrelide hcl 1

EPOGEN 2 PA

HEMLIBRA 2 PA; QL

LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG

2

NEUPOGEN 2 QL

PROCRIT 2 PA

tranexamic acid oral 1 QL

ZARXIO 2 QL

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

acebutolol hcl oral 1

acetazolamide oral tablet 125 mg

1

afeditab cr 1

ALDACTAZIDE ORAL TABLET 50-50 MG

2

alprostadil injection 1

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1

amiodarone hcl oral tablet 200 mg

1

amlodipine besylate oral 1

amlodipine besylate-benazepril hcl

1

amlodipine-olmesartan 1

atenolol oral 1

atenolol-chlorthalidone 1

Drug Name Drug Tier

Notes

atorvastatin calcium oral 1

benazepril hcl oral 1

benazepril-hydrochlorothiazide

1

betaxolol hcl oral 1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

captopril oral 1

captopril-hydrochlorothiazide

1

cartia xt 1

carvedilol 1

chlorothiazide 1

chlorthalidone 1

cholestyramine light packets

1

cholestyramine oral packets

1

clonidine 1

clonidine hcl oral 1

colestipol hcl 1

digitek 1

digox 1

digoxin injection 1

digoxin oral 1

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

1

diltiazem hcl er 1

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

diltiazem hcl oral 1

dilt-xr 1

disopyramide phosphate 1

DIURIL 2

doxazosin mesylate oral 1


Drug Name Drug Tier

Notes

DYRENIUM 2

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 PA

epinephrine injection solution 30 mg/30ml

1

epinephrine pf 1

eplerenone 1

ethacrynic acid 1 PA

ezetimibe 1 PA

ezetimibe-simvastatin 1 PA

felodipine er 1

fenofibrate micronized 1

fenofibrate oral capsule 134 mg, 200 mg, 67 mg

1

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid oral tablet 1

flecainide acetate 1

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide injection 1

furosemide oral 1

gemfibrozil oral 1

guanfacine hcl 1

hydralazine hcl oral 1

hydrochlorothiazide oral 1

indapamide 1

irbesartan 1

irbesartan-hydrochlorothiazide

1

ISORDIL TITRADOSE ORAL TABLET 40 MG

2

isosorbide dinitrate 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

isradipine 1

labetalol hcl oral 1

Drug Name Drug Tier

Notes

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

losartan potassium 1

losartan potassium-hctz 1

lovastatin 1

methyclothiazide oral tablet 5 mg

1

methyldopa 1

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

metoprolol-hydrochlorothiazide

1

mexiletine hcl oral 1

midodrine hcl 1

minitran 1

minoxidil oral 1

moexipril hcl 1

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

1

nadolol oral 1

nicardipine hcl oral 1

nifedipine er 1

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

NITRO-BID 2

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin er oral capsule extended release 9 mg

1

nitroglycerin sublingual 1

nitroglycerin transdermal 1


Drug Name Drug Tier

Notes

nitro-time oral capsule extended release 9 mg

1

NORPACE CR 2

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

pacerone oral tablet 200 mg

1

papaverine hcl injection 1

pentoxifylline er 1

perindopril erbumine 1

phenoxybenzamine hcl oral

1

phentolamine mesylate injection

1

pindolol 1

pravastatin sodium 1

prazosin hcl oral 1

prevalite 1

procainamide hcl injection 1

propafenone hcl 1

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

quinidine sulfate 1

ramipril 1

RECTIV 2

rosuvastatin calcium 1

simvastatin oral 1

sorine 1

sotalol hcl (af) 1

sotalol hcl oral 1

spironolactone oral 1

spironolactone-hctz 1

Drug Name Drug Tier

Notes

timolol maleate oral 1

torsemide 1

trandolapril 1

triamterene oral 1

triamterene-hctz 1

valsartan 1

valsartan-hydrochlorothiazide

1

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release

1

verapamil hcl oral 1

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL XR 1 QL

amphetamine-dextroamphetamine

1

amphetamine-dextroamphetamine er

1 QL

atomoxetine hcl 1 ST

CONCERTA 1 QL

dexmethylphenidate hcl 1

dextroamphetamine sulfate er

1 QL

dextroamphetamine sulfate oral tablet

1

guanfacine hcl er 1

metadate er 1 QL

methylphenidate hcl er 1 QL

methylphenidate hcl er (cd)

1 QL

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg

1 ST; QL

methylphenidate hcl oral tablet

1

relexxii 1 QL


Drug Name Drug Tier

Notes

Central Nervous System Agents - Drugs for Multiple Sclerosis

AVONEX PEN 2 PA; QL

AVONEX PREFILLED 2 PA; QL

AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG

2 PA; QL

EXTAVIA 1 QL

GILENYA 2 PA; QL

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml

1 QL

glatopa subcutaneous solution prefilled syringe 20 mg/ml

1 QL

REBIF 2 PA; QL

REBIF REBIDOSE 2 PA; QL

REBIF REBIDOSE TITRATION PACK

2 PA; QL

REBIF TITRATION PACK 2 PA; QL

Central Nervous System Agents - Miscellaneous

caffeine citrate oral 1

pregabalin oral 1 QL

riluzole 1 QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

chlorhexidine gluconate mouth/throat

1

lidocaine viscous mouth/throat solution 2 %

1

oralone 1

paroex 1

periogard 1

pilocarpine hcl oral tablet 5 mg

1

triamcinolone acetonide mouth/throat

1

Dermatological Agents - Drugs for Skin Conditions

acitretin 1 QL

Drug Name Drug Tier

Notes

adapalene external cream 1

adapalene external gel 1

ADAPALENE EXTERNAL LOTION 0.1 %

2

ala-cort external cream 2.5 %

1

alclometasone dipropionate

1

AMELUZ 2 QL

amnesteem 1

avar cleanser 1

avita 1

azelaic acid external 1

AZELEX 2

benzoyl peroxide-erythromycin

1

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

betamethasone valerate external

1

calcipotriene 1

CAPEX 2

CARAC 2

claravis 1

clindacin etz external swab

1

clindacin-p 1

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1

clindamycin phosphate external gel

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

clobetasol propionate external gel

1


Drug Name Drug Tier

Notes

clobetasol propionate external lotion

1

clobetasol propionate external ointment

1

clobetasol propionate external solution

1

clotrimazole-betamethasone

1

CONDYLOX 2

CORDRAN EXTERNAL TAPE

2

cormax scalp application external solution 0.05 %

1

CORTISPORIN EXTERNAL OINTMENT

2

desonide external 1

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external ointment

1

DIFFERIN EXTERNAL CREAM

1

DIFFERIN EXTERNAL LOTION

2

DRYSOL 2

ELIDEL 1

erythromycin external 1

FINACEA EXTERNAL FOAM

2

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide emulsified base

1

fluocinonide external cream 0.05 %

1

fluocinonide external gel 1

Drug Name Drug Tier

Notes

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOROPLEX 2

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

fluorouracil external solution

1

fluticasone propionate external cream

1

halobetasol propionate external cream

1

halobetasol propionate external ointment

1

hydrocortisone ace-pramoxine external

1

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone in absorbase external ointment 1 %

1

hydrocortisone valerate 1

imiquimod external 1

isotretinoin oral 1

LEVULAN KERASTICK 2 QL

methoxsalen oral 1 QL

methoxsalen rapid 1 QL

metronidazole external cream

1


Drug Name Drug Tier

Notes

metronidazole external gel 0.75 %

1

mometasone furoate external

1

myorisan 1

PICATO 2 QL

pimecrolimus cream 1 % external

1

PIMECROLIMUS CREAM 1 % EXTERNAL

2

podofilox external 1

PRAMOSONE EXTERNAL CREAM 1-1 %

2

PRAMOSONE EXTERNAL LOTION

2

rea lo 40 external cream 40 %

1

RETIN-A 1

RETIN-A MICRO GEL 0.04 %, 0.1 %

1

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %

1

rosadan external cream 1

rosadan external gel 1

rosanil cleanser external emulsion 10-5 %

1

SANTYL 2

selenium sulfide external lotion

1

sodium sulfacetamide 1

sulfacetamide sodium (acne)

1

sulfacetamide sodium-sulfur external emulsion

1

sulfacetamide sodium-sulfur external lotion 10-5 %

1

sulfacetamide-sulfur in urea

1

tacrolimus external 1

tazarotene external 1

Drug Name Drug Tier

Notes

TAZORAC EXTERNAL CREAM 0.05 %

2

TAZORAC EXTERNAL CREAM 0.1 %

1

TAZORAC EXTERNAL GEL

2

tretinoin external cream 1

tretinoin external gel 0.01 %, 0.025 %

1

tretinoin microsphere 1

tretinoin microsphere pump

1

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triderm 1

urea external cream 40 % 1

uremez-40 1

VECTICAL 1

zenatane 1

Diabetes - Antidiabetic Agents

acarbose oral 1

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

glyburide oral 1

JARDIANCE 2 PA; QL

metformin hcl er 1

METFORMIN HCL ORAL SOLUTION

2

metformin hcl oral tablet 1

RIOMET 2

tolazamide oral tablet 250 mg, 500 mg

1

tolbutamide 1


Drug Name Drug Tier

Notes

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO

1

ACCU-CHEK COMPACT PLUS CONTROL

1

ACCU-CHEK FASTCLIX LANCET KIT

1

ACCU-CHEK GUIDE CONTROL

1

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

1

ACCU-CHEK SMARTVIEW CONTROL

1

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

1

AUTOLET LANCING DEVICE

1

BAYER BREEZE 2 TEST IN VITRO DISK

1 PA; QL

BAYER CONTOUR IN VITRO LIQUID HIGH , LOW , NORMAL

1

CARETOUCH LANCING/EJECTOR

1

CONTOUR NEXT CONTROL

1

CONTOUR NEXT TEST 1 PA; QL

DIATHRIVE GLUCOSE CONTROL SOLN

1

DIATHRIVE LANCING DEVICE

1

EASYMAX CONTROL 1

EMBRACE TALK GLUCOSE CONTROL

1

FORTISCARE CONTROL 1

FREESTYLE TEST 1 PA; QL

GENTEEL LANCING KIT (BLUE)

1

LANCETS 1

LANCETS KIT 1

MICROLET NEXT LANCING DEVICE

1

Drug Name Drug Tier

Notes

ONETOUCH DELICA LANCING DEV

1

ONETOUCH DELICA PLUS LANCING

1

ONETOUCH ULTRA BLUE TEST STRIPS

1 QL

ONETOUCH VERIO IN VITRO SOLUTION HIGH

1

ONETOUCH VERIO TEST STRIPS

1 QL

SURESTEP PRO HIGH GLUCOSE

1

SURESTEP PRO LOW GLUCOSE

1

SURESTEP PRO NORMAL GLUCOSE

1

TRUE METRIX LEVEL 1 1



UNISTRIP CONTROL IN VITRO SOLUTION LOW

1

VIVAGUARD INO CONTROL SOLUTION

1

VIVAGUARD LANCING DEVICE

1

Diabetes - Glycemic Agents

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY

2

PROGLYCEM 2

Diabetes - Insulins

BD AUTOSHIELD DUO PEN NEEDLES

1

BD ULTRA-FINE INSULIN SYRINGES

1

BD ULTRA-FINE PEN NEEDLES

1

HUMALOG 2

HUMALOG KWIKPEN 2

HUMALOG U-100 JUNIOR KWIKPEN

2


Drug Name Drug Tier

Notes

HUMULIN 70/30 KWIKPEN

1

HUMULIN 70/30 VIAL 1

HUMULIN N KWIKPEN 1

HUMULIN N VIAL 1

HUMULIN R U-500 KWIKPEN

1

HUMULIN R U-500 VIAL (CONCENTRATED)

1

HUMULIN R VIAL 1

INSULIN PEN NEEDLES 1

INSULIN SYRINGES 1

LANTUS SOLOSTAR 2 PA

LANTUS U-100 VIAL 2 PA

LEVEMIR U-100 FLEXTOUCH

2 PA

LEVEMIR U-100 VIAL 2 PA

MAXICOMFORT SYR 27G X 1/2"

1

NOVOFINE AUTOCOVER PEN NEEDLE

1

NOVOFINE PEN NEEDLE

1

NOVOFINE PLUS PEN NEEDLE

1

NOVOTWIST PEN NEEDLE

1

ULTIGUARD SAFEPACK PEN NEEDLE

1

Electrolytes / Minerals / Metals / Vitamins

argyle sterile saline 1

CARNITOR ORAL 1

CARNITOR SF 1

curity sterile saline 1

cyanocobalamin injection solution 1000 mcg/ml

1

cytra k crystals 1

ergocalciferol oral capsule 1

Drug Name Drug Tier

Notes

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 2.2 (1 f) mg

1

FLURA-DROPS 2

folic acid injection 1

folic acid oral tablet 1 mg 1

kionex oral powder 1

klor-con 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

2

klor-con m20 1

klor-con sprinkle 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ

1

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ

2

levocarnitine oral solution 1

levocarnitine oral tablet 1

ludent oral tablet chewable 0.55 (0.25 f) mg

1

MEPHYTON 1

nafrinse 1

ORACIT 2

phospha 250 neutral 1

phosphorous 1

phospho-trin 250 neutral 1

phytonadione injection 1

phytonadione oral 1

potassium chloride crys er 1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1


Drug Name Drug Tier

Notes

potassium citrate-citric acid

1

potassium citrate-citric acid oral packet 3300-1002 mg

1

sod citrate-citric acid 1

sodium chloride injection solution 0.9 %

1

sodium chloride irrigation 1

sodium fluoride oral solution

1

sodium fluoride oral tablet 1.1 (0.5 f) mg

1

sodium fluoride oral tablet chewable

1

sodium polystyrene sulfonate oral

1

sps 1

taron-crystals 1

tricitrates 1

virt-phos 250 neutral 1

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin k1 injection 1

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

CARAFATE ORAL SUSPENSION

2

cimetidine hcl 1

cimetidine oral 1

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1

lansoprazole oral capsule delayed release

1 ST

misoprostol oral 1

omeprazole oral capsule delayed release

1

pantoprazole sodium oral 1

Drug Name Drug Tier

Notes

rabeprazole sodium oral tablet delayed release

1 ST

ranitidine hcl oral syrup 1

ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral suspension 2

sucralfate oral tablet 1

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

belladonna alkaloids-opium

1

chlordiazepoxide-clidinium

1

constulose 1

dicyclomine hcl oral 1

diphenoxylate-atropine 1

enulose 1

gavilyte-c 1

gavilyte-g oral solution reconstituted 236 gm

1

gavilyte-n with flavor pack 1

generlac 1

glycopyrrolate injection solution

1

glycopyrrolate oral tablet 1 mg, 2 mg

1

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

2

lactulose encephalopathy 1

lactulose oral solution 1

loperamide hcl oral capsule

1

opium 1

peg 3350/electrolytes oral solution reconstituted 240 gm

1

peg 3350-kcl-na bicarb-nacl

1

peg-3350/electrolytes 1


Drug Name Drug Tier

Notes

pegylax oral powder 1

polyethylene glycol 3350 oral

1

propantheline bromide oral

1

PYLERA 2

RELISTOR SUBCUTANEOUS

2

trilyte 1

ursodiol oral 1

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

CERDELGA 2 PA; QL

CREON 2

CYSTAGON 2 PA

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation 1

bethanechol chloride oral 1

calcium acetate (phos binder)

1

CUPRIMINE 1 PA; QL

DEPEN TITRATABS 2 PA; QL

D-PENAMINE 2 PA; QL

ELMIRON 2

flavoxate hcl 1

oxybutynin chloride er 1

oxybutynin chloride oral 1

penicillamine oral 1 PA; QL

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

sevelamer carbonate 1

sevelamer hcl 1

solifenacin succinate 1

tolterodine tartrate 1

tolterodine tartrate er 1

Drug Name Drug Tier

Notes

trospium chloride 1

trospium chloride er 1

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

dutasteride oral 1

finasteride oral tablet 5 mg

1

tamsulosin hcl 1

terazosin hcl 1

Hormonal Agents - Adrenal

cortisone acetate oral 1

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

2

dexamethasone intensol 2

dexamethasone oral elixir 1

dexamethasone oral solution

1

dexamethasone oral tablet

1

dexamethasone sod phosphate pf injection solution

1

dexamethasone sodium phosphate injection

1

fludrocortisone acetate oral

1

hydrocortisone oral 1

MEDROL ORAL TABLET 2 MG

2

methylprednisolone oral 1

methylprednisolone sodium succ injection solution reconstituted 125 mg

1

prednisolone oral 1

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisone oral 1


Drug Name Drug Tier

Notes

SOLU-CORTEF 2

Hormonal Agents - Men's Health

danazol oral 1

DEPO-TESTOSTERONE (brand testosterone cypionate intramuscular)

1 PA

TESTOSTERONE CYPIONATE INJECTION

1 PA

testosterone cypionate intramuscular

1 PA

testosterone enanthate intramuscular

1 PA

testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

1 PA; QL

Hormonal Agents - Osteoporosis

raloxifene hcl 1 PA

Hormonal Agents - Pituitary

ACTHAR 2 PA; QL

cabergoline 1

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate spray

1

leuprolide acetate injection

1

LUPRON DEPOT (1-MONTH)

2

LUPRON DEPOT (3-MONTH)

2

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2

Drug Name Drug Tier

Notes

LUPRON DEPOT-PED (1-MONTH)

2

LUPRON DEPOT-PED (3-MONTH)

2

NOCTIVA 2

octreotide acetate 1

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA; QL

SANDOSTATIN LAR DEPOT

2 QL

STIMATE 2

Hormonal Agents - Prostaglandins

CERVIDIL 2

PREPIDIL 2

PROSTIN E2 2

Hormonal Agents - Sex Hormones and Birth Control

afirmelle 1

altavera 1

alyacen 1/35 1

alyacen 7/7/7 1

apri 1

aranelle 1

aubra 1

aubra eq 1

aurovela 1.5/30 1

aurovela 1/20 1

aurovela fe 1.5/30 1

aurovela fe 1/20 1

aviane 1

ayuna 1

balziva 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

briellyn 1

camila 1

caziant 1


Drug Name Drug Tier

Notes

chateal 1

chateal eq 1

CLIMARA 1

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1

cyred 1

cyred eq 1

dasetta 1/35 1

dasetta 7/7/7 1

deblitane 1

DELESTROGEN 2

delyla 1

DEPO-ESTRADIOL 2

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

1

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

1

elinest 1

ELLA 2

emoquette 1

enpresse-28 1

enskyce 1

errin 1

estarylla 1

estradiol oral 1

estradiol transdermal patch weekly

1

estradiol vaginal 1

estradiol valerate intramuscular

1

ESTRING 2

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg

1

ethynodiol diac-eth estradiol

1

falmina 1

Drug Name Drug Tier

Notes

FEMRING 2

femynor 1

gildagia oral tablet 0.4-35 mg-mcg

1

hailey 1.5/30 1

heather 1

incassia 1

isibloom 1

jencycla 1

jolivette oral tablet 0.35 mg

1

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

kalliga 1

kelnor 1/35 1

kelnor 1/50 1

kurvelo 1

larin 1.5/30 1

larin 1/20 1

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

leena 1

lessina 1

levonest 1

levonorgestrel 1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1

levonorg-eth estrad triphasic oral tablet

1

levora 0.15/30 (28) 1

lillow 1

low-ogestrel 1

lutera 1


Drug Name Drug Tier

Notes

lyza 1

MAKENA SUBCUTANEOUS

2 QL

marlissa 1

medroxyprogesterone acetate intramuscular

1

medroxyprogesterone acetate oral

1

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

1

megestrol acetate oral tablet

1

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1.5/30 1

microgestin fe 1/20 1

mili 1

MIRENA (52 MG) 2

mono-linyah 1

mononessa 1

myzilra oral tablet 50-30/75-40/ 125-30 mcg

1

necon 0.5/35 (28) 1

necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg

1

nora-be 1

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg

1

norethindrone acetate oral

1

norethindrone acet-ethinyl est

1

norethindrone oral 1

norgestimate-eth estradiol 1

norgestimate-ethinyl estradiol triphasic

1

norlyda 1

norlyroc 1

nortrel 0.5/35 (28) 1

Drug Name Drug Tier

Notes

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

nortrel 7/7/7 1

NUVARING 2

ocella 1

ogestrel 1

orsythia 1

PARAGARD INTRAUTERINE COPPER

2

philith 1

pirmella 1/35 1

pirmella 7/7/7 1

PLAN B ONE-STEP 1

portia-28 1

PREMARIN VAGINAL 2

PREVENTEZA 1

previfem 1

progesterone intramuscular

1

progesterone micronized oral

1

reclipsen 1

sharobel 1

SKYLA 2

sprintec 28 1

sronyx 1

syeda 1

tarina fe 1/20 1

tarina fe 1/20 eq 1

tri femynor 1

tri-estarylla 1

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1


Drug Name Drug Tier

Notes

tri-mili 1

trinessa (28) 1

trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg

1

tri-previfem 1

tri-sprintec 1

trivora (28) 1

tri-vylibra 1

tri-vylibra lo 1

tulana 1

velivet 1

vienva 1

vyfemla 1

vylibra 1

wera 1

xulane 1

yuvafem 1

zarah 1

zenchent oral tablet 0.4-35 mg-mcg

1

zovia 1/35e (28) 1

zovia 1/50e (28) oral tablet 1-50 mg-mcg

1

zumandimine 1

Hormonal Agents - Thyroid

levothyroxine sodium oral 1

liothyronine sodium oral 1

methimazole oral 1

propylthiouracil oral 1

Immunological Agents - Drugs for Immune System Stimulation or Suppression

azathioprine oral 1

BERINERT 2 PA; QL

COSENTYX (300 MG DOSE)

2 PA; QL

COSENTYX 150 MG/ML 2 PA; QL

COSENTYX SENSOREADY (300 MG)

2 PA; QL

Drug Name Drug Tier

Notes

COSENTYX SENSOREADY PEN

2 PA; QL

CUVITRU 2 PA; QL

cyclosporine modified 1

cyclosporine oral 1

ENBREL 2 PA; QL

ENBREL MINI 2 PA; QL

ENBREL SURECLICK 2 PA; QL

FIRAZYR 2 PA; QL

gengraf 1

HIZENTRA 2 PA; QL

HUMIRA 2 PA; QL

HUMIRA PEDIATRIC CROHNS START

2 PA; QL

HUMIRA PEN 2 PA; QL

HUMIRA CITRATE FREE 2 PA; QL

HUMIRA PEN-PS/UV/ADOL HS START

2 PA; QL

HYPERHEP B S/D 2

HYQVIA 2 PA; QL

icatibant acetate 2 QL

leflunomide oral 1

methotrexate oral 1

methotrexate sodium 1

methotrexate sodium (pf) 1

mycophenolate mofetil 1

mycophenolate sodium 1

NABI-HB 2

ORENCIA CLICKJECT 2 PA; QL

ORENCIA SUBCUTANEOUS

2 PA; QL

OTEZLA 2 PA; QL

RASUVO 2

RIDAURA 2 QL

sirolimus oral 1

STELARA SUBCUTANEOUS

2 PA; QL

tacrolimus oral 1

XELJANZ 2 PA; QL


Drug Name Drug Tier

Notes

XELJANZ XR 2 PA; QL

Immunological Agents - Drugs for Vaccination

ACTHIB 2

ADACEL 2

AFLURIA INTRAMUSCULAR SUSPENSION

1

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

1

AFLURIA QUADRIVALENT

1

BEXSERO 2

BOOSTRIX 2

DAPTACEL 2

DIPHTHERIA-TETANUS TOXOIDS DT

2

ENGERIX-B 2

EZ FLU SHOT-FLUCELVAX QUAD INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML

1

FLUAD 1

FLUARIX QUADRIVALENT

1

FLUBLOK INTRAMUSCULAR SOLUTION

1

FLUBLOK QUADRIVALENT

1

FLUCELVAX QUADRIVALENT

1

FLULAVAL QUADRIVALENT

1

FLUMIST QUADRIVALENT

1

FLUVIRIN INTRAMUSCULAR SUSPENSION

1

Drug Name Drug Tier

Notes

FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

1

FLUZONE HIGH-DOSE 1

FLUZONE QUADRIVALENT

1

FLUZONE QUADRIVALENT INTRADERMAL SUSPENSION PEN-INJECTOR 9 MCG/STRAIN

1

GARDASIL 9 2

HAVRIX 2

HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5ML

2

HIBERIX 2

INFANRIX 2

IPOL 2

KINRIX 2

MENACTRA 2

MENVEO 2

M-M-R II SUBCUTANEOUS INJECTABLE

2

PEDIARIX 2

PEDVAX HIB 2

PENTACEL 2

PNEUMOVAX 23 2

PREVNAR 13 2

PROQUAD SUBCUTANEOUS INJECTABLE

2

QUADRACEL 2

RECOMBIVAX HB 2

ROTARIX 2

ROTATEQ 2

SHINGRIX 2


Drug Name Drug Tier

Notes

TDVAX 2

TENIVAC 2

TRUMENBA 2

VAQTA INTRAMUSCULAR SUSPENSION 50 UNIT/ML

2

VARIVAX 2

ZOSTAVAX 2

Inflammatory Bowel Disease Agents

balsalazide disodium 1

colocort 1

CORTIFOAM 2

hydrocortisone rectal cream 2.5 %

1

hydrocortisone rectal enema

1

LIALDA 1 ST

mesalamine oral tablet delayed release

1 ST

mesalamine rectal 1

PENTASA 2 ST

PROCTOFOAM HC 2

procto-med hc 1

proctosol hc 1

proctozone-hc 1

sulfasalazine oral 1

Metabolic Bone Disease Agents - Drugs for Osteoporosis

alendronate sodium 1

ibandronate sodium oral 1

risedronate sodium oral tablet

1 ST

Metabolic Bone Disease Agents - Other

calcitriol oral 1

etidronate disodium 1

Miscellaneous Therapeutic Agents

ALCOHOL PREP PADS PAD , 70 %

1

Drug Name Drug Tier

Notes

BREATHE EASE LARGE 2

BREATHE EASE MEDIUM

2

BREATHE EASE SMALL 2

BREATHERITE 2

CAYA 2

COMPACT SPACE CHAMBER/LG MASK

2

COMPACT SPACE CHAMBER/MED MASK

2

COMPACT SPACE CHAMBER/SM MASK

2

deferoxamine mesylate injection solution reconstituted 500 mg

1

EASIVENT 2

FEMCAP 2

FLEXICHAMBER ADULT MASK/SMALL

2

FLEXICHAMBER CHILD MASK/LARGE

2

FLEXICHAMBER CHILD MASK/SMALL

2

GLUCAGEN DIAGNOSTIC

2

GLUCAGON HCL (DIAGNOSTIC)

2

MASK VORTEX 2

methergine 1

methylergonovine maleate

1

PANDA MASK LARGE 2

PANDA MASK MEDIUM 2

PANDA MASK SMALL 2

PEDIATRIC PANDA MASK

2

pocket spacer 2

PRO COMFORT SPACER ADULT

2

PRO COMFORT SPACER CHILD

2


Drug Name Drug Tier

Notes

PROCARE SPACER/ADULT MASK

2

PROCARE SPACER/CHILD MASK

2

WIDE-SEAL DIAPHRAGM 60

2

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ALOMIDE 2

azelastine hcl ophthalmic 1

bacitracin ophthalmic 1

CILOXAN OPHTHALMIC OINTMENT

2

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

dexamethasone sodium phosphate ophthalmic

1

diclofenac sodium ophthalmic

1

DUREZOL 2

erythromycin ophthalmic 1

fluorometholone 1

flurbiprofen sodium 1

FML 2

FML FORTE 2

gatifloxacin ophthalmic 1

gentak 1

gentamicin sulfate ophthalmic

1

ketorolac tromethamine ophthalmic

1

MOXEZA 2

moxifloxacin hcl ophthalmic

1

NATACYN 2

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic solution 0.1 %

1

PRED MILD 2

Drug Name Drug Tier

Notes

prednisolone acetate ophthalmic

1

prednisolone acetate p-f 1

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX OPHTHALMIC OINTMENT

2

trifluridine 1

VIGAMOX 2

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral tablet 250 mg

1

AZOPT 2

betaxolol hcl ophthalmic 1

BETOPTIC-S 2

bimatoprost ophthalmic 1

brimonidine tartrate ophthalmic solution 0.2 %

1

carteolol hcl 1

dorzolamide hcl ophthalmic

1

dorzolamide hcl-timolol mal

1

latanoprost ophthalmic 1

levobunolol hcl 1

LUMIGAN 2

methazolamide oral 1

metipranolol ophthalmic solution 0.3 %

1

pilocarpine hcl ophthalmic 1

timolol maleate ophthalmic gel forming solution

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1

TRAVATAN Z 2

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions


Drug Name Drug Tier

Notes

ak-poly-bac 1

altafrin 1

ATROPINE SULFATE OPHTHALMIC EMULSION

1

atropine sulfate ophthalmic ointment

1

atropine sulfate ophthalmic solution

1

ATROPINE SULFATE-NACL OPHTHALMIC SOLUTION 0.01-0.9 %

2

bacitracin-polymyxin b ophthalmic

1

bacitra-neomycin-polymyxin-hc

1

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

2 PA

homatropaire 1

homatropine hbr 1

LACRISERT 2

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin

1

neo-polycin hc 1

phenylephrine hcl ophthalmic

1

polycin 1

polymyxin b-trimethoprim 1

PRED-G 2

PRED-G S.O.P. 2

RESTASIS 2 PA

Drug Name Drug Tier

Notes

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

2 PA

sulfacetamide-prednisolone ophthalmic solution

1

TOBRADEX OPHTHALMIC OINTMENT

2

tobramycin-dexamethasone

1

XIIDRA 2 PA

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CIPRO HC 2

CIPRODEX 2

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

azelastine hcl nasal 1

benzonatate oral capsule 100 mg, 200 mg

1

carbinoxamine maleate 1

clemastine fumarate oral tablet 2.68 mg

1

cyproheptadine hcl oral 1

desloratadine 1

diphenhydramine hcl injection

1

flunisolide nasal 1

hydrocodone-homatropine

1

hydromet 1

ipratropium bromide nasal 1

levocetirizine dihydrochloride oral

1

nebusal inhalation nebulization solution 3 %

1

phenadoz 1


Drug Name Drug Tier

Notes

phenergan rectal suppository 12.5 mg, 25 mg, 50 mg

1

promethazine hcl oral 1

promethazine hcl rectal 1

promethazine vc plain oral solution 6.25-5 mg/5ml

1

promethazine-dm 1

promethazine-dm oral solution 6.25-15 mg/5ml

1

promethazine-phenylephrine

1

promethegan 1

pulmosal 1

ryvent 1

sodium chloride inhalation nebulization solution 0.9 %, 3 %, 7 %

1

SSKI 2

SURVANTA 2

tussigon oral tablet 5-1.5 mg

1

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

acetylcysteine inhalation 1

ADVAIR DISKUS 1 ST

ADVAIR HFA 2 ST

albuterol sulfate inhalation 1

albuterol sulfate oral 1

ALVESCO 2

ASMANEX (120 METERED DOSES)

2 ST


2 ST


2 ST


2 ST


2 ST

Drug Name Drug Tier

Notes

ASMANEX HFA 2 ST

ATROVENT HFA 2

budesonide inhalation 1

COMBIVENT RESPIMAT 2

cromolyn sodium inhalation

1

epinephrine injection solution 0.3 mg/0.3ml

1

epinephrine injection solution auto-injector

1

EPIPEN 2-PAK 2

EPIPEN JR 2-PAK 2

ESBRIET 2 PA; QL

FLOVENT DISKUS 2 PA

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT

2 PA

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

2

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1 ST

ipratropium bromide inhalation

1

ipratropium-albuterol 1

metaproterenol sulfate oral

1

metaproterenol sulfate oral tablet 10 mg, 20 mg

1

montelukast sodium oral 1

OFEV 2 PA; QL

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT

2

SEREVENT DISKUS 2 ST

SPIRIVA HANDIHALER 2


Drug Name Drug Tier

Notes

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

2 ST

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT 2 PA

terbutaline sulfate oral 1

theochron 1

theophylline 1

theophylline er 1

VENTOLIN HFA 2 QL

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

PULMOZYME 2

tobramycin inhalation 1 PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ambrisentan 1 PA; QL

bosentan 1 PA; QL

OPSUMIT 2 PA; QL

sildenafil citrate oral tablet 20 mg

1 PA

TYVASO 2 PA; QL

TYVASO REFILL 2 PA; QL

TYVASO STARTER 2 PA; QL

UPTRAVI 2 PA; QL

VENTAVIS 2 PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen oral 1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

1 QL

dantrolene sodium oral 1

methocarbamol injection 1

methocarbamol oral 1 QL

orphenadrine citrate er 1 QL

Drug Name Drug Tier

Notes

tizanidine hcl oral tablet 1

Sleep Disorder Agents

eszopiclone 1

flurazepam hcl 1

modafinil 1

SECONAL 2

temazepam oral capsule 15 mg, 30 mg, 7.5 mg

1

zaleplon 1

zolpidem tartrate oral 1

41

Index of Drugs

A abacavir sulfate ............... 18 abacavir sulfate-lamivudine

.................................... 18 abacavir-lamivudine-

zidovudine ................... 18 ABILIFY MAINTENA ........ 17 abiraterone acetate.......... 16 acamprosate calcium ....... 12 acarbose ......................... 25 ACCU-CHEK AVIVA

DEVICE ....................... 26 ACCU-CHEK COMPACT

PLUS CONTROL ......... 26 ACCU-CHEK FASTCLIX

LANCET KIT ................ 26 ACCU-CHEK GUIDE

CONTROL ................... 26 ACCU-CHEK MULTICLIX

LANCET DEVICE KIT .. 26 ACCU-CHEK SMARTVIEW

CONTROL ................... 26 ACCU-CHEK SOFTCLIX

LANCET DEVICE KIT .. 26 acebutolol hcl .................. 20 acetaminophen-codeine .. 11 acetaminophen-codeine #2

.................................... 11 acetaminophen-codeine #3

.................................... 11 acetaminophen-codeine #4

.................................... 11 acetazolamide ........... 20, 36 acetazolamide er ............. 36 acetic acid ................. 29, 37 acetylcysteine .................. 38 acitretin ............................ 23 ACTHAR ......................... 30 ACTHIB ........................... 34 acyclovir .......................... 18 ADACEL .......................... 34 adapalene ....................... 23 ADAPALENE ................... 23 ADDERALL XR ............... 22 adefovir dipivoxil .............. 18 ADVAIR DISKUS ............. 38 ADVAIR HFA ................... 38 afeditab cr ....................... 20 AFINITOR ....................... 16 AFINITOR DISPERZ ....... 16 afirmelle ........................... 30 AFLURIA ......................... 34

AFLURIA PRESERVATIVE FREE........................... 34

AFLURIA QUADRIVALENT .................................... 34

ak-poly-bac...................... 37 ala-cort ............................ 23 albendazole ..................... 17 albuterol sulfate ............... 38 alclometasone dipropionate

.................................... 23 ALCOHOL PREP PADS .. 35 ALDACTAZIDE ............... 20 alendronate sodium ......... 35 alfuzosin hcl er ................ 29 ALINIA ............................. 17 allopurinol ........................ 16 ALOMIDE ........................ 36 alprazolam....................... 19 alprazolam er .................. 19 alprazolam xr ................... 19 alprostadil ........................ 20 altafrin ............................. 37 altavera ........................... 30 ALVESCO ....................... 38 alyacen 1/35 .................... 30 alyacen 7/7/7 ................... 30 amantadine hcl ................ 17 ambrisentan .................... 39 AMELUZ ......................... 23 amiloride hcl .................... 20 amiloride-

hydrochlorothiazide ..... 20 amiodarone hcl ................ 20 amitriptyline hcl ............... 14 amlodipine besylate ......... 20 amlodipine besylate-

benazepril hcl .............. 20 amlodipine-olmesartan .... 20 amnesteem ..................... 23 amoxapine....................... 14 amoxicillin ....................... 12 amoxicillin-potassium

clavulanate .................. 12 amphetamine-

dextroamphetamine ..... 22 amphetamine-

dextroamphetamine er . 22 ampicillin ......................... 12 ampicillin sodium ............. 12 anagrelide hcl .................. 20 anastrozole...................... 16 aprepitant ........................ 15 apri .................................. 30

APTIVUS......................... 18 aranelle ........................... 30 argyle sterile saline ......... 27 aripiprazole ..................... 17 ARISTADA ...................... 17 ARISTADA INITIO ........... 17 ASMANEX (120 METERED

DOSES) ...................... 38 ASMANEX (14 METERED




DOSES) ...................... 38 ASMANEX HFA .............. 38 aspirin-dipyridamole er .... 17 atazanavir sulfate ............ 18 atenolol ........................... 20 atenolol-chlorthalidone .... 20 atomoxetine hcl ............... 22 atorvastatin calcium ........ 20 atovaquone ..................... 17 ATRIPLA ......................... 18 atropine sulfate ............... 37 ATROPINE SULFATE ..... 37 ATROPINE SULFATE-

NACL .......................... 37 ATROVENT HFA ............ 38 aubra ............................... 30 aubra eq .......................... 30 aurovela 1.5/30 ............... 30 aurovela 1/20 .................. 30 aurovela fe 1.5/30 ........... 30 aurovela fe 1/20 .............. 30 AUTOLET LANCING

DEVICE ....................... 26 avar cleanser .................. 23 aviane ............................. 30 avidoxy ............................ 12 avita ................................ 23 AVONEX PEN ................. 23 AVONEX PREFILLED ..... 23 AVONEX VIAL

INTRAMUSCULAR KIT .................................... 23

ayuna .............................. 30 azathioprine .................... 33 azelaic acid ..................... 23 azelastine hcl ............ 36, 37 AZELEX .......................... 23 azithromycin .................... 12

42

AZOPT ............................ 36 B bacitracin ......................... 36 bacitracin-polymyxin b ..... 37 bacitra-neomycin-

polymyxin-hc ............... 37 baclofen ........................... 39 balsalazide disodium ....... 35 balziva ............................. 30 BARACLUDE .................. 18 BAYER BREEZE 2 TEST 26 BAYER CONTOUR ......... 26 BD AUTOSHIELD DUO

PEN NEEDLES ........... 26 BD ULTRA-FINE INSULIN

SYRINGES .................. 26 BD ULTRA-FINE PEN

NEEDLES .................... 26 belladonna alkaloids-opium

.................................... 28 benazepril hcl .................. 20 benazepril-

hydrochlorothiazide ..... 20 benzonatate .................... 37 benzoyl peroxide-

erythromycin ................ 23 benztropine mesylate ...... 17 BERINERT ...................... 33 betamethasone

dipropionate ................. 23 betamethasone

dipropionate aug .......... 23 betamethasone valerate .. 23 betaxolol hcl .............. 20, 36 bethanechol chloride ....... 29 BETOPTIC-S ................... 36 BEXSERO ....................... 34 bicalutamide .................... 16 BICILLIN L-A ................... 12 BIKTARVY ...................... 18 bimatoprost ..................... 36 bisoprolol fumarate .......... 20 bisoprolol-

hydrochlorothiazide ..... 20 BLEPHAMIDE ................. 37 BLEPHAMIDE S.O.P. ...... 37 blisovi fe 1.5/30 ............... 30 blisovi fe 1/20 .................. 30 BOOSTRIX ...................... 34 bosentan ......................... 39 BREATHE EASE LARGE 35 BREATHE EASE MEDIUM

.................................... 35 BREATHE EASE SMALL 35 BREATHERITE ............... 35

briellyn ............................. 30 BRILINTA ........................ 17 brimonidine tartrate ......... 36 bromocriptine mesylate ... 17 budesonide...................... 38 bumetanide ..................... 20 buprenorphine hcl............ 12 buprenorphine hcl-naloxone

hcl ............................... 12 bupropion hcl ................... 14 bupropion hcl er (smoking

det) .............................. 12 bupropion hcl er (sr) ........ 14 bupropion hcl er (xl) ......... 14 buspirone hcl ................... 19 butalbital-apap-caffeine ... 11 butalbital-aspirin-caffeine . 11 C cabergoline...................... 30 caffeine citrate ................. 23 calcipotriene .................... 23 calcitriol ........................... 35 calcium acetate (phos

binder) ......................... 29 camila .............................. 30 capecitabine .................... 16 CAPEX ............................ 23 captopril .......................... 20 captopril-

hydrochlorothiazide ..... 20 CARAC ........................... 23 CARAFATE ..................... 28 carbamazepine ................ 14 carbamazepine er............ 14 carbidopa ........................ 17 carbidopa-levodopa ......... 17 carbidopa-levodopa er ..... 17 carbidopa-levodopa-

entacapone ................. 17 carbinoxamine maleate ... 37 CARETOUCH

LANCING/EJECTOR ... 26 CARNITOR ..................... 27 CARNITOR SF ................ 27 carteolol hcl ..................... 36 cartia xt ........................... 20 carvedilol ......................... 20 CAYA .............................. 35 caziant ............................. 30 cefadroxil ......................... 12 cefazolin sodium ............. 12 cefdinir ............................ 12 cefixime ........................... 12 cefprozil ........................... 12 ceftazidime ...................... 12

CEFTIN ........................... 12 ceftriaxone sodium .......... 12 cefuroxime axetil ............. 12 celecoxib ......................... 11 CELONTIN ...................... 14 cephalexin ................. 12, 13 CERDELGA .................... 29 CERVIDIL ....................... 30 CHANTIX ........................ 12 CHANTIX CONTINUING

MONTH PAK ............... 12 CHANTIX STARTING

MONTH PAK ............... 12 chateal ............................ 30 chateal eq ....................... 30 chlordiazepoxide hcl ........ 19 chlordiazepoxide-clidinium

.................................... 28 chlorhexidine gluconate ... 23 chloroquine phosphate .... 17 chlorothiazide .................. 20 chlorpromazine hcl .......... 17 chlorthalidone .................. 20 cholestyramine ................ 20 cholestyramine light ........ 20 choline-mag trisalicylate .. 11 ciclodan ........................... 15 ciclopirox ......................... 15 ciclopirox olamine ............ 15 cilostazol ......................... 17 CILOXAN ........................ 36 CIMDUO ......................... 18 cimetidine ........................ 28 cimetidine hcl .................. 28 CIPRO ............................ 13 CIPRO HC ...................... 37 CIPRODEX ..................... 37 ciprofloxacin .................... 13 ciprofloxacin hcl......... 13, 36 citalopram hydrobromide . 14 claravis ............................ 23 clarithromycin .................. 13 clemastine fumarate ........ 37 CLIMARA ........................ 30 clindacin etz .................... 23 clindacin-p ....................... 23 clindamycin hcl ................ 13 clindamycin palmitate hcl 13 clindamycin phosphate ... 13,

23 clindamycin phosphate-

benzoyl peroxide ......... 23 clobetasol propionate 23, 24 clomipramine hcl ............. 14 clonazepam ..................... 19

43

clonidine .......................... 20 clonidine hcl .................... 20 clopidogrel bisulfate ......... 17 clorazepate dipotassium .. 19 clotrimazole ..................... 15 clotrimazole-betamethasone

.................................... 24 clozapine ......................... 17 codeine sulfate ................ 11 colchicine ........................ 16 COLCHICINE .................. 16 colchicine-probenecid ...... 16 COLCRYS ....................... 16 colestipol hcl .................... 20 colocort ............................ 35 COMBIVENT RESPIMAT 38 COMPACT SPACE

CHAMBER/LG MASK .. 35 COMPACT SPACE

CHAMBER/MED MASK .................................... 35

COMPACT SPACE CHAMBER/SM MASK . 35

COMPLERA .................... 18 compro ............................ 15 CONCERTA .................... 22 CONDYLOX .................... 24 constulose ....................... 28 CONTOUR NEXT

CONTROL ................... 26 CONTOUR NEXT TEST .. 26 CORDRAN ...................... 24 cormax scalp application . 24 CORTIFOAM ................... 35 cortisone acetate ............. 29 CORTISPORIN ............... 24 COSENTYX (300 MG

DOSE) ......................... 33 COSENTYX 150 MG/ML . 33 COSENTYX

SENSOREADY (300 MG) .................................... 33

COSENTYX SENSOREADY PEN ... 33

COTELLIC ....................... 16 CREON ........................... 29 CRESEMBA .................... 15 CRIXIVAN ....................... 18 cromolyn sodium ....... 36, 38 crotan .............................. 17 cryselle-28 ....................... 30 CUPRIMINE .................... 29 curity sterile saline ........... 27 CUVITRU ........................ 33 cyanocobalamin .............. 27

cyclafem 1/35 .................. 30 cyclafem 7/7/7 ................. 31 cyclobenzaprine hcl ......... 39 cyclopentolate hcl ............ 37 cyclophosphamide ........... 16 cyclosporine .................... 33 CYCLOSPORINE IN

KLARITY ..................... 37 cyclosporine modified ...... 33 cyproheptadine hcl .......... 37 cyred ............................... 31 cyred eq .......................... 31 CYSTAGON .................... 29 cytra k crystals ................ 27 D danazol ........................... 29 dantrolene sodium ........... 39 dapsone .......................... 16 DAPTACEL ..................... 34 DARAPRIM ..................... 17 dasetta 1/35 .................... 31 dasetta 7/7/7 ................... 31 deblitane ......................... 31 deferoxamine mesylate ... 35 DELESTROGEN ............. 31 delyla............................... 31 DEPEN TITRATABS ....... 29 DEPO-ESTRADIOL ......... 31 DEPO-MEDROL ............. 29 DEPO-TESTOSTERONE 29 DESCOVY....................... 18 desipramine hcl ............... 14 desloratadine ................... 37 desmopressin ace spray

refrig ............................ 30 desmopressin acetate ..... 30 desmopressin acetate spray

.................................... 30 desogestrel-ethinyl estradiol

.................................... 31 desonide ......................... 24 desoximetasone .............. 24 dexamethasone ............... 29 dexamethasone intensol.. 29 dexamethasone sod

phosphate pf................ 29 dexamethasone sodium

phosphate ............. 29, 36 dexmethylphenidate hcl ... 22 dextroamphetamine sulfate

.................................... 22 dextroamphetamine sulfate

er ................................. 22 DIASTAT PEDIATRIC ..... 14

DIATHRIVE GLUCOSE CONTROL SOLN ........ 26

DIATHRIVE LANCING DEVICE ....................... 26

diazepam .................. 14, 19 diclofenac potassium ....... 11 diclofenac sodium ..... 11, 36 diclofenac sodium er ....... 11 dicloxacillin sodium ......... 13 dicyclomine hcl ................ 28 didanosine ....................... 18 DIFFERIN ....................... 24 diflunisal .......................... 11 digitek ............................. 20 digox ............................... 20 digoxin ............................ 20 dihydroergotamine mesylate

.................................... 16 DILANTIN........................ 14 diltiazem cd ..................... 20 diltiazem hcl .................... 20 diltiazem hcl er ................ 20 diltiazem hcl er coated

beads .......................... 20 dilt-xr ............................... 20 dimenhydrinate ............... 15 diphenhydramine hcl ....... 37 diphenoxylate-atropine .... 28 DIPHTHERIA-TETANUS

TOXOIDS DT .............. 34 dipyridamole .................... 17 disopyramide phosphate . 20 disulfiram......................... 12 DIURIL ............................ 20 divalproex sodium ........... 14 divalproex sodium er ....... 14 donepezil hcl ................... 14 dorzolamide hcl ............... 36 dorzolamide hcl-timolol mal

.................................... 36 doxazosin mesylate ......... 20 doxepin hcl ...................... 14 doxycycline hyclate ......... 13 doxycycline monohydrate 13 D-PENAMINE ................. 29 dronabinol ....................... 15 drospirenone-ethinyl

estradiol ...................... 31 DROXIA .......................... 16 DRYSOL ......................... 24 duloxetine hcl .................. 14 DUOPA ........................... 17 DUREZOL ....................... 36 dutasteride ...................... 29 DYRENIUM ..................... 20

44

E EASIVENT ...................... 35 EASYMAX CONTROL ..... 26 EDURANT ....................... 18 efavirenz .......................... 18 ELIDEL ............................ 24 elinest .............................. 31 ELLA ............................... 31 ELMIRON ........................ 29 EMBRACE TALK

GLUCOSE CONTROL . 26 emoquette ....................... 31 EMTRIVA ........................ 18 enalapril maleate ............. 21 enalapril-

hydrochlorothiazide ..... 21 ENBREL .......................... 33 ENBREL MINI ................. 33 ENBREL SURECLICK ..... 33 endocet ........................... 11 ENGERIX-B..................... 34 enoxaparin sodium .......... 13 enpresse-28 .................... 31 enskyce ........................... 31 entacapone ..................... 17 entecavir .......................... 18 ENTRESTO ..................... 21 enulose ............................ 28 EPCLUSA ....................... 18 epinephrine ............... 21, 38 epinephrine pf .................. 21 EPIPEN 2-PAK ................ 38 EPIPEN JR 2-PAK........... 38 epitol ............................... 14 EPIVIR HBV .................... 18 eplerenone ...................... 21 EPOGEN ......................... 20 ergocalciferol ................... 27 ERGOMAR ...................... 16 ergotamine-caffeine ......... 16 erlotinib hcl ...................... 16 errin ................................. 31 erythromycin .............. 24, 36 ESBRIET ......................... 38 escitalopram oxalate ........ 14 estarylla ........................... 31 estradiol ........................... 31 estradiol valerate ............. 31 ESTRING ........................ 31 estropipate ...................... 31 eszopiclone ..................... 39 ethacrynic acid ................ 21 ethambutol hcl ................. 16 ethosuximide ................... 14

ethynodiol diac-eth estradiol .................................... 31

etidronate disodium ......... 35 etodolac .......................... 11 etoposide ........................ 16 EURAX ............................ 17 exemestane ..................... 16 EXTAVIA ......................... 23 EZ FLU SHOT-

FLUCELVAX QUAD .... 34 ezetimibe ......................... 21 ezetimibe-simvastatin ...... 21 F falmina ............................ 31 famotidine ....................... 28 felodipine er ..................... 21 FEMCAP ......................... 35 FEMRING ....................... 31 femynor ........................... 31 fenofibrate ....................... 21 fenofibrate micronized ..... 21 fenofibric acid .................. 21 fentanyl ........................... 11 FINACEA ........................ 24 finasteride ....................... 29 FIRAZYR ......................... 33 FIRVANQ ........................ 13 flavoxate hcl .................... 29 flecainide acetate ............ 21 FLEXICHAMBER ADULT

MASK/SMALL ............. 35 FLEXICHAMBER CHILD

MASK/LARGE ............. 35 FLEXICHAMBER CHILD

MASK/SMALL ............. 35 FLOVENT DISKUS ......... 38 FLOVENT HFA ............... 38 FLUAD ............................ 34 FLUARIX QUADRIVALENT

.................................... 34 FLUBLOK ........................ 34 FLUBLOK QUADRIVALENT

.................................... 34 FLUCELVAX

QUADRIVALENT ........ 34 fluconazole ...................... 15 flucytosine ....................... 15 fludrocortisone acetate .... 29 FLULAVAL

QUADRIVALENT ........ 34 FLUMIST QUADRIVALENT

.................................... 34 flunisolide ........................ 37 fluocinolone acetonide ..... 24

fluocinolone acetonide body .................................... 24

fluocinolone acetonide scalp .................................... 24

fluocinonide ..................... 24 fluocinonide emulsified base

.................................... 24 fluoritab ........................... 27 fluorometholone .............. 36 FLUOROPLEX ................ 24 fluorouracil ...................... 24 FLUOROURACIL ............ 24 fluoxetine hcl ................... 15 fluoxetine hcl (pmdd) ....... 15 fluphenazine decanoate .. 17 fluphenazine hcl .............. 17 FLURA-DROPS .............. 27 flurazepam hcl ................. 39 flurbiprofen ...................... 11 flurbiprofen sodium .......... 36 flutamide ......................... 16 fluticasone propionate ..... 24 fluticasone-salmeterol ..... 38 FLUVIRIN........................ 34 fluvoxamine maleate ....... 15 FLUZONE HIGH-DOSE .. 34 FLUZONE

QUADRIVALENT ........ 34 FML ................................. 36 FML FORTE .................... 36 folic acid .......................... 27 fondaparinux sodium ....... 13 FORTISCARE CONTROL

.................................... 26 fosamprenavir calcium .... 18 fosinopril sodium ............. 21 fosinopril sodium-hctz ..... 21 FREESTYLE TEST ......... 26 furosemide ...................... 21 G gabapentin ...................... 14 galantamine hydrobromide

.................................... 14 galantamine hydrobromide

er ................................. 14 GARDASIL 9 ................... 34 gatifloxacin ...................... 36 gavilyte-c ......................... 28 gavilyte-g......................... 28 gavilyte-n with flavor pack 28 gemfibrozil ....................... 21 generlac .......................... 28 gengraf ............................ 33 gentak ............................. 36 gentamicin sulfate ..... 13, 36

45

GENTEEL LANCING KIT (BLUE) ........................ 26

GENVOYA ...................... 18 gildagia ............................ 31 GILENYA ......................... 23 GILOTRIF ........................ 16 glatiramer acetate ............ 23 glatopa ............................ 23 GLEOSTINE .................... 16 glimepiride ....................... 25 glipizide er ....................... 25 glipizide ir ........................ 25 glipizide xl ........................ 25 GLUCAGEN DIAGNOSTIC

.................................... 35 GLUCAGEN HYPOKIT .... 26 GLUCAGON EMERGENCY

.................................... 26 GLUCAGON HCL

(DIAGNOSTIC) ............ 35 glyburide .......................... 25 glycopyrrolate .................. 28 glydo ............................... 12 GOLYTELY ..................... 28 griseofulvin microsize ...... 15 griseofulvin ultramicrosize15 guanfacine hcl ................. 21 guanfacine hcl er ............. 22 H hailey 1.5/30 .................... 31 halobetasol propionate .... 24 haloperidol ....................... 18 haloperidol decanoate ..... 18 haloperidol lactate ........... 18 HARVONI ........................ 18 HAVRIX ........................... 34 heather ............................ 31 HEMLIBRA ...................... 20 heparin sodium (porcine) . 14 heparin sodium (porcine) pf

.................................... 14 HEPLISAV-B ................... 34 HIBERIX .......................... 34 HIZENTRA ...................... 33 homatropaire ................... 37 homatropine hbr .............. 37 HUMALOG ...................... 26 HUMALOG KWIKPEN ..... 26 HUMALOG U-100 JUNIOR

KWIKPEN .................... 26 HUMIRA .......................... 33 HUMIRA PEDIATRIC

CROHNS START ........ 33 HUMIRA PEN .................. 33

HUMIRA PEN-CD/UC/HS STARTER ................... 33

HUMIRA PEN-PS/UV/ADOL HS START .................. 33

HUMULIN 70/30 KWIKPEN .................................... 26

HUMULIN 70/30 VIAL ..... 26 HUMULIN N KWIKPEN ... 27 HUMULIN N VIAL............ 27 HUMULIN R U-500

KWIKPEN .................... 27 HUMULIN R U-500 VIAL

(CONCENTRATED) .... 27 HUMULIN R VIAL............ 27 hydralazine hcl ................ 21 hydrochlorothiazide ......... 21 hydrocodone-

acetaminophen ............ 11 hydrocodone-homatropine

.................................... 37 hydrocortisone ..... 24, 29, 35 hydrocortisone ace-

pramoxine ................... 24 hydrocortisone butyrate ... 24 hydrocortisone in absorbase

.................................... 24 hydrocortisone valerate ... 24 hydromet ......................... 37 hydromorphone hcl .......... 11 hydroxychloroquine sulfate

.................................... 17 hydroxyurea .................... 16 hydroxyzine hcl ............... 19 hydroxyzine pamoate ...... 19 HYPERHEP B S/D .......... 33 HYQVIA .......................... 33 I ibandronate sodium ......... 35 ibu ................................... 11 ibuprofen ......................... 11 icatibant acetate .............. 33 imatinib mesylate............. 16 IMBRUVICA .................... 16 imipramine hcl ................. 15 imiquimod ........................ 24 incassia ........................... 31 indapamide...................... 21 indomethacin ................... 11 indomethacin er ............... 11 INFANRIX ....................... 34 INSULIN PEN NEEDLES 27 INSULIN SYRINGES ....... 27 INTELENCE .................... 18 INTRON A ....................... 18 INVEGA SUSTENNA ...... 18

INVEGA TRINZA ............. 18 INVIRASE ....................... 18 IPOL ................................ 34 ipratropium bromide .. 37, 38 ipratropium-albuterol ....... 38 irbesartan ........................ 21 irbesartan-

hydrochlorothiazide ..... 21 IRESSA ........................... 16 ISENTRESS .................... 18 ISENTRESS HD .............. 18 isibloom ........................... 31 isoniazid .......................... 16 ISORDIL TITRADOSE .... 21 isosorbide dinitrate .......... 21 isosorbide mononitrate .... 21 isosorbide mononitrate er 21 isotretinoin ....................... 24 isradipine......................... 21 itraconazole ..................... 15 J jantoven .......................... 14 JARDIANCE .................... 25 jencycla ........................... 31 jolivette ............................ 31 juleber ............................. 31 JULUCA .......................... 18 junel 1.5/30 ..................... 31 junel 1/20 ........................ 31 junel fe 1.5/30 ................. 31 junel fe 1/20 .................... 31 K KALETRA........................ 18 kalliga .............................. 31 kelnor 1/35 ...................... 31 kelnor 1/50 ...................... 31 ketoconazole ................... 15 ketorolac tromethamine .. 11,

36 KINRIX ............................ 34 kionex ............................. 27 klor-con ........................... 27 klor-con 10 ...................... 27 klor-con m10 ................... 27 KLOR-CON M15 ............. 27 klor-con m20 ................... 27 klor-con sprinkle .............. 27 KRINTAFEL .................... 17 K-TAB ............................. 27 kurvelo ............................ 31 L labetalol hcl ..................... 21 LACRISERT .................... 37 lactulose .......................... 28 lactulose encephalopathy 28

46

lamivudine ....................... 18 lamivudine-zidovudine ..... 18 lamotrigine ....................... 14 LANCETS ........................ 26 lansoprazole .................... 28 LANTUS SOLOSTAR ...... 27 LANTUS U-100 VIAL ....... 27 larin 1.5/30 ...................... 31 larin 1/20 ......................... 31 larin fe 1.5/30................... 31 larin fe 1/20 ..................... 31 larissia ............................. 31 latanoprost ...................... 36 LEDIPASVIR-

SOFOSBUVIR ............. 18 leena ............................... 31 leflunomide ...................... 33 lessina ............................. 31 letrozole ........................... 16 leucovorin calcium ........... 16 LEUKERAN ..................... 16 LEUKINE ......................... 20 leuprolide acetate ............ 30 LEVEMIR U-100

FLEXTOUCH ............... 27 LEVEMIR U-100 VIAL ..... 27 levetiracetam ................... 14 levetiracetam er ............... 14 levobunolol hcl ................. 36 levocarnitine .................... 27 levocetirizine

dihydrochloride ............ 37 levofloxacin ..................... 13 levonest ........................... 31 levonorgestrel .................. 31 levonorgestrel-ethinyl estrad

.................................... 31 levonorg-eth estrad triphasic

.................................... 31 levora 0.15/30 (28) .......... 31 levorphanol tartrate.......... 11 levothyroxine sodium ....... 33 LEVULAN KERASTICK ... 24 LEXIVA ............................ 18 LIALDA ............................ 35 lidocaine .......................... 12 lidocaine hcl .................... 12 lidocaine hcl

urethral/mucosal .......... 12 lidocaine viscous ............. 23 lidocaine-prilocaine .......... 12 lillow ................................ 31 linezolid ........................... 13 liothyronine sodium.......... 33 lisinopril ........................... 21

lisinopril-hydrochlorothiazide .................................... 21

lithium .............................. 20 lithium carbonate ............. 20 lithium carbonate er ......... 20 loperamide hcl ................. 28 lopinavir-ritonavir ............. 18 lorazepam ....................... 19 lorazepam intensol .......... 19 lorcet ............................... 11 lorcet hd .......................... 11 lorcet plus ........................ 11 losartan potassium .......... 21 losartan potassium-hctz... 21 lovastatin ......................... 21 LOVENOX ....................... 14 low-ogestrel ..................... 31 loxapine succinate ........... 18 ludent .............................. 27 LUMIGAN ........................ 36 LUPRON DEPOT (1-

MONTH) ...................... 30 LUPRON DEPOT (3-

MONTH) ...................... 30 LUPRON DEPOT (4-

MONTH) INTRAMUSCULAR KIT 30MG .......................... 30

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG .......................... 30

LUPRON DEPOT-PED (1-MONTH) ...................... 30

LUPRON DEPOT-PED (3-MONTH) ...................... 30

lutera ............................... 31 lyza ................................. 31 M MAKENA ......................... 31 maprotiline hcl ................. 15 marlissa ........................... 31 MASK VORTEX .............. 35 MATULANE ..................... 16 MAXICOMFORT SYR 27G

X 1/2 ............................ 27 meclofenamate sodium ... 11 MEDROL ......................... 29 medroxyprogesterone

acetate ........................ 32 megestrol acetate ............ 32 MEKINIST ....................... 16 meloxicam ....................... 11 melphalan ....................... 16 memantine hcl ................. 14

MENACTRA .................... 34 MENVEO ........................ 34 MEPHYTON .................... 27 mercaptopurine ............... 16 mesalamine ..................... 35 mesna ............................. 16 MESNEX ......................... 16 MESTINON ..................... 16 metadate er ..................... 22 metaproterenol sulfate..... 38 metformin hcl er .............. 25 metformin hcl ir ............... 25 METFORMIN HCL IR ...... 25 methadone hcl ................ 11 methadone hcl intensol ... 11 methadose ...................... 11 methazolamide ................ 36 methenamine hippurate ... 13 methergine ...................... 35 methimazole .................... 33 methocarbamol ............... 39 methotrexate ................... 33 methotrexate sodium ....... 33 methotrexate sodium (pf) 33 methoxsalen .................... 24 methoxsalen rapid ........... 24 methyclothiazide ............. 21 methyldopa ..................... 21 methylergonovine maleate

.................................... 35 methylphenidate hcl ........ 22 methylphenidate hcl er .... 22 methylphenidate hcl er (cd)

.................................... 22 methylphenidate hcl er (la)

.................................... 22 methylprednisolone ......... 29 methylprednisolone sodium

succ............................. 29 metipranolol .................... 36 metoclopramide hcl ......... 15 metolazone ..................... 21 metoprolol succinate er ... 21 metoprolol tartrate ........... 21 metoprolol-

hydrochlorothiazide ..... 21 metronidazole ........... 13, 24 mexiletine hcl .................. 21 microgestin 1.5/30 ........... 32 microgestin 1/20 .............. 32 microgestin fe 1.5/30 ....... 32 microgestin fe 1/20 .......... 32 MICROLET NEXT

LANCING DEVICE ...... 26 midazolam hcl ................. 19

47

midodrine hcl ................... 21 MIGERGOT ..................... 16 mili ................................... 32 minitran ........................... 21 minocycline hcl ................ 13 minoxidil .......................... 21 MIRENA (52 MG) ............ 32 mirtazapine ...................... 15 misoprostol ...................... 28 M-M-R II .......................... 34 modafinil .......................... 39 moderiba ......................... 18 moexipril hcl .................... 21 moexipril-

hydrochlorothiazide ..... 21 mometasone furoate ........ 25 mondoxyne nl .................. 13 mono-linyah ..................... 32 mononessa ...................... 32 montelukast sodium ......... 38 morgidox ......................... 13 morphine sulfate .............. 11 morphine sulfate

(concentrate) ............... 11 morphine sulfate er .......... 11 MOXEZA ......................... 36 moxifloxacin hcl ......... 13, 36 mupirocin ......................... 13 mupirocin calcium ............ 13 mycophenolate mofetil ..... 33 mycophenolate sodium .... 33 MYLERAN ....................... 16 myorisan .......................... 25 myzilra ............................. 32 N NABI-HB .......................... 33 nabumetone .................... 11 nadolol............................. 21 nafrinse ........................... 27 naloxone hcl .................... 12 naltrexone hcl .................. 12 naproxen ......................... 11 naproxen sodium ............. 11 naratriptan hcl .................. 16 NARCAN ......................... 12 NATACYN ....................... 36 nebusal ............................ 37 necon 0.5/35 (28) ............ 32 necon 7/7/7 ..................... 32 neomycin sulfate ............. 13 neomycin-polymyxin-

dexameth ..................... 37 neomycin-polymyxin-

gramicidin .................... 37 neomycin-polymyxin-hc ... 37

neo-polycin hc ................. 37 NEUPOGEN .................... 20 nevirapine ....................... 18 nevirapine er ................... 18 NEXAVAR ....................... 16 nicardipine hcl ................. 21 NICORETTE ................... 12 nicotine polacrilex ............ 12 nicotine step 1 ................. 12 nicotine step 2 ................. 12 nicotine step 3 ................. 12 nifedipine ......................... 21 nifedipine er ..................... 21 nifedipine er osmotic

release ........................ 21 nimodipine ....................... 21 NITRO-BID ...................... 21 NITRO-DUR .................... 21 nitrofurantoin ................... 13 nitrofurantoin macrocrystal

.................................... 13 nitrofurantoin monohydrate

macrocrystals .............. 13 nitroglycerin ..................... 21 nitroglycerin er ................. 21 nitro-time ......................... 21 NOCTIVA ........................ 30 nora-be ............................ 32 norethin ace-eth estrad-fe 32 norethindrone .................. 32 norethindrone acetate ..... 32 norethindrone acet-ethinyl

est ............................... 32 norgestimate-eth estradiol

.................................... 32 norgestimate-ethinyl

estradiol triphasic ........ 32 norlyda ............................ 32 norlyroc ........................... 32 NORPACE CR ................ 22 nortrel 0.5/35 (28) ............ 32 nortrel 1/35 (21) ............... 32 nortrel 1/35 (28) ............... 32 nortrel 7/7/7 ..................... 32 nortriptyline hcl ................ 15 NORVIR .................... 18, 19 NOVOFINE AUTOCOVER

PEN NEEDLE .............. 27 NOVOFINE PEN NEEDLE

.................................... 27 NOVOFINE PLUS PEN

NEEDLE ...................... 27 NOVOTWIST PEN

NEEDLE ...................... 27 NUVARING ..................... 32

nyamyc ........................... 15 nyata ............................... 15 nystatin ........................... 15 nystatin-triamcinolone ..... 15 nystop ............................. 15 O ocella .............................. 32 octreotide acetate ............ 30 ODEFSEY ....................... 19 OFEV .............................. 38 ofloxacin .................... 36, 37 ogestrel ........................... 32 okebo .............................. 13 olanzapine ....................... 18 olmesartan medoxomil .... 22 olmesartan medoxomil-hctz

.................................... 22 olopatadine hcl ................ 36 omeprazole ..................... 28 OMNITROPE .................. 30 ondansetron hcl............... 15 ondansetron odt .............. 15 ONE TOUCH VERIO KIT

W/DEVICE .................. 26 ONETOUCH DELICA

LANCING DEV ............ 26 ONETOUCH DELICA PLUS

LANCING .................... 26 ONETOUCH ULTRA BLUE

TEST STRIPS ............. 26 opium .............................. 28 OPSUMIT........................ 39 ORACIT .......................... 27 oralone ............................ 23 ORENCIA........................ 33 ORENCIA CLICKJECT ... 33 orphenadrine citrate er .... 39 orsythia ........................... 32 oseltamivir phosphate ..... 19 OTEZLA .......................... 33 oxazepam ....................... 20 oxcarbazepine ................. 14 oxybutynin chloride ......... 29 oxybutynin chloride er ..... 29 oxycodone hcl ........... 11, 12 OXYCODONE HCL ER ... 11 oxycodone-acetaminophen

.................................... 12 oxycodone-aspirin ........... 12 OXYCONTIN ................... 12 P pacerone ......................... 22 PANDA MASK LARGE .... 35 PANDA MASK MEDIUM . 35 PANDA MASK SMALL .... 35

48

pantoprazole sodium ....... 28 papaverine hcl ................. 22 PARAGARD

INTRAUTERINE COPPER ..................... 32

paroex ............................. 23 paroxetine hcl .................. 15 PAXIL .............................. 15 PEDIARIX ....................... 34 PEDIATRIC PANDA MASK

.................................... 35 PEDVAX HIB ................... 34 peg 3350/electrolytes ...... 28 peg 3350-kcl-na bicarb-nacl

.................................... 28 peg-3350/electrolytes ...... 28 PEGASYS ....................... 19 PEGASYS PROCLICK .... 19 PEGINTRON ................... 19 pegylax ............................ 28 penicillamine.................... 29 penicillin v potassium ....... 13 PENTACEL ..................... 34 PENTASA ....................... 35 pentoxifylline er ............... 22 perindopril erbumine ........ 22 periogard ......................... 23 permethrin ....................... 17 perphenazine................... 15 perphenazine-amitriptyline

.................................... 15 PERSERIS ...................... 18 phenadoz ........................ 37 phenazo .......................... 29 phenazopyridine hcl ......... 29 phenelzine sulfate ........... 15 phenergan ....................... 38 phenobarbital................... 14 phenobarbital sodium ...... 14 phenoxybenzamine hcl .... 22 phentolamine mesylate .... 22 phenylephrine hcl ............ 37 phenytoin ......................... 14 phenytoin infatabs ........... 14 phenytoin sodium ............ 14 phenytoin sodium extended

.................................... 14 philith ............................... 32 phospha 250 neutral ........ 27 phosphorous.................... 27 phospho-trin 250 neutral .. 27 phytonadione ................... 27 PICATO ........................... 25 pilocarpine hcl ........... 23, 36 pimecrolimus ................... 25

PIMECROLIMUS............. 25 pimozide .......................... 18 pindolol ............................ 22 pirmella 1/35 .................... 32 pirmella 7/7/7 ................... 32 piroxicam ......................... 11 PLAN B ONE-STEP ........ 32 PNEUMOVAX 23 ............ 34 pocket spacer .................. 35 podofilox .......................... 25 polycin ............................. 37 polyethylene glycol 3350 . 28 polymyxin b-trimethoprim 37 portia-28 .......................... 32 potassium chloride .......... 27 potassium chloride crys er

.................................... 27 potassium chloride er ...... 27 potassium citrate er ......... 27 potassium citrate-citric acid

.................................... 27 PRADAXA ....................... 14 pramipexole dihydrochloride

.................................... 17 PRAMOSONE ................. 25 prasugrel hcl .................... 17 pravastatin sodium .......... 22 praziquantel ..................... 17 prazosin hcl ..................... 22 PRED MILD ..................... 36 PRED-G .......................... 37 PRED-G S.O.P. ............... 37 prednisolone .................... 29 prednisolone acetate ....... 36 prednisolone acetate p-f .. 36 prednisolone sodium

phosphate ................... 29 prednisone ...................... 29 pregabalin ....................... 23 PREMARIN ..................... 32 PREPIDIL ........................ 30 prevalite .......................... 22 PREVENTEZA ................ 32 previfem .......................... 32 PREVNAR 13 .................. 34 PREZCOBIX ................... 19 PREZISTA....................... 19 PRIFTIN .......................... 16 prilovix ............................. 12 prilovix ultralite ................ 12 primaquine phosphate ..... 17 primidone ........................ 14 PRIMSOL ........................ 13 PRO COMFORT SPACER

ADULT ........................ 35

PRO COMFORT SPACER CHILD ......................... 35

probenecid ...................... 16 procainamide hcl ............. 22 PROCARE

SPACER/ADULT MASK .................................... 36

PROCARE SPACER/CHILD MASK .......................... 36

prochlorperazine ............. 15 prochlorperazine edisylate

.................................... 15 prochlorperazine maleate 15 PROCRIT ........................ 20 PROCTOFOAM HC ........ 35 procto-med hc ................. 35 proctosol hc ..................... 35 proctozone-hc ................. 35 progesterone ................... 32 progesterone micronized . 32 PROGLYCEM ................. 26 promethazine hcl ............. 38 promethazine vc plain ..... 38 promethazine-dm ............ 38 promethazine-

phenylephrine .............. 38 promethegan ................... 38 propafenone hcl .............. 22 propantheline bromide..... 28 propranolol hcl ................ 22 propranolol hcl er ............ 22 propranolol-hctz .............. 22 propylthiouracil ................ 33 PROQUAD ...................... 34 PROSTIN E2 ................... 30 protriptyline hcl ................ 15 pulmosal ......................... 38 PULMOZYME ................. 39 PYLERA .......................... 28 pyrazinamide ................... 16 pyridostigmine bromide ... 16 pyridostigmine bromide er16 Q QUADRACEL .................. 34 quetiapine fumarate ........ 18 quetiapine fumarate er .... 18 quinapril hcl ..................... 22 quinapril-

hydrochlorothiazide ..... 22 quinidine gluconate er ..... 22 quinidine sulfate .............. 22 QVAR .............................. 38 R rabeprazole sodium ......... 28 raloxifene hcl ................... 30

49

ramipril ............................ 22 ranitidine hcl .................... 28 rasagiline mesylate .......... 17 RASUVO ......................... 33 rea lo 40 .......................... 25 REBETOL ....................... 19 REBIF.............................. 23 REBIF REBIDOSE .......... 23 REBIF REBIDOSE

TITRATION PACK ....... 23 REBIF TITRATION PACK23 reclipsen .......................... 32 RECOMBIVAX HB........... 34 RECTIV ........................... 22 RELENZA DISKHALER ... 19 relexxii ............................. 22 RELISTOR ...................... 29 RESCRIPTOR ................. 19 RESTASIS ...................... 37 RESTASIS MULTIDOSE . 37 RETIN-A .......................... 25 RETIN-A MICRO GEL 0.04

%, 0.1 % ...................... 25 RETIN-A MICRO PUMP .. 25 REVLIMID ....................... 16 REYATAZ ........................ 19 ribasphere ....................... 19 ribavirin ............................ 19 RIDAURA ........................ 33 rifabutin ........................... 16 rifampin ........................... 16 riluzole ............................. 23 rimantadine hcl ................ 19 RIOMET .......................... 25 risedronate sodium .......... 35 RISPERDAL CONSTA .... 18 risperidone ...................... 18 ritonavir ........................... 19 rivastigmine tartrate ......... 14 rizatriptan benzoate ......... 16 ropinirole hcl .................... 17 rosadan ........................... 25 rosanil cleanser ............... 25 rosuvastatin calcium ........ 22 ROTARIX ........................ 34 ROTATEQ ....................... 34 roweepra ......................... 14 roweepra xr ..................... 14 RYDAPT .......................... 16 ryvent .............................. 38 S salsalate .......................... 11 SANDOSTATIN LAR

DEPOT ........................ 30 SANTYL .......................... 25

SECONAL ....................... 39 selegiline hcl .................... 17 selenium sulfide .............. 25 SELZENTRY ................... 19 SEREVENT DISKUS ....... 38 sertraline hcl .................... 15 sevelamer carbonate ....... 29 sevelamer hcl .................. 29 sharobel .......................... 32 SHINGRIX ....................... 34 sildenafil citrate ............... 39 silver sulfadiazine ............ 13 simvastatin ...................... 22 sirolimus .......................... 33 SIVEXTRO ...................... 13 SKYLA ............................ 32 sod citrate-citric acid ........ 28 sodium chloride ......... 28, 38 sodium fluoride ................ 28 sodium polystyrene

sulfonate ...................... 28 sodium sulfacetamide ...... 25 SOFOSBUVIR-

VELPATASVIR ............ 19 solifenacin succinate ....... 29 SOLU-CORTEF .............. 29 sorine .............................. 22 sotalol hcl ........................ 22 sotalol hcl (af) .................. 22 SOVALDI ........................ 19 SPIRIVA HANDIHALER .. 38 SPIRIVA RESPIMAT ....... 39 spironolactone ................. 22 spironolactone-hctz ......... 22 sprintec 28....................... 32 SPRYCEL ....................... 16 sps .................................. 28 sronyx ............................. 32 ssd .................................. 13 SSKI ................................ 38 stavudine ......................... 19 STELARA ........................ 33 STIMATE ........................ 30 STIOLTO RESPIMAT ...... 39 STIVARGA ...................... 16 STRIBILD ........................ 19 STRIVERDI RESPIMAT .. 39 subvenite ......................... 14 sucralfate ........................ 28 sulfacetamide sodium ...... 36 sulfacetamide sodium

(acne) .......................... 25 sulfacetamide sodium-sulfur

.................................... 25

sulfacetamide-prednisolone .................................... 37

sulfacetamide-sulfur in urea .................................... 25

sulfamethoxazole-trimethoprim ................ 13

sulfasalazine ................... 35 sulfatrim pediatric ............ 13 sulindac ........................... 11 sumatriptan ..................... 16 sumatriptan succinate ..... 16 sumatriptan succinate refill

.................................... 16 SUPRAX ......................... 13 SURESTEP PRO HIGH

GLUCOSE................... 26 SURESTEP PRO LOW

GLUCOSE................... 26 SURESTEP PRO NORMAL

GLUCOSE................... 26 SURVANTA .................... 38 SUTENT ......................... 17 syeda .............................. 32 SYMFI ............................. 19 SYMFI LO ....................... 19 SYMTUZA ....................... 19 T TABLOID......................... 17 tacrolimus.................. 25, 33 TAFINLAR ....................... 17 TAGRISSO ..................... 17 TAMIFLU......................... 19 tamoxifen citrate .............. 17 tamsulosin hcl ................. 29 tarina fe 1/20 ................... 32 tarina fe 1/20 eq .............. 32 taron-crystals .................. 28 tazarotene ....................... 25 tazicef ............................. 13 TAZORAC ....................... 25 TDVAX ............................ 35 temazepam ..................... 39 temozolomide .................. 17 TENIVAC ........................ 35 tenofovir disoproxil fumarate

.................................... 19 terazosin hcl .................... 29 terbinafine hcl .................. 15 terbutaline sulfate ............ 39 testosterone .................... 30 testosterone cypionate .... 30 TESTOSTERONE

CYPIONATE ............... 29 testosterone enanthate.... 30 THALOMID ..................... 17

50

theochron ........................ 39 theophylline ..................... 39 theophylline er ................. 39 thiothixene ....................... 18 timolol maleate .......... 22, 36 TIVICAY .......................... 19 tizanidine hcl.................... 39 TOBRADEX..................... 37 tobramycin ................. 36, 39 tobramycin-dexamethasone

.................................... 37 TOBREX ......................... 36 tolazamide ....................... 25 tolbutamide ...................... 25 tolmetin sodium ............... 11 tolterodine tartrate ........... 29 tolterodine tartrate er ....... 29 topiramate ....................... 14 torsemide ........................ 22 tramadol hcl ir .................. 12 tramadol-acetaminophen . 12 trandolapril ...................... 22 tranexamic acid ............... 20 tranylcypromine sulfate .... 15 TRAVATAN Z .................. 36 trazodone hcl ................... 15 tretinoin ..................... 17, 25 tretinoin microsphere ....... 25 tretinoin microsphere pump

.................................... 25 tri femynor ....................... 32 triamcinolone acetonide .. 23,

25 triamterene ...................... 22 triamterene-hctz .............. 22 triazolam .......................... 20 tricitrates .......................... 28 triderm ............................. 25 tri-estarylla ....................... 32 trifluoperazine hcl ............ 18 trifluridine ......................... 36 trihexyphenidyl hcl ........... 17 tri-linyah ........................... 32 tri-lo-estarylla ................... 32 tri-lo-marzia ..................... 32 tri-lo-mili ........................... 32 tri-lo-sprintec.................... 32 trilyte ............................... 29 trimethoprim .................... 13 tri-mili............................... 32 TRIMPEX ........................ 13 trinessa (28) .................... 32 trinessa lo ........................ 32

tri-previfem ...................... 33 tri-sprintec ....................... 33 TRIUMEQ ....................... 19 trivora (28) ....................... 33 tri-vylibra ......................... 33 tri-vylibra lo ...................... 33 trospium chloride ............. 29 trospium chloride er ......... 29 TRUE METRIX LEVEL 1 . 26 TRUE METRIX LEVEL 2 . 26 TRUE METRIX LEVEL 3 . 26 TRUMENBA .................... 35 TRUVADA ....................... 19 tulana .............................. 33 tussigon ........................... 38 TYBOST .......................... 19 TYKERB .......................... 17 TYVASO ......................... 39 TYVASO REFILL............. 39 TYVASO STARTER ........ 39 U ULESFIA ......................... 17 ULTIGUARD SAFEPACK

PEN NEEDLE .............. 27 UNISTRIP CONTROL ..... 26 UPTRAVI ........................ 39 urea ................................. 25 uremez-40 ....................... 25 ursodiol ........................... 29 V valacyclovir hcl ................ 19 valganciclovir hcl ............. 19 valproate sodium ............. 14 valproic acid .................... 14 valsartan ......................... 22 valsartan-

hydrochlorothiazide ..... 22 vancomycin hcl ................ 13 vandazole ........................ 13 VAQTA ............................ 35 VARIVAX ........................ 35 VECTICAL....................... 25 velivet .............................. 33 VENCLEXTA ................... 17 VENCLEXTA STARTING

PACK .......................... 17 venlafaxine hcl ................ 15 venlafaxine hcl er ............ 15 VENTAVIS ...................... 39 VENTOLIN HFA .............. 39 verapamil hcl ................... 22 verapamil hcl er ............... 22 VIDEX ............................. 19

vienva ............................. 33 VIGAMOX ....................... 36 VIRACEPT ...................... 19 VIREAD .......................... 19 virt-phos 250 neutral ....... 28 vitamin d (ergocalciferol) . 28 vitamin k1 ........................ 28 VIVAGUARD INO

CONTROL SOLUTION 26 VIVAGUARD LANCING

DEVICE ....................... 26 VIVITROL........................ 12 voriconazole .................... 15 VOSEVI .......................... 19 VOTRIENT ...................... 17 vyfemla ........................... 33 vylibra ............................. 33 W warfarin sodium ............... 14 wera ................................ 33 WIDE-SEAL DIAPHRAGM

60 ................................ 36 X XARELTO ....................... 14 XARELTO STARTER PACK

.................................... 14 XELJANZ ........................ 33 XELJANZ XR .................. 33 XIIDRA ............................ 37 XTANDI ........................... 17 xulane ............................. 33 Y yuvafem .......................... 33 Z zaleplon .......................... 39 zarah ............................... 33 ZARXIO .......................... 20 ZELBORAF ..................... 17 zenatane ......................... 25 zenchent ......................... 33 ZENPEP ......................... 29 zidovudine ....................... 19 ziprasidone hcl ................ 18 zolmitriptan ...................... 16 zolpidem tartrate ............. 39 zonisamide ...................... 14 ZOSTAVAX ..................... 35 zovia 1/35e (28) .............. 33 zovia 1/50e (28) .............. 33 zumandimine ................... 33 ZYDELIG......................... 17 ZYPREXA RELPREVV ... 18 ZYTIGA ........................... 17

Appendix A: OVER-THE-COUNTER (OTC) MEDICATION

BENEFIT LIST

The medications listed below are covered only for members who have purchased a special benefit offered through Kaiser Permanente

Washington called the Over-the-Counter Pharmacy Benefit.

***Typically, if a generic product is available for a drug, the Brand Name product may not be covered.***

Generic Product Name ***Brand Name*** Forms

ALLERGY COUGH AND COLD

Antihistamines CHLORPHENIRAMINE CHLOR-TRIMETON® Tab, Liquid

CLEMASTINE TAVIST® Tab, Liquid

DIPHENHYDRAMINE BENADRYL® Cap, Liquid

LORATADINE CLARITIN® Tab, Liquid

Decongestants OXYMETAZOLINE NASAL SPRAY AFRIN® Spray

PHENYLEPHRINE NASAL SPRAY NEO-SYNEPHRINE® Spray

PSEUDOEPHEDRINE SUDAFED® Tablet

Antihistamine/Decongestant Combinations TRIPROLIDINE/PSEUDOEPHEDRINE ACTIFED® Tablet

BROMPHENIRAMINE/PSEUDOEPHEDRINE DIMETAPP® Liquid

Expectorants/Cough Agents GUAIFENESIN ROBITUSSIN® Liquid

GUAIFENESIN/DEXTROMETHORPHAN ROBITUSSIN-DM® Liquid

DEXTROMETHORPHAN ROBITUSSIN COUGH® Liquid

DEXTROMETHORPHAN EXTEND RELEASE DELSYM® Liquid

AUTONOMICS AND CNS

Analgesics, Miscellaneous ACETAMINOPHEN TYLENOL® Tab, Chew, Supp,

Liquid

Non-Steroidal Anti-Inflammatories IBUPROFEN MOTRIN®, ADVIL® Tab, Liquid

Salicylates ASPIRIN BAYER®, ASCRIPTIN® Tab, Supp

DERMATOLOGICAL/ TOPICAL AGENTS

Acne/Psoriasis, Topical BENZOYL PEROXIDE 5%, 10% BENZAC® Gel, Wash, Lotion

COAL TAR Solution

Anesthetic Agents, Topical BENZOCAINE HURRICAINE® Gel

PRAMOXINE ANUSOL® Ointment

Antifungals, Topical

CLOTRIMAZOLE 1% LOTRIMIN® Cream, Solution

MICONAZOLE 2% MICATIN®, DESENEX® Cream, Powder

Anti-Infectives, Topical BACITRACIN BACIGUENT® Ointment

BACITRACIN, POLYMIXIN B POLYSPORIN® Ointment

BACITRACIN, NEOMYCIN, POLYMYXIN B NEOSPORIN® Ointment

OATMEAL, COLLOIDAL AVEENO® BATH POWDER Powder

Anti-Itch, Topical CALAMINE CALAMINE Lotion

CAMPHOR/ MENTHOL SARNA® Lotion

CAPSAICIN ZOSTRIX®, ZOSTRIX-HP® Cream

Anti-Virals, Topical DOCOSANOL 10% ABREVA® Cream

Corticosteroids, Topical, Low Potency HYDROCORTISONE 0.5%, 1% CORTIZONE® Cream, Oint,

Lotion

Keratolytics SALICYLIC ACID 17% DUOFILM® Liquid

SALICYLIC ACID 40% MEDIPLAST® Plaster

UREA 10%, 20% UREACIN®, CARMOL® 20 Cream, Lotion

Dermatologics, Miscellaneous ALUMINUM ACETATE BUROWS® Liquid

AMMONIUM LACTATE 12% AMLACTIN® Cream, Lotion

HYDROGEN PEROXIDE HYDROGEN PEROXIDE Liquid

VITAMIN A&D A AND D® OINTMENT Ointment

WITCH HAZEL TUCKS® Solution, Pads

ZINC OXIDE, COD LIVER OIL & LANOLIN DESITIN® Oint, Paste

ZINC OXIDE 20% BALMEX® Ointment

Scabicides PERMETHRIN NIX® Rinse

PYRETHRINS, PIPERONYL BUTOXIDE RID®, R & C® Shampoo

Skin Protectants LANOLIN, HYDROUS LANOLIN Ointment

PETROLATUM, GLYCERIN,BENZYL ALC MOISTUREL® Lotion

PETROLATUM, MINERAL OIL/WAX, ETC. AQUAPHOR®, EUCERIN® Ointment

EYE, EAR, NOSE AND THROAT

Otics CARBAMIDE DEBROX® Solution

Nasal Agents CROMOLYN NASALCROM® Spray

Ophthalmics ARTIFICIAL TEARS HYOPTEARS®, PURALUBE® Drops, Ointment

CARBOXYMETHYLCELLULOSE CELLUVISC®, REFRESH PLUS® Drops

HYDROXYPROPYL METHYLCELLULOSE TEARS NATURALE II® Drops

KETOTIFEN FUMARATE 0.025% ZADITOR® Drops

NAPHAZOLINE/ PHENIRAMINE OPCON-A® Drops

POLYVINYL ALCOHOL, POVIDONE REFRESH® PF Drops

SODIUM CHLORIDE 5% MURO®-128 Drops, Ointment

Throat and Mouth Agents

CETYLPYRIDINIUM CL, BENZYL ALCOHOL CEPACOL® Lozenge

GASTROINTESTINAL AGENTS

Antacids/Adsorbents CHARCOAL, ACTIVATED W/O SORBITOL ACTIDOSE Liquid

ALUMINUM/ MAGNESIUM MAALOX® Tablet, Liquid

ALUMINUM/ MAGNESIUM/ SIMETHICONE MINTOX® PLUS, MI-ACID Tablet, Liquid

ALUM/ MAGN/TRISILIS/ALG AC/SOD BICAR GAVISCON®, GENATON Tablet

ALUMINUM HYDROXIDE ALTERNAGEL®, AMPHOGEL® Liquid

MAGNESIUM OXIDE MAG-OX® Tablet

Antidiarrheals BISMUTH SUBSALICYLATE PEPTO BISMOL® Tablet, Liquid

LOPERAMIDE IMMODIUM® Tablet, Liquid

Antinauseants DIMENHYDRINATE DRAMAMINE® Tablet, Liquid

MECLIZINE BONINE®, ANTIVERT® Tablet

Laxatives/Cathartics BISACODYL DULCOLAX® Tablet, Supp

DOCUSATE SODIUM COLACE® Tablet, Liquid

GLYCERIN GLYCERIN Liquid, Supp

MAGNESIUM CITRATE CITRO-MAG® Liquid

MILK OF MAGNESIA MILK OF MAGNESIA Liquid

MINERAL OIL FLEET® MINERAL OIL Liquid

PSYLLIUM METAMUCIL® Powder

POLYETHYLENE GLYCOL MIRALAX® Powder

SENNA SENOKOT® Tablet, Liquid

Histamine H2 Blockers RANITIDINE ZANTAC® Tablet

Gastrointestinal, Miscellaneous SIMETHICONE MYLICON® Tablet

LACTOBACILLUS BACID® Capsule

SHARK LIVER OIL, COCOA BUTTER, PHENYLEPHRINE

HEMORRHOIDAL SUPPOSITORIES

Supp

Proton Pump Inhibitors OMEPRAZOLE PRILOSEC OTC Tablet

GENITOURINARY

Overactive bladder treatment OXYBUTYNIN OXYTROL® PATCH Patch

HORMONES

Contraceptive LEVONORGESTROL PLAN B ONE STEP Tablet

LIPID LOWERING AGENTS

Non-Prescription Agents NIACIN NIACIN Tablet

NIACIN EXTENDED-RELEASE SLO-NIACIN® Tablet

FISH OILS SEA-OMEGA®-50 Capsule

NUTRITIONALS AND SUPPLEMENTS

Vitamins/Dietary Supplements ACETYLCYSTEINE NAC® Capsule

ASCORBIC ACID (VIT C) Tablet

CYANOCOBALAMIN (VIT B12) Tablet

CHOLECALCIFEROL (VIT D) Tablet

FOLIC ACID Tablet

NIACINAMIDE (VIT B3) Tablet

PRENATAL VITAMINS W/ FOLIC ACID Tablet

PYRIDOXINE (VIT B6) Tablet

THIAMINE (VIT B1) Tablet

VITAMIN A Capsule

VITAMIN B COMPLEX Tablet

VITAMIN B COMPLEX W/C Tablet

VITAMIN E Capsule

Electrolytes, Iron, & Minerals CALCIUM CARBONATE TUMS® Chew tabs, Liquid

CALCIUM CITRATE CAL-CITRATE® Tablet

CALCIUM CITRATE w/VITAMIN D CITRACAL® Tablet

ELECTROLYTE ORAL PEDIALYTE® Liquid

FERROUS GLUCONATE FERGON® Tablet

FERROUS SULFATE FER-IN-SOL® Tablet, Liquid

MAGNESIUM OXIDE URO-MAG® Capsule

SODIUM BICARBONATE Tablet

ZINC SULFATE ZINCATE® Capsule

VAGINAL PREPARATIONS

Vaginal Anti-Infectives POVIDONE-IODINE BETADINE® Douche

Vaginal Antifungals CLOTRIMAZOLE MYCELEX®-7, GYNE-LOTRIMIN®-

3 Cream, Vag tabs

MICONAZOLE MONISTAT® Cream

Miscellaneous LUBRICATING JELLY K-Y JELLY® JELLY

Kaiser Permanente Nondiscrimination Notice and Language Access Services

KAISER PERMANENTE NONDISCRIMINATION NOTICE

Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (“Kaiser Permanente”) comply with applicable federal civil rights laws and do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or any other basis protected by applicable federal, state, or local law. We also:

Provide free aids and services to people with disabilities to help ensure effective communication, such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, and accessible electronic formats)• Assistive devices (magnifiers, Pocket Talkers, and other aids)

Provide free language services to people whose primary language is not English, such as:

• Qualified interpreters• Information written in other languages

If you need these services, contact Kaiser Permanente.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance. Please call us if you need help submitting a grievance. The Civil Rights Coordinator will be notified of all grievances related to discrimination.

Kaiser Permanente Phone: 206-630-4636 Toll-free: 1-888-901-4636

TTY Washington Relay Service: 1-800-833-6388 or 711 TTY Idaho Relay Service: 1-800-377-3529 or 711

Electronically: kp.org/wa/feedback

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

For Medicare Advantage Plans Only: Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted2018-XB-7_ACA_Notice_Taglines

http://www.hhs.gov/ocr/office/file/index.html

LANGUAGE ACCESS SERVICES

English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).

Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

中文 (Chinese)：注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。

Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

ភាសាខ្មែរ (Khmer)៖ របយ័ត៖ េ េបើសិនអកនិខ្យមរ, េ សជំនួខ្យផក េ យមិនគិតល គឺចនសំប់បំេ រអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។日本語 (Japanese): 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、お電話にてご連絡ください。

አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).

Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।

تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة في ومعلومات مساعدة على الحصول حق لديكم :(Arabic) العربية: (6388-833-800-1 / 711) .والبكم الصم هاتف رقم 4636-901-888-1 برقم اتصل .بالمجان لك

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ,ແມ່ນມີ ພ້ອມ ໃຫ້ທ່ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).

Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).

Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

می فراهم شما برای رايگان بصورت زبانی تسهيالت کنيد، می گفتگو فارسی زبان به اگر :توجه :(Farsi) فارسی.بگيريد تماس (TTY: 1-800-833-6388 / 711) 4636-901-888-1 با .باشد

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2019 drug formulary - kaiser permanente · 2019 drug formulary for members covered through large...

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