2021 prescription drug list...formulary introduction formulary the ambetter from arizonacomplete...

2021 Prescription Drug List Effective January 1 2021

Formulary Introduction FORMULARY

The Ambetter from Arizona Complete Health Formulary or Preferred Drug List is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription

drug benefit Generic drugs have the same active ingredients as their brand name counterparts and should be

considered the first line of treatment The FDA requires generics to be safe and work the same as brand name

drugs If there is no generic available there may be more than one brand name drug to treat a condition Preferred

brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate safe and cost-

effective treatment options if a generic medication on the formulary is not suitable for your condition

Please note the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit

Not all dosage forms or strengths of a drug may be covered This list is periodically reviewed and updated and may

be subject to change Drugs may be added or removed or additional requirements may be added in order to approve

continued usage of a specific drug

Specific prescription benefit plan designs may not cover certain products or categories regardless of their

appearance in this document Please check your benefits for coverage limitations and your share of cost for your

drugs

Drug List Key

Brand name drugs are listed in CAPS and generic drugs are lower case Drugs are covered under different copay tiers depending on your benefit

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Affordable Care Act Select oral contraceptives vitamin D folic acid for women of child bearing age over-the-counter (OTC) aspirin and smoking cessation products may be covered under this tier Certain age or gender limits apply

Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similar conditions Select over-the-counter (OTC) generic or brand name drugs may be covered under this tier

Tier 2 - Medium copayment covers brand name drugs that are generally more affordable or may be preferred compared to other drugs to treat the same conditions

Tier 3 - Highest copayment covers higher cost brand name drugs This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage

Tier 4 - Coverage for this tier is for ldquospecialtyrdquo drugs Specialty drugs are used to treat complex chronic conditions and may require special handling storage or clinical management Prescription drugs covered under the specialty tier require fulfillment at a pharmacy that participates in Ambetterrsquos ldquospecialtyrdquo or ldquohemophiliardquo networks For additional information on which pharmacies are within our ldquospecialtyrdquo or ldquohemophiliardquo networks please consult Ambetter websitersquos pharmacy information section

Coverage for this tier is for oncology or anti-cancer drugs Cost-share is set to be equivalent to members Tier 6 - medical benefit cost-share

Abbreviation

Prior Authorization for Non-Formulary Drugs To obtain prior authorization for a non-formulary drug your provider must fill out the Prior Authorization form Envolve

Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgent

requests and within 72 hours for non-urgent requests unless state law requires faster response If the request is

disapproved the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the

prior authorization request or if the request was incomplete the explanation will identify the missing material

Formulary Abbreviations

Term What it means

AL Age Limit Some drugs are only covered for certain ages

QL Quantity Limit Some drugs are only covered for a certain amount

PA Prior Authorization Your doctor must ask for approval from Ambetter before

some drugs will be covered

ST Step Therapy

In some cases you must first try certain drugs before

Ambetter covers another drug for your medical condition

For example if Drug A and Drug B both treat your

medical condition Ambetter may not cover Drug B

unless you try Drug A first

NF Non-formulary

This product is not covered unless you or your provider

request an exception Alternative medications are listed

next to non-covered product

RXOTC Prescription and OTC These drugs are made in both prescription form and

Over-the-counter (OTC) form

Drug Name DrugTier

RequirementsLimits

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to TreatADHD Sleep and Eating Disorders

Amphetamines ADDERALL TABS 125 MG-125 MG-125 MG-125 MG 1875 MG-1875 MG-1875 MG-1875 MG 25 MG-25 MG-25 MG-25 MG 3125 MG-3125 MG-3125 MG-3125 MG 375 MG-375 MG-375 MG-375 MG 5 MG-5 MG-5 MG-5 MG (Use amphetamine-dextroamphetamine)

NF

QL(3 ea daily)

ADDERALL TABS 75 MG-75 MG-75 MG-75 MG (Use amphetamine-dextroamphetamine)

NF

QL(2 ea daily)

ADDERALL XR CP24 125 MG-125 MG-125 MG-125 MG 25 MG-25 MG-25 MG-25 MG (Use amphetamine-dextroamphetamine)

NF

QL(1 ea daily)

ADDERALL XR CP24 375 MG-375 MG-375 MG-375 MG (Use amphetamine-dextroamphetamine)

NF

ADDERALL XR CP24 5 MG-5 MG-5 MG-5 MG 625 MG-625 MG-625 MG-625 MG 75 MG-75 MG-75 MG-75 MG (Use amphetamine-dextroamphetamine)

NF

QL(2 ea daily)

ADZENYS ER SUER (Use amphetamine) NF

amphetamine-dextroamphetamine cp24125 mg-125 mg-125 mg-125 mg 25 mg-25 mg-25 mg-25 mg

1

QL(1 ea daily)

amphetamine-dextroamphetamine cp24375 mg-375 mg-375 mg-375 mg

1

Drug Name DrugTier

RequirementsLimits

amphetamine-dextroamphetamine cp24 5mg-5 mg-5 mg-5 mg 625mg-625 mg-625 mg-625mg 75 mg-75 mg-75 mg-75 mg

1

QL(2 ea daily)

amphetamine-dextroamphetamine tabs125 mg-125 mg-125 mg-125 mg 1875 mg-1875mg-1875 mg-1875 mg25 mg-25 mg-25 mg-25mg 3125 mg-3125 mg-3125 mg-3125 mg 375mg-375 mg-375 mg-375mg 5 mg-5 mg-5 mg-5 mg

1

QL(3 ea daily)

amphetamine-dextroamphetamine tabs75 mg-75 mg-75 mg-75 mg

1

QL(2 ea daily)

DESOXYN TABS (Use methamphetamine hcl) NF

QL(5 ea daily)AL(At least 6yrs old)

DEXEDRINE CP24 10 MG 15 MG (Use dextroamphetaminesulfate)

NF

QL(4 ea daily)

DEXEDRINE CP24 5 MG (Use dextroamphetaminesulfate)

NF

dextroamphetamine sulfatecp24 10 mg 15 mg 1 QL(4 ea daily)

dextroamphetamine sulfatecp24 5 mg 1

dextroamphetamine sulfatetabs 10 mg 5 mg 1 QL(4 ea daily)

methamphetamine hcl tabs 3 QL(5 ea daily)AL(At least 6yrs old)

VYVANSE CAPS 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG

3 ST QL(1 eadaily)

Anorexiants Non-Amphetamine ADIPEX-P CAPS (Use phentermine hcl) NF PA

phendimetrazine tartratetabs 1 PA

AZ Essential Rx Drug List Updated August 1 2021

1

Drug Name DrugTier

RequirementsLimits

phentermine hcl caps 1 PA

Anti-Obesity Agents

BELVIQ TABS 3 PA QL(2 eadaily)

CONTRAVE TB12 3 PA QL(4 eadaily)

Attention-DeficitHyperactivity Disorder (ADHD)

atomoxetine hcl caps 10mg 18 mg 25 mg 40 mg 1


atomoxetine hcl caps 100mg 60 mg 80 mg 1


clonidine hcl (adhd) tb12 1

guanfacine hcl (adhd) tb24 1 QL(1 ea daily)AL(At least 6yrs old)

INTUNIV TB24 (Use guanfacine hcl (adhd)) NF


KAPVAY TB12 (Use clonidine hcl (adhd)) NF

STRATTERA CAPS 10 MG 18 MG 25 MG 40 MG (Use atomoxetine hcl)

NF QL(2 ea daily)AL(At least 6yrs old)

STRATTERA CAPS 100 MG 60 MG 80 MG (Use atomoxetine hcl)


Dopamine and Norepinephrine Reuptake

SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1

PA QL(1 eadaily) AL(Atleast 17 yrsold)

CONCERTA TBCR 18 MG 27 MG (Use methylphenidate hcl)




DAYTRANA PTCH 3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

dexmethylphenidate hclcp24 35 mg 15 mg 20 mg25 mg 40 mg 5 mg 10mg 30 mg

1

QL(1 ea daily)

dexmethylphenidate hcltabs 25 mg 10 mg 5 mg 1


FOCALIN TABS (Use dexmethylphenidate hcl) NF


FOCALIN XR CP24 (Use dexmethylphenidate hcl) NF QL(1 ea daily)

METHYLIN SOLN (Use methylphenidate hcl) NF

QL(30 mldaily) AL(Atleast 6 yrs old)

methylphenidate hcl cp2420 mg 40 mg 1 AL(At least 6

yrs old)

methylphenidate hcl cp2430 mg 1


methylphenidate hcl cpcr40 mg 10 mg 20 mg 30mg 50 mg 60 mg

1 QL(1 ea daily)AL(At least 6yrs old)

methylphenidate hcl soln10 mg5ml 5 mg5ml 1


methylphenidate hcl tabs10 mg 20 mg 1


methylphenidate hcl tabs 5 mg 1


methylphenidate hcl tbcr 10mg 20 mg 1






modafinil tabs 100 mg 1



2

Drug Name DrugTier

RequirementsLimits



NUVIGIL TABS (Use armodafinil) NF


PROVIGIL TABS 100 MG (Use modafinil) NF




RITALIN LA CP24 20 MG 40 MG (Use methylphenidate hcl)

NF AL(At least 6yrs old)

RITALIN LA CP24 30 MG (Use methylphenidate hcl) NF


RITALIN TABS 10 MG 20 MG (Use methylphenidate hcl)


RITALIN TABS 5 MG (Use methylphenidate hcl) NF


ALLERGENIC EXTRACTSBIOLOGICALS MISC

Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

amikacin sulfate soln 1

ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits

gentamicin in saline soln08 mgml-09 09 -1mgml 09 -12 mgml09 -16 mgml

1

gentamicin sulfate soln 40mgml 1

HUMATIN CAPS (Use paromomycin sulfate) NF

KITABIS PAK NEBU (Use tobramycin) NF PA

neomycin sulfate tabs 1

paromomycin sulfate caps 1

streptomycin sulfate solr 3

TOBI NEBU (Use tobramycin) NF PA

tobramycin nebu 300mg5ml 4 PA

tobramycin sulfate soln 10mgml 40 mgml 80mg2ml

1

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain Swelling Muscle and JointConditions

Anti-TNF-alpha - Monoclonal Antibodies

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

4

PA 1 rtl packlmt amt180 rtl pack lmtday(s)1 mailpack lmtamt180 mail pack lmtday(s)

HUMIRA PEN PNKT 40 MG04ML 40 MG08ML 4 PA QL(0143

ea daily)

HUMIRA PEN PNKT 80 MG08ML 4


HUMIRA PEN-CDUCHSSTARTER PNKT 40 MG08ML

4 PA QL(0143ea daily)


3

Drug Name DrugTier

RequirementsLimits


4


HUMIRA PEN-PEDIATRIC UC STARTER PACK PNKT

4


HUMIRA PEN-PSUVSTARTER PNKT 4


HUMIRA PEN-PSUVSTARTER PNKT 4 PA QL(0143

ea daily)

HUMIRA PSKT 4 PA QL(0143ea daily)

Antirheumatic - Enzyme Inhibitors

RINVOQ TB24 4 PA QL(1 eadaily)

XELJANZ TABS 10 MG 4 PA QL(2 eadaily)

XELJANZ TABS 5 MG 4 PA QL(2 eadaily) SP

XELJANZ XR TB24 4 PA QL(1 eadaily)

Antirheumatic Antimetabolites

METHOTREXATE TABS 6 PA QL(1714ea daily) SP

Gold Compounds

RIDAURA CAPS 3 QL(3 ea daily)

Interleukin-1 Blockers

ARCALYST SOLR 4 PA QL(0286ea daily) SP

Drug Name DrugTier

RequirementsLimits

Interleukin-1beta Blockers

ILARIS SOLN 4 PA QL(0072ml daily)

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ARTHROTEC 50 TBEC (Use diclofenac wmisoprostol)

NF

ARTHROTEC 75 TBEC (Use diclofenac wmisoprostol)

NF

CELEBREX CAPS (Use celecoxib) NF PA

celecoxib caps 1 PA

CHILDRENS ADVIL SUSP (Use ibuprofen) NF RXOTC

CHILDRENS MOTRIN SUSP (Use ibuprofen) NF RXOTC

DAYPRO TABS (Use oxaprozin) NF

diclofenac potassium tabs 1

diclofenac sodium tb24 1

diclofenac sodium tbec 1

diclofenac w misoprostoltbec 1

EC-NAPROSYN TBEC 500 MG (Use naproxen) NF

etodolac caps 200 mg 300 mg 1

etodolac tabs 400 mg 500 mg 1

FELDENE CAPS (Use piroxicam) NF

fenoprofen calcium tabs600 mg 1 ST QL(4 ea

daily)

flurbiprofen tabs 1

ibuprofen susp 100 mg5ml 1 RXOTC

ibuprofen tabs 400 mg 800mg 600 mg 1

indomethacin caps 25 mg50 mg 1


4

Drug Name DrugTier

RequirementsLimits

indomethacin cpcr 75 mg 1

ketoprofen caps 50 mg 75 mg 1

ketorolac tromethamine tabs or 10 mg 1 QL(0667 ea

daily) LODINE TABS (Use etodolac) NF

meclofenamate sodium caps 1

mefenamic acid caps 1 ST QL(6 eadaily)

meloxicam tabs 15 mg 75 mg 1 QL(1 ea daily)

MOBIC TABS (Use meloxicam) NF QL(1 ea daily)

nabumetone tabs 1

NALFON TABS 600 MG (Use fenoprofen calcium) NF ST QL(4 ea

daily) NAPROSYN SUSP 125 MG5ML (Use naproxen) NF PA

NAPROSYN TABS 500 MG (Use naproxen) NF

naproxen sodium tabs 550 mg 1

naproxen susp 125 mg5ml 1 PA

naproxen tabs 250 mg 375mg 500 mg 1

naproxen tbec 500 mg 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

tolmetin sodium caps 1

tolmetin sodium tabs 1

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS 4 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4

PA 1 rtl packlmt amt180 rtl pack lmtday(s)

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use leflunomide) NF QL(1 ea daily)

leflunomide tabs 1 QL(1 ea daily)

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT 4 PA QL(015 mldaily)

ENBREL SOLN 25 MG05ML 4 PA QL(0146

ml daily)

ENBREL SOLR 25 MG 4 PA QL(0286ea daily) SP

ENBREL SOSY 25 MG05ML 4 PA QL(0146

ml daily) SP

ENBREL SOSY 50 MGML 4 PA QL(028 mldaily) SP

ENBREL SURECLICK SOAJ 4 PA QL(0143

ml daily) SP

ANALGESICS - NonNarcotic - Drugs to TreatPain Muscle and Joint Conditions

Analgesic Combinations butalbital-acetaminophentabs 50 mg-325 mg 1

butalbital-acetaminophen-caffeine caps 40 mg-50mg-300 mg 40 mg-50 mg-325 mg

1

butalbital-acetaminophen-caffeine tabs 40 mg-50 mg-325 mg

1

butalbital-aspirin-caffeine caps 1

BUTALBITALACETAMINOPHEN CAPS (Use butalbital-acetaminophen)

NF

ESGIC TABS (Use butalbital-acetaminophen-caffeine)

NF

FIORICET CAPS (Use butalbital-acetaminophen-caffeine)

NF


5

Drug Name DrugTier

RequirementsLimits

FIORINAL CAPS (Use butalbital-aspirin-caffeine) NF

Salicylates

aspirin chew 81 mg 0 AL(At least 45yrs old - Up to79 yrs old)

aspirin tabs 325 mg 0 AL(At least 45yrs old - Up to79 yrs old)

aspirin tbec 325 mg 1

aspirin tbec 81 mg 0 AL(At least 45yrs old - Up to79 yrs old)

diflunisal tabs 1

ECOTRIN REGULAR STRENGTH TBEC (Use aspirin)

NF

ECOTRIN TBEC (Use aspirin) NF

salsalate tabs 1

ANALGESICS - OPIOID - Drugs to Treat PainMuscle and Joint Conditions

Opioid Agonists ACTIQ LPOP (Use fentanyl citrate) NF PA QL(4 ea

daily)

CODEINE SULFATE TABS 15 MG 60 MG 1

New starts limited to 7 daysupply

codeine sulfate tabs 30 mg 1 New starts limited to 7 daysupply

CONZIP CP24 (Use tramadol hcl) NF

DEMEROL SOLN 100 MGML 25 MGML 50MGML (Use meperidine hcl)

NF

DILAUDID LIQD OR 1 MGML (Use hydromorphone hcl)

NF New starts limited to 7 daysupply

DILAUDID SOLN IJ 1 MGML 2 MGML (Use hydromorphone hcl)

NF

Drug Name DrugTier

RequirementsLimits

DILAUDID TABS OR 2 MG 4 MG 8 MG (Use hydromorphone hcl)

NF

New starts limited to 7 daysupplyQL(8 eadaily)

DOLOPHINE TABS 10 MG (Use methadone hcl) NF QL(10 ea daily)


DURAGESIC PT72 (Use fentanyl) NF QL(034 ea

daily)

EMBEDA CPCR 3 PA QL(2 eadaily)

fentanyl citrate lpop bu1200 mcg 1600 mcg 200mcg 400 mcg 600 mcg800 mcg

1

PA QL(4 eadaily)

fentanyl pt72 td 100mcghr 12 mcghr 25mcghr 50 mcghr 75mcghr

1

QL(034 eadaily)

FENTORA TABS (Use fentanyl citrate) NF

hydrocodone bitartratecp12 20 mg 10 mg 15 mg30 mg 40 mg 50 mg

1 PA QL(2 eadaily)

hydromorphone hcl liqd or1 mgml 1


hydromorphone hcl soln ij10 mgml 50 mg5ml 500mg50ml

1

hydromorphone hcl tabs or2 mg 4 mg 8 mg 1


hydromorphone hcl tb24 or12 mg 16 mg 8 mg 1 PA QL(2 ea

daily) hydromorphone hcl tb24 or32 mg 1 PA QL(1 ea

daily) HYDROMORPHONE HYDROCHLORIDE SOLN IJ 10 MGML (Use hydromorphone hcl)

NF

KADIAN CP24 100 MG 20 MG 30 MG 50 MG 60 MG 80 MG (Use morphine sulfate)

NF

PA QL(2 eadaily)


6

Drug Name DrugTier

RequirementsLimits

levorphanol tartrate tabs 2 mg 1


meperidine hcl soln ij 100mgml 25 mgml 50 mgml 1

meperidine hcl soln or 50mg5ml 1

New starts limited to 7 daysupplyQL(500ml per fill retail)

meperidine hcl tabs or 50 mg 1


methadone hcl conc or 10 mgml 1 QL(10 ml daily)

methadone hcl soln ij 10mgml 1

METHADONE HCL SOLN IJ 10 MGML (Use methadone hcl)

1

methadone hcl soln or 10 mg5ml 1 QL(50 ml daily)

methadone hcl soln or 5 mg5ml 1 QL(100 ml

daily) methadone hcl tabs or 10 mg 1 QL(10 ea daily)

methadone hcl tabs or 5 mg 1 QL(4 ea daily)

methadone hcl tbso or 40 mg 1 QL(2 ea daily)

METHADOSE CONC (Use methadone hcl) NF QL(10 ml daily)

METHADOSE SUGAR-FREE CONC (Use methadone hcl)

NF QL(10 ml daily)

MORPHABOND ER T12A 100 MG 30 MG 60 MG 3 PA QL(1 ea

daily) MORPHABOND ER T12A 15 MG 3 PA QL(3 ea

daily) morphine sulfate cp24 or100 mg 20 mg 30 mg 50mg 60 mg 80 mg

1 PA QL(2 eadaily)

morphine sulfate soln ij 05mgml 1 mgml 1

MORPHINE SULFATE SOLN IV 10 MGML (Use morphine sulfate)

NF

Drug Name DrugTier

RequirementsLimits

morphine sulfate soln or 10mg5ml 1

New starts limited to 7 daysupplyQL(100ml daily)



morphine sulfate tabs or 15 mg 1

morphine sulfate tabs or 15mg 30 mg 1


morphine sulfate tbcr or100 mg 15 mg 200 mg 30mg 60 mg

1 QL(2 ea daily)

MS CONTIN TBCR (Use morphine sulfate) NF QL(2 ea daily)

NUCYNTA ER TB12 2 PA QL(2 eadaily)

NUCYNTA TABS 2 PA QL(6 eadaily)

OPANA TABS (Use oxymorphone hcl) NF PA QL(12 ea

daily)

OXAYDO TABS 5 MG 2

New starts limited to 7 daysupplyQL(12ea daily)

oxycodone hcl t12a 15 mg30 mg 60 mg 80 mg 10mg 20 mg 40 mg

3 PA QL(2 eadaily)

oxycodone hcl tabs 10 mg20 mg 15 mg 30 mg 5 mg 1


OXYCONTIN T12A 3 PA QL(2 eadaily)

oxymorphone hcl tabs 10mg 5 mg 1 PA QL(12 ea

daily) oxymorphone hcl tb12 10mg 15 mg 20 mg 30 mg5 mg 75 mg

1 PA QL(2 eadaily)

oxymorphone hcl tb12 40 mg 1 PA QL(4 ea

daily)


7

Drug Name DrugTier

RequirementsLimits

ROXICODONE TABS (Use oxycodone hcl) NF


SUBSYS LIQD 100 MCG 3 PA QL(3 eadaily)

SUBSYS LIQD 1200 MCG 1600 MCG 800 MCG 3 PA QL(8 ea

daily) SUBSYS LIQD 200 MCG 400 MCG 600 MCG 3 PA QL(4 ea

daily)

tramadol hcl tabs 50 mg 1


tramadol hcl tb24 100 mg200 mg 300 mg 1 QL(1 ea daily)

ULTRAM TABS (Use tramadol hcl) NF


XTAMPZA ER C12A 2 PA QL(2 eadaily)

ZOHYDRO ER CP12 (Use hydrocodone bitartrate) 3 PA QL(2 ea

daily) Opioid Combinations

acetaminophen w codeinesoln 12 mg5ml-120mg5ml

1


acetaminophen w codeinetabs 15 mg-300 mg 1


acetaminophen w codeinetabs 30 mg-300 mg 300mg-30 mg

1




acetaminophen-caff-dihydrocod caps 16 mg-30mg-3205 mg

1 New starts limited to 7 daysupply


3 PA New starts limited to 7 daysupply

Drug Name DrugTier

RequirementsLimits

butalbital-acetaminophen-caffeine w codeine caps30 mg-40 mg-50 mg-300 mg

1



1


butalbital-aspirin-caffeinewcod caps 1


FIORICETCODEINECAPS (Use butalbital-acetaminophen-caffeine wcodeine)

NF


FIORINALCODEINE 3CAPS (Use butalbital-aspirin-caffeine wcod)

NF


hydrocodone-acetaminophen soln 10mg15ml-325 mg15ml


hydrocodone-acetaminophen soln 25mg5ml-108 mg5ml 5mg10ml-217 mg10ml 75mg15ml-325 mg15ml

1


hydrocodone-acetaminophen tabs 5 mg-300 mg 75 mg-300 mg 10mg-300 mg 300 mg-10 mg

1


hydrocodone-acetaminophen tabs 5 mg-325 mg 10 mg-325 mg325 mg-10 mg 325 mg-75mg 75 mg-325 mg

1


hydrocodone-ibuprofentabs 10 mg-200 mg 5 mg-200 mg

1 PA

hydrocodone-ibuprofentabs 75 mg-200 mg 1


LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits

NORCO TABS (Use hydrocodone-acetaminophen)

NF


oxycodone wacetaminophen tabs 10mg-325 mg 5 mg-325 mg75 mg-325 mg

1


oxycodone-ibuprofen tabs 1


PERCOCET TABS 10 MG-325 MG 325 MG-75 MG 5 MG-325 MG (Use oxycodone wacetaminophen)

NF


tramadol-acetaminophentabs 1


TYLENOLCODEINE 3TABS (Use acetaminophenw codeine)

NF



NF


ULTRACET TABS (Use tramadol-acetaminophen) NF


Opioid Partial Agonists BUNAVAIL FILM 03 MG-21 MG 21 MG-03 MG 3 PA QL(4 ea

daily) BUNAVAIL FILM 07 MG-42 MG 3 PA QL(2 ea


daily) BUPRENEX SOLN (Use buprenorphine hcl) NF

buprenorphine hcl soln ij03 mgml 1

buprenorphine hcl subl sl 2mg 8 mg 1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

buprenorphine hcl-naloxone hcl dihydrate film05 mg-2 mg 1 mg-4 mg

1 QL(3 ea daily)


1 QL(2 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl05 mg-2 mg 2 mg-8 mg

1 QL(3 ea daily)

buprenorphine ptwk td 10mcghr 15 mcghr 20mcghr 5 mcghr 75mcghr

1

PA QL(0143ea daily)

butorphanol tartrate soln ij1 mgml 2 mgml 1

butorphanol tartrate soln na10 mgml 1 PA

BUTRANS PTWK 10 MCGHR 15 MCGHR 20MCGHR 5 MCGHR (Use buprenorphine)

NF

PA QL(0143ea daily)

BUTRANS PTWK 75 MCGHR (Use buprenorphine)


nalbuphine hcl soln 1 QL(8 ml daily)

pentazocine w naloxonetabs 1


SUBOXONE FILM 05 MG-2 MG 1 MG-4 MG 2 MG-05 MG (Use buprenorphine hcl-naloxone hcl dihydrate)

NF

QL(3 ea daily)

SUBOXONE FILM 2 MG-8 MG 3 MG-12 MG (Use buprenorphine hcl-naloxone hcl dihydrate)

NF

QL(2 ea daily)

ANDROGENS-ANABOLIC - Drugs to Regulate Hormones

Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits

ANDRODERM PT24 2 PA QL(1 eadaily)

ANDROGEL GEL 25 MG25GM 50 MG5GM(Use testosterone)

NF

danazol caps 1

DEPO-TESTOSTERONE SOLN (Use testosterone cypionate)

NF

METHITEST TABS 3

TESTIM GEL (Use testosterone) NF

TESTOSTERONE CYPIONATE SOLN IJ 200 MGML

1

testosterone cypionate solnij 200 mgml 1

testosterone cypionate solnim 100 mgml 200 mgml 1

testosterone enanthate soln im 1

VOGELXO GEL (Use testosterone) NF

VOGELXO PUMP GEL (Use testosterone) NF

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (Use hydrocortisone (intrarectal)) NF

hydrocortisone (intrarectal) enem 1

UCERIS FOAM RE 2 MGACT 4 PA QL(32 gm

daily) Rectal Steroids ANUSOL-HC CREA (Use hydrocortisone (rectal)) NF

hydrocortisone (rectal) crea 1

hydrocortisone acetate(rectal) supp 1

PROCTOCORT CREA (Use hydrocortisone(rectal))

NF

Drug Name DrugTier

RequirementsLimits

PROCTOCORT SUPP (Use hydrocortisoneacetate (rectal))

NF

Vasodilating Agents

RECTIV OINT 3 QL(2 gm daily)

ANTHELMINTICS - Drugs to Treat Worm Infections

Anthelmintics

albendazole tabs 1 PA

ALBENZA TABS (Use albendazole) NF PA

BILTRICIDE TABS (Use praziquantel) NF PA

EMVERM CHEW 2

QL(2 ea daily6ea per fillretail)1 rtl MAXfill60 rtl day(s)supply

ivermectin tabs or 3 mg 1

praziquantel tabs 1 PA

STROMECTOL TABS (Use ivermectin) NF

ANTI-INFECTIVE AGENTS - MISC - Drugs to Treat Bacterial Infections

Anti-infective Agents - Misc bacitracin solr 3

FLAGYL TABS 500 MG (Use metronidazole) NF

IMPAVIDO CAPS 3 PA QL(3 eadaily)

metronidazole tabs or 250 mg 500 mg 1

trimethoprim tabs 1

XIFAXAN TABS 3 PA AL(At least12 yrs old)

Anti-infective Misc - Combinations BACTRIM DS TABS (Use sulfamethoxazole-trimethoprim)

NF


10

Drug Name DrugTier

RequirementsLimits

BACTRIM TABS (Use sulfamethoxazole-trimethoprim)

NF

sulfamethoxazole-trimethoprim soln 1

sulfamethoxazole-trimethoprim susp 1

sulfamethoxazole-trimethoprim tabs 1

Antiprotozoal Agents ALINIA SUSR 100 MG5ML 2 PA

ALINIA TABS 500 MG (Use nitazoxanide) 2 PA

atovaquone susp 1

MEPRON SUSP (Use atovaquone) NF

nitazoxanide tabs 1 PA

Carbapenems

ertapenem sodium solr 1

imipenem-cilastatin solr 1

INVANZ SOLR (Use ertapenem sodium) NF

meropenem solr 1

MERREM SOLR (Use meropenem) NF

PRIMAXIN IV SOLR (Use imipenem-cilastatin) NF

Chloramphenicols chloramphenicol sodiumsuccinate solr 4 PA SP

Cyclic Lipopeptides CUBICIN RF SOLR (Use daptomycin) NF

CUBICIN SOLR (Use daptomycin) NF

DAPTOMYCIN SOLR 350 MG (Use daptomycin) NF

daptomycin solr 500 mg 1

Drug Name DrugTier

RequirementsLimits

Glycopeptides

FIRVANQ SOLR 2 QL(300 ml perfill retail)

VANCOCIN CAPS (Use vancomycin hcl) NF

QL(4 eadaily40 ea perfill retail)

VANCOCIN HCL CAPS (Use vancomycin hcl) NF


vancomycin hcl caps or125 mg 250 mg 1


VANCOMYCIN HYDROCHLORIDE SOLR OR 250 MG5ML

2 QL(300 ml perfill retail)

Leprostatics

dapsone tabs 1

Lincosamides CLEOCIN CAPS OR 75 MG 150 MG 300 MG (Use clindamycin hcl)

NF

CLEOCIN PEDIATRIC GRANULES SOLR (Use clindamycin palmitatehydrochloride)

NF

CLEOCIN PHOSPHATE SOLN IJ 300 MG2ML 600MG4ML 900 MG6ML 9GM60ML (Use clindamycin phosphate)

NF

clindamycin hcl caps 1

clindamycin palmitatehydrochloride solr 1

clindamycin phosphate soln 1

LINCOCIN SOLN (Use lincomycin hcl) NF

lincomycin hcl soln 1

Monobactams AZACTAM SOLR (Use aztreonam) NF

aztreonam solr 1


11

Drug Name DrugTier

RequirementsLimits

Oxazolidinones linezolid susr or 100 mg5ml 1

linezolid tabs or 600 mg 1 PA QL(2 eadaily)

SIVEXTRO TABS OR 3 PA

ZYVOX SUSR OR 100 MG5ML (Use linezolid) NF

ZYVOX TABS OR 600 MG (Use linezolid) NF PA QL(2 ea

daily) Polymyxins

polymyxin b sulfate solr 1

Urinary Anti-infectives fosfomycin tromethaminepack 1

FURADANTIN SUSP (Use nitrofurantoin) NF

HIPREX TABS (Use methenamine hippurate) NF

MACROBID CAPS (Use nitrofurantoin monohyd macro)

NF

MACRODANTIN CAPS 100 MG 50 MG (Use nitrofurantoin macrocrystal)

NF

methenamine hippuratetabs 1

MONUROL PACK (Use fosfomycin tromethamine) 3

nitrofurantoin macrocrystalcaps 100 mg 50 mg 1

nitrofurantoin monohyd macro caps 1

nitrofurantoin susp 1

ANTIANGINAL AGENTS - Drugs to Treat Chest Pain

Antianginals-Other RANEXA TB12 1000 MG (Use ranolazine) NF QL(2 ea daily)

RANEXA TB12 500 MG (Use ranolazine) NF QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

ranolazine tb12 1000 mg 1 QL(2 ea daily)


Nitrates ISORDIL TITRADOSE TABS 5 MG (Use isosorbide dinitrate)

NF

isosorbide dinitrate tabs 30 mg 10 mg 20 mg 5 mg 1

isosorbide dinitrate tbcr 40 mg 1

isosorbide mononitrate tabs 1

isosorbide mononitrate tb24 1

NITRO-BID OINT 3

NITRO-DUR PT24 01 MGHR 02 MGHR 04MGHR 06 MGHR (Use nitroglycerin)

NF

nitroglycerin cpcr or 9 mg25 mg 65 mg 1 QL(4 ea daily)

nitroglycerin pt24 td 01mghr 02 mghr 04mghr 06 mghr

1

NITROGLYCERIN SOLN IV 5 MGML 1

nitroglycerin subl sl 03 mg04 mg 06 mg 1

NITROSTAT SUBL (Use nitroglycerin) NF

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc buspirone hcl tabs 10 mg30 mg 75 mg 15 mg 1

buspirone hcl tabs 5 mg 1 QL(6 ea daily)

hydroxyzine hcl soln im 50mgml 1

hydroxyzine hcl syrp or 10mg5ml 1

hydroxyzine hcl tabs or 10mg 25 mg 50 mg 1


12

Drug Name DrugTier

RequirementsLimits

hydroxyzine pamoate caps 1

meprobamate tabs 1

VISTARIL CAPS (Use hydroxyzine pamoate) NF

Benzodiazepines alprazolam tabs 025 mg05 mg 1 mg 2 mg 1 QL(4 ea daily)

alprazolam tb24 05 mg 1mg 2 mg 3 mg 1

alprazolam tbdp 025 mg05 mg 1 mg 2 mg 1

ATIVAN TABS OR 05 MG 2 MG (Use lorazepam) NF QL(3 ea daily)

ATIVAN TABS OR 1 MG (Use lorazepam) NF QL(4 ea daily)

chlordiazepoxide hcl caps 1

clorazepate dipotassiumtabs 1

diazepam conc or 5 mgml 1

diazepam soln or 5 mg5ml 1

diazepam tabs or 10 mg 2mg 5 mg 1 QL(4 ea daily)

lorazepam conc or 2 mgml 1

lorazepam tabs or 05 mg2 mg 1 QL(3 ea daily)

lorazepam tabs or 1 mg 1 QL(4 ea daily)

oxazepam caps 10 mg 30mg 15 mg 1

TRANXENE T TABS (Use clorazepate dipotassium) NF

VALIUM TABS (Use diazepam) NF QL(4 ea daily)

XANAX TABS (Use alprazolam) NF QL(4 ea daily)

XANAX XR TB24 (Use alprazolam) NF

ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms

Antiarrhythmics Type I-A

Drug Name DrugTier

RequirementsLimits

disopyramide phosphate caps 1

NORPACE CAPS (Use disopyramide phosphate) NF

procainamide hcl soln 500mgml 1

quinidine sulfate tabs 1

Antiarrhythmics Type I-B mexiletine hcl caps 150mg 200 mg 250 mg 1

Antiarrhythmics Type I-C

flecainide acetate tabs 1

propafenone hcl cp12 1

propafenone hcl tabs 1

RYTHMOL SR CP12 (Use propafenone hcl) NF

Antiarrhythmics Type III amiodarone hcl soln iv 150 mg3ml 50 mgml 1

amiodarone hcl tabs or 100 mg 200 mg 400 mg 1

dofetilide caps 1

MULTAQ TABS 3

TIKOSYN CAPS (Use dofetilide) NF

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

cromolyn sodium nebu 1 QL(8 ml daily)

Antiasthmatic - Monoclonal Antibodies

FASENRA PEN SOAJ 4 PA

FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOSY 4 PA

XOLAIR SOLR 150 MG 4 PA QL(0214ea daily) SP

XOLAIR SOSY 150 MGML 75 MG05ML 4 PA

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 3 QL(044 gmdaily)

INCRUSE ELLIPTA AEPB 2 QL(1 ea daily)

ipratropium bromide soln 1 QL(15 ml daily)

SPIRIVA HANDIHALER CAPS 2 QL(1 ea daily)

SPIRIVA RESPIMAT AERS 2 QL(014 gm

daily) Leukotriene Modulators ACCOLATE TABS (Use zafirlukast) NF QL(2 ea daily)

montelukast sodium chew 4 mg 5 mg 1 QL(1 ea daily)

montelukast sodium pack 4 mg 1 PA QL(1 ea

daily) montelukast sodium tabs 10 mg 1 QL(1 ea daily)

SINGULAIR CHEW 4 MG 5 MG (Use montelukast sodium)

NF QL(1 ea daily)

SINGULAIR PACK 4 MG (Use montelukast sodium) NF PA QL(1 ea

daily) SINGULAIR TABS 10 MG (Use montelukast sodium) NF QL(1 ea daily)

zafirlukast tabs 1 QL(2 ea daily)

zileuton tb12 1 QL(4 ea daily)

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS 250 MCG 3

QL(1 eadaily)30 rtlMAX day(s)supply180 rtllmt day(s)30mail MAX day(s)supply180 maillmt day(s)

Drug Name DrugTier

RequirementsLimits

DALIRESP TABS 500 MCG 3 QL(1 ea daily)

Steroid Inhalants ARNUITY ELLIPTA AEPB 100 MCGACT 200MCGACT

2

ARNUITY ELLIPTA AEPB 50 MCGACT 2 MP

budesonide (inhalation) susp 1 PA QL(4 ml

daily)

FLOVENT DISKUS AEPB 2

FLOVENT HFA AERO 2

PULMICORT FLEXHALER AEPB 2

PULMICORT SUSP (Use budesonide (inhalation)) NF PA QL(4 ml

daily)

QVAR REDIHALER AERB 2

Sympathomimetics ADVAIR DISKUS AEPB (Use fluticasone-salmeterol)

NF

ADVAIR HFA AERO 2

AIRDUO RESPICLICK 11314 AEPB (Use fluticasone-salmeterol)

NF


NF


NF

albuterol sulfate aers in 108 mcgact 1

Limit 2 Inhalers per month1 rtlpack lmt perfill2 rtl MAX fill30 rtl day(s)supply


Limit 2 inhalers per month1 rtlpack lmt perfill2 rtl MAX fill30 rtl day(s)supply


14

Drug Name DrugTier

RequirementsLimits

albuterol sulfate nebu in 0083 063 mg3ml 125mg3ml

1 QL(15 ml daily)

albuterol sulfate nebu in 05 25 mg05ml 1

albuterol sulfate syrp or 2mg5ml 1

albuterol sulfate tabs or 2 mg 4 mg 1

albuterol sulfate tb12 or 4 mg 8 mg 1

ANORO ELLIPTA AEPB 2 QL(2 ea daily)

ARCAPTA NEOHALER CAPS 2

arformoterol tartrate nebu 1 PA QL(4 mldaily)

BEVESPI AEROSPHERE AERO 2 QL(036 gm

daily)

BREO ELLIPTA AEPB 2

BROVANA NEBU (Use arformoterol tartrate) 3 PA QL(4 ml

daily) budesonide-formoterol fumarate dihydrate aero 1

fluticasone-salmeterol aepb50 mcgdose-500mcgdose 50 mcgact-100mcgact 50 mcgact-250mcgact 50 mcgdose-100mcgdose 50 mcgdose-250 mcgdose

1

ipratropium-albuterol soln 1 QL(18 ml daily)

levalbuterol hcl nebu 031 mg3ml 063 mg3ml 125mg3ml

1 PA QL(12 mldaily)

levalbuterol hcl nebu 125 mg05ml 1 PA

levalbuterol tartrate aero 1

PA Limit 2 inhalers permonthQL(1 gmdaily)

PROAIR HFA AERS (Use albuterol sulfate) NF

PROVENTIL HFA AERS (Use albuterol sulfate) NF

Drug Name DrugTier

RequirementsLimits

SEREVENT DISKUS AEPB 2

STRIVERDI RESPIMAT AERS 2

SYMBICORT AERO (Use budesonide-formoterol fumarate dihydrate)

2

terbutaline sulfate soln 1

terbutaline sulfate tabs 1

TRELEGY ELLIPTA AEPB 2 QL(2 ea daily)

UTIBRON NEOHALER CAPS 3 PA QL(2 ea

daily) VENTOLIN HFA AERS (Use albuterol sulfate) NF

XOPENEX CONCENTRATE NEBU (Use levalbuterol hcl)

NF PA

XOPENEX HFA AERO (Use levalbuterol tartrate) 3


XOPENEX NEBU (Use levalbuterol hcl) NF PA QL(12 ml

daily) Xanthines

aminophylline soln 1

ELIXOPHYLLIN ELIX 1

theophylline soln 80mg15ml 1 QL(56 ml daily)

theophylline tb12 100 mg200 mg 300 mg 450 mg 1

theophylline tb24 400 mg600 mg 1

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (Use warfarin sodium) 2

warfarin sodium tabs 1

Direct Factor Xa Inhibitors


15

Drug Name DrugTier

RequirementsLimits

BEVYXXA CAPS 3

QL(42 ea per42 daysretail42 ea per42 days mail)

ELIQUIS STARTER PACK TBPK 2 QL(247 ea

daily)

ELIQUIS TABS 2 QL(247 eadaily)

XARELTO STARTER PACK TBPK 2

1 rtl MAX fill365 rtl day(s) supply

XARELTO TABS 10 MG 20 MG 2 QL(1 ea daily)


Heparins And Heparinoid-Like Agents

ARIXTRA SOLN 10 MG08ML (Use fondaparinux sodium)

NF

QL(72 ml per180 daysretail72 ml per180 days mail)SP


NF



NF



NF


enoxaparin sodium soln ij300 mg3ml 4 QL(6 ml daily)

enoxaparin sodium soln sc100 mgml 150 mgml 4 QL(2 ml daily)

enoxaparin sodium soln sc120 mg08ml 80 mg08ml 4 QL(16 ml

daily) enoxaparin sodium soln sc30 mg03ml 4 QL(06 ml

daily) SP

enoxaparin sodium soln sc40 mg04ml 4

QL(08 mldaily30 day(s)limit) SP

Drug Name DrugTier

RequirementsLimits



fondaparinux sodium soln10 mg08ml 4




fondaparinux sodium soln 5mg04ml 4




FRAGMIN SOLN 10000 UNITML 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 2500UNIT02ML 5000UNIT02ML 7500UNIT03ML

4

PA SP

HEPARIN LOCK FLUSH SOLN (Use heparin sodium(porcine) lock flush)

NF

heparin sod (porcine) ind5w soln 5 -40 unitml 1

heparin sodium (porcine)soln 10000 unitml 20000unitml 5000 unitml

1

HEPARIN SODIUMNACL045 SOLN 045 -12500 UNIT250ML

1

HEPARIN SODIUMSODIUMCHLORIDE 09 PREMIX SOLN (Use heparin(porcine) in sodium chloride)

NF


16

Drug Name DrugTier

RequirementsLimits

LOVENOX SOLN IJ 300 MG3ML (Use enoxaparin sodium)

NF QL(6 ml daily)

LOVENOX SOLN SC 100 MGML 150 MGML (Use enoxaparin sodium)

NF QL(2 ml daily)

LOVENOX SOLN SC 120 MG08ML 80 MG08ML(Use enoxaparin sodium)

NF QL(16 mldaily)

LOVENOX SOLN SC 30 MG03ML (Use enoxaparin sodium)

NF QL(06 mldaily) SP


NF QL(08 mldaily30 day(s)limit) SP



ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists FYCOMPA TABS 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG

3 PA

Anticonvulsants - Benzodiazepines

clobazam susp 25 mgml 1 PA QL(16 mldaily)

clobazam tabs 10 mg 20 mg 1 PA QL(2 ea

daily) clonazepam tabs 05 mg 1mg 2 mg 1

DIASTAT ACUDIAL GEL (Use diazepam(anticonvulsant))

3

DIASTAT PEDIATRIC GEL (Use diazepam(anticonvulsant))

3

diazepam (anticonvulsant)gel 3

KLONOPIN TABS (Use clonazepam) NF

NAYZILAM SOLN 3 PA QL(10 eaper 30 daysretail)

ONFI SUSP 25 MGML(Use clobazam) NF PA QL(16 ml

daily)

Drug Name DrugTier

RequirementsLimits

ONFI TABS 10 MG 20 MG (Use clobazam) NF PA QL(2 ea

daily)

VALTOCO LIQD 4 PA QL(10 eaper 30 daysretail)

VALTOCO LQPK 4 PA QL(10 eaper 30 daysretail)

Anticonvulsants - Misc

APTIOM TABS 3 ST QL(2 eadaily)

BANZEL SUSP 40 MGML(Use rufinamide) 2 PA QL(80 ml

daily) BANZEL TABS 200 MG (Use rufinamide) 2 PA QL(2 ea


daily) BRIVIACT SOLN OR 10 MGML 3 PA

BRIVIACT TABS OR 10 MG 100 MG 25 MG 50 MG 75 MG

3 PA

carbamazepine chew 100 mg 1

carbamazepine cp12 100 mg 1

carbamazepine cp12 200 mg 1 QL(6 ea daily)


carbamazepine susp 100mg5ml 1

carbamazepine tabs 200 mg 1

carbamazepine tb12 100mg 400 mg 1 QL(4 ea daily)

carbamazepine tb12 200 mg 1 QL(6 ea daily)

CARBATROL CP12 100 MG (Use carbamazepine) NF

CARBATROL CP12 200 MG (Use carbamazepine) NF QL(6 ea daily)


DIACOMIT CAPS 250 MG 4 PA QL(12 eadaily)


17

Drug Name DrugTier

RequirementsLimits


DIACOMIT PACK 250 MG 4 PA QL(12 eadaily)


EPIDIOLEX SOLN 3 PA

gabapentin caps 100 mg300 mg 400 mg 1

gabapentin soln 250mg5ml 300 mg6ml 1 QL(60 ml daily)

gabapentin tabs 600 mg800 mg 1

KEPPRA SOLN IV 500 MG5ML (Use levetiracetam)

NF QL(30 ml daily)

KEPPRA SOLN OR 100 MGML (Use levetiracetam) NF QL(30 ml daily)

KEPPRA TABS OR 1000 MG (Use levetiracetam) NF QL(3 ea daily)

KEPPRA TABS OR 250 MG 750 MG (Use levetiracetam)

NF QL(4 ea daily)


KEPPRA XR TB24 (Use levetiracetam) NF QL(4 ea daily)

LAMICTAL CHEWABLE DISPERSIBLE CHEW 25 MG (Use lamotrigine)

NF QL(20 ea daily)


NF QL(100 eadaily)

LAMICTAL ODT TBDP 100 MG 200 MG 25 MG 50 MG (Use lamotrigine)

NF QL(1 ea daily)

LAMICTAL TABS (Use lamotrigine) NF

lamotrigine chew 25 mg 1 QL(20 ea daily)

lamotrigine chew 5 mg 1 QL(100 eadaily)

lamotrigine tabs 100 mg150 mg 200 mg 25 mg 1

lamotrigine tbdp 100 mg200 mg 25 mg 50 mg 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

levetiracetam soln iv 500 mg5ml 1 QL(30 ml daily)

levetiracetam soln or 100 mgml 500 mg5ml 1 QL(30 ml daily)

levetiracetam tabs or 1000 mg 1 QL(3 ea daily)

levetiracetam tabs or 250 mg 750 mg 1 QL(4 ea daily)


levetiracetam tb24 or 500 mg 750 mg 1 QL(4 ea daily)

LYRICA CAPS 100 MG 150 MG 200 MG 25 MG 50 MG 75 MG (Use pregabalin)

NF

PA QL(3 eadaily)

LYRICA CAPS 225 MG 300 MG (Use pregabalin) NF PA QL(2 ea

daily) LYRICA SOLN 20 MGML(Use pregabalin) NF PA QL(30 ml

daily) MYSOLINE TABS (Use primidone) NF

NEURONTIN CAPS 100 MG 300 MG 400 MG (Use gabapentin)

NF

NEURONTIN SOLN 250 MG5ML (Use gabapentin) NF QL(60 ml daily)

NEURONTIN TABS 600 MG 800 MG (Use gabapentin)

NF

oxcarbazepine susp 300mg5ml 60 mgml 1 QL(40 ml daily)

oxcarbazepine tabs 150mg 300 mg 1 QL(3 ea daily)

oxcarbazepine tabs 600 mg 1 QL(4 ea daily)

pregabalin caps 100 mg150 mg 200 mg 25 mg 50mg 75 mg

1 PA QL(3 eadaily)

pregabalin caps 225 mg300 mg 1 PA QL(2 ea

daily)

pregabalin soln 20 mgml 1 PA QL(30 mldaily)

primidone tabs 1

QUDEXY XR CS24 (Use topiramate) NF


18

Drug Name DrugTier

RequirementsLimits

rufinamide susp 40 mgml 1 PA QL(80 mldaily)

rufinamide tabs 200 mg 1 PA QL(2 eadaily)


TEGRETOL SUSP (Use carbamazepine) 2

TEGRETOL TABS (Use carbamazepine) 2

TEGRETOL-XR TB12 100 MG 400 MG (Use carbamazepine)

NF QL(4 ea daily)

TEGRETOL-XR TB12 200 MG (Use carbamazepine) NF QL(6 ea daily)

TOPAMAX SPRINKLE CPSP 15 MG (Use topiramate)

NF QL(6 ea daily)


NF QL(8 ea daily)

TOPAMAX TABS 100 MG 25 MG (Use topiramate) NF QL(4 ea daily)

TOPAMAX TABS 200 MG (Use topiramate) NF QL(2 ea daily)


topiramate cpsp 15 mg 1 QL(6 ea daily)


topiramate tabs 100 mg 25 mg 1 QL(4 ea daily)

topiramate tabs 200 mg 1 QL(2 ea daily)


TRILEPTAL SUSP 300 MG5ML (Use oxcarbazepine)

NF QL(40 ml daily)

TRILEPTAL TABS 150 MG 300 MG (Use oxcarbazepine)

NF QL(3 ea daily)

TRILEPTAL TABS 600 MG (Use oxcarbazepine) NF QL(4 ea daily)

VIMPAT SOLN IV 200 MG20ML 3 QL(40 ml daily)

Drug Name DrugTier

RequirementsLimits

VIMPAT SOLN OR 10 MGML 3 PA QL(40 ml

daily) VIMPAT TABS OR 100 MG 150 MG 200 MG 50 MG

3 PA QL(2 eadaily)

ZONEGRAN CAPS (Use zonisamide) NF QL(6 ea daily)

zonisamide caps 1 QL(6 ea daily)

Carbamates

felbamate susp 600 mg5ml 1 QL(30 ml daily)

felbamate tabs 400 mg 1 QL(9 ea daily)


FELBATOL SUSP 600 MG5ML (Use felbamate) NF QL(30 ml daily)

FELBATOL TABS 400 MG (Use felbamate) NF QL(9 ea daily)


GABA Modulators GABITRIL TABS 2 MG 4 MG (Use tiagabine hcl) NF

SABRIL PACK (Use vigabatrin) NF PA QL(6 ea

daily) SP SABRIL TABS (Use vigabatrin) NF PA QL(6 ea

daily) SP tiagabine hcl tabs 2 mg 4 mg 1

vigabatrin pack 4 PA QL(6 eadaily) SP

vigabatrin tabs 4 PA QL(6 eadaily) SP

Hydantoins CEREBYX SOLN (Use fosphenytoin sodium) NF

DILANTIN CAPS 100 MG (Use phenytoin sodiumextended)

2

DILANTIN CAPS 30 MG 2

DILANTIN INFATABS CHEW (Use phenytoin) 2


19

Drug Name DrugTier

RequirementsLimits

DILANTIN-125 SUSP (Use phenytoin) 2

fosphenytoin sodium soln 1

PEGANONE TABS 3

PHENYTEK CAPS (Use phenytoin sodiumextended)

2

phenytoin chew 1

phenytoin sodium extended caps 1

phenytoin sodium soln 1

phenytoin susp 1

Succinimides

CELONTIN CAPS 3 QL(4 ea daily)

ethosuximide caps 250 mg 1 QL(6 ea daily)

ethosuximide soln 250 mg5ml 1 QL(30 ml daily)

ZARONTIN CAPS 250 MG (Use ethosuximide) 2 QL(6 ea daily)

ZARONTIN SOLN 250 MG5ML (Use ethosuximide)

NF QL(30 ml daily)

Valproic Acid DEPACON SOLN (Use valproate sodium) NF

DEPAKENE CAPS (Use valproic acid) NF

DEPAKOTE ER TB24 (Use divalproex sodium) NF

DEPAKOTE TBEC (Use divalproex sodium) NF

divalproex sodium tb24 250mg 500 mg 1

divalproex sodium tbec 125mg 250 mg 500 mg 1

valproate sodium soln 1

valproic acid caps or 1

Drug Name DrugTier

RequirementsLimits

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 mg 1 QL(3 ea daily)

mirtazapine tabs 30 mg 1 QL(15 eadaily)

mirtazapine tabs 45 mg75 mg 1 QL(1 ea daily)

mirtazapine tbdp 15 mg 1 QL(3 ea daily)

mirtazapine tbdp 30 mg 1 QL(15 eadaily)


REMERON SOLTAB TBDP 15 MG (Use mirtazapine) NF QL(3 ea daily)

REMERON SOLTAB TBDP 30 MG (Use mirtazapine) NF QL(15 ea

daily) REMERON SOLTAB TBDP 45 MG (Use mirtazapine) NF QL(1 ea daily)

REMERON TABS 15 MG (Use mirtazapine) NF QL(3 ea daily)

REMERON TABS 30 MG (Use mirtazapine) NF QL(15 ea

daily) Antidepressants - Misc bupropion hcl tabs 100 mg75 mg 1 QL(3 ea daily)

bupropion hcl tb12 100 mg 1 QL(4 ea daily)





FORFIVO XL TB24 (Use bupropion hcl) NF

maprotiline hcl tabs 1

WELLBUTRIN SR TB12 100 MG (Use bupropion hcl)

NF QL(4 ea daily)


20

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)


NF QL(2 ea daily)

WELLBUTRIN XL TB24 150 MG (Use bupropion hcl)

NF QL(3 ea daily)


NF QL(1 ea daily)

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 3 QL(1 ea daily)

MARPLAN TABS 2 QL(6 ea daily)

NARDIL TABS (Use phenelzine sulfate) NF

PARNATE TABS (Use tranylcypromine sulfate) NF

phenelzine sulfate tabs 1

tranylcypromine sulfatetabs 1

N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE SOPK 4 PA

SPRAVATO 84MG DOSE SOPK 4 PA

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use citalopramhydrobromide)

NF QL(4 ea daily)

CELEXA TABS 20 MG (Use citalopramhydrobromide)

NF QL(2 ea daily)


NF QL(1 ea daily)

citalopram hydrobromidesoln 10 mg5ml 1 QL(20 ml daily)

citalopram hydrobromidetabs 10 mg 1 QL(4 ea daily)


Drug Name DrugTier

RequirementsLimits


escitalopram oxalate soln 5mg5ml 1 QL(20 ml daily)

escitalopram oxalate tabs10 mg 1 QL(2 ea daily)


escitalopram oxalate tabs 5 mg 1 QL(4 ea daily)

fluoxetine hcl caps 10 mg 1 QL(1 ea daily)



fluoxetine hcl cpdr 90 mg 1

fluoxetine hcl soln 20 mg5ml 1 QL(20 ml daily)

fluoxetine hcl tabs 10 mg60 mg 1 QL(1 ea daily)

fluoxetine hcl tabs 20 mg 1 QL(3 ea daily)

FLUOXETINE HYDROCHLORIDE TABS (Use fluoxetine hcl)

NF QL(1 ea daily)

fluvoxamine maleate tabs 100 mg 1 QL(3 ea daily)

fluvoxamine maleate tabs 25 mg 50 mg 1 QL(2 ea daily)

LEXAPRO TABS 10 MG (Use escitalopram oxalate) NF QL(2 ea daily)



paroxetine hcl tabs 10 mg 1 QL(6 ea daily)




paroxetine hcl tb24 125 mg 1 QL(1 ea daily)


21

Drug Name DrugTier

RequirementsLimits

paroxetine hcl tb24 375mg 25 mg 1 QL(2 ea daily)

PAXIL CR TB24 125 MG (Use paroxetine hcl) NF QL(1 ea daily)

PAXIL CR TB24 375 MG 25 MG (Use paroxetine hcl) NF QL(2 ea daily)

PAXIL SUSP 10 MG5ML 3 QL(30 ml daily)

PAXIL TABS 10 MG (Use paroxetine hcl) NF QL(6 ea daily)




PROZAC CAPS 10 MG (Use fluoxetine hcl) NF QL(1 ea daily)



sertraline hcl conc 20 mgml 1 QL(10 ml daily)

sertraline hcl tabs 100 mg 1 QL(2 ea daily)

sertraline hcl tabs 25 mg50 mg 1 QL(4 ea daily)

ZOLOFT CONC 20 MGML(Use sertraline hcl) NF QL(10 ml daily)

ZOLOFT TABS 100 MG (Use sertraline hcl) NF QL(2 ea daily)

ZOLOFT TABS 25 MG 50 MG (Use sertraline hcl) NF QL(4 ea daily)

Serotonin Modulators

nefazodone hcl tabs 1

trazodone hcl tabs 1

TRINTELLIX TABS 3 PA QL(1 eadaily)

VIIBRYD STARTER PACK KIT 3


Drug Name DrugTier

RequirementsLimits

VIIBRYD TABS 3 PA QL(1 eadaily)

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use duloxetine hcl) NF QL(2 ea daily)

desvenlafaxine succinate tb24 100 mg 1 QL(4 ea daily)

desvenlafaxine succinate tb24 25 mg 50 mg 1 QL(1 ea daily)

duloxetine hcl cpep or 20mg 60 mg 30 mg 1 QL(2 ea daily)

duloxetine hcl cpep or 40 mg 1

EFFEXOR XR CP24 150 MG (Use venlafaxine hcl) NF QL(2 ea daily)



FETZIMA CP24 3 PA

FETZIMA TITRATION PACK C4PK 3 PA

KHEDEZLA TB24 (Use desvenlafaxine) NF

PRISTIQ TB24 100 MG (Use desvenlafaxine succinate)

NF QL(4 ea daily)

PRISTIQ TB24 25 MG 50 MG (Use desvenlafaxine succinate)

NF QL(1 ea daily)

venlafaxine hcl cp24 150 mg 1 QL(2 ea daily)



venlafaxine hcl tabs 100 mg 25 mg 375 mg 50mg 75 mg

1 QL(3 ea daily)

venlafaxine hcl tb24 150 mg 1 QL(2 ea daily)

venlafaxine hcl tb24 225 mg 1 ST QL(1 ea

daily) venlafaxine hcl tb24 75 mg375 mg 1 QL(1 ea daily)


22

Drug Name DrugTier

RequirementsLimits

Tricyclic Agents

amitriptyline hcl tabs 1

amoxapine tabs 3

ANAFRANIL CAPS (Use clomipramine hcl) NF PA

clomipramine hcl caps 1 PA

desipramine hcl tabs 1

doxepin hcl caps 1

doxepin hcl conc 1

imipramine hcl tabs 1

imipramine pamoate caps 1

NORPRAMIN TABS (Use desipramine hcl) NF

nortriptyline hcl caps 1

nortriptyline hcl soln 1

PAMELOR CAPS (Use nortriptyline hcl) NF

protriptyline hcl tabs 1

TOFRANIL TABS (Use imipramine hcl) NF

trimipramine maleate caps 1

ANTIDIABETICS - Drugs to Regulate Blood Sugar Alpha-Glucosidase Inhibitors

acarbose tabs 1 QL(3 ea daily)

GLYSET TABS (Use miglitol) NF

miglitol tabs 1

PRECOSE TABS (Use acarbose) NF QL(3 ea daily)

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN 2 PA QL(036 mldaily)

Drug Name DrugTier

RequirementsLimits


Antidiabetic Combinations ACTOPLUS MET TABS (Use pioglitazone hcl-metformin hcl)

NF QL(2 ea daily)

DUETACT TABS (Use pioglitazone hcl-glimepiride)

NF QL(1 ea daily)

glipizide-metformin hcl tabs25 mg-250 mg 25 mg-500 mg

1 QL(2 ea daily)

glipizide-metformin hcl tabs5 mg-500 mg 1 QL(4 ea daily)

glyburide-metformin tabs125 mg-250 mg 1 QL(2 ea daily)

glyburide-metformin tabs25 mg-500 mg 5 mg-500 mg

1 QL(4 ea daily)

GLYXAMBI TABS 2

JANUMET TABS 2 QL(2 ea daily)

JANUMET XR TB24 2 QL(1 ea daily)

KAZANO TABS (Use alogliptin-metformin hcl) NF

OSENI TABS (Use alogliptin-pioglitazone) NF

pioglitazone hcl-glimepiridetabs 1 QL(1 ea daily)

pioglitazone hcl-metforminhcl tabs 1 QL(2 ea daily)

repaglinide-metformin hcltabs 1 QL(2 ea daily)

SEGLUROMET TABS 2 QL(2 ea daily)MP

SYNJARDY TABS 2 QL(2 ea daily)

SYNJARDY XR TB24 10 MG-1000 MG 125 MG-1000 MG 5 MG-1000 MG

2 QL(2 ea daily)

SYNJARDY XR TB24 25 MG-1000 MG 2 QL(1 ea daily)

TRIJARDY XR TB24 2


23

Drug Name DrugTier

RequirementsLimits

XIGDUO XR TB24 10 MG-1000 MG 10 MG-500 MG 5 MG-500 MG

3 PA QL(1 eadaily)

XIGDUO XR TB24 25 MG-1000 MG 3 QL(2 ea daily)

XIGDUO XR TB24 5 MG-1000 MG 3 PA QL(2 ea

daily)

XULTOPHY 10036 SOPN 2 PA QL(05 mldaily)

Biguanides metformin hcl tabs 1000 mg 1 QL(25 ea

daily)

metformin hcl tabs 500 mg 1 QL(5 ea daily)


metformin hcl tb24 500 mg 1 QL(4 ea daily)


Diabetic Other BAQSIMI ONE PACK POWD 3 QL(0069 ea

daily) BAQSIMI TWO PACK POWD 3 QL(0069 ea

daily)

diazoxide susp 1

GLUCAGEN HYPOKIT SOLR 3 QL(0035 ea

daily)

glucagon (rdna) kit 1 QL(0035 eadaily)

GLUCAGON EMERGENCY KIT KIT (Use glucagon (rdna))

3 QL(0035 eadaily)

GVOKE PFS SOSY 3 QL(002 mldaily)

PROGLYCEM SUSP (Use diazoxide) NF

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin benzoate tabs 1 QL(1 ea daily)

JANUVIA TABS 2 QL(1 ea daily)

NESINA TABS (Use alogliptin benzoate) NF

Dopamine Receptor Agonists - Antidiabetic

Drug Name DrugTier

RequirementsLimits

CYCLOSET TABS 3 QL(6 ea daily)

Incretin Mimetic Agents (GLP-1 Receptor OZEMPIC SOPN 2 MG15ML 2 PA QL(0054

ml daily) OZEMPIC SOPN 2 MG15ML 4 MG3ML 2 PA QL(0108

ml daily)

TRULICITY SOPN 2 PA QL(0143ml daily)

VICTOZA SOPN 2 PA QL(03 mldaily)

Insulin Sensitizing Agents ACTOS TABS (Use pioglitazone hcl) NF QL(1 ea daily)

AVANDIA TABS 3 QL(1 ea daily)

pioglitazone hcl tabs 1 QL(1 ea daily)

Insulin

APIDRA SOLN 3 PA

APIDRA SOLOSTAR SOPN 3 PA

BASAGLAR KWIKPEN SOPN 2

FIASP FLEXTOUCH SOPN 2

FIASP PENFILL SOCT 2

FIASP SOLN 2

HUMULIN R U-500 (CONCENTRATED) SOLN 2

HUMULIN R U-500 KWIKPEN SOPN 2

LEVEMIR FLEXTOUCH SOPN 2

LEVEMIR SOLN 2

NOVOLIN 7030 FLEXPENRELION SUPN 2

NOVOLIN 7030 FLEXPENSUPN 2

NOVOLIN 7030 RELIONSUSP 2


24

Drug Name DrugTier

RequirementsLimits

NOVOLIN 7030 SUSP 2

NOVOLIN N RELION SUSP 2

NOVOLIN N SUSP 2

NOVOLIN R RELION SOLN 2

NOVOLIN R SOLN 2

NOVOLOG FLEXPEN SOPN 2

NOVOLOG MIX 7030PREFILLED FLEXPEN SUPN

2

NOVOLOG MIX 7030SUSP 2

NOVOLOG PENFILL SOCT 2

NOVOLOG SOLN 2

TRESIBA FLEXTOUCH SOPN 3 PA

TRESIBA SOLN 3 PA

Meglitinide Analogues

nateglinide tabs 1 QL(3 ea daily)

PRANDIN TABS 1 MG (Use repaglinide) NF QL(4 ea daily)


repaglinide tabs 05 mg 1 mg 1 QL(4 ea daily)

repaglinide tabs 2 mg 1 QL(8 ea daily)

STARLIX TABS (Use nateglinide) NF QL(3 ea daily)

Sodium-Glucose Co-Transporter 2 (SGLT2)

FARXIGA TABS 3 PA QL(1 eadaily)

JARDIANCE TABS 2 QL(1 ea daily)

STEGLATRO TABS 2 QL(1 ea daily)

Sulfonylureas

Drug Name DrugTier

RequirementsLimits

AMARYL TABS 1 MG 2 MG (Use glimepiride) NF QL(4 ea daily)

AMARYL TABS 4 MG (Use glimepiride) NF QL(2 ea daily)

glimepiride tabs 1 mg 2 mg 1 QL(4 ea daily)

glimepiride tabs 4 mg 1 QL(2 ea daily)

glipizide tabs 10 mg 5 mg 1 QL(4 ea daily)

glipizide tb24 10 mg 25mg 5 mg 1 QL(2 ea daily)

GLUCOTROL TABS (Use glipizide) NF QL(4 ea daily)

GLUCOTROL XL TB24 (Use glipizide) NF QL(2 ea daily)

glyburide micronized tabs 1 QL(4 ea daily)

glyburide tabs 1 QL(4 ea daily)

GLYNASE TABS (Use glyburide micronized) NF QL(4 ea daily)

tolbutamide tabs 1 QL(6 ea daily)

ANTIDIARRHEALPROBIOTIC AGENTS - Drugs to Treat Diarrhea

Antiperistaltic Agents diphenoxylate w atropineliqd 1

diphenoxylate w atropinetabs 1

IMODIUM A-D CAPS (Use loperamide hcl) NF RXOTC

LOMOTIL TABS (Use diphenoxylate w atropine) NF

loperamide hcl caps 1 RXOTC

MOTOFEN TABS 3

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

CHEMET CAPS 3

deferasirox pack 180 mg360 mg 90 mg 4 PA


25

Drug Name DrugTier

RequirementsLimits

deferasirox tabs 180 mg360 mg 90 mg 4 PA SP

deferasirox tbso 125 mg250 mg 500 mg 4 PA SP

deferiprone tabs 1

EXJADE TBSO (Use deferasirox) NF PA SP

FERRIPROX TABS 500 MG (Use deferiprone) 3

JADENU SPRINKLE PACK (Use deferasirox) NF PA

JADENU TABS (Use deferasirox) NF PA SP

Antidotes and Specific Antagonists

VISTOGARD PACK 4 PA

Opioid Antagonists naloxone hcl soln 04 mgml 4 mg10ml 1

naltrexone hcl tabs 1

NARCAN LIQD 3

QL(2 ea per fillretail)2 rtl MAXfill30 rtl day(s)supply

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists ALOXI SOLN (Use palonosetron hcl) NF

ANZEMET TABS 3 PA QL(0167ea daily)

granisetron hcl soln iv 1mgml 1

granisetron hcl tabs or 1 mg 1 QL(034 ea

daily) ondansetron hcl soln ij 4mg2ml 1

ondansetron hcl soln or 4 mg5ml 1 QL(334 ml

daily) ondansetron hcl tabs or 24 mg 1 QL(0143 ea

daily)

Drug Name DrugTier

RequirementsLimits

ondansetron hcl tabs or 4 mg 1

QL(4 eadaily60 ea perfill retail60 ea per fill mail)



ondansetron tbdp 4 mg 1 QL(1 ea daily)

ondansetron tbdp 8 mg 1

palonosetron hcl soln 1

ZOFRAN TABS 4 MG (Use ondansetron hcl) NF




Antiemetics - Anticholinergic

meclizine hcl tabs 1 RXOTC

scopolamine pt72 1 QL(034 eadaily)

TIGAN CAPS OR 300 MG (Use trimethobenzamide hcl)

NF

TRANSDERM SCOP PT72 (Use scopolamine) NF QL(034 ea

daily) TRANSDERM-SCOP PT72 (Use scopolamine) NF QL(034 ea

daily) trimethobenzamide hcl caps 1

Antiemetics - Miscellaneous AKYNZEO CAPS OR 05 MG-300 MG 3 PA

BONJESTA TBCR 3

QL(4 ea daily)3rtl MAX fill365 rtl day(s)supply

CESAMET CAPS 3


26

Drug Name DrugTier

RequirementsLimits

DICLEGIS TBEC (Use doxylamine-pyridoxine) NF

PA QL(4 eadaily)3 rtl MAXfill365 rtl day(s) supply

doxylamine-pyridoxine tbec 1


dronabinol caps 1

MARINOL CAPS (Use dronabinol) NF

Substance PNeurokinin 1 (NK1) Receptor aprepitant caps 1 PA

aprepitant caps 125 mg 40 mg 1 PA QL(0067

ea daily)

aprepitant caps 80 mg 1 PA QL(0134ea daily)

aprepitant misc 1 PA

EMEND CAPS OR 125 MG 40 MG (Use aprepitant)

NF PA QL(0067ea daily)

EMEND CAPS OR 80 MG (Use aprepitant) NF PA QL(0134

ea daily) EMEND SOLR IV 150 MG (Use fosaprepitantdimeglumine)

NF

EMEND TRIPACK CAPS (Use aprepitant) NF PA

VARUBI TBPK 3 PA

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors CANCIDAS SOLR (Use caspofungin acetate) NF

caspofungin acetate solr 50mg 70 mg 1

ERAXIS SOLR 3

micafungin sodium solr 100mg 50 mg 1

MYCAMINE SOLR 3

Antifungals

Drug Name DrugTier

RequirementsLimits

ABELCET SUSP 3

AMBISOME SUSR 3

amphotericin b solr 3

ANCOBON CAPS (Use flucytosine) NF

flucytosine caps 1

griseofulvin microsize susp125 mg5ml 1 AL(At least 2

yrs old) griseofulvin microsize tabs500 mg 1

griseofulvin ultramicrosizetabs 1

nystatin tabs 1

terbinafine hcl tabs 1 QL(1 ea daily)

Imidazole-Related Antifungals CRESEMBA CAPS OR 186 MG 3 PA

DIFLUCAN SUSR (Use fluconazole) NF

DIFLUCAN TABS (Use fluconazole) NF

fluconazole susr 1

fluconazole tabs 1

itraconazole caps 100 mg 1 PA QL(4 eadaily)

itraconazole soln 10 mgml 1 PA QL(20 mldaily)

ketoconazole tabs 1

NOXAFIL SUSP OR 40 MGML 3 QL(20 ml daily)

SPORANOX CAPS 100 MG (Use itraconazole) NF PA QL(4 ea

daily) SPORANOX PULSEPAK CAPS (Use itraconazole) NF PA QL(4 ea

daily) SPORANOX SOLN 10 MGML (Use itraconazole) NF PA QL(20 ml

daily)

TOLSURA CAPS 4 PA


27

Drug Name DrugTier

RequirementsLimits

VFEND TABS 200 MG 50 MG (Use voriconazole) NF QL(4 ea daily)

voriconazole tabs or 200 mg 50 mg 1 QL(4 ea daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines dexchlorpheniraminemaleate soln 1

Antihistamines - Ethanolamines carbinoxamine maleate soln 4 mg5ml 1

carbinoxamine maleate tabs 4 mg 1

CLEMASTINE FUMARATE SYRP 067 MG5ML 1

clemastine fumarate tabs 268 mg 1

diphenhydramine hcl capsor 50 mg 1

diphenhydramine hcl elix or125 mg5ml 1

diphenhydramine hcl liqd or125 mg5ml 1

diphenhydramine hcl soln ij50 mgml 1

Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG5ML (Use fexofenadine hcl)

1

QL(30 ml daily)

ALLEGRA ALLERGY CHILDRENS TBDP 30 MG 1 QL(2 ea daily)

ALLEGRA ALLERGY TABS 180 MG (Use fexofenadine hcl)

1 QL(1 ea daily)


1 QL(2 ea daily)

cetirizine hcl caps 10 mg 1 QL(1 ea daily)

cetirizine hcl chew 5 mg10 mg 1 QL(1 ea daily)

cetirizine hcl soln 1 mgml5 mg5ml 1 QL(10 ml

daily) RXOTC

Drug Name DrugTier

RequirementsLimits

cetirizine hcl syrp 1 mgml5 mg5ml 1 QL(10 ml

daily) RXOTC cetirizine hcl tabs 5 mg 10 mg 1 QL(1 ea daily)

CLARINEX TABS (Use desloratadine) NF QL(1 ea daily)

CLARITIN ALLERGY CHILDRENS SYRP (Use loratadine)

1

CLARITIN CAPS (Use loratadine) 1

CLARITIN CHEW (Use loratadine) 1

CLARITIN CHILDRENS CHEW (Use loratadine) 1

CLARITIN REDITABS TBDP 10 MG (Use loratadine)

1

CLARITIN REDITABS TBDP 5 MG 1

CLARITIN SYRP (Use loratadine) 1

CLARITIN TABS (Use loratadine) 1

desloratadine tabs 5 mg 1 QL(1 ea daily)

desloratadine tbdp 25 mg 1 QL(1 ea daily)

fexofenadine hcl susp 30mg5ml 1 QL(30 ml daily)

fexofenadine hcl tabs 180 mg 1 QL(1 ea daily)


levocetirizine dihydrochloride soln 25mg5ml

1 QL(10 mldaily) RXOTC

levocetirizine dihydrochloride tabs 5 mg 1 QL(1 ea daily)

RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1


28

Drug Name DrugTier

RequirementsLimits

loratadine tabs 1

loratadine tbdp 1

XYZAL ALLERGY 24HR CHILDRENS SOLN (Use levocetirizine dihydrochloride)

NF

QL(10 mldaily) RXOTC

XYZAL ALLERGY 24HR TABS (Use levocetirizine dihydrochloride)

NF QL(1 ea daily)RXOTC

ZYRTEC ALLERGY CAPS (Use cetirizine hcl) 1 QL(1 ea daily)

ZYRTEC ALLERGY TABS (Use cetirizine hcl) 1 QL(1 ea daily)

ZYRTEC CHILDRENS ALLERGY SOLN (Use cetirizine hcl)


Antihistamines - Phenothiazines PHENERGAN SOLN (Use promethazine hcl) NF

promethazine hcl soln 1

promethazine hcl supp 1

promethazine hcl syrp 1

promethazine hcl tabs 1

Antihistamines - Piperidines

cyproheptadine hcl syrp 1

cyproheptadine hcl tabs 1

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations

ezetimibe-simvastatin tabs 1 QL(1 ea daily)

VYTORIN TABS (Use ezetimibe-simvastatin) NF QL(1 ea daily)

Antihyperlipidemics - Misc

icosapent ethyl caps 1 PA QL(4 eadaily)

LOVAZA CAPS (Use omega-3-acid ethyl esters) NF QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

omega-3-acid ethyl esters caps 1 QL(4 ea daily)

VASCEPA CAPS 05 GM 3 PA

VASCEPA CAPS 1 GM 3 PA QL(4 eadaily)

Bile Acid Sequestrants cholestyramine light pack 4 gm 1 QL(6 ea daily)

cholestyramine light powd4 gmdose 1 QL(24 gm

daily)

cholestyramine pack 4 gm 1 QL(6 ea daily)

cholestyramine powd 4gmdose 1 QL(252 gm

daily) colesevelam hcl pack 375 gm 1 PA QL(1 ea

daily) colesevelam hcl tabs 625 mg 1 QL(7 ea daily)

MP COLESTID FLAVORED GRAN 5 GM (Use colestipol hcl)

NF QL(6 gm daily)

COLESTID FLAVORED PACK 5 GM75GM (Use colestipol hcl)

NF QL(6 ea daily)

COLESTID GRAN 5 GM (Use colestipol hcl) NF QL(6 gm daily)

COLESTID PACK 5 GM (Use colestipol hcl) NF QL(6 ea daily)

COLESTID TABS 1 GM (Use colestipol hcl) NF QL(16 ea daily)

colestipol hcl gran 5 gm 1 QL(6 gm daily)

colestipol hcl pack 5 gm 1 QL(6 ea daily)

colestipol hcl tabs 1 gm 1 QL(16 ea daily)

QUESTRAN LIGHT POWD (Use cholestyramine light) NF QL(24 gm

daily) QUESTRAN PACK 4 GM (Use cholestyramine) NF QL(6 ea daily)

QUESTRAN POWD 4 GMDOSE (Use cholestyramine)

NF QL(252 gmdaily)

WELCHOL PACK 375 GM (Use colesevelam hcl) NF PA QL(1 ea

daily)


29

Drug Name DrugTier

RequirementsLimits

WELCHOL TABS 625 MG (Use colesevelam hcl) NF QL(7 ea daily)

MP

Fibric Acid Derivatives fenofibrate micronized caps134 mg 67 mg 200 mg 1 QL(1 ea daily)

fenofibrate tabs 145 mg 48mg 54 mg 160 mg 1 QL(1 ea daily)

FIBRICOR TABS (Use fenofibric acid) NF

gemfibrozil tabs 1 QL(2 ea daily)

LIPOFEN CAPS (Use fenofibrate) NF

LOPID TABS (Use gemfibrozil) NF QL(2 ea daily)

TRICOR TABS (Use fenofibrate) NF QL(1 ea daily)

HMG CoA Reductase Inhibitors

ALTOPREV TB24 3 ST QL(1 eadaily)

atorvastatin calcium tabs 1 QL(1 ea daily)

CRESTOR TABS (Use rosuvastatin calcium) NF QL(1 ea daily)

fluvastatin sodium caps 20 mg 1 QL(1 ea daily)


LIPITOR TABS (Use atorvastatin calcium) NF QL(1 ea daily)

LIVALO TABS 3 ST QL(1 eadaily)

lovastatin tabs 10 mg 20 mg 1

$0 copay forgeneric onlyage 40 to76QL(1 eadaily) PV

lovastatin tabs 40 mg 1


PRAVACHOL TABS (Use pravastatin sodium) NF QL(1 ea daily)

pravastatin sodium tabs 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

rosuvastatin calcium tabs 3 QL(1 ea daily)

simvastatin tabs 5 mg 80mg 10 mg 20 mg 40 mg 1 QL(1 ea daily)

ZOCOR TABS (Use simvastatin) NF QL(1 ea daily)

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 1 QL(1 ea daily)

ZETIA TABS (Use ezetimibe) NF QL(1 ea daily)

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1000 mg 500 mg 750 mg

1 QL(2 ea daily)

NIASPAN TBCR (Use niacin (antihyperlipidemic)) NF QL(2 ea daily)

Proprotein Convertase SubtilisinKexin Type 9 REPATHA PUSHTRONEX SYSTEM SOCT 4 PA QL(025 ml

daily)

REPATHA SOSY 4 PA QL(00714ml daily)

REPATHA SURECLICK SOAJ 4 PA QL(00714

ml daily) ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors ACCUPRIL TABS (Use quinapril hcl) NF

ALTACE CAPS (Use ramipril) NF

benazepril hcl tabs 1

captopril tabs 1

enalapril maleate tabs 1

fosinopril sodium tabs 1

lisinopril tabs 1

LOTENSIN TABS (Use benazepril hcl) NF

moexipril hcl tabs 1


30

Drug Name DrugTier

RequirementsLimits

perindopril erbumine tabs 1

PRINIVIL TABS (Use lisinopril) NF

quinapril hcl tabs 1

ramipril caps 1

trandolapril tabs 1

VASOTEC TABS (Use enalapril maleate) NF

ZESTRIL TABS (Use lisinopril) NF

Agents for Pheochromocytoma DIBENZYLINE CAPS (Use phenoxybenzamine hcl) NF PA

phenoxybenzamine hcl caps 3 PA

Angiotensin II Receptor Antagonists ATACAND TABS (Use candesartan cilexetil) NF QL(1 ea daily)

AVAPRO TABS (Use irbesartan) NF QL(1 ea daily)

BENICAR TABS (Use olmesartan medoxomil) NF QL(1 ea daily)

candesartan cilexetil tabs 1 QL(1 ea daily)

COZAAR TABS (Use losartan potassium) NF QL(1 ea daily)

DIOVAN TABS (Use valsartan) NF QL(1 ea daily)

EDARBI TABS 3 ST QL(1 eadaily)

eprosartan mesylate tabs 1 QL(1 ea daily)

irbesartan tabs 1 QL(1 ea daily)

losartan potassium tabs or100 mg 25 mg 50 mg 1 QL(1 ea daily)

MICARDIS TABS (Use telmisartan) NF QL(1 ea daily)

olmesartan medoxomil tabs 1 QL(1 ea daily)

telmisartan tabs 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

valsartan tabs 1 QL(1 ea daily)

Antiadrenergic Antihypertensives CARDURA TABS (Use doxazosin mesylate) NF

CATAPRES TABS (Use clonidine hcl) NF QL(8 ea daily)

CATAPRES-TTS-1 PTWK (Use clonidine) NF QL(015 ea

daily) CATAPRES-TTS-2 PTWK (Use clonidine) NF QL(015 ea


daily)

clonidine hcl tabs 1 QL(8 ea daily)

clonidine ptwk 3 QL(015 eadaily)

doxazosin mesylate tabs 1

guanfacine hcl tabs 1

methyldopa tabs 1 QL(6 ea daily)

MINIPRESS CAPS (Use prazosin hcl) NF QL(4 ea daily)

prazosin hcl caps 1 QL(4 ea daily)

terazosin hcl caps 1

Antihypertensive Combinations ACCURETIC TABS 10 MG-125 MG (Use quinapril-hydrochlorothiazide)

NF

QL(3 ea daily)

ACCURETIC TABS 125 MG-20 MG (Use quinapril-hydrochlorothiazide)

NF QL(4 ea daily)


NF QL(2 ea daily)

amlodipine besylate-benazepril hcl caps 1

amlodipine besylate-olmesartan medoxomil tabs 1 ST

amlodipine besylate-valsartan tabs 1


31

Drug Name DrugTier

RequirementsLimits

amlodipine-valsartan-hydrochlorothiazide tabs 1

ATACAND HCT TABS (Use candesartan cilexetil-hydrochlorothiazide)

NF

atenolol amp chlorthalidone tabs 1

AVALIDE TABS (Use irbesartan-hydrochlorothiazide)

NF

AZOR TABS (Use amlodipine besylate-olmesartan medoxomil)

NF ST

benazepril amphydrochlorothiazide tabs 1

BENICAR HCT TABS (Use olmesartan medoxomil-hydrochlorothiazide)

NF

bisoprolol amphydrochlorothiazide tabs 1 QL(2 ea daily)

candesartan cilexetil-hydrochlorothiazide tabs 1

DIOVAN HCT TABS (Use valsartan-hydrochlorothiazide)

NF

enalapril maleate amphydrochlorothiazide tabs 1

EXFORGE HCT TABS 2

EXFORGE TABS (Use amlodipine besylate-valsartan)

NF

fosinopril sodium amphydrochlorothiazide tabs 1

HYZAAR TABS 125 MG-100 MG 25 MG-100 MG (Use losartan potassium amphydrochlorothiazide)

NF

QL(1 ea daily)

HYZAAR TABS 125 MG-50 MG (Use losartan potassium amphydrochlorothiazide)

NF

QL(2 ea daily)

irbesartan-hydrochlorothiazide tabs 1

lisinopril amphydrochlorothiazide tabs 1

Drug Name DrugTier

RequirementsLimits

LOPRESSOR HCT TABS (Use metoprolol amphydrochlorothiazide)

NF

losartan potassium amphydrochlorothiazide tabs125 mg-100 mg 25 mg-100 mg

1

QL(1 ea daily)

losartan potassium amphydrochlorothiazide tabs125 mg-50 mg

1 QL(2 ea daily)

LOTENSIN HCT TABS (Use benazepril amphydrochlorothiazide)

NF

LOTREL CAPS (Use amlodipine besylate-benazepril hcl)

NF

metoprolol amphydrochlorothiazide tabs 1

MICARDIS HCT TABS (Use telmisartan-hydrochlorothiazide)

NF

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

1 ST

olmesartan medoxomil-hydrochlorothiazide tabs 1

quinapril-hydrochlorothiazide tabs 10mg-125 mg

1 QL(3 ea daily)

quinapril-hydrochlorothiazide tabs125 mg-20 mg

1 QL(4 ea daily)


1 QL(2 ea daily)

TARKA TBCR (Use trandolapril-verapamil hcl) NF

telmisartan-amlodipine tabs 1

telmisartan-hydrochlorothiazide tabs 1

TENORETIC 100 TABS (Use atenolol amp chlorthalidone)

NF


NF


32

Drug Name DrugTier

RequirementsLimits

trandolapril-verapamil hcltbcr 1

TRIBENZOR TABS (Use olmesartan medoxomil-amlodipine-hydrochlorothiazide)

NF

ST

TWYNSTA TABS (Use telmisartan-amlodipine) NF

valsartan-hydrochlorothiazide tabs 1

VASERETIC TABS (Use enalapril maleate amphydrochlorothiazide)

NF

ZESTORETIC TABS (Use lisinopril amphydrochlorothiazide)

NF

ZIAC TABS (Use bisoprololamp hydrochlorothiazide) NF QL(2 ea daily)

Antihypertensives - Misc VECAMYL TABS 3 PA

Direct Renin Inhibitors

aliskiren fumarate tabs 1 QL(1 ea daily)

TEKTURNA TABS (Use aliskiren fumarate) NF QL(1 ea daily)

Selective Aldosterone Receptor Antagonists

eplerenone tabs 1

INSPRA TABS (Use eplerenone) NF

Vasodilators

hydralazine hcl soln 1

hydralazine hcl tabs 1

minoxidil tabs 1

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations

Drug Name DrugTier

RequirementsLimits

atovaquone-proguanil hcltabs 1

Covered for malaria treatment onlyLimit 1 fill every180 daysQL(12 eaper fill retail12ea per fillmail)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

COARTEM TABS 2


MALARONE TABS (Use atovaquone-proguanil hcl) NF


Antimalarials

chloroquine phosphate tabs 1

DARAPRIM TABS 3 PA QL(3 eadaily)

hydroxychloroquine sulfatetabs 1


33

Drug Name DrugTier

RequirementsLimits

KRINTAFEL TABS 3 QL(2 ea per 30days retail)

mefloquine hcl tabs 1

Covered for malaria treatment onlyLimit 1 fill every180 daysQL(5ea daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PLAQUENIL TABS (Use hydroxychloroquine sulfate) NF

primaquine phosphate tabs 3

PRIMAQUINE PHOSPHATE TABS (Use primaquine phosphate)

NF

pyrimethamine tabs 1 PA QL(3 eadaily)

QUALAQUIN CAPS (Use quinine sulfate) NF PA

quinine sulfate caps 1 PA

ANTIMYASTHENICCHOLINERGIC AGENTS

AntimyasthenicCholinergic Agents

FIRDAPSE TABS 4 PA

GUANIDINE HCL TABS 2

MESTINON SOLN (Use pyridostigmine bromide) NF

MESTINON TABS (Use pyridostigmine bromide) NF

MESTINON TIMESPAN TBCR (Use pyridostigminebromide)

NF

NEOSTIGMINE METHYLSULFATE SOSY 3 MG3ML

3 PA

pyridostigmine bromidesoln 60 mg5ml 1

pyridostigmine bromidetabs 60 mg 1

Drug Name DrugTier

RequirementsLimits

pyridostigmine bromide tbcr180 mg 1

RUZURGI TABS 4 PA QL(10 eadaily)

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Anti TB Combinations

RIFAMATE CAPS 3

RIFATER TABS 3 QL(6 ea daily)

Antimycobacterial Agents CAPASTAT SULFATE SOLR 3

cycloserine caps 1 QL(4 ea daily)

ethambutol hcl tabs 1

isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1

MYAMBUTOL TABS (Use ethambutol hcl) NF

MYCOBUTIN CAPS (Use rifabutin) NF PA

PASER PACK 3 QL(3 ea daily)

PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA

RIFADIN CAPS (Use rifampin) NF

RIFADIN SOLR (Use rifampin) NF

rifampin caps 1

rifampin solr 1

SIRTURO TABS 100 MG 3 PA


34

Drug Name DrugTier

RequirementsLimits

TRECATOR TABS 3 QL(4 ea daily)

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN SOLR (Use melphalan hcl) 6

ALKERAN TABS (Use melphalan) 6

BELRAPZO SOLN 6

BENDAMUSTINE HYDROCHLORIDE SOLN 6

BENDEKA SOLN 6

BICNU SOLR (Use carmustine) 6 PA SP

busulfan soln 6 PA SP

BUSULFEX SOLN (Use busulfan) 6 PA SP

carboplatin soln 450mg45ml 50 mg5ml 600mg60ml 150 mg15ml

6 PA

carboplatin soln 50 mg5ml 6 PA SP

carmustine solr 6 PA SP

cisplatin soln 100mg100ml 6 PA SP

cisplatin soln 200mg200ml 50 mg50ml 6 PA

CISPLATIN SOLR 50 MG 6

cyclophosphamide caps or25 mg 50 mg 1 PA

CYCLOPHOSPHAMIDE SOLN IV 1 GM5ML 500MG25ML

6

cyclophosphamide solr ij 1gm 2 gm 500 mg 6 PA SP

EVOMELA SOLR 6

GLEOSTINE CAPS 6 PA

IFEX SOLR 1 GM (Use ifosfamide) 6 PA SP

Drug Name DrugTier

RequirementsLimits

IFEX SOLR 3 GM 6 PA

ifosfamide soln 1 gm20ml 6 PA SP

ifosfamide soln 3 gm60ml 6 PA

ifosfamide solr 1 gm 6 PA SP

IFOSFAMIDE SOLR 3 GM 6 PA

LEUKERAN TABS 6 PA SP

melphalan hcl solr 1

melphalan tabs 1

MYLERAN TABS 6 PA SP

oxaliplatin soln 100mg20ml 50 mg10ml 6 PA SP

oxaliplatin solr 100 mg 50 mg 6 PA

TEMODAR CAPS OR 100 MG 140 MG 180 MG 20 MG 250 MG 5 MG (Use temozolomide)

6

PA SP

TEMODAR SOLR IV 100 MG 6 PA SP

temozolomide caps 6 PA SP

TEPADINA SOLR 100 MG (Use thiotepa) 6 PA

TEPADINA SOLR 15 MG (Use thiotepa) 6 PA SP

thiotepa solr 100 mg 6 PA

thiotepa solr 15 mg 6 PA SP

TREANDA SOLR 6 PA SP

YONDELIS SOLR 6

ZANOSAR SOLR 6 PA SP

ZEPZELCA SOLR 6

Antimetabolites


35

Drug Name DrugTier

RequirementsLimits

ALIMTA SOLR 100 MG 6 PA

ALIMTA SOLR 500 MG 6 PA SP

ARRANON SOLN 6 PA SP

azacitidine susr 6 PA SP

capecitabine tabs 6 PA SP

cladribine soln 6 PA

clofarabine soln 6 PA SP

CLOLAR SOLN (Use clofarabine) 6 PA SP

cytarabine soln 100 mgml20 mgml 6 PA SP

cytarabine soln 20 mgml 6 PA

DACOGEN SOLR (Use decitabine) 6 PA SP

decitabine solr 6 PA SP

floxuridine solr 6 PA SP

fludarabine phosphate soln 6 PA SP

fludarabine phosphate solr 6 PA SP

fluorouracil soln 1 gm20ml25 gm50ml 5 gm100ml 6 PA

fluorouracil soln 500 mg10ml 6 PA SP

FOLOTYN SOLN 20 MGML 6 PA SP

FOLOTYN SOLN 40 MG2ML 6 PA

gemcitabine hcl soln 1gm10ml 2 gm20ml 200mg2ml

6

gemcitabine hcl soln 1gm263ml 2 gm526ml200 mg526ml

6 PA

gemcitabine hcl solr 1 gm 6 PA

gemcitabine hcl solr 2 gm200 mg 6 PA SP

Drug Name DrugTier

RequirementsLimits

GEMCITABINE HYDROCHLORIDE SOLN 1 GM10ML 2 GM20ML200 MG2ML (Use gemcitabine hcl)

6

GEMCITABINE HYDROCHLORIDE SOLN 1 GM263ML 2GM526ML 200MG526ML (Use gemcitabine hcl)

6

PA

GEMCITABINE HYDROCHLORIDE SOLN 15 GM15ML

6

INFUGEM SOLN 6

mercaptopurine tabs 1

methotrexate sodium soln ij1 gm40ml 250 mg10ml 6 PA

methotrexate sodium soln ij250 mg10ml 50 mg2ml 1

methotrexate sodium solr ij1 gm 1 SP

methotrexate sodium tabs or 25 mg 1 SP

PURIXAN SUSP 6 PA

TABLOID TABS 6 PA SP

TREXALL TABS 6 PA SP

VIDAZA SUSR (Use azacitidine) 6 PA SP

XATMEP SOLN 6 PA

XELODA TABS (Use capecitabine) 6 PA SP

Antineoplastic - Angiogenesis Inhibitors AVASTIN SOLN 100 MG4ML 6 PA SP

CYRAMZA SOLN 6 PA

INLYTA TABS 6 PA QL(2 eadaily) SP

LENVIMA 10 MG DAILY DOSE CPPK 6 PA QL(1 ea

daily)


36

Drug Name DrugTier

RequirementsLimits

LENVIMA 12MG DAILY DOSE CPPK 6 PA QL(3 ea

daily) LENVIMA 14 MG DAILY DOSE CPPK 6 PA QL(2 ea






daily)

MVASI SOLN 6 PA

ZALTRAP SOLN 100 MG4ML 6 PA SP

ZALTRAP SOLN 200 MG8ML 6 PA

ZIRABEV SOLN 6 PA

Antineoplastic - Anti-HER2 Agents

HERCEPTIN SOLR 6 PA SP

HERZUMA SOLR 6

KANJINTI SOLR 6

OGIVRI SOLR 6

ONTRUZANT SOLR 6

PERJETA SOLN 6 PA SP

TRAZIMERA SOLR 420 MG 6

TUKYSA TABS 6 PA

Antineoplastic - Antibodies

ADCETRIS SOLR 6 PA SP

ARZERRA CONC 6 PA SP

BAVENCIO SOLN 6

Drug Name DrugTier

RequirementsLimits

BESPONSA SOLR 6

BLENREP SOLR 6

BLINCYTO SOLR 6 PA

DARZALEX SOLN 6

EMPLICITI SOLR 6

ENHERTU SOLR 6

GAZYVA SOLN 6 PA

IMFINZI SOLN 6

KADCYLA SOLR 6 PA

KEYTRUDA SOLN 6 PA

LIBTAYO SOLN 6

LUMOXITI SOLR 6

MONJUVI SOLR 6

MYLOTARG SOLR 6

OPDIVO SOLN 6 PA

PADCEV SOLR 6

POLIVY SOLR 140 MG 6

POTELIGEO SOLN 6

RITUXAN SOLN 6 PA SP

RUXIENCE SOLN 6

SARCLISA SOLN 6

TECENTRIQ SOLN 6

TRUXIMA SOLN 6

UNITUXIN SOLN 6

YERVOY SOLN 6 PA SP


37

Drug Name DrugTier

RequirementsLimits

ZEVALIN Y-90 KIT 6 PA

Antineoplastic - BCL-2 Inhibitors VENCLEXTA STARTING PACK TBPK 6 PA

VENCLEXTA TABS 6 PA

Antineoplastic - Cellular Immunotherapy

KYMRIAH SUSP 6 PA

PROVENGE SUSP 6 PA

TECARTUS SUSP 6

YESCARTA SUSP 6

Antineoplastic - EGFR Inhibitors

ERBITUX SOLN 6 PA SP

erlotinib hcl tabs 6 PA QL(1 eadaily) SP

GILOTRIF TABS 6 PA QL(1 eadaily)

IRESSA TABS 6

PORTRAZZA SOLN 6

TAGRISSO TABS 6 PA

TARCEVA TABS (Use erlotinib hcl) 6 PA QL(1 ea

daily) SP VECTIBIX SOLN 100 MG5ML 6 PA SP

VECTIBIX SOLN 400 MG20ML 6 PA

VIZIMPRO TABS 6 PA

Antineoplastic - Hedgehog Pathway Inhibitors

DAURISMO TABS 6 PA

ERIVEDGE CAPS 6 PA QL(1 eadaily) SP

ODOMZO CAPS 6 PA QL(1 eadaily)

Antineoplastic - Hormonal and Related Agents

Drug Name DrugTier

RequirementsLimits

abiraterone acetate tabs 250 mg 6 PA QL(4 ea

daily) SP abiraterone acetate tabs 500 mg 6 PA QL(2 ea

daily)

anastrozole tabs 1 QL(1 ea daily)

ARIMIDEX TABS (Use anastrozole) 6 QL(1 ea daily)

AROMASIN TABS (Use exemestane) 6 QL(1 ea daily)

SP

bicalutamide tabs 6 PA QL(1 eadaily) SP

CASODEX TABS (Use bicalutamide) 6 PA QL(1 ea

daily) SP

DEPO-PROVERA SUSP 6 PA

ELIGARD KIT 225 MG 6 PA SP



ELIGARD KIT 75 MG 6 PA QL(00089ea daily) SP

EMCYT CAPS 6 PA SP

ERLEADA TABS 6 PA

exemestane tabs 6 QL(1 ea daily)SP

FARESTON TABS (Use toremifene citrate) 6

FASLODEX SOLN (Use fulvestrant) 6 PA QL(0357

ml daily) SP FEMARA TABS (Use letrozole) 6

FIRMAGON SOLR 6 PA QL(0143ea daily) SP

flutamide caps 6 PA QL(6 eadaily) SP

fulvestrant soln 6 PA QL(0357ml daily) SP

hydroxyprogesteronecaproate (antineoplastic)soln

6

letrozole tabs 1


38

Drug Name DrugTier

RequirementsLimits

leuprolide acetate kit 6 PA SP

LEUPROLIDE ACETATEBUPIVACAINEHYDROCHLORIDE SOLN

6

LUPRON DEPOT (1-MONTH) KIT 6 PA QL(00357

ea daily) SP LUPRON DEPOT (3-MONTH) KIT 6 PA SP


ea daily) SP LUPRON DEPOT (6-MONTH) KIT 6 PA QL(00089

ea daily) SP

LYSODREN TABS 6 PA SP

megestrol acetate susp 1

megestrol acetate tabs 1

NILANDRON TABS (Use nilutamide) 6 QL(2 ea daily)

nilutamide tabs 1 QL(2 ea daily)

NUBEQA TABS 6 PA

SOLTAMOX SOLN 6 PA

tamoxifen citrate tabs 0

toremifene citrate tabs 6

TRELSTAR MIXJECT SUSR 6 PA SP

VANTAS KIT 6 PA

XTANDI CAPS 40 MG 6 PA QL(4 eadaily) SP

YONSA TABS 6 PA

ZOLADEX IMPL 108 MG 6 PA QL(00119ea daily) SP


ZYTIGA TABS 250 MG (Use abiraterone acetate) 6 PA QL(4 ea

daily) SP ZYTIGA TABS 500 MG (Use abiraterone acetate) 6 PA QL(2 ea

daily)

Drug Name DrugTier

RequirementsLimits

Antineoplastic - Immunomodulators

POMALYST CAPS 6 PA QL(1 eadaily)

Antineoplastic - PDGFR-alpha Inhibitors AYVAKIT TABS 100 MG 200 MG 300 MG 6 PA SL(1 ea

daily)

LARTRUVO SOLN 6

Antineoplastic - XPO1 Inhibitors XPOVIO 100 MG ONCE WEEKLY TBPK 6 PA

XPOVIO 40 MG ONCE WEEKLY TBPK 6

XPOVIO 40 MG TWICE WEEKLY TBPK 6

XPOVIO 60 MG ONCE WEEKLY TBPK 6 PA



XPOVIO 80 MG TWICE WEEKLY TBPK 6 PA

Antineoplastic Antibiotics bleomycin sulfate solr 15unit 6 PA SP

bleomycin sulfate solr 30unit 6 PA

COSMEGEN SOLR (Use dactinomycin) 6 PA SP

dactinomycin solr 6 PA SP

daunorubicin hcl soln 6

DAUNORUBICIN HYDROCHLORIDE SOLN 20 MG4ML (Use daunorubicin hcl)

6

DAUNORUBICIN HYDROCHLORIDE SOLN 50 MG10ML

6

DOXIL INJ (Use doxorubicin hcl liposomal) 6 PA SP

doxorubicin hcl liposomalinj 6 PA SP


39

Drug Name DrugTier

RequirementsLimits

doxorubicin hcl soln 2 mgml 200 mg100ml 6 PA SP

doxorubicin hcl solr 50 mg10 mg 6 PA SP

ELLENCE SOLN 200 MG100ML (Use epirubicin hcl)

6 PA


6 PA SP

epirubicin hcl soln 200mg100ml 6 PA

epirubicin hcl soln 50mg25ml 6 PA SP

IDAMYCIN PFS SOLN 10 MG10ML 5 MG5ML (Use idarubicin hcl)

6 PA SP

IDAMYCIN PFS SOLN 20 MG20ML (Use idarubicin hcl)

6 PA

idarubicin hcl soln 10 mg10ml 5 mg5ml 6 PA SP

idarubicin hcl soln 20 mg20ml 6 PA

JELMYTO SOLR 6

mitomycin solr iv 20 mg 6 PA SP

mitomycin solr iv 40 mg 5 mg 6 PA

MITOMYCIN SOSY IS 20 MG40ML 6

mitoxantrone hcl conc 6 PA

mitoxantrone hcl conc 6 PA SP

valrubicin soln 6 PA SP

VALSTAR SOLN (Use valrubicin) 6 PA SP

Antineoplastic Combinations DARZALEX FASPRO SOLN 6

HERCEPTIN HYLECTA SOLN 6

INQOVI TABS 6

Drug Name DrugTier

RequirementsLimits

KISQALI FEMARA 200 DOSE TBPK 6 PA



LONSURF TABS 6 PA

PHESGO SOLN 6

RITUXAN HYCELA SOLN 6 PA

VYXEOS SUSR 6

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO 6 PA

AFINITOR TABS 10 MG 6 PA QL(1 eadaily) SP

AFINITOR TABS 25 MG 5 MG 75 MG (Use everolimus)

6 PA QL(1 eadaily) SP

ALECENSA CAPS 6 PA QL(4 eadaily)

ALIQOPA SOLR 6

ALUNBRIG TABS 6 PA QL(1 eadaily)

ALUNBRIG TBPK 6 PA QL(1 eadaily)

BALVERSA TABS 6 PA

BELEODAQ SOLR 6 PA

BORTEZOMIB SOLR 6 PA

BOSULIF TABS 100 MG 500 MG 6 PA QL(1 ea

daily) SP

BOSULIF TABS 400 MG 6 PA

BRAFTOVI CAPS 6 PA

BRUKINSA CAPS 6 PA

CABOMETYX TABS 6 PA

CALQUENCE CAPS 6 PA


40

Drug Name DrugTier

RequirementsLimits

CAPRELSA TABS 6 PA QL(1 eadaily) SP

COMETRIQ KIT 6 PA QL(2 eadaily) SP



COPIKTRA CAPS 6 PA

COTELLIC TABS 6 PA

everolimus tabs 6 PA QL(1 eadaily) SP

FARYDAK CAPS 6 PA

GLEEVEC TABS (Use imatinib mesylate) 6 PA QL(2 ea

daily) SP

IBRANCE CAPS 6 PA

IBRANCE TABS 6 PA

ICLUSIG TABS 10 MG 30 MG 45 MG 6 PA QL(1 ea

daily)

ICLUSIG TABS 15 MG 6 PA QL(2 eadaily)

IDHIFA TABS 6 PA

imatinib mesylate tabs 6 PA QL(2 eadaily) SP

IMBRUVICA CAPS 140 MG 6 PA QL(3 ea

daily)

IMBRUVICA CAPS 70 MG 6 PA QL(1 eadaily)

IMBRUVICA TABS 140 MG 280 MG 420 MG 560 MG

6 PA QL(1 eadaily)

INREBIC CAPS 6 PA

ISTODAX (OVERFILL) SOLR 6 PA SP

JAKAFI TABS 10 MG 20 MG 6 PA SP

JAKAFI TABS 15 MG 25 MG 5 MG 6 PA QL(2 ea

daily) SP

KISQALI TBPK 6 PA

Drug Name DrugTier

RequirementsLimits

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 6 PA

lapatinib ditosylate tabs 6 PA QL(6 eadaily) SP

LORBRENA TABS 6 PA

LYNPARZA TABS 6 PA QL(16 eadaily)

MEKINIST TABS 05 MG 6 PA QL(3 eadaily)


MEKTOVI TABS 6 PA

NERLYNX TABS 6 PA

NEXAVAR TABS 6 PA QL(4 eadaily) SP

NINLARO CAPS 6 PA QL(0143ea daily)

PEMAZYRE TABS 6 PA QL(1 eadaily)

PIQRAY 200MG DAILY DOSE TBPK 6 PA



QINLOCK TABS 6 PA

RETEVMO CAPS 6 PA

ROMIDEPSIN SOLN 275 MG55ML 6

ROMIDEPSIN SOLR 10 MG 6 PA SP

ROZLYTREK CAPS 6 PA

RUBRACA TABS 6 PA QL(4 eadaily)

RYDAPT CAPS 6 PA

SPRYCEL TABS 6 PA QL(1 eadaily) SP


41

Drug Name DrugTier

RequirementsLimits

STIVARGA TABS 6 PA QL(4 eadaily) SP

SUTENT CAPS 125 MG 25 MG 50 MG 6 PA QL(1 ea

daily) SP

SUTENT CAPS 375 MG 6 PA

TABRECTA TABS 6 PA

TAFINLAR CAPS 6 PA QL(4 eadaily)

TALZENNA CAPS 6 PA

TASIGNA CAPS 150 MG 200 MG 6 PA QL(4 ea

daily) SP

TASIGNA CAPS 50 MG 6 PA QL(4 eadaily)

TAZVERIK TABS 6 PA

temsirolimus soln 6 PA QL(0143ml daily) SP

TIBSOVO TABS 6 PA

TORISEL SOLN (Use temsirolimus) 6 PA QL(0143

ml daily) SP

TURALIO CAPS 6 PA AC

TYKERB TABS (Use lapatinib ditosylate) 6 PA QL(6 ea

daily) SP

VELCADE SOLR 6 PA SP

VERZENIO TABS 6 PA

VITRAKVI CAPS 6 PA

VITRAKVI SOLN 6 PA

VOTRIENT TABS 6 PA QL(4 eadaily) SP

XALKORI CAPS 6 PA QL(2 eadaily) SP

XOSPATA TABS 6 PA

ZEJULA CAPS 6 PA QL(3 eadaily)

ZELBORAF TABS 6 PA SP

ZOLINZA CAPS 6 PA QL(4 eadaily) SP

Drug Name DrugTier

RequirementsLimits

ZYDELIG TABS 6 PA QL(2 eadaily)

ZYKADIA CAPS 6 PA QL(5 eadaily)

ZYKADIA TABS 6

Antineoplastic Enzymes

ASPARLAS SOLN 6

ERWINASE SOLR 6 PA SP

ERWINAZE SOLR 6 PA SP

ONCASPAR SOLN 6 PA SP

Antineoplastic Radiopharmaceuticals AZEDRA DOSIMETRIC SOLN 6

AZEDRA THERAPEUTIC SOLN 6

LUTATHERA SOLN 6

QUADRAMET SOLN 6 PA

STRONTIUM CHLORIDE SR-89 SOLN 6 PA

XOFIGO SOLN 6 PA

Antineoplastics Misc ACTIMMUNE SOLN 6 PA SP

ALFERON N SOLN 6 PA

arsenic trioxide soln 10 mg10ml 6 PA SP

arsenic trioxide soln 12 mg6ml 6

bexarotene caps 6 PA SP

dacarbazine solr 100 mg 6 PA

dacarbazine solr 200 mg 6 PA SP

ELZONRIS SOLN 6

HYDREA CAPS (Use hydroxyurea) NF


42

Drug Name DrugTier

RequirementsLimits

hydroxyurea caps 1

INTRON A SOLN 10 MUML 6000000 UNITML 6 PA

INTRON A SOLR 10 MU 50 MU 6 PA

INTRON A SOLR 18 MU 6 PA SP

MATULANE CAPS 6 PA SP

NIPENT SOLR 6 PA SP

PHOTOFRIN SOLR 6 PA SP

PROLEUKIN SOLR 6 PA SP

SYLATRON KIT 6 PA SP

SYNRIBO SOLR 6 PA SP

TARGRETIN CAPS OR 75 MG (Use bexarotene) 6 PA SP

tretinoin (chemotherapy) caps 1

TRISENOX SOLN (Use arsenic trioxide) 6

UVADEX SOLN 6 PA SP

Chemotherapy Adjuncts

ELITEK SOLR 6 PA

KEPIVANCE SOLR 6 PA SP

Chemotherapy RescueAntidoteProtective Agents

dexrazoxane hcl solr 6 PA

ETHYOL SOLR 6

FUSILEV SOLR (Use levoleucovorin calcium) 6 PA

KHAPZORY SOLR 6

leucovorin calcium soln ij500 mg50ml 6

leucovorin calcium solr ij350 mg 500 mg 100 mg200 mg 50 mg

1

Drug Name DrugTier

RequirementsLimits

leucovorin calcium tabs or 25 mg 5 mg 10 mg 15 mg 1

levoleucovorin calcium soln 175 mg175ml 6 PA

levoleucovorin calcium soln 250 mg25ml 6

levoleucovorin calcium solr 50 mg 6 PA

mesna soln 6 PA

MESNEX SOLN IV 100 MGML (Use mesna) 6 PA

MESNEX TABS OR 400 MG 6 PA

TOTECT SOLR 6 PA

VORAXAZE SOLR 6 PA SP

ZINECARD SOLR (Use dexrazoxane hcl) 6 PA

Mitotic Inhibitors

ABRAXANE SUSR 6 PA SP

DOCETAXEL CONC 160 MG8ML (Use docetaxel) 6 PA

DOCETAXEL CONC 160 MG8ML 80 MG4ML 6 PA

docetaxel conc 160 mg8ml 80 mg4ml 6 PA

DOCETAXEL CONC 20 MGML 6 PA SP

docetaxel conc 20 mgml 6 PA SP

DOCETAXEL CONC 200 MG10ML 6

DOCETAXEL SOLN 160 MG16ML 80 MG8ML 6 PA

docetaxel soln 160 mg16ml 80 mg8ml 6 PA

DOCETAXEL SOLN 160 MG16ML 80 MG8ML(Use docetaxel)

6 PA

DOCETAXEL SOLN 20 MG2ML 6 PA SP

docetaxel soln 20 mg2ml 6 PA SP


43

Drug Name DrugTier

RequirementsLimits

DOCETAXEL SOLN 20 MG2ML (Use docetaxel) 6 PA SP

ETOPOPHOS SOLR 6 PA SP

etoposide caps 6 PA SP

etoposide soln 6 PA SP

HALAVEN SOLN 6 PA SP

IXEMPRA KIT SOLR 15 MG 6 PA SP

IXEMPRA KIT SOLR 45 MG 6 PA

JEVTANA SOLN 6 PA SP

MARQIBO SUSP 6 PA

NAVELBINE SOLN 10 MGML (Use vinorelbine tartrate)

6 PA SP

NAVELBINE SOLN 50 MG5ML (Use vinorelbine tartrate)

6 PA

paclitaxel conc 150mg25ml 100 mg167ml 6mgml

6 PA SP

paclitaxel conc 30 mg5ml300 mg50ml 6 mgml 6 PA

TAXOTERE CONC (Use docetaxel) 6 PA SP

TENIPOSIDE SOLN 6 PA SP

vinblastine sulfate soln 6 PA

vincristine sulfate soln 6 PA SP

vinorelbine tartrate soln 10 mgml 6 PA SP

vinorelbine tartrate soln 50 mg5ml 6 PA

Topoisomerase I Inhibitors CAMPTOSAR SOLN 100 MG5ML 40 MG2ML (Use irinotecan hcl)

6 PA SP

Drug Name DrugTier

RequirementsLimits

CAMPTOSAR SOLN 300 MG15ML (Use irinotecan hcl)

6 PA

HYCAMTIN CAPS OR 025 MG 1 MG 6 PA SP

HYCAMTIN SOLR IV 4 MG (Use topotecan hcl) 6 PA SP

irinotecan hcl soln 100 mg5ml 40 mg2ml 6 PA SP

irinotecan hcl soln 300 mg15ml 500 mg25ml 6 PA

ONIVYDE INJ 6

TOPOTECAN HCL SOLN 4 MG4ML 6 PA

topotecan hcl soln 4mg4ml 6 PA

TOPOTECAN HCL SOLN 4 MG4ML (Use topotecan hcl)

6 PA

topotecan hcl solr 4 mg 6 PA SP

TRODELVY SOLR 6

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease

Antiparkinson Adjunctive Therapy

carbidopa tabs 1

LODOSYN TABS (Use carbidopa) NF

Antiparkinson Anticholinergics

benztropine mesylate soln 1

benztropine mesylate tabs 1

COGENTIN SOLN (Use benztropine mesylate) NF

trihexyphenidyl hcl soln 1

trihexyphenidyl hcl tabs 1

Antiparkinson COMT Inhibitors COMTAN TABS (Use entacapone) NF QL(8 ea daily)


44

Drug Name DrugTier

RequirementsLimits

entacapone tabs 1 QL(8 ea daily)

TASMAR TABS (Use tolcapone) NF

tolcapone tabs 1

Antiparkinson Dopaminergics

amantadine hcl caps 1

amantadine hcl syrp 1

amantadine hcl tabs 1

APOKYN SOCT 4 PA

bromocriptine mesylate caps 1

bromocriptine mesylatetabs 1

carbidopa-levodopa tabs 1

carbidopa-levodopa tbcr 1

carbidopa-levodopa tbdp 1

carbidopa-levodopa-entacapone tabs 1

MIRAPEX TABS 0125 MG (Use pramipexoledihydrochloride)

NF QL(4 ea daily)

MIRAPEX TABS 025 MG 05 MG 075 MG 1 MG 15 MG (Use pramipexoledihydrochloride)

NF

NEUPRO PT24 2

PARLODEL CAPS (Use bromocriptine mesylate) NF

PARLODEL TABS (Use bromocriptine mesylate) NF

pramipexoledihydrochloride tabs 0125 mg

1 QL(4 ea daily)

pramipexoledihydrochloride tabs 025mg 05 mg 075 mg 1 mg15 mg

1

Drug Name DrugTier

RequirementsLimits

REQUIP XL TB24 12 MG 8 MG (Use ropinirolehydrochloride)

NF ST QL(2 eadaily)


NF ST QL(1 eadaily)

ropinirole hydrochloridetabs 025 mg 3 mg 05mg 1 mg 2 mg 4 mg 5 mg

1

ropinirole hydrochloridetb24 12 mg 8 mg 1 ST QL(2 ea

daily) ropinirole hydrochloridetb24 2 mg 4 mg 6 mg 1 ST QL(1 ea

daily) SINEMET CR TBCR (Use carbidopa-levodopa) NF

SINEMET TABS (Use carbidopa-levodopa) NF

STALEVO 100 TABS (Use carbidopa-levodopa-entacapone)

1


NF


1


NF


1


NF


1


NF

STALEVO 50 TABS 125 MG-50 MG-200 MG (Use carbidopa-levodopa-entacapone)

1


45

Drug Name DrugTier

RequirementsLimits


NF


1


NF

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Use rasagiline mesylate) NF PA QL(1 ea

daily)

rasagiline mesylate tabs 1 PA QL(1 eadaily)

selegiline hcl caps 1

selegiline hcl tabs 1

ANTIPSYCHOTICSANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents

lithium carbonate caps 1

lithium carbonate tabs 1

lithium carbonate tbcr 1

LITHIUM SOLN 1

LITHOBID TBCR (Use lithium carbonate) NF

Antipsychotics - Misc

EQUETRO CP12 100 MG 3 ST QL(2 eadaily)



GEODON CAPS OR 20 MG 40 MG 60 MG 80 MG (Use ziprasidone hcl)


LATUDA TABS 3 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

ziprasidone hcl caps 1 QL(2 ea daily)AL(At least 18yrs old)

Benzisoxazoles

FANAPT TABS 2 PA QL(2 eadaily)

FANAPT TITRATION PACK TABS 2 PA

INVEGA TB24 15 MG 3 MG 9 MG (Use paliperidone)

NF QL(1 ea daily)

INVEGA TB24 6 MG (Use paliperidone) NF QL(2 ea daily)

paliperidone tb24 15 mg 3mg 9 mg 1 QL(1 ea daily)

paliperidone tb24 6 mg 1 QL(2 ea daily)

PERSERIS PRSY 2 PA QL(0072ea daily)

RISPERDAL CONSTA SRER 2 PA QL(0072

ea daily) RISPERDAL SOLN 1 MGML (Use risperidone) NF QL(8 ml daily)

RISPERDAL TABS 025 MG 05 MG 1 MG 2 MG 3 MG 4 MG (Use risperidone)

NF

QL(4 ea daily)

risperidone soln 1 mgml 1 QL(8 ml daily)

risperidone tabs 025 mg05 mg 1 mg 2 mg 3 mg4 mg

1 QL(4 ea daily)

risperidone tbdp 025 mg05 mg 1 mg 2 mg 3 mg4 mg

1 QL(2 ea daily)

Butyrophenones HALDOL DECANOATE 100 SOLN (Use haloperidol decanoate)

NF QL(0036 mldaily)

HALDOL DECANOATE 50 SOLN (Use haloperidoldecanoate)

NF QL(0036 mldaily)

HALDOL SOLN (Use haloperidol lactate) NF

haloperidol decanoate soln 1 QL(0036 mldaily)


46

Drug Name DrugTier

RequirementsLimits

haloperidol lactate conc 1

haloperidol lactate soln 1

haloperidol tabs 1

Dibenzapines asenapine maleate subl 10mg 5 mg 1 PA QL(2 ea

daily) asenapine maleate subl 25 mg 1 PA QL(4 ea

daily) clozapine tabs 200 mg 50mg 100 mg 25 mg 1

clozapine tbdp 100 mg 1 QL(9 ea daily)

clozapine tbdp 125 mg150 mg 1 QL(6 ea daily)



CLOZARIL TABS (Use clozapine) NF

FAZACLO TBDP 100 MG (Use clozapine) NF QL(9 ea daily)


FAZACLO TBDP 150 MG (Use clozapine) 1 QL(6 ea daily)



loxapine succinate caps 1

olanzapine solr im 10 mg 1 QL(0215 eadaily)

olanzapine tabs or 10 mg15 mg 20 mg 75 mg 1 QL(2 ea daily)

olanzapine tabs or 25 mg5 mg 1 QL(4 ea daily)

olanzapine tbdp or 10 mg15 mg 5 mg 1 QL(2 ea daily)

olanzapine tbdp or 20 mg 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

quetiapine fumarate tabs100 mg 200 mg 25 mg 50 mg


quetiapine fumarate tabs300 mg 400 mg 1


quetiapine fumarate tb24150 mg 200 mg 50 mg 1


quetiapine fumarate tb24300 mg 400 mg 1


SAPHRIS SUBL 10 MG 5 MG (Use asenapinemaleate)

3 PA QL(2 eadaily)

SAPHRIS SUBL 25 MG (Use asenapine maleate) 3 PA QL(4 ea

daily)

SAPHRIS SUBL 5 MG 3 PA QL(2 eadaily)

SEROQUEL TABS 100 MG 200 MG 25 MG 50 MG (Use quetiapinefumarate)

NF


SEROQUEL TABS 300 MG 400 MG (Use quetiapine fumarate)


SEROQUEL XR TB24 150 MG 200 MG 50 MG (Use quetiapine fumarate)

NF


SEROQUEL XR TB24 300 MG 400 MG (Use quetiapine fumarate)

NF


ZYPREXA SOLR IM 10 MG (Use olanzapine) NF QL(0215 ea

daily) ZYPREXA TABS OR 10 MG 15 MG 20 MG 75 MG (Use olanzapine)

NF QL(2 ea daily)

ZYPREXA TABS OR 25 MG 5 MG (Use olanzapine)

NF QL(4 ea daily)

ZYPREXA ZYDIS TBDP 10 MG 15 MG 5 MG (Use olanzapine)

NF QL(2 ea daily)


47

Drug Name DrugTier

RequirementsLimits

ZYPREXA ZYDIS TBDP 20 MG (Use olanzapine) NF QL(1 ea daily)

Phenothiazines chlorpromazine hcl soln ij25 mgml 50 mg2ml 3

chlorpromazine hcl tabs or10 mg 100 mg 200 mg 25mg 50 mg

1

fluphenazine hcl conc or 5mgml 1

fluphenazine hcl elix or 25mg5ml 1

fluphenazine hcl soln ij 25mgml 1

fluphenazine hcl tabs or 1mg 10 mg 25 mg 5 mg 1

perphenazine tabs 1

prochlorperazine maleatetabs 1

prochlorperazine supp 1

thioridazine hcl tabs 1

trifluoperazine hcl tabs 1

Quinolinone Derivatives

ABILIFY TABS (Use aripiprazole) NF


aripiprazole soln 1 mgml 3 QL(30 mldaily) AL(Atleast 6 yrs old)

aripiprazole tabs 10 mg 15mg 2 mg 20 mg 30 mg 5 mg


REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 20 mgml 1 QL(32 ml daily)

Drug Name DrugTier

RequirementsLimits

abacavir sulfate tabs 300 mg 1 QL(2 ea daily)

abacavir sulfate-lamivudine tabs 1 QL(1 ea daily)

abacavir sulfate-lamivudine-zidovudine tabs 1 QL(2 ea daily)

APTIVUS CAPS 250 MG 2 QL(4 ea daily)

APTIVUS SOLN 100 MGML 2 QL(10 ml daily)

atazanavir sulfate caps 150mg 300 mg 1 QL(1 ea daily)

atazanavir sulfate caps 200 mg 1 QL(2 ea daily)

ATRIPLA TABS (Use efavirenz-emtricitabine-tenofovir disoproxilfumarate)

3

QL(1 ea daily)

BIKTARVY TABS 2 QL(1 ea daily)

CIMDUO TABS 2 ST QL(1 eadaily)

COMBIVIR TABS (Use lamivudine-zidovudine) NF QL(2 ea daily)

COMPLERA TABS 3 QL(1 ea daily)

CRIXIVAN CAPS 200 MG 2 QL(9 ea daily)


DELSTRIGO TABS 3 QL(1 ea daily)

DESCOVY TABS 2 PA QL(1 eadaily)

didanosine cpdr 200 mg 1 QL(2 ea daily)

didanosine cpdr 250 mg400 mg 1 QL(1 ea daily)

DOVATO TABS 2 QL(1 ea daily)

EDURANT TABS 2 QL(1 ea daily)

efavirenz caps 200 mg 1 QL(2 ea daily)


efavirenz tabs 600 mg 1 QL(1 ea daily)


48

Drug Name DrugTier

RequirementsLimits

efavirenz-emtricitabine-tenofovir disoproxilfumarate tabs

1 QL(1 ea daily)

efavirenz-lamivudine-tenofovir disoproxilfumarate tabs

1 QL(1 ea daily)

emtricitabine caps 1 QL(1 ea daily)

emtricitabine-tenofovir disoproxil fumarate tabs100 mg-150 mg 133 mg-200 mg 167 mg-250 mg

1

QL(1 eadaily30 day(s)limit)

emtricitabine-tenofovir disoproxil fumarate tabs200 mg-300 mg

0 QL(1 ea daily)


0 QL(1 eadaily30 day(s)limit)

EMTRIVA CAPS 200 MG (Use emtricitabine) 2 QL(1 ea daily)

EMTRIVA SOLN 10 MGML 2 QL(24 ml daily)

EPIVIR SOLN 10 MGML(Use lamivudine) NF QL(30 ml daily)

EPIVIR TABS 150 MG (Use lamivudine) NF QL(2 ea daily)


EPZICOM TABS (Use abacavir sulfate-lamivudine)

NF QL(1 ea daily)

etravirine tabs 100 mg 1 QL(4 ea daily)


fosamprenavir calcium tabs 1 QL(4 ea daily)

FUZEON SOLR 4 PA SP

GENVOYA TABS 2 QL(1 ea daily)

INTELENCE TABS 100 MG (Use etravirine) 2 QL(4 ea daily)


INTELENCE TABS 25 MG 2 QL(8 ea daily)

Drug Name DrugTier

RequirementsLimits

INVIRASE TABS 2 QL(4 ea daily)

ISENTRESS CHEW 100 MG 25 MG 2 QL(6 ea daily)

ISENTRESS HD TABS 2 QL(2 ea daily)

ISENTRESS TABS 400 MG 2 QL(2 ea daily)

JULUCA TABS 3 QL(1 ea daily)

KALETRA SOLN 100 MG5ML-400 MG5ML(Use lopinavir-ritonavir)

NF QL(125 mldaily)

KALETRA TABS 25 MG-100 MG 50 MG-200 MG (Use lopinavir-ritonavir)

2 QL(4 ea daily)

lamivudine soln 10 mgml 1 QL(30 ml daily)

lamivudine tabs 150 mg 1 QL(2 ea daily)


lamivudine-zidovudine tabs 1 QL(2 ea daily)

LEXIVA SUSP 50 MGML 2 QL(56 ml daily)

LEXIVA TABS 700 MG (Use fosamprenavircalcium)

NF QL(4 ea daily)

lopinavir-ritonavir soln 100mg5ml-400 mg5ml 1 QL(125 ml

daily) lopinavir-ritonavir tabs 25mg-100 mg 50 mg-200 mg 1 QL(4 ea daily)

nevirapine susp 50 mg5ml 1 QL(40 ml daily)

nevirapine tabs 200 mg 1 QL(2 ea daily)

nevirapine tb24 100 mg 1 QL(3 ea daily)


NORVIR PACK 100 MG 2

QL(12 eadaily)30 rtl lmtday(s)30 maillmt day(s)

NORVIR SOLN 80 MGML 2 QL(15 ml daily)


49

Drug Name DrugTier

RequirementsLimits

NORVIR TABS 100 MG (Use ritonavir) NF QL(12 ea daily)

ODEFSEY TABS 2 QL(1 ea daily)

PIFELTRO TABS 2 QL(1 ea daily)

PREZCOBIX TABS 2 QL(1 ea daily)

PREZISTA SUSP 100 MGML 2 QL(12 ml daily)

PREZISTA TABS 150 MG 600 MG 75 MG 2 QL(2 ea daily)

PREZISTA TABS 800 MG 2 QL(1 ea daily)

RESCRIPTOR TABS 2 QL(6 ea daily)

RETROVIR CAPS 100 MG (Use zidovudine) NF QL(6 ea daily)

RETROVIR IV INFUSION SOLN 1

RETROVIR SYRP 50 MG5ML (Use zidovudine) NF QL(60 ml daily)

REYATAZ CAPS 150 MG 300 MG (Use atazanavir sulfate)

NF QL(1 ea daily)

REYATAZ CAPS 200 MG (Use atazanavir sulfate) NF QL(2 ea daily)

ritonavir tabs 1 QL(12 ea daily)

RUKOBIA TB12 4 PA

SELZENTRY SOLN 20 MGML 2 QL(30 ml daily)

SELZENTRY TABS 150 MG 25 MG 75 MG 2 QL(2 ea daily)

SELZENTRY TABS 300 MG 2 QL(4 ea daily)

stavudine caps 15 mg 20mg 30 mg 40 mg 1 QL(2 ea daily)

STAVUDINE CAPS 15 MG 30 MG 2 QL(2 ea daily)


STRIBILD TABS 3 QL(1 ea daily)

SUSTIVA CAPS 200 MG (Use efavirenz) NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits


SUSTIVA TABS 600 MG (Use efavirenz) NF QL(1 ea daily)

SYMFI LO TABS (Use efavirenz-lamivudine-tenofovir disoproxilfumarate)

2

QL(1 ea daily)

SYMFI TABS (Use efavirenz-lamivudine-tenofovir disoproxilfumarate)

2

QL(1 ea daily)

SYMTUZA TABS 3 ST QL(1 eadaily)

TEMIXYS TABS 2 ST QL(1 eadaily)

tenofovir disoproxilfumarate tabs 1

TIVICAY TABS 3 QL(2 ea daily)

TRIUMEQ TABS 2 QL(1 ea daily)

TRIZIVIR TABS (Use abacavir sulfate-lamivudine-zidovudine)

NF QL(2 ea daily)

TRUVADA TABS (Use emtricitabine-tenofovir disoproxil fumarate)


TYBOST TABS 2 QL(1 ea daily)

VIDEX EC CPDR 125 MG 2 QL(2 ea daily)

VIDEX EC CPDR 200 MG (Use didanosine) NF QL(2 ea daily)

VIDEX EC CPDR 250 MG 400 MG (Use didanosine) NF QL(1 ea daily)

VIDEXPEDIATRIC SOLR 2

VIRACEPT TABS 250 MG 2 QL(10 ea daily)


VIRAMUNE SUSP 50 MG5ML (Use nevirapine) NF QL(40 ml daily)

VIRAMUNE TABS 200 MG (Use nevirapine) NF QL(2 ea daily)

VIRAMUNE XR TB24 (Use nevirapine) NF QL(1 ea daily)


50

Drug Name DrugTier

RequirementsLimits

VIREAD POWD 40 MGGM 2

VIREAD TABS 150 MG 200 MG 250 MG 2 QL(1 ea daily)

VIREAD TABS 300 MG (Use tenofovir disoproxilfumarate)

NF

ZIAGEN SOLN 20 MGML(Use abacavir sulfate) NF QL(32 ml daily)

ZIAGEN TABS 300 MG (Use abacavir sulfate) NF QL(2 ea daily)

zidovudine caps 100 mg 1 QL(6 ea daily)

zidovudine syrp 50 mg5ml 1 QL(60 ml daily)

zidovudine tabs 300 mg 1 QL(2 ea daily)

CMV Agents

cidofovir soln 3

CYTOVENE SOLR (Use ganciclovir sodium) NF

ganciclovir sodium solr 1

VALCYTE TABS 450 MG (Use valganciclovir hcl) NF PA QL(4 ea

daily) valganciclovir hcl tabs 450 mg 1 PA QL(4 ea

daily) Hepatitis Agents

adefovir dipivoxil tabs 4 PA QL(1 eadaily) SP

BARACLUDE SOLN 005 MGML 4 PA QL(20 ml

daily) SP BARACLUDE TABS 05 MG 1 MG (Use entecavir) NF PA QL(1 ea

daily) SP

entecavir tabs 4 PA QL(1 eadaily) SP

EPCLUSA TABS 100 MG-400 MG 4 PA QL(1 ea

daily) EPIVIR HBV SOLN 5 MGML 4 PA QL(60 ml

daily) SP EPIVIR HBV TABS 100 MG (Use lamivudine (hbv)) NF QL(3 ea daily)

SP HEPSERA TABS (Use adefovir dipivoxil) NF PA QL(1 ea

daily) SP

Drug Name DrugTier

RequirementsLimits

lamivudine (hbv) tabs 1 QL(3 ea daily)SP

MAVYRET TABS 4 PA QL(3 eadaily)

PEGASYS PROCLICK SOLN 4 PA QL(00714

ml daily) SP

PEGASYS SOLN 4 PA QL(00714ml daily) SP

PEGINTRON KIT 4 PA QL(0143ea daily) SP

REBETOL SOLN 4 PA QL(35 mldaily) SP

RIBASPHERE RIBAPAK TBPK 400 MG 600 MG 4 PA

RIBASPHERE TABS 4 PA

ribavirin (hepatitis c) caps200 mg 1 PA QL(7 ea

daily) ribavirin (hepatitis c) tabs200 mg 1 PA QL(7 ea

daily) ribavirin (hepatitis c) tabs600 mg 4 PA

SOFOSBUVIRVELPATASVIR TABS 4 PA QL(1 ea

daily)

VEMLIDY TABS 4 PA QL(1 eadaily) SP

VOSEVI TABS 4 PA QL(1 eadaily)

ZEPATIER TABS 4 PA

Herpes Agents

acyclovir caps 200 mg 1


acyclovir susp 200 mg5ml 1 QL(1334 mldaily)

acyclovir tabs 400 mg 800 mg 1 QL(5 ea daily)

famciclovir tabs 125 mg250 mg 1 QL(3 ea daily)

famciclovir tabs 500 mg 1 QL(4 ea daily)

valacyclovir hcl tabs 1 gm1000 mg 1 QL(4 ea daily)


51

Drug Name DrugTier

RequirementsLimits

valacyclovir hcl tabs 500 mg 1 QL(2 ea daily)

VALTREX TABS 1 GM (Use valacyclovir hcl) NF QL(4 ea daily)

VALTREX TABS 500 MG (Use valacyclovir hcl) NF QL(2 ea daily)

ZOVIRAX CAPS OR 200 MG (Use acyclovir) NF


ZOVIRAX SUSP OR 200 MG5ML (Use acyclovir) NF QL(1334 ml

daily) ZOVIRAX TABS OR 400 MG 800 MG (Use acyclovir)

NF QL(5 ea daily)

Influenza Agents FLUMADINE TABS (Use rimantadine hydrochloride) NF QL(2 ea daily)

oseltamivir phosphate capsor 30 mg 45 mg 75 mg 1

Limit 1 fill every90 daysQL(10ea per fillretail10 ea perfill mail)1 rtlMAX fill90 rtl day(s) supply1mail MAX fill90 mail day(s)supply

oseltamivir phosphate susror 6 mgml 1

Limit 1 fill every90 days1 rtlMAX fill90 rtl day(s) supply1mail MAX fill90 mail day(s)supply

RELENZA DISKHALER AEPB 2

1 rtl pack lmtamt30 rtl packlmt day(s)

rimantadine hydrochloridetabs 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

TAMIFLU CAPS 30 MG 45 MG 75 MG (Use oseltamivir phosphate)

NF


TAMIFLU SUSR 6 MGML(Use oseltamivir phosphate)

NF


BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol tabs 1

COREG TABS (Use carvedilol) NF

labetalol hcl soln iv 5 mgml 1

labetalol hcl tabs or 100 mg 200 mg 300 mg 1

Beta Blockers Cardio-Selective

acebutolol hcl caps 1

atenolol tabs 1

betaxolol hcl tabs 1

bisoprolol fumarate tabs or10 mg 5 mg 1

BYSTOLIC TABS 10 MG 25 MG 5 MG 2 PA QL(1 ea

daily)

BYSTOLIC TABS 20 MG 2 PA QL(2 eadaily)

LOPRESSOR TABS (Use metoprolol tartrate) NF

metoprolol succinate tb24 1

metoprolol tartrate soln iv 5mg5ml 1


52

Drug Name DrugTier

RequirementsLimits

metoprolol tartrate tabs or100 mg 25 mg 50 mg 1

TENORMIN TABS (Use atenolol) NF

TOPROL XL TB24 (Use metoprolol succinate) NF

Beta Blockers Non-Selective BETAPACE AF TABS (Use sotalol hcl (afibafl)) NF

BETAPACE TABS (Use sotalol hcl) NF QL(2 ea daily)

CORGARD TABS (Use nadolol) NF

HEMANGEOL SOLN 4 PA QL(75 mldaily)

INDERAL LA CP24 (Use propranolol hcl) NF

nadolol tabs 1

pindolol tabs 1

propranolol hcl cp24 1

propranolol hcl soln 1

propranolol hcl tabs 1

sotalol hcl (afibafl) tabs 1

sotalol hcl tabs 120 mg160 mg 80 mg 1 QL(2 ea daily)

sotalol hcl tabs 240 mg 1

timolol maleate tabs 1

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers ADALAT CC TB24 (Use nifedipine) NF

amlodipine besylate tabs 1

CALAN SR TBCR (Use verapamil hcl) NF

CALAN TABS (Use verapamil hcl) NF

Drug Name DrugTier

RequirementsLimits

CARDIZEM CD CP24 (Use diltiazem hcl coated beads) NF

CARDIZEM LA TB24 180 MG 240 MG 300 MG 360 MG 420 MG (Use diltiazem hcl coated beads)

NF

CARDIZEM TABS (Use diltiazem hcl) NF

diltiazem hcl coated beads cp24 1

diltiazem hcl coated beads tb24 1

diltiazem hcl cp12 or 120mg 60 mg 90 mg 1


diltiazem hcl extended release beads cp24 120mg 180 mg 240 mg 300mg 360 mg

1

diltiazem hcl soln iv 50 mg10ml 1

DILTIAZEM HCL SOLR IV 100 MG 1

diltiazem hcl tabs or 120 mg 30 mg 60 mg 90 mg 1

felodipine tb24 1

isradipine caps 1

nicardipine hcl caps 1

nicardipine hcl soln 1

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1

nisoldipine tb24 17 mg 20mg 30 mg 34 mg 40 mg85 mg

1

NORVASC TABS (Use amlodipine besylate) NF

PROCARDIA CAPS (Use nifedipine) NF


53

Drug Name DrugTier

RequirementsLimits

PROCARDIA XL TB24 (Use nifedipine) NF

SULAR TB24 (Use nisoldipine) NF

TIAZAC CP24 120 MG 180 MG 240 MG 300 MG 360 MG (Use diltiazem hcl extended release beads)

NF

verapamil hcl cp24 1

verapamil hcl soln 1

verapamil hcl tabs 1

verapamil hcl tbcr 1

VERELAN CP24 120 MG 180 MG 240 MG (Use verapamil hcl)

NF

VERELAN CP24 360 MG (Use verapamil hcl) 1

VERELAN PM CP24 100 MG 300 MG (Use verapamil hcl)

1

VERELAN PM CP24 200 MG (Use verapamil hcl) NF

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

digoxin soln 1

digoxin tabs 1

LANOXIN SOLN IJ 025 MGML (Use digoxin) 2

LANOXIN TABS OR 250 MCG 125 MCG (Use digoxin)

2

LANOXIN TABS OR 625 MCG 2

CARDIOVASCULAR AGENTS - MISC - Drugs toTreat Heart and Circulation Conditions

Cardioplegic Solutions PLEGISOL SOLN (Use cardioplegic soln) NF

Cardiovascular Agents Misc - Combinations

Drug Name DrugTier

RequirementsLimits

amlodipine besylate-atorvastatin calcium tabs 1 QL(1 ea daily)

BIDIL TABS 2

CADUET TABS (Use amlodipine besylate-atorvastatin calcium)

NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents

CIALIS TABS 5 MG (Use tadalafil) NF

PA BPH OnlyQL(1 eadaily)

sildenafil citrate tabs 1 PA QL(01334ea daily)

STENDRA TABS 3 QL(0134 eadaily)

tadalafil tabs 5 mg 1 PA BPH OnlyQL(1 eadaily)

VIAGRA TABS (Use sildenafil citrate) NF PA QL(01334

ea daily) Prostaglandin Vasodilators

epoprostenol sodium solr 4 PA

FLOLAN SOLR (Use epoprostenol sodium) NF PA

ORENITRAM TBCR 0125 MG 025 MG 1 MG 25 MG

3 PA

treprostinil soln 4 PA SP

VELETRI SOLR (Use epoprostenol sodium) NF PA

VENTAVIS SOLN 4 PA SP

Pulmonary Hypertension - Endothelin Receptor

ambrisentan tabs 4 PA QL(1 eadaily) SP

bosentan tabs 125 mg 4 PA QL(2 eadaily) SP

bosentan tabs 625 mg 4 PA QL(2 eadaily)

LETAIRIS TABS (Use ambrisentan) NF PA QL(1 ea

daily) SP


54

Drug Name DrugTier

RequirementsLimits

OPSUMIT TABS 4 PA QL(1 eadaily)

TRACLEER TABS 125 MG (Use bosentan) NF PA QL(2 ea

daily) SP TRACLEER TABS 625 MG (Use bosentan) NF PA QL(2 ea

daily)

TRACLEER TBSO 32 MG 4 PA QL(2 eadaily) SP

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (Use tadalafil (pulmonaryhypertension))

NF PA QL(2 eadaily) SP

REVATIO SOLN IV 10 MG125ML (Use sildenafil citrate (pulmonaryhypertension))

NF

PA QL(375 mldaily) SP

REVATIO SUSR OR 10 MGML (Use sildenafil citrate (pulmonaryhypertension))

NF

PA QL(6 mldaily)

REVATIO TABS OR 20 MG (Use sildenafil citrate (pulmonary hypertension))


sildenafil citrate (pulmonaryhypertension) soln iv 10mg125ml

4 PA QL(375 mldaily) SP

sildenafil citrate (pulmonaryhypertension) susr or 10mgml

4 PA QL(6 mldaily)

sildenafil citrate (pulmonaryhypertension) tabs or 20 mg


tadalafil (pulmonaryhypertension) tabs 4 PA QL(2 ea

daily) SP

Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 05 MG 15 MG 2 MG 25 MG 4 PA QL(3 ea

daily) Sinus Node Inhibitors CORLANOR SOLN 5 MG5ML 3 PA QL(15 ml

daily) CORLANOR TABS 5 MG 75 MG 3 PA QL(2 ea

daily) Transthyretin Stabilizers

VYNDAMAX CAPS 4 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

VYNDAQEL CAPS 4 PA QL(4 eadaily)

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1

cefazolin sodium solr ij 20gm 500 mg 1 gm 10 gm 1

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1

KEFLEX CAPS (Use cephalexin) NF

Cephalosporins - 2nd Generation

cefaclor caps 1

cefaclor susr 1

CEFOTAN SOLR (Use cefotetan disodium) NF

cefotetan disodium solr 1 gm 2 gm 1

cefotetan disodium solr 10 gm 3

cefoxitin sodium solr ij 10 gm 1

cefoxitin sodium solr iv 2 gm 1 gm 1

cefprozil susr 1

cefprozil tabs 1

cefuroxime axetil tabs 1

cefuroxime sodium solr ij750 mg 1

Cephalosporins - 3rd Generation

cefdinir caps 1


55

Drug Name DrugTier

RequirementsLimits

cefdinir susr 1

cefditoren pivoxil tabs 200 mg 3


cefixime susr 100 mg5ml200 mg5ml 1 ST

cefotaxime sodium solr 1

cefpodoxime proxetil susr 1

cefpodoxime proxetil tabs 1

ceftazidime solr ij 2 gm 1gm 6 gm 1

ceftriaxone sodium solr ij 1gm 2 gm 250 mg 500 mg 1

FORTAZ SOLR IJ 1 GM (Use ceftazidime) NF

SUPRAX SUSR 100 MG5ML 200 MG5ML(Use cefixime)

NF ST

Cephalosporins - 4th Generation

cefepime hcl solr 1

MAXIPIME SOLR IJ 1 GM 2 GM (Use cefepime hcl) NF


TEFLARO SOLR 3

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral BALCOLTRA TABS 0

BEYAZ TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

NF

desogestrel amp ethinylestradiol tabs 0

desogestrel-ethinylestradiol (biphasic) tabs 0

desogestrel-ethinylestradiol (triphasic) tabs 0

Drug Name DrugTier

RequirementsLimits

drospirenone-ethinylestradiol tabs 0

drospirenone-ethinylestradiol-levomefolate calcium tabs

0

ESTROSTEP FE TABS (Use norethindrone acetate-ethinyl estradiol-fe)

NF

ethynodiol diacet amp ethestrad tabs 0

FALESSA KIT 0

GENERESS FE CHEW (Use norethindrone amp ethinyl estradiol-fe)

NF

levonorgestrel amp ethestradiol tabs 0

levonorgestrel-eth estradiol(triphasic) tabs 0

levonorgestrel-ethinylestradiol (91-day) tabs 0

levonorgestrel-ethinylestradiol (continuous) tabs 0

LO LOESTRIN FE TABS 0

LOSEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

MINASTRIN 24 FE CHEW (Use norethin acet amp estrad-fe)

NF

MIRCETTE TABS (Use desogestrel-ethinylestradiol (biphasic))

NF

NATAZIA TABS 0

norethin acet amp estrad-fe caps 0

norethin acet amp estrad-fe chew 0

norethin acet amp estrad-fe tabs 0

norethindrone amp eth estradiol tabs 0

norethindrone amp ethinylestradiol-fe chew 0


56

Drug Name DrugTier

RequirementsLimits

norethindrone acet amp eth estra tabs 0

norethindrone acetate-ethinyl estradiol-fe tabs 0

norethindrone-eth estradiol (triphasic) tabs 0

norgestimate-ethinylestradiol (triphasic) tabs 0

norgestimate-ethinylestradiol tabs 0

norgestrel amp ethinylestradiol tabs 0

ORTHO TRI-CYCLEN LO TABS (Use norgestimate-ethinyl estradiol (triphasic))

NF

ORTHO-NOVUM 135TABS (Use norethindrone amp eth estradiol)

NF

ORTHO-NOVUM 777TABS (Use norethindrone-eth estradiol (triphasic))

NF

QUARTETTE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

SAFYRAL TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

NF

SEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

TAYTULLA CAPS (Use norethin acet amp estrad-fe) 0

TYBLUME CHEW 0

YASMIN 28 TABS (Use drospirenone-ethinylestradiol)

NF

YAZ TABS (Use drospirenone-ethinylestradiol)

NF

Combination Contraceptives - Transdermal norelgestromin-ethinylestradiol ptwk 0

TWIRLA PTWK 0 QL(3 ea per 28days retail)

Drug Name DrugTier

RequirementsLimits

Combination Contraceptives - Vaginal ANNOVERA RING 0 PA

etonogestrel-ethinylestradiol ring 0

NUVARING RING (Use etonogestrel-ethinylestradiol)

NF

Copper Contraceptives - IUD PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A IUD

0

Emergency Contraceptives

ELLA TABS 0

levonorgestrel (emergencyoc) tabs 0

PLAN B ONE-STEP TABS (Use levonorgestrel(emergency oc))

NF

Progestin Contraceptives - IUD

KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0

Progestin Contraceptives - Implants

NEXPLANON IMPL 0

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (Use medroxyprogesteroneacetate (contraceptive))

NF

QL(1 ml per 90days retail)

DEPO-PROVERA CONTRACEPTIVE SUSY (Use medroxyprogesteroneacetate (contraceptive))

NF

QL(90 day(s)limit1 ml per90 days retail)

DEPO-SUBQ PROVERA 104 SUSY 0


57

Drug Name DrugTier

RequirementsLimits

medroxyprogesteroneacetate (contraceptive) susp

0 QL(1 ml per 90days retail)

medroxyprogesteroneacetate (contraceptive) susy

0 QL(90 day(s)limit1 ml per90 days retail)

Progestin Contraceptives - Oral norethindrone (contraceptive) tabs 0

ORTHO MICRONOR TABS (Use norethindrone (contraceptive))

NF

SLYND TABS 0 QL(1 ea daily)

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids

budesonide cpep 3 mg 1 QL(3 ea daily)

CELESTONE-SOLUSPAN SUSP (Use betamethasone sod phosphate amp acetate)

NF

CORTEF TABS (Use hydrocortisone) NF

cortisone acetate tabs 1

DEPO-MEDROL SUSP 20 MGML 3

DEPO-MEDROL SUSP 80 MGML 40 MGML (Use methylprednisolone acetate)

NF

dexamethasone elix 05 mg5ml 1

DEXAMETHASONE INTENSOL CONC 1

dexamethasone sodium phosphate soln ij 120mg30ml 20 mg5ml 4mgml

1

dexamethasone soln 05 mg5ml 1

dexamethasone tabs 1 mg15 mg 2 mg 4 mg 05mg 075 mg 6 mg

1

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA

ENTOCORT EC CPEP (Use budesonide) NF QL(3 ea daily)

hydrocortisone tabs 1

KENALOG-40 SUSP (Use triamcinolone acetonide) NF

MEDROL DOSEPAK TBPK (Use methylprednisolone) NF

MEDROL TABS 16 MG 32 MG 8 MG 4 MG (Use methylprednisolone)

NF

MEDROL TABS 2 MG 3

methylprednisolone acetatesusp 80 mgml 40 mgml 1

methylprednisolone sodsucc solr 1

methylprednisolone tabs 1

methylprednisolone tbpk 1

MILLIPRED DP TBPK 3

MILLIPRED TABS 3

ORAPRED ODT TBDP (Use prednisolone sodiumphosphate)

NF

PEDIAPRED SOLN (Use prednisolone sodiumphosphate)

NF

prednisolone sodiumphosphate soln or 10mg5ml 15 mg5ml 20mg5ml 25 mg5ml 5mg5ml 67 mg5ml

1

prednisolone sodiumphosphate tbdp or 10 mg15 mg 30 mg

3

prednisolone soln 1

prednisone soln 1


58

Drug Name DrugTier

RequirementsLimits

prednisone tabs 1

prednisone tbpk 1

SOLU-CORTEF SOLR 100 MG 1000 MG 500 MG 3

2 rtl MAX fill30 rtl day(s)supply

SOLU-CORTEF SOLR 250 MG 3

SOLU-MEDROL SOLR 2 GM 3

SOLU-MEDROL SOLR 500 MG 1000 MG 125 MG 40 MG (Use methylprednisolone sod succ)

NF

triamcinolone acetonide susp 40 mgml 1

Mineralocorticoids fludrocortisone acetate tabs 1

COUGHCOLDALLERGY - Drugs to TreatCough Cold and Allergy Symptoms

Antitussives

benzonatate caps 100 mg 1 QL(6 ea daily)



TESSALON PERLES CAPS (Use benzonatate) NF QL(6 ea daily)

CoughColdAllergy Combinations ALLEGRA-D 12 HOUR ALLERGY amp CONGESTION TB12 (Use fexofenadine-pseudoephedrine)

NF

QL(2 ea daily)

ALLEGRA-D 24 HOUR ALLERGY amp CONGESTION TB24 (Use fexofenadine-pseudoephedrine)

NF

QL(1 ea daily)

cetirizine-pseudoephedrinetb12 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

CLARITIN-D 12 HOUR TB12 (Use loratadine amp pseudoephedrine)

1 QL(2 ea daily)


1 QL(1 ea daily)

fexofenadine-pseudoephedrine tb12 60mg-120 mg

1 QL(2 ea daily)


1 QL(1 ea daily)

loratadine amp pseudoephedrine tb12 5mg-120 mg

1 QL(2 ea daily)

loratadine amp pseudoephedrine tb24 10mg-10 mg-240 mg-240 mg

1 QL(1 ea daily)

TUZISTRA XR SUER 2 PA

ZYRTEC-D ALLERGYCONGESTIONTB12 (Use cetirizine-pseudoephedrine)

1

QL(2 ea daily)

Misc Respiratory Inhalants HYPER-SAL NEBU (Use sodium chloride (inhalant)) NF

HYPERSAL NEBU 35 1

HYPERSAL NEBU 7 (Use sodium chloride (inhalant))

NF

NEBUSAL NEBU 1

sodium chloride (inhalant)nebu 7 1

Mucolytics

acetylcysteine soln 1

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products ABSORICA CAPS 30 MG 10 MG 20 MG 40 MG (Use isotretinoin)

NF PA AL(At least12 yrs old)


59

Drug Name DrugTier

RequirementsLimits

adapalene crea 01 1 PA AL(At least12 yrs old)

adapalene gel 01 1 PA AL(At least12 yrs old)RXOTC

adapalene gel 03 1 ST AL(At least12 yrs old)

adapalene lotn 01 1 ST AL(At least12 yrs old)

adapalene-benzoylperoxide gel 1 ST AL(At least

12 yrs old)

AZELEX CREA 3 ST AL(At least12 yrs old)

BENZACLIN GEL (Use clindamycin phosphate-benzoyl peroxide)


BENZACLIN WITH PUMP GEL (Use clindamycinphosphate-benzoylperoxide)

NF

PA AL(At least12 yrs old)

BENZAMYCIN GEL (Use benzoyl peroxide-erythromycin)


BENZOYL PEROXIDE CLEANSER LIQD 2 AL(At least 12

yrs old)

benzoyl peroxide foam 53 1

AL(At least 12yrs old)RXOTC

benzoyl peroxide foam 98 1 AL(At least 12

yrs old) benzoyl peroxide gel 5 10 1 AL(At least 12

yrs old) benzoyl peroxide liqd 4 7 10 1 AL(At least 12

yrs old) benzoyl peroxide-erythromycin gel 1 PA AL(At least

12 yrs old) CLEOCIN-T GEL (Use clindamycin phosphate(topical))


CLEOCIN-T LOTN (Use clindamycin phosphate(topical))


CLINDAGEL GEL (Use clindamycin phosphate(topical))


clindamycin phosphate(topical) foam 1 PA AL(At least

12 yrs old)

Drug Name DrugTier

RequirementsLimits

clindamycin phosphate(topical) gel 1 AL(At least 12

yrs old) clindamycin phosphate(topical) lotn 1 AL(At least 12

yrs old)

clindamycin phosphate(topical) soln 1

QL(4 ml daily)AL(At least 12yrs old)

clindamycin phosphate(topical) swab 1 AL(At least 12

yrs old) clindamycin phosphate-benzoyl peroxide(refrigerate) gel

1 PA AL(At least12 yrs old)

clindamycin phosphate-benzoyl peroxide gel 1 -5 5 -1


clindamycin phosphate-tretinoin gel 1 ST AL(At least

12 yrs old) DIFFERIN CREA 01 (Use adapalene) NF PA AL(At least

12 yrs old)

DIFFERIN GEL 01 (Use adapalene) NF

PA AL(At least12 yrs old)RXOTC

DIFFERIN GEL 03 (Use adapalene) NF ST AL(At least

12 yrs old)

DIFFERIN LOTN 01 1 ST AL(At least12 yrs old)

DUAC GEL (Use clindamycin phosphate-benzoyl peroxide(refrigerate))

NF


EPIDUO GEL (Use adapalene-benzoylperoxide)

NF ST AL(At least12 yrs old)

erythromycin (acne aid)pads 1 AL(At least 12

yrs old) erythromycin (acne aid)soln 1 AL(At least 12

yrs old) EVOCLIN FOAM (Use clindamycin phosphate(topical))


isotretinoin caps 30 mg 10mg 20 mg 40 mg 3 PA AL(At least

12 yrs old) KLARON LOTN (Use sulfacetamide sodium (acne))



60

Drug Name DrugTier

RequirementsLimits

RETIN-A CREA (Use tretinoin) NF

AL(At least 12yrs old - Up to30 yrs old)

RETIN-A GEL (Use tretinoin) NF


RETIN-A MICRO GEL 01 (Use tretinoin microsphere)

NF PA AL(At least12 yrs old - Upto 30 yrs old)

RETIN-A MICRO PUMP GEL 01 (Use tretinoin microsphere)


sulfacetamide sodium (acne) lotn 1 AL(At least 12

yrs old) sulfacetamide sodium wsulfur crea 5 -10 1 AL(At least 12

yrs old) sulfacetamide sodium wsulfur emul 10 -5 5 -10

1 AL(At least 12yrs old)

sulfacetamide sodium wsulfur liqd 45 -9 1 ST AL(At least

12 yrs old) sulfacetamide sodium-sulfur in urea vehicle emul 1 AL(At least 12

yrs old) SUMADAN WASH LIQD (Use sulfacetamide sodium w sulfur)


tretinoin crea 005 0025 01 1


tretinoin gel 001 0025 1


tretinoin microsphere gel01 1

PA AL(At least12 yrs old - Upto 30 yrs old)

VELTIN GEL (Use clindamycin phosphate-tretinoin)


ZIANA GEL (Use clindamycin phosphate-tretinoin)


Agents for External Genital and Perianal Warts

VEREGEN OINT 3

Anti-inflammatory Agents - Topical

diclofenac epolamine ptch 1 PA QL(2 eadaily)

Drug Name DrugTier

RequirementsLimits

diclofenac sodium (topical)gel 1 1 QL(334 gm

daily) RXOTC FLECTOR PTCH (Use diclofenac epolamine) 3 PA QL(2 ea

daily) VOLTAREN GEL (Use diclofenac sodium (topical)) NF QL(334 gm

daily) RXOTC

Antibiotics - Topical ALTABAX OINT 2

gentamicin sulfate (topical) crea 1 QL(1 gm daily)

gentamicin sulfate (topical)oint 1

mupirocin oint 1

NEO-SYNALAR CREA 3 PA

Antifungals - Topical butenafine hcl crea 1 RXOTC

CICLODAN SOLUTION KIT KIT (Use ciclopirox) NF

ciclopirox gel ex 077 1

ciclopirox olamine crea 1

QL(90 gm perfill retail)1 rtlMAX fill30 rtl day(s) supply

ciclopirox olamine susp 1

ciclopirox sham ex 1 1

ciclopirox soln ex 8 1

clotrimazole (topical) crea 1 RXOTC

clotrimazole (topical) soln 1 RXOTC

clotrimazole wbetamethasone crea 1

clotrimazole wbetamethasone lotn 1

econazole nitrate crea 1 QL(85 gm perfill retail85 gmper fill mail)

ERTACZO CREA 3


61

Drug Name DrugTier

RequirementsLimits

EXELDERM CREA (Use sulconazole nitrate) 3

EXELDERM SOLN 3

EXELDERM SOLN (Use sulconazole nitrate) 3

JUBLIA SOLN 3 PA

KERYDIN SOLN (Use tavaborole) 3 PA

ketoconazole (topical) crea2 1

ketoconazole (topical)sham 2 1

LOPROX CREA (Use ciclopirox olamine) NF


LOPROX SHAMPOO SHAM (Use ciclopirox) NF

LOPROX SUSP (Use ciclopirox olamine) NF

LOTRIMIN AF CREA (Use clotrimazole (topical)) NF RXOTC

LOTRIMIN AF JOCK ITCH CREA (Use clotrimazole (topical))

NF RXOTC

LOTRIMIN ULTRA CREA (Use butenafine hcl) 1 RXOTC

LOTRISONE CREA (Use clotrimazole wbetamethasone)

NF

luliconazole crea 1 PA

LUZU CREA (Use luliconazole) 3 PA

naftifine hcl crea 1 1

QL(3 gmdaily)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

Drug Name DrugTier

RequirementsLimits



naftifine hcl gel 1 1


NAFTIFINE HYDROCHLORIDE CREA (Use naftifine hcl)

NF


NAFTIN CREA 2 (Use naftifine hcl) NF


NAFTIN GEL 1 (Use naftifine hcl) NF


NIZORAL SHAM (Use ketoconazole (topical)) NF

nystatin (topical) crea 1

nystatin (topical) oint 1

nystatin (topical) powd 1

nystatin-triamcinolone crea 1

nystatin-triamcinolone oint 1


62

Drug Name DrugTier

RequirementsLimits

oxiconazole nitrate crea 1

Limit 1 Fill per180 daysQL(3gm daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

OXISTAT CREA (Use oxiconazole nitrate) NF


OXISTAT LOTN 2

Limit 1 Fill per180 daysQL(2ml daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PENLAC NAIL LACQUER SOLN (Use ciclopirox) NF

sulconazole nitrate crea 1

sulconazole nitrate soln 1

tavaborole soln 1 PA

VUSION OINT (Use miconazole-zinc oxide-white petrolatum)

NF

Antineoplastic or Premalignant Lesion Agents -CARAC CREA (Use fluorouracil (topical)) 6 PA

diclofenac sodium (actinickeratoses) gel 1 PA QL(334

gm daily) EFUDEX CREA (Use fluorouracil (topical)) NF

FLUOROPLEX CREA 6 PA

fluorouracil (topical) crea05 6 PA

fluorouracil (topical) crea 5 1

Drug Name DrugTier

RequirementsLimits

fluorouracil (topical) soln 2 1

fluorouracil (topical) soln 5 1 PA

LEVULAN KERASTICK SOLR 6 PA

PANRETIN GEL 6

PICATO GEL 0015 6


PICATO GEL 005 6


TARGRETIN GEL EX 1 6 PA SP

VALCHLOR GEL 6 PA

Antipruritics - Topical

doxepin hcl (antipruritic) crea 3

PA Limit 1 fill every 180daysQL(45 gmper fill retail45gm per fillmail)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PRUDOXIN CREA (Use doxepin hcl (antipruritic)) 3



63

Drug Name DrugTier

RequirementsLimits

ZONALON CREA (Use doxepin hcl (antipruritic)) 3


Antipsoriatics acitretin caps 10 mg 175 mg 1 QL(1 ea daily)

acitretin caps 25 mg 1 QL(2 ea daily)

calcipotriene crea 1 PA QL(4 gmdaily)

calcipotriene oint 1 PA QL(4 gmdaily)

calcipotriene soln 1 PA QL(4 mldaily)

calcitriol (topical) oint 1 QL(334 gmdaily)

COSENTYX SENSOREADY PEN SOAJ 4 PA QL(0072

ml daily) COSENTYX SOSY 150 MGML 4 PA QL(0036


ml daily) DOVONEX CREA (Use calcipotriene) NF PA QL(4 gm

daily)

methoxsalen rapid caps 1 QL(4 ea daily)

OXSORALEN ULTRA CAPS (Use methoxsalen rapid)

NF QL(4 ea daily)

SKYRIZI PSKT 75 MG083ML 4 PA QL(0025

ea daily) SORIATANE CAPS 10 MG (Use acitretin) NF QL(1 ea daily)

SORIATANE CAPS 25 MG (Use acitretin) NF QL(2 ea daily)

STELARA SOLN SC 45 MG05ML 4 PA QL(0012

ml daily) STELARA SOSY SC 45 MG05ML 4 PA QL(0012

ml daily)

Drug Name DrugTier

RequirementsLimits

STELARA SOSY SC 90 MGML 4 PA QL(0018

ml daily) SP

tazarotene crea 1 PA

TAZORAC CREA 005 2

TAZORAC CREA 01 (Use tazarotene) NF PA

TAZORAC GEL 005 01 2

TREMFYA SOPN 4 PA QL(0018ml daily)

TREMFYA SOSY 4 PA QL(0018ml daily)

VECTICAL OINT (Use calcitriol (topical)) 1 QL(334 gm

daily) Antiseborrheic Products

selenium sulfide lotn 1

Antivirals - Topical acyclovir topical crea 1

acyclovir topical oint 1

DENAVIR CREA 3 QL(018 gmdaily)

ZOVIRAX CREA EX 5 (Use acyclovir topical) NF

ZOVIRAX OINT EX 5 (Use acyclovir topical) NF

Burn Products

mafenide acetate pack 3

SILVADENE CREA (Use silver sulfadiazine) NF

silver sulfadiazine crea 1

SULFAMYLON CREA 85 MGGM 3

SULFAMYLON PACK 5 (Use mafenide acetate) NF

Corticosteroids - Topical alclometasone dipropionate crea 1

alclometasone dipropionateoint 1


64

Drug Name DrugTier

RequirementsLimits

amcinonide crea 1

QL(60 gm perfill retail60 gmper fill mail)1 rtlMAX fill30 rtl day(s) supply1mail MAX fill30 mail day(s)supply

amcinonide lotn 3

AMCINONIDE OINT 3

betamethasone dipropionate (topical) crea 1

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint 1

betamethasone dipropionate augmented crea

1

betamethasone dipropionate augmentedlotn

1

betamethasone dipropionate augmentedoint

1

betamethasone valerate crea 01 1

betamethasone valerate foam 012 1 QL(167 gm

daily) betamethasone valerate lotn 01 1

betamethasone valerate oint 01 1

calcipotriene-betamethasone dipropionate oint

1 ST

calcipotriene-betamethasone dipropionate susp

1 ST

clobetasol propionate crea 1 PA QL(3 gmdaily)

clobetasol propionateemollient base crea 1 PA QL(1 gm

daily)

clobetasol propionate foam 1 ST QL(3 gmdaily)

Drug Name DrugTier

RequirementsLimits

clobetasol propionate gel 1 ST QL(2 gmdaily)

clobetasol propionate oint 1 PA QL(1 gmdaily)

clobetasol propionate soln 1 PA QL(334 mldaily)

clocortolone pivalate crea 3

CLODERM CREA 3

CLODERM CREA (Use clocortolone pivalate) 3

CLODERM PUMP CREA 3

CORDRAN CREA 005 (Use flurandrenolide) NF

CORDRAN LOTN 005 (Use flurandrenolide) NF

CORDRAN TAPE 4 MCGSQCM 3

CUTIVATE LOTN (Use fluticasone propionate) NF QL(6 ml daily)

DERMA-SMOOTHEFSBODY OIL (Use fluocinolone acetonide)

NF

QL(11828 mlper fill retail)1rtl MAX fill30 rtl day(s) supply

DERMA-SMOOTHEFSSCALP OIL (Use fluocinolone acetonide)

NF

desonide crea 1 QL(4 gm daily)

desonide lotn 1 QL(4 ml daily)

desonide oint 1 QL(3 gm daily)

DESOWEN CREA (Use desonide) NF QL(4 gm daily)

desoximetasone crea 025 1

desoximetasone gel 005 1

desoximetasone oint 025 1

diflorasone diacetate crea 1 PA

diflorasone diacetate oint 1 PA


65

Drug Name DrugTier

RequirementsLimits

DIPROLENE AF CREA (Use betamethasone dipropionate augmented)

NF

DIPROLENE OINT (Use betamethasone dipropionate augmented)

NF

ELOCON CREA (Use mometasone furoate) NF

fluocinolone acetonide crea 001 0025 1

fluocinolone acetonide oil 001 1



fluocinolone acetonide oint 0025 1

fluocinolone acetonide soln 001 1

fluocinonide crea 005 1 QL(2 gm daily)

fluocinonide emulsified base crea 1 QL(2 gm daily)

fluocinonide gel 005 1

fluocinonide oint 005 1 QL(2 gm daily)

fluocinonide soln 005 1 QL(2 ml daily)

flurandrenolide crea 2 QL(2 gm daily)

flurandrenolide lotn 2 QL(2 ml daily)

fluticasone propionate crea005 1

fluticasone propionate lotn005 1 QL(6 ml daily)

fluticasone propionate oint0005 1

halcinonide crea 1 PA

halobetasol propionate crea 1

halobetasol propionate oint 1

HALOG CREA (Use halcinonide) NF PA

Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA

hydrocortisone (topical)crea 1 1 RXOTC

hydrocortisone (topical)crea 25 1

hydrocortisone (topical) lotn25 1

hydrocortisone (topical) oint1 1 RXOTC

hydrocortisone (topical) oint25 1

hydrocortisone butyrate crea 1

hydrocortisone butyrateoint 1

hydrocortisone butyratesoln 1

hydrocortisone valerate crea 1

hydrocortisone valerate oint 1

LOCOID CREA (Use hydrocortisone butyrate) NF

LOCOID SOLN (Use hydrocortisone butyrate) NF

LUXIQ FOAM (Use betamethasone valerate) NF QL(167 gm

daily)

mometasone furoate crea 1

mometasone furoate oint 1

mometasone furoate soln 1

MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use hydrocortisone(topical))

NF

RXOTC

OLUX FOAM (Use clobetasol propionate) NF ST QL(3 gm

daily)

prednicarbate crea 1

prednicarbate oint 1

PSORCON CREA 2 PA


66

Drug Name DrugTier

RequirementsLimits

SYNALAR CREA (Use fluocinolone acetonide) NF

SYNALAR OINT (Use fluocinolone acetonide) NF

SYNALAR SOLN (Use fluocinolone acetonide) NF

TACLONEX OINT (Use calcipotriene-betamethasone dipropionate)

NF

ST

TACLONEX SUSP (Use calcipotriene-betamethasone dipropionate)

3

ST

TEMOVATE CREA (Use clobetasol propionate) NF PA QL(3 gm

daily) TEMOVATE OINT (Use clobetasol propionate) NF PA QL(1 gm

daily) TOPICORT CREA 025 (Use desoximetasone) NF

TOPICORT GEL 005 (Use desoximetasone) NF

TOPICORT OINT 025 (Use desoximetasone) NF

triamcinolone acetonide (topical) crea 0025 05

1

triamcinolone acetonide (topical) crea 01 1 QL(334 gm

daily) triamcinolone acetonide (topical) lotn 0025 01

1

triamcinolone acetonide (topical) oint 0025 01 05

1

triamcinolone acetonide-dimethicone-silicone kit 1 PA

TRIDESILON CREA (Use desonide) NF QL(4 gm daily)

ULTRAVATE CREA (Use halobetasol propionate) NF

ULTRAVATE OINT (Use halobetasol propionate) NF

Eczema Agents DUPIXENT SOPN 300 MG2ML 4 PA

Drug Name DrugTier

RequirementsLimits

DUPIXENT SOSY 200 MG114ML 300 MG2ML 4 PA

EmollientKeratolytic Agents HYDRO 35 FOAM (Use urea in lactic acid vehicle) NF

Emollients LAC-HYDRIN CREA (Use lactic acid (ammoniumlactate))

NF RXOTC

LAC-HYDRIN TWELVE LOTN (Use lactic acid (ammonium lactate))

NF RXOTC

lactic acid (ammoniumlactate) crea 1 RXOTC

lactic acid (ammoniumlactate) lotn 1 RXOTC

Enzymes - Topical SANTYL OINT 3 PA

Immunomodulating Agents - Topical

ALDARA CREA (Use imiquimod) NF

QL(12 ea perfill retail12 ea per fill mail)

imiquimod crea 5 1 QL(12 ea perfill retail12 ea per fill mail)

ZYCLARA CREA (Use imiquimod) NF

ZYCLARA PUMP CREA 375 (Use imiquimod) NF

Immunosuppressive Agents - Topical ELIDEL CREA (Use pimecrolimus) NF PA AL(At least

2 yrs old)

pimecrolimus crea 1 PA AL(At least2 yrs old)

PROTOPIC OINT (Use tacrolimus (topical)) NF PA AL(At least

2 yrs old)

tacrolimus (topical) oint 1 PA AL(At least2 yrs old)

KeratolyticAntimitotic Agents

podofilox soln 1

Local Anesthetics - Topical


67

Drug Name DrugTier

RequirementsLimits

lidocaine hcl gel ex 2 1 QL(4 ml daily)

lidocaine hcl gel ex 2 1 QL(4 ml daily)RXOTC

lidocaine hcl prsy ex 2 1 QL(4 ml daily)

lidocaine hcl soln ex 4 1

lidocaine ptch ex 5 1 PA

lidocaine-prilocaine crea 1 QL(1 gm daily)

LIDODERM PTCH (Use lidocaine) NF PA

SYNERA PTCH 3

QL(10 ea perfill retail10 ea per fill mail)1 rtlMAX fill30 rtl day(s) supply1mail MAX fill30 mail day(s)supply

Phosphodiesterase 4 (PDE4) Inhibitors - Topical

EUCRISA OINT 3 PA QL(2 gmdaily)

Rosacea Agents

azelaic acid gel 1 PA

FINACEA GEL (Use azelaic acid) NF PA

METROCREAM CREA (Use metronidazole (topical))

NF

METROGEL GEL (Use metronidazole (topical)) NF

METROLOTION LOTN (Use metronidazole (topical))

NF

metronidazole (topical) crea 1

metronidazole (topical) gel 1

metronidazole (topical) lotn 1

MIRVASO GEL 3 PA QL(1 gmdaily)

Drug Name DrugTier

RequirementsLimits

ORACEA CPDR (Use doxycycline (rosacea)) NF

SOOLANTRA CREA (Use ivermectin (rosacea)) NF

Scabicides amp Pediculicides

crotamiton lotn 1 PA

ELIMITE CREA (Use permethrin) NF

EURAX CREA 3

EURAX LOTN (Use crotamiton) NF PA

ivermectin (pediculicide)lotn 1 PA RXOTC

IVERMECTIN LOTN EX 05 3 PA RXOTC

lindane sham 1

malathion lotn 1

NATROBA SUSP (Use spinosad) 1 PA

NIX CREME RINSE LIQD (Use permethrin) NF

OVIDE LOTN (Use malathion) NF

permethrin crea 1

permethrin liqd 1

SKLICE LOTN (Use ivermectin (pediculicide)) 3 PA RXOTC

spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS

Diagnostic Drugs GLUCAGEN DIAGNOSTIC SOLR 3 QL(0035 ea

daily)


68

Drug Name DrugTier

RequirementsLimits

THYROGEN SOLR 3

PA 1 rtl MAX fill365 rtl day(s) supply1mail MAX fill365 mail day(s) supply

Diagnostic Tests

CHEMSTRIP-K STRP 1

FORA GTEL BLOOD KETONE TEST STRIPS STRP

1

GOJJI BLOOD KETONE TEST STRIPS STRP 1

KETONE STRP 1

KETONE TEST STRIPS STRP 1

KETOSTIX STRP 1

NOVA MAX PLUS KETONE TESTSTRIPS STRP

1

PRECISION XTRA STRP VI 1

PTS PANELS KETONE TEST STRP 1

RELION KETONE TEST STRIPS STRP 1

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

1

Limit 100 permonthQL(334ea daily)RXOTC

TRUETRACK TEST STRP 1


DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

DIURETICS - Drugs to Treat Heart CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors acetazolamide cp12 500 mg 1 QL(2 ea daily)

acetazolamide sodium solr 1

acetazolamide tabs 125 mg 1 QL(8 ea daily)


KEVEYIS TABS 4 PA QL(4 eadaily)

methazolamide tabs 1 QL(6 ea daily)

Diuretic Combinations ALDACTAZIDE TABS 25 MG-25 MG (Use spironolactone amphydrochlorothiazide)

NF

amiloride amp hydrochlorothiazide tabs 1

DYAZIDE CAPS (Use triamterene amp hydrochlorothiazide)

NF

MAXZIDE TABS (Use triamterene amp hydrochlorothiazide)

NF

MAXZIDE-25 TABS (Use triamterene amp hydrochlorothiazide)

NF

spironolactone amphydrochlorothiazide tabs 1

triamterene amp hydrochlorothiazide caps 1

triamterene amp hydrochlorothiazide tabs 1

Loop Diuretics bumetanide soln ij 025mgml 1

bumetanide tabs or 05 mg1 mg 2 mg 1 QL(5 ea daily)

BUMEX TABS (Use bumetanide) NF QL(5 ea daily)

EDECRIN TABS (Use ethacrynic acid) NF QL(16 ea daily)


69

Drug Name DrugTier

RequirementsLimits

ethacrynic acid tabs 1 QL(16 ea daily)

furosemide soln 1

furosemide tabs 1

LASIX TABS (Use furosemide) NF

torsemide tabs 1

Potassium Sparing Diuretics ALDACTONE TABS (Use spironolactone) NF

amiloride hcl tabs 1

DYRENIUM CAPS (Use triamterene) NF QL(3 ea daily)

spironolactone tabs 1

triamterene caps 1 QL(3 ea daily)

Thiazides and Thiazide-Like Diuretics

chlorothiazide tabs 1

chlorthalidone tabs 1

hydrochlorothiazide caps 1 QL(2 ea daily)

hydrochlorothiazide tabs 1 QL(2 ea daily)

indapamide tabs 125 mg 1 QL(1 ea daily)


metolazone tabs 1 QL(2 ea daily)

ENDOCRINE AND METABOLIC AGENTS -MISC - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators ACTONEL TABS 150 MG (Use risedronate sodium) NF PA QL(0036

ea daily) ACTONEL TABS 35 MG (Use risedronate sodium) NF PA QL(0143

ea daily) ACTONEL TABS 5 MG (Use risedronate sodium) NF PA QL(1 ea

daily)

Drug Name DrugTier

RequirementsLimits

alendronate sodium tabs 40 mg 10 mg 5 mg 1 QL(1 ea daily)

alendronate sodium tabs 70 mg 35 mg 1 QL(0143 ea

daily) ATELVIA TBEC (Use risedronate sodium) NF PA

BONIVA SOLN IV 3 MG3ML (Use ibandronate sodium)

NF PA SP

BONIVA TABS OR 150 MG (Use ibandronate sodium) NF QL(0036 ea

daily) calcitonin (salmon) soln na200 unitact 1

etidronate disodium tabs 1

FOSAMAX PLUS D TABS 3 PA QL(0143ea daily)

FOSAMAX TABS (Use alendronate sodium) NF QL(0143 ea

daily) ibandronate sodium soln iv 3 mg3ml 4 PA SP

ibandronate sodium tabs or 150 mg 1 QL(0036 ea

daily) pamidronate disodium soln30 mg10ml 90 mg10ml 4 PA SP

PAMIDRONATE DISODIUM SOLN 6 MGML

4 PA SP

pamidronate disodium solr30 mg 90 mg 4 PA SP

PROLIA SOSY 4

PA 1 rtl MAX fill180 rtl day(s) supplySP

RECLAST SOLN (Use zoledronic acid) NF PA SP

risedronate sodium tabs 150 mg 1 PA QL(0036

ea daily) risedronate sodium tabs 30 mg 5 mg 1 PA QL(1 ea

daily) risedronate sodium tabs 35 mg 1 PA QL(0143

ea daily) risedronate sodium tbec 35 mg 1 PA

TYMLOS SOPN 4 PA


70

Drug Name DrugTier

RequirementsLimits

XGEVA SOLN 4 PA SP

zoledronic acid conc 4 mg5ml 4 PA SP

ZOLEDRONIC ACID SOLN 4 MG100ML 4 PA SP

zoledronic acid soln 4 mg100ml 5 mg100ml 4 PA SP

ZOLEDRONIC ACID SOLR 4 MG 4 PA SP

Corticotropin

ACTHAR GEL 4 PA

Fertility Regulators CHORIONIC GONADOTROPIN SOLR 4 PA SP

NOVAREL SOLR 10000 UNIT 4 PA SP

PREGNYL WDILUENTBENZYLALCOHOLNACLSOLR

4 PA SP

GnRHLHRH Antagonists

CETROTIDE KIT 4 PA

ganirelix acetate sosy 4 PA

GANIRELIX ACETATE SOSY (Use ganirelix acetate)

NF PA

Growth Hormone Receptor Antagonists SOMAVERT SOLR 10 MG 15 MG 20 MG 4 PA SP

Growth Hormone Releasing Hormones (GHRH) EGRIFTA SOLR 4 PA

EGRIFTA SV SOLR 4 PA

Growth Hormones GENOTROPIN MINIQUICK SOLR 02 MG 4 PA SP

GENOTROPIN SOLR 5 MG 4 PA SP

HUMATROPE COMBO PACK SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

HUMATROPE SOLR 4 PA SP

NORDITROPIN FLEXPRO SOPN 10 MG15ML 15MG15ML 5 MG15ML

4 PA SP

NORDITROPIN FLEXPRO SOPN 30 MG3ML 4 PA

NUTROPIN AQ NUSPIN 10 SOPN 4 PA SP

OMNITROPE SOCT 10 MG15ML 5 MG15ML 4 PA SP

SAIZEN SOLR 4 PA SP

SAIZENPREP RECONSTITUTIONKIT SOLR

4 PA SP

SEROSTIM SOLR 4 PA SP

ZOMACTON SOLR 4 PA SP

ZORBTIVE SOLR 4 PA SP

Hormone Receptor Modulators EVISTA TABS (Use raloxifene hcl) NF QL(1 ea daily)

OSPHENA TABS 3 PA

raloxifene hcl tabs 0 QL(1 ea daily)

Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN 4 PA SP

LHRHGnRH Agonist Analog Pituitary

FENSOLVI KIT 6 PA SP

LUPANETA PACK KIT 4 PA

LUPRON DEPOT-PED (1-MONTH) KIT 6 PA SP

LUPRON DEPOT-PED (3-MONTH) KIT 1125 MG 6 PA

LUPRON DEPOT-PED (3-MONTH) KIT 30 MG 6 PA SP

SYNAREL SOLN 4 PA SP

Metabolic Modifiers


71

Drug Name DrugTier

RequirementsLimits

ALDURAZYME SOLN 4 PA SP

BUPHENYL POWD (Use sodium phenylbutyrate) NF PA

BUPHENYL TABS (Use sodium phenylbutyrate) NF PA

calcitriol caps 1

calcitriol soln 1

CARBAGLU TABS 4 PA SP

cinacalcet hcl tabs 4 PA QL(4 eadaily) SP

CYSTADANE POWD 4 PA SP

doxercalciferol caps 1

doxercalciferol soln 1

ELAPRASE SOLN 4 PA SP

FABRAZYME SOLR 35 MG 4 PA SP

GALAFOLD CAPS 4 PA QL(05 eadaily)

HECTOROL SOLN 4 MCG2ML (Use doxercalciferol)

NF

KUVAN PACK (Use sapropterindihydrochloride)

NF PA

KUVAN TABS (Use sapropterindihydrochloride)

NF PA

LUMIZYME SOLR 4 PA SP

MYALEPT SOLR 4 PA

NAGLAZYME SOLN 4 PA SP

nitisinone caps 4 PA SP

ORFADIN CAPS 10 MG 2 MG 5 MG (Use nitisinone) NF PA SP

PALYNZIQ SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

paricalcitol caps 1

paricalcitol soln 1

ROCALTROL CAPS (Use calcitriol) NF

ROCALTROL SOLN (Use calcitriol) NF

sapropterin dihydrochloridepack 4 PA

sapropterin dihydrochloridetabs 4 PA

SENSIPAR TABS (Use cinacalcet hcl) NF PA QL(4 ea

daily) SP sodium phenylbutyratepowd 1 PA

sodium phenylbutyrate tabs 1 PA

ZEMPLAR CAPS (Use paricalcitol) NF

ZEMPLAR SOLN (Use paricalcitol) NF

Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCGML (Use desmopressin acetate)

NF PA

DDAVP SOLN NA 001 (Use desmopressin acetate spray)

NF

DDAVP TABS OR 01 MG (Use desmopressin acetate)

NF QL(6 ea daily)


NF QL(8 ea daily)

desmopressin acetate solnij 4 mcgml 1 PA

DESMOPRESSIN ACETATE SOLN NA 15 MGML

4 PA SP

desmopressin acetatespray refrigerated soln 1

desmopressin acetatespray soln 1

desmopressin acetate tabsor 01 mg 1 QL(6 ea daily)


72

Drug Name DrugTier

RequirementsLimits


STIMATE SOLN 4 PA SP

Prolactin Inhibitors

cabergoline tabs 1

Somatostatic Agents

octreotide acetate soln 4 PA SP

SANDOSTATIN SOLN (Use octreotide acetate) NF PA SP

SIGNIFOR SOLN 4 PA

SOMATULINE DEPOT SOLN 120 MG05ML 4 PA QL(00179

ml daily) SP SOMATULINE DEPOT SOLN 60 MG02ML 4 PA QL(00075


ml daily) SP

Vasopressin Receptor Antagonists JYNARQUE TABS 15 MG 30 MG 4 PA QL(2 ea

daily) SP

JYNARQUE TBPK 4 PA

SAMSCA TABS (Use tolvaptan) 4 PA QL(2 ea

daily) SP

tolvaptan tabs 4 PA QL(2 eadaily) SP

ESTROGENS - Hormone ReplacementModifyingDrugs

Estrogen Combinations

CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA

FEMHRT TABS (Use norethindrone acetate-ethinyl estradiol)

NF

norethindrone acetate-ethinyl estradiol tabs 1

PREMPHASE TABS 2

PREMPRO TABS 2

Drug Name DrugTier

RequirementsLimits

Estrogens CLIMARA PTWK (Use estradiol) NF

DELESTROGEN OIL 10 MGML 1

DELESTROGEN OIL 20 MGML 40 MGML (Use estradiol valerate)

NF

DEPO-ESTRADIOL OIL 3

DIVIGEL GEL 025 MG025GM 05MG05GM 1 MGGM

3

ELESTRIN GEL 3

ESTRACE TABS (Use estradiol) NF

estradiol pttw td 0025mg24hr 00375 mg24hr005 mg24hr 0075mg24hr 01 mg24hr

1

QL(0286 eadaily)

estradiol ptwk td 0025mg24hr 0075 mg24hr01 mg24hr 005 mg24hr006 mg24hr 375mcg24hr

1

estradiol tabs or 1 mg 2mg 05 mg 1

estradiol valerate oil 1

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3

MINIVELLE PTTW (Use estradiol) NF QL(0286 ea

daily)

PREMARIN SOLR 2

PREMARIN TABS 2

VIVELLE-DOT PTTW (Use estradiol) NF QL(0286 ea

daily)


73

Drug Name DrugTier

RequirementsLimits

FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones AVELOX SOLN IV 08 -400 MG250ML (Use moxifloxacin hcl in sodium chloride)

1

AVELOX TABS OR 400 MG (Use moxifloxacin hcl) NF

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA

CIPRO SUSR 5 GM100ML 500 MG5ML 2


CIPRO TABS 250 MG 500 MG (Use ciprofloxacin hcl) NF

ciprofloxacin hcl tabs 1

ciprofloxacin in d5w soln 5-200 mg100ml 3

ciprofloxacin susr 1 2 rtl MAX fill30 rtl day(s)supply

LEVAQUIN TABS (Use levofloxacin) NF

levofloxacin in d5w soln 5 -500 mg100ml 1

levofloxacin soln 1

levofloxacin tabs 1

moxifloxacin hcl in sodium chloride soln 1

moxifloxacin hcl tabs 1

ofloxacin tabs 1

GASTROINTESTINAL AGENTS - MISC -Miscellaneous Gastrointestinal Drugs

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS 4 PA SP

Gallstone Solubilizing Agents

Drug Name DrugTier

RequirementsLimits

ACTIGALL CAPS (Use ursodiol) NF

URSO 250 TABS (Use ursodiol) NF

URSO FORTE TABS (Use ursodiol) NF

ursodiol caps 1

ursodiol tabs 1

Gastrointestinal Chloride Channel Activators AMITIZA CAPS (Use lubiprostone) 2 PA QL(2 ea

daily)

lubiprostone caps 1 PA QL(2 eadaily)

Gastrointestinal Stimulants metoclopramide hcl soln ij5 mgml 1

metoclopramide hcl soln or10 mg10ml 5 mg5ml 1 QL(60 ml daily)

metoclopramide hcl tabs or10 mg 5 mg 1 QL(6 ea daily)

REGLAN TABS (Use metoclopramide hcl) NF QL(6 ea daily)

Inflammatory Bowel Agents APRISO CP24 (Use mesalamine) NF

ASACOL HD TBEC (Use mesalamine) NF QL(6 ea daily)

AVSOLA SOLR 4 PA

AZULFIDINE EN-TABS TBEC (Use sulfasalazine) NF

AZULFIDINE TABS (Use sulfasalazine) NF

balsalazide disodium caps 1

CANASA SUPP (Use mesalamine) NF

COLAZAL CAPS (Use balsalazide disodium) NF

DELZICOL CPDR (Use mesalamine) NF

DIPENTUM CAPS 2


74

Drug Name DrugTier

RequirementsLimits

INFLECTRA SOLR 4 PA 30 rtl lmt day(s)30 maillmt day(s)

LIALDA TBEC (Use mesalamine) NF

mesalamine cp24 or 0375 gm 1

mesalamine cpdr or 400 mg 1

mesalamine enem re 4 gm 1

mesalamine supp re 1000 mg 1

mesalamine tbec or 12 gm 1

mesalamine tbec or 800 mg 1 QL(6 ea daily)

RENFLEXIS SOLR 4 PA 30 rtl lmt day(s)30 maillmt day(s)

STELARA SOLN IV 130 MG26ML 4 PA

sulfasalazine tabs 1

sulfasalazine tbec 1

Intestinal Acidifiers lactulose (encephalopathy)soln 1

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs 1 QL(2 ea daily)

LINZESS CAPS 2 PA QL(1 eadaily)

LOTRONEX TABS (Use alosetron hcl) NF QL(2 ea daily)

Peripheral Opioid Receptor Antagonists

alvimopan caps 1

ENTEREG CAPS (Use alvimopan) 3

RELISTOR SOLN SC 12 MG06ML 8 MG04ML 3 PA

Phosphate Binder Agents calcium acetate (phosphatebinder) caps 1

Drug Name DrugTier

RequirementsLimits

calcium acetate (phosphatebinder) tabs 1 RXOTC

FOSRENOL CHEW 1000 MG 500 MG 750 MG (Use lanthanum carbonate)

NF

lanthanum carbonate chew 1

PHOSLYRA SOLN 2

RENVELA PACK (Use sevelamer carbonate) NF

RENVELA TABS (Use sevelamer carbonate) NF

sevelamer carbonate pack 1

sevelamer carbonate tabs 1

VELPHORO CHEW 3 PA

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System

Alkalinizers potassium citrate(alkalinizer) tbcr 10 meq1080 mg

1

sodium citrate amp citric acid soln 1 RXOTC

UROCIT-K 10 TBCR (Use potassium citrate(alkalinizer))

NF

Cystinosis Agents

CYSTAGON CAPS 3 PA

Genitourinary Irrigants

acetic acid soln 1

glycine (gu irrigant) soln 1

RESECTISOL SOLN 1

sodium chloride (guirrigant) soln 1

SORBITOL SOLN 1

SORBITOL-MANNITOL SOLN 1


75

Drug Name DrugTier

RequirementsLimits

SORBITOLMANNITOLIRRIGATION SOLN 1

Interstitial Cystitis Agents

ELMIRON CAPS 2

Prostatic Hypertrophy Agents

alfuzosin hcl tb24 1 QL(1 ea daily)

AVODART CAPS (Use dutasteride) NF QL(1 ea daily)

dutasteride caps 1 QL(1 ea daily)

finasteride tabs 1 5 mg only

FLOMAX CAPS (Use tamsulosin hcl) NF

PROSCAR TABS (Use finasteride) NF 5 mg only

RAPAFLO CAPS (Use silodosin) NF

silodosin caps 8 mg 4 mg 1

tamsulosin hcl caps 1

UROXATRAL TB24 (Use alfuzosin hcl) NF QL(1 ea daily)

Urinary Analgesics

phenazopyridine hcl tabs 1

PYRIDIUM TABS (Use phenazopyridine hcl) NF

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w probenecidtabs 1

Gout Agents

allopurinol tabs 1

colchicine tabs 1 QL(1 ea daily)

COLCRYS TABS (Use colchicine) NF QL(1 ea daily)

febuxostat tabs 1 PA QL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

KRYSTEXXA SOLN 4 PA

MITIGARE CAPS (Use colchicine) NF

ULORIC TABS (Use febuxostat) NF PA QL(1 ea

daily) ZYLOPRIM TABS (Use allopurinol) NF

Uricosurics

probenecid tabs 1

HEMATOLOGICAL AGENTS - MISC - Drugs toTreat Blood Disorders

Bradykinin B2 Receptor Antagonists FIRAZYR SOLN (Use icatibant acetate) NF PA QL(9 ml

daily)

icatibant acetate soln 4 PA QL(9 mldaily)

Complement Inhibitors

CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA

RUCONEST SOLR 4 PA QL(0143ea daily)

SOLIRIS SOLN 4 PA

Hemataologic - Tyrosine Kinase Inhibitors

TAVALISSE TABS 4 PA

Hematorheologic Agents

pentoxifylline tbcr 1 QL(3 ea daily)

Plasma Kallikrein Inhibitors

TAKHZYRO SOLN 4 PA

Platelet Aggregation Inhibitors AGGRENOX CP12 (Use aspirin-dipyridamole) NF PA QL(2 ea

daily) AGRYLIN CAPS (Use anagrelide hcl) NF

anagrelide hcl caps 1

aspirin-dipyridamole cp12 1 PA QL(2 eadaily)


76

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1

clopidogrel bisulfate tabs300 mg 1

clopidogrel bisulfate tabs75 mg 1 QL(1 ea daily)

dipyridamole tabs 1

EFFIENT TABS (Use prasugrel hcl) NF QL(1 ea daily)

PLAVIX TABS (Use clopidogrel bisulfate) NF QL(1 ea daily)

prasugrel hcl tabs 1 QL(1 ea daily)

REOPRO SOLN 3

ZONTIVITY TABS 3 PA

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Gaucher Disease

CERDELGA CAPS 4 PA QL(2 eadaily)

CEREZYME SOLR 4 PA SP

ELELYSO SOLR 4 PA SP

miglustat caps 4 PA QL(3 eadaily) SP

VPRIV SOLR 4 PA SP

ZAVESCA CAPS (Use miglustat) NF PA QL(3 ea

daily) SP

Agents for Sickle Cell Disease

DROXIA CAPS 3

OXBRYTA TABS 4 PA

Cobalamins cyanocobalamin soln ij1000 mcgml 1 QL(1 ml daily)

Folic AcidFolates

Drug Name DrugTier

RequirementsLimits

folic acid tabs or 1 mg 0 RXOTC

folic acid tabs or 800 mcg400 mcg 0

Hematopoietic Growth Factors ARANESP ALBUMIN FREE SOLN 100 MCGML40 MCGML 60 MCGML

4 PA SP

ARANESP ALBUMIN FREE SOLN 25 MCGML 4 SP

ARANESP ALBUMIN FREE SOSY 150 MCG03ML 200MCG04ML 300MCG06ML 500 MCGML

4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA

LEUKINE SOLR 4 PA SP

MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA

NEULASTA ONPRO KIT PSKT 4 PA SP

NEULASTA SOSY 4 PA SP

NEUPOGEN SOLN 4 PA SP

NEUPOGEN SOSY 4 PA SP

NIVESTYM SOSY 300 MCG05ML 480MCG08ML

4 PA

NPLATE SOLR 250 MCG 500 MCG 4 PA SP

PROCRIT SOLN 10000 UNITML 2000 UNITML20000 UNITML 3000UNITML 4000 UNITML

3

PA SP

PROCRIT SOLN 40000 UNITML 4 PA SP

PROMACTA PACK 125 MG 4 PA QL(1 ea

daily)


77

Drug Name DrugTier

RequirementsLimits

PROMACTA TABS 125 MG 25 MG 50 MG 75 MG 4 PA SP

RETACRIT SOLN 10000 UNITML 2000 UNITML20000 UNIT2ML 3000UNITML 4000 UNITML40000 UNITML

4

PA

UDENYCA SOSY 4 PA

ZARXIO SOSY 4 PA 30 rtl lmt day(s)30 maillmt day(s)

ZIEXTENZO SOSY 4 PA

Hematopoietic Mixtures ferrous fumarate-folic acid tabs 1 QL(1 ea daily)

Iron FER-IN-SOL SOLN (Use ferrous sulfate) 0 AL(Up to 1 yrs

old ) ferrous sulfate soln or 15 mgml 0 AL(Up to 1 yrs

old ) ferrous sulfate tabs or 325 mg 65 mg 0

ferrous sulfate tbec or 325 mg 0

Stem Cell Mobilizers

MOZOBIL SOLN 4 PA SP

HEMOSTATICS - Drugs to Stop BleedingTreatBlood Disorders

Hemostatics - Systemic AMICAR TABS 1000 MG 500 MG (Use aminocaproic acid)

NF PA

aminocaproic acid tabs or1000 mg 500 mg 1 PA

CYKLOKAPRON SOLN (Use tranexamic acid) NF

LYSTEDA TABS (Use tranexamic acid) NF

tranexamic acid soln 1

tranexamic acid tabs 1

Drug Name DrugTier

RequirementsLimits

HYPNOTICSSEDATIVESSLEEP DISORDERAGENTS

Barbiturate Hypnotics phenobarbital elix 20mg5ml 1

phenobarbital soln 20mg5ml 1

phenobarbital tabs 100 mg648 mg 972 mg 15 mg162 mg 30 mg 324 mg

1

Hypnotics - Tricyclic Agents

doxepin hcl (sleep) tabs 1 PA QL(1 eadaily)

SILENOR TABS (Use doxepin hcl (sleep)) NF PA QL(1 ea

daily) Non-Barbiturate Hypnotics

AMBIEN CR TBCR (Use zolpidem tartrate) NF

ST Must tryimmediate release zolpidemQL(1ea daily)

AMBIEN TABS (Use zolpidem tartrate) NF


DORAL TABS (Use quazepam) NF

estazolam tabs 1

eszopiclone tabs 1

ST QL(1 eadaily) AL(Atleast 18 yrsold)

HALCION TABS (Use triazolam) NF

LUNESTA TABS (Use eszopiclone) NF


RESTORIL CAPS (Use temazepam) NF QL(1 ea daily)

temazepam caps 1 QL(1 ea daily)

triazolam tabs 1


78

Drug Name DrugTier

RequirementsLimits

zaleplon caps 10 mg 1 QL(2 ea daily)AL(At least 18yrs old)


zolpidem tartrate tabs or 10mg 5 mg 1


zolpidem tartrate tbcr or625 mg 125 mg 1


Orexin Receptor Antagonists

BELSOMRA TABS 3 PA

Selective Melatonin Receptor Agonists

HETLIOZ CAPS 3 PA QL(1 eadaily)

ramelteon tabs 1


ROZEREM TABS (Use ramelteon) NF


LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs 1

FIBERCON TABS (Use calcium polycarbophil) NF

Laxative Combinations

CLENPIQ SOLN 3 PA

COLYTE-FLAVOR PACKS SOLR (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

NF

GOLYTELY SOLR 297 GM-586 GM-674 GM-2274 GM-236 GM (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

0

Drug Name DrugTier

RequirementsLimits

MOVIPREP SOLR (Use peg 3350-kcl-nacl-nasulfate-na ascorbate-ascorbic acid)

2

PA

peg 3350-kcl-nacl-nasulfate-na ascorbate-ascorbic acid solr

1 PA

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr 297 gm-586 gm-674gm-2274 gm-236 gm

0

PREPOPIK PACK 3 PA

SUPREP BOWEL PREP KIT SOLN 0

Laxatives - Miscellaneous lactulose soln 10 gm15ml20 gm30ml 1

Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1

DULCOLAX TBEC (Use bisacodyl) NF

Surfactant Laxatives COLACE CAPS (Use docusate sodium) NF

docusate calcium caps 1

docusate sodium caps 1

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing

Local Anesthetics - Amides lidocaine hcl (local anesth)soln 05 1 2 1

MARCAINE SOLN 05 (Use bupivacaine hcl) NF

NAROPIN SOLN 5 MGML2 MGML (Use ropivacaine hcl)

NF

XYLOCAINE SOLN 05 1 (Use lidocaine hcl (local anesth))

NF


79

Drug Name DrugTier

RequirementsLimits

XYLOCAINE-MPF SOLN 05 1 2 (Use lidocaine hcl (localanesth))

NF

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin

azithromycin pack or 1 gm 1

azithromycin solr iv 500 mg 1

azithromycin susr or 100mg5ml 200 mg5ml 1

azithromycin tabs or 250 mg 1

QL(6 ea per fillretail6 ea perfill mail)



azithromycin tabs or 600 mg 1 QL(0286 ea

daily) ZITHROMAX PACK OR 1 GM (Use azithromycin) 1

ZITHROMAX SOLR IV 500 MG (Use azithromycin) NF

ZITHROMAX SUSR OR 100 MG5ML 200 MG5ML(Use azithromycin)

NF

ZITHROMAX TABS OR 250 MG (Use azithromycin) NF




ZITHROMAX TABS OR 600 MG (Use azithromycin) NF QL(0286 ea

daily)

ZITHROMAX TRI-PAK TABS (Use azithromycin) NF


ZITHROMAX Z-PAK TABS (Use azithromycin) NF


Clarithromycin

clarithromycin susr 1

clarithromycin tabs 1

Drug Name DrugTier

RequirementsLimits

clarithromycin tb24 1

Erythromycins EES GRANULES SUSR (Use erythromycinethylsuccinate)

NF

ERYPED 200 SUSR (Use erythromycinethylsuccinate)

NF


3

erythromycin base cpep250 mg 3

erythromycin base tabs 250mg 500 mg 3

erythromycin base tbec 250mg 333 mg 500 mg 1

erythromycinethylsuccinate susr 200mg5ml 400 mg5ml

1

erythromycinethylsuccinate tabs 400 mg 3

Fidaxomicin

DIFICID TABS 200 MG 2

MEDICAL DEVICES AND SUPPLIES

Contraceptives AIMSCO LUBRICATED MISC 0 QL(2 ea daily)

CAYA DPRH 0

DUREX EXTRA SENSITIVE DEVI 0 QL(2 ea daily)

FANTASY LUBRICATED MISC 0 QL(2 ea daily)

FANTASY LUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

FC FEMALE CONDOM MISC 0 QL(1 ea daily)

FEMCAP DEVI 0

K-Y ME amp YOU EXTRA LUBRICATED DEVI 0 QL(2 ea daily)


80

Drug Name DrugTier

RequirementsLimits

K-Y ME amp YOU INTENSE DEVI 0 QL(2 ea daily)

KAMELEON LUBRICATED MISC 0 QL(2 ea daily)

KIMONO COLORS DEVI 0 QL(2 ea daily)

KIMONO LUBRICATED MISC 0 QL(2 ea daily)

KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO PLUS SPERMICIDELUBRICATED MISC

0 QL(2 ea daily)

KIMONO PS LUBRICATED MISC 0 QL(2 ea daily)

KIMONO PS PLUS SPERMICIDELUBRICATED MISC

0 QL(2 ea daily)

KIMONO SENSATION LUBRICATED MISC 0 QL(2 ea daily)

KIMONO SENSATION PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO SPECIAL DEVI 0 QL(2 ea daily)

MAXX LUBRICATED MISC 0 QL(2 ea daily)

MAXX PLUS SPERMICIDE LUBRICATED MISC 0 QL(2 ea daily)

OMNIFLEX DIAPHRAGM DPRH 0

PREMIUM CONDOMS LUBRICATED MISC 0 QL(2 ea daily)

REALITY LATEX CONDOMSLUBRICATEDMISC

0 QL(2 ea daily)

REALITY LATEXULTRATEXTURED DEVI 0 QL(2 ea daily)

REALITY LATEXULTRATHIN DEVI 0 QL(2 ea daily)

TRUSTEX COLOR CONDOMS + LUBE MISC 0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

TRUSTEX LUBRICATED EXTRALARGE MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED EXTRASTRENGTH MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATEDRIBBEDSTUDDED MISC

0 QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE EXTRA LARGE MISC

0 QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE EXTRA STRENGTH MISC

0

QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

TRUSTEX NATURAL CONDOMS +LUBELUBRICATEDMISC

0

QL(2 ea daily)

TRUSTEX WITH NONOXYNOL-9RIBBEDSTUDDEDMISC

0

QL(2 ea daily)

TRUSTEXRIALUBRICATED MISC 0 QL(2 ea daily)

TRUSTEXRIALUBRICATED SPERMICIDE MISC

0 QL(2 ea daily)

TRUSTEXRIALUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

WIDE-SEAL SILICONE DIAPHRAGM KIT 60 DPRH

0


0


0


0


81

Drug Name DrugTier

RequirementsLimits


0


0


0


0

Diabetic Supplies 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

1 QL(66667 eadaily)

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC

1 QL(66667 eadaily)

ACCU-CHEK FASTCLIX LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK MULTICLIX LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SAFE-T-PRO LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SAFE-T-PRO PLUSLANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SOFTCLIX LANCETS MISC 1 QL(66667 ea

daily) ACTI-LANCE LANCETS 28G MISC 1 QL(66667 ea

daily) ACTI-LANCE LITE SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

ACTI-LANCE SPECIAL SAFETY LANCETS 17G MISC

1 QL(66667 eadaily)

ACTI-LANCE SPECIAL SAFETYLANCETS 17G MISC

1 QL(66667 eadaily)

ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G MISC

1 QL(66667 eadaily)

ADJUSTABLE LANCING DEVICE MISC 1

ADVANCED MOBILE LANCET 30G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

ADVOCATE LANCETS 30G MISC 1 QL(66667 ea

daily) ADVOCATE LANCETS MISC 1 QL(66667 ea

daily) ADVOCATE LANCING DEVICE MISC 1

ADVOCATE RAPID-SAFE LANCING DEVICE MISC 1

ADVOCATE SAFETY LANCETS 26G MISC 1 QL(66667 ea

daily) ADVOCATE SAFETY LANCETS MISC 1 QL(66667 ea

daily) AGAMATRIX ULTRA-THIN LANCETS 33G MISC 1 QL(66667 ea

daily) AIMSCO TWIST LANCETS 32G MISC 1 QL(66667 ea


daily) ALTERNATE SITE LANCING DEVICE MISC 1

AQUA LANCE ADJUSTABLE LANCING DEVICE DEVI

1

ASSURE HAEMOLANCE PLUS HIGH FLOW 18G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS LOW FLOW 25G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS MICRO FLOW 28G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE MISC

1 QL(66667 eadaily)

ASSURE LANCE LANCETS 21G MISC 1 QL(66667 ea

daily) ASSURE LANCE LANCETS MISC 1 QL(66667 ea

daily) ASSURE LANCE PLUS SAFETYLANCETS 25G MISC

1 QL(66667 eadaily)


82

Drug Name DrugTier

RequirementsLimits

ASSURE LANCE PLUS SAFETYLANCETS 30G MISC

1 QL(66667 eadaily)

ASSURE LANCE SAFETY LANCET 28G MISC 1 QL(66667 ea

daily)

ASSURE LANCETS MISC 1 QL(66667 eadaily)

AURORA LANCET SUPER THIN30G MISC 1 QL(66667 ea

daily) AURORA LANCET THIN 23G MISC 1 QL(66667 ea

daily)

AUTO-LANCET MINI MISC 1

AUTO-LANCET MISC 1

AUTOLET IMPRESSION LANCING DEVICE MISC 1

AUTOLET LANCING DEVICE MISC 1

AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1

BD LANCET ULTRAFINE 30G MISC 1 QL(66667 ea

daily) BD LANCET ULTRAFINE 33G MISC 1 QL(66667 ea

daily) BD MICROTAINER LANCETS MISC 1 QL(66667 ea

daily) BULLSEYE MINI SAFETY LANCETS MISC 1 QL(66667 ea

daily) BULLSEYE SAFETY LANCETS MISC 1 QL(66667 ea

daily) CARDIOCOM LANCING DEVICE MISC 1

CAREONE ADVANCED LANCINGDEVICE MISC 1

CAREONE LANCET SUPER THIN30G MISC 1 QL(66667 ea

daily) CAREONE LANCET THIN MISC 1 QL(66667 ea

daily) CARESENS LANCETS MISC 1 QL(66667 ea

daily) CARETOUCH LANCING DEVICEWITH EJECTOR MISC

1

Drug Name DrugTier

RequirementsLimits

CARETOUCH SAFETY LANCETS26G MISC 1 QL(66667 ea

daily) CARETOUCH SAFETY LANCETS28G MISC 1 QL(66667 ea


daily) CARETOUCH TWIST LANCETS 28G MISC 1 QL(66667 ea



daily) CLEANLET LANCETS 28G MISC 1 QL(66667 ea

daily) COAGUCHEK LANCETS MISC 1 QL(66667 ea

daily) COMFORT ASSURED LANCETS MICRO THIN 33G MISC

1 QL(66667 eadaily)

COMFORT ASSURED LANCETS SUPER THIN 28G MISC

1 QL(66667 eadaily)

COMFORT LANCETS MISC 1 QL(66667 ea

daily)

CVS LANCETS 21G MISC 1 QL(66667 eadaily)

CVS LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) CVS LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) CVS LANCETS ORIGINAL MISC 1 QL(66667 ea

daily) CVS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) CVS LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) CVS LANCETS ULTRA-THIN 30G MISC 1 QL(66667 ea

daily) CVS LANCING DEVICE MISC 1

CVS ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily) DIATHRIVE LANCETS MISC 1 QL(66667 ea

daily) DIATHRIVE LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily)


83

Drug Name DrugTier

RequirementsLimits

DIATHRIVE LANCING DEVICE MISC 1

DROPLET GENTEEL LANCING DEVICE MISC 1

DROPLET LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) DROPLET LANCING DEVICE MISC 1

DROPLET PERSONAL LANCETS30G MISC 1 QL(66667 ea

daily) DRUG MART ADJUSTABLE LANCING DEVICE MISC

1

DRUG MART LANCETS THIN MISC 1 QL(66667 ea

daily) DRUG MART ON-THE-GO LANCETS GENTLE 30G MISC

1 QL(66667 eadaily)

DRUG MART UNILET LANCETSSUPER THIN 30G MISC

1 QL(66667 eadaily)

DRUG MART UNILET LANCETSULTRA THIN 28G MISC

1 QL(66667 eadaily)

DRUG MART UNILET MICRO THIN LANCETS 33G MISC

1 QL(66667 eadaily)

E-Z JECT LANCETS 21G MISC 1 QL(66667 ea

daily) E-Z JECT LANCETS COLOR MISC 1 QL(66667 ea

daily)

E-Z JECT LANCETS MISC 1 QL(66667 eadaily)

E-Z JECT LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) E-Z JECT LANCETS THIN 26G MISC 1 QL(66667 ea

daily) E-ZJECT LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) EASY MINI EJECT LANCING DEVICE MISC 1

EASY MINI LANCING DEVICE MISC 1

EASY TOUCH LANCETS 21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)

EASY TOUCH LANCETS 26GPULL-TOP MISC 1 QL(66667 ea

daily) EASY TOUCH LANCETS 28GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)


daily) EASY TOUCH LANCETS 28GTWIST MISC 1 QL(66667 ea

daily) EASY TOUCH LANCETS 30GBUTTON-ACTIVATEDMISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)




daily) EASY TOUCH LANCING DEVICEEJECTOR MISC 1

EASY TOUCH SAFETY LANCETS21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)

EASY TOUCH SAFETY LANCETS26GBUTTONACTIVATED MISC

1 QL(66667 eadaily)


84

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)

EASY TWIST amp CAP LANCETS MISC 1 QL(66667 ea

daily) EMBRACE LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) EMBRACE LANCING DEVICE WITH EJECTOR MISC

1

EQL COLOR LANCETS 21G MISC 1 QL(66667 ea

daily) EQL COLOR LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) EQL SUPER THIN LANCETS 30G MISC 1 QL(66667 ea

daily) EQL THIN LANCETS 26G MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 21G MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 26G SUPER-SOFT MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 28G ULTRA-SOFT MISC 1 QL(66667 ea


daily) FIFTY50 SAFETY SEAL LANCETS 30G MISC 1 QL(66667 ea


daily) FIFTY50 UNILET LANCETS 33G MISC 1 QL(66667 ea

daily)

FINE 30 MISC 1 QL(66667 eadaily)

FINGERSTIX LANCETS MISC 1 QL(66667 ea

daily)

FORA LANCETS MISC 1 QL(66667 eadaily)

FORA LANCING DEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

FORA LANCING DEVICECLEARCAP MISC 1

FREDS PHARMACY AUTOLET LANCING DEVICE MISC

1

FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

FREESTYLE LANCETS MISC 1 QL(66667 ea

daily) FREESTYLE UNISTICK II LANCETS MISC 1 QL(66667 ea

daily) GENTEEL BUTTERFLY TOUCH LANCETS MISC 1 QL(66667 ea

daily) GENTEEL LANCING DEVICEGLORIOUSGOLD MISC

1

GENTEEL LANCING DEVICEPRECIOUSPLATINUM MISC

1

GENTEEL LANCING DEVICESTATELY SILVERMISC

1

GENTEEL PLUS LANCING DEVICEBUFF BLACKMISC

1

GENTEEL PLUS LANCING DEVICEBUTTERFLYBLUE MISC

1

GENTEEL PLUS LANCING DEVICEPLAYFULPURPLE MISC

1

GENTEEL PLUS LANCING DEVICEPRINCESS PINKMISC

1

GENTEEL PLUS LANCING DEVICEWILLOWY WHITEMISC

1

GENTLE-LET GP LANCETS MISC 1 QL(66667 ea

daily) GENTLE-LET LANCETS GENERAL PURPOSE STYLEFINE POINT MISC

1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits

GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINTMISC

1

QL(66667 eadaily)

GENTLE-LET LANCETS SAFETY STYLEFINEPOINT MISC

1 QL(66667 eadaily)

GENTLE-LET LANCETS SAFETY STYLEMEDIUMPOINT MISC

1 QL(66667 eadaily)

GLOBAL LANCING DEVICE MISC 1

GLUCOCOM LANCETS 28G MISC 1 QL(66667 ea

daily) GLUCOCOM LANCETS 30G MISC 1 QL(66667 ea


daily)

GNP LANCETS 21G MISC 1 QL(66667 eadaily)

GNP LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) GNP LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) GNP LANCETS THIN 26G MISC 1 QL(66667 ea

daily) GNP LANCETS THIN MISC 1 QL(66667 ea

daily) GOJJI LANCING DEVICECLEAR CAPMISC

1

GOJJI STERILE LANCETS 30G MISC 1 QL(66667 ea

daily) GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS ULTRA-THIN 30G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)

GOODSENSE LANCING DEVICE MISC 1

H-E-B INCONTROL ADVANCEDLANCING DEVICE MISC

1

H-E-B INCONTROL LANCETS MICRO THIN 33G MISC

1 QL(66667 eadaily)

H-E-B INCONTROL LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

HAEMOLANCE LOW FLOW LANCETS MISC 1 QL(66667 ea

daily)

HAEMOLANCE MISC 1 QL(66667 eadaily)

HAEMOLANCE PLUS HIGH FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS LOW FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS MAX FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS PEDIATRIC FLOW MISC 1 QL(66667 ea

daily) HEALTH CARE LANCING DEVICE MISC 1

HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MISC

1

HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

HY-VEE LANCETS MISC 1 QL(66667 eadaily)

HY-VEE THIN LANCETS MISC 1 QL(66667 ea

daily) IN TOUCH LANCING DEVICE MISC 1

IN TOUCH STERILE LANCETS30G MISC 1 QL(66667 ea

daily)


86

Drug Name DrugTier

RequirementsLimits

KINNEY LANCETS MISC 1 QL(66667 eadaily)

KINNEY THIN LANCETS MISC 1 QL(66667 ea

daily) KROGER AUTOLET LANCING DEVICE MISC 1

KROGER HEALTHPRO TWIST LANCETS26GMISC

1 QL(66667 eadaily)

KROGER LANCETS 21G MISC 1 QL(66667 ea

daily) KROGER LANCETS MICRO THIN33G MISC 1 QL(66667 ea

daily)

KROGER LANCETS MISC 1 QL(66667 eadaily)

KROGER LANCETS SUPER THIN MISC 1 QL(66667 ea

daily) KROGER LANCETS THIN 26G MISC 1 QL(66667 ea

daily) KROGER LANCETS THIN MISC 1 QL(66667 ea

daily) KROGER LANCETS ULTRATHIN30G MISC 1 QL(66667 ea

daily) KROGER LANCING DEVICE MISC 1

LANCET DEVICE ADJUSTABLE MISC 1

LANCET DEVICE WITH EJECTOR MISC 1

LANCETS 26G TWIST TOP MISC 1 QL(66667 ea

daily)

LANCETS 30G MISC 1 QL(66667 eadaily)


daily) LANCETS 30GTWISTTOP MISC 1 QL(66667 ea

daily) LANCETS 31G TWIST TOP MISC 1 QL(66667 ea

daily) LANCETS 33G EXTRA FINE MISC 1 QL(66667 ea

daily) LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily)

LANCETS MISC 1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

LANCETS SAFETY SEAL 21G MISC 1 QL(66667 ea

daily) LANCETS SAFETY SEAL 26G MISC 1 QL(66667 ea



daily) LANCETS SUPER THIN 28G MISC 1 QL(66667 ea

daily)

LANCETS THIN MISC 1 QL(66667 eadaily)

LANCETS TWIST TOP MISC 1 QL(66667 ea

daily) LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) LANCETSBULLSEYE SAFETY MISC 1 QL(66667 ea

daily) LANCING DEVICE ADJUSTABLE MISC 1

LANCING DEVICE MISC 1

LANZO MISC 1

LEADER ADVANCED LANCING DEVICE MISC 1

LIBERTY MEDICAL LANCETS 30G MISC 1 QL(66667 ea

daily) LIBERTY MINI LANCING DEVICE MISC 1

LIFESCAN UNISTIK 2 DEEP PENETRATION MISC

1 QL(66667 eadaily)

LIFESCAN UNISTIK II LANCETS MISC 1 QL(66667 ea

daily) LITE TOUCH LANCETS MISC 1 QL(66667 ea

daily) LITE TOUCH LANCING PEN MISC 1

LITETOUCH LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) LIVE BETTER ADVANCED LANCING DEVICE MISC 1


87

Drug Name DrugTier

RequirementsLimits

LIVE BETTER LANCET SUPERTHIN 30G MISC 1 QL(66667 ea

daily) LIVE BETTER LANCET ULTRATHIN 28G MISC 1 QL(66667 ea

daily) LONGS LANCETS STANDARD MISC 1 QL(66667 ea

daily) LONGS LANCETS THIN MISC 1 QL(66667 ea

daily) LONGS LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) MEDICHOICE PRE-SET SAFETY LANCET DUAL USE MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE SAFETY LANCETEXTRA MISC 1 QL(66667 ea

daily) MEDICHOICE SAFETY LANCETNORMAL MISC 1 QL(66667 ea

daily) MEDISENSE THIN LANCETS MISC 1 QL(66667 ea

daily) MEDLANCE PLUS EXTRA LANCETS 21G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS LANCETS LITE 25G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS LANCETS MISC 1 QL(66667 ea

daily) MEDLANCE PLUS LITE LANCETS 25G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS SPECIAL LANCETS 08MM MISC

1 QL(66667 eadaily)

MEDLANCE PLUS SUPERLITE 30G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS SUPERLITE 30GCOMFORT MAXMISC

1

QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

MEDLANCE PLUS UNIVERSAL LANCETS 21G MISC

1 QL(66667 eadaily)

MEDLANCE PLUSLITE25G MISC 1 QL(66667 ea

daily)

MEDLANCEEXTRA MISC 1 QL(66667 eadaily)

MEDLANCELITE MISC 1 QL(66667 eadaily)

MEDLANCEUNIVERSALMISC 1 QL(66667 ea

daily) MEIJER COLOR LANCETS UNIVERSAL 33G MISC

1 QL(66667 eadaily)

MEIJER LANCETS MISC 1 QL(66667 eadaily)

MEIJER LANCETS THIN MISC 1 QL(66667 ea

daily) MEIJER LANCETS UNIVERSAL21G MISC 1 QL(66667 ea



daily) MEIJER SUPER THIN LANCETS MISC 1 QL(66667 ea

daily) MICROLET LANCETS MISC 1 QL(66667 ea

daily)

MICROLET NEXT MISC 1

MINI LANCING DEVICE MISC 1

MM LANCING DEVICE MISC 1

MM TWIST LANCETS MISC 1 QL(66667 ea

daily) MONOLET LANCETS MISC 1 QL(66667 ea

daily) MONOLET OPD LANCETS MISC 1 QL(66667 ea

daily) MONOLETTOR SAFETY LANCETS MISC 1 QL(66667 ea

daily) MPD SAFETY LANCET 21G18MM MISC 1 QL(66667 ea


daily)


88

Drug Name DrugTier

RequirementsLimits

MPD SAFETY LANCET 30G18MM MISC 1 QL(66667 ea

daily) MPD SAFETY LANCETS 23G18MM MISC 1 QL(66667 ea

daily) MULTI-LANCET DEVICE MISC 1

MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G MISC

1 QL(66667 eadaily)

NOVA SAFETY LANCETS 23G MISC 1 QL(66667 ea

daily) NOVA SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) NOVA SUREFLEX LANCETS MISC 1 QL(66667 ea

daily) NOVA SUREFLEX LANCING DEVICE MISC 1

ON CALL LANCING DEVICE MISC 1

ON CALL PLUS LANCING DEVICE MISC 1

ONETOUCH CLUB LANCETS FINE POINT MISC

1 QL(66667 eadaily)

ONETOUCH DELICA LANCETS EXTRA FINE 33G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA LANCETS FINE 30G MISC 1 QL(66667 ea

daily) ONETOUCH DELICA LANCING DEVICE MISC 1

ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA PLUS LANCETS FINE 30G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA PLUS LANCING DEVICE MISC

1

ONETOUCH FINEPOINT LANCETS MISC 1 QL(66667 ea

daily) ONETOUCH ULTRASOFT LANCETS MISC 1 QL(66667 ea

daily) PC LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

PERFECT LANCETS 30G MISC 1 QL(66667 ea

daily) PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

PHARMACY COUNTER LANCETS MISC 1 QL(66667 ea

daily)

PIP LANCETS28G MISC 1 QL(66667 eadaily)


PRECISION THINS GP LANCET MISC 1 QL(66667 ea

daily) PREFERRED PLUS LANCETS COLORED 21G MISC

1 QL(66667 eadaily)

PREFERRED PLUS LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

PREFERRED PLUS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) PRESSURE ACTIVATED SAFETYLANCET 21G MISC

1 QL(66667 eadaily)

PRODIGY LANCING DEVICE MISC 1

PRODIGY PRESSURE ACTIVATED SAFETY LANCETS MISC

1 QL(66667 eadaily)

PRODIGY SAFETY LANCETS MISC 1 QL(66667 ea

daily) PRODIGY TWIST TOP LANCETS MISC 1 QL(66667 ea

daily) PSS SELECT GP LANCETS MISC 1 QL(66667 ea

daily) PSS SELECT SAFETY LANCETS MISC 1 QL(66667 ea

daily) PUSH BUTTON SAFETY LANCETS 21G MISC 1 QL(66667 ea


daily) PX ADVANCED LANCING DEVICE MISC 1

PX LANCET AUTO INJECTOR MISC 1


89

Drug Name DrugTier

RequirementsLimits

PX LANCETS ULTRA THIN 28G MISC 1 QL(66667 ea

daily) PX LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) QC ADVANCED LANCING DEVICE MISC 1

QC LANCETS SUPER THIN MISC 1 QL(66667 ea

daily) QC LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) QC UNILET LANCETS 28GULTRA THIN MISC 1 QL(66667 ea

daily) QC UNILET LANCETS 33GMICRO THIN MISC 1 QL(66667 ea

daily) RA E-ZJECT LANCETS 28G MISC 1 QL(66667 ea

daily) RA E-ZJECT LANCETS THIN 26G MISC 1 QL(66667 ea


daily) RA E-ZJECT LANCETS ULTRATHIN 30G MISC 1 QL(66667 ea

daily) READYLANCE SAFETY LANCETS21G22MMMISC

1 QL(66667 eadaily)

READYLANCE SAFETY LANCETS23G18MMMISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)

REALITY LANCETS MISC 1 QL(66667 eadaily)

REALITY TRIGGER LANCETS MISC 1 QL(66667 ea

daily) RELION 2-IN-1 LANCET DEVICES 30G MISC 1

RELION 2-IN-1 LANCING DEVICE 25G MISC 1

Drug Name DrugTier

RequirementsLimits


RELION LANCETS MICRO-THIN33G MISC 1 QL(66667 ea

daily) RELION LANCETS THIN 26G MISC 1 QL(66667 ea

daily) RELION LANCETS ULTRA-THIN30G MISC 1 QL(66667 ea

daily) RELION LANCING DEVICE MISC 1

RELION ULTRA THIN LANCETS30G MISC 1 QL(66667 ea

daily) RELION ULTRA THIN LANCETS30G MISC 1 QL(66667 ea

daily) RELION ULTRA THIN PLUS LANCETS 32G MISC

1 QL(66667 eadaily)

RELION ULTRA THIN PLUS LANCETS 33G MISC

1 QL(66667 eadaily)

REXALL LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) RIGHTEST GD500 LANCING DEVICE MISC 1

RIGHTEST GL300 LANCETS MISC 1 QL(66667 ea

daily) SAFE-T-LANCE LOW FLOW 25G MISC 1 QL(66667 ea

daily) SAFE-T-LANCE NORMAL FLOW21G MISC 1 QL(66667 ea

daily) SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW MISC

1 QL(66667 eadaily)

SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW MISC

1 QL(66667 eadaily)

SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW MISC

1 QL(66667 eadaily)

SAFETY LANCET 21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)


90

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)

SAFETY LANCETS 21G MISC 1 QL(66667 ea

daily) SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) SAFETY LET LANCETS MISC 1 QL(66667 ea

daily)

SB LANCETS THIN MISC 1 QL(66667 eadaily)

SB LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) SELECT-LITE LANCING DEVICE MISC 1

SHOPKO AUTOLET LANCING DEVICE MISC 1

SHOPKO ON-THE-GO COMFORTLANCETS 30G MISC

1 QL(66667 eadaily)

SHOPKO UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

SHOPKO UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

SIDE BUTTON SAFETY LANCET21G MISC 1 QL(66667 ea

daily) SIMPLE DIAGNOSTICS LANCING DEVICE MISC 1

SINGLE-LET MISC 1 QL(66667 eadaily)

SM MICRO THIN LANCETS 33G MISC 1 QL(66667 ea

daily) SM TRUEDRAW LANCING DEVICE MISC 1

SMART DIABETES VANTAGE LANCING DEVICE MISC

1

SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC

1 QL(66667 eadaily)

SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC

1 QL(66667 eadaily)

SMART SENSE THIN LANCETSUNIVERSAL 26G MISC

1 QL(66667 eadaily)

SMARTEST LANCETS 28G MISC 1 QL(66667 ea

daily) SOLUS V2 LANCING DEVICE MISC 1

SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

SOLUS V2 TWIST LANCETS 30G MISC 1 QL(66667 ea

daily)

STERILANCE TL MISC 1 QL(66667 eadaily)

SUPER THIN LANCETS MISC 1 QL(66667 ea

daily) SURE COMFORT LANCETS 18G MISC 1 QL(66667 ea





daily) SURE COMFORT LANCING PEN MISC 1

SURE-LANCE FLAT LANCETS MISC 1 QL(66667 ea

daily) SURE-LANCE LANCETS 26G MISC 1 QL(66667 ea

daily) SURE-LANCE THIN LANCETS 28G MISC 1 QL(66667 ea

daily) SURE-LANCE ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily)

SURE-PEN MISC 1

SURE-TOUCH LANCETS UNIVERSAL MISC 1 QL(66667 ea

daily) SURELITE LANCETS MISC 1 QL(66667 ea

daily)


91

Drug Name DrugTier

RequirementsLimits

TECHLITE AST LANCETS MISC 1 QL(66667 ea

daily) TECHLITE LANCETS 30G MISC 1 QL(66667 ea

daily) TECHLITE LANCETS MISC 1 QL(66667 ea

daily) TGT LANCET MICRO THIN 33G MISC 1 QL(66667 ea

daily) TGT LANCET THIN 26G MISC 1 QL(66667 ea

daily) TGT LANCET ULTRA THIN 30G MISC 1 QL(66667 ea

daily) TGT LANCING DEVICE MISC 1

THINLETS GP LANCETS MISC 1 QL(66667 ea

daily) TODAYS HEALTH ADVANCED LANCING DEVICE MISC

1

TODAYS HEALTH SUPER THINLANCETS 30G MISC 1 QL(66667 ea

daily) TODAYS HEALTH ULTRA THINLANCETS 28G MISC 1 QL(66667 ea

daily) TOPCARE LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) TRAVEL LANCETS 30G MISC 1 QL(66667 ea

daily) TRAVEL LANCETS ADVANCED 28G MISC 1 QL(66667 ea

daily) TRUE METRIX CONTROL SOLUTION LEVEL 3 SOLN

1

TRUEDRAW LANCING DEVICE MISC 1

TRUEPLUS LANCETS 26G MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 28G MISC 1 QL(66667 ea


daily) TRUEPLUS LANCETS 28G SUPER THIN MISC 1 QL(66667 ea


daily) TRUEPLUS LANCETS 30G ULTRA THIN MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

TRUEPLUS LANCETS 33G MICRO THIN MISC 1 QL(66667 ea


daily) TRUEPLUS SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) ULTI-LANCE AUTOMATICCLEAR TIP MISC 1

ULTILET CLASSIC LANCETS MISC 1 QL(66667 ea

daily) ULTILET LANCETS 33G MISC 1 QL(66667 ea

daily)

ULTILET LANCETS MISC 1 QL(66667 eadaily)

ULTILET SAFETY LANCETS 21G X 22MM MISC

1 QL(66667 eadaily)

ULTILET SAFETY LANCETS 23G MISC 1 QL(66667 ea

daily) ULTRA THIN LANCETS 31G MISC 1 QL(66667 ea

daily) ULTRA-THIN II AUTO LANCET MISC 1 QL(66667 ea

daily) ULTRA-THIN II LANCETS 28G MISC 1 QL(66667 ea


daily) UNILET COMFORTOUCH LANCET MISC 1 QL(66667 ea

daily)

UNILET EXCELITE II MISC 1 QL(66667 eadaily)

UNILET EXCELITE MISC 1 QL(66667 eadaily)

UNILET GP LANCET MISC 1 QL(66667 ea

daily) UNILET GP SUPERLITE LANCET MISC 1 QL(66667 ea

daily) UNILET GP 28 ULTRA THIN MISC 1 QL(66667 ea

daily)

UNILET LANCET MISC 1 QL(66667 eadaily)

UNILET LANCETS MICRO-THIN33G MISC 1 QL(66667 ea

daily) UNILET LANCETS SUPER-THIN30G MISC 1 QL(66667 ea

daily)


92

Drug Name DrugTier

RequirementsLimits

UNILET LANCETS ULTRA-THIN 28G MISC 1 QL(66667 ea

daily) UNILET SUPERLITE LANCET MISC 1 QL(66667 ea

daily)

UNISTIK 3 GENTLE MISC 1 QL(66667 eadaily)

UNISTIK PRO SAFETY LANCET 21G MISC 1 QL(66667 ea

daily) UNISTIK PRO SAFETY LANCET 25G MISC 1 QL(66667 ea


daily) UNISTIK SAFETY LANCETS 28G MISC 1 QL(66667 ea


daily) UNISTIK TOUCH SAFETY LANCETS 21G MISC 1 QL(66667 ea




daily) UNIVERSAL 1 LANCETS THIN26G MISC 1 QL(66667 ea

daily) UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) UNIVERSAL 1 LANCETS33GMICRO-THIN MISC

1 QL(66667 eadaily)

VALUE PLUS LANCETS STANDARD 21G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCETS SUPERTHIN 30G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCING DEVICE MISC 1

VALUMARK LANCET SUPER THIN 30G MISC 1 QL(66667 ea

daily) VALUMARK LANCET ULTRA THIN 28G MISC 1 QL(66667 ea

daily) VIDA MIA AUTOLET LANCINGDEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

VIDA MIA UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

VIVAGUARD LANCETS MISC 1 QL(66667 ea

daily) VIVAGUARD LANCING DEVICE MISC 1

WALGREENS ADVANCED TRAVELLANCETS 28G MISC

1 QL(66667 eadaily)

WALGREENS COMFORT ASSUREDLANCETS MICRO THIN33G MISC

1 QL(66667 eadaily)

WALGREENS COMFORT ASSUREDLANCETS SUPER THIN28G MISC

1 QL(66667 eadaily)

WALGREENS LANCETS MISC 1 QL(66667 ea

daily) WALGREENS THIN LANCETS MISC 1 QL(66667 ea

daily) WALGREENS ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily) Parenteral Therapy Supplies ADVOCATE INSULIN SYRINGEU-10003ML29GX12 MISC

1 QL(5 ea daily)RXOTC

ADVOCATE INSULIN SYRINGEU-10003ML30GX516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ADVOCATE INSULIN SYRINGEU-10005ML29GX12 MISC



1

QL(5 ea daily)RXOTC


93

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)






1 QL(5 ea daily)

ASSURE ID INSULIN SAFETYSYRINGEU-10005ML29G X 12MISC

1

QL(5 ea daily)RXOTC

ASSURE ID INSULIN SAFETYSYRINGEU-1001ML29G X 12 MISC


B-D INSULIN SYRINGE ULTRAFINE II03ML31GX 516 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II1ML31G X516 MISC

1 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE03ML30G X12 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)

BD LO-DOSE INSULIN SYRINGE MICROFINE IV05ML28G X 12 MISC


BD AUTOSHIELD 29G X 316 MISC 1 QL(5 ea daily)


BD AUTOSHIELD DUO 30G X 5MM MISC 1 QL(5 ea daily)

BD INSULIN SYRINGE LUER-LOKU-1001MLMISC


Drug Name DrugTier

RequirementsLimits

BD INSULIN SYRINGE MICROFINE IVU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC

BD INSULIN SYRINGE MICROFINE IVU-1001ML27G X 58 MISC

1 QL(5 ea daily)



BD INSULIN SYRINGE MICROFINEU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC

BD INSULIN SYRINGE MICROFINEU-1001ML27G X 58 MISC

1 QL(5 ea daily)



BD INSULIN SYRINGE SAFETYGLIDE1ML29G X12 MISC


BD INSULIN SYRINGE SLIP TIPU-1001ML MISC 1 QL(5 ea daily)

RXOTC BD INSULIN SYRINGE ULTRA-FINE03ML30G X127MM MISC

1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE03ML31G X8MM MISC

1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE12UNIT03ML31G X 8MMMISC

1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits

BD INSULIN SYRINGE ULTRAFINE HALF-UNIT03ML31G X 516MISC

1

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE03ML30G X12 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

BD INSULIN SYRINGE ULTRAFINEU-1001ML29G X 12 MISC



1

QL(5 ea daily)

BD INSULIN SYRINGE03ML29G X127MM MISC








Drug Name DrugTier

RequirementsLimits

BD INSULIN SYRINGEDETACHABLENEEDLEU-1001ML25GX 1 MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

BD INSULIN SYRINGEU-1001ML27G X 12 MISC 1 QL(5 ea daily)

RXOTC BD PEN NEEDLEMICROULTRA-FINE32G X 6MM MISC

1 QL(5 ea daily)

BD PEN NEEDLEMINIULTRA-FINE31G X 5MM MISC


BD PEN NEEDLENANO2ND GEN32G X 532MISC


BD PEN NEEDLENANOULTRA-FINE32G X 4MM MISC


BD PEN NEEDLEORIGINALULTRA-FINE29G X 127MMMISC

1

QL(5 ea daily)

BD PEN NEEDLESHORTULTRA-FINE31G X 8MM MISC


BD SAFETY-GLIDE INSULIN SYRINGE05ML29G X12 MISC

1

QL(5 ea daily)RXOTC

BD SAFETY-LOK INSULIN SYRINGEPERMNEEDLEUF1ML29G X12 MISC

1

QL(5 ea daily)RXOTC

BD SAFETYGLIDE INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)

BD SAFETYGLIDE INSULIN SYSYRINGE05ML30G X516 MISC

1

QL(5 ea daily)RXOTC

BD VEO INSULIN SYRINGE ULTRA-FINE1ML31G X 6MMMISC

1

QL(5 ea daily)

BD VEO INSULIN SYRINGE ULTRA-FINEU-1001ML31G X 1564MISC

1

QL(5 ea daily)

CAREONE INSULIN SYRINGES03ML30G X12 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

CAREONE INSULIN SYRINGES1ML31GX516 MISC

1 QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

CLEVER CHOICE COMFORT EZINSULIN SYRINGEU-1001ML31GX516 MISC

1

QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits

COMFORT ASSIST INSULIN SYRINGE 03ML29G X 12 MISC


COMFORT ASSIST INSULIN SYRINGE03ML30G X516 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

COMFORT ASSIST INSULIN SYRINGE1ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGEU-10005ML31G X 516MISC

1

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGEU-1001ML31GX 516 MISC

1 QL(5 ea daily)

DROPLET INSULIN SYRINGE 03ML29G X12 MISC




Drug Name DrugTier

RequirementsLimits

DROPLET INSULIN SYRINGE 1ML29G X 12MISC


DROPLET INSULIN SYRINGE U-1000331G X516 MISC

1 QL(5 ea daily)

DROPLET INSULIN SYRINGE U-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

DROPLET INSULIN SYRINGE U-1001ML30GX 12 MISC

1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

DROPLET INSULIN SYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


97

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)

DROPLET INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE05ML30G X516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGEU-10005ML30G X 12MISC

1

QL(5 ea daily)

EASY COMFORT INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML29GX12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

EASY TOUCH INSULIN SYRINGE03ML30G X516 MISC



1 QL(5 ea daily)







EASY TOUCH INSULIN SYRINGESAFETYU-10005ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

EASY TOUCH INSULIN SYRINGESAFETYU-1001ML29G X 12 MISC



1 QL(5 ea daily)

EASY TOUCH INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


98

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGEU-1001ML27GX 12 MISC







1 QL(5 ea daily)


1 QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML29GX12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML30GX12MISC

1

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE03ML31G X516 MISC

1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits



ELITE-THIN INSULIN SYRINGEU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGEU-1001ML28GX 12 MISC





1 QL(5 ea daily)

EQL INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)






1 QL(5 ea daily)

EQL INSULIN SYRINGE1ML29G X 12MISC





1 QL(5 ea daily)


99

Drug Name DrugTier

RequirementsLimits

EXEL COMFORT POINT INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

EXEL COMFORT POINT INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE03ML31G X516 MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGEU-10005ML30G X 516MISC

1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGESU-1001ML30G X 516MISC

1

QL(5 ea daily)RXOTC

GLOBAL EASY GLIDE INSULIN SYRINGE1ML31G X1564 MISC

1

QL(5 ea daily)

GLOBAL EASY GLIDE INSULINSYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML28G X 12 MISC





1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

GLOBAL INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)

GLOBAL INSULIN SYRINGESU-10003ML30GX516MISC

1

QL(5 ea daily)RXOTC

GLUCOPRO INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

GLUCOPRO INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)




1 QL(5 ea daily)

GNP INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)








1 QL(5 ea daily)

GNP INSULIN SYRINGE1ML28G X 12MISC





101

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC

GNP ULTRA COMFORT INSULIN SYRINGE03ML30G X516 SHORT MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

GNP ULTRA COMFORT INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

HEALTHWISE INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

HEALTHWISE INSULIN SYRINGEU-1001ML30GX 516 MISC



1 QL(5 ea daily)

HM ULTICARE INSULIN SYRINGE1ML30G X 12MISC

1 QL(5 ea daily)

HM ULTICARE INSULIN SYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)

INSULIN SYRINGE03ML29G X 1MISC

1 QL(5 ea daily)

INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






102

Drug Name DrugTier

RequirementsLimits



INSULIN SYRINGENEEDLE03ML30G X 516 MISC



1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)

INSULIN SYRINGEU-10003ML29G X 12MISC




INSULIN SYRINGEU-1001ML29G X 12 MISC 1 QL(5 ea daily)

RXOTC INSULIN SYRINGEU-1001ML30G X 516MISC

1 QL(5 ea daily)




1 QL(5 ea daily)

INSULIN SYRINGES05ML27GX12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)

INSULIN SYRINGES1ML27GX12MISC









1 QL(5 ea daily)


1 QL(5 ea daily)

KINRAY INSULIN SYRINGE PREFERRED PLUS03ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

KINRAY INSULIN SYRINGE05ML29G X12 MISC



103

Drug Name DrugTier

RequirementsLimits

KMART VALU PLUS INSULIN SYRINGE1ML29G MISC




KROGER INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)






1 QL(5 ea daily)

KROGER INSULIN SYRINGE1ML29G X 12MISC





1 QL(5 ea daily)

LEADER INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

LEADER INSULIN SYRINGE1ML28G X 12MISC







1 QL(5 ea daily)

LITETOUCH INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)




1 QL(5 ea daily)



LITETOUCH INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


104

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

LITETOUCH INSULIN SYRINGEU-1001ML28GX 12 MISC







1 QL(5 ea daily)

LONGS INSULIN SYRINGE05ML31G X516 MISC

1 QL(5 ea daily)

MAGELLAN INSULIN SAFETY SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

MAGELLAN INSULIN SAFETY SYRINGEU-1001ML29G X 12 MISC


Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC

MAXI-COMFORT INSULIN SYRINGEU-10005ML28GX12 MISC




MAXICOMFORT INSULIN SYRINGES 27G X 12MISC

1 QL(5 ea daily)



MEDIC INSULIN SYRINGE03ML30G X516 MISC




MM INSULIN SYRINGEU-10003ML30G X 516MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

MONOJECT INSULIN SYRINGE1ML MISC 1 QL(5 ea daily)

RXOTC MONOJECT INSULIN SYRINGE1ML31G X516 MISC

1 QL(5 ea daily)


105

Drug Name DrugTier

RequirementsLimits

MONOJECT INSULIN SYRINGEDETACHNEEDLE1ML25G X 58MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEPERMNEEDLE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEPERMNEEDLEU-10005ML28GX 12 MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29G X 12MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29GX12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESOFTPACK1ML27G X 12 MISC


MONOJECT INSULIN SYRINGESOFTPACKU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

MONOJECT INSULIN SYRINGEU-1001ML28GX 12 MISC




MONOJECT INSULIN SYRINGEREGULAR LUER TIPSOFTPACK1ML MISC


MONOJECT ULTRA COMFORT INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

MONOJECT ULTRA COMFORT INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

MS INSULIN SYRINGE03ML31G X516 MISC

1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE03ML30G X516 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC

PRECISION SURE-DOSE PLUSINSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC

PRECISION SURE-DOSE PLUSINSULIN SYRINGE1ML29G X 12MISC

1

QL(5 ea daily)RXOTC

PREFERRED PLUS INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

PREFERRED PLUS INSULIN SYRINGEU-1001ML28G X 12 MISC





1

QL(5 ea daily)RXOTC

PRO COMFORT INSULIN SYRINGES05ML30G X12 MISC

1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)

PRODIGY INSULIN SYRINGU-10003ML31GX 516 MISC

1 QL(5 ea daily)

PRODIGY INSULIN SYRINGE12ML31G X516 MISC

1 QL(5 ea daily)

PRODIGY INSULIN SYRINGE1ML28G X 12MISC


PX INSULIN SYRINGEU-10005ML30G X 12MISC

1 QL(5 ea daily)


107

Drug Name DrugTier

RequirementsLimits

RA INSULIN SYRINGE05ML29G X12 MISC


RA INSULIN SYRINGE1ML29G X 12MISC


RA INSULIN SYRINGEU-10005ML30G X 516MISC


RA INSULIN SYRINGEU-1001 ML30G X 516MISC


REALITY INSULIN SYRINGEU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

REALITY INSULIN SYRINGEU-1001ML28GX 12 MISC




RELION INSULIN SYRINGE 1ML31GX1564 MISC

1 QL(5 ea daily)

RELION INSULIN SYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

RELION INSULIN SYRINGEU-1001ML31GX 1564 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

SAFESNAP INSULIN SYRINGE03ML30G X516 MISC






SAFESNAP INSULIN SYRINGE1ML28G X 12MISC




SAFETY INSULIN SYRINGES 05ML29GX12 MISC




SAFETY INSULIN SYRINGES 1ML27GX12MISC





1 QL(5 ea daily)

SB INSULIN SYRINGEU-10005ML29G X 12MISC




SB INSULIN SYRINGEU-1001ML29G X 12 MISC 1 QL(5 ea daily)

RXOTC SB INSULIN SYRINGEU-1001ML30G X 516MISC



1 QL(5 ea daily)

SECURESAFE SAFETY INSULIN SYRINGESU-10005ML29GX12 MISC



108

Drug Name DrugTier

RequirementsLimits



SURE COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

SURE COMFORT INSULIN SYRINGEU-1001ML28G X 12 MISC


Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

SURE-JECT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

SURE-JECT INSULIN SYRINGEU-1001ML28GX 12 MISC





109

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-1001ML29GX 12 MISC



1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE03ML30G X516 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

TOPCARE ULTRA COMFORT INSULIN SYRINGEU-1001ML29GX 12 MISC

1

QL(5 ea daily)RXOTC

TRUE COMFORT INSULIN SYRINGE05ML31G X516 MISC

1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGE05ML30G X 516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGEU-10005ML30G X 12MISC

1

QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGEU-1001ML30G X 12 MISC

1 QL(5 ea daily)

TRUEPLUS INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)

TRUEPLUS INSULIN SYRINGEU-1001ML28GX 12 MISC







1 QL(5 ea daily)

ULTICARE INSULIN SAFETY SYRINGE05ML29G X12 MISC

1

QL(5 ea daily)RXOTC

ULTICARE INSULIN SAFETY SYRINGE1ML29G X 12MISC

1

QL(5 ea daily)RXOTC

ULTICARE INSULIN SYRINGE03ML29G X12 MISC



1 QL(5 ea daily)








1 QL(5 ea daily)



ULTICARE INSULIN SYRINGE1ML28G X 12MISC



111

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)



ULTICARE INSULIN SYRINGESHORT03ML30G X 516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

ULTICARE INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

ULTICARE INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-10003ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 03ML30G X 12SHARPSC MISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 12ML30G X 12SHARPS CMISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 30G X 12SHARPS CONMISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 31G X 516SHARPS COMISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE03ML30G X12SHARPS C MISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE03ML31G X516SHARPS MISC

1

QL(5 ea daily)


1

QL(5 ea daily)

ULTIGUARD SAFEPACKSYRINGENEEDLE31G X516SHARPS CONTAINMISC

1

QL(5 ea daily)


112

Drug Name DrugTier

RequirementsLimits

ULTILET INSULIN SYRINGE03ML30G X8MM MISC



1 QL(5 ea daily)






1 QL(5 ea daily)

ULTILET INSULIN SYRINGESHORT03ML30G X 127MM MISC

1 QL(5 ea daily)

ULTILET INSULIN SYRINGESHORT03ML30G X 516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

ULTILET INSULIN SYRINGEU-10005ML30G X 12MISC

1

QL(5 ea daily)

ULTILET INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

ULTRA COMFORT INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

ULTRA FLO INSULIN SYRINGE 03ML29G X12 MISC


ULTRA FLO INSULIN SYRINGE 03ML30GX12MISC

1 QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 03ML30GX516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 12UNIT03ML30GX12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 1M29GX12MISC



1 QL(5 ea daily)




1 QL(5 ea daily)


113

Drug Name DrugTier

RequirementsLimits

ULTRA-COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA-COMFORT INSULIN SYRINGEU-1001ML28G X 12 MISC





1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML30GX516MISC

1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML30GX516 MISC



1 QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGEU-10005ML29GX12 MISC




ULTRACARE INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRACARE INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)


114

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

VALUE HEALTH INSULIN SYRINGEU-10005ML29G X 12MISC

1

QL(5 ea daily)RXOTC

VALUE HEALTH INSULIN SYRINGEU-1001ML29GX 12 MISC


VANISHPOINT INSULIN SYRINGE05ML30G X12 MISC

1 QL(5 ea daily)



VANISHPOINT INSULIN SYRINGE1ML29G X 12MISC




VP INSULIN SYRINGEU-10003ML29G X 12MISC


MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Calcitonin Gene-Related Peptide (CGRP)

AIMOVIG SOAJ 2 PA QL(004 mldaily)

EMGALITY SOAJ 120 MGML 2 PA QL(007 ml

daily) EMGALITY SOSY 100 MGML 3 PA QL(007 ml


daily) Migraine Combinations CAFERGOT TABS (Use ergotamine w caffeine) NF

ergotamine w caffeine tabsor 1 mg-100 mg 1

Drug Name DrugTier

RequirementsLimits

sumatriptan-naproxensodium tabs 3


TREXIMET TABS (Use sumatriptan-naproxensodium)

NF


Migraine Products DHE 45 SOLN (Use dihydroergotaminemesylate)

NF

dihydroergotaminemesylate soln ij 1 mgml 1

dihydroergotaminemesylate soln na 4 mgml 1 PA QL(0267

ml daily) dihydroergotaminemesylate soln na 4 mgml 1 QL(0267 ml

daily)

ERGOMAR SUBL 3 QL(0667 eadaily)

MIGRANAL SOLN (Use dihydroergotaminemesylate)

NF QL(0267 mldaily)

Serotonin Agonists

almotriptan malate tabs125 mg 1




AMERGE TABS (Use naratriptan hcl) NF

QL(03 eadaily) AL(Atleast 18 yrsold)

eletriptan hydrobromidetabs 1


FROVA TABS (Use frovatriptan succinate) NF



115

Drug Name DrugTier

RequirementsLimits

frovatriptan succinate tabs 1


IMITREX SOLN NA 20 MGACT 5 MGACT (Use sumatriptan)

NF


IMITREX SOLN SC 6 MG05ML (Use sumatriptan succinate)

NF

QL(0134 mldaily) AL(Atleast 18 yrsold)

IMITREX STATDOSE REFILL SOCT (Use sumatriptan succinate)

NF


IMITREX STATDOSE SYSTEM SOAJ (Use sumatriptan succinate)

NF


IMITREX TABS OR 50 MG 100 MG 25 MG (Use sumatriptan succinate)

NF


MAXALT TABS (Use rizatriptan benzoate) NF

QL(06 eadaily) AL(Atleast 6 yrs old)

MAXALT-MLT TBDP 10 MG (Use rizatriptanbenzoate)

NF QL(06 eadaily) AL(Atleast 6 yrs old)

MAXALT-MLT TBDP 5 MG (Use rizatriptan benzoate) NF


naratriptan hcl tabs 1


RELPAX TABS (Use eletriptan hydrobromide) NF


rizatriptan benzoate tabs10 mg 1


rizatriptan benzoate tabs 5 mg 1


Drug Name DrugTier

RequirementsLimits

rizatriptan benzoate tbdp10 mg 1


rizatriptan benzoate tbdp 5 mg 1


sumatriptan soln 1


sumatriptan succinate soajsc 4 mg05ml 6 mg05ml 1


sumatriptan succinate soctsc 4 mg05ml 6 mg05ml 1


sumatriptan succinate solnsc 6 mg05ml 1


sumatriptan succinate sosysc 6 mg05ml 1


sumatriptan succinate tabsor 50 mg 100 mg 25 mg 1


zolmitriptan soln na 25 mg5 mg 1


zolmitriptan tabs or 25 mg5 mg 1


zolmitriptan tbdp or 25 mg5 mg 1


ZOMIG SOLN NA 25 MG 5 MG (Use zolmitriptan) 3



116

Drug Name DrugTier

RequirementsLimits

ZOMIG TABS OR 25 MG 5 MG (Use zolmitriptan) NF


ZOMIG ZMT TBDP (Use zolmitriptan) NF


MINERALS amp ELECTROLYTES

Bicarbonates SODIUM ACETATE SOLN 2 MEQML 1

SODIUM ACETATE SOLN 2 MEQML (Use sodium acetate)

1

sodium acetate soln 2 meqml 4 meqml 1

Calcium calcium chloride (dihydrate)soln 1

CALCIUM GLUCONATE SOLN 1

calcium gluconate soln 1

Electrolyte Mixtures DEXTROSE 5NACL03 SOLN (Use dextrose w sodium chloride)

NF

dextrose in lactated ringerssoln 1

DEXTROSESODIUMCHLORIDE SOLN (Use dextrose w sodiumchloride)

NF

IONOSOL-MBDEXTROSE5 SOLN 20 MEQL-3MEQL-3 MEQL-5 -22MEQL-23 MEQL-25MEQL 3 MEQL-3MMOLEL-5 -20 MEQL-22 MEQL-23 MEQL-25MEQL

1

ISOLYTE-PDEXTROSE5 SOLN 1

ISOLYTE-S SOLN 1

Drug Name DrugTier

RequirementsLimits

KCL 03D5WNACL09 SOLN 1

lactated ringers soln 109meql-3 meql-4 meql-28meql-130 meql 20mg100ml-30 mg100ml-310 mg100ml-600mg100ml 3 meql-4 meql-28 meql-109 meql-130meql

1

NORMOSOL-M IN D5W SOLN 1

NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1

parenteral electrolytes conc 1

PLASMA-LYTE A SOLN 1

PLASMA-LYTE-148 SOLN 1

potassium chloride indextrose amp sodium chloride soln

1

potassium chloride indextrose soln 1

potassium chloride in naclsoln 045 -20 meql 09-015 09 -20 meql09 -40 meql

1

POTASSIUM CHLORIDEDEXTROSELACTATED RINGERS SOLN 27 MEQL-5 -24MEQL-28 MEQL-129MEQL-130 MEQL 3MEQL-130 MEQL-5 -24MEQL-28 MEQL-149MEQL 3 MEQL-5 -24MEQL-28 MEQL-130MEQL-149 MEQL

1

POTASSIUM CHLORIDESODIUMCHLORIDE SOLN 045 -20 MEQL (Use potassiumchloride in nacl)

1

ringers soln 1


117

Drug Name DrugTier

RequirementsLimits

Magnesium magnesium sulfate soln ij50 1

Phosphate potassium phosphates soln224 mgml-236 mgml 1

Potassium K-TAB TBCR 10 MEQ (Use potassium chloride) NF

K-TAB TBCR 8 MEQ (Use potassium chloride) 1

potassium acetate soln 1

potassium bicarbonate tbef 1

potassium chloride cpcr or10 meq 8 meq 1

potassium chloridemicroencapsulated crystalser tbcr 15 meq 20 meq 10 meq

1

potassium chloride pack or20 meq 1 PA

POTASSIUM CHLORIDE SOLN IV 10 MEQ100ML10 MEQ50ML

1

potassium chloride soln iv10 meq50ml 20meq50ml 2 meqml

1

potassium chloride soln or10 1

potassium chloride tbcr or10 meq 8 meq 1

Sodium sodium chloride soln ij 25meqml 1

sodium chloride soln iv 3 5 4 meqml 045 09

1

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS (Use penicillamine) NF PA

Drug Name DrugTier

RequirementsLimits

DEPEN TITRATABS TABS (Use penicillamine) NF QL(8 ea daily)

penicillamine caps 1 PA

penicillamine tabs 1 QL(8 ea daily)

SYPRINE CAPS (Use trientine hcl) NF PA QL(8 ea

daily) SP

trientine hcl caps 4 PA QL(8 eadaily) SP

Immunomodulators REVLIMID CAPS 10 MG 15 MG 25 MG 25 MG 5 MG


REVLIMID CAPS 20 MG 6 PA

THALOMID CAPS 4 PA QL(3 eadaily) SP

Immunosuppressive Agents

ATGAM INJ 4 PA SP

AZASAN TABS 3

AZATHIOPRINE SOLR IJ 100 MG 1

azathioprine tabs or 50 mg 1

CELLCEPT CAPS 250 MG (Use mycophenolatemofetil)

NF

CELLCEPT TABS 500 MG (Use mycophenolatemofetil)

NF

cyclosporine caps 1

cyclosporine modified (formicroemulsion) caps 1

cyclosporine modified (formicroemulsion) soln 1

cyclosporine soln 1

everolimus (immunosuppressant) tabs 4 PA QL(20 ea

daily) SP IMURAN TABS (Use azathioprine) NF

mycophenolate mofetilcaps or 250 mg 1


118

Drug Name DrugTier

RequirementsLimits

mycophenolate mofetil tabsor 500 mg 1

mycophenolate sodiumtbec 1

MYFORTIC TBEC (Use mycophenolate sodium) NF

NEORAL CAPS (Use cyclosporine modified (formicroemulsion))

NF

NEORAL SOLN (Use cyclosporine modified (formicroemulsion))

NF

NULOJIX SOLR 4 PA SP

PROGRAF CAPS OR 05 MG 1 MG 5 MG (Use tacrolimus)

NF

PROGRAF PACK OR 02 MG 1 MG 2 PA

PROGRAF SOLN IV 5 MGML 2

RAPAMUNE TABS 05 MG 1 MG 2 MG (Use sirolimus)

NF

SANDIMMUNE CAPS OR 100 MG 25 MG (Use cyclosporine)

NF

SANDIMMUNE SOLN IV 50 MGML (Use cyclosporine)

NF

SIMULECT SOLR 3

sirolimus tabs 05 mg 1mg 2 mg 1

tacrolimus caps 1

THYMOGLOBULIN SOLR 4 PA SP

ZORTRESS TABS 025 MG 05 MG 075 MG (Use everolimus (immunosuppressant))

NF

PA QL(20 eadaily) SP

Irrigation Solutions irrigation solutionsphysiological soln 1

lactated ringers (irrigation)soln 1

Drug Name DrugTier

RequirementsLimits

ringers irrigation soln 1

water for irrigation sterilesoln 1

Lymphatic Agents

SYLVANT SOLR 6 PA

Potassium Removing Agents sodium polystyrenesulfonate powd 1

sodium polystyrenesulfonate susp 1

MOUTHTHROATDENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 2 1 QL(4 ml daily)

lidocaine hcl (mouth-throat)soln 4 1

Anti-infectives - Throat clotrimazole troc 1

nystatin (mouth-throat) susp 1

Antiseptics - MouthThroat chlorhexidine gluconate(mouth-throat) soln 1

DEBACTEROL SOLN 2

PERIDEX SOLN (Use chlorhexidine gluconate(mouth-throat))

NF

Dental Products

stannous fluoride conc 0 RXOTC

Steroids - MouthThroatDental triamcinolone acetonide (mouth) pste 1

Throat Products - Misc cevimeline hcl caps 1

EVOXAC CAPS (Use cevimeline hcl) NF

pilocarpine hcl (oral) tabs 1


119

Drug Name DrugTier

RequirementsLimits

SALAGEN TABS (Use pilocarpine hcl (oral)) NF

MULTIVITAMINS

Prenatal Vitamins CLASSIC PRENATAL TABS 2 QL(1 ea daily)

CVS PRENATAL TABS 2 QL(1 ea daily)

EQL PRENATAL FORMULA TABS 2 QL(1 ea daily)

GNP PRENATAL TABS 2 QL(1 ea daily)

GOODSENSE PRENATAL VITAMINS TABS 2 QL(1 ea daily)

HM PRENATAL TABS 2 QL(1 ea daily)

KP PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily)

M-NATAL PLUS TABS 2 QL(1 ea daily)RXOTC

MULTI PRENATAL TABS 2 QL(1 ea daily)

NEONATAL COMPLETE TABS 02 MG-184 MG-2 MG-2 MG-3 MG-5 MG-92 MG-10 MCG-10 MG-12 MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1000 MCG-1200 MCG

2

QL(1 ea daily)RXOTC

NEONATAL PLUS TABS 2 QL(1 ea daily)RXOTC

NEONATAL VITAMIN TABS 2 QL(1 ea daily)

NIVA-PLUS TABS 2 QL(1 ea daily)RXOTC

O-CAL FA TABS 2 QL(1 ea daily)RXOTC

ONE VITE WOMENS PRENATALVITAMIN PLUS TABS


ONE VITE WOMENS PRENATALVITAMIN TABS 2 QL(1 ea daily)

PRENATAL LOW IRON TABS 2 QL(1 ea daily)

PRENATAL MULTIVITAMIN TABS 2 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

PRENATAL ONE DAILY TABS 2 QL(1 ea daily)

PRENATAL TABS 08 MG-15 MG-17 MG-26 MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 MG-263 MG-400 UNIT-4000 UNIT 08 MG-15 MG-17 MG-26 MG-4 MCG-18 MG-27 MG-100 MG-263 MG-400 UNIT-4000 UNIT-25 MG-11 UNIT 08 MG-17 MG-18 MG-26 MG-8 MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-4000 UNIT 15 MG-17 MG-26 MG-4 MCG-5 MG-10 MCG-18 MG-25 MG-27 MG-100 MG-200 MG-800 MCG-1200 MCG 17 MG-18 MG-26 MG-8 MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-800 MCG-4000 UNIT 17 MG-184 MG-26 MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 MG-160 MG-200 MG-400 UNIT-800 MCG-4000 UNIT 18 MG-20 MG-17 MG-26 MG-8 MCG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-800 MCG-4000 UNIT

2

QL(1 ea daily)

PRENATAL TABS 1 MG-184 MG-2 MG-3 MG-10 MCG-10 MG-10 MG-12 MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1200 MCG

2

QL(1 ea daily)RXOTC

PRENATAL VITAMIN amp MINERAL TABS 2 QL(1 ea daily)

PRENATAL VITAMIN TABS 2 QL(1 ea daily)

PRENATAL VITAMINIRON TABS 2 QL(1 ea daily)

PRENATAL VITAMINS PLUS LOW IRON TABS 2 QL(1 ea daily)

RXOTC PRENATAL VITAMINS TABS 2 QL(1 ea daily)


120

Drug Name DrugTier

RequirementsLimits

PRENATRIX TABS 2 QL(1 ea daily)RXOTC

PRENATRYL TABS 2 QL(1 ea daily)RXOTC

PREPLUS TABS 2 QL(1 ea daily)RXOTC

PX PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily)

QC PRENATAL TABS 2 QL(1 ea daily)

RA PRENATAL FORMULAFOLICACIDTABS

2 QL(1 ea daily)

RA PRENATAL TABS 2 QL(1 ea daily)

RIGHT STEP PRENATAL TABS 2 QL(1 ea daily)

SM PRENATAL VITAMINS TABS 2 QL(1 ea daily)

THERANATAL CORE NUTRITION TABS 2 QL(1 ea daily)

RXOTC

TRICARE TABS 2 QL(1 ea daily)RXOTC

VITATHELYGINGERTABS 2 QL(1 ea daily)

RXOTC

VOL-PLUS TABS 2 QL(1 ea daily)RXOTC

WESTAB PLUS TABS 2 QL(1 ea daily)RXOTC

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants baclofen tabs or 10 mg 20 mg 1

carisoprodol tabs 1

chlorzoxazone tabs 500 mg 1 QL(6 ea daily)

cyclobenzaprine hcl tabs10 mg 5 mg 1 QL(3 ea daily)

metaxalone tabs 800 mg 1 QL(4 ea daily)

methocarbamol tabs or 500 mg 750 mg 1

orphenadrine citrate tb12or 100 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

ROBAXIN-750 TABS (Use methocarbamol) NF

SKELAXIN TABS (Use metaxalone) NF QL(4 ea daily)

SOMA TABS (Use carisoprodol) NF

tizanidine hcl caps 1

tizanidine hcl tabs 1

ZANAFLEX CAPS (Use tizanidine hcl) NF

ZANAFLEX TABS (Use tizanidine hcl) NF

Direct Muscle Relaxants DANTRIUM CAPS (Use dantrolene sodium) NF QL(4 ea daily)

dantrolene sodium caps or100 mg 50 mg 25 mg 1 QL(4 ea daily)

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Antiallergy

azelastine hcl soln 1

olopatadine hcl (nasal) soln 1

PATANASE SOLN (Use olopatadine hcl (nasal)) NF

Nasal Anticholinergics ipratropium bromide (nasal)soln 003 1 QL(1 ml daily)

ipratropium bromide (nasal)soln 006 1

Nasal Steroids

budesonide (nasal) susp 1

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use fluticasone propionate (nasal))

NF

Limit 2 inhalers permonthQL(32ml per 30 daysretail) RXOTC

FLONASE ALLERGY RELIEF SUSP (Use fluticasone propionate(nasal))

NF



121

Drug Name DrugTier

RequirementsLimits

flunisolide (nasal) soln 1 1 rtl pack lmtper fill

fluticasone propionate(nasal) susp 1


mometasone furoate (nasal) susp 1 PA QL(114

gm daily) NASACORT ALLERGY 24HR AERO (Use triamcinolone acetonide (nasal))

NF

NASACORT ALLERGY 24HR CHILDRENS AERO (Use triamcinolone acetonide (nasal))

NF

NASONEX SUSP (Use mometasone furoate (nasal))

NF PA QL(114gm daily)

triamcinolone acetonide (nasal) aero 1

NEUROMUSCULAR AGENTS - Drugs toRelaxParalyze Muscles

ALS Agents RILUTEK TABS (Use riluzole) NF

riluzole tabs 3

Neuromuscular Blocking Agent - Neurotoxins

BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS

Proteins CLINIMIX 425DEXTROSE 10SOLN

3

CLINIMIX 425DEXTROSE 25SOLN

3

Drug Name DrugTier

RequirementsLimits


3

CLINIMIX 5DEXTROSE25 SOLN 3

CLINIMIX E 5DEXTROSE 20SOLN

3

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

LACRISERT INST 3

Beta-blockers - Ophthalmic

betaxolol hcl (ophth) soln 1

carteolol hcl (ophth) soln 1

COMBIGAN SOLN 2

COSOPT SOLN (Use dorzolamide hcl-timolol maleate)

NF

dorzolamide hcl-timolol maleate soln 05 -2 223 mgml-68 mgml 5mgml-20 mgml 68mgml-223 mgml

1

levobunolol hcl soln 1

timolol maleate (ophth) solg025 05 1

timolol maleate (ophth) soln025 05 1

TIMOPTIC SOLN (Use timolol maleate (ophth)) NF

TIMOPTIC-XE SOLG (Use timolol maleate (ophth)) NF

Cycloplegic Mydriatics MYDRIACYL SOLN (Use tropicamide) NF

tropicamide soln 1

Miotics ISOPTO CARPINE SOLN (Use pilocarpine hcl) NF


122

Drug Name DrugTier

RequirementsLimits

PHOSPHOLINE IODIDE SOLR 3

pilocarpine hcl soln 1

Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 015 (Use brimonidine tartrate)

NF

apraclonidine hcl soln 1

brimonidine tartrate soln 1

IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA

Ophthalmic Anti-infectives

AZASITE SOLN 3

bacitracin (ophthalmic) oint 3

BLEPH-10 SOLN (Use sulfacetamide sodium (ophth))

NF

CILOXAN SOLN (Use ciprofloxacin hcl (ophth)) NF

ciprofloxacin hcl (ophth)soln 1

erythromycin (ophth) oint 1

gatifloxacin (ophth) soln 1

gentamicin sulfate (ophth)oint 1

gentamicin sulfate (ophth)soln 1

KLARITY-A SOLN 3

levofloxacin (ophth) soln 1

moxifloxacin hcl (ophth)soln 1

NATACYN SUSP 2

neomycin-bacitracin zn-polymyxin oint 1

Drug Name DrugTier

RequirementsLimits

OCUFLOX SOLN (Use ofloxacin (ophth)) NF

ofloxacin (ophth) soln 1

polymyxin b-trimethoprimsoln 1

POLYTRIM SOLN (Use polymyxin b-trimethoprim) NF

sulfacetamide sodium (ophth) soln 1

tobramycin (ophth) soln 1

TOBREX SOLN (Use tobramycin (ophth)) NF

trifluridine soln 1

VIGAMOX SOLN (Use moxifloxacin hcl (ophth)) NF

ZIRGAN GEL 2

ZYMAXID SOLN (Use gatifloxacin (ophth)) NF

Ophthalmic Immunomodulators

RESTASIS EMUL 2 PA

RESTASIS MULTIDOSE EMUL 2 PA

Ophthalmic Local Anesthetics ALCAINE SOLN (Use proparacaine hcl) NF

proparacaine hcl soln 1

Ophthalmic Nerve Growth Factors

OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA

dexamethasone sodium phosphate (ophth) soln 1

DUREZOL EMUL 3 PA

fluorometholone (ophth) susp 1

FML FORTE SUSP 3 PA


123

Drug Name DrugTier

RequirementsLimits

FML LIQUIFILM SUSP (Use fluorometholone (ophth))

NF

FML OINT 3 PA

LOTEMAX GEL (Use loteprednol etabonate) 3 PA

LOTEMAX OINT 3 PA

LOTEMAX SUSP (Use loteprednol etabonate) NF PA

loteprednol etabonate gel 1 PA

loteprednol etabonate susp 1 PA

MAXIDEX SUSP 3 PA

MAXITROL OINT (Use neomycin-polymy-dexameth)

NF

MAXITROL SUSP (Use neomycin-polymy-dexameth)

NF

neomycin-polymy-dexameth oint 1

neomycin-polymy-dexameth susp 1

neomycin-polymyxin-hc(ophth) susp 1

PRED FORTE SUSP (Use prednisolone acetate(ophth))

NF

PRED MILD SUSP 3 PA

prednisolone acetate(ophth) susp 1

PREDNISOLONE ACETATE P-F SUSP 1

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1

3

TOBRADEX SUSP (Use tobramycin-dexamethasone)

NF

tobramycin-dexamethasone susp 1

Ophthalmics - Misc

Drug Name DrugTier

RequirementsLimits

ACULAR LS SOLN (Use ketorolac tromethamine (ophth))

NF

ACULAR SOLN (Use ketorolac tromethamine (ophth))

NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA

azelastine hcl (ophth) soln 1

bepotastine besilate soln 3 PA

BEPREVE SOLN (Use bepotastine besilate) 3 PA

bromfenac sodium (ophth)soln 1

cromolyn sodium (ophth)soln 1

CYSTARAN SOLN 2 PA QL(2143ml daily)

diclofenac sodium (ophth)soln 1

dorzolamide hcl soln 1

epinastine hcl (ophth) soln 1

flurbiprofen sodium soln 1

ILEVRO SUSP 3 ST QL(02 mldaily)

ketorolac tromethamine (ophth) soln 1

ketotifen fumarate (ophth)soln 1

LASTACAFT SOLN 3 PA

NEVANAC SUSP 3 ST QL(02 mldaily)

olopatadine hcl soln 1 RXOTC

PATADAY SOLN (Use olopatadine hcl) NF RXOTC

PATANOL SOLN (Use olopatadine hcl) NF RXOTC


124

Drug Name DrugTier

RequirementsLimits

TRUSOPT SOLN (Use dorzolamide hcl) NF

ZADITOR SOLN (Use ketotifen fumarate (ophth)) NF

ZERVIATE SOLN 3 PA

Prostaglandins - Ophthalmic

bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST

TRAVATAN Z SOLN (Use travoprost) NF

travoprost soln 1

XALATAN SOLN (Use latanoprost) NF

ZIOPTAN SOLN 2

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln 1

Otic Anti-infectives CETRAXAL SOLN (Use ciprofloxacin hcl (otic)) 1

ciprofloxacin hcl (otic) soln 1

FLOXIN OTIC SOLN (Use ofloxacin (otic)) NF

ofloxacin (otic) soln 1

Otic Combinations

CIPRO HC SUSP 3

CIPRODEX SUSP (Use ciprofloxacin-dexamethasone)

NF PA

ciprofloxacin-dexamethasone susp 1 PA

ciprofloxacin-fluocinoloneacetonide soln 1 PA QL(05 ea

daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits

CORTISPORIN-TC SUSP 3

neomycin-polymyxin-hc(otic) soln 1

neomycin-polymyxin-hc(otic) susp 1

OTOVEL SOLN (Use ciprofloxacin-fluocinoloneacetonide)

3 PA QL(05 eadaily)

Otic Steroids DERMOTIC OIL (Use fluocinolone acetonide (otic))

NF

fluocinolone acetonide (otic) oil 1

hydrocortisone waceticacid soln 1

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums CUVITRU SOLN 1 GM5ML 10 GM50ML 2GM10ML 4 GM20ML

4 PA SP

GAMMAGARD LIQUID SOLN 1 GM10ML 10GM100ML 25 GM25ML20 GM200ML 5 GM50ML

4

PA SP

GAMMAGARD LIQUID SOLN 30 GM300ML 4 PA

GAMMAGARD SD IGALESS THAN 1MCGMLSOLR

4 PA SP

GAMMAKED SOLN 4 PA SP

GAMUNEX-C SOLN 4 PA SP

HIZENTRA SOLN 1 GM5ML 10 GM50ML 2GM10ML 4 GM20ML

4 PA SP

Passive Immunizing Agents - Combinations

HYQVIA KIT 4 PA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins


125

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1

ampicillin sodium solr ij 1 gm 1

ampicillin sodium solr iv 10 gm 1

Natural Penicillins PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE SOLN 40000 UNITML60000 UNITML

1

penicillin g potassium solr5000000 unit 1

PENICILLIN G PROCAINE SUSP 3

penicillin g sodium solr 3

penicillin v potassium solr 1

penicillin v potassium tabs 1

Penicillin Combinations amoxicillin amp potclavulanate chew 1

amoxicillin amp potclavulanate susr 1

amoxicillin amp potclavulanate tabs 1

amoxicillin amp potclavulanate tb12 1

ampicillin amp sulbactamsodium solr ij 05 gm-1 gm1 gm-2 gm

1

ampicillin amp sulbactamsodium solr iv 5 gm-10 gm 1

AUGMENTIN ES-600 SUSR (Use amoxicillin amp pot clavulanate)

NF

Drug Name DrugTier

RequirementsLimits

AUGMENTIN SUSR 625 MG5ML-250 MG5ML(Use amoxicillin amp potclavulanate)

NF

AUGMENTIN TABS 125 MG-500 MG (Use amoxicillin amp potclavulanate)

NF

piperacillin sodium-tazobactam sodium solr 1

UNASYN BULK PACK SOLR (Use ampicillin ampsulbactam sodium)

NF

UNASYN SOLR (Use ampicillin amp sulbactamsodium)

NF

ZOSYN SOLR 025 GM-2 GM 0375 GM-3 GM 05 GM-4 GM 45 GM-36 GM (Use piperacillin sodium-tazobactam sodium)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps 1

nafcillin sodium solr ij 1 gm 1

oxacillin sodium solr ij 1 gm 1

oxacillin sodium solr iv 10 gm 1

PROGESTINS - Hormone ReplacementModifyingDrugs

Progestins AYGESTIN TABS (Use norethindrone acetate) NF

medroxyprogesteroneacetate tabs 1

MEGACE ES SUSP (Use megestrol acetate(appetite))

NF PA

megestrol acetate(appetite) susp 1 PA

norethindrone acetate tabs 0

progesterone caps or 100mg 200 mg 1


126

Drug Name DrugTier

RequirementsLimits

PROMETRIUM CAPS (Use progesterone) NF

PROVERA TABS (Use medroxyprogesterone acetate)

NF

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec 1

ANTABUSE TABS (Use disulfiram) NF

disulfiram tabs 1

LUCEMYRA TABS 3 PA QL(224 eaper 14 daysretail)

Anti-Cataplectic Agents

XYREM SOLN 4 PA QL(18 mldaily) SP

Antidementia Agents ARICEPT TABS 10 MG (Use donepezilhydrochloride)

NF QL(2 ea daily)

ARICEPT TABS 5 MG (Use donepezilhydrochloride)

NF QL(1 ea daily)

donepezil hydrochloridetabs 10 mg 1 QL(2 ea daily)


donepezil hydrochloridetbdp 10 mg 1 QL(2 ea daily)


galantamine hydrobromidecp24 16 mg 24 mg 8 mg 1 QL(1 ea daily)

galantamine hydrobromidesoln 4 mgml 1 QL(6 ml daily)

galantamine hydrobromidetabs 12 mg 4 mg 8 mg 1 QL(2 ea daily)

memantine hcl tabs 1

memantine hcl tabs 10 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits


NAMENDA TABS 10 MG (Use memantine hcl) NF QL(2 ea daily)


NAMENDA TITRATION PAK TABS (Use memantine hcl)

NF

RAZADYNE ER CP24 (Use galantamine hydrobromide) NF QL(1 ea daily)

RAZADYNE TABS (Use galantamine hydrobromide) NF QL(2 ea daily)

rivastigmine tartrate caps 1

Combination Psychotherapeutics perphenazine-amitriptylinetabs 1 QL(4 ea daily)

Fibromyalgia Agents

SAVELLA TABS 2 PA QL(2 eadaily)

SAVELLA TITRATION PACK MISC 2 PA

Movement Disorder Drug Therapy

AUSTEDO TABS 4 PA QL(4 eadaily)

tetrabenazine tabs 4 PA QL(3 eadaily) SP

XENAZINE TABS (Use tetrabenazine) NF PA QL(3 ea

daily) SP

Multiple Sclerosis Agents AMPYRA TB12 (Use dalfampridine) NF PA QL(2 ea

daily) SP

AUBAGIO TABS 4 PA

AVONEX PEN AJKT 4 PA QL(00714ea daily) SP

AVONEX PSKT 4 PA QL(00714ml daily) SP

BETASERON KIT 4 PA QL(00357ea daily) SP

COPAXONE SOSY 20 MGML (Use glatiramer acetate)



127

Drug Name DrugTier

RequirementsLimits


3 PA QL(0429ml daily) SP

dalfampridine tb12 4 PA QL(2 eadaily) SP

dimethyl fumarate cpdr 4 PA

dimethyl fumarate misc 4 PA

EXTAVIA KIT 4 PA QL(00357ea daily) SP

GILENYA CAPS 4 PA

glatiramer acetate sosy 20mgml 3 PA QL(1 ml

daily) SP glatiramer acetate sosy 40mgml 3 PA QL(0429

ml daily) SP

MAVENCLAD TBPK 4 PA

MAYZENT STARTER PACK TBPK 4 PA

MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA

PLEGRIDY SOPN SC 4 PA QL(00357ml daily)

PLEGRIDY SOSY SC 4 PA

PLEGRIDY STARTER PACK SOPN 4 PA

PLEGRIDY STARTER PACK SOSY 4 PA QL(00357

ml daily)

REBIF REBIDOSE SOAJ 4 PA QL(0214ml daily) SP

REBIF REBIDOSE TITRATIONPACK SOAJ 4 PA SP

REBIF SOSY 4 PA QL(0214ml daily) SP

REBIF TITRATION PACK SOSY 4 PA SP

TECFIDERA CPDR (Use dimethyl fumarate) NF PA

TECFIDERA STARTER PACK MISC (Use dimethyl fumarate)

NF PA

Drug Name DrugTier

RequirementsLimits

TYSABRI CONC 4 PA QL(0536ml daily) SP

Postherpetic Neuralgia (PHN)Neuropathic Pain LYRICA CR TB24 165 MG 825 MG (Use pregabalin(once-daily))

3 PA QL(1 eadaily)

LYRICA CR TB24 330 MG (Use pregabalin (once-daily))

3 PA QL(2 eadaily)

pregabalin (once-daily)tb24 165 mg 825 mg 3 PA QL(1 ea

daily) pregabalin (once-daily)tb24 330 mg 3 PA QL(2 ea

daily) Premenstrual Dysphoric Disorder (PMDD) Agents fluoxetine hcl (pmdd) caps10 mg 1 QL(1 ea daily)

fluoxetine hcl (pmdd) caps20 mg 1 QL(3 ea daily)

Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS 3 PA

Psychotherapeutic and Neurological Agents -ergoloid mesylates tabs 1

pimozide tabs 1

Restless Leg Syndrome (RLS) Agents

HORIZANT TBCR 3 PA QL(2 eadaily)

Smoking Deterrents

APO-VARENICLINE TABS 0 QL(2 ea daily)

bupropion hcl (smokingdeterrent) tb12 0 QL(2 ea daily)

CHANTIX CONTINUING MONTHPAK TABS 0 QL(2 ea daily)

CHANTIX STARTING MONTH PAK TABS 0

CHANTIX TABS 0 QL(2 ea daily)

NICODERM CQ PT24 (Use nicotine) NF QL(1 ea daily)

NICORETTE GUM (Use nicotine polacrilex) NF


128

Drug Name DrugTier

RequirementsLimits

NICORETTE LOZG (Use nicotine polacrilex) NF

NICORETTE MINI LOZG (Use nicotine polacrilex) NF

NICORETTE STARTER KIT GUM (Use nicotine polacrilex)

NF

nicotine polacrilex gum 0

nicotine polacrilex lozg 0

nicotine pt24 0 QL(1 ea daily)

NICOTINE TRANSDERMAL SYSTEM KIT

0

NICOTROL INHALER INHA 0

NICOTROL NS SOLN 0

ZYBAN TB12 (Use bupropion hcl (smokingdeterrent))

NF QL(2 ea daily)

Transthyretin Amyloidosis Agents

TEGSEDI SOSY 4 PA

RESPIRATORY AGENTS - MISC - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human) ARALAST NP SOLR 1000 MG 4 PA SP

ARALAST NP SOLR 500 MG 4 PA

PROLASTIN-C SOLN 1000 MG20ML 4 PA

PROLASTIN-C SOLR 1000 MG 4 PA SP

ZEMAIRA SOLR 4 PA SP

Cystic Fibrosis Agents

KALYDECO TABS 150 MG 4 PA QL(2 eadaily) SP

ORKAMBI PACK 100 MG-125 MG 150 MG-188 MG 4 PA QL(2 ea

daily) ORKAMBI TABS 100 MG-125 MG 125 MG-200 MG 4 PA QL(4 ea

daily)

Drug Name DrugTier

RequirementsLimits

PULMOZYME SOLN 4 PA QL(25 mldaily) SP

TRIKAFTA TBPK 50 MG-100 MG 4 PA QL(3 ea

daily) Pleural Sclerosing Agents SCLEROSOL INTRAPLEURAL AERP 6 PA

STERILE TALC POWDER SUSR 6 PA

Pulmonary Fibrosis Agents

OFEV CAPS 4 PA QL(2 eadaily)

SULFONAMIDES - Drugs to Treat BacterialInfections

Sulfonamides

SULFADIAZINE TABS 1

TETRACYCLINES - Drugs to Treat BacterialInfections

Glycylcyclines

tigecycline solr 1

TYGACIL SOLR (Use tigecycline) NF

Tetracyclines

demeclocycline hcl tabs 1

doxycycline (monohydrate)caps 50 mg 100 mg 1 QL(2 ea daily)

doxycycline (monohydrate)caps 75 mg 1

doxycycline (monohydrate)tabs 100 mg 1 QL(2 ea daily)

doxycycline (monohydrate)tabs 50 mg 1

doxycycline hyclate caps or50 mg 100 mg 1 QL(2 ea daily)

doxycycline hyclate solr iv100 mg 1

doxycycline hyclate tabs or100 mg 20 mg 1 QL(2 ea daily)

MINOCIN CAPS OR 50 MG (Use minocycline hcl) NF QL(3 ea daily)


129

Drug Name DrugTier

RequirementsLimits

minocycline hcl caps 100mg 50 mg 75 mg 1 QL(3 ea daily)

minocycline hcl tabs 100mg 50 mg 75 mg 1 QL(3 ea daily)

TARGADOX TABS (Use doxycycline hyclate) NF

tetracycline hcl caps 1 QL(8 ea daily)

VIBRAMYCIN CAPS 100 MG (Use doxycyclinehyclate)

NF QL(2 ea daily)

XIMINO CP24 135 MG 45 MG 90 MG (Use minocycline hcl)

NF

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents

methimazole tabs 1

propylthiouracil tabs 1

TAPAZOLE TABS (Use methimazole) NF

Thyroid Hormones ARMOUR THYROID TABS 120 MG 15 MG 30 MG 60 MG 90 MG (Use thyroid)

2

QL(1 ea daily)

ARMOUR THYROID TABS 180 MG 240 MG 300 MG 2 QL(1 ea daily)

CYTOMEL TABS (Use liothyronine sodium) NF

levothyroxine sodium tabsor 300 mcg 100 mcg 112mcg 125 mcg 137 mcg150 mcg 175 mcg 200mcg 25 mcg 50 mcg 75mcg 88 mcg

1

liothyronine sodium soln 1

liothyronine sodium tabs 1

NATURE-THROID NT-25 TABS 2

NATURE-THROID TABS 2

Drug Name DrugTier

RequirementsLimits

SYNTHROID TABS (Use levothyroxine sodium) 2

thyroid tabs 1 QL(1 ea daily)

TRIOSTAT SOLN (Use liothyronine sodium) NF

WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

ULCER DRUGS - Drugs to Treat Bowel Intestineand Stomach Conditions

Antispasmodics atropine sulfate soln ij 04mgml 1 mgml 1

atropine sulfate sosy ij 025mg5ml 1

chlordiazepoxide hcl-clidinium bromide caps 1

dicyclomine hcl caps or 10 mg 1

dicyclomine hcl soln or 10mg5ml 1

dicyclomine hcl tabs or 20 mg 1

glycopyrrolate soln ij 4mg20ml 1

glycopyrrolate tabs or 1mg 2 mg 1

LIBRAX CAPS (Use chlordiazepoxide hcl-clidinium bromide)

NF

methscopolamine bromidetabs 1

H-2 Antagonists cimetidine hcl soln 300 mg5ml 1 QL(20 ml daily)

cimetidine tabs 200 mg 1 RXOTC


130

Drug Name DrugTier

RequirementsLimits

cimetidine tabs 300 mg400 mg 800 mg 1

famotidine in nacl soln 1

famotidine soln iv 20 mg2ml 200 mg20ml 40mg4ml

1

famotidine susr or 40 mg5ml 1 QL(10 ml daily)

famotidine tabs or 20 mg 1 RXOTC

famotidine tabs or 40 mg 1

nizatidine caps 150 mg300 mg 1

nizatidine soln 15 mgml 1 QL(20 ml daily)

PEPCID AC MAXIMUM STRENGTH TABS (Use famotidine)

NF RXOTC

PEPCID AC TABS (Use famotidine) NF RXOTC

PEPCID TABS 20 MG (Use famotidine) NF RXOTC

PEPCID TABS 40 MG (Use famotidine) NF

ranitidine hcl caps or 150mg 300 mg 1

ranitidine hcl soln ij 150mg6ml 1

ranitidine hcl syrp or 15mgml 150 mg10ml 75mg5ml

1 QL(40 ml daily)

ranitidine hcl tabs or 150 mg 1 RXOTC

ranitidine hcl tabs or 300 mg 1

TAGAMET HB TABS (Use cimetidine) NF RXOTC

ZANTAC 150 MAXIMUM STRENGTH TABS (Use ranitidine hcl)

NF RXOTC

ZANTAC SOLN 25 MGML(Use ranitidine hcl) NF

Misc Anti-Ulcer CARAFATE SUSP 1 GM10ML (Use sucralfate) NF QL(40 ml daily)

Drug Name DrugTier

RequirementsLimits

CARAFATE TABS 1 GM (Use sucralfate) NF QL(4 ea daily)

sucralfate susp 1 gm10ml 1 QL(40 ml daily)

sucralfate tabs 1 gm 1 QL(4 ea daily)

Proton Pump Inhibitors ACIPHEX TBEC (Use rabeprazole sodium) NF QL(1 ea daily)

DEXILANT CPDR 3 PA QL(1 eadaily)

esomeprazole magnesiumcpdr 20 mg 1 QL(2 ea daily)

RXOTC esomeprazole magnesiumcpdr 40 mg 3 QL(1 ea daily)

lansoprazole cpdr 15 mg 1 QL(2 ea daily)RXOTC MP

lansoprazole cpdr 30 mg 1

NEXIUM 24HR TBEC 1 QL(2 ea daily)

NEXIUM CPDR 20 MG (Use esomeprazolemagnesium)



NF QL(1 ea daily)

omeprazole cpdr 10 mg 40 mg 1 QL(2 ea daily)

omeprazole cpdr 20 mg 1 QL(2 ea daily)RXOTC

omeprazole magnesiumcpdr 1 QL(4 ea daily)

omeprazole magnesiumtbec 1 QL(4 ea daily)

omeprazole tbec 20 mg 1 QL(2 ea daily)

pantoprazole sodium tbecor 20 mg 1 QL(1 ea daily)

pantoprazole sodium tbecor 40 mg 1

PREVACID 24HR CPDR (Use lansoprazole) NF QL(2 ea daily)

RXOTC MP PREVACID CPDR 15 MG (Use lansoprazole) NF QL(2 ea daily)

RXOTC MP


131

Drug Name DrugTier

RequirementsLimits

PREVACID CPDR 30 MG (Use lansoprazole) NF

PRILOSEC OTC TBEC (Use omeprazolemagnesium)

1 QL(4 ea daily)

PROTONIX TBEC OR 20 MG (Use pantoprazolesodium)

NF QL(1 ea daily)


NF

rabeprazole sodium tbec 1 QL(1 ea daily)

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use misoprostol) NF QL(4 ea daily)

misoprostol tabs 1 QL(4 ea daily)

Ulcer Therapy Combinations omeprazole-sodiumbicarbonate caps 20 mg-1100 mg


ZEGERID CAPS 20 MG-1100 MG (Use omeprazole-sodiumbicarbonate)

NF

RXOTC

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics darifenacin hydrobromidetb24 1 QL(1 ea daily)

DETROL LA CP24 (Use tolterodine tartrate) NF QL(1 ea daily)

DETROL TABS (Use tolterodine tartrate) NF

DITROPAN XL TB24 (Use oxybutynin chloride) NF

ENABLEX TB24 (Use darifenacin hydrobromide) NF QL(1 ea daily)

oxybutynin chloride syrp 1

oxybutynin chloride tabs 1

oxybutynin chloride tb24 1

Drug Name DrugTier

RequirementsLimits

solifenacin succinate tabs 1 PA QL(1 eadaily)

tolterodine tartrate cp24 2mg 4 mg 1 QL(1 ea daily)

tolterodine tartrate tabs 1 mg 2 mg 1

TOVIAZ TB24 3 PA QL(1 eadaily)

trospium chloride cp24 60 mg 1 QL(1 ea daily)

trospium chloride tabs 20 mg 1

VESICARE TABS (Use solifenacin succinate) NF PA QL(1 ea

daily) Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24 3 PA

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs 10 mg 5 mg 50 mg 1 QL(4 ea daily)

bethanechol chloride tabs 25 mg 1

URECHOLINE TABS 10 MG 5 MG 50 MG (Use bethanechol chloride)

NF QL(4 ea daily)

URECHOLINE TABS 25 MG (Use bethanechol chloride)

NF

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs 1

VACCINES

Bacterial Vaccines

BCG VACCINE INJ 6 PA

MENACTRA INJ 0

MENQUADFI INJ 0

MENVEO SOLR 0

PNEUMOVAX 23 INJ 0

PNEUMOVAX 231 DOSEINJ 0


132

Drug Name DrugTier

RequirementsLimits

PREVNAR 13 SUSP 0

Viral Vaccines

AFLURIA QUADRIVALENT 2019-2020 SUSP 0

Limit 1 dose per season1 rtlMAX fill180 rtl day(s) supply

AFLURIA QUADRIVALENT 2019-2020 SUSY 0










ENGERIX-B INJ 0

3 rtl MAX fill365 rtl day(s) supply3mail MAX fill365 mail day(s) supply

ENGERIX-B SUSP 0


FLUAD 2019-2020 SUSY 0




Drug Name DrugTier

RequirementsLimits

FLUAD QUADRIVALENT 2021-2022 PRSY 0


FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS PRSY

0 1 rtl MAX fill180 rtl day(s) supply

FLUARIX QUADRIVALENT 2019-2020 SUSY 0






FLUBLOK QUADRIVALENT 2019-2020 SOSY

0



0



0


FLUCELVAX QUADRIVALENT 2019-2020 SUSP

0


FLUCELVAX QUADRIVALENT 2019-2020 SUSY

0



0



0



133

Drug Name DrugTier

RequirementsLimits


0



0


FLULAVAL QUADRIVALENT 2019-2020 SUSP

0


FLULAVAL QUADRIVALENT 2019-2020 SUSY

0



0



0


FLUMIST QUADRIVALENT SUSP 0


FLUZONE HIGH-DOSE PF 2019-2020 SUSY 0






FLUZONE QUADRIVALENT 2019-2020 SUSP

0


FLUZONE QUADRIVALENT 2019-2020 SUSY

0


Drug Name DrugTier

RequirementsLimits


0



0



0



0


GARDASIL 9 SUSP 0 3 rtl MAX fill365 rtl day(s) supply

GARDASIL 9 SUSY 0 3 rtl MAX fill365 rtl day(s) supply

HAVRIX SUSP 0 1 rtl MAX fill365 rtl day(s) supply

HEPLISAV-B SOLN 0 1 rtl MAX fill365 rtl day(s) supply

HEPLISAV-B SOSY 0 1 rtl MAX fill365 rtl day(s) supply

IPOL INACTIVATED IPV INJ 0


M-M-R II SOLR 0 1 rtl MAX fill365 rtl day(s) supply

RECOMBIVAX HB SUSP 0 1 rtl MAX fill365 rtl day(s) supply

ROTARIX SUSR 0 1 rtl MAX fill365 rtl day(s) supply

ROTATEQ SOLN 0 1 rtl MAX fill365 rtl day(s) supply


134

Drug Name DrugTier

RequirementsLimits

SHINGRIX SUSR 0

2 rtl pack lmtamt999 rtl pack lmtday(s) AL(Atleast 50 yrsold)

TWINRIX SUSY 0 1 rtl MAX fill365 rtl day(s) supply

VAQTA SUSP 0 1 rtl MAX fill365 rtl day(s) supply

VARIVAX INJ 0 2 rtl MAX fill365 rtl day(s) supply

ZOSTAVAX SUSR 0


VAGINAL AND RELATED PRODUCTS

Miscellaneous Vaginal Products

INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0

Vaginal Anti-infectives CLEOCIN CREA VA 2 (Use clindamycinphosphate vaginal)

NF

clindamycin phosphatevaginal crea 1

clotrimazole vaginal crea 1

GYNAZOLE-1 CREA 3

GYNE-LOTRIMIN CREA (Use clotrimazole vaginal) NF

METROGEL-VAGINAL GEL (Use metronidazole vaginal)

NF

Drug Name DrugTier

RequirementsLimits

metronidazole vaginal gel 1

miconazole nitrate vaginal supp 1

terconazole vaginal crea 1

terconazole vaginal supp 1

Vaginal Contraceptive - pH Modulators

PHEXXI GEL 0 PV

Vaginal Estrogens ESTRACE CREA (Use estradiol vaginal) NF

estradiol vaginal crea 1

estradiol vaginal tabs 1

FEMRING RING 3

PREMARIN CREA 2

VAGIFEM TABS (Use estradiol vaginal) NF

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents ADRENALIN SOLN IJ 30 MG30ML (Use epinephrine(anaphylaxis))

NF

epinephrine (anaphylaxis)soaj 015 mg03ml 1

QL(2 ea per fillretail2 ea perfill mail)2 rtlMAX fill365 rtl day(s) supply2mail MAX fill365 mail day(s) supply


QL(2 ea per fillretail)2 rtl MAXfill365 rtl day(s) supply

EPIPEN 2-PAK SOAJ (Use epinephrine (anaphylaxis)) NF


135

Drug Name DrugTier

RequirementsLimits

EPIPEN-JR 2-PAK SOAJ (Use epinephrine(anaphylaxis))

2


Vasopressors

midodrine hcl tabs 1

VITAMINS

Oil Soluble Vitamins cholecalciferol caps 125mg 50000 unit 1

cholecalciferol tabs 400 unit 0

DRISDOL CAPS (Use ergocalciferol) 0

ergocalciferol caps or 125mg 50000 unit 0

ergocalciferol soln or 200mcgml 8000 unitml 1

VITAMIN D2 TABS 0 AL(At least 65yrs old)

Water Soluble Vitamins niacin cpcr or 250 mg 500 mg 1

niacin tabs or 250 mg 50mg 100 mg 500 mg 1

niacin tbcr or 750 mg 250mg 500 mg 1

NIACIN TR TBCR 1

niacinamide tabs or 100 mg 500 mg 1

SLO-NIACIN TBCR (Use niacin) 1


136

Index 1ST TIER UNILET COMFORTOUCH LANCETS 28G 82 1ST TIER UNILET COMFORTOUCH LANCETS 30G 82 abacavir sulfate 48

ACTIMMUNE 42 ADVOCATE INSULIN SYRINGEU-1001ML31GX516ACTIQ 6

94 ACTONEL 70 ADVOCATE LANCETS 82 ACTOPLUS MET 23 ADVOCATE LANCETS 30G 82 ACTOS 24 ADVOCATE LANCING ACULAR 124 DEVICE 82

abacavir sulfate-lamivudine 48 ADVOCATE RAPID-SAFE ACULAR LS 124 abacavir sulfate-lamivudine- LANCING DEVICE 82 acyclovir 51 zidovudine 48 ADVOCATE SAFETY

acyclovir topical 64 LANCETS 82 ABELCET 27 ADACEL 130 ADVOCATE SAFETY LANCETS ABILIFY 48 26G 82 ADALAT CC 53 abiraterone acetate 38 ADZENYS ER 1 adapalene 60 ABRAXANE 43 AFINITOR 40 adapalene-benzoylABSORICA 59 peroxide 60 AFINITOR DISPERZ 40

acamprosate calcium 127 ADCETRIS 37 AFLURIA QUADRIVALENT acarbose 23 2019-2020 133 ADCIRCA 55 AFLURIA QUADRIVALENT ACCOLATE 14 ADDERALL 1 2020-2021 133 ACCU-CHEK FASTCLIX ADDERALL XR 1 AFLURIA QUADRIVALENT LANCETS 82 2021-2022 133 ACCU-CHEK MULTICLIX adefovir dipivoxil 51 AGAMATRIX ULTRA-THIN LANCETS 82 ADEMPAS 55 LANCETS 33G 82 ACCU-CHEK SAFE-T-PRO ADIPEX-P 1 AGGRENOX 76 LANCETS 82 ADJUSTABLE LANCING ACCU-CHEK SAFE-T-PRO AGRYLIN 76 DEVICE 82 PLUSLANCETS 82 AIMOVIG 115 ADRENALIN 135 ACCU-CHEK SOFTCLIX AIMSCO LUBRICATED 80 LANCETS 82 ADVAIR DISKUS 14 AIMSCO TWIST LANCETS ACCUPRIL 30 ADVAIR HFA 14 32G 82 ACCURETIC 31 ADVANCED MOBILE LANCET AIMSCO TWIST LANCETS

30G 82 acebutolol hcl 52 33G 82 ADVOCATE INSULIN AIRDUO RESPICLICK acetaminophen w codeine 8 SYRINGEU- 11314 14 acetaminophen-caff- 10003ML29GX12 93 AIRDUO RESPICLICK dihydrocod 8 ADVOCATE INSULIN 23214 14 acetazolamide 69 SYRINGEU- AIRDUO RESPICLICK 551414

acetazolamide sodium 69 10003ML30GX516 93 AKYNZEO 26 ADVOCATE INSULIN acetic acid 75 SYRINGEU- albendazole 10 acetic acid (otic) 125 10003ML31GX516 93 ALBENZA 10 acetylcysteine 59 ADVOCATE INSULIN albuterol sulfate 1415 ACIPHEX 131 SYRINGEU-

ALCAINE 123 10005ML29GX12 93 acitretin 64 ADVOCATE INSULIN alclometasone dipropionate 64 ACTHAR 71 SYRINGEU- ALDACTAZIDE 69 ACTI-LANCE LANCETS 10005ML30GX516 93 ALDACTONE 70 28G 82 ADVOCATE INSULIN ACTI-LANCE LITE SAFETY SYRINGEU- ALDARA 67 LANCETS 28G 82 10005ML31GX516 94 ALDURAZYME 72 ACTI-LANCE SPECIAL SAFETY ADVOCATE INSULIN ALECENSA 40 LANCETS 17G 82 SYRINGEU-ACTI-LANCE SPECIAL alendronate sodium 70 1001ML29GX12 94 SAFETYLANCETS 17G 82 ADVOCATE INSULIN ALFERON N 42 ACTI-LANCE UNIVERSAL SYRINGEU- alfuzosin hcl 76 SAFETY LANCETS 23G 82 1001ML30GX516 94 ALIMTA 36 ACTIGALL 74

Index 1

ALINIA 11 amlodipine besylate- ARCAPTA NEOHALER 15 atorvastatin calcium 54 ALIQOPA 40 arformoterol tartrate 15 amlodipine besylate-benazepril

aliskiren fumarate 33 ARICEPT 127 hcl 31 ALKERAN 35 amlodipine besylate-olmesartan ARIKAYCE 3

medoxomil 31 ALLEGRA ALLERGY 28 ARIMIDEX 38 amlodipine besylate-ALLEGRA ALLERGY aripiprazole 48 valsartan 31 CHILDRENS 28 amlodipine-valsartan- ARIXTRA 16 ALLEGRA-D 12 HOUR hydrochlorothiazide 32 armodafinil 2 ALLERGY amp CONGESTION 59 amoxapine 23 ALLEGRA-D 24 HOUR ARMOUR THYROID 130 ALLERGY amp CONGESTION 59 amoxicillin 126 ARNUITY ELLIPTA 14 allopurinol 76 amoxicillin amp pot AROMASIN 38 clavulanate 126 almotriptan malate 115 amphetamine- ARRANON 36 ALOCRIL 124 dextroamphetamine 1 arsenic trioxide 42 alogliptin benzoate 24 amphotericin b 27 ARTHROTEC 50 4 ALOMIDE 124 ampicillin 126 ARTHROTEC 75 4 alosetron hcl 75 ampicillin amp sulbactam ARZERRA 37 ALOXI 26 sodium 126 ASACOL HD 74 ampicillin sodium 126 ALPHAGAN P 123 asenapine maleate 47 AMPYRA 127 alprazolam 13 ASPARLAS 42 ANADROL-50 9 ALREX 123 aspirin 6 ANAFRANIL 23 ALTABAX 61 aspirin-dipyridamole 76 anagrelide hcl 76 ALTACE 30 ASSURE HAEMOLANCE PLUS ALTERNATE SITE LANCING anastrozole 38 HIGH FLOW 18G 82 DEVICE 82 ANCOBON 27 ASSURE HAEMOLANCE PLUS ALTOPREV 30 LOW FLOW 25G 82 ANDRODERM 10

ASSURE HAEMOLANCE PLUS ALUNBRIG 40 ANDROGEL 10 MICRO FLOW 28G 82 alvimopan 75 ANNOVERA 57 ASSURE HAEMOLANCE PLUS amantadine hcl 45 ANORO ELLIPTA 15 NORMAL FLOW 21G 82 AMARYL 25 ASSURE HAEMOLANCE PLUS ANTABUSE 127 PEDIATRIC BLADE 82 AMBIEN 78 ANUSOL-HC 10 ASSURE ID INSULIN AMBIEN CR 78 ANZEMET 26 SAFETYSYRINGEU-AMBISOME 27 APIDRA 24 10005ML29G X 12 94

ASSURE ID INSULIN ambrisentan 54 APIDRA SOLOSTAR 24 SAFETYSYRINGEU-amcinonide 65 APO-VARENICLINE 128 1001ML29G X 12 94 AMCINONIDE 65 APOKYN 45 ASSURE LANCE LANCETS 82 AMERGE 115 apraclonidine hcl 123 ASSURE LANCE LANCETS AMICAR 78 aprepitant 27 21G 82

ASSURE LANCE PLUS amikacin sulfate 3 APRISO 74 SAFETYLANCETS 25G 82 amiloride amp APTIOM 17 ASSURE LANCE PLUS hydrochlorothiazide 69 SAFETYLANCETS 30G 83 APTIVUS 48 amiloride hcl 70 ASSURE LANCE SAFETY AQUA LANCE ADJUSTABLE aminocaproic acid 78 LANCET 28G 83 LANCING DEVICE 82 aminophylline 15 ARALAST NP 129 ASSURE LANCETS 83 amiodarone hcl 13 ARANESP ALBUMIN ATACAND 31 AMITIZA 74 FREE 77 ATACAND HCT 32 amitriptyline hcl 23 ARAVA 5 atazanavir sulfate 48

ARCALYST 4 ATELVIA 70 amlodipine besylate 53

Index 2

atenolol 52 azelastine hcl (ophth) 124 BD INSULIN SYRINGE MICROFINE IVU-atenolol amp chlorthalidone 32 AZELEX 60 10005ML28G X 12 94 ATGAM 118 AZILECT 46 BD INSULIN SYRINGE

ATIVAN 13 azithromycin 80 MICROFINE IVU-1001ML27Gatomoxetine hcl 2 AZOR 32 X 58 94

BD INSULIN SYRINGE atorvastatin calcium 30 aztreonam 11 MICROFINE IVU-1001ML28Gatovaquone 11 AZULFIDINE 74 X 12 94 atovaquone-proguanil hcl 33 AZULFIDINE EN-TABS 74 BD INSULIN SYRINGE

B-D INSULIN SYRINGE MICROFINEU-10005ML28G XATRIPLA 48 ULTRAFINE II03ML31G X 12 94 atropine sulfate 130 516 94 BD INSULIN SYRINGE

ATROVENT HFA 14 B-D INSULIN SYRINGE MICROFINEU-1001ML27G XAUBAGIO 127 ULTRAFINE II05ML31G X 58 94

516 94 BD INSULIN SYRINGE AUGMENTIN 126 B-D INSULIN SYRINGE MICROFINEU-1001ML28G X

AUGMENTIN ES-600 126 ULTRAFINE II1ML31G X 12 94 AURORA LANCET SUPER BD INSULIN SYRINGE 516 94 THIN30G 83 B-D INSULIN SYRINGE SAFETYGLIDE1ML29G XAURORA LANCET THIN ULTRAFINE03ML30G X 12 94 23G 83 12 94 BD INSULIN SYRINGE SLIP AUSTEDO 127 B-D INSULIN SYRINGE TIPU-1001ML 94 AUTO-LANCET 83 ULTRAFINE05ML30G X BD INSULIN SYRINGE ULTRA-

12 94 FINE03ML30G X 127MM 94 AUTO-LANCET MINI 83 BD INSULIN SYRINGE ULTRA-bacitracin 10 AUTOLET IMPRESSION FINE03ML31G X 8MM 94 LANCING DEVICE 83 bacitracin (ophthalmic) 123 BD INSULIN SYRINGE ULTRA-AUTOLET LANCING baclofen 121 FINE05ML30G X 127MM 94 DEVICE 83 BD INSULIN SYRINGE ULTRA-BACTRIM 11 AUTOLET MINI 83 FINE05ML31G X 8MM 94 BACTRIM DS 10 AUTOLET PLUS 83 BD INSULIN SYRINGE ULTRA-

BALCOLTRA 56 FINE12 UNIT03ML31G XAVALIDE 32 balsalazide disodium 74 8MM 94 AVANDIA 24 BD INSULIN SYRINGE ULTRA-BALVERSA 40 AVAPRO 31 FINE1ML30G X 127MM 94 BANZEL 17 BD INSULIN SYRINGE ULTRA-AVASTIN 36 BAQSIMI ONE PACK 24 FINE1ML31G X 8MM 94 AVELOX 74 BD INSULIN SYRINGE BAQSIMI TWO PACK 24 AVODART 76 ULTRAFINE HALF-BARACLUDE 51 AVONEX 127 UNIT03ML31G X 516 95 BASAGLAR KWIKPEN 24 BD INSULIN SYRINGE AVONEX PEN 127 BAVENCIO 37 ULTRAFINE03ML30G XAVSOLA 74 12 95 BAXDELA 74 AYGESTIN 126 BD INSULIN SYRINGE BCG VACCINE 132 AYVAKIT 39 ULTRAFINE03ML31G XBD LO-DOSE INSULIN 516 95 azacitidine 36 SYRINGE MICROFINE BD INSULIN SYRINGE

AZACTAM 11 IV05ML28G X 12 94 ULTRAFINE05ML30G XAZASAN 118 BD AUTOSHIELD 29G X 12 95

316 94 BD INSULIN SYRINGE AZASITE 123 BD AUTOSHIELD 29G X ULTRAFINE05ML31G XAZATHIOPRINE 118 516 94 516 95 azathioprine 118 BD AUTOSHIELD DUO 30G X BD INSULIN SYRINGE AZEDRA DOSIMETRIC 42 5MM 94 ULTRAFINE1ML30G X

BD INSULIN SYRINGE LUER- 12 95 AZEDRA THERAPEUTIC 42 LOKU-1001ML 94 BD INSULIN SYRINGE azelaic acid 68 ULTRAFINEU-10003ML29G Xazelastine hcl 121 12 95

Index 3

BD INSULIN SYRINGE BD SAFETY-LOK INSULIN BETAPACE AF 53 ULTRAFINEU-10005ML29G X12 95 BD INSULIN SYRINGE ULTRAFINEU-1001ML29G X12 95 BD INSULIN SYRINGE ULTRAFINEU-1001ML31G X516 95 BD INSULIN SYRINGE03ML29G X127MM 95 BD INSULIN SYRINGE05ML29G X127MM 95 BD INSULIN SYRINGE1ML27GX 127MM 95 BD INSULIN SYRINGE1ML29GX 127MM 95 BD INSULIN SYRINGEDETACHABLENEEDLEU-1001ML25G X1 95 BD INSULIN SYRINGEDETACHABLENEEDLEU-1001ML25G X58 95 BD INSULIN SYRINGEDETACHABLENEEDLEU-1001ML26G X12 95 BD INSULIN SYRINGEU-1001ML27G X 12 95 BD LANCET ULTRAFINE 30G 83

SYRINGEPERMNEEDLEUF1ML29G X12 95 BD SAFETYGLIDE INSULIN SYRINGE03ML29G X12 95 BD SAFETYGLIDE INSULIN SYRINGE03ML31G X516 96 BD SAFETYGLIDE INSULIN SYRINGE1ML31G X1564 96 BD SAFETYGLIDE INSULIN SYSYRINGE05ML30G X516 96 BD VEO INSULIN SYRINGE ULTRA-FINE1ML31G X6MM 96 BD VEO INSULIN SYRINGE ULTRA-FINEU-1001ML31GX 1564 96 BELEODAQ 40 BELRAPZO 35 BELSOMRA 79 BELVIQ 2 benazepril amphydrochlorothiazide 32 benazepril hcl 30 BENDAMUSTINE HYDROCHLORIDE 35 BENDEKA 35 BENICAR 31

BETASERON betaxolol hcl betaxolol hcl (ophth) bethanechol chloride BEVESPI AEROSPHERE BEVYXXA bexarotene BEYAZ bicalutamide BICNU BIDIL BIKTARVY BILTRICIDE bimatoprost bisacodyl bisoprolol amphydrochlorothiazide bisoprolol fumarate BLENREP bleomycin sulfate BLEPH-10 BLINCYTO BONIVA BONJESTA BOOSTRIX BORTEZOMIB bosentan

127 52

122 132

15 16 42 56 38 35 54 48 10

125 79

32 52 37 39

123 37 70 26

130 40 54

BD LANCET ULTRAFINE 33G BD MICROTAINER LANCETS

83

83

BENICAR HCT 32 BENZACLIN 60 BENZACLIN WITH PUMP 60

BOSULIF BOTOX BRAFTOVI

40 122

40 BD PEN NEEDLEMICROULTRA-FINE32G X 6MM 95 BD PEN NEEDLEMINIULTRA-FINE31G X 5MM 95 BD PEN NEEDLENANO 2NDGEN32G X 532 95 BD PEN NEEDLENANOULTRA-FINE32G X 4MM 95 BD PEN NEEDLEORIGINALULTRA-FINE29G X 127MM 95 BD PEN NEEDLESHORTULTRA-FINE31G X 8MM 95 BD SAFETY-GLIDE INSULIN SYRINGE05ML29G X 12 95

BENZAMYCIN 60 benzonatate 59 benzoyl peroxide 60 BENZOYL PEROXIDE CLEANSER 60 benzoyl peroxide-erythromycin 60 benztropine mesylate 44 bepotastine besilate 124 BEPREVE 124 BESPONSA 37 betamethasone dipropionate(topical) 65 betamethasone dipropionateaugmented 65 betamethasone valerate 65 BETAPACE 53

BREO ELLIPTA 15 BRILINTA 77 brimonidine tartrate 123 BRIVIACT 17 bromfenac sodium (ophth) 124 bromocriptine mesylate 45 BROVANA 15 BRUKINSA 40 budesonide 58 budesonide (inhalation) 14 budesonide (nasal) 121 budesonide-formoterol fumarate dihydrate 15 BULLSEYE MINI SAFETY LANCETS 83 BULLSEYE SAFETY LANCETS 83

Index 4

bumetanide 69 CANASA 74 CARETOUCH SAFETY LANCETS26G 83 BUMEX 69 CANCIDAS 27 CARETOUCH SAFETY

BUNAVAIL 9 candesartan cilexetil 31 LANCETS28G 83 BUPHENYL 72 candesartan cilexetil- CARETOUCH SAFETY BUPRENEX 9 buprenorphine 9 buprenorphine hcl 9 buprenorphine hcl-naloxone hcldihydrate 9 bupropion hcl 20 bupropion hcl (smokingdeterrent) 128 buspirone hcl 12 busulfan 35 BUSULFEX 35 butalbital-acetaminophen 5 butalbital-acetaminophen-caffeine 5 butalbital-acetaminophen-caffeine w codeine 8 butalbital-aspirin-caffeine 5 butalbital-aspirin-caffeinewcod 8 BUTALBITALACETAMINOPHEN

5 butenafine hcl 61 butorphanol tartrate 9 BUTRANS 9

hydrochlorothiazide CAPASTAT SULFATE capecitabine CAPRELSA captopril CARAC CARAFATE CARBAGLU carbamazepine CARBATROL carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carbinoxamine maleate carboplatin CARDIOCOM LANCING DEVICE CARDIZEM CARDIZEM CD CARDIZEM LA CARDURA CAREONE ADVANCED

32 34 36 41 30 63

131 72 17 17 44 45

45 28 35

83 53 53 53 31

LANCETS30G 83 CARETOUCH TWIST LANCETS 28G 83 CARETOUCH TWIST LANCETS 30G 83 CARETOUCH TWIST LANCETS 33G 83 carisoprodol 121 carmustine 35 carteolol hcl (ophth) 122 carvedilol 52 CASODEX 38 caspofungin acetate 27 CATAPRES 31 CATAPRES-TTS-1 31 CATAPRES-TTS-2 31 CATAPRES-TTS-3 31 CAYA 80 cefaclor 55 cefadroxil 55 cefazolin sodium 55 cefdinir 55 cefditoren pivoxil 56

BYSTOLIC cabergoline CABLIVI CABOMETYX

52 73 77 40

LANCINGDEVICE CAREONE INSULIN SYRINGES03ML30G X12 CAREONE INSULIN

83

96

cefepime hcl cefixime CEFOTAN cefotaxime sodium

56 56 55 56

CADUET 54 CAFERGOT 115 CALAN 53 CALAN SR 53 calcipotriene 64 calcipotriene-betamethasonedipropionate 65 calcitonin (salmon) 70 calcitriol 72 calcitriol (topical) 64 calcium acetate (phosphatebinder) 75 calcium chloride (dihydrate)117 CALCIUM GLUCONATE 117 calcium gluconate 117 calcium polycarbophil 79 CALQUENCE 40

SYRINGES03ML31G X516 96 CAREONE INSULIN SYRINGES05ML30G X12 96 CAREONE INSULIN SYRINGES05ML31G X516 96 CAREONE INSULIN SYRINGES1ML30G X12 96 CAREONE INSULIN SYRINGES1ML31GX516

96 CAREONE LANCET SUPER THIN30G 83 CAREONE LANCET THIN 83 CARESENS LANCETS 83 CARETOUCH LANCING DEVICEWITH EJECTOR 83

cefotetan disodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime ceftriaxone sodium cefuroxime axetil cefuroxime sodium CELEBREX celecoxib CELESTONE-SOLUSPAN CELEXA CELLCEPT CELONTIN cephalexin CERDELGA

55 55 56 55 56 56 55 55

4 4

58 21

118 20 55 77

CAMPTOSAR 44 CEREBYX 19

Index 5

CEREZYME 77 ciprofloxacin 74 CLEVER CHOICE COMFORT EZINSULIN CESAMET 26 ciprofloxacin hcl 74 SYRINGE05ML28G X 12 96 cetirizine hcl 28 ciprofloxacin hcl (ophth) 123 CLEVER CHOICE COMFORT

cetirizine-pseudoephedrine 59 CETRAXAL 125 CETROTIDE 71 cevimeline hcl 119 CHANTIX 128 CHANTIX CONTINUING MONTHPAK 128 CHANTIX STARTING MONTH PAK 128 CHEMET 25 CHEMSTRIP-K 69 CHILDRENS ADVIL 4

ciprofloxacin hcl (otic) 125 ciprofloxacin in d5w 74 ciprofloxacin-dexamethasone

125 ciprofloxacin-fluocinoloneacetonide 125 cisplatin 35 CISPLATIN 35 citalopram hydrobromide 21 cladribine 36 CLARINEX 28 clarithromycin 80

EZINSULIN SYRINGE05ML29G X 12 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML30G X 12 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML30G X516 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML31G X516 96 CLEVER CHOICE COMFORT

CHILDRENS MOTRIN 4 CLARITIN 28 EZINSULIN chloramphenicol sodiumsuccinate 11 chlordiazepoxide hcl 13 chlordiazepoxide hcl-clidiniumbromide 130 chlorhexidine gluconate (mouth-throat) 119 chloroquine phosphate 33 chlorothiazide 70 chlorpromazine hcl 48 chlorthalidone 70 chlorzoxazone 121 CHOLBAM 74 cholecalciferol 136 cholestyramine 29 cholestyramine light 29 CHORIONIC GONADOTROPIN 71 CIALIS 54 CICLODAN SOLUTION KIT 61 ciclopirox 61 ciclopirox olamine 61 cidofovir 51 cilostazol 77 CILOXAN 123 CIMDUO 48 cimetidine 130131 cimetidine hcl 130 cinacalcet hcl 72 CINRYZE 76 CIPRO 74 CIPRO HC 125 CIPRODEX 125

CLARITIN ALLERGY CHILDRENS 28 CLARITIN CHILDRENS 28 CLARITIN REDITABS 28 CLARITIN-D 12 HOUR 59 CLARITIN-D 24 HOUR 59 CLASSIC PRENATAL 120 CLEANLET LANCETS 28G 83 CLEMASTINE FUMARATE 28 clemastine fumarate 28 CLENPIQ 79 CLEOCIN 11135 CLEOCIN PEDIATRIC GRANULES 11 CLEOCIN PHOSPHATE 11 CLEOCIN-T 60 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML29G X12 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML30G X12 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML30G X516 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML31G X516 96

SYRINGE10ML30G X 12 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML28GX 12 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML29GX 12 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML30GX 516 96 CLEVER CHOICE COMFORT EZINSULIN SYRINGEU-1001ML31GX516 96 CLIMARA 73 CLIMARA PRO 73 CLINDAGEL 60 clindamycin hcl 11 clindamycin palmitatehydrochloride 11 clindamycin phosphate 11 clindamycin phosphate(topical) 60 clindamycin phosphatevaginal 135 clindamycin phosphate-benzoylperoxide 60 clindamycin phosphate-benzoylperoxide (refrigerate) 60 clindamycin phosphate-tretinoin 60 CLINIMIX 425DEXTROSE10 122 CLINIMIX 425DEXTROSE25 122 CLINIMIX 425DEXTROSE5 122 CLINIMIX 5DEXTROSE25 122

Index 6

CLINIMIX E 5DEXTROSE20 122 clobazam 17 clobetasol propionate 65 clobetasol propionate emollientbase 65 clocortolone pivalate 65 CLODERM 65 CLODERM PUMP 65 clofarabine 36 CLOLAR 36

COMFORT ASSIST INSULIN SYRINGE03ML30G X516 97 COMFORT ASSIST INSULIN SYRINGE03ML31G X516 97 COMFORT ASSIST INSULIN SYRINGE05ML29G X12 97 COMFORT ASSIST INSULIN SYRINGE05ML30G X516 97 COMFORT ASSIST INSULIN

COSMEGEN COSOPT COTELLIC COUMADIN COZAAR CREON CRESEMBA CRESTOR CRIXIVAN cromolyn sodium

39 122

41 15 31 69 27 30 48 13

clomipramine hcl clonazepam clonidine clonidine hcl

23 17 31 31

SYRINGE05ML31G X516 97 COMFORT ASSIST INSULIN SYRINGE1ML29G X 12 97 COMFORT ASSIST INSULIN

cromolyn sodium (ophth) crotamiton CUBICIN CUBICIN RF

124 68 11 11

clonidine hcl (adhd) clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole (topical) clotrimazole vaginal clotrimazole wbetamethasone clozapine CLOZARIL COAGUCHEK LANCETS COARTEM CODEINE SULFATE codeine sulfate COGENTIN COLACE COLAZAL colchicine colchicine w probenecid COLCRYS

2 77 13

119 61

135

61 47 47 83 33

6 6

44 79 74 76 76 76

SYRINGE1ML30G X516 97 COMFORT ASSIST INSULIN SYRINGE1ML31G X516 97 COMFORT ASSURED LANCETS MICRO THIN 33G 83 COMFORT ASSURED LANCETS SUPER THIN 28G 83 COMFORT EZ INSULIN SYRINGEU-10005ML31G X516 97 COMFORT EZ INSULIN SYRINGEU-1001ML31G X516 97 COMFORT LANCETS 83 COMPLERA 48 COMTAN 44 CONCERTA 2 CONTRAVE 2 CONZIP 6

CUPRIMINE 118 CUTIVATE 65 CUVITRU 125 CVS LANCETS 21G 83 CVS LANCETS MICRO THIN 33G 83 CVS LANCETS MICRO-THIN 33G 83 CVS LANCETS ORIGINAL 83 CVS LANCETS THIN 26G 83 CVS LANCETS ULTRA THIN 30G 83 CVS LANCETS ULTRA-THIN 30G 83 CVS LANCING DEVICE 83 CVS PRENATAL 120 CVS ULTRA THIN LANCETS 83 cyanocobalamin 77 cyclobenzaprine hcl 121 cyclophosphamide 35 CYCLOPHOSPHAMIDE 35

colesevelam hcl COLESTID COLESTID FLAVORED

29 29 29

COPAXONE COPIKTRA CORDRAN

127128 41 65

cyclophosphamide cycloserine CYCLOSET

35 34 24

colestipol hcl 29 COLY-MYCIN S 125 COLYTE-FLAVOR PACKS 79 COMBIGAN 122 COMBIVIR 48 COMETRIQ 41 COMFORT ASSIST INSULIN

COREG CORGARD CORLANOR CORTEF CORTENEMA cortisone acetate CORTISPORIN-TC

52 53 55 58 10 58

125

cyclosporine cyclosporine modified (formicroemulsion) CYKLOKAPRON CYMBALTA cyproheptadine hcl CYRAMZA

118

118 78 22 29 36

SYRINGE 03ML29G X 12 97 COSENTYX 64 CYSTADANE 72 COSENTYX SENSOREADY CYSTAGON 75 PEN 64 CYSTARAN 124

Index 7

cytarabine CYTOMEL CYTOTEC CYTOVENE DHE 45 dacarbazine DACOGEN dactinomycin dalfampridine DALIRESP danazol DANTRIUM dantrolene sodium dapsone DAPTOMYCIN daptomycin DARAPRIM darifenacin hydrobromide DARZALEX DARZALEX FASPRO daunorubicin hcl DAUNORUBICIN

36 130 132

51 115

42 36 39

128 14 10

121 121

11 11 11 33

132 37 40 39

DEPO-SUBQ PROVERA 104 57 DEPO-TESTOSTERONE 10 DERMA-SMOOTHEFSBODY 65 DERMA-SMOOTHEFSSCALP 65 DERMOTIC 125 DESCOVY 48 desipramine hcl 23 desloratadine 28 desmopressin acetate 72 DESMOPRESSIN ACETATE 72 desmopressin acetate 7273 desmopressin acetate spray 72 desmopressin acetate sprayrefrigerated 72 desogestrel amp ethinylestradiol 56 desogestrel-ethinyl estradiol(biphasic) 56 desogestrel-ethinyl estradiol(triphasic) 56 desonide 65

DIASTAT ACUDIAL 17 DIASTAT PEDIATRIC 17 DIATHRIVE LANCETS 83 DIATHRIVE LANCETS ULTRA THIN 30G 83 DIATHRIVE LANCING DEVICE 84 diazepam 13 diazepam (anticonvulsant) 17 diazoxide 24 DIBENZYLINE 31 DICLEGIS 27 diclofenac epolamine 61 diclofenac potassium 4 diclofenac sodium 4 diclofenac sodium (actinickeratoses) 63 diclofenac sodium (ophth) 124 diclofenac sodium (topical) 61 diclofenac w misoprostol 4 dicloxacillin sodium 126 dicyclomine hcl 130 didanosine 48

HYDROCHLORIDE DAURISMO DAYPRO DAYTRANA DDAVP DEBACTEROL decitabine deferasirox deferiprone DELESTROGEN DELSTRIGO DELZICOL demeclocycline hcl DEMEROL DENAVIR DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPEN TITRATABS

39 38

4 2

72 119

36 2526

26 73 48 74

129 6

64 20 20 20 20

118

DESOWEN 65 desoximetasone 65 DESOXYN 1 desvenlafaxine succinate 22 DETROL 132 DETROL LA 132 dexamethasone 58 DEXAMETHASONE INTENSOL 58 dexamethasone sodium phosphate 58 dexamethasone sodium phosphate (ophth) 123 dexchlorpheniraminemaleate 28 DEXEDRINE 1 DEXILANT 131 dexmethylphenidate hcl 2 dexrazoxane hcl 43 dextroamphetamine sulfate 1 DEXTROSE 5NACL03 117

DIFFERIN 60 DIFICID 80 diflorasone diacetate 65 DIFLUCAN 27 diflunisal 6 digoxin 54 dihydroergotaminemesylate 115 DILANTIN 19 DILANTIN INFATABS 19 DILANTIN-125 20 DILAUDID 6 diltiazem hcl 53 DILTIAZEM HCL 53 diltiazem hcl 53 diltiazem hcl coated beads 53 diltiazem hcl extended release beads 53 dimethyl fumarate 128 DIOVAN 31 DIOVAN HCT 32

DEPO-ESTRADIOL DEPO-MEDROL DEPO-PROVERA DEPO-PROVERA CONTRACEPTIVE

73 58 38

57

dextrose in lactated ringers DEXTROSESODIUMCHLORIDE DIACOMIT

117

117 1718

DIPENTUM diphenhydramine hcl diphenoxylate w atropine DIPROLENE

74 28 25 66

Index 8

DIPROLENE AF 66 dipyridamole 77 disopyramide phosphate 13 disulfiram 127 DITROPAN XL 132 divalproex sodium 20 DIVIGEL 73 DOCETAXEL 43 docetaxel 43 DOCETAXEL 43 docetaxel 43 DOCETAXEL 43 docetaxel 43 DOCETAXEL 43 docetaxel 43 docusate calcium 79 docusate sodium 79 dofetilide 13 DOLOPHINE 6 donepezil hydrochloride 127 DOPTELET 77 DORAL 78 dorzolamide hcl 124 dorzolamide hcl-timolol maleate 122 DOVATO 48 DOVONEX 64 doxazosin mesylate 31 doxepin hcl 23 doxepin hcl (antipruritic) 63 doxepin hcl (sleep) 78 doxercalciferol 72 DOXIL 39 doxorubicin hcl 40 doxorubicin hcl liposomal 39 doxycycline (monohydrate) 129 doxycycline hyclate 129 doxylamine-pyridoxine 27 DRISDOL 136 dronabinol 27 DROPLET GENTEEL LANCING DEVICE 84 DROPLET INSULIN SYRINGE 03ML29G X 12 97 DROPLET INSULIN SYRINGE 05ML29G X 12 97 DROPLET INSULIN SYRINGE 1ML29G X 12 97

DROPLET INSULIN SYRINGE U-1000331G X 516 97 DROPLET INSULIN SYRINGE U-10003ML30G X 12 97 DROPLET INSULIN SYRINGE U-10003ML30G X 516 97 DROPLET INSULIN SYRINGE U-10005ML30G X 12 97 DROPLET INSULIN SYRINGE U-10005ML30G X 516 97 DROPLET INSULIN SYRINGE U-10005ML31G X 516 97 DROPLET INSULIN SYRINGE U-1001ML30G X 12 97 DROPLET INSULIN SYRINGE U-1001ML30G X 516 97 DROPLET INSULIN SYRINGE U-1001ML31G X 1564 97 DROPLET INSULIN SYRINGE U-1001ML31G X 516 97 DROPLET INSULIN SYRINGEU-10003ML31G X516 97 DROPLET INSULIN SYRINGEU-10005ML30G X12 97 DROPLET INSULIN SYRINGEU-10005ML31G X516 98 DROPLET INSULIN SYRINGEU-1001ML30G X12 98 DROPLET INSULIN SYRINGEU-1001ML31G X1564 98 DROPLET INSULIN SYRINGEU-1001ML31G X516 98 DROPLET LANCETS ULTRA THIN 30G 84 DROPLET LANCING DEVICE 84 DROPLET PERSONAL LANCETS30G 84 drospirenone-ethinylestradiol 56 drospirenone-ethinyl estradiol-levomefolate calcium 56 DROXIA 77 DRUG MART ADJUSTABLE LANCING DEVICE 84 DRUG MART LANCETS THIN 84 DRUG MART ON-THE-GO LANCETS GENTLE 30G 84 DRUG MART UNILET LANCETSSUPER THIN 30G 84

DRUG MART UNILET LANCETSULTRA THIN 28G 84 DRUG MART UNILET MICRO THIN LANCETS 33G 84 DUAC 60 DUAVEE 73 DUETACT 23 DULCOLAX 79 duloxetine hcl 22 DUPIXENT 67 DURAGESIC 6 DUREX EXTRA SENSITIVE 80 DUREZOL 123 dutasteride 76 DYAZIDE 69 DYRENIUM 70 DYSPORT 122 E-Z JECT LANCETS 84 E-Z JECT LANCETS 21G 84 E-Z JECT LANCETS COLOR 84 E-Z JECT LANCETS SUPER THIN 30G 84 E-Z JECT LANCETS THIN 26G 84 E-ZJECT LANCETS MICRO-THIN 33G 84 EES GRANULES 80 EASY COMFORT INSULIN SYRINGE05ML30G X516 98 EASY COMFORT INSULIN SYRINGE05ML31G X516 98 EASY COMFORT INSULIN SYRINGE1ML30G X 516 98 EASY COMFORT INSULIN SYRINGE1ML31G X 516 98 EASY COMFORT INSULIN SYRINGEU-10005ML30G X12 98 EASY COMFORT INSULIN SYRINGEU-1001ML30G X12 98 EASY MINI EJECT LANCING DEVICE 84 EASY MINI LANCING DEVICE 84 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML29GX12 98 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML30GX12 98

Index 9

EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH SAFETY SAFETY INSULIN SYRINGE SYRINGEU-1001ML30G X LANCETS28GBUTTON1ML30GX516 98 12 99 ACTIVATED 85 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH SAFETY SAFETY INSULIN SYRINGE SYRINGEU-1001ML31G X LANCETS28GPRESSURE1ML31GX516 98 516 99 ACTIVATED 85 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE03ML30G X 21GPRESSURE SAFETY INSULIN SYRINGE 516 98 ACTIVATED 84 1ML29GX12 99 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE03ML31G X 23GPRESSURE SAFETY INSULIN SYRINGE 516 98 ACTIVATED 84 1ML30GX516 99 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK SYRINGE05ML29G X 12 98 26GPRESSURE SAFETY INSULIN SYRINGE EASY TOUCH INSULIN ACTIVATED 84 1ML31GX516 99 SYRINGE05ML30G X EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK 516 98 26GPULL-TOP 84 SAFETY SYRINGE EASY TOUCH INSULIN EASY TOUCH LANCETS 1ML30GX12 99 SYRINGE1ML30G X 516 98 28GPRESSURE EASY TWIST amp CAP EASY TOUCH INSULIN ACTIVATED 84 LANCETS 85 SYRINGESAFETYU- EASY TOUCH LANCETS EC-NAPROSYN 4 10005ML29G X 12 98 28GPULL-TOP 84 econazole nitrate 61 EASY TOUCH INSULIN EASY TOUCH LANCETS

ECOTRIN 6 SYRINGESAFETYU- 28GTWIST 84 10005ML30G X 516 98 EASY TOUCH LANCETS ECOTRIN REGULAR EASY TOUCH INSULIN 30GBUTTON-ACTIVATED STRENGTH 6 SYRINGESAFETYU- 84 EDARBI 31 1001ML29G X 12 98 EASY TOUCH LANCETS EDECRIN 69 EASY TOUCH INSULIN 30GPRESSURE EDURANT 48 SYRINGESAFETYU- ACTIVATED 84 1001ML30G X 12 98 EASY TOUCH LANCETS efavirenz 48 EASY TOUCH INSULIN 30GPULL-TOP 84 efavirenz-emtricitabine-tenofovir SYRINGEU-10003ML30G X EASY TOUCH LANCETS disoproxil fumarate 49 12 98 30GTWIST 84 efavirenz-lamivudine-tenofovir EASY TOUCH INSULIN EASY TOUCH LANCETS disoproxil fumarate 49 SYRINGEU-10005ML27G X 32GPRESSURE EFFEXOR XR 22

ACTIVATED 84 12 98 EFFIENT 77 EASY TOUCH INSULIN EASY TOUCH LANCETS EFUDEX 63 SYRINGEU-10005ML28G X 32GPULL-TOP 84 12 98 EASY TOUCH LANCETS EGRIFTA 71 EASY TOUCH INSULIN 32GTWIST 84 EGRIFTA SV 71 SYRINGEU-10005ML29G X EASY TOUCH LANCETS ELAPRASE 72 12 98 33GTWIST 84

ELELYSO 77 EASY TOUCH INSULIN EASY TOUCH LANCING SYRINGEU-10005ML30G X DEVICEEJECTOR 84 ELESTRIN 73 12 99 EASY TOUCH SAFETY eletriptan hydrobromide 115 EASY TOUCH INSULIN LANCETS21GPRESSURE ELIDEL 67 SYRINGEU-10005ML31G X ACTIVATED 84 516 99 EASY TOUCH SAFETY ELIGARD 38 EASY TOUCH INSULIN LANCETS23GPRESSURE ELIMITE 68 SYRINGEU-1001ML27G X ACTIVATED 84 ELIQUIS 16 12 99 EASY TOUCH SAFETY

LANCETS26GBUTTON ELIQUIS STARTER PACK 16 EASY TOUCH INSULIN SYRINGEU-1001ML28G X ACTIVATED 84 ELITE-THIN INSULIN 12 99 EASY TOUCH SAFETY SYRINGE03ML31G XEASY TOUCH INSULIN LANCETS26GPRESSURE 516 99 SYRINGEU-1001ML29G X ACTIVATED 85 ELITE-THIN INSULIN 12 99 SYRINGE05ML29G X 12 99

Index 10

ELITE-THIN INSULIN ENHERTU 37 EQL PRENATAL SYRINGE05ML30G X FORMULA 120 enoxaparin sodium 16 516 99 EQL SUPER THIN LANCETS

entacapone 45 ELITE-THIN INSULIN 30G 85 SYRINGE1ML30G X 516 99 ELITE-THIN INSULIN SYRINGEU-10005ML28G X12 99 ELITE-THIN INSULIN

entecavir ENTEREG ENTOCORT EC ENTRESTO

51 75 58 54

EQL THIN LANCETS 26G EQUETRO ERAXIS ERBITUX

85 46 27 38

SYRINGEU-10005ML31G X516 99 ELITE-THIN INSULIN SYRINGEU-1001ML28G X12 99 ELITE-THIN INSULIN SYRINGEU-1001ML29G X12 99 ELITE-THIN INSULIN

EPCLUSA 51 EPIDIOLEX 18 EPIDUO 60 epinastine hcl (ophth) 124 epinephrine (anaphylaxis)135 EPIPEN 2-PAK 135 EPIPEN-JR 2-PAK 136

ergocalciferol ergoloid mesylates ERGOMAR ergotamine w caffeine ERIVEDGE ERLEADA erlotinib hcl

136 128 115 115

38 38 38

SYRINGEU-1001ML31G X516 99 ELITEK 43 ELIXOPHYLLIN 15 ELLA 57 ELLENCE 40 ELMIRON 76 ELOCON 66 ELZONRIS 42 EMBEDA 6 EMBRACE LANCETS ULTRA THIN 30G 85 EMBRACE LANCING DEVICE WITH EJECTOR 85 EMCYT 38 EMEND 27 EMEND TRIPACK 27 EMFLAZA 58 EMGALITY 115 EMPLICITI 37 EMSAM 21 emtricitabine 49 emtricitabine-tenofovir disoproxilfumarate 49 EMTRIVA 49 EMVERM 10 ENABLEX 132 enalapril maleate 30 enalapril maleate amphydrochlorothiazide 32 ENBREL 5 ENBREL MINI 5 ENBREL SURECLICK 5 ENGERIX-B 133

epirubicin hcl 40 EPIVIR 49 EPIVIR HBV 51 eplerenone 33 EPOGEN 77 epoprostenol sodium 54 eprosartan mesylate 31 EPZICOM 49 EQL COLOR LANCETS 21G 85 EQL COLOR LANCETS MICRO THIN 33G 85 EQL INSULIN SYRINGE03ML29G X12 99 EQL INSULIN SYRINGE03ML30G X516 99 EQL INSULIN SYRINGE03ML31G X516 99 EQL INSULIN SYRINGE05ML29G X12 99 EQL INSULIN SYRINGE05ML30G X516 99 EQL INSULIN SYRINGE05ML31G X516 99 EQL INSULIN SYRINGE1ML29G X 12 99 EQL INSULIN SYRINGE1ML30G X516 99 EQL INSULIN SYRINGE1ML31G X516 99

ERTACZO 61 ertapenem sodium 11 ERWINASE 42 ERWINAZE 42 ERYPED 200 80 ERYPED 400 80 erythromycin (acne aid) 60 erythromycin (ophth) 123 erythromycin base 80 erythromycin ethylsuccinate 80 escitalopram oxalate 21 ESGIC 5 esomeprazole magnesium 131 estazolam 78 ESTRACE 73 estradiol 73 estradiol vaginal 135 estradiol valerate 73 ESTROGEL 73 ESTROSTEP FE 56 eszopiclone 78 ethacrynic acid 70 ethambutol hcl 34 ethosuximide 20 ethynodiol diacet amp ethestrad 56 ETHYOL 43 etidronate disodium 70 etodolac 4 etonogestrel-ethinyl estradiol57 ETOPOPHOS 44 etoposide 44

Index 11

etravirine 49 famotidine in nacl 131 FIFTY50 SAFETY SEAL

EUCRISA 68 EURAX 68 EVAMIST 73 everolimus 41 everolimus (immunosuppressant) 118 EVISTA 71 EVOCLIN 60 EVOMELA 35 EVOXAC 119 EXEL COMFORT POINT INSULIN SYRINGE03ML29G X12 100 EXEL COMFORT POINT INSULIN SYRINGE03ML30G X516 100 EXEL COMFORT POINT

FANAPT 46 FANAPT TITRATION PACK 46 FANTASY LUBRICATED 80 FANTASY LUBRICATEDSPERMICIDE

80 FARESTON 38 FARXIGA 25 FARYDAK 41 FASENRA 13 FASENRA PEN 13 FASLODEX 38 FAZACLO 47 FC FEMALE CONDOM 80 febuxostat 76

LANCETS 30G 85 FIFTY50 SAFETY SEAL LANCETS 32G 85 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE03ML31G X516 100 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE05ML31G X516 100 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE1ML31G X516 100 FIFTY50 UNILET LANCETS 33G 85 FINACEA 68 finasteride 76

INSULIN SYRINGE05ML28G X12 100 EXEL COMFORT POINT INSULIN SYRINGE05ML29G X12 100 EXEL COMFORT POINT INSULIN SYRINGE05ML30G X516 100 EXEL COMFORT POINT

felbamate FELBATOL FELDENE felodipine FEMARA FEMCAP FEMHRT

19 19

4 53 38 80 73

FINE 30 FINGERSTIX LANCETS FIORICET FIORICETCODEINE FIORINAL FIORINALCODEINE 3 FIRAZYR

85 85

5 8 6 8

76 INSULIN SYRINGE1ML28G X12 100 EXEL COMFORT POINT INSULIN SYRINGE1ML29G X12 100 EXEL COMFORT POINT INSULIN SYRINGE1ML30G X516 100 EXELDERM 62 exemestane 38 EXFORGE 32 EXFORGE HCT 32 EXJADE 26 EXTAVIA 128 EZ-LETS LANCETS 21G 85 EZ-LETS LANCETS 26G SUPER-SOFT 85 EZ-LETS LANCETS 28G ULTRA-SOFT 85 EZ-LETS LANCETS 30G 85 ezetimibe 30 ezetimibe-simvastatin 29 FABRAZYME 72 FALESSA 56 famciclovir 51

FEMRING 135 fenofibrate 30 fenofibrate micronized 30 fenoprofen calcium 4 FENSOLVI 71 fentanyl 6 fentanyl citrate 6 FENTORA 6 FER-IN-SOL 78 FERRIPROX 26 ferrous fumarate-folic acid 78 ferrous sulfate 78 FETZIMA 22 FETZIMA TITRATION PACK 22 fexofenadine hcl 28 fexofenadine-pseudoephedrine

59 FIASP 24 FIASP FLEXTOUCH 24 FIASP PENFILL 24 FIBERCON 79 FIBRICOR 30

FIRDAPSE 34 FIRMAGON 38 FIRVANQ 11 FLAGYL 10 flavoxate hcl 132 flecainide acetate 13 FLECTOR 61 FLOLAN 54 FLOMAX 76 FLONASE ALLERGY RELIEF 121 FLONASE ALLERGY RELIEF CHILDRENS 121 FLOVENT DISKUS 14 FLOVENT HFA 14 FLOXIN OTIC 125 floxuridine 36 FLUAD 2019-2020 133 FLUAD 2020-2021 133 FLUAD QUADRIVALENT 2021-2022 133 FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS 133

famotidine 131

Index 12

FLUARIX QUADRIVALENT 2019-2020 133 FLUARIX QUADRIVALENT 2020-2021 133 FLUARIX QUADRIVALENT 2021-2022 133 FLUBLOK QUADRIVALENT 2019-2020 133 FLUBLOK QUADRIVALENT 2020-2021 133 FLUBLOK QUADRIVALENT 2021-2022 133 FLUCELVAX QUADRIVALENT 2019-2020 133 FLUCELVAX QUADRIVALENT 2020-2021 133

fluvastatin sodium 30 fluvoxamine maleate 21 FLUZONE HIGH-DOSE PF 2019-2020 134 FLUZONE HIGH-DOSE PF 2020-2021 134 FLUZONE HIGH-DOSE PF 2021-2022 134 FLUZONE QUADRIVALENT 2019-2020 134 FLUZONE QUADRIVALENT 2020-2021 134 FLUZONE QUADRIVALENT 2021-2022 134 FML 124

FREESTYLE PRECISION INSULIN SYRINGEU-10005ML31G X 516 FREESTYLE PRECISION INSULIN SYRINGEU-1001ML31G X 516 FREESTYLE PRECISION INSULIN SYRINGESU-1001ML30G X 516 FREESTYLE UNISTICK II LANCETS FROVA frovatriptan succinate FULPHILA fulvestrant

100

100

100

85 115 116

77 38

FLUCELVAX QUADRIVALENT 2021-2022 134 fluconazole 27 flucytosine 27 fludarabine phosphate 36 fludrocortisone acetate 59 FLULAVAL QUADRIVALENT 2019-2020 134 FLULAVAL QUADRIVALENT 2020-2021 134 FLULAVAL QUADRIVALENT 2021-2022 134 FLUMADINE 52 FLUMIST QUADRIVALENT134 flunisolide (nasal) 122 fluocinolone acetonide 66 fluocinolone acetonide

FML FORTE 123 FML LIQUIFILM 124 FOCALIN 2 FOCALIN XR 2 folic acid 77 FOLOTYN 36 fondaparinux sodium 16 FORA GTEL BLOOD KETONE TEST STRIPS 69 FORA LANCETS 85 FORA LANCING DEVICE 85 FORA LANCING DEVICECLEARCAP 85 FORFIVO XL 20 FORTAZ 56 FOSAMAX 70

FURADANTIN 12 furosemide 70 FUSILEV 43 FUZEON 49 FYCOMPA 17 gabapentin 18 GABITRIL 19 GALAFOLD 72 galantamine hydrobromide 127 GAMMAGARD LIQUID 125 GAMMAGARD SD IGA LESSTHAN 1MCGML 125 GAMMAKED 125 GAMUNEX-C 125 ganciclovir sodium 51

(otic) 125 fluocinonide 66 fluocinonide emulsified base 66 fluorometholone (ophth) 123 FLUOROPLEX 63 fluorouracil 36 fluorouracil (topical) 63 fluoxetine hcl 21 fluoxetine hcl (pmdd) 128 FLUOXETINE HYDROCHLORIDE 21 fluphenazine hcl 48 flurandrenolide 66

FOSAMAX PLUS D 70 fosamprenavir calcium 49 fosfomycin tromethamine 12 fosinopril sodium 30 fosinopril sodium amphydrochlorothiazide 32 fosphenytoin sodium 20 FOSRENOL 75 FRAGMIN 16 FREDS PHARMACY AUTOLET LANCING DEVICE 85 FREDS PHARMACY UNILET LANCETS SUPER THIN

ganirelix acetate 71 GANIRELIX ACETATE 71 GARDASIL 9 134 gatifloxacin (ophth) 123 GAZYVA 37 gemcitabine hcl 36 GEMCITABINE HYDROCHLORIDE 36 gemfibrozil 30 GENERESS FE 56 GENOTROPIN 71 GENOTROPIN MINIQUICK 71 gentamicin in saline 3

flurbiprofen flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate(nasal) fluticasone-salmeterol

4 124

38 66

122 15

30G 85 FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G 85 FREESTYLE LANCETS 85 FREESTYLE PRECISION INSULIN SYRINGEU-10005ML30G X 516 100

gentamicin sulfate 3 gentamicin sulfate (ophth) 123 gentamicin sulfate (topical) 61 GENTEEL BUTTERFLY TOUCH LANCETS 85 GENTEEL LANCING DEVICEGLORIOUS GOLD 85

Index 13

GENTEEL LANCING GLOBAL INJECT EASE GLUCOPRO INSULIN DEVICEPRECIOUSPLATINUM GENTEEL LANCING

85 INSULIN SYRINGEU-10005ML28G X 12 GLOBAL INJECT EASE

100 SYRINGEU-10003ML31G X516 101 GLUCOPRO INSULIN

DEVICESTATELY SILVER 85 GENTEEL PLUS LANCING DEVICEBUFF BLACK 85 GENTEEL PLUS LANCING DEVICEBUTTERFLY BLUE 85 GENTEEL PLUS LANCING

INSULIN SYRINGEU-10005ML29G X 12 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML30G X 12 GLOBAL INJECT EASE

100

100

SYRINGEU-10005ML30G X12 101 GLUCOPRO INSULIN SYRINGEU-10005ML30G X516 101 GLUCOPRO INSULIN

DEVICEPLAYFUL PURPLE 85 GENTEEL PLUS LANCING DEVICEPRINCESS PINK 85 GENTEEL PLUS LANCING DEVICEWILLOWY WHITE 85 GENTLE-LET GP LANCETS 85


101

101


GENTLE-LET LANCETS GENERAL PURPOSE STYLEFINE POINT 85 GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINT 86 GENTLE-LET LANCETS SAFETY STYLEFINEPOINT 86 GENTLE-LET LANCETS SAFETY STYLEMEDIUMPOINT 86 GENVOYA 49 GEODON 46 GILENYA 128 GILOTRIF 38 glatiramer acetate 128 GLEEVEC 41 GLEOSTINE 35 glimepiride 25 glipizide 25 glipizide-metformin hcl 23 GLOBAL EASY GLIDE INSULIN SYRINGE1ML31G X1564 100 GLOBAL EASY GLIDE INSULINSYRINGEU-10003ML31G X 516 100 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML29G X12 100 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML30G X12 100 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML30G X516 100 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML31G X516 100

INSULIN SYRINGEU-1001ML28G X 12 101 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML29G X 12 101 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML30G X 12 101 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML30G X 516 101 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML31G X 516 101 GLOBAL INSULIN SYRINGEU-10003ML30G X12 101 GLOBAL INSULIN SYRINGESU-10003ML30GX516 101 GLOBAL LANCING DEVICE 86 GLUCAGEN DIAGNOSTIC 68 GLUCAGEN HYPOKIT 24 glucagon (rdna) 24 GLUCAGON EMERGENCY KIT 24 GLUCOCOM LANCETS 28G 86 GLUCOCOM LANCETS 30G 86 GLUCOCOM LANCETS 33G 86 GLUCOPRO INSULIN SYRINGEU-10003ML30G X12 101 GLUCOPRO INSULIN SYRINGEU-10003ML30G X516 101

SYRINGEU-1001ML30G X516 101 GLUCOPRO INSULIN SYRINGEU-1001ML31G X516 101 GLUCOTROL 25 GLUCOTROL XL 25 glyburide 25 glyburide micronized 25 glyburide-metformin 23 glycine (gu irrigant) 75 glycopyrrolate 130 GLYNASE 25 GLYSET 23 GLYXAMBI 23 GNP INSULIN SYRINGE03ML29G X12 101 GNP INSULIN SYRINGE03ML30G X516 101 GNP INSULIN SYRINGE03ML31G X516 101 GNP INSULIN SYRINGE05ML28G X12 101 GNP INSULIN SYRINGE05ML29G X12 101 GNP INSULIN SYRINGE05ML30G X516 101 GNP INSULIN SYRINGE05ML31G X516 101 GNP INSULIN SYRINGE1ML28G X 12 101 GNP INSULIN SYRINGE1ML29G X 12 101

Index 14

GNP INSULIN SYRINGE1ML30G X516 102 GNP INSULIN SYRINGE1ML31G X516 102 GNP LANCETS 21G 86 GNP LANCETS MICRO THIN 33G 86 GNP LANCETS SUPER THIN 30G 86 GNP LANCETS THIN 86 GNP LANCETS THIN 26G 86 GNP PRENATAL 120 GNP ULTRA COMFORT INSULIN SYRINGE03ML29G X12 102 GNP ULTRA COMFORT INSULIN SYRINGE03ML30G X516 SHORT 102 GNP ULTRA COMFORT INSULIN SYRINGE05ML28G X12 102 GNP ULTRA COMFORT INSULIN SYRINGE05ML29G X12 102 GNP ULTRA COMFORT INSULIN SYRINGE1ML28G X12 102 GNP ULTRA COMFORT INSULIN SYRINGE1ML29G X12 102 GOJJI BLOOD KETONE TEST STRIPS 69 GOJJI LANCING DEVICECLEAR CAP 86 GOJJI STERILE LANCETS 30G 86 GOLYTELY 79 GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL 86 GOODSENSE LANCETS MICRO-THIN 33G 86 GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL 86 GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL 86 GOODSENSE LANCETS ULTRA-THIN 30G 86 GOODSENSE LANCETS ULTRA-THIN 30G UNIVERSAL 86 GOODSENSE LANCING DEVICE 86

GOODSENSE PRENATAL VITAMINS 120 granisetron hcl 26 GRASTEK 3 griseofulvin microsize 27 griseofulvin ultramicrosize 27 guanfacine hcl 31 guanfacine hcl (adhd) 2 GUANIDINE HCL 34 GVOKE PFS 24 GYNAZOLE-1 135 GYNE-LOTRIMIN 135 H-E-B INCONTROL ADVANCEDLANCING DEVICE 86 H-E-B INCONTROL LANCETS MICRO THIN 33G 86 H-E-B INCONTROL LANCETS SUPER THIN 30G 86 H-E-B INCONTROL LANCETS ULTRA THIN 28G 86 HAEGARDA 76 HAEMOLANCE 86 HAEMOLANCE LOW FLOW LANCETS 86 HAEMOLANCE PLUS 86 HAEMOLANCE PLUS HIGH FLOW 86 HAEMOLANCE PLUS LOW FLOW 86 HAEMOLANCE PLUS MAX FLOW 86 HAEMOLANCE PLUS PEDIATRIC FLOW 86 HALAVEN 44 halcinonide 66 HALCION 78 HALDOL 46 HALDOL DECANOATE 100 46 HALDOL DECANOATE 50 46 halobetasol propionate 66 HALOG 66 haloperidol 47 haloperidol decanoate 46 haloperidol lactate 47 HAVRIX 134 HEALTH CARE LANCING DEVICE 86 HEALTHWISE INSULIN SYRINGEU-10003ML30G X516 102

HEALTHWISE INSULIN SYRINGEU-10003ML31G X516 102 HEALTHWISE INSULIN SYRINGEU-10005ML30G X516 102 HEALTHWISE INSULIN SYRINGEU-10005ML31G X516 102 HEALTHWISE INSULIN SYRINGEU-1001ML30G X516 102 HEALTHWISE INSULIN SYRINGEU-1001ML31G X516 102 HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE 86 HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G 86 HECTOROL 72 HEMANGEOL 53 HEPARIN LOCK FLUSH 16 heparin sod (porcine) in d5w 16 heparin sodium (porcine) 16 HEPARIN SODIUMNACL045 16 HEPARIN SODIUMSODIUMCHLORIDE 09 PREMIX 16 HEPLISAV-B 134 HEPSERA 51 HERCEPTIN 37 HERCEPTIN HYLECTA 40 HERZUMA 37 HETLIOZ 79 HIPREX 12 HIZENTRA 125 HM PRENATAL 120 HM ULTICARE INSULIN SYRINGE1ML30G X 12 102 HM ULTICARE INSULIN SYRINGEU-10003ML31G X516 102 HORIZANT 128 HUMATIN 3 HUMATROPE 71 HUMATROPE COMBO PACK 71 HUMIRA 4 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 3 HUMIRA PEN 3

Index 15

HUMIRA PEN-CDUCHS idarubicin hcl 40 INSULIN SYRINGE05ML30G XSTARTER 34 516 102 IDHIFA 41 HUMIRA PEN-PEDIATRIC UC INSULIN SYRINGE05ML31G X

IFEX 35 STARTER PACK 4 516 102 HUMIRA PEN-PSUV ifosfamide 35 INSULIN SYRINGE1ML28G XSTARTER 4 12 102 IFOSFAMIDE 35 HUMULIN R U-500 INSULIN SYRINGE1ML29G XILARIS 4 (CONCENTRATED) 24 12 102 HUMULIN R U-500 ILEVRO 124 INSULIN SYRINGE1ML30G XKWIKPEN 24 imatinib mesylate 41 516 103 HY-VEE LANCETS 86 INSULIN SYRINGENEEDLEIMBRUVICA 41 03ML30G X 516 103 HY-VEE THIN LANCETS 86 IMFINZI 37 INSULIN SYRINGENEEDLEHYCAMTIN 44 imipenem-cilastatin 11 03ML31G X 516 103 hydralazine hcl 33 INSULIN SYRINGENEEDLEimipramine hcl 23 05ML29G X 12 103 HYDREA 42 imipramine pamoate 23 INSULIN SYRINGENEEDLEHYDRO 35 67 imiquimod 67 05ML30G X 516 103 hydrochlorothiazide 70 IMITREX 116 INSULIN SYRINGENEEDLEhydrocodone bitartrate 6 IMITREX STATDOSE 05ML31G X 516 103

INSULIN SYRINGENEEDLEhydrocodone-acetaminophen 8 REFILL 116 1ML29G X 12 103 IMITREX STATDOSE hydrocodone-ibuprofen 8 INSULIN SYRINGENEEDLESYSTEM 116 hydrocortisone 58 1ML30G X 516 103 IMODIUM A-D 25 INSULIN SYRINGENEEDLEhydrocortisone (intrarectal) 10 IMPAVIDO 10 1ML31G X 516 103 hydrocortisone (rectal) 10 IMURAN 118 INSULIN SYRINGEU-hydrocortisone (topical) 66 IN TOUCH LANCING 10003ML29G X 12 103 hydrocortisone acetate DEVICE 86 INSULIN SYRINGEU-(rectal) 10 IN TOUCH STERILE 10005ML29G X 12 103 hydrocortisone butyrate 66 LANCETS30G 86 INSULIN SYRINGEU-

1001ML29G X 12 103 hydrocortisone valerate 66 INCRELEX 71 INSULIN SYRINGEU-hydrocortisone wacetic INCRUSE ELLIPTA 14 1001ML30G X 516 103 acid 125 indapamide 70 INSULIN SYRINGEU-hydromorphone hcl 6 INDERAL LA 53 1001ML31G X 516 103 HYDROMORPHONE INSULIN indomethacin 45 HYDROCHLORIDE 6 SYRINGES05ML27GX12hydroxychloroquine sulfate 33 INFLECTRA 75 103 hydroxyprogesterone caproate INFUGEM 36 INSULIN (antineoplastic) 38 INLYTA 36 SYRINGES05ML28GX12hydroxyurea 43 INQOVI 40

103 INSULIN hydroxyzine hcl 12 INREBIC 41 SYRINGES05ML29GX12

hydroxyzine pamoate 13 INSPRA 33 103 HYPER-SAL 59 INSULIN SYRINGE03ML29G INSULIN

SYRINGES05ML30GX516HYPERSAL 59 X 1 102 INSULIN SYRINGE03ML29G 103 HYQVIA 125 INSULIN X 12 102 HYZAAR 32 INSULIN SYRINGE03ML30G SYRINGES05ML31GX

ibandronate sodium 70 X 516 102 516 103 INSULIN SYRINGE03ML31G INSULIN IBRANCE 41 X 516 102 SYRINGES05ML31GX516

ibuprofen 4 INSULIN SYRINGE05ML27G 103 icatibant acetate 76 X 12 102 INSULIN ICLUSIG 41 INSULIN SYRINGE05ML28G SYRINGES1ML27GX12

X 12 102 icosapent ethyl 29 103 INSULIN SYRINGE05ML30G INSULIN

IDAMYCIN PFS 40 X 12 102 SYRINGES1ML27GX12 103

Index 16

INSULIN SYRINGES1ML28GX12 103 INSULIN SYRINGES1ML29GX12 103 INSULIN SYRINGES1ML30GX12 103 INSULIN SYRINGES1ML31GX516

103 INTELENCE 49 INTRAROSA 135 INTRON A 43 INTUNIV 2 INVANZ 11 INVEGA 46 INVIRASE 49 IONOSOL-MBDEXTROSE5 117 IOPIDINE 123 IPOL INACTIVATED IPV 134 ipratropium bromide 14 ipratropium bromide (nasal)121 ipratropium-albuterol 15 irbesartan 31 irbesartan-hydrochlorothiazide

32 IRESSA 38 irinotecan hcl 44 irrigation solutionsphysiological 119 ISENTRESS 49 ISENTRESS HD 49 ISOLYTE-PDEXTROSE5 117 ISOLYTE-S 117 isoniazid 34 ISOPTO CARPINE 122 ISORDIL TITRADOSE 12 isosorbide dinitrate 12 isosorbide mononitrate 12 isotretinoin 60 isradipine 53 ISTODAX (OVERFILL) 41 itraconazole 27 ivermectin 10 IVERMECTIN 68 ivermectin (pediculicide) 68 IXEMPRA KIT 44 JADENU 26 JADENU SPRINKLE 26

JAKAFI 41 JANUMET 23 JANUMET XR 23 JANUVIA 24 JARDIANCE 25 JELMYTO 40 JEVTANA 44 JUBLIA 62 JULUCA 49 JYNARQUE 73 K-TAB 118 K-Y ME amp YOU EXTRA LUBRICATED 80 K-Y ME amp YOU INTENSE 81 KADCYLA 37 KADIAN 6 KALETRA 49 KALYDECO 129 KAMELEON LUBRICATED 81 KANJINTI 37 KAPVAY 2 KAZANO 23 KCL 03D5WNACL09 117 KEFLEX 55 KENALOG-40 58 KEPIVANCE 43 KEPPRA 18 KEPPRA XR 18 KERYDIN 62 ketoconazole 27 ketoconazole (topical) 62 KETONE 69 KETONE TEST STRIPS 69 ketoprofen 5 ketorolac tromethamine 5 ketorolac tromethamine (ophth) 124 KETOSTIX 69 ketotifen fumarate (ophth)124 KEVEYIS 69 KEYTRUDA 37 KHAPZORY 43 KHEDEZLA 22 KIMONO COLORS 81 KIMONO LUBRICATED 81

KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED81 KIMONO PLUS SPERMICIDE LUBRICATED 81 KIMONO PLUS SPERMICIDELUBRICATED

81 KIMONO PS LUBRICATED 81 KIMONO PS PLUS SPERMICIDELUBRICATED

81 KIMONO SENSATION LUBRICATED 81 KIMONO SENSATION PLUS SPERMICIDE LUBRICATED81 KIMONO SPECIAL 81 KINNEY LANCETS 87 KINNEY THIN LANCETS 87 KINRAY INSULIN SYRINGE PREFERRED PLUS03ML31GX 516 103 KINRAY INSULIN SYRINGE PREFERRED PLUS05ML31GX 516 103 KINRAY INSULIN SYRINGE PREFERRED PLUS1ML31G X516 103 KINRAY INSULIN SYRINGE05ML29G X12 103 KISQALI 41 KISQALI FEMARA 200 DOSE 40 KISQALI FEMARA 400 DOSE 40 KISQALI FEMARA 600 DOSE 40 KITABIS PAK 3 KLARITY-A 123 KLARON 60 KLONOPIN 17 KMART VALU PLUS INSULIN SYRINGE1ML29G 104 KMART VALU PLUS INSULIN SYRINGE1ML30G 104 KOSELUGO 41 KP PRENATAL MULTIVITAMINS 120 KRINTAFEL 34 KROGER AUTOLET LANCING DEVICE 87 KROGER HEALTHPRO TWIST LANCETS26G 87 KROGER INSULIN SYRINGE03ML29G X12 104

Index 17

KROGER INSULIN LAMICTAL ODT 18 LEADER ADVANCED LANCING SYRINGE03ML30G X516 104 KROGER INSULIN SYRINGE03ML31G X516 104 KROGER INSULIN SYRINGE05ML29G X12 104 KROGER INSULIN SYRINGE05ML30G X516 104 KROGER INSULIN SYRINGE05ML31G X516 104 KROGER INSULIN SYRINGE1ML29G X 12 104 KROGER INSULIN SYRINGE1ML30G X516 104 KROGER INSULIN

lamivudine lamivudine (hbv) lamivudine-zidovudine lamotrigine LANCET DEVICE ADJUSTABLE LANCET DEVICE WITH EJECTOR LANCETS LANCETS 26G TWIST TOP LANCETS 30G LANCETS 30G TWIST TOP LANCETS 30GTWISTTOP LANCETS 31G TWIST TOP

49 51 49 18

87

87 87

87 87

87

87

87

DEVICE LEADER INSULIN SYRINGE03ML29G X12 LEADER INSULIN SYRINGE03ML30G X516 LEADER INSULIN SYRINGE03ML31G X516 LEADER INSULIN SYRINGE05ML28G X12 LEADER INSULIN SYRINGE05ML29G X12 LEADER INSULIN SYRINGE05ML30G X516 LEADER INSULIN

87

104

104

104

104

104

104

SYRINGE1ML31G X516 104 KROGER LANCETS 87 KROGER LANCETS 21G 87 KROGER LANCETS MICRO THIN33G 87 KROGER LANCETS SUPER THIN 87 KROGER LANCETS THIN 87 KROGER LANCETS THIN 26G 87 KROGER LANCETS ULTRATHIN30G 87 KROGER LANCING DEVICE 87 KRYSTEXXA 76 KUVAN 72 KYLEENA 57 KYMRIAH 38 KYPROLIS 41 labetalol hcl 52 LAC-HYDRIN 67 LAC-HYDRIN TWELVE 67

LANCETS 33G EXTRA FINE 87 LANCETS MICRO THIN 33G 87 LANCETS SAFETY SEAL 21G 87 LANCETS SAFETY SEAL 26G 87 LANCETS SAFETY SEAL 28G 87 LANCETS SAFETY SEAL 30G 87 LANCETS SUPER THIN 28G 87 LANCETS THIN 87 LANCETS TWIST TOP 87 LANCETS ULTRA THIN 87 LANCETS ULTRA THIN 30G 87 LANCETSBULLSEYE SAFETY 87 LANCING DEVICE 87 LANCING DEVICE ADJUSTABLE 87 LANOXIN 54

SYRINGE05ML31G X516 104 LEADER INSULIN SYRINGE1ML28G X 12 104 LEADER INSULIN SYRINGE1ML29G X 12 104 LEADER INSULIN SYRINGE1ML30G X516 104 LEADER INSULIN SYRINGE1ML31G X516 104 leflunomide 5 LENVIMA 10 MG DAILY DOSE 36 LENVIMA 12MG DAILY DOSE 37 LENVIMA 14 MG DAILY DOSE 37 LENVIMA 18 MG DAILY DOSE 37 LENVIMA 20 MG DAILY DOSE 37 LENVIMA 24 MG DAILY DOSE 37 LENVIMA 4 MG DAILY

LACRISERT 122 lactated ringers 117 lactated ringers (irrigation) 119 lactic acid (ammoniumlactate) 67 lactulose 79 lactulose (encephalopathy) 75 LAMICTAL 18 LAMICTAL CHEWABLE DISPERSIBLE 18

lansoprazole lanthanum carbonate LANZO lapatinib ditosylate LARTRUVO LASIX LASTACAFT latanoprost LATUDA

131 75 87 41 39 70

124 125

46

DOSE LENVIMA 8 MG DAILY DOSE LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate

37

37 54 38 43 35 77 39

Index 18

LEUPROLIDE linezolid 12 LITETOUCH INSULIN ACETATEBUPIVACAINE SYRINGEU-1001ML31G XLINZESS 75 HYDROCHLORIDE 39 516 105 liothyronine sodium 130 levalbuterol hcl 15 LITETOUCH LANCETS MICRO

LIPITOR 30 THIN 33G 87 levalbuterol tartrate 15 LIPOFEN 30 LITHIUM 46 LEVAQUIN 74 lisinopril 30 lithium carbonate 46 LEVEMIR 24 lisinopril amp LITHOBID 46 LEVEMIR FLEXTOUCH 24 hydrochlorothiazide 32 LIVALO 30 levetiracetam 18 LITE TOUCH LANCETS 87 LIVE BETTER ADVANCED

levobunolol hcl 122 LITE TOUCH LANCING LANCING DEVICE 87 levocetirizine dihydrochloride28 PEN 87 LIVE BETTER LANCET

LITETOUCH INSULIN SUPERTHIN 30G 88 levofloxacin 74 SYRINGE03ML29G X LIVE BETTER LANCET levofloxacin (ophth) 123 12 104 ULTRATHIN 28G 88 levofloxacin in d5w 74 LITETOUCH INSULIN LO LOESTRIN FE 56

SYRINGE03ML30G Xlevoleucovorin calcium 43 LOCOID 66 516 104 levonorgestrel amp eth LITETOUCH INSULIN LODINE 5 estradiol 56 SYRINGE03ML31G Xlevonorgestrel (emergency LODOSYN 44 516 104 oc) 57 LOMOTIL 25 LITETOUCH INSULIN levonorgestrel-eth estradiol LONGS INSULIN SYRINGE05ML30G X(triphasic) 56 SYRINGE05ML31G X

levonorgestrel-ethinyl estradiol 516 104 516 105 LITETOUCH INSULIN (91-day) 56 LONGS LANCETS SYRINGE05ML31G Xlevonorgestrel-ethinyl estradiol STANDARD 88 516 104 (continuous) 56 LONGS LANCETS THIN 88 LITETOUCH INSULIN levorphanol tartrate 7 SYRINGE1ML30G X LONGS LANCETS ULTRA levothyroxine sodium 130 THIN 88 516 104 LEVULAN KERASTICK 63 LITETOUCH INSULIN LONSURF 40 LEXAPRO 21 SYRINGEU-10003ML30G X loperamide hcl 25

516 104 LEXIVA 49 LOPID 30 LITETOUCH INSULIN LIALDA 75 lopinavir-ritonavir 49 SYRINGEU-10003ML31G XLIBERTY MEDICAL LANCETS 516 104 LOPRESSOR 52 30G 87 LITETOUCH INSULIN LOPRESSOR HCT 32 LIBERTY MINI LANCING SYRINGEU-10005ML28G X LOPROX 62 DEVICE 87 12 104 LIBRAX 130 LITETOUCH INSULIN LOPROX SHAMPOO 62

SYRINGEU-10005ML29G X loratadine 28 LIBTAYO 37 12 105 loratadine amp lidocaine 68 LITETOUCH INSULIN pseudoephedrine 59 lidocaine hcl 68 SYRINGEU-10005ML30G X lorazepam 13 lidocaine hcl (local anesth) 79 516 105 LORBRENA 41 LITETOUCH INSULIN lidocaine hcl (mouth-throat) 119 SYRINGEU-10005ML31G X LORTAB 8 lidocaine-prilocaine 68 516 105 losartan potassium 31 LIDODERM 68 LITETOUCH INSULIN losartan potassium ampLIFESCAN UNISTIK 2 DEEP SYRINGEU-1001ML28G X hydrochlorothiazide 32 PENETRATION 87 12 105 LOSEASONIQUE 56 LIFESCAN UNISTIK II LITETOUCH INSULIN

LOTEMAX 124 LANCETS 87 SYRINGEU-1001ML29G XLILETTA 57 12 105 LOTENSIN 30

LITETOUCH INSULIN LOTENSIN HCT 32 LINCOCIN 11 SYRINGEU-1001ML30G Xlincomycin hcl 11 516 105 loteprednol etabonate 124

LOTREL 32 lindane 68

Index 19

LOTRIMIN AF 62 MAGELLAN INSULIN SAFETY MEDICHOICE PRE-SET

LOTRIMIN AF JOCK ITCH LOTRIMIN ULTRA

62 62

SYRINGEU-10005ML30G X516 105 MAGELLAN INSULIN SAFETY

SAFETY LANCET LOW FLOW MEDICHOICE PRE-SET

88

LOTRISONE LOTRONEX lovastatin LOVAZA LOVENOX loxapine succinate lubiprostone

62 75 30 29 17 47 74

SYRINGEU-1001ML29G X12 105 MAGELLAN INSULIN SAFETY SYRINGEU-1001ML30G X516 105 magnesium sulfate 118 MALARONE 33 malathion 68

SAFETY LANCET MEDIUM FLOW 88 MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW 88 MEDICHOICE SAFETY LANCETEXTRA 88 MEDICHOICE SAFETY LANCETNORMAL 88

LUCEMYRA luliconazole LUMIGAN LUMIZYME

127 62

125 72

maprotiline hcl MARCAINE MARINOL MARPLAN

20 79 27 21

MEDISENSE THIN LANCETS MEDLANCE PLUS EXTRA LANCETS 21G MEDLANCE PLUS

88

88

LUMOXITI 37 LUNESTA 78 LUPANETA PACK 71 LUPRON DEPOT (1-MONTH) 39 LUPRON DEPOT (3-MONTH) 39 LUPRON DEPOT (4-MONTH) 39 LUPRON DEPOT (6-MONTH) 39 LUPRON DEPOT-PED (1-MONTH) 71 LUPRON DEPOT-PED (3-MONTH) 71 LUTATHERA 42 LUXIQ 66 LUZU 62 LYNPARZA 41 LYRICA 18 LYRICA CR 128 LYSODREN 39 LYSTEDA 78 M-M-R II 134 M-NATAL PLUS 120 MACROBID 12 MACRODANTIN 12 mafenide acetate 64 MAGELLAN INSULIN SAFETY SYRINGEU-10003ML29G X12 105 MAGELLAN INSULIN SAFETY SYRINGEU-10003ML30G X516 105 MAGELLAN INSULIN SAFETY SYRINGEU-10005ML29G X12 105

MARQIBO 44 MATULANE 43 MAVENCLAD 128 MAVYRET 51 MAXALT 116 MAXALT-MLT 116 MAXI-COMFORT INSULIN SYRINGEU-10005ML28GX12 105 MAXI-COMFORT INSULIN SYRINGEU-1001ML28GX12 105 MAXICOMFORT INSULIN SYRINGES 27G X 12 105 MAXIDEX 124 MAXIPIME 56 MAXITROL 124 MAXX LUBRICATED 81 MAXX PLUS SPERMICIDE LUBRICATED 81 MAXZIDE 69 MAXZIDE-25 69 MAYZENT 128 MAYZENT STARTER PACK 128 meclizine hcl 26 meclofenamate sodium 5 MEDIC INSULIN SYRINGE03ML30G X516 105 MEDIC INSULIN SYRINGE05ML30G X516 105 MEDICHOICE PRE-SET SAFETY LANCET DUAL USE 88

LANCETS 88 MEDLANCE PLUS LANCETS LITE 25G 88 MEDLANCE PLUS LITE LANCETS 25G 88 MEDLANCE PLUS SPECIAL LANCETS 08MM 88 MEDLANCE PLUS SUPERLITE 30G 88 MEDLANCE PLUS SUPERLITE 30GCOMFORT MAX 88 MEDLANCE PLUS UNIVERSAL LANCETS 21G 88 MEDLANCE PLUSLITE25G 88 MEDLANCEEXTRA 88 MEDLANCELITE 88 MEDLANCEUNIVERSAL 88 MEDROL 58 MEDROL DOSEPAK 58 medroxyprogesterone acetate 126 medroxyprogesterone acetate(contraceptive) 58 mefenamic acid 5 mefloquine hcl 34 MEGACE ES 126 megestrol acetate 39 megestrol acetate(appetite) 126 MEIJER COLOR LANCETS UNIVERSAL 33G 88 MEIJER LANCETS 88 MEIJER LANCETS THIN 88 MEIJER LANCETS UNIVERSAL21G 88 MEIJER LANCETS UNIVERSAL30G 88

Index 20

MEIJER LANCETS UNIVERSAL33G 88 MEIJER SUPER THIN LANCETS 88 MEKINIST 41 MEKTOVI 41 meloxicam 5 melphalan 35 melphalan hcl 35 memantine hcl 127 MENACTRA 132 MENEST 73 MENOSTAR 73 MENQUADFI 132 MENVEO 132 meperidine hcl 7 meprobamate 13 MEPRON 11 mercaptopurine 36 meropenem 11 MERREM 11 mesalamine 75 mesna 43 MESNEX 43 MESTINON 34 MESTINON TIMESPAN 34 metaxalone 121 metformin hcl 24 methadone hcl 7 METHADONE HCL 7 methadone hcl 7 METHADOSE 7 METHADOSE SUGAR-FREE 7

methylprednisolone acetate 58 methylprednisolone sod succ 58 metoclopramide hcl 74 metolazone 70 metoprolol amphydrochlorothiazide 32 metoprolol succinate 52 metoprolol tartrate 5253 METROCREAM 68 METROGEL 68 METROGEL-VAGINAL 135 METROLOTION 68 metronidazole 10 metronidazole (topical) 68 metronidazole vaginal 135 mexiletine hcl 13 micafungin sodium 27 MICARDIS 31 MICARDIS HCT 32 miconazole nitrate vaginal 135 MICROLET LANCETS 88 MICROLET NEXT 88 midodrine hcl 136 miglitol 23 miglustat 77 MIGRANAL 115 MILLIPRED 58 MILLIPRED DP 58 MINASTRIN 24 FE 56 MINI LANCING DEVICE 88 MINIPRESS 31

mitoxantrone hcl 40 MM INSULIN SYRINGEU-10003ML30G X 516 105 MM INSULIN SYRINGEU-10003ML31G X 516 105 MM INSULIN SYRINGEU-10012ML30G X 516 105 MM INSULIN SYRINGEU-10012ML31G X 516 105 MM INSULIN SYRINGEU-1001ML30G X 516 105 MM INSULIN SYRINGEU-1001ML31G X 516 105 MM LANCING DEVICE 88 MM TWIST LANCETS 88 MOBIC 5 modafinil 23 moexipril hcl 30 mometasone furoate 66 mometasone furoate (nasal) 122 MONISTAT SOOTHING CARE ITCH RELIEF 66 MONJUVI 37 MONOJECT INSULIN SYRINGE1ML 105 MONOJECT INSULIN SYRINGE1ML31G X516 105 MONOJECT INSULIN SYRINGEDETACHNEEDLE1ML25G X 58 106 MONOJECT INSULIN SYRINGEDETACHNEEDLE1ML27G X 12 106 MONOJECT INSULIN SYRINGEPERMNEEDLE1ML28G X 12 106 MONOJECT INSULIN

methamphetamine hcl methazolamide methenamine hippurate methimazole METHITEST methocarbamol METHOTREXATE

1 69 12

130 10

121 4

MINIVELLE MINOCIN minocycline hcl minoxidil MIRAPEX MIRCERA MIRCETTE

73 129 130

33 45 77 56

SYRINGEPERM NEEDLEU-10005ML28G X 12 106 MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29G X 12 106 MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29GX12 106 MONOJECT INSULIN

methotrexate sodium 36 methoxsalen rapid 64 methscopolamine bromide 130 methyldopa 31 METHYLIN 2 methylphenidate hcl 2 methylprednisolone 58

MIRENA mirtazapine MIRVASO misoprostol MITIGARE mitomycin MITOMYCIN

57 20 68

132 76 40 40

SYRINGESAFETYPERMNEEDLE05ML29G X 12 106 MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE1ML29G X 12 106 MONOJECT INSULIN SYRINGESOFTPACK1ML27GX 12 106

Index 21

MONOJECT INSULIN SYRINGESOFTPACKU-10005ML28G X 12 106 MONOJECT INSULIN SYRINGEU-10003ML30G X516 106 MONOJECT INSULIN SYRINGEU-10005ML30G X516 106 MONOJECT INSULIN SYRINGEU-1001ML28G X12 106 MONOJECT INSULIN SYRINGEU-1001ML30G X516 106 MONOJECT INSULIN SYRINGEREGULAR LUER TIPSOFTPACK1ML 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE03ML29G X12 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE03ML30G X516 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE03ML31G X516 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE05ML28G X12 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE05ML29G X12 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE05ML30G X516 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE05ML31G X516 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE1ML28G X12 106 MONOJECT ULTRA COMFORT INSULIN SYRINGE1ML29G X12 106 MONOLET LANCETS 88 MONOLET OPD LANCETS 88 MONOLETTOR SAFETY LANCETS 88 montelukast sodium 14 MONUROL 12 MORPHABOND ER 7 morphine sulfate 7 MORPHINE SULFATE 7 morphine sulfate 7 MOTOFEN 25

MOVIPREP 79 moxifloxacin hcl 74 moxifloxacin hcl (ophth) 123 moxifloxacin hcl in sodium

516 106

chloride 74 MOZOBIL 78 MPD SAFETY LANCET 21G18MM MPD SAFETY LANCET

88

28G18MM MPD SAFETY LANCET

88

30G18MM MPD SAFETY LANCETS

89

23G18MM MS CONTIN

89 7

MS INSULIN SYRINGE03ML31G X

MS INSULIN SYRINGE05ML31G X516 107 MS INSULIN SYRINGE1ML31G X516 107 MULPLETA 77 MULTAQ 13 MULTI PRENATAL 120 MULTI-LANCET DEVICE 89 mupirocin 61 MVASI 37 MYALEPT 72 MYAMBUTOL 34 MYCAMINE 27 MYCOBUTIN 34 mycophenolatemofetil 118119 mycophenolate sodium 119 MYDRIACYL 122 MYFORTIC 119 MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G 89 MYLERAN 35 MYLOTARG 37 MYRBETRIQ 132 MYSOLINE 18 nabumetone 5 nadolol 53 nafcillin sodium 126 naftifine hcl 62 NAFTIFINE HYDROCHLORIDE 62

NAFTIN 62 NAGLAZYME 72 nalbuphine hcl 9 NALFON 5 naloxone hcl 26 naltrexone hcl 26 NAMENDA 127 NAMENDA TITRATION PAK 127 NAPROSYN 5 naproxen 5 naproxen sodium 5 naratriptan hcl 116 NARCAN 26 NARDIL 21 NAROPIN 79 NASACORT ALLERGY 24HR 122 NASACORT ALLERGY 24HR CHILDRENS 122 NASONEX 122 NATACYN 123 NATAZIA 56 nateglinide 25 NATROBA 68 NATURE-THROID 130 NATURE-THROID NT-25 130 NAVELBINE 44 NAYZILAM 17 NEBUSAL 59 nefazodone hcl 22 NEO-SYNALAR 61 neomycin sulfate 3 neomycin-bacitracin zn-polymyxin 123 neomycin-polymy-dexameth 124 neomycin-polymyxin-hc(ophth) 124 neomycin-polymyxin-hc(otic) 125 NEONATAL COMPLETE 120 NEONATAL PLUS 120 NEONATAL VITAMIN 120 NEORAL 119 NEOSTIGMINE METHYLSULFATE 34 NERLYNX 41 NESINA 24 NEULASTA 77

Index 22

NEULASTA ONPRO KIT 77 NIVESTYM 77 NOVOLIN 7030 RELION 24 NEUPOGEN 77 NIX CREME RINSE 68 NOVOLIN N 25 NEUPRO 45 nizatidine 131 NOVOLIN N RELION 25 NEURONTIN 18 NIZORAL 62 NOVOLIN R 25 NEVANAC 124 NORCO 9 NOVOLIN R RELION 25 nevirapine NEXAVAR NEXIUM NEXIUM 24HR NEXPLANON niacin niacin (antihyperlipidemic) NIACIN TR niacinamide NIASPAN nicardipine hcl NICODERM CQ NICORETTE NICORETTE MINI NICORETTE STARTER

49 41

131 131

57 136

30 136 136

30 53

128 128 129

NORDITROPIN FLEXPRO 71 norelgestromin-ethinylestradiol 57 norethin acet amp estrad-fe 56 norethindrone amp eth estradiol 56 norethindrone amp ethinylestradiol-fe 56 norethindrone (contraceptive) 58 norethindrone acet amp eth estra 57 norethindrone acetate 126 norethindrone acetate-ethinylestradiol 73 norethindrone acetate-ethinylestradiol-fe 57 norethindrone-eth estradiol

NOVOLOG 25 NOVOLOG FLEXPEN 25 NOVOLOG MIX 7030 25 NOVOLOG MIX 7030PREFILLED FLEXPEN 25 NOVOLOG PENFILL 25 NOXAFIL 27 NPLATE 77 NUBEQA 39 NUCALA 13 NUCYNTA 7 NUCYNTA ER 7 NUEDEXTA 128 NULOJIX 119 NUTROPIN AQ NUSPIN 10 71

KIT 129 nicotine 129 nicotine polacrilex 129 NICOTINE TRANSDERMAL SYSTEM 129 NICOTROL INHALER 129 NICOTROL NS 129 nifedipine 53 NILANDRON 39 nilutamide 39 nimodipine 53 NINLARO 41 NIPENT 43 nisoldipine 53 nitazoxanide 11 nitisinone 72 NITRO-BID 12 NITRO-DUR 12 nitrofurantoin 12 nitrofurantoin macrocrystal 12 nitrofurantoin monohyd macro 12 nitroglycerin 12

(triphasic) 57 norgestimate-ethinylestradiol 57 norgestimate-ethinyl estradiol(triphasic) 57 norgestrel amp ethinylestradiol 57 NORMOSOL-M IN D5W 117 NORMOSOL-MD5W 117 NORMOSOL-R 117 NORPACE 13 NORPRAMIN 23 nortriptyline hcl 23 NORVASC 53 NORVIR 49 NOVA MAX PLUS KETONE TESTSTRIPS 69 NOVA SAFETY LANCETS 23G 89 NOVA SAFETY LANCETS 28G 89 NOVA SUREFLEX LANCETS 89 NOVA SUREFLEX LANCING DEVICE 89 NOVAREL 71

NUVARING 57 NUVIGIL 3 nystatin 27 nystatin (mouth-throat) 119 nystatin (topical) 62 nystatin-triamcinolone 62 O-CAL FA 120 OCREVUS 128 octreotide acetate 73 OCUFLOX 123 ODEFSEY 50 ODOMZO 38 OFEV 129 ofloxacin 74 ofloxacin (ophth) 123 ofloxacin (otic) 125 OGIVRI 37 olanzapine 47 olmesartan medoxomil 31 olmesartan medoxomil-amlodipine-hydrochlorothiazide

32 olmesartan medoxomil-

NITROGLYCERIN nitroglycerin NITROSTAT NIVA-PLUS

12 12 12

120

NOVOLIN 7030 25 NOVOLIN 7030FLEXPEN 24 NOVOLIN 7030 FLEXPENRELION 24

hydrochlorothiazide olopatadine hcl olopatadine hcl (nasal) OLUX omega-3-acid ethyl esters

32 124 121

66 29

Index 23

omeprazole 131 oseltamivir phosphate 52 PASER 34 omeprazole magnesium 131 omeprazole-sodiumbicarbonate 132 OMNIFLEX DIAPHRAGM 81 OMNITROPE 71 ON CALL LANCING DEVICE 89 ON CALL PLUS LANCING DEVICE 89 ONCASPAR 42 ondansetron 26 ondansetron hcl 26 ONE VITE WOMENS PRENATALVITAMIN 120 ONE VITE WOMENS PRENATALVITAMIN PLUS 120 ONETOUCH CLUB LANCETS FINE POINT 89 ONETOUCH DELICA LANCETS EXTRA FINE 33G 89

OSENI OSMOPREP OSPHENA OTEZLA OTOVEL OVIDE oxacillin sodium oxaliplatin oxandrolone oxaprozin OXAYDO oxazepam OXBRYTA oxcarbazepine OXERVATE oxiconazole nitrate OXISTAT

23 79 71

5 125

68 126

35 9 5 7

13 77 18

123 63 63

PATADAY 124 PATANASE 121 PATANOL 124 PAXIL 22 PAXIL CR 22 PC LANCETS SUPER THIN 30G 89 PEDIAPRED 58 peg 3350-kcl-nacl-na sulfate-naascorbate-ascorbic acid 79 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 79 PEGANONE 20 PEGASYS 51 PEGASYS PROCLICK 51 PEGINTRON 51 PEMAZYRE 41 penicillamine 118

ONETOUCH DELICA LANCETS FINE 30G 89 ONETOUCH DELICA LANCING

OXSORALEN ULTRA oxybutynin chloride

64 132

penicillin g potassium 126 PENICILLIN G POTASSIUM IN ISO-OSMOTIC

DEVICE 89 ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G 89 ONETOUCH DELICA PLUS LANCETS FINE 30G 89 ONETOUCH DELICA PLUS LANCING DEVICE 89 ONETOUCH FINEPOINT LANCETS 89 ONETOUCH ULTRASOFT LANCETS 89 ONFI 17

oxycodone hcl oxycodone wacetaminophen oxycodone-ibuprofen OXYCONTIN oxymorphone hcl OZEMPIC paclitaxel PADCEV paliperidone palonosetron hcl

7

9 9 7 7

24 44 37 46 26

DEXTROSE 126 PENICILLIN G PROCAINE 126 penicillin g sodium 126 penicillin v potassium 126 PENLAC NAIL LACQUER 63 pentazocine w naloxone 9 pentoxifylline 76 PEPCID 131 PEPCID AC 131 PEPCID AC MAXIMUM STRENGTH 131

ONIVYDE 44 PALYNZIQ 72 PERCOCET 9 ONTRUZANT 37 PAMELOR 23 PERFECT LANCETS 30G 89 OPANA OPDIVO OPSUMIT ORACEA ORAPRED ODT ORENITRAM ORFADIN ORKAMBI orphenadrine citrate ORTHO MICRONOR

7 37 55 68 58 54 72

129 121

58

pamidronate disodium 70 PAMIDRONATE DISODIUM 70 pamidronate disodium 70 PANRETIN 63 pantoprazole sodium 131 PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A 57 parenteral electrolytes 117 paricalcitol 72

PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G 89 PERIDEX 119 perindopril erbumine 31 PERJETA 37 permethrin 68 perphenazine 48 perphenazine-amitriptyline 127 PERSERIS 46 PHARMACY COUNTER

ORTHO TRI-CYCLEN LO 57 PARLODEL 45 LANCETS 89 ORTHO-NOVUM 135 57 PARNATE 21 phenazopyridine hcl 76 ORTHO-NOVUM 777 57 paromomycin sulfate 3 phendimetrazine tartrate 1

paroxetine hcl 2122 phenelzine sulfate 21

Index 24

PHENERGAN 29 phenobarbital 78 phenoxybenzamine hcl 31 phentermine hcl 2 PHENYTEK 20 phenytoin 20 phenytoin sodium 20 phenytoin sodium extended 20 PHESGO 40 PHEXXI 135 PHOSLYRA 75 PHOSPHOLINE IODIDE 123 PHOTOFRIN 43 PICATO 63 PIFELTRO 50 pilocarpine hcl 123 pilocarpine hcl (oral) 119 pimecrolimus 67 pimozide 128 pindolol 53 pioglitazone hcl 24 pioglitazone hcl-glimepiride 23 pioglitazone hcl-metforminhcl 23 PIP LANCETS28G 89 PIP LANCETS30G 89 piperacillin sodium-tazobactamsodium 126 PIQRAY 200MG DAILY DOSE 41 PIQRAY 250MG DAILY DOSE 41 PIQRAY 300MG DAILY DOSE 41 piroxicam 5 PLAN B ONE-STEP 57 PLAQUENIL 34 PLASMA-LYTE A 117 PLASMA-LYTE-148 117 PLAVIX 77 PLEGISOL 54 PLEGRIDY 128 PLEGRIDY STARTER PACK 128 PNEUMOVAX 23 132 PNEUMOVAX 231 DOSE 132 podofilox 67 POLIVY 37 polymyxin b sulfate 12

polymyxin b-trimethoprim 123 POLYTRIM 123 POMALYST 39 PORTRAZZA 38 potassium acetate 118 potassium bicarbonate 118 potassium chloride 118 POTASSIUM CHLORIDE 118 potassium chloride 118 potassium chloride indextrose 117 potassium chloride in dextroseamp sodium chloride 117 potassium chloride innacl 117 potassium chloridemicroencapsulated crystals er 118 POTASSIUM CHLORIDEDEXTROSELACTATED RINGERS 117 POTASSIUM CHLORIDESODIUMCHLORIDE 117 potassium citrate(alkalinizer) 75 potassium phosphates 118 POTELIGEO 37 pramipexoledihydrochloride 45 PRANDIN 25 prasugrel hcl 77 PRAVACHOL 30 pravastatin sodium 30 praziquantel 10 prazosin hcl 31 PRECISION SURE-DOSE INSULIN SYRINGE03ML30GX 516 107 PRECISION SURE-DOSE INSULIN SYRINGE05ML28GX 12 107 PRECISION SURE-DOSE INSULIN SYRINGE05ML29GX 12 107 PRECISION SURE-DOSE INSULIN SYRINGE05ML30GX 38 107 PRECISION SURE-DOSE INSULIN SYRINGE1ML28G X12 107

PRECISION SURE-DOSE PLUSINSULIN SYRINGE03ML29G X12 107 PRECISION SURE-DOSE PLUSINSULIN SYRINGE1ML29G X 12 107 PRECISION THINS GP LANCET 89 PRECISION XTRA 69 PRECOSE 23 PRED FORTE 124 PRED MILD 124 prednicarbate 66 prednisolone 58 prednisolone acetate(ophth) 124 PREDNISOLONE ACETATE P-F 124 prednisolone sodiumphosphate 58 PREDNISOLONE SODIUM PHOSPHATE 124 prednisone 58 PREFERRED PLUS INSULIN SYRINGEU-10003ML29G X12 107 PREFERRED PLUS INSULIN SYRINGEU-10003ML30G X516 107 PREFERRED PLUS INSULIN SYRINGEU-10005ML28G X12 107 PREFERRED PLUS INSULIN SYRINGEU-10005ML29G X12 107 PREFERRED PLUS INSULIN SYRINGEU-10005ML30G X516 107 PREFERRED PLUS INSULIN SYRINGEU-1001ML28G X12 107 PREFERRED PLUS INSULIN SYRINGEU-1001ML29G X12 107 PREFERRED PLUS INSULIN SYRINGEU-1001ML30G X516 107 PREFERRED PLUS LANCETS COLORED 21G 89 PREFERRED PLUS LANCETS SUPER THIN 30G 89 PREFERRED PLUS LANCETS THIN 26G 89 pregabalin 18 pregabalin (once-daily) 128

Index 25

PREGNYL WDILUENT PRO COMFORT INSULIN PROVENTIL HFA 15 BENZYLALCOHOLNACL 71 SYRINGES1ML30G X PROVERA 127 PREMARIN 73 516 107 PROVIGIL 3 PRO COMFORT INSULIN PREMIUM CONDOMS LUBRICATED 81 SYRINGES1ML31G X PROZAC 22

516 107 PREMPHASE 73 PRUDOXIN 63 PROAIR HFA 15 PREMPRO 73 PSORCON 66 probenecid 76 PRENATAL 120 PSS SELECT GP LANCETS 89 procainamide hcl 13 PSS SELECT SAFETY PRENATAL LOW IRON 120 PROCARDIA 53 LANCETS 89 PRENATAL PTS PANELS KETONE MULTIVITAMIN 120 PROCARDIA XL 54 TEST 69 PRENATAL ONE DAILY 120 prochlorperazine 48 PULMICORT 14

PRENATAL VITAMIN 120 prochlorperazine maleate 48 PULMICORT FLEXHALER 14 PRENATAL VITAMIN amp PROCRIT 77 PULMOZYME 129 MINERAL 120 PROCTOCORT 10 PRENATAL PURIXAN 36 PRODIGY INSULIN VITAMINIRON 120 PUSH BUTTON SAFETY SYRINGU-10003ML31G XPRENATAL VITAMINS 120 LANCETS 21G 89 516 107 PRENATAL VITAMINS PLUS PUSH BUTTON SAFETY PRODIGY INSULIN LOW IRON 120 LANCETS 28G 89 SYRINGE12ML31G X PX ADVANCED LANCING PRENATRIX 121 516 107 DEVICE 89 PRENATRYL 121 PRODIGY INSULIN PX INSULIN SYRINGEU-SYRINGE1ML28G XPREPLUS 121 10005ML30G X 12 107 12 107 PREPOPIK 79 PX LANCET AUTO PRODIGY LANCING INJECTOR 89 PRESSURE ACTIVATED DEVICE 89 SAFETYLANCET 21G 89 PX LANCETS ULTRA THIN 90 PRODIGY PRESSURE PREVACID 131132 ACTIVATED SAFETY PX LANCETS ULTRA THIN

28G 90 PREVACID 24HR 131 LANCETS 89 PX PRENATAL PRODIGY SAFETY PREVNAR 13 133 MULTIVITAMINS 121 LANCETS 89 PREZCOBIX 50 PRODIGY TWIST TOP pyrazinamide 34 PREZISTA 50 LANCETS 89 PYRIDIUM 76 PRIFTIN 34 progesterone 126 pyridostigmine bromide 34 PRILOSEC OTC 132 PROGLYCEM 24 pyrimethamine 34 primaquine phosphate 34 PROGRAF 119 QC ADVANCED LANCING PRIMAQUINE PHOSPHATE 34 PROLASTIN-C 129 DEVICE 90

QC LANCETS SUPER THIN 90 PRIMAXIN IV 11 PROLEUKIN 43 QC LANCETS ULTRA THIN 90 primidone 18 PROLIA 70 QC PRENATAL 121 PRINIVIL 31 PROMACTA 7778 QC UNILET LANCETS PRISTIQ 22 promethazine hcl 29 28GULTRA THIN 90

PRO COMFORT INSULIN PROMETRIUM 127 QC UNILET LANCETS SYRINGES05ML30G X propafenone hcl 13 33GMICRO THIN 90 12 107 proparacaine hcl 123 QINLOCK 41 PRO COMFORT INSULIN SYRINGES05ML30G X propranolol hcl 53 QUADRAMET 42 516 107 propylthiouracil 130 QUALAQUIN 34 PRO COMFORT INSULIN PROSCAR 76 QUARTETTE 57 SYRINGES05ML31G X PROTONIX 132 QUDEXY XR 18 516 107 PRO COMFORT INSULIN PROTOPIC 67 QUESTRAN 29 SYRINGES1ML30G X protriptyline hcl 23 QUESTRAN LIGHT 29 12 107 PROVENGE 38 quetiapine fumarate 47

Index 26

quinapril hcl 31 REALITY INSULIN RELION ULTRA THIN PLUS quinapril-hydrochlorothiazide SYRINGEU-1001ML29G X LANCETS 32G 90

32 12 108 RELION ULTRA THIN PLUS

quinidine sulfate 13 REALITY LANCETS 90 LANCETS 33G 90 REALITY LATEX RELISTOR 75 quinine sulfate 34 CONDOMSLUBRICATED 81 RELPAX 116 QVAR REDIHALER 14 REALITY LATEXULTRA REMERON 20 RA E-ZJECT LANCETS 28G90 TEXTURED 81

RA E-ZJECT LANCETS THIN REALITY LATEXULTRA REMERON SOLTAB 20 26G 90 THIN 81 RENFLEXIS 75 RA E-ZJECT LANCETS THIN REALITY TRIGGER RENVELA 75 28G 90 LANCETS 90 REOPRO 77 RA E-ZJECT LANCETS REBETOL 51

repaglinide 25 ULTRATHIN 30G 90 REBIF 128 RA INSULIN repaglinide-metformin hcl 23 REBIF REBIDOSE 128 SYRINGE05ML29G X REPATHA 30 REBIF REBIDOSE 12 108 REPATHA PUSHTRONEX RA INSULIN SYRINGE1ML29G TITRATIONPACK 128 SYSTEM 30 X 12 108 REBIF TITRATION PACK128 REPATHA SURECLICK RA INSULIN SYRINGEU- RECLAST 70 30

10005ML30G X 516 108 REQUIP XL 45 RECOMBIVAX HB 134 RA INSULIN SYRINGEU-1001 RESCRIPTOR 50 RECTIV 10 ML30G X 516 108 RESECTISOL 75 RA PRENATAL 121 REGLAN 74

RESTASIS 123 RA PRENATAL REGRANEX 68 RESTASIS MULTIDOSE 123 FORMULAFOLICACID 121 RELENZA DISKHALER 52

rabeprazole sodium 132 RESTORIL 78 RELION 2-IN-1 LANCET raloxifene hcl 71 DEVICES 30G 90 RETACRIT 78

RELION 2-IN-1 LANCING RETEVMO ramelteon 79 41 DEVICE 25G 90 ramipril 31 RETIN-A 61 RELION 2-IN-1 LANCING

RANEXA 12 90 RETIN-A MICRO 61 DEVICE 30G ranitidine hcl 131 RELION INSULIN SYRINGE RETIN-A MICRO PUMP 61

1ML31GX1564 108 ranolazine 12 RETROVIR 50 RELION INSULIN SYRINGEU-RAPAFLO 76 RETROVIR IV INFUSION 50 10003ML31G X 516 108 RAPAMUNE 119 RELION INSULIN SYRINGEU- REVATIO 55

10005ML29G X 12 108 REVLIMID 118 rasagiline mesylate 46 RELION INSULIN SYRINGEU- REXALL LANCETS ULTRA RAZADYNE 127 10005ML31G X 516 108 THIN 90 RAZADYNE ER 127 RELION INSULIN SYRINGEU- REXULTI 48 READYLANCE SAFETY 1001ML31G X 1564 108 LANCETS21G22MM 90 RELION INSULIN SYRINGEU- REYATAZ 50 READYLANCE SAFETY 1001ML31G X 516 108 RIBASPHERE 51 LANCETS23G18MM 90 RELION KETONE TEST RIBASPHERE RIBAPAK 51 READYLANCE SAFETY STRIPS 69 ribavirin (hepatitis c) 51 LANCETS26G18MM 90 RELION LANCETS MICRO-READYLANCE SAFETY THIN33G 90 RIDAURA 4 LANCETS28G18MM 90 RELION LANCETS THIN rifabutin 34 READYLANCE SAFETY 26G 90 RIFADIN 34 LANCETS30G16MM 90 RELION LANCETS ULTRA-REALITY INSULIN SYRINGEU- THIN30G 90 RIFAMATE 34 10005ML28G X 12 108 RELION LANCING rifampin 34 REALITY INSULIN SYRINGEU- DEVICE 90 RIFATER 34 10005ML29G X 12 108 RELION ULTRA THIN RIGHT STEP PRENATAL 121 REALITY INSULIN SYRINGEU- LANCETS30G 90 1001ML28G X 12 108 RELION ULTRA THIN RIGHTEST GD500 LANCING

DEVICE 90 LANCETS30G 90

Index 27

127 RIGHTEST GL300 SAFE-T-LANCE PLUS SAVELLA TITRATION LANCETS 90 SAFETYLANCET NORMAL PACK RILUTEK riluzole rimantadine hydrochloride ringers ringers irrigation RINVOQ risedronate sodium RISPERDAL RISPERDAL CONSTA risperidone RITALIN RITALIN LA ritonavir RITUXAN RITUXAN HYCELA rivastigmine tartrate rizatriptan benzoate ROBAXIN-750 ROCALTROL ROMIDEPSIN ropinirole hydrochloride rosuvastatin calcium ROTARIX ROTATEQ ROXICODONE ROZEREM ROZLYTREK RUBRACA RUCONEST rufinamide RUKOBIA RUXIENCE RUZURGI

122 122

52 117 119

4 70 46 46 46

3 3

50 37 40

127 116 121

72 41 45 30

134 134

8 79 41 41 76 19 50 37 34

FLOW 90 SAFESNAP INSULIN SYRINGE03ML30G X516 108 SAFESNAP INSULIN SYRINGE05ML29G X12 108 SAFESNAP INSULIN SYRINGE05ML30G X516 108 SAFESNAP INSULIN SYRINGE1ML28G X12 108 SAFESNAP INSULIN SYRINGE1ML29G X12 108 SAFETY INSULIN SYRINGES 05ML29GX12 108 SAFETY INSULIN SYRINGES 05ML30GX516 108 SAFETY INSULIN SYRINGES 1ML27GX12 108 SAFETY INSULIN SYRINGES 1ML29GX12 108 SAFETY INSULIN SYRINGES 1ML30GX12 108 SAFETY LANCET 21GPRESSUREACTIVATED 90 SAFETY LANCET 23GPRESSUREACTIVATED 90 SAFETY LANCET 28GPRESSUREACTIVATED 91 SAFETY LANCETS 21G 91 SAFETY LANCETS 28G 91 SAFETY LET LANCETS 91 SAFYRAL 57 SAIZEN 71 SAIZENPREP

SB INSULIN SYRINGEU-10005ML29G X 12 108 SB INSULIN SYRINGEU-10005ML30G X 516 108 SB INSULIN SYRINGEU-1001ML29G X 12 108 SB INSULIN SYRINGEU-1001ML30G X 516 108 SB INSULIN SYRINGEU-1001ML31G X 516 108 SB LANCETS THIN 91 SB LANCETS ULTRA THIN 91 SCLEROSOL INTRAPLEURAL 129 scopolamine 26 SEASONIQUE 57 SECURESAFE SAFETY INSULIN SYRINGESU-10005ML29GX12 108 SECURESAFE SAFETY INSULIN SYRINGESU-1001ML29GX12 109 SEGLUROMET 23 SELECT-LITE LANCING DEVICE 91 selegiline hcl 46 selenium sulfide 64 SELZENTRY 50 SENSIPAR 72 SEREVENT DISKUS 15 SEROQUEL 47 SEROQUEL XR 47 SEROSTIM 71 sertraline hcl 22 sevelamer carbonate 75 SHINGRIX 135 SHOPKO AUTOLET LANCING DEVICE 91

RYDAPT 41 RECONSTITUTIONKIT 71 SHOPKO ON-THE-GO RYTHMOL SR 13 SABRIL 19 SAFE-T-LANCE LOW FLOW 25G 90 SAFE-T-LANCE NORMAL FLOW21G 90 SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW 90 SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW 90

SALAGEN salsalate SAMSCA SANDIMMUNE SANDOSTATIN SANTYL SAPHRIS sapropterindihydrochloride SARCLISA SAVELLA

120 6

73 119

73 67 47

72 37

127

COMFORTLANCETS 30G 91 SHOPKO UNILET LANCETS SUPER THIN 30G 91 SHOPKO UNILET LANCETS ULTRA THIN 28G 91 SHUR-SEAL 135 SIDE BUTTON SAFETY LANCET21G 91 SIGNIFOR 73 sildenafil citrate 54 sildenafil citrate (pulmonaryhypertension) 55 SILENOR 78

Index 28

silodosin 76 SOLOSEC 3 STIMATE 73 SILVADENE 64 SOLTAMOX 39 STIVARGA 42 silver sulfadiazine 64 SOLU-CORTEF 59 STRATTERA 2 SIMBRINZA 123 SOLU-MEDROL 59 streptomycin sulfate 3 SIMPLE DIAGNOSTICS SOLUS V2 LANCING STRIBILD 50 LANCING DEVICE 91 DEVICE 91 STRIVERDI RESPIMAT 15 SIMULECT 119 SOLUS V2 PRESSURE

STROMECTOL 10 ACTIVATED SAFETY simvastatin 30 LANCETS 28G 91 STRONTIUM CHLORIDE SR-SINEMET 45 SOLUS V2 TWIST LANCETS 89 42 SINEMET CR 45 30G 91 SUBOXONE 9 SINGLE-LET 91 SOMA 121 SUBSYS 8 SINGULAIR 14 SOMATULINE DEPOT 73 SUCRAID 69 sirolimus 119 SOMAVERT 71 sucralfate 131 SIRTURO 34 SOOLANTRA 68 SULAR 54 SIVEXTRO 12 SORBITOL 75 sulconazole nitrate 63 SKELAXIN 121 SORBITOL-MANNITOL 75 sulfacetamide sodium (acne)61 SKLICE 68 SORBITOLMANNITOL sulfacetamide sodium

IRRIGATION 76 (ophth) 123 SKYLA 57 SORIATANE 64 sulfacetamide sodium wSKYRIZI 64 sulfur 61 sotalol hcl 53 SLO-NIACIN 136 sulfacetamide sodium-sulfur in sotalol hcl (afibafl) 53 urea vehicle 61 SLYND 58 spinosad 68 SULFADIAZINE 129 SM MICRO THIN LANCETS 33G 91 SPIRIVA HANDIHALER 14 sulfamethoxazole-trimethoprimSM PRENATAL VITAMINS 121 SPIRIVA RESPIMAT 14 11 SM TRUEDRAW LANCING spironolactone 70 SULFAMYLON 64 DEVICE 91 spironolactone amp sulfasalazine 75 SMART DIABETES VANTAGE hydrochlorothiazide 69 sulindac 5 LANCING DEVICE 91 SPORANOX 27 SUMADAN WASH 61 SMART SENSE COLOR SPORANOX PULSEPAK 27 LANCETS UNIVERSAL 33G 91 sumatriptan 116 SMART SENSE STANDARD SPRAVATO 56MG DOSE 21 sumatriptan succinate 116 LANCETS UNIVERSAL 21G 91 SPRAVATO 84MG DOSE 21 sumatriptan-naproxenSMART SENSE SUPER THIN SPRYCEL 41 sodium 115 LANCETS UNIVERSAL 30G 91 SUNOSI 2 STALEVO 100 45 SMART SENSE THIN

SUPER THIN LANCETS 91 LANCETSUNIVERSAL 26G 91 STALEVO 125 45 SMARTEST LANCETS 28G 91 STALEVO 150 45 SUPRAX 56 SODIUM ACETATE 117 STALEVO 200 45 SUPREP BOWEL PREP KIT79

SURE COMFORT INSULIN sodium acetate 117 STALEVO 50 4546 SYRINGEU-10003ML29G Xsodium chloride 118 STALEVO 75 46 12 109 sodium chloride (gu irrigant) 75 stannous fluoride 119 SURE COMFORT INSULIN sodium chloride (inhalant) 59 STARLIX 25 SYRINGEU-10003ML30G X

12 109 sodium citrate amp citric acid 75 stavudine 50 SURE COMFORT INSULIN sodium phenylbutyrate 72 STAVUDINE 50 SYRINGEU-10003ML30G Xsodium polystyrene STEGLATRO 25 516 109 sulfonate 119 SURE COMFORT INSULIN STELARA 6475 SOFOSBUVIRVELPATASVIR SYRINGEU-10003ML31G XSTENDRA 54 51 516 109 solifenacin succinate 132 STERILANCE TL 91 SURE COMFORT INSULIN SOLIRIS 76 STERILE TALC SYRINGEU-10003ML31G X

POWDER 129 516 109

Index 29

SURE COMFORT INSULIN SYRINGEU-10005ML28G X12 109 SURE COMFORT INSULIN SYRINGEU-10005ML29G X12 109 SURE COMFORT INSULIN SYRINGEU-10005ML30G X12 109 SURE COMFORT INSULIN SYRINGEU-10005ML30G X516 109 SURE COMFORT INSULIN SYRINGEU-10005ML31G X516 109 SURE COMFORT INSULIN SYRINGEU-1001ML28G X12 109 SURE COMFORT INSULIN SYRINGEU-1001ML29G X12 109 SURE COMFORT INSULIN SYRINGEU-1001ML30G X12 109 SURE COMFORT INSULIN SYRINGEU-1001ML30G X516 109 SURE COMFORT INSULIN SYRINGEU-1001ML31G X516 109 SURE COMFORT LANCETS 18G 91 SURE COMFORT LANCETS 21G 91 SURE COMFORT LANCETS 23G 91 SURE COMFORT LANCETS 28G 91 SURE COMFORT LANCETS 30G 91 SURE COMFORT LANCING PEN 91 SURE-JECT INSULIN SYRINGEU-10003ML29G X12 109 SURE-JECT INSULIN SYRINGEU-10003ML30G X516 109 SURE-JECT INSULIN SYRINGEU-10003ML31G X516 109 SURE-JECT INSULIN SYRINGEU-10005ML28G X12 109 SURE-JECT INSULIN SYRINGEU-10005ML29G X12 109

SURE-JECT INSULIN SYRINGEU-10005ML30G X516 109 SURE-JECT INSULIN SYRINGEU-10005ML31G X516 109 SURE-JECT INSULIN SYRINGEU-1001ML28G X12 109 SURE-JECT INSULIN SYRINGEU-1001ML29G X12 109 SURE-JECT INSULIN SYRINGEU-1001ML30G X516 110 SURE-JECT INSULIN SYRINGEU-1001ML31G X516 110 SURE-LANCE FLAT LANCETS 91 SURE-LANCE LANCETS 26G 91 SURE-LANCE THIN LANCETS 28G 91 SURE-LANCE ULTRA THIN LANCETS 91 SURE-PEN 91 SURE-TOUCH LANCETS UNIVERSAL 91 SURELITE LANCETS 91 SUSTIVA 50 SUTENT 42 SYLATRON 43 SYLVANT 119 SYMBICORT 15 SYMFI 50 SYMFI LO 50 SYMLINPEN 120 23 SYMLINPEN 60 23 SYMTUZA 50 SYNALAR 67 SYNAREL 71 SYNERA 68 SYNJARDY 23 SYNJARDY XR 23 SYNRIBO 43 SYNTHROID 130 SYPRINE 118 TABLOID 36 TABRECTA 42 TACLONEX 67 tacrolimus 119

tacrolimus (topical) 67 tadalafil 54 tadalafil (pulmonaryhypertension) 55 TAFINLAR 42 TAGAMET HB 131 TAGRISSO 38 TAKHZYRO 76 TALZENNA 42 TAMIFLU 52 tamoxifen citrate 39 tamsulosin hcl 76 TAPAZOLE 130 TARCEVA 38 TARGADOX 130 TARGRETIN 4363 TARKA 32 TASIGNA 42 TASMAR 45 tavaborole 63 TAVALISSE 76 TAXOTERE 44 TAYTULLA 57 tazarotene 64 TAZORAC 64 TAZVERIK 42 TECARTUS 38 TECENTRIQ 37 TECFIDERA 128 TECFIDERA STARTER PACK 128 TECHLITE AST LANCETS 92 TECHLITE INSULIN SYRINGEU-10003ML29G X 12 110 TECHLITE INSULIN SYRINGEU-10003ML30G X 12 110 TECHLITE INSULIN SYRINGEU-10003ML30G X 516 110 TECHLITE INSULIN SYRINGEU-10003ML31G X 516 110 TECHLITE INSULIN SYRINGEU-10005ML29G X 12 110 TECHLITE INSULIN SYRINGEU-10005ML30G X 12 110 TECHLITE INSULIN SYRINGEU-10005ML30G X 516 110 TECHLITE INSULIN SYRINGEU-10005ML31G X 516 110 TECHLITE INSULIN SYRINGEU-1001ML29G X 12 110

Index 30

TECHLITE INSULIN SYRINGEU- theophylline 15 TOPCARE ULTRA COMFORT 1001ML30G X 12 110 THERANATAL CORE INSULIN SYRINGE03ML30G XTECHLITE INSULIN SYRINGEU- NUTRITION 516 110 121 1001ML30G X 516 110 TOPCARE ULTRA COMFORT THINLETS GP LANCETS 92 TECHLITE INSULIN SYRINGEU- INSULIN SYRINGE03ML31G X1001ML31G X 1564 110 thioridazine hcl 48 516 110 TECHLITE INSULIN SYRINGEU- thiotepa 35 TOPCARE ULTRA COMFORT 1001ML31G X 516 110 thiothixene 48 INSULIN SYRINGE05ML30G XTECHLITE LANCETS 92 516 110 THYMOGLOBULIN 119 TOPCARE ULTRA COMFORT TECHLITE LANCETS 30G 92 THYROGEN 69 INSULIN SYRINGE05ML31G XTEFLARO 56 thyroid 130 516 110 TEGRETOL 19 TOPCARE ULTRA COMFORT tiagabine hcl 19 TEGRETOL-XR 19 INSULIN SYRINGE1ML30G XTIAZAC 54 516 110 TEGSEDI 129 TIBSOVO 42 TOPCARE ULTRA COMFORT TEKTURNA 33 TIGAN 26 INSULIN SYRINGE1ML31G Xtelmisartan 31 516 110 tigecycline 129 telmisartan-amlodipine 32 TOPCARE ULTRA COMFORT

TIKOSYN 13 INSULIN SYRINGEU-telmisartan-hydrochlorothiazide timolol maleate 53 10003ML29G X 12 110 32 TOPCARE ULTRA COMFORT temazepam 78 timolol maleate (ophth) 122 INSULIN SYRINGEU-TIMOPTIC 122 TEMIXYS 50 10005ML29G X 12 110

TEMODAR 35 TIMOPTIC-XE 122 TOPCARE ULTRA COMFORT TIVICAY 50 INSULIN SYRINGEU-TEMOVATE 67 1001ML29G X 12 110 tizanidine hcl 121 temozolomide 35 TOPICORT 67 TOBI 3 temsirolimus 42 topiramate 19 TOBRADEX 124 TENIPOSIDE 44 TOPOTECAN HCL 44

tenofovir disoproxil fumarate 50 tobramycin 3 topotecan hcl 44

TENORETIC 100 32 tobramycin (ophth) 123 TOPROL XL 53

TENORETIC 50 32 tobramycin sulfate 3 toremifene citrate 39 tobramycin-TENORMIN 53 dexamethasone 124 TORISEL 42

TEPADINA 35 TOBREX 123 torsemide 70 terazosin hcl 31 TODAY SPONGE 135 TOTECT 43 terbinafine hcl 27 TODAYS HEALTH ADVANCED TOVIAZ 132 terbutaline sulfate 15 LANCING DEVICE 92 TRACLEER 55 TODAYS HEALTH SUPER terconazole vaginal 135 tramadol hcl 8 THINLANCETS 30G 92 TESSALON PERLES 59 TODAYS HEALTH ULTRA tramadol-acetaminophen 9 TESTIM 10 THINLANCETS 28G 92 trandolapril 31 TESTOSTERONE TOFRANIL 23 trandolapril-verapamil hcl 33 CYPIONATE 10 tolbutamide 25 testosterone cypionate 10 tranexamic acid 78

tolcapone 45 testosterone enanthate 10 TRANSDERM SCOP 26

tolmetin sodium 5 tetrabenazine 127 TRANSDERM-SCOP 26

TOLSURA 27 tetracycline hcl 130 TRANXENE T 13

tolterodine tartrate 132 TGT LANCET MICRO THIN tranylcypromine sulfate 21 tolvaptan 73 33G 92 TRAVATAN Z 125

TGT LANCET THIN 26G 92 TOPAMAX 19 TRAVEL LANCETS 30G 92 TGT LANCET ULTRA THIN TOPAMAX SPRINKLE 19 TRAVEL LANCETS ADVANCED 30G 92 TOPCARE LANCETS MICRO- 28G 92 TGT LANCING DEVICE 92 THIN 33G 92 travoprost 125 THALOMID 118

Index 31

TRAZIMERA 37 tropicamide 122 TRUEPLUS INSULIN SYRINGEU-1001ML29G Xtrazodone hcl 22 trospium chloride 132 12 111 TREANDA 35 TRUE COMFORT INSULIN TRUEPLUS INSULIN SYRINGE05ML31G XTRECATOR 35 SYRINGEU-1001ML30G X516 110 TRELEGY ELLIPTA 15 516 111 TRUE COMFORT INSULIN TRUEPLUS INSULIN TRELSTAR MIXJECT 39 SYRINGE1ML31G X SYRINGEU-1001ML31G X

TREMFYA 64 516 111 516 111 TRUE COMFORT PRO treprostinil 54 TRUEPLUS LANCETS 26G 92 INSULINSYRINGE05ML30GTRESIBA 25 X 516 111 TRUEPLUS LANCETS 28G 92 TRESIBA FLEXTOUCH 25 TRUE COMFORT PRO TRUEPLUS LANCETS 28G

INSULINSYRINGE05ML31G SUPER THIN 92 tretinoin 61 X 516 111 TRUEPLUS LANCETS 30G 92 tretinoin (chemotherapy) 43 TRUE COMFORT PRO TRUEPLUS LANCETS 30G tretinoin microsphere 61 INSULINSYRINGE1ML30G X ULTRA THIN 92 TREXALL 36 516 111 TRUEPLUS LANCETS 33G 92 TRUE COMFORT PRO TREXIMET 115 TRUEPLUS LANCETS 33G INSULINSYRINGE1ML31G X MICRO THIN 92 triamcinolone acetonide 59 516 111 TRUEPLUS SAFETY LANCETS triamcinolone acetonide TRUE COMFORT PRO 28G 92 (mouth) 119 INSULINSYRINGEU- TRUETRACK TEST 69 triamcinolone acetonide 10005ML30G X 12 111 (nasal) 122 TRUE COMFORT PRO TRULICITY 24 triamcinolone acetonide INSULINSYRINGEU- TRUSOPT 125 (topical) 67 1001ML30G X 12 111 TRUSTEX COLOR CONDOMS + triamcinolone acetonide- TRUE METRIX BLOOD LUBE 81 dimethicone-silicone 67 GLUCOSETEST STRIPS 69 TRUSTEX LUBRICATED 81 triamterene 70 TRUE METRIX CONTROL TRUSTEX LUBRICATED triamterene amp SOLUTION LEVEL 3 92 EXTRALARGE 81 hydrochlorothiazide 69 TRUEDRAW LANCING TRUSTEX LUBRICATED DEVICE 92 triazolam 78 EXTRASTRENGTH 81 TRUEPLUS INSULIN TRIBENZOR 33 TRUSTEX SYRINGEU-10003ML29G XTRICARE 121 12 111 LUBRICATEDRIBBEDSTUDDE

D 81 TRICOR 30 TRUEPLUS INSULIN TRUSTEX SYRINGEU-10003ML30G XTRIDESILON 67 LUBRICATEDSPERMICIDE516 111 trientine hcl 118 81 TRUEPLUS INSULIN TRUSTEX trifluoperazine hcl 48 SYRINGEU-10003ML31G X LUBRICATEDSPERMICIDEtrifluridine 123 516 111 EXTRA LARGE 81 TRUEPLUS INSULIN trihexyphenidyl hcl 44 TRUSTEX SYRINGEU-10005ML28G XTRIJARDY XR 23 LUBRICATEDSPERMICIDE12 111 EXTRA STRENGTH 81 TRIKAFTA 129 TRUEPLUS INSULIN TRUSTEX NATURAL TRILEPTAL 19 SYRINGEU-10005ML29G X CONDOMS 12 111 trimethobenzamide hcl 26 +LUBELUBRICATED 81 TRUEPLUS INSULIN TRUSTEX WITH NONOXYNOL-trimethoprim 10 SYRINGEU-10005ML30G X 9RIBBEDSTUDDED 81 trimipramine maleate 23 516 111 TRUSTEXRIATRUEPLUS INSULIN TRINTELLIX 22 LUBRICATED 81 SYRINGEU-10005ML31G XTRIOSTAT 130 TRUSTEXRIA LUBRICATED516 111 SPERMICIDE 81 TRISENOX 43 TRUEPLUS INSULIN TRUSTEXRIATRIUMEQ 50 SYRINGEU-1001ML28G X LUBRICATEDSPERMICIDE12 111 TRIZIVIR 50 81 TRODELVY 44 TRUVADA 50

Index 32

TRUXIMA 37 ULTICARE INSULIN ULTIGUARD SAFEPACK SYRINGE1ML30G X INSULIN SYRINGE 1ML 31G X TUKYSA 37 516 112 516SHARPS CO 112 TURALIO 42 ULTICARE INSULIN ULTIGUARD SAFEPACK

TUZISTRA XR 59 SYRINGESHORT03ML30G INSULIN SYRINGE03ML30G XTWINRIX 135 X 516 112 12SHARPS C 112

ULTICARE INSULIN ULTIGUARD SAFEPACK TWIRLA 57 SYRINGESHORT03ML31G INSULIN SYRINGE03ML31G XTWYNSTA 33 X 516 112 516SHARPS 112 TYBLUME 57 ULTICARE INSULIN ULTIGUARD SAFEPACK

SYRINGESHORT05ML30G INSULIN SYRINGE05ML30G XTYBOST 50 X 516 112 12SHARPS C 112 TYGACIL 129 ULTICARE INSULIN ULTIGUARD TYKERB 42 SYRINGESHORT05ML31G SAFEPACKSYRINGENEEDLETYLENOLCODEINE 3 9 X 516 112 31G X 516SHARPS

ULTICARE INSULIN CONTAIN 112 TYLENOLCODEINE 4 9 SYRINGESHORT1ML30G X ULTILET CLASSIC TYMLOS 70 516 112 LANCETS 92 TYSABRI 128 ULTICARE INSULIN ULTILET INSULIN UCERIS 10 SYRINGESHORT1ML31G X SYRINGE03ML30G X

516 112 8MM 113 UDENYCA 78 ULTICARE INSULIN ULTILET INSULIN ULESFIA 68 SYRINGEU-10003ML30G X SYRINGE03ML31G XULORIC 76 12 112 8MM 113 ULTI-LANCE AUTOMATIC ULTICARE INSULIN ULTILET INSULIN CLEAR TIP 92 SYRINGEU-10003ML31G X SYRINGE05ML30G XULTICARE INSULIN SAFETY 516 112 8MM 113 SYRINGE05ML29G X ULTICARE INSULIN ULTILET INSULIN 12 111 SYRINGEU-10005ML30G X SYRINGE1ML30G X 8MM113 ULTICARE INSULIN SAFETY 12 112 ULTILET INSULIN SYRINGE1ML29G X 12 111 ULTICARE INSULIN SYRINGE1ML31G X 8MM113 ULTICARE INSULIN SYRINGEU-10005ML31G X ULTILET INSULIN SYRINGE03ML29G X 516 112 SYRINGESHORT03ML30G X12 111 ULTICARE INSULIN 127MM 113 ULTICARE INSULIN SYRINGEU-1001ML30G X ULTILET INSULIN SYRINGE03ML30G X 12 112 SYRINGESHORT03ML30G X12 111 ULTICARE INSULIN 516 113 ULTICARE INSULIN SYRINGEU-1001ML31G X ULTILET INSULIN SYRINGE03ML30G X 516 112 SYRINGESHORT03ML31G X516 111 ULTICARE INSULIN 516 113 ULTICARE INSULIN SYRINGEULTRAFINE U- ULTILET INSULIN SYRINGE05ML28G X 10003ML31G X 516 112 SYRINGESHORT05ML30G X12 111 ULTICARE INSULIN 516 113 ULTICARE INSULIN SYRINGEULTRAFINE U- ULTILET INSULIN SYRINGE05ML29G X 10005ML31G X 516 112 SYRINGESHORT05ML31G X12 111 ULTICARE INSULIN 516 113 ULTICARE INSULIN SYRINGEULTRAFINE U- ULTILET INSULIN SYRINGE05ML30G X 1001ML31G X 516 112 SYRINGESHORT1ML30G X12 111 ULTIGUARD SAFEPACK 516 113 ULTICARE INSULIN INSULIN SYRINGE 03ML30G ULTILET INSULIN SYRINGE05ML30G X X 12SHARPS C 112 SYRINGESHORT1ML31G X516 111 ULTIGUARD SAFEPACK 516 113 ULTICARE INSULIN INSULIN SYRINGE 12ML 30G ULTILET INSULIN SYRINGEU-SYRINGE1ML28G X 12 111 X 12SHARPS C 112 10005ML30G X 12 113 ULTICARE INSULIN ULTIGUARD SAFEPACK ULTILET INSULIN SYRINGEU-SYRINGE1ML29G X 12 112 INSULIN SYRINGE 1ML 30G X 1001ML30G X 12 113 ULTICARE INSULIN 12SHARPS CON 112 ULTILET LANCETS 92 SYRINGE1ML30G X 12 112 ULTILET LANCETS 33G 92

Index 33

ULTILET SAFETY LANCETS 21G X 22MM 92 ULTILET SAFETY LANCETS 23G 92 ULTRA COMFORT INSULIN SYRINGEU-10003ML30G X516 113 ULTRA FLO INSULIN SYRINGE 03ML29G X 12 113 ULTRA FLO INSULIN SYRINGE 03ML30GX12 113 ULTRA FLO INSULIN SYRINGE 03ML30GX516 113 ULTRA FLO INSULIN SYRINGE 03ML31GX516 113 ULTRA FLO INSULIN SYRINGE 05ML29GX12 113 ULTRA FLO INSULIN SYRINGE 05ML30GX12 113 ULTRA FLO INSULIN SYRINGE 05ML30GX516 113 ULTRA FLO INSULIN SYRINGE 05ML31GX516 113 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML30GX12 113 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML30GX516

113 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML31GX516

113 ULTRA FLO INSULIN SYRINGE 1M29GX12 113 ULTRA FLO INSULIN SYRINGE 1ML30GX12 113 ULTRA FLO INSULIN SYRINGE 1ML30GX516 113 ULTRA FLO INSULIN SYRINGE 1ML31GX516 113 ULTRA THIN LANCETS 31G 92 ULTRA-COMFORT INSULIN SYRINGEU-10003ML29G X12 114 ULTRA-COMFORT INSULIN SYRINGEU-10003ML30G X516 114 ULTRA-COMFORT INSULIN SYRINGEU-10003ML31G X516 114 ULTRA-COMFORT INSULIN SYRINGEU-10005ML28G X12 114 ULTRA-COMFORT INSULIN SYRINGEU-10005ML29G X12 114 ULTRA-COMFORT INSULIN SYRINGEU-10005ML30G X516 114

ULTRA-COMFORT INSULIN SYRINGEU-10005ML31G X516 114 ULTRA-COMFORT INSULIN SYRINGEU-1001ML28G X12 114 ULTRA-COMFORT INSULIN SYRINGEU-1001ML29G X12 114 ULTRA-COMFORT INSULIN SYRINGEU-1001ML30G X516 114 ULTRA-COMFORT INSULIN SYRINGEU-1001ML31G X516 114 ULTRA-THIN II AUTO LANCET 92 ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML30GX516 114 ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML31GX516 114 ULTRA-THIN II INSULIN SYRINGE SHORTU-10005ML30GX516 114 ULTRA-THIN II INSULIN SYRINGE SHORTU-10005ML31GX516 114 ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML30GX516 114 ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML31GX516 114 ULTRA-THIN II INSULIN SYRINGEU-10005ML29GX12 114 ULTRA-THIN II INSULIN SYRINGEU-1001ML29GX12 114 ULTRA-THIN II LANCETS 28G 92 ULTRA-THIN II LANCETS 30G 92 ULTRACARE INSULIN SYRINGEU-10003ML30G X516 114 ULTRACARE INSULIN SYRINGEU-10003ML31G X516 114 ULTRACARE INSULIN SYRINGEU-10005ML30G X12 114 ULTRACARE INSULIN SYRINGEU-10005ML30G X516 114

ULTRACARE INSULIN SYRINGEU-10005ML31G X516 114 ULTRACARE INSULIN SYRINGEU-1001ML30G X12 114 ULTRACARE INSULIN SYRINGEU-1001ML30G X516 115 ULTRACARE INSULIN SYRINGEU-1001ML31G X516 115 ULTRACET 9 ULTRAM 8 ULTRAVATE 67 UNASYN 126 UNASYN BULK PACK 126 UNILET COMFORTOUCH LANCET 92 UNILET EXCELITE 92 UNILET EXCELITE II 92 UNILET GP LANCET 92 UNILET GP SUPERLITE LANCET 92 UNILET GP 28 ULTRA THIN92 UNILET LANCET 92 UNILET LANCETS MICRO-THIN33G 92 UNILET LANCETS SUPER-THIN30G 92 UNILET LANCETS ULTRA-THIN 28G 93 UNILET SUPERLITE LANCET 93 UNISTIK 3 GENTLE 93 UNISTIK PRO SAFETY LANCET 21G 93 UNISTIK PRO SAFETY LANCET 25G 93 UNISTIK PRO SAFETY LANCET 28G 93 UNISTIK SAFETY LANCETS 28G 93 UNISTIK SAFETY LANCETS 30G 93 UNISTIK TOUCH SAFETY LANCETS 21G 93 UNISTIK TOUCH SAFETY LANCETS 23G 93 UNISTIK TOUCH SAFETY LANCETS 28G 93 UNISTIK TOUCH SAFETY LANCETS 30G 93 UNITUXIN 37 UNIVERSAL 1 LANCETS THIN26G 93

Index 34

UNIVERSAL 1 LANCETS ULTRA VANISHPOINT INSULIN VIDEX EC 50 THIN 30G 93 UNIVERSAL 1 LANCETS33GMICRO-THIN

93 URECHOLINE 132 UROCIT-K 10 75 UROXATRAL 76 URSO 250 74

SYRINGE05ML30G X12 VANISHPOINT INSULIN SYRINGE05ML30G X516 VANISHPOINT INSULIN SYRINGE1ML29G X12 VANISHPOINT INSULIN

115

115

115

VIDEXPEDIATRIC 50 vigabatrin 19 VIGAMOX 123 VIIBRYD 22 VIIBRYD STARTER PACK 22 VIMPAT 19 vinblastine sulfate 44

URSO FORTE 74 ursodiol 74 UTIBRON NEOHALER 15 UVADEX 43 VAGIFEM 135 valacyclovir hcl 5152 VALCHLOR 63 VALCYTE 51 valganciclovir hcl 51 VALIUM 13 valproate sodium 20 valproic acid 20 valrubicin 40 valsartan 31 valsartan-hydrochlorothiazide

33

SYRINGE1ML30G X516 VANTAS VAQTA VARIVAX VARUBI VASCEPA VASERETIC VASOTEC VECAMYL VECTIBIX VECTICAL VELCADE VELETRI VELPHORO VELTIN

115 39

135 135

27 29 33 31 33 38 64 42 54 75 61

vincristine sulfate vinorelbine tartrate VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VISTARIL VISTOGARD VITAMIN D2 VITATHELYGINGER VITRAKVI VIVAGUARD LANCETS VIVAGUARD LANCING DEVICE VIVELLE-DOT VIZIMPRO

44 44 50 50 50 51 13 26

136 121

42 93

93 73 38

VALSTAR 40 VEMLIDY 51 VOGELXO 10 VALTOCO 17 VENCLEXTA 38 VOGELXO PUMP 10 VALTREX 52 VALUE HEALTH INSULIN SYRINGEU-10005ML29G X12 115 VALUE HEALTH INSULIN SYRINGEU-1001ML29G X12 115 VALUE PLUS LANCETS STANDARD 21G 93 VALUE PLUS LANCETS SUPERTHIN 30G 93 VALUE PLUS LANCETS THIN

VENCLEXTA STARTING PACK venlafaxine hcl VENTAVIS VENTOLIN HFA verapamil hcl VEREGEN VERELAN VERELAN PM VERZENIO

38 22 54 15 54 61 54 54 42

VOL-PLUS VOLTAREN VORAXAZE voriconazole VOSEVI VOTRIENT VP INSULIN SYRINGEU-10003ML29G X 12 VPRIV VUSION

121 61 43 28 51 42

115 77 63

26G 93 VALUE PLUS LANCING DEVICE 93 VALUMARK LANCET SUPER

VESICARE VFEND VIAGRA

132 28 54

VYNDAMAX VYNDAQEL VYTORIN

55 55 29

THIN 30G 93 VIBRAMYCIN 130 VYVANSE 1 VALUMARK LANCET ULTRA THIN 28G 93 VANCOCIN 11 VANCOCIN HCL 11

VICTOZA 24 VIDA MIA AUTOLET LANCINGDEVICE 93 VIDA MIA UNILET LANCETS

VYXEOS WALGREENS ADVANCED TRAVELLANCETS 28G WALGREENS COMFORT

40

93

vancomycin hcl VANCOMYCIN HYDROCHLORIDE

11

11

SUPER THIN 30G 93 VIDA MIA UNILET LANCETS ULTRA THIN 28G 93 VIDAZA 36

ASSUREDLANCETS MICRO THIN33G 93 WALGREENS COMFORT ASSUREDLANCETS SUPER THIN28G 93

Index 35

WALGREENS LANCETS 93 XOSPATA 42 ZERVIATE 125 WALGREENS THIN XPOVIO 100 MG ONCE ZESTORETIC 33 LANCETS 93 WALGREENS ULTRA THIN LANCETS 93

WEEKLY XPOVIO 40 MG ONCE WEEKLY

39

39

ZESTRIL ZETIA

31 30

warfarin sodium 15 XPOVIO 40 MG TWICE ZEVALIN Y-90 38 water for irrigation sterile 119 WELCHOL 2930


39

39

ZIAC ZIAGEN

33 51

WELLBUTRIN SR 2021 XPOVIO 60 MG TWICE ZIANA 61 WELLBUTRIN XL WESTAB PLUS WESTHROID

21 121 130

WEEKLY XPOVIO 80 MG ONCE WEEKLY XPOVIO 80 MG TWICE

39

39

zidovudine ZIEXTENZO zileuton

51 78 14

WIDE-SEAL SILICONE WEEKLY 39 ZINECARD 43 DIAPHRAGM KIT 60 WIDE-SEAL SILICONE DIAPHRAGM KIT 65 WIDE-SEAL SILICONE

81

81

XTAMPZA ER XTANDI XULTOPHY 10036

8 39 24

ZIOPTAN ziprasidone hcl ZIRABEV

125 46 37

DIAPHRAGM KIT 70 WIDE-SEAL SILICONE DIAPHRAGM KIT 75 WIDE-SEAL SILICONE

81

81

XYLOCAINE XYLOCAINE-MPF XYREM

79 80

127

ZIRGAN ZITHROMAX ZITHROMAX TRI-PAK

123 80 80

DIAPHRAGM KIT 80 82 XYZAL ALLERGY 24HR 29 ZITHROMAX Z-PAK 80 WIDE-SEAL SILICONE DIAPHRAGM KIT 85 82 WIDE-SEAL SILICONE DIAPHRAGM KIT 90 82 WIDE-SEAL SILICONE DIAPHRAGM KIT 95 82 WP THYROID 130 XALATAN 125 XALKORI 42 XANAX 13 XANAX XR 13 XARELTO 16 XARELTO STARTER PACK 16 XATMEP 36 XELJANZ 4 XELJANZ XR 4 XELODA 36 XENAZINE 127 XEOMIN 122 XGEVA 71 XIFAXAN 10 XIGDUO XR 24 XIMINO 130 XOFIGO 42 XOLAIR 14 XOPENEX 15 XOPENEX CONCENTRATE 15 XOPENEX HFA 15

XYZAL ALLERGY 24HR CHILDRENS 29 YASMIN 28 57 YAZ 57 YERVOY 37 YESCARTA 38 YONDELIS 35 YONSA 39 ZADITOR 125 zafirlukast 14 zaleplon 79 ZALTRAP 37 ZANAFLEX 121 ZANOSAR 35 ZANTAC 131 ZANTAC 150 MAXIMUM STRENGTH 131 ZARONTIN 20 ZARXIO 78 ZAVESCA 77 ZEGERID 132 ZEJULA 42 ZELBORAF 42 ZEMAIRA 129 ZEMPLAR 72 ZENPEP 69 ZEPATIER 51 ZEPZELCA 35

ZOCOR ZOFRAN ZOHYDRO ER ZOLADEX zoledronic acid ZOLEDRONIC ACID zoledronic acid ZOLEDRONIC ACID ZOLINZA zolmitriptan ZOLOFT zolpidem tartrate ZOMACTON ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZOSTAVAX ZOSYN ZOVIRAX ZYBAN ZYCLARA ZYCLARA PUMP

30 26

8 39 71 71 71 71 42

116 22 79 71

116 117

64 19 19 77 71

119 135 126

5264 129

67 67

Index 36

ZYDELIG 42 ZYKADIA 42 ZYLOPRIM 76 ZYMAXID 123 ZYPREXA 47 ZYPREXA ZYDIS 4748 ZYRTEC ALLERGY 29 ZYRTEC CHILDRENS ALLERGY 29 ZYRTEC-D ALLERGYCONGESTION 59 ZYTIGA 39 ZYVOX 12

Index 37

FROM I arizona complete healthtrade

AMB19-AZ-C-00236 copy 2020 Arizona Complete Health which is underwritten by Health Net of Arizona Inc All rights reserved

Discrimination is Against the Law Arizona Complete Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Arizona Complete Health does not exclude people or treat them differently because of race color national origin age disability or sex

Arizona Complete Health

bull Provides free aids and services to people with disabilities to communicate efectively with us such as qualifed sign language interpreters

bull Written information in other formats (large print audio accessible electronic formats other formats) bull Provides free language services to people whose primary language is not English such as qualifed interpreters

and information written in other languages

If you need these services contact Member Services at Arizona Complete Health 1-866-918-4450 (TTY 711)

If you believe that Arizona Complete Health failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with the Chief Compliance Officer Cheyenne Ross You can file a grievance in person by mail fax or email Your grievance must be in writing and must be submitted within 180 days of the date that the person filing the grievance becomes aware of what is believed to be discrimination

Submit your grievance to Arizona Complete Health- Chief Compliance Officer-Cheyenne Ross 1870 W Rio Salado Parkway Tempe AZ 85281 Fax 1-866-388-2247 Email AzCHGrievanceAndAppealsAZCompleteHealthcom

You can also fle a civil rights complaint with the US Department of Health and Human Services Ofce for Civil Rights electronically through the Ofce for Civil Rights Complaint Portal available at httpsocrportalhhsgov ocrportallobbyjsf or by mail at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 or by phone 1-800-368-1019 1-800-537-7697 (TTY)

Complaint forms are available at httpwwwhhsgovocrofcefleindexhtml

AMB19-AZ-HP-1000

Attention If you speak a language other than English oral interpretation and written translation are available to you free of charge to understand the information provided Call 1-866-918-4450 (TTYTDD 711)

Spanish Si habla espantildeol dispone sin cargo alguno de interpretacioacuten oral y traduccioacuten escrita Llame al 1-866-918-4450 (TTYTDD 711)

Navajo Din4 krsquoehj7 y1n7[tirsquogo atarsquo hanersquo n1 h0l= d00 naaltsoos trsquo11 Din4 krsquoehj7 bee bikrsquoersquoashch98go nichrsquo8rsquo 1dooln7i[go bee hazrsquo3 a[d0rsquo 1ko d77 trsquo11 1trsquo4 trsquo11 j77krsquoe k0trsquo4ego nichrsquo8rsquo 22rsquo1trsquo4 Koj8rsquo h0lnersquo 1-866-918-4450 (TTYTDD 711)

Chinese (Mandarin) 若您讲中文我们会免费为您提供口译和笔译服务请致电 1-866-918-4450 (TTYTDD 711)

Chinese (Cantonese) 我們為中文使用者免費提供口譯和筆譯請致電 1-866-918-4450 (TTYTDD 711)

Vietnamese Nếu quyacute vị noacutei Tiếng Việt coacute sẵn caacutec dịch vụ thocircng dịch bằng lời vagrave biecircn dịch văn bản miễn phiacute dagravenh cho quyacute vị Hatildey gọi 1-866-918-4450 (TTYTDD 711)

Arabic ا ر لك ترجمة شفهية وترجمة تحريرية مجان تتحدث اللغة العربية تتوف إذك انت مTDD (TTY 1171 (8-966-18- 0544 رقلاتصل با

Tagalog Kung ikaw ay nagsasalita ng Tagalog mayroong libreng oral na interpretasyon at nakasulat na pagsasalin na maaari mong gamitin Tumawag sa 1-866-918-4450 (TTYTDD 711)

Korean 한국어를 하실 경우 구두 통역 및 서면 번역 서비스를 무료로 제공해드릴 수 있습니다 1-866-918-4450 (TTYTDD 711) 번으로 전화하십시오

French Si vous parlez franccedilaisvous disposez gratuitement drsquoune interpreacutetation orale et drsquoune traduction eacutecrite Appelez le 1-866-918-4450 (TTYTDD711)

German Fuumlr alle die Deutsch sprechen stehen kostenlose Dolmetscher- und Uumlbersetzungsservices zur Verfuumlgung Telefon 1-866-918-4450 (TTYTDD 711)

Russian Если вы говорите по-русски услуги устного и письменного перевода предоставляются вам бесплатно Звоните по телефону 1-866-918-4450 (TTYTDD 711)

Japanese 日本語を話される方は通訳（口頭）および翻訳（筆記）を無料でご利用いただけます電話番号 1-866-918-4450 (TTYTDD 711)

Persian (Farsi) قابل دسترسی ميباشد شما ه بریابی بدون هزينف انرسی صحبت ميکنيد ترجمه شهافی و تکاگر به زبا ه تماس بگیرید TYTDD (TT 171 ( 4450-918-866-1با شمار

Syriac ܓܢܐܝܬ ܐ ܡ ܝܢܒܝܡܗܪ ܟܬ ܐ ܘ ܡܠܠ ܐ ܡ ܐ ܪܩܡܐ ܩܐ ܬܘܪܓ ܝܬ ܩܪܝܡܘܢ ܠܐ ܟܝܬܘܢ ܣܘ ܢ ܡܚ ܐ1-866-918-4450 (TTYTDD 711)

Serbo-Croatian Ako govorite srpsko hrvatski usmeno i pismeno prevođenje vam je dostupno besplatno Nazovite 1-866-918-4450 (TTYTDD 711)

Thai หากคณพดภาษา ไทย เรามบรการล ามและแปลเอกสาร โดยไม มค าใช จ าย โทรศพท 1-866-918-4450 (TTYTDD 711)

AZCompleteHealthcom AMB19-AZ-HP-1001

Classes

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to Treat ADHD Sleep and Eating Disorders


AMEBICIDES

AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections

ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain Swelling Muscle and Joint Conditions

ANALGESICS - NonNarcotic - Drugs to Treat Pain Muscle and Joint Conditions

ANALGESICS - OPIOID - Drugs to Treat Pain Muscle and Joint Conditions


ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain Swelling and Itching










ANTIDIABETICS - Drugs to Regulate Blood Sugar



ANTIEMETICS - Drugs to Treat Nausea and Vomiting



ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol

ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure

ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections)


ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections)

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer


ANTIPSYCHOTICSANTIMANIC AGENTS - Drugs to Treat Mood Disorders


BETA BLOCKERS - Drugs to Treat High Blood Pressure

CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure

CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm

CARDIOVASCULAR AGENTS - MISC - Drugs to Treat Heart and Circulation Conditions

CEPHALOSPORINS - Drugs to Treat Bacterial Infections

CONTRACEPTIVES - Drugs to Prevent Pregnancy

CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions

COUGHCOLDALLERGY - Drugs to Treat Cough Cold and Allergy Symptoms

DERMATOLOGICALS - Drugs to Treat Skin Conditions

DIAGNOSTIC PRODUCTS

DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes

DIURETICS - Drugs to Treat Heart Circulation Conditions and Blood Pressure

ENDOCRINE AND METABOLIC AGENTS - MISC - Drugs to Treat Bone Disease and Regulate Hormones

ESTROGENS - Hormone ReplacementModifying Drugs

FLUOROQUINOLONES - Drugs to Treat Bacterial Infections

GASTROINTESTINAL AGENTS - MISC - Miscellaneous Gastrointestinal Drugs

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System


HEMATOLOGICAL AGENTS - MISC - Drugs to Treat Blood Disorders

HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders

HEMOSTATICS - Drugs to Stop BleedingTreat Blood Disorders

HYPNOTICSSEDATIVESSLEEP DISORDER AGENTS


LOCAL ANESTHETICS-Parenteral - Drugs for Numbing

MACROLIDES - Drugs to Treat Bacterial Infections


MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches




MULTIVITAMINS

MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms

NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus

NEUROMUSCULAR AGENTS - Drugs to RelaxParalyze Muscles

NUTRIENTS



PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune System


PROGESTINS - Hormone ReplacementModifying Drugs

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental and Emotional Conditions

RESPIRATORY AGENTS - MISC - Drugs to Treat Lung Conditions

SULFONAMIDES - Drugs to Treat Bacterial Infections

TETRACYCLINES - Drugs to Treat Bacterial Infections

THYROID AGENTS - Drugs to Regulate Thyroid Hormones

TOXOIDS

ULCER DRUGS - Drugs to Treat Bowel Intestine and Stomach Conditions

URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms

VACCINES


VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions

VITAMINS

Formulary Introduction FORMULARY

The Ambetter from Arizona Complete Health Formulary or Preferred Drug List is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription

drug benefit Generic drugs have the same active ingredients as their brand name counterparts and should be

considered the first line of treatment The FDA requires generics to be safe and work the same as brand name

drugs If there is no generic available there may be more than one brand name drug to treat a condition Preferred

brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate safe and cost-

effective treatment options if a generic medication on the formulary is not suitable for your condition

Please note the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit

Not all dosage forms or strengths of a drug may be covered This list is periodically reviewed and updated and may

be subject to change Drugs may be added or removed or additional requirements may be added in order to approve

continued usage of a specific drug

Specific prescription benefit plan designs may not cover certain products or categories regardless of their

appearance in this document Please check your benefits for coverage limitations and your share of cost for your

drugs

Drug List Key

Brand name drugs are listed in CAPS and generic drugs are lower case Drugs are covered under different copay tiers depending on your benefit

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Affordable Care Act Select oral contraceptives vitamin D folic acid for women of child bearing age over-the-counter (OTC) aspirin and smoking cessation products may be covered under this tier Certain age or gender limits apply

Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similar conditions Select over-the-counter (OTC) generic or brand name drugs may be covered under this tier

Tier 2 - Medium copayment covers brand name drugs that are generally more affordable or may be preferred compared to other drugs to treat the same conditions

Tier 3 - Highest copayment covers higher cost brand name drugs This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage

Tier 4 - Coverage for this tier is for ldquospecialtyrdquo drugs Specialty drugs are used to treat complex chronic conditions and may require special handling storage or clinical management Prescription drugs covered under the specialty tier require fulfillment at a pharmacy that participates in Ambetterrsquos ldquospecialtyrdquo or ldquohemophiliardquo networks For additional information on which pharmacies are within our ldquospecialtyrdquo or ldquohemophiliardquo networks please consult Ambetter websitersquos pharmacy information section

Coverage for this tier is for oncology or anti-cancer drugs Cost-share is set to be equivalent to members Tier 6 - medical benefit cost-share

Abbreviation







Term What it means





ST Step Therapy






NF Non-formulary






Drug Name DrugTier

RequirementsLimits



NF

QL(3 ea daily)


NF

QL(2 ea daily)


NF

QL(1 ea daily)


NF


NF

QL(2 ea daily)



1

QL(1 ea daily)


1

Drug Name DrugTier

RequirementsLimits


1

QL(2 ea daily)


1

QL(3 ea daily)


1

QL(2 ea daily)




NF

QL(4 ea daily)


NF






3 ST QL(1 eadaily)




1

Drug Name DrugTier

RequirementsLimits


Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1







Drug Name DrugTier

RequirementsLimits


1

QL(1 ea daily)









yrs old)




















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


celecoxib caps 1 PA













daily)

flurbiprofen tabs 1





4

Drug Name DrugTier

RequirementsLimits









nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1





Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


NF


NF


5

Drug Name DrugTier

RequirementsLimits


Salicylates





diflunisal tabs 1


NF


salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF





daily)



1

PA QL(4 eadaily)


1

QL(034 eadaily)



1 PA QL(2 eadaily)




1






NF


NF

PA QL(2 eadaily)


6

Drug Name DrugTier

RequirementsLimits











1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF

Drug Name DrugTier

RequirementsLimits









1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)


7

Drug Name DrugTier

RequirementsLimits






daily)










1





1








Drug Name DrugTier

RequirementsLimits


1



1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1 QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1



NF


10

Drug Name DrugTier

RequirementsLimits


NF






atovaquone susp 1



Carbapenems




meropenem solr 1








Drug Name DrugTier

RequirementsLimits

Glycopeptides










Leprostatics

dapsone tabs 1


NF


NF


NF







aztreonam solr 1


11

Drug Name DrugTier

RequirementsLimits






daily) Polymyxins






NF


NF









Drug Name DrugTier

RequirementsLimits




NF





NITRO-BID OINT 3


NF



1











12

Drug Name DrugTier

RequirementsLimits


meprobamate tabs 1






















Drug Name DrugTier

RequirementsLimits













dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOSY 4 PA














NF QL(1 ea daily)








Drug Name DrugTier

RequirementsLimits



2



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF






14

Drug Name DrugTier

RequirementsLimits


1 QL(15 ml daily)









daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)






Drug Name DrugTier

RequirementsLimits




2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1









15

Drug Name DrugTier

RequirementsLimits

BEVYXXA CAPS 3



daily)








NF



NF



NF



NF






daily) SP



Drug Name DrugTier

RequirementsLimits












4

PA SP


NF



1


1


NF


16

Drug Name DrugTier

RequirementsLimits


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA






3


3





daily)

Drug Name DrugTier

RequirementsLimits


daily)










3 PA














17

Drug Name DrugTier

RequirementsLimits




EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)




NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits








NF

PA QL(3 eadaily)





NF



NF





1 PA QL(3 eadaily)


daily)


primidone tabs 1



18

Drug Name DrugTier

RequirementsLimits







NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)










NF QL(40 ml daily)


NF QL(3 ea daily)



Drug Name DrugTier

RequirementsLimits



3 PA QL(2 eadaily)



Carbamates















2




19

Drug Name DrugTier

RequirementsLimits



PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)









Drug Name DrugTier

RequirementsLimits






















NF QL(4 ea daily)


20

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)


NF QL(2 ea daily)


NF QL(3 ea daily)


NF QL(1 ea daily)










NF QL(4 ea daily)


NF QL(2 ea daily)


NF QL(1 ea daily)




Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)












21

Drug Name DrugTier

RequirementsLimits
























Drug Name DrugTier

RequirementsLimits










FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)





1 QL(3 ea daily)





22

Drug Name DrugTier

RequirementsLimits

Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1













miglitol tabs 1




Drug Name DrugTier

RequirementsLimits



NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)




1 QL(4 ea daily)

GLYXAMBI TABS 2











2 QL(2 ea daily)


TRIJARDY XR TB24 2


23

Drug Name DrugTier

RequirementsLimits


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



3 QL(0035 eadaily)








Drug Name DrugTier

RequirementsLimits




ml daily)






Insulin

APIDRA SOLN 3 PA





FIASP SOLN 2




LEVEMIR SOLN 2





24

Drug Name DrugTier

RequirementsLimits

NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 3 PA












Sulfonylureas

Drug Name DrugTier

RequirementsLimits



















MOTOFEN TABS 3



CHEMET CAPS 3



25

Drug Name DrugTier

RequirementsLimits



deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3










daily)

Drug Name DrugTier

RequirementsLimits
















NF





BONJESTA TBCR 3


CESAMET CAPS 3


26

Drug Name DrugTier

RequirementsLimits





dronabinol caps 1




ea daily)







NF


VARUBI TBPK 3 PA




ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

Drug Name DrugTier

RequirementsLimits

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA


27

Drug Name DrugTier

RequirementsLimits














1

QL(30 ml daily)



1 QL(1 ea daily)


1 QL(2 ea daily)




daily) RXOTC

Drug Name DrugTier

RequirementsLimits





1





1












RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1


28

Drug Name DrugTier

RequirementsLimits

loratadine tabs 1

loratadine tbdp 1


NF






















Drug Name DrugTier

RequirementsLimits






daily)






NF QL(6 gm daily)


NF QL(6 ea daily)










NF QL(252 gmdaily)


daily)


29

Drug Name DrugTier

RequirementsLimits


MP






















Drug Name DrugTier

RequirementsLimits








1 QL(2 ea daily)



daily)







captopril tabs 1



lisinopril tabs 1




30

Drug Name DrugTier

RequirementsLimits




ramipril caps 1

trandolapril tabs 1


















Drug Name DrugTier

RequirementsLimits







daily)










NF

QL(3 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)





31

Drug Name DrugTier

RequirementsLimits



NF



NF


NF ST



NF




NF


EXFORGE HCT TABS 2


NF



NF

QL(1 ea daily)


NF

QL(2 ea daily)



Drug Name DrugTier

RequirementsLimits


NF


1

QL(1 ea daily)


1 QL(2 ea daily)


NF


NF



NF


1 ST



1 QL(3 ea daily)


1 QL(4 ea daily)


1 QL(2 ea daily)





NF


NF


32

Drug Name DrugTier

RequirementsLimits



NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


Drug Name DrugTier

RequirementsLimits



COARTEM TABS 2




Antimalarials





33

Drug Name DrugTier

RequirementsLimits







NF






FIRDAPSE TABS 4 PA





NF


3 PA



Drug Name DrugTier

RequirementsLimits




RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

rifampin solr 1



34

Drug Name DrugTier

RequirementsLimits




BELRAPZO SOLN 6


BENDEKA SOLN 6





6 PA








6


EVOMELA SOLR 6

GLEOSTINE CAPS 6 PA


Drug Name DrugTier

RequirementsLimits

IFEX SOLR 3 GM 6 PA







melphalan tabs 1





6

PA SP








YONDELIS SOLR 6


ZEPZELCA SOLR 6

Antimetabolites


35

Drug Name DrugTier

RequirementsLimits





















6


6 PA



Drug Name DrugTier

RequirementsLimits


6


6

PA


6

INFUGEM SOLN 6






PURIXAN SUSP 6 PA




XATMEP SOLN 6 PA



CYRAMZA SOLN 6 PA



daily)


36

Drug Name DrugTier

RequirementsLimits








daily)

MVASI SOLN 6 PA



ZIRABEV SOLN 6 PA



HERZUMA SOLR 6

KANJINTI SOLR 6

OGIVRI SOLR 6

ONTRUZANT SOLR 6



TUKYSA TABS 6 PA




BAVENCIO SOLN 6

Drug Name DrugTier

RequirementsLimits

BESPONSA SOLR 6

BLENREP SOLR 6

BLINCYTO SOLR 6 PA

DARZALEX SOLN 6

EMPLICITI SOLR 6

ENHERTU SOLR 6

GAZYVA SOLN 6 PA

IMFINZI SOLN 6

KADCYLA SOLR 6 PA

KEYTRUDA SOLN 6 PA

LIBTAYO SOLN 6

LUMOXITI SOLR 6

MONJUVI SOLR 6

MYLOTARG SOLR 6

OPDIVO SOLN 6 PA

PADCEV SOLR 6


POTELIGEO SOLN 6


RUXIENCE SOLN 6

SARCLISA SOLN 6

TECENTRIQ SOLN 6

TRUXIMA SOLN 6

UNITUXIN SOLN 6

YERVOY SOLN 6 PA SP


37

Drug Name DrugTier

RequirementsLimits



VENCLEXTA TABS 6 PA


KYMRIAH SUSP 6 PA

PROVENGE SUSP 6 PA

TECARTUS SUSP 6

YESCARTA SUSP 6





IRESSA TABS 6

PORTRAZZA SOLN 6

TAGRISSO TABS 6 PA




VIZIMPRO TABS 6 PA


DAURISMO TABS 6 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP






EMCYT CAPS 6 PA SP

ERLEADA TABS 6 PA









6

letrozole tabs 1


38

Drug Name DrugTier

RequirementsLimits



6





ea daily) SP






NUBEQA TABS 6 PA

SOLTAMOX SOLN 6 PA




VANTAS KIT 6 PA


YONSA TABS 6 PA





daily)

Drug Name DrugTier

RequirementsLimits




daily)

LARTRUVO SOLN 6














6


6




39

Drug Name DrugTier

RequirementsLimits




6 PA


6 PA SP




6 PA SP


6 PA



JELMYTO SOLR 6










INQOVI TABS 6

Drug Name DrugTier

RequirementsLimits




LONSURF TABS 6 PA

PHESGO SOLN 6


VYXEOS SUSR 6







ALIQOPA SOLR 6



BALVERSA TABS 6 PA

BELEODAQ SOLR 6 PA



daily) SP


BRAFTOVI CAPS 6 PA

BRUKINSA CAPS 6 PA

CABOMETYX TABS 6 PA

CALQUENCE CAPS 6 PA


40

Drug Name DrugTier

RequirementsLimits





COPIKTRA CAPS 6 PA

COTELLIC TABS 6 PA


FARYDAK CAPS 6 PA


daily) SP

IBRANCE CAPS 6 PA

IBRANCE TABS 6 PA


daily)


IDHIFA TABS 6 PA



daily)



6 PA QL(1 eadaily)

INREBIC CAPS 6 PA




daily) SP

KISQALI TBPK 6 PA

Drug Name DrugTier

RequirementsLimits

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 6 PA


LORBRENA TABS 6 PA




MEKTOVI TABS 6 PA

NERLYNX TABS 6 PA







QINLOCK TABS 6 PA

RETEVMO CAPS 6 PA



ROZLYTREK CAPS 6 PA


RYDAPT CAPS 6 PA



41

Drug Name DrugTier

RequirementsLimits



daily) SP


TABRECTA TABS 6 PA


TALZENNA CAPS 6 PA


daily) SP


TAZVERIK TABS 6 PA


TIBSOVO TABS 6 PA


ml daily) SP



daily) SP


VERZENIO TABS 6 PA

VITRAKVI CAPS 6 PA

VITRAKVI SOLN 6 PA



XOSPATA TABS 6 PA




Drug Name DrugTier

RequirementsLimits



ZYKADIA TABS 6


ASPARLAS SOLN 6






LUTATHERA SOLN 6

QUADRAMET SOLN 6 PA


XOFIGO SOLN 6 PA


ALFERON N SOLN 6 PA






ELZONRIS SOLN 6



42

Drug Name DrugTier

RequirementsLimits

hydroxyurea caps 1





NIPENT SOLR 6 PA SP








UVADEX SOLN 6 PA SP


ELITEK SOLR 6 PA




ETHYOL SOLR 6


KHAPZORY SOLR 6



1

Drug Name DrugTier

RequirementsLimits





mesna soln 6 PA



TOTECT SOLR 6 PA



Mitotic Inhibitors











6 PA




43

Drug Name DrugTier

RequirementsLimits









MARQIBO SUSP 6 PA


6 PA SP


6 PA


6 PA SP









6 PA SP

Drug Name DrugTier

RequirementsLimits


6 PA





ONIVYDE INJ 6




6 PA


TRODELVY SOLR 6



carbidopa tabs 1










44

Drug Name DrugTier

RequirementsLimits



tolcapone tabs 1





APOKYN SOCT 4 PA








NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)


1

Drug Name DrugTier

RequirementsLimits


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


1


45

Drug Name DrugTier

RequirementsLimits


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1









Drug Name DrugTier

RequirementsLimits


Benzisoxazoles




NF QL(1 ea daily)








NF

QL(4 ea daily)



1 QL(4 ea daily)


1 QL(2 ea daily)


NF QL(0036 mldaily)


NF QL(0036 mldaily)




46

Drug Name DrugTier

RequirementsLimits



haloperidol tabs 1




















Drug Name DrugTier

RequirementsLimits










3 PA QL(2 eadaily)


daily)



NF





NF



NF




NF QL(2 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)


47

Drug Name DrugTier

RequirementsLimits




1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1



Drug Name DrugTier

RequirementsLimits









3

QL(1 ea daily)

















48

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(1 ea daily)



1



0 QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP





Drug Name DrugTier

RequirementsLimits







NF QL(125 mldaily)


2 QL(4 ea daily)







NF QL(4 ea daily)











49

Drug Name DrugTier

RequirementsLimits













NF QL(1 ea daily)



RUKOBIA TB12 4 PA









Drug Name DrugTier

RequirementsLimits




2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)














50

Drug Name DrugTier

RequirementsLimits




NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP

Drug Name DrugTier

RequirementsLimits




ml daily) SP










daily)



ZEPATIER TABS 4 PA

Herpes Agents









51

Drug Name DrugTier

RequirementsLimits








NF QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


NF



NF



Alpha-Beta Blockers

carvedilol tabs 1






atenolol tabs 1




daily)






52

Drug Name DrugTier

RequirementsLimits









nadolol tabs 1

pindolol tabs 1













Drug Name DrugTier

RequirementsLimits



NF







1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1




53

Drug Name DrugTier

RequirementsLimits




NF






NF



1



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





Drug Name DrugTier

RequirementsLimits


BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents











3 PA









daily) SP


54

Drug Name DrugTier

RequirementsLimits




daily)





NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP






Drug Name DrugTier

RequirementsLimits




cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1






cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1


55

Drug Name DrugTier

RequirementsLimits

cefdinir susr 1











NF ST


cefepime hcl solr 1



TEFLARO SOLR 3




NF




Drug Name DrugTier

RequirementsLimits



0


NF


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0







56

Drug Name DrugTier

RequirementsLimits








NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF



Drug Name DrugTier

RequirementsLimits




NF


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF




57

Drug Name DrugTier

RequirementsLimits







NF






NF





NF




1



1

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA






NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1


58

Drug Name DrugTier

RequirementsLimits

prednisone tabs 1

prednisone tbpk 1






NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics






59

Drug Name DrugTier

RequirementsLimits






12 yrs old)





NF





yrs old)














12 yrs old)

Drug Name DrugTier

RequirementsLimits



yrs old)










12 yrs old)




12 yrs old)



NF












60

Drug Name DrugTier

RequirementsLimits




























VEREGEN OINT 3



Drug Name DrugTier

RequirementsLimits




daily) RXOTC




mupirocin oint 1















ERTACZO CREA 3


61

Drug Name DrugTier

RequirementsLimits


EXELDERM SOLN 3


JUBLIA SOLN 3 PA










NF RXOTC



NF





Drug Name DrugTier

RequirementsLimits






NF













62

Drug Name DrugTier

RequirementsLimits





OXISTAT LOTN 2







NF







Drug Name DrugTier

RequirementsLimits




PANRETIN GEL 6

PICATO GEL 0015 6


PICATO GEL 005 6



VALCHLOR GEL 6 PA







63

Drug Name DrugTier

RequirementsLimits













daily)



NF QL(4 ea daily)






ml daily)

Drug Name DrugTier

RequirementsLimits


ml daily) SP


TAZORAC CREA 005 2













Burn Products









64

Drug Name DrugTier

RequirementsLimits

amcinonide crea 1


amcinonide lotn 3

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)


Drug Name DrugTier

RequirementsLimits





CLODERM CREA 3


CLODERM PUMP CREA 3






NF



NF











65

Drug Name DrugTier

RequirementsLimits


NF


NF






















Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA














daily)





NF

RXOTC


daily)



PSORCON CREA 2 PA


66

Drug Name DrugTier

RequirementsLimits





NF

ST


3

ST







1



1


1






Drug Name DrugTier

RequirementsLimits




NF RXOTC


NF RXOTC











2 yrs old)



2 yrs old)



podofilox soln 1



67

Drug Name DrugTier

RequirementsLimits








SYNERA PTCH 3




Rosacea Agents




NF



NF





Drug Name DrugTier

RequirementsLimits






EURAX CREA 3




lindane sham 1

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS


daily)


68

Drug Name DrugTier

RequirementsLimits

THYROGEN SOLR 3


Diagnostic Tests

CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1





1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits









NF



NF


NF


NF









69

Drug Name DrugTier

RequirementsLimits


furosemide soln 1

furosemide tabs 1


torsemide tabs 1


















daily)

Drug Name DrugTier

RequirementsLimits





NF PA SP










4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA


70

Drug Name DrugTier

RequirementsLimits

XGEVA SOLN 4 PA SP





Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



NF PA







Drug Name DrugTier

RequirementsLimits



4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA










Metabolic Modifiers


71

Drug Name DrugTier

RequirementsLimits




calcitriol caps 1

calcitriol soln 1










NF


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP





72

Drug Name DrugTier

RequirementsLimits




cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP

JYNARQUE TBPK 4 PA


daily) SP




CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2

Drug Name DrugTier

RequirementsLimits




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2


daily)


73

Drug Name DrugTier

RequirementsLimits



1


BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA









levofloxacin soln 1

levofloxacin tabs 1



ofloxacin tabs 1





Drug Name DrugTier

RequirementsLimits




ursodiol caps 1

ursodiol tabs 1


daily)








AVSOLA SOLR 4 PA







DIPENTUM CAPS 2


74

Drug Name DrugTier

RequirementsLimits



















alvimopan caps 1




Drug Name DrugTier

RequirementsLimits



NF


PHOSLYRA SOLN 2





VELPHORO CHEW 3 PA



1



NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1



75

Drug Name DrugTier

RequirementsLimits



ELMIRON CAPS 2












Urinary Analgesics





Gout Agents

allopurinol tabs 1




Drug Name DrugTier

RequirementsLimits

KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA


TAVALISSE TABS 4 PA




TAKHZYRO SOLN 4 PA






76

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




REOPRO SOLN 3

ZONTIVITY TABS 3 PA







VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates

Drug Name DrugTier

RequirementsLimits




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA






4 PA



3

PA SP



daily)


77

Drug Name DrugTier

RequirementsLimits



4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










NF PA






Drug Name DrugTier

RequirementsLimits





1










estazolam tabs 1

eszopiclone tabs 1







triazolam tabs 1


78

Drug Name DrugTier

RequirementsLimits








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives




CLENPIQ SOLN 3 PA


NF


0

Drug Name DrugTier

RequirementsLimits


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1









NF


NF


79

Drug Name DrugTier

RequirementsLimits


NF


Azithromycin












NF






daily)





Clarithromycin



Drug Name DrugTier

RequirementsLimits



NF


NF


3





1


Fidaxomicin




CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0



80

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)







0 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits





0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)



0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


81

Drug Name DrugTier

RequirementsLimits


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)

Drug Name DrugTier

RequirementsLimits












1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


82

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1












1

Drug Name DrugTier

RequirementsLimits










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)












daily)


83

Drug Name DrugTier

RequirementsLimits







1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)








1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


84

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1












daily)



daily)



Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1


1


1


1



1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)







1



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)









1


1 QL(66667 eadaily)





daily)


86

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



daily)










daily)







daily)


Drug Name DrugTier

RequirementsLimits






daily)








LANZO MISC 1





1 QL(66667 eadaily)







87

Drug Name DrugTier

RequirementsLimits







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)









1 QL(66667 eadaily)



1

QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)










daily)


88

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1




daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1 QL(66667 eadaily)










89

Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


90

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)













daily)

SURE-PEN MISC 1



daily)


91

Drug Name DrugTier

RequirementsLimits










1







1








daily)

Drug Name DrugTier

RequirementsLimits







daily)



1 QL(66667 eadaily)







daily)






daily)




daily)


92

Drug Name DrugTier

RequirementsLimits



daily)














1 QL(66667 eadaily)








Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


93

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)








Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


97

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


98

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


99

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)






101

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






102

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




103

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


104

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


105

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


107

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




108

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






109

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






111

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


112

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


113

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


114

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)

















Drug Name DrugTier

RequirementsLimits




NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists












115

Drug Name DrugTier

RequirementsLimits




NF



NF



NF



NF



NF
















Drug Name DrugTier

RequirementsLimits





sumatriptan soln 1





















116

Drug Name DrugTier

RequirementsLimits








1






NF



NF


1


ISOLYTE-S SOLN 1

Drug Name DrugTier

RequirementsLimits



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1

ringers soln 1


117

Drug Name DrugTier

RequirementsLimits









1



1


1





1



Drug Name DrugTier

RequirementsLimits





daily) SP







ATGAM INJ 4 PA SP

AZASAN TABS 3




NF


NF

cyclosporine caps 1



cyclosporine soln 1





118

Drug Name DrugTier

RequirementsLimits





NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1



NF




Drug Name DrugTier

RequirementsLimits



Lymphatic Agents

SYLVANT SOLR 6 PA









DEBACTEROL SOLN 2


NF

Dental Products







119

Drug Name DrugTier

RequirementsLimits


MULTIVITAMINS











2

QL(1 ea daily)RXOTC










Drug Name DrugTier

RequirementsLimits



2

QL(1 ea daily)


2

QL(1 ea daily)RXOTC







120

Drug Name DrugTier

RequirementsLimits







2 QL(1 ea daily)





RXOTC



RXOTC





carisoprodol tabs 1






Drug Name DrugTier

RequirementsLimits











Nasal Antiallergy






Nasal Steroids



NF



NF



121

Drug Name DrugTier

RequirementsLimits






NF


NF






riluzole tabs 3


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3

Drug Name DrugTier

RequirementsLimits


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1







tropicamide soln 1



122

Drug Name DrugTier

RequirementsLimits




NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF







KLARITY-A SOLN 3



NATACYN SUSP 2


Drug Name DrugTier

RequirementsLimits








trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA





OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA


DUREZOL EMUL 3 PA


FML FORTE SUSP 3 PA


123

Drug Name DrugTier

RequirementsLimits


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF





NF

PRED MILD SUSP 3 PA




3


NF


Ophthalmics - Misc

Drug Name DrugTier

RequirementsLimits


NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA














LASTACAFT SOLN 3 PA






124

Drug Name DrugTier

RequirementsLimits



ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2








Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins


125

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1











1



NF

Drug Name DrugTier

RequirementsLimits


NF


NF



NF


NF


NF










NF PA





126

Drug Name DrugTier

RequirementsLimits



NF





disulfiram tabs 1





NF QL(2 ea daily)


NF QL(1 ea daily)










Drug Name DrugTier

RequirementsLimits





NF





Fibromyalgia Agents







daily) SP


daily) SP

AUBAGIO TABS 4 PA







127

Drug Name DrugTier

RequirementsLimits







GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA





ml daily)







NF PA

Drug Name DrugTier

RequirementsLimits



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)






NUEDEXTA CAPS 3 PA


pimozide tabs 1



Smoking Deterrents









128

Drug Name DrugTier

RequirementsLimits




NF





0


NICOTROL NS SOLN 0


NF QL(2 ea daily)


TEGSEDI SOSY 4 PA











daily)

Drug Name DrugTier

RequirementsLimits








Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines











129

Drug Name DrugTier

RequirementsLimits






NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)




1





Drug Name DrugTier

RequirementsLimits




WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0











NF





130

Drug Name DrugTier

RequirementsLimits




1







NF RXOTC







1 QL(40 ml daily)





NF RXOTC



Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)










RXOTC MP


131

Drug Name DrugTier

RequirementsLimits



1 QL(4 ea daily)


NF QL(1 ea daily)


NF







NF

RXOTC










Drug Name DrugTier

RequirementsLimits









MYRBETRIQ TB24 3 PA




NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines


MENACTRA INJ 0

MENQUADFI INJ 0

MENVEO SOLR 0

PNEUMOVAX 23 INJ 0



132

Drug Name DrugTier

RequirementsLimits

PREVNAR 13 SUSP 0

Viral Vaccines













ENGERIX-B INJ 0


ENGERIX-B SUSP 0






Drug Name DrugTier

RequirementsLimits












0



0



0



0



0



0



0



133

Drug Name DrugTier

RequirementsLimits


0



0



0



0



0



0











0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0














134

Drug Name DrugTier

RequirementsLimits

SHINGRIX SUSR 0





ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3



NF

Drug Name DrugTier

RequirementsLimits






PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF







135

Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




136










Index 1








Index 2













Index 3




127 52

122 132

15 16 42 56 38 35 54 48 10

125 79

32 52 37 39

123 37 70 26

130 40 54


83

83



40 122




Index 4





32 34 36 41 30 63

131 72 17 17 44 45

45 28 35

83 53 53 53 31



52 73 77 40


83

96


56 56 55 56





55 55 56 55 56 56 55 55

4 4

58 21

118 20 55 77


Index 5









Index 6




39 122

41 15 31 69 27 30 48 13


23 17 31 31



124 68 11 11


2 77 13

119 61

135

61 47 47 83 33

6 6

44 79 74 76 76 76




29 29 29


127128 41 65


35 34 24



52 53 55 58 10 58

125


118

118 78 22 29 36


Index 7


36 130 132

51 115

42 36 39

128 14 10

121 121

11 11 11 33

132 37 40 39




39 38

4 2

72 119

36 2526

26 73 48 74

129 6

64 20 20 20 20

118




73 58 38

57


117

117 1718


74 28 25 66

Index 8




Index 9






Index 10




51 75 58 54


85 46 27 38




136 128 115 115

38 38 38




Index 11








19 19

4 53 38 80 73


85 85

5 8 6 8





famotidine 131

Index 12




100

100

100

85 115 116

77 38








4 124

38 66

122 15



Index 13






100

100




101

101





Index 14




Index 15












Index 16








Index 17



49 51 49 18

87

87 87

87 87

87

87

87


87

104

104

104

104

104

104






131 75 87 41 39 70

124 125

46


37

37 54 38 43 35 77 39

Index 18












Index 19



62 62



88


62 75 30 29 17 47 74




127 62

125 72


20 79 27 21


88

88




Index 20





1 69 12

130 10

121 4


73 129 130

33 45 77 56




57 20 68

132 76 40 40


Index 21



516 106


88


88


89

23G18MM MS CONTIN

89 7




Index 22


49 41

131 131

57 136

30 136 136

30 53

128 128 129








12 12 12

120



32 124 121

66 29

Index 23



23 79 71

5 125

68 126

35 9 5 7

13 77 18

123 63 63




64 132




7

9 9 7 7

24 44 37 46 26



7 37 55 68 58 54 72

129 121

58





Index 24




Index 25







Index 26














Index 27


122 122

52 117 119

4 70 46 46 46

3 3

50 37 40

127 116 121

72 41 45 30

134 134

8 79 41 41 76 19 50 37 34





120 6

73 119

73 67 47

72 37

127


Index 28







POWDER 129 516 109

Index 29




Index 30













Index 31





Index 32







Index 33






Index 34




115

115

115



33


115 39

135 135

27 29 33 31 33 38 64 42 54 75 61


44 44 50 50 50 51 13 26

136 121

42 93

93 73 38



38 22 54 15 54 61 54 54 42


121 61 43 28 51 42

115 77 63



132 28 54


55 55 29




40

93


11

11



Index 35



39

39

ZESTRIL ZETIA

31 30



39

39

ZIAC ZIAGEN

33 51


21 121 130


39

39


51 78 14


81

81


8 39 24


125 46 37


81

81


79 80

127


123 80 80




30 26

8 39 71 71 71 71 42

116 22 79 71

116 117

64 19 19 77 71

119 135 126

5264 129

67 67

Index 36


Index 37













AMB19-AZ-HP-1000



















Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Abbreviation







Term What it means





ST Step Therapy






NF Non-formulary






Drug Name DrugTier

RequirementsLimits



NF

QL(3 ea daily)


NF

QL(2 ea daily)


NF

QL(1 ea daily)


NF


NF

QL(2 ea daily)



1

QL(1 ea daily)


1

Drug Name DrugTier

RequirementsLimits


1

QL(2 ea daily)


1

QL(3 ea daily)


1

QL(2 ea daily)




NF

QL(4 ea daily)


NF






3 ST QL(1 eadaily)




1

Drug Name DrugTier

RequirementsLimits


Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1







Drug Name DrugTier

RequirementsLimits


1

QL(1 ea daily)









yrs old)




















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


celecoxib caps 1 PA













daily)

flurbiprofen tabs 1





4

Drug Name DrugTier

RequirementsLimits









nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1





Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


NF


NF


5

Drug Name DrugTier

RequirementsLimits


Salicylates





diflunisal tabs 1


NF


salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF





daily)



1

PA QL(4 eadaily)


1

QL(034 eadaily)



1 PA QL(2 eadaily)




1






NF


NF

PA QL(2 eadaily)


6

Drug Name DrugTier

RequirementsLimits











1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF

Drug Name DrugTier

RequirementsLimits









1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)


7

Drug Name DrugTier

RequirementsLimits






daily)










1





1








Drug Name DrugTier

RequirementsLimits


1



1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1 QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1



NF


10

Drug Name DrugTier

RequirementsLimits


NF






atovaquone susp 1



Carbapenems




meropenem solr 1








Drug Name DrugTier

RequirementsLimits

Glycopeptides










Leprostatics

dapsone tabs 1


NF


NF


NF







aztreonam solr 1


11

Drug Name DrugTier

RequirementsLimits






daily) Polymyxins






NF


NF









Drug Name DrugTier

RequirementsLimits




NF





NITRO-BID OINT 3


NF



1











12

Drug Name DrugTier

RequirementsLimits


meprobamate tabs 1






















Drug Name DrugTier

RequirementsLimits













dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOSY 4 PA














NF QL(1 ea daily)








Drug Name DrugTier

RequirementsLimits



2



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF






14

Drug Name DrugTier

RequirementsLimits


1 QL(15 ml daily)









daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)






Drug Name DrugTier

RequirementsLimits




2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1









15

Drug Name DrugTier

RequirementsLimits

BEVYXXA CAPS 3



daily)








NF



NF



NF



NF






daily) SP



Drug Name DrugTier

RequirementsLimits












4

PA SP


NF



1


1


NF


16

Drug Name DrugTier

RequirementsLimits


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA






3


3





daily)

Drug Name DrugTier

RequirementsLimits


daily)










3 PA














17

Drug Name DrugTier

RequirementsLimits




EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)




NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits








NF

PA QL(3 eadaily)





NF



NF





1 PA QL(3 eadaily)


daily)


primidone tabs 1



18

Drug Name DrugTier

RequirementsLimits







NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)










NF QL(40 ml daily)


NF QL(3 ea daily)



Drug Name DrugTier

RequirementsLimits



3 PA QL(2 eadaily)



Carbamates















2




19

Drug Name DrugTier

RequirementsLimits



PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)









Drug Name DrugTier

RequirementsLimits






















NF QL(4 ea daily)


20

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)


NF QL(2 ea daily)


NF QL(3 ea daily)


NF QL(1 ea daily)










NF QL(4 ea daily)


NF QL(2 ea daily)


NF QL(1 ea daily)




Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)












21

Drug Name DrugTier

RequirementsLimits
























Drug Name DrugTier

RequirementsLimits










FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)





1 QL(3 ea daily)





22

Drug Name DrugTier

RequirementsLimits

Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1













miglitol tabs 1




Drug Name DrugTier

RequirementsLimits



NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)




1 QL(4 ea daily)

GLYXAMBI TABS 2











2 QL(2 ea daily)


TRIJARDY XR TB24 2


23

Drug Name DrugTier

RequirementsLimits


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



3 QL(0035 eadaily)








Drug Name DrugTier

RequirementsLimits




ml daily)






Insulin

APIDRA SOLN 3 PA





FIASP SOLN 2




LEVEMIR SOLN 2





24

Drug Name DrugTier

RequirementsLimits

NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 3 PA












Sulfonylureas

Drug Name DrugTier

RequirementsLimits



















MOTOFEN TABS 3



CHEMET CAPS 3



25

Drug Name DrugTier

RequirementsLimits



deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3










daily)

Drug Name DrugTier

RequirementsLimits
















NF





BONJESTA TBCR 3


CESAMET CAPS 3


26

Drug Name DrugTier

RequirementsLimits





dronabinol caps 1




ea daily)







NF


VARUBI TBPK 3 PA




ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

Drug Name DrugTier

RequirementsLimits

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA


27

Drug Name DrugTier

RequirementsLimits














1

QL(30 ml daily)



1 QL(1 ea daily)


1 QL(2 ea daily)




daily) RXOTC

Drug Name DrugTier

RequirementsLimits





1





1












RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1


28

Drug Name DrugTier

RequirementsLimits

loratadine tabs 1

loratadine tbdp 1


NF






















Drug Name DrugTier

RequirementsLimits






daily)






NF QL(6 gm daily)


NF QL(6 ea daily)










NF QL(252 gmdaily)


daily)


29

Drug Name DrugTier

RequirementsLimits


MP






















Drug Name DrugTier

RequirementsLimits








1 QL(2 ea daily)



daily)







captopril tabs 1



lisinopril tabs 1




30

Drug Name DrugTier

RequirementsLimits




ramipril caps 1

trandolapril tabs 1


















Drug Name DrugTier

RequirementsLimits







daily)










NF

QL(3 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)





31

Drug Name DrugTier

RequirementsLimits



NF



NF


NF ST



NF




NF


EXFORGE HCT TABS 2


NF



NF

QL(1 ea daily)


NF

QL(2 ea daily)



Drug Name DrugTier

RequirementsLimits


NF


1

QL(1 ea daily)


1 QL(2 ea daily)


NF


NF



NF


1 ST



1 QL(3 ea daily)


1 QL(4 ea daily)


1 QL(2 ea daily)





NF


NF


32

Drug Name DrugTier

RequirementsLimits



NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


Drug Name DrugTier

RequirementsLimits



COARTEM TABS 2




Antimalarials





33

Drug Name DrugTier

RequirementsLimits







NF






FIRDAPSE TABS 4 PA





NF


3 PA



Drug Name DrugTier

RequirementsLimits




RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

rifampin solr 1



34

Drug Name DrugTier

RequirementsLimits




BELRAPZO SOLN 6


BENDEKA SOLN 6





6 PA








6


EVOMELA SOLR 6

GLEOSTINE CAPS 6 PA


Drug Name DrugTier

RequirementsLimits

IFEX SOLR 3 GM 6 PA







melphalan tabs 1





6

PA SP








YONDELIS SOLR 6


ZEPZELCA SOLR 6

Antimetabolites


35

Drug Name DrugTier

RequirementsLimits





















6


6 PA



Drug Name DrugTier

RequirementsLimits


6


6

PA


6

INFUGEM SOLN 6






PURIXAN SUSP 6 PA




XATMEP SOLN 6 PA



CYRAMZA SOLN 6 PA



daily)


36

Drug Name DrugTier

RequirementsLimits








daily)

MVASI SOLN 6 PA



ZIRABEV SOLN 6 PA



HERZUMA SOLR 6

KANJINTI SOLR 6

OGIVRI SOLR 6

ONTRUZANT SOLR 6



TUKYSA TABS 6 PA




BAVENCIO SOLN 6

Drug Name DrugTier

RequirementsLimits

BESPONSA SOLR 6

BLENREP SOLR 6

BLINCYTO SOLR 6 PA

DARZALEX SOLN 6

EMPLICITI SOLR 6

ENHERTU SOLR 6

GAZYVA SOLN 6 PA

IMFINZI SOLN 6

KADCYLA SOLR 6 PA

KEYTRUDA SOLN 6 PA

LIBTAYO SOLN 6

LUMOXITI SOLR 6

MONJUVI SOLR 6

MYLOTARG SOLR 6

OPDIVO SOLN 6 PA

PADCEV SOLR 6


POTELIGEO SOLN 6


RUXIENCE SOLN 6

SARCLISA SOLN 6

TECENTRIQ SOLN 6

TRUXIMA SOLN 6

UNITUXIN SOLN 6

YERVOY SOLN 6 PA SP


37

Drug Name DrugTier

RequirementsLimits



VENCLEXTA TABS 6 PA


KYMRIAH SUSP 6 PA

PROVENGE SUSP 6 PA

TECARTUS SUSP 6

YESCARTA SUSP 6





IRESSA TABS 6

PORTRAZZA SOLN 6

TAGRISSO TABS 6 PA




VIZIMPRO TABS 6 PA


DAURISMO TABS 6 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP






EMCYT CAPS 6 PA SP

ERLEADA TABS 6 PA









6

letrozole tabs 1


38

Drug Name DrugTier

RequirementsLimits



6





ea daily) SP






NUBEQA TABS 6 PA

SOLTAMOX SOLN 6 PA




VANTAS KIT 6 PA


YONSA TABS 6 PA





daily)

Drug Name DrugTier

RequirementsLimits




daily)

LARTRUVO SOLN 6














6


6




39

Drug Name DrugTier

RequirementsLimits




6 PA


6 PA SP




6 PA SP


6 PA



JELMYTO SOLR 6










INQOVI TABS 6

Drug Name DrugTier

RequirementsLimits




LONSURF TABS 6 PA

PHESGO SOLN 6


VYXEOS SUSR 6







ALIQOPA SOLR 6



BALVERSA TABS 6 PA

BELEODAQ SOLR 6 PA



daily) SP


BRAFTOVI CAPS 6 PA

BRUKINSA CAPS 6 PA

CABOMETYX TABS 6 PA

CALQUENCE CAPS 6 PA


40

Drug Name DrugTier

RequirementsLimits





COPIKTRA CAPS 6 PA

COTELLIC TABS 6 PA


FARYDAK CAPS 6 PA


daily) SP

IBRANCE CAPS 6 PA

IBRANCE TABS 6 PA


daily)


IDHIFA TABS 6 PA



daily)



6 PA QL(1 eadaily)

INREBIC CAPS 6 PA




daily) SP

KISQALI TBPK 6 PA

Drug Name DrugTier

RequirementsLimits

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 6 PA


LORBRENA TABS 6 PA




MEKTOVI TABS 6 PA

NERLYNX TABS 6 PA







QINLOCK TABS 6 PA

RETEVMO CAPS 6 PA



ROZLYTREK CAPS 6 PA


RYDAPT CAPS 6 PA



41

Drug Name DrugTier

RequirementsLimits



daily) SP


TABRECTA TABS 6 PA


TALZENNA CAPS 6 PA


daily) SP


TAZVERIK TABS 6 PA


TIBSOVO TABS 6 PA


ml daily) SP



daily) SP


VERZENIO TABS 6 PA

VITRAKVI CAPS 6 PA

VITRAKVI SOLN 6 PA



XOSPATA TABS 6 PA




Drug Name DrugTier

RequirementsLimits



ZYKADIA TABS 6


ASPARLAS SOLN 6






LUTATHERA SOLN 6

QUADRAMET SOLN 6 PA


XOFIGO SOLN 6 PA


ALFERON N SOLN 6 PA






ELZONRIS SOLN 6



42

Drug Name DrugTier

RequirementsLimits

hydroxyurea caps 1





NIPENT SOLR 6 PA SP








UVADEX SOLN 6 PA SP


ELITEK SOLR 6 PA




ETHYOL SOLR 6


KHAPZORY SOLR 6



1

Drug Name DrugTier

RequirementsLimits





mesna soln 6 PA



TOTECT SOLR 6 PA



Mitotic Inhibitors











6 PA




43

Drug Name DrugTier

RequirementsLimits









MARQIBO SUSP 6 PA


6 PA SP


6 PA


6 PA SP









6 PA SP

Drug Name DrugTier

RequirementsLimits


6 PA





ONIVYDE INJ 6




6 PA


TRODELVY SOLR 6



carbidopa tabs 1










44

Drug Name DrugTier

RequirementsLimits



tolcapone tabs 1





APOKYN SOCT 4 PA








NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)


1

Drug Name DrugTier

RequirementsLimits


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


1


45

Drug Name DrugTier

RequirementsLimits


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1









Drug Name DrugTier

RequirementsLimits


Benzisoxazoles




NF QL(1 ea daily)








NF

QL(4 ea daily)



1 QL(4 ea daily)


1 QL(2 ea daily)


NF QL(0036 mldaily)


NF QL(0036 mldaily)




46

Drug Name DrugTier

RequirementsLimits



haloperidol tabs 1




















Drug Name DrugTier

RequirementsLimits










3 PA QL(2 eadaily)


daily)



NF





NF



NF




NF QL(2 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)


47

Drug Name DrugTier

RequirementsLimits




1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1



Drug Name DrugTier

RequirementsLimits









3

QL(1 ea daily)

















48

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(1 ea daily)



1



0 QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP





Drug Name DrugTier

RequirementsLimits







NF QL(125 mldaily)


2 QL(4 ea daily)







NF QL(4 ea daily)











49

Drug Name DrugTier

RequirementsLimits













NF QL(1 ea daily)



RUKOBIA TB12 4 PA









Drug Name DrugTier

RequirementsLimits




2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)














50

Drug Name DrugTier

RequirementsLimits




NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP

Drug Name DrugTier

RequirementsLimits




ml daily) SP










daily)



ZEPATIER TABS 4 PA

Herpes Agents









51

Drug Name DrugTier

RequirementsLimits








NF QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


NF



NF



Alpha-Beta Blockers

carvedilol tabs 1






atenolol tabs 1




daily)






52

Drug Name DrugTier

RequirementsLimits









nadolol tabs 1

pindolol tabs 1













Drug Name DrugTier

RequirementsLimits



NF







1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1




53

Drug Name DrugTier

RequirementsLimits




NF






NF



1



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





Drug Name DrugTier

RequirementsLimits


BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents











3 PA









daily) SP


54

Drug Name DrugTier

RequirementsLimits




daily)





NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP






Drug Name DrugTier

RequirementsLimits




cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1






cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1


55

Drug Name DrugTier

RequirementsLimits

cefdinir susr 1











NF ST


cefepime hcl solr 1



TEFLARO SOLR 3




NF




Drug Name DrugTier

RequirementsLimits



0


NF


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0







56

Drug Name DrugTier

RequirementsLimits








NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF



Drug Name DrugTier

RequirementsLimits




NF


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF




57

Drug Name DrugTier

RequirementsLimits







NF






NF





NF




1



1

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA






NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1


58

Drug Name DrugTier

RequirementsLimits

prednisone tabs 1

prednisone tbpk 1






NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics






59

Drug Name DrugTier

RequirementsLimits






12 yrs old)





NF





yrs old)














12 yrs old)

Drug Name DrugTier

RequirementsLimits



yrs old)










12 yrs old)




12 yrs old)



NF












60

Drug Name DrugTier

RequirementsLimits




























VEREGEN OINT 3



Drug Name DrugTier

RequirementsLimits




daily) RXOTC




mupirocin oint 1















ERTACZO CREA 3


61

Drug Name DrugTier

RequirementsLimits


EXELDERM SOLN 3


JUBLIA SOLN 3 PA










NF RXOTC



NF





Drug Name DrugTier

RequirementsLimits






NF













62

Drug Name DrugTier

RequirementsLimits





OXISTAT LOTN 2







NF







Drug Name DrugTier

RequirementsLimits




PANRETIN GEL 6

PICATO GEL 0015 6


PICATO GEL 005 6



VALCHLOR GEL 6 PA







63

Drug Name DrugTier

RequirementsLimits













daily)



NF QL(4 ea daily)






ml daily)

Drug Name DrugTier

RequirementsLimits


ml daily) SP


TAZORAC CREA 005 2













Burn Products









64

Drug Name DrugTier

RequirementsLimits

amcinonide crea 1


amcinonide lotn 3

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)


Drug Name DrugTier

RequirementsLimits





CLODERM CREA 3


CLODERM PUMP CREA 3






NF



NF











65

Drug Name DrugTier

RequirementsLimits


NF


NF






















Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA














daily)





NF

RXOTC


daily)



PSORCON CREA 2 PA


66

Drug Name DrugTier

RequirementsLimits





NF

ST


3

ST







1



1


1






Drug Name DrugTier

RequirementsLimits




NF RXOTC


NF RXOTC











2 yrs old)



2 yrs old)



podofilox soln 1



67

Drug Name DrugTier

RequirementsLimits








SYNERA PTCH 3




Rosacea Agents




NF



NF





Drug Name DrugTier

RequirementsLimits






EURAX CREA 3




lindane sham 1

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS


daily)


68

Drug Name DrugTier

RequirementsLimits

THYROGEN SOLR 3


Diagnostic Tests

CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1





1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits









NF



NF


NF


NF









69

Drug Name DrugTier

RequirementsLimits


furosemide soln 1

furosemide tabs 1


torsemide tabs 1


















daily)

Drug Name DrugTier

RequirementsLimits





NF PA SP










4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA


70

Drug Name DrugTier

RequirementsLimits

XGEVA SOLN 4 PA SP





Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



NF PA







Drug Name DrugTier

RequirementsLimits



4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA










Metabolic Modifiers


71

Drug Name DrugTier

RequirementsLimits




calcitriol caps 1

calcitriol soln 1










NF


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP





72

Drug Name DrugTier

RequirementsLimits




cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP

JYNARQUE TBPK 4 PA


daily) SP




CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2

Drug Name DrugTier

RequirementsLimits




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2


daily)


73

Drug Name DrugTier

RequirementsLimits



1


BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA









levofloxacin soln 1

levofloxacin tabs 1



ofloxacin tabs 1





Drug Name DrugTier

RequirementsLimits




ursodiol caps 1

ursodiol tabs 1


daily)








AVSOLA SOLR 4 PA







DIPENTUM CAPS 2


74

Drug Name DrugTier

RequirementsLimits



















alvimopan caps 1




Drug Name DrugTier

RequirementsLimits



NF


PHOSLYRA SOLN 2





VELPHORO CHEW 3 PA



1



NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1



75

Drug Name DrugTier

RequirementsLimits



ELMIRON CAPS 2












Urinary Analgesics





Gout Agents

allopurinol tabs 1




Drug Name DrugTier

RequirementsLimits

KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA


TAVALISSE TABS 4 PA




TAKHZYRO SOLN 4 PA






76

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




REOPRO SOLN 3

ZONTIVITY TABS 3 PA







VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates

Drug Name DrugTier

RequirementsLimits




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA






4 PA



3

PA SP



daily)


77

Drug Name DrugTier

RequirementsLimits



4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










NF PA






Drug Name DrugTier

RequirementsLimits





1










estazolam tabs 1

eszopiclone tabs 1







triazolam tabs 1


78

Drug Name DrugTier

RequirementsLimits








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives




CLENPIQ SOLN 3 PA


NF


0

Drug Name DrugTier

RequirementsLimits


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1









NF


NF


79

Drug Name DrugTier

RequirementsLimits


NF


Azithromycin












NF






daily)





Clarithromycin



Drug Name DrugTier

RequirementsLimits



NF


NF


3





1


Fidaxomicin




CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0



80

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)







0 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits





0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)



0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


81

Drug Name DrugTier

RequirementsLimits


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)

Drug Name DrugTier

RequirementsLimits












1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


82

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1












1

Drug Name DrugTier

RequirementsLimits










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)












daily)


83

Drug Name DrugTier

RequirementsLimits







1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)








1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


84

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1












daily)



daily)



Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1


1


1


1



1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)







1



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)









1


1 QL(66667 eadaily)





daily)


86

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



daily)










daily)







daily)


Drug Name DrugTier

RequirementsLimits






daily)








LANZO MISC 1





1 QL(66667 eadaily)







87

Drug Name DrugTier

RequirementsLimits







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)









1 QL(66667 eadaily)



1

QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)










daily)


88

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1




daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1 QL(66667 eadaily)










89

Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


90

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)













daily)

SURE-PEN MISC 1



daily)


91

Drug Name DrugTier

RequirementsLimits










1







1








daily)

Drug Name DrugTier

RequirementsLimits







daily)



1 QL(66667 eadaily)







daily)






daily)




daily)


92

Drug Name DrugTier

RequirementsLimits



daily)














1 QL(66667 eadaily)








Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


93

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)








Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


97

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


98

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


99

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)






101

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






102

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




103

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


104

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


105

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


107

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




108

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






109

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






111

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


112

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


113

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


114

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)

















Drug Name DrugTier

RequirementsLimits




NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists












115

Drug Name DrugTier

RequirementsLimits




NF



NF



NF



NF



NF
















Drug Name DrugTier

RequirementsLimits





sumatriptan soln 1





















116

Drug Name DrugTier

RequirementsLimits








1






NF



NF


1


ISOLYTE-S SOLN 1

Drug Name DrugTier

RequirementsLimits



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1

ringers soln 1


117

Drug Name DrugTier

RequirementsLimits









1



1


1





1



Drug Name DrugTier

RequirementsLimits





daily) SP







ATGAM INJ 4 PA SP

AZASAN TABS 3




NF


NF

cyclosporine caps 1



cyclosporine soln 1





118

Drug Name DrugTier

RequirementsLimits





NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1



NF




Drug Name DrugTier

RequirementsLimits



Lymphatic Agents

SYLVANT SOLR 6 PA









DEBACTEROL SOLN 2


NF

Dental Products







119

Drug Name DrugTier

RequirementsLimits


MULTIVITAMINS











2

QL(1 ea daily)RXOTC










Drug Name DrugTier

RequirementsLimits



2

QL(1 ea daily)


2

QL(1 ea daily)RXOTC







120

Drug Name DrugTier

RequirementsLimits







2 QL(1 ea daily)





RXOTC



RXOTC





carisoprodol tabs 1






Drug Name DrugTier

RequirementsLimits











Nasal Antiallergy






Nasal Steroids



NF



NF



121

Drug Name DrugTier

RequirementsLimits






NF


NF






riluzole tabs 3


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3

Drug Name DrugTier

RequirementsLimits


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1







tropicamide soln 1



122

Drug Name DrugTier

RequirementsLimits




NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF







KLARITY-A SOLN 3



NATACYN SUSP 2


Drug Name DrugTier

RequirementsLimits








trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA





OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA


DUREZOL EMUL 3 PA


FML FORTE SUSP 3 PA


123

Drug Name DrugTier

RequirementsLimits


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF





NF

PRED MILD SUSP 3 PA




3


NF


Ophthalmics - Misc

Drug Name DrugTier

RequirementsLimits


NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA














LASTACAFT SOLN 3 PA






124

Drug Name DrugTier

RequirementsLimits



ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2








Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins


125

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1











1



NF

Drug Name DrugTier

RequirementsLimits


NF


NF



NF


NF


NF










NF PA





126

Drug Name DrugTier

RequirementsLimits



NF





disulfiram tabs 1





NF QL(2 ea daily)


NF QL(1 ea daily)










Drug Name DrugTier

RequirementsLimits





NF





Fibromyalgia Agents







daily) SP


daily) SP

AUBAGIO TABS 4 PA







127

Drug Name DrugTier

RequirementsLimits







GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA





ml daily)







NF PA

Drug Name DrugTier

RequirementsLimits



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)






NUEDEXTA CAPS 3 PA


pimozide tabs 1



Smoking Deterrents









128

Drug Name DrugTier

RequirementsLimits




NF





0


NICOTROL NS SOLN 0


NF QL(2 ea daily)


TEGSEDI SOSY 4 PA











daily)

Drug Name DrugTier

RequirementsLimits








Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines











129

Drug Name DrugTier

RequirementsLimits






NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)




1





Drug Name DrugTier

RequirementsLimits




WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0











NF





130

Drug Name DrugTier

RequirementsLimits




1







NF RXOTC







1 QL(40 ml daily)





NF RXOTC



Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)










RXOTC MP


131

Drug Name DrugTier

RequirementsLimits



1 QL(4 ea daily)


NF QL(1 ea daily)


NF







NF

RXOTC










Drug Name DrugTier

RequirementsLimits









MYRBETRIQ TB24 3 PA




NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines


MENACTRA INJ 0

MENQUADFI INJ 0

MENVEO SOLR 0

PNEUMOVAX 23 INJ 0



132

Drug Name DrugTier

RequirementsLimits

PREVNAR 13 SUSP 0

Viral Vaccines













ENGERIX-B INJ 0


ENGERIX-B SUSP 0






Drug Name DrugTier

RequirementsLimits












0



0



0



0



0



0



0



133

Drug Name DrugTier

RequirementsLimits


0



0



0



0



0



0











0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0














134

Drug Name DrugTier

RequirementsLimits

SHINGRIX SUSR 0





ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3



NF

Drug Name DrugTier

RequirementsLimits






PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF







135

Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




136










Index 1








Index 2













Index 3




127 52

122 132

15 16 42 56 38 35 54 48 10

125 79

32 52 37 39

123 37 70 26

130 40 54


83

83



40 122




Index 4





32 34 36 41 30 63

131 72 17 17 44 45

45 28 35

83 53 53 53 31



52 73 77 40


83

96


56 56 55 56





55 55 56 55 56 56 55 55

4 4

58 21

118 20 55 77


Index 5









Index 6




39 122

41 15 31 69 27 30 48 13


23 17 31 31



124 68 11 11


2 77 13

119 61

135

61 47 47 83 33

6 6

44 79 74 76 76 76




29 29 29


127128 41 65


35 34 24



52 53 55 58 10 58

125


118

118 78 22 29 36


Index 7


36 130 132

51 115

42 36 39

128 14 10

121 121

11 11 11 33

132 37 40 39




39 38

4 2

72 119

36 2526

26 73 48 74

129 6

64 20 20 20 20

118




73 58 38

57


117

117 1718


74 28 25 66

Index 8




Index 9






Index 10




51 75 58 54


85 46 27 38




136 128 115 115

38 38 38




Index 11








19 19

4 53 38 80 73


85 85

5 8 6 8





famotidine 131

Index 12




100

100

100

85 115 116

77 38








4 124

38 66

122 15



Index 13






100

100




101

101





Index 14




Index 15












Index 16








Index 17



49 51 49 18

87

87 87

87 87

87

87

87


87

104

104

104

104

104

104






131 75 87 41 39 70

124 125

46


37

37 54 38 43 35 77 39

Index 18












Index 19



62 62



88


62 75 30 29 17 47 74




127 62

125 72


20 79 27 21


88

88




Index 20





1 69 12

130 10

121 4


73 129 130

33 45 77 56




57 20 68

132 76 40 40


Index 21



516 106


88


88


89

23G18MM MS CONTIN

89 7




Index 22


49 41

131 131

57 136

30 136 136

30 53

128 128 129








12 12 12

120



32 124 121

66 29

Index 23



23 79 71

5 125

68 126

35 9 5 7

13 77 18

123 63 63




64 132




7

9 9 7 7

24 44 37 46 26



7 37 55 68 58 54 72

129 121

58





Index 24




Index 25







Index 26














Index 27


122 122

52 117 119

4 70 46 46 46

3 3

50 37 40

127 116 121

72 41 45 30

134 134

8 79 41 41 76 19 50 37 34





120 6

73 119

73 67 47

72 37

127


Index 28







POWDER 129 516 109

Index 29




Index 30













Index 31





Index 32







Index 33






Index 34




115

115

115



33


115 39

135 135

27 29 33 31 33 38 64 42 54 75 61


44 44 50 50 50 51 13 26

136 121

42 93

93 73 38



38 22 54 15 54 61 54 54 42


121 61 43 28 51 42

115 77 63



132 28 54


55 55 29




40

93


11

11



Index 35



39

39

ZESTRIL ZETIA

31 30



39

39

ZIAC ZIAGEN

33 51


21 121 130


39

39


51 78 14


81

81


8 39 24


125 46 37


81

81


79 80

127


123 80 80




30 26

8 39 71 71 71 71 42

116 22 79 71

116 117

64 19 19 77 71

119 135 126

5264 129

67 67

Index 36


Index 37













AMB19-AZ-HP-1000



















Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Drug Name DrugTier

RequirementsLimits



NF

QL(3 ea daily)


NF

QL(2 ea daily)


NF

QL(1 ea daily)


NF


NF

QL(2 ea daily)



1

QL(1 ea daily)


1

Drug Name DrugTier

RequirementsLimits


1

QL(2 ea daily)


1

QL(3 ea daily)


1

QL(2 ea daily)




NF

QL(4 ea daily)


NF






3 ST QL(1 eadaily)




1

Drug Name DrugTier

RequirementsLimits


Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1







Drug Name DrugTier

RequirementsLimits


1

QL(1 ea daily)









yrs old)




















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


celecoxib caps 1 PA













daily)

flurbiprofen tabs 1





4

Drug Name DrugTier

RequirementsLimits









nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1





Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


NF


NF


5

Drug Name DrugTier

RequirementsLimits


Salicylates





diflunisal tabs 1


NF


salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF





daily)



1

PA QL(4 eadaily)


1

QL(034 eadaily)



1 PA QL(2 eadaily)




1






NF


NF

PA QL(2 eadaily)


6

Drug Name DrugTier

RequirementsLimits











1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF

Drug Name DrugTier

RequirementsLimits









1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)


7

Drug Name DrugTier

RequirementsLimits






daily)










1





1








Drug Name DrugTier

RequirementsLimits


1



1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1 QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1



NF


10

Drug Name DrugTier

RequirementsLimits


NF






atovaquone susp 1



Carbapenems




meropenem solr 1








Drug Name DrugTier

RequirementsLimits

Glycopeptides










Leprostatics

dapsone tabs 1


NF


NF


NF







aztreonam solr 1


11

Drug Name DrugTier

RequirementsLimits






daily) Polymyxins






NF


NF









Drug Name DrugTier

RequirementsLimits




NF





NITRO-BID OINT 3


NF



1











12

Drug Name DrugTier

RequirementsLimits


meprobamate tabs 1






















Drug Name DrugTier

RequirementsLimits













dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOSY 4 PA














NF QL(1 ea daily)








Drug Name DrugTier

RequirementsLimits



2



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF






14

Drug Name DrugTier

RequirementsLimits


1 QL(15 ml daily)









daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)






Drug Name DrugTier

RequirementsLimits




2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1









15

Drug Name DrugTier

RequirementsLimits

BEVYXXA CAPS 3



daily)








NF



NF



NF



NF






daily) SP



Drug Name DrugTier

RequirementsLimits












4

PA SP


NF



1


1


NF


16

Drug Name DrugTier

RequirementsLimits


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA






3


3





daily)

Drug Name DrugTier

RequirementsLimits


daily)










3 PA














17

Drug Name DrugTier

RequirementsLimits




EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)




NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits








NF

PA QL(3 eadaily)





NF



NF





1 PA QL(3 eadaily)


daily)


primidone tabs 1



18

Drug Name DrugTier

RequirementsLimits







NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)










NF QL(40 ml daily)


NF QL(3 ea daily)



Drug Name DrugTier

RequirementsLimits



3 PA QL(2 eadaily)



Carbamates















2




19

Drug Name DrugTier

RequirementsLimits



PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)









Drug Name DrugTier

RequirementsLimits






















NF QL(4 ea daily)


20

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)


NF QL(2 ea daily)


NF QL(3 ea daily)


NF QL(1 ea daily)










NF QL(4 ea daily)


NF QL(2 ea daily)


NF QL(1 ea daily)




Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)












21

Drug Name DrugTier

RequirementsLimits
























Drug Name DrugTier

RequirementsLimits










FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)





1 QL(3 ea daily)





22

Drug Name DrugTier

RequirementsLimits

Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1













miglitol tabs 1




Drug Name DrugTier

RequirementsLimits



NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)




1 QL(4 ea daily)

GLYXAMBI TABS 2











2 QL(2 ea daily)


TRIJARDY XR TB24 2


23

Drug Name DrugTier

RequirementsLimits


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



3 QL(0035 eadaily)








Drug Name DrugTier

RequirementsLimits




ml daily)






Insulin

APIDRA SOLN 3 PA





FIASP SOLN 2




LEVEMIR SOLN 2





24

Drug Name DrugTier

RequirementsLimits

NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 3 PA












Sulfonylureas

Drug Name DrugTier

RequirementsLimits



















MOTOFEN TABS 3



CHEMET CAPS 3



25

Drug Name DrugTier

RequirementsLimits



deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3










daily)

Drug Name DrugTier

RequirementsLimits
















NF





BONJESTA TBCR 3


CESAMET CAPS 3


26

Drug Name DrugTier

RequirementsLimits





dronabinol caps 1




ea daily)







NF


VARUBI TBPK 3 PA




ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

Drug Name DrugTier

RequirementsLimits

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA


27

Drug Name DrugTier

RequirementsLimits














1

QL(30 ml daily)



1 QL(1 ea daily)


1 QL(2 ea daily)




daily) RXOTC

Drug Name DrugTier

RequirementsLimits





1





1












RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1


28

Drug Name DrugTier

RequirementsLimits

loratadine tabs 1

loratadine tbdp 1


NF






















Drug Name DrugTier

RequirementsLimits






daily)






NF QL(6 gm daily)


NF QL(6 ea daily)










NF QL(252 gmdaily)


daily)


29

Drug Name DrugTier

RequirementsLimits


MP






















Drug Name DrugTier

RequirementsLimits








1 QL(2 ea daily)



daily)







captopril tabs 1



lisinopril tabs 1




30

Drug Name DrugTier

RequirementsLimits




ramipril caps 1

trandolapril tabs 1


















Drug Name DrugTier

RequirementsLimits







daily)










NF

QL(3 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)





31

Drug Name DrugTier

RequirementsLimits



NF



NF


NF ST



NF




NF


EXFORGE HCT TABS 2


NF



NF

QL(1 ea daily)


NF

QL(2 ea daily)



Drug Name DrugTier

RequirementsLimits


NF


1

QL(1 ea daily)


1 QL(2 ea daily)


NF


NF



NF


1 ST



1 QL(3 ea daily)


1 QL(4 ea daily)


1 QL(2 ea daily)





NF


NF


32

Drug Name DrugTier

RequirementsLimits



NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


Drug Name DrugTier

RequirementsLimits



COARTEM TABS 2




Antimalarials





33

Drug Name DrugTier

RequirementsLimits







NF






FIRDAPSE TABS 4 PA





NF


3 PA



Drug Name DrugTier

RequirementsLimits




RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

rifampin solr 1



34

Drug Name DrugTier

RequirementsLimits




BELRAPZO SOLN 6


BENDEKA SOLN 6





6 PA








6


EVOMELA SOLR 6

GLEOSTINE CAPS 6 PA


Drug Name DrugTier

RequirementsLimits

IFEX SOLR 3 GM 6 PA







melphalan tabs 1





6

PA SP








YONDELIS SOLR 6


ZEPZELCA SOLR 6

Antimetabolites


35

Drug Name DrugTier

RequirementsLimits





















6


6 PA



Drug Name DrugTier

RequirementsLimits


6


6

PA


6

INFUGEM SOLN 6






PURIXAN SUSP 6 PA




XATMEP SOLN 6 PA



CYRAMZA SOLN 6 PA



daily)


36

Drug Name DrugTier

RequirementsLimits








daily)

MVASI SOLN 6 PA



ZIRABEV SOLN 6 PA



HERZUMA SOLR 6

KANJINTI SOLR 6

OGIVRI SOLR 6

ONTRUZANT SOLR 6



TUKYSA TABS 6 PA




BAVENCIO SOLN 6

Drug Name DrugTier

RequirementsLimits

BESPONSA SOLR 6

BLENREP SOLR 6

BLINCYTO SOLR 6 PA

DARZALEX SOLN 6

EMPLICITI SOLR 6

ENHERTU SOLR 6

GAZYVA SOLN 6 PA

IMFINZI SOLN 6

KADCYLA SOLR 6 PA

KEYTRUDA SOLN 6 PA

LIBTAYO SOLN 6

LUMOXITI SOLR 6

MONJUVI SOLR 6

MYLOTARG SOLR 6

OPDIVO SOLN 6 PA

PADCEV SOLR 6


POTELIGEO SOLN 6


RUXIENCE SOLN 6

SARCLISA SOLN 6

TECENTRIQ SOLN 6

TRUXIMA SOLN 6

UNITUXIN SOLN 6

YERVOY SOLN 6 PA SP


37

Drug Name DrugTier

RequirementsLimits



VENCLEXTA TABS 6 PA


KYMRIAH SUSP 6 PA

PROVENGE SUSP 6 PA

TECARTUS SUSP 6

YESCARTA SUSP 6





IRESSA TABS 6

PORTRAZZA SOLN 6

TAGRISSO TABS 6 PA




VIZIMPRO TABS 6 PA


DAURISMO TABS 6 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP






EMCYT CAPS 6 PA SP

ERLEADA TABS 6 PA









6

letrozole tabs 1


38

Drug Name DrugTier

RequirementsLimits



6





ea daily) SP






NUBEQA TABS 6 PA

SOLTAMOX SOLN 6 PA




VANTAS KIT 6 PA


YONSA TABS 6 PA





daily)

Drug Name DrugTier

RequirementsLimits




daily)

LARTRUVO SOLN 6














6


6




39

Drug Name DrugTier

RequirementsLimits




6 PA


6 PA SP




6 PA SP


6 PA



JELMYTO SOLR 6










INQOVI TABS 6

Drug Name DrugTier

RequirementsLimits




LONSURF TABS 6 PA

PHESGO SOLN 6


VYXEOS SUSR 6







ALIQOPA SOLR 6



BALVERSA TABS 6 PA

BELEODAQ SOLR 6 PA



daily) SP


BRAFTOVI CAPS 6 PA

BRUKINSA CAPS 6 PA

CABOMETYX TABS 6 PA

CALQUENCE CAPS 6 PA


40

Drug Name DrugTier

RequirementsLimits





COPIKTRA CAPS 6 PA

COTELLIC TABS 6 PA


FARYDAK CAPS 6 PA


daily) SP

IBRANCE CAPS 6 PA

IBRANCE TABS 6 PA


daily)


IDHIFA TABS 6 PA



daily)



6 PA QL(1 eadaily)

INREBIC CAPS 6 PA




daily) SP

KISQALI TBPK 6 PA

Drug Name DrugTier

RequirementsLimits

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 6 PA


LORBRENA TABS 6 PA




MEKTOVI TABS 6 PA

NERLYNX TABS 6 PA







QINLOCK TABS 6 PA

RETEVMO CAPS 6 PA



ROZLYTREK CAPS 6 PA


RYDAPT CAPS 6 PA



41

Drug Name DrugTier

RequirementsLimits



daily) SP


TABRECTA TABS 6 PA


TALZENNA CAPS 6 PA


daily) SP


TAZVERIK TABS 6 PA


TIBSOVO TABS 6 PA


ml daily) SP



daily) SP


VERZENIO TABS 6 PA

VITRAKVI CAPS 6 PA

VITRAKVI SOLN 6 PA



XOSPATA TABS 6 PA




Drug Name DrugTier

RequirementsLimits



ZYKADIA TABS 6


ASPARLAS SOLN 6






LUTATHERA SOLN 6

QUADRAMET SOLN 6 PA


XOFIGO SOLN 6 PA


ALFERON N SOLN 6 PA






ELZONRIS SOLN 6



42

Drug Name DrugTier

RequirementsLimits

hydroxyurea caps 1





NIPENT SOLR 6 PA SP








UVADEX SOLN 6 PA SP


ELITEK SOLR 6 PA




ETHYOL SOLR 6


KHAPZORY SOLR 6



1

Drug Name DrugTier

RequirementsLimits





mesna soln 6 PA



TOTECT SOLR 6 PA



Mitotic Inhibitors











6 PA




43

Drug Name DrugTier

RequirementsLimits









MARQIBO SUSP 6 PA


6 PA SP


6 PA


6 PA SP









6 PA SP

Drug Name DrugTier

RequirementsLimits


6 PA





ONIVYDE INJ 6




6 PA


TRODELVY SOLR 6



carbidopa tabs 1










44

Drug Name DrugTier

RequirementsLimits



tolcapone tabs 1





APOKYN SOCT 4 PA








NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)


1

Drug Name DrugTier

RequirementsLimits


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


1


45

Drug Name DrugTier

RequirementsLimits


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1









Drug Name DrugTier

RequirementsLimits


Benzisoxazoles




NF QL(1 ea daily)








NF

QL(4 ea daily)



1 QL(4 ea daily)


1 QL(2 ea daily)


NF QL(0036 mldaily)


NF QL(0036 mldaily)




46

Drug Name DrugTier

RequirementsLimits



haloperidol tabs 1




















Drug Name DrugTier

RequirementsLimits










3 PA QL(2 eadaily)


daily)



NF





NF



NF




NF QL(2 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)


47

Drug Name DrugTier

RequirementsLimits




1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1



Drug Name DrugTier

RequirementsLimits









3

QL(1 ea daily)

















48

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(1 ea daily)



1



0 QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP





Drug Name DrugTier

RequirementsLimits







NF QL(125 mldaily)


2 QL(4 ea daily)







NF QL(4 ea daily)











49

Drug Name DrugTier

RequirementsLimits













NF QL(1 ea daily)



RUKOBIA TB12 4 PA









Drug Name DrugTier

RequirementsLimits




2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)














50

Drug Name DrugTier

RequirementsLimits




NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP

Drug Name DrugTier

RequirementsLimits




ml daily) SP










daily)



ZEPATIER TABS 4 PA

Herpes Agents









51

Drug Name DrugTier

RequirementsLimits








NF QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


NF



NF



Alpha-Beta Blockers

carvedilol tabs 1






atenolol tabs 1




daily)






52

Drug Name DrugTier

RequirementsLimits









nadolol tabs 1

pindolol tabs 1













Drug Name DrugTier

RequirementsLimits



NF







1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1




53

Drug Name DrugTier

RequirementsLimits




NF






NF



1



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





Drug Name DrugTier

RequirementsLimits


BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents











3 PA









daily) SP


54

Drug Name DrugTier

RequirementsLimits




daily)





NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP






Drug Name DrugTier

RequirementsLimits




cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1






cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1


55

Drug Name DrugTier

RequirementsLimits

cefdinir susr 1











NF ST


cefepime hcl solr 1



TEFLARO SOLR 3




NF




Drug Name DrugTier

RequirementsLimits



0


NF


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0







56

Drug Name DrugTier

RequirementsLimits








NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF



Drug Name DrugTier

RequirementsLimits




NF


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF




57

Drug Name DrugTier

RequirementsLimits







NF






NF





NF




1



1

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA






NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1


58

Drug Name DrugTier

RequirementsLimits

prednisone tabs 1

prednisone tbpk 1






NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics






59

Drug Name DrugTier

RequirementsLimits






12 yrs old)





NF





yrs old)














12 yrs old)

Drug Name DrugTier

RequirementsLimits



yrs old)










12 yrs old)




12 yrs old)



NF












60

Drug Name DrugTier

RequirementsLimits




























VEREGEN OINT 3



Drug Name DrugTier

RequirementsLimits




daily) RXOTC




mupirocin oint 1















ERTACZO CREA 3


61

Drug Name DrugTier

RequirementsLimits


EXELDERM SOLN 3


JUBLIA SOLN 3 PA










NF RXOTC



NF





Drug Name DrugTier

RequirementsLimits






NF













62

Drug Name DrugTier

RequirementsLimits





OXISTAT LOTN 2







NF







Drug Name DrugTier

RequirementsLimits




PANRETIN GEL 6

PICATO GEL 0015 6


PICATO GEL 005 6



VALCHLOR GEL 6 PA







63

Drug Name DrugTier

RequirementsLimits













daily)



NF QL(4 ea daily)






ml daily)

Drug Name DrugTier

RequirementsLimits


ml daily) SP


TAZORAC CREA 005 2













Burn Products









64

Drug Name DrugTier

RequirementsLimits

amcinonide crea 1


amcinonide lotn 3

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)


Drug Name DrugTier

RequirementsLimits





CLODERM CREA 3


CLODERM PUMP CREA 3






NF



NF











65

Drug Name DrugTier

RequirementsLimits


NF


NF






















Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA














daily)





NF

RXOTC


daily)



PSORCON CREA 2 PA


66

Drug Name DrugTier

RequirementsLimits





NF

ST


3

ST







1



1


1






Drug Name DrugTier

RequirementsLimits




NF RXOTC


NF RXOTC











2 yrs old)



2 yrs old)



podofilox soln 1



67

Drug Name DrugTier

RequirementsLimits








SYNERA PTCH 3




Rosacea Agents




NF



NF





Drug Name DrugTier

RequirementsLimits






EURAX CREA 3




lindane sham 1

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS


daily)


68

Drug Name DrugTier

RequirementsLimits

THYROGEN SOLR 3


Diagnostic Tests

CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1





1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits









NF



NF


NF


NF









69

Drug Name DrugTier

RequirementsLimits


furosemide soln 1

furosemide tabs 1


torsemide tabs 1


















daily)

Drug Name DrugTier

RequirementsLimits





NF PA SP










4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA


70

Drug Name DrugTier

RequirementsLimits

XGEVA SOLN 4 PA SP





Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



NF PA







Drug Name DrugTier

RequirementsLimits



4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA










Metabolic Modifiers


71

Drug Name DrugTier

RequirementsLimits




calcitriol caps 1

calcitriol soln 1










NF


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP





72

Drug Name DrugTier

RequirementsLimits




cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP

JYNARQUE TBPK 4 PA


daily) SP




CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2

Drug Name DrugTier

RequirementsLimits




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2


daily)


73

Drug Name DrugTier

RequirementsLimits



1


BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA









levofloxacin soln 1

levofloxacin tabs 1



ofloxacin tabs 1





Drug Name DrugTier

RequirementsLimits




ursodiol caps 1

ursodiol tabs 1


daily)








AVSOLA SOLR 4 PA







DIPENTUM CAPS 2


74

Drug Name DrugTier

RequirementsLimits



















alvimopan caps 1




Drug Name DrugTier

RequirementsLimits



NF


PHOSLYRA SOLN 2





VELPHORO CHEW 3 PA



1



NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1



75

Drug Name DrugTier

RequirementsLimits



ELMIRON CAPS 2












Urinary Analgesics





Gout Agents

allopurinol tabs 1




Drug Name DrugTier

RequirementsLimits

KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA


TAVALISSE TABS 4 PA




TAKHZYRO SOLN 4 PA






76

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




REOPRO SOLN 3

ZONTIVITY TABS 3 PA







VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates

Drug Name DrugTier

RequirementsLimits




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA






4 PA



3

PA SP



daily)


77

Drug Name DrugTier

RequirementsLimits



4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










NF PA






Drug Name DrugTier

RequirementsLimits





1










estazolam tabs 1

eszopiclone tabs 1







triazolam tabs 1


78

Drug Name DrugTier

RequirementsLimits








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives




CLENPIQ SOLN 3 PA


NF


0

Drug Name DrugTier

RequirementsLimits


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1









NF


NF


79

Drug Name DrugTier

RequirementsLimits


NF


Azithromycin












NF






daily)





Clarithromycin



Drug Name DrugTier

RequirementsLimits



NF


NF


3





1


Fidaxomicin




CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0



80

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)







0 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits





0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)



0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


81

Drug Name DrugTier

RequirementsLimits


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)

Drug Name DrugTier

RequirementsLimits












1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


82

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1












1

Drug Name DrugTier

RequirementsLimits










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)












daily)


83

Drug Name DrugTier

RequirementsLimits







1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)








1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


84

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1












daily)



daily)



Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1


1


1


1



1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)







1



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)









1


1 QL(66667 eadaily)





daily)


86

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



daily)










daily)







daily)


Drug Name DrugTier

RequirementsLimits






daily)








LANZO MISC 1





1 QL(66667 eadaily)







87

Drug Name DrugTier

RequirementsLimits







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)









1 QL(66667 eadaily)



1

QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)










daily)


88

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1




daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1 QL(66667 eadaily)










89

Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


90

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)













daily)

SURE-PEN MISC 1



daily)


91

Drug Name DrugTier

RequirementsLimits










1







1








daily)

Drug Name DrugTier

RequirementsLimits







daily)



1 QL(66667 eadaily)







daily)






daily)




daily)


92

Drug Name DrugTier

RequirementsLimits



daily)














1 QL(66667 eadaily)








Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


93

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)








Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


97

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


98

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


99

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)






101

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






102

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




103

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


104

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


105

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


107

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




108

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






109

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






111

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


112

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


113

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


114

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)

















Drug Name DrugTier

RequirementsLimits




NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists












115

Drug Name DrugTier

RequirementsLimits




NF



NF



NF



NF



NF
















Drug Name DrugTier

RequirementsLimits





sumatriptan soln 1





















116

Drug Name DrugTier

RequirementsLimits








1






NF



NF


1


ISOLYTE-S SOLN 1

Drug Name DrugTier

RequirementsLimits



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1

ringers soln 1


117

Drug Name DrugTier

RequirementsLimits









1



1


1





1



Drug Name DrugTier

RequirementsLimits





daily) SP







ATGAM INJ 4 PA SP

AZASAN TABS 3




NF


NF

cyclosporine caps 1



cyclosporine soln 1





118

Drug Name DrugTier

RequirementsLimits





NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1



NF




Drug Name DrugTier

RequirementsLimits



Lymphatic Agents

SYLVANT SOLR 6 PA









DEBACTEROL SOLN 2


NF

Dental Products







119

Drug Name DrugTier

RequirementsLimits


MULTIVITAMINS











2

QL(1 ea daily)RXOTC










Drug Name DrugTier

RequirementsLimits



2

QL(1 ea daily)


2

QL(1 ea daily)RXOTC







120

Drug Name DrugTier

RequirementsLimits







2 QL(1 ea daily)





RXOTC



RXOTC





carisoprodol tabs 1






Drug Name DrugTier

RequirementsLimits











Nasal Antiallergy






Nasal Steroids



NF



NF



121

Drug Name DrugTier

RequirementsLimits






NF


NF






riluzole tabs 3


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3

Drug Name DrugTier

RequirementsLimits


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1







tropicamide soln 1



122

Drug Name DrugTier

RequirementsLimits




NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF







KLARITY-A SOLN 3



NATACYN SUSP 2


Drug Name DrugTier

RequirementsLimits








trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA





OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA


DUREZOL EMUL 3 PA


FML FORTE SUSP 3 PA


123

Drug Name DrugTier

RequirementsLimits


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF





NF

PRED MILD SUSP 3 PA




3


NF


Ophthalmics - Misc

Drug Name DrugTier

RequirementsLimits


NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA














LASTACAFT SOLN 3 PA






124

Drug Name DrugTier

RequirementsLimits



ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2








Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins


125

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1











1



NF

Drug Name DrugTier

RequirementsLimits


NF


NF



NF


NF


NF










NF PA





126

Drug Name DrugTier

RequirementsLimits



NF





disulfiram tabs 1





NF QL(2 ea daily)


NF QL(1 ea daily)










Drug Name DrugTier

RequirementsLimits





NF





Fibromyalgia Agents







daily) SP


daily) SP

AUBAGIO TABS 4 PA







127

Drug Name DrugTier

RequirementsLimits







GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA





ml daily)







NF PA

Drug Name DrugTier

RequirementsLimits



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)






NUEDEXTA CAPS 3 PA


pimozide tabs 1



Smoking Deterrents









128

Drug Name DrugTier

RequirementsLimits




NF





0


NICOTROL NS SOLN 0


NF QL(2 ea daily)


TEGSEDI SOSY 4 PA











daily)

Drug Name DrugTier

RequirementsLimits








Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines











129

Drug Name DrugTier

RequirementsLimits






NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)




1





Drug Name DrugTier

RequirementsLimits




WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0











NF





130

Drug Name DrugTier

RequirementsLimits




1







NF RXOTC







1 QL(40 ml daily)





NF RXOTC



Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)










RXOTC MP


131

Drug Name DrugTier

RequirementsLimits



1 QL(4 ea daily)


NF QL(1 ea daily)


NF







NF

RXOTC










Drug Name DrugTier

RequirementsLimits









MYRBETRIQ TB24 3 PA




NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines


MENACTRA INJ 0

MENQUADFI INJ 0

MENVEO SOLR 0

PNEUMOVAX 23 INJ 0



132

Drug Name DrugTier

RequirementsLimits

PREVNAR 13 SUSP 0

Viral Vaccines













ENGERIX-B INJ 0


ENGERIX-B SUSP 0






Drug Name DrugTier

RequirementsLimits












0



0



0



0



0



0



0



133

Drug Name DrugTier

RequirementsLimits


0



0



0



0



0



0











0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0














134

Drug Name DrugTier

RequirementsLimits

SHINGRIX SUSR 0





ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3



NF

Drug Name DrugTier

RequirementsLimits






PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF







135

Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




136










Index 1








Index 2













Index 3




127 52

122 132

15 16 42 56 38 35 54 48 10

125 79

32 52 37 39

123 37 70 26

130 40 54


83

83



40 122




Index 4





32 34 36 41 30 63

131 72 17 17 44 45

45 28 35

83 53 53 53 31



52 73 77 40


83

96


56 56 55 56





55 55 56 55 56 56 55 55

4 4

58 21

118 20 55 77


Index 5









Index 6




39 122

41 15 31 69 27 30 48 13


23 17 31 31



124 68 11 11


2 77 13

119 61

135

61 47 47 83 33

6 6

44 79 74 76 76 76




29 29 29


127128 41 65


35 34 24



52 53 55 58 10 58

125


118

118 78 22 29 36


Index 7


36 130 132

51 115

42 36 39

128 14 10

121 121

11 11 11 33

132 37 40 39




39 38

4 2

72 119

36 2526

26 73 48 74

129 6

64 20 20 20 20

118




73 58 38

57


117

117 1718


74 28 25 66

Index 8




Index 9






Index 10




51 75 58 54


85 46 27 38




136 128 115 115

38 38 38




Index 11








19 19

4 53 38 80 73


85 85

5 8 6 8





famotidine 131

Index 12




100

100

100

85 115 116

77 38








4 124

38 66

122 15



Index 13






100

100




101

101





Index 14




Index 15












Index 16








Index 17



49 51 49 18

87

87 87

87 87

87

87

87


87

104

104

104

104

104

104






131 75 87 41 39 70

124 125

46


37

37 54 38 43 35 77 39

Index 18












Index 19



62 62



88


62 75 30 29 17 47 74




127 62

125 72


20 79 27 21


88

88




Index 20





1 69 12

130 10

121 4


73 129 130

33 45 77 56




57 20 68

132 76 40 40


Index 21



516 106


88


88


89

23G18MM MS CONTIN

89 7




Index 22


49 41

131 131

57 136

30 136 136

30 53

128 128 129








12 12 12

120



32 124 121

66 29

Index 23



23 79 71

5 125

68 126

35 9 5 7

13 77 18

123 63 63




64 132




7

9 9 7 7

24 44 37 46 26



7 37 55 68 58 54 72

129 121

58





Index 24




Index 25







Index 26














Index 27


122 122

52 117 119

4 70 46 46 46

3 3

50 37 40

127 116 121

72 41 45 30

134 134

8 79 41 41 76 19 50 37 34





120 6

73 119

73 67 47

72 37

127


Index 28







POWDER 129 516 109

Index 29




Index 30













Index 31





Index 32







Index 33






Index 34




115

115

115



33


115 39

135 135

27 29 33 31 33 38 64 42 54 75 61


44 44 50 50 50 51 13 26

136 121

42 93

93 73 38



38 22 54 15 54 61 54 54 42


121 61 43 28 51 42

115 77 63



132 28 54


55 55 29




40

93


11

11



Index 35



39

39

ZESTRIL ZETIA

31 30



39

39

ZIAC ZIAGEN

33 51


21 121 130


39

39


51 78 14


81

81


8 39 24


125 46 37


81

81


79 80

127


123 80 80




30 26

8 39 71 71 71 71 42

116 22 79 71

116 117

64 19 19 77 71

119 135 126

5264 129

67 67

Index 36


Index 37













AMB19-AZ-HP-1000



















Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Drug Name DrugTier

RequirementsLimits


Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1







Drug Name DrugTier

RequirementsLimits


1

QL(1 ea daily)









yrs old)




















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


celecoxib caps 1 PA













daily)

flurbiprofen tabs 1





4

Drug Name DrugTier

RequirementsLimits









nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1





Drug Name DrugTier

RequirementsLimits

OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


NF


NF


5

Drug Name DrugTier

RequirementsLimits


Salicylates





diflunisal tabs 1


NF


salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF





daily)



1

PA QL(4 eadaily)


1

QL(034 eadaily)



1 PA QL(2 eadaily)




1






NF


NF

PA QL(2 eadaily)


6

Drug Name DrugTier

RequirementsLimits











1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF

Drug Name DrugTier

RequirementsLimits









1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)


7

Drug Name DrugTier

RequirementsLimits






daily)










1





1








Drug Name DrugTier

RequirementsLimits


1



1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1 QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1



NF


10

Drug Name DrugTier

RequirementsLimits


NF






atovaquone susp 1



Carbapenems




meropenem solr 1








Drug Name DrugTier

RequirementsLimits

Glycopeptides










Leprostatics

dapsone tabs 1


NF


NF


NF







aztreonam solr 1


11

Drug Name DrugTier

RequirementsLimits






daily) Polymyxins






NF


NF









Drug Name DrugTier

RequirementsLimits




NF





NITRO-BID OINT 3


NF



1











12

Drug Name DrugTier

RequirementsLimits


meprobamate tabs 1






















Drug Name DrugTier

RequirementsLimits













dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOSY 4 PA














NF QL(1 ea daily)








Drug Name DrugTier

RequirementsLimits



2



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF






14

Drug Name DrugTier

RequirementsLimits


1 QL(15 ml daily)









daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)






Drug Name DrugTier

RequirementsLimits




2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1









15

Drug Name DrugTier

RequirementsLimits

BEVYXXA CAPS 3



daily)








NF



NF



NF



NF






daily) SP



Drug Name DrugTier

RequirementsLimits












4

PA SP


NF



1


1


NF


16

Drug Name DrugTier

RequirementsLimits


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA






3


3





daily)

Drug Name DrugTier

RequirementsLimits


daily)










3 PA














17

Drug Name DrugTier

RequirementsLimits




EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)




NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits








NF

PA QL(3 eadaily)





NF



NF





1 PA QL(3 eadaily)


daily)


primidone tabs 1



18

Drug Name DrugTier

RequirementsLimits







NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)










NF QL(40 ml daily)


NF QL(3 ea daily)



Drug Name DrugTier

RequirementsLimits



3 PA QL(2 eadaily)



Carbamates















2




19

Drug Name DrugTier

RequirementsLimits



PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)









Drug Name DrugTier

RequirementsLimits






















NF QL(4 ea daily)


20

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)


NF QL(2 ea daily)


NF QL(3 ea daily)


NF QL(1 ea daily)










NF QL(4 ea daily)


NF QL(2 ea daily)


NF QL(1 ea daily)




Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)












21

Drug Name DrugTier

RequirementsLimits
























Drug Name DrugTier

RequirementsLimits










FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)





1 QL(3 ea daily)





22

Drug Name DrugTier

RequirementsLimits

Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1













miglitol tabs 1




Drug Name DrugTier

RequirementsLimits



NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)




1 QL(4 ea daily)

GLYXAMBI TABS 2











2 QL(2 ea daily)


TRIJARDY XR TB24 2


23

Drug Name DrugTier

RequirementsLimits


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



3 QL(0035 eadaily)








Drug Name DrugTier

RequirementsLimits




ml daily)






Insulin

APIDRA SOLN 3 PA





FIASP SOLN 2




LEVEMIR SOLN 2





24

Drug Name DrugTier

RequirementsLimits

NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 3 PA












Sulfonylureas

Drug Name DrugTier

RequirementsLimits



















MOTOFEN TABS 3



CHEMET CAPS 3



25

Drug Name DrugTier

RequirementsLimits



deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3










daily)

Drug Name DrugTier

RequirementsLimits
















NF





BONJESTA TBCR 3


CESAMET CAPS 3


26

Drug Name DrugTier

RequirementsLimits





dronabinol caps 1




ea daily)







NF


VARUBI TBPK 3 PA




ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

Drug Name DrugTier

RequirementsLimits

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA


27

Drug Name DrugTier

RequirementsLimits














1

QL(30 ml daily)



1 QL(1 ea daily)


1 QL(2 ea daily)




daily) RXOTC

Drug Name DrugTier

RequirementsLimits





1





1












RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1


28

Drug Name DrugTier

RequirementsLimits

loratadine tabs 1

loratadine tbdp 1


NF






















Drug Name DrugTier

RequirementsLimits






daily)






NF QL(6 gm daily)


NF QL(6 ea daily)










NF QL(252 gmdaily)


daily)


29

Drug Name DrugTier

RequirementsLimits


MP






















Drug Name DrugTier

RequirementsLimits








1 QL(2 ea daily)



daily)







captopril tabs 1



lisinopril tabs 1




30

Drug Name DrugTier

RequirementsLimits




ramipril caps 1

trandolapril tabs 1


















Drug Name DrugTier

RequirementsLimits







daily)










NF

QL(3 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)





31

Drug Name DrugTier

RequirementsLimits



NF



NF


NF ST



NF




NF


EXFORGE HCT TABS 2


NF



NF

QL(1 ea daily)


NF

QL(2 ea daily)



Drug Name DrugTier

RequirementsLimits


NF


1

QL(1 ea daily)


1 QL(2 ea daily)


NF


NF



NF


1 ST



1 QL(3 ea daily)


1 QL(4 ea daily)


1 QL(2 ea daily)





NF


NF


32

Drug Name DrugTier

RequirementsLimits



NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


Drug Name DrugTier

RequirementsLimits



COARTEM TABS 2




Antimalarials





33

Drug Name DrugTier

RequirementsLimits







NF






FIRDAPSE TABS 4 PA





NF


3 PA



Drug Name DrugTier

RequirementsLimits




RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

rifampin solr 1



34

Drug Name DrugTier

RequirementsLimits




BELRAPZO SOLN 6


BENDEKA SOLN 6





6 PA








6


EVOMELA SOLR 6

GLEOSTINE CAPS 6 PA


Drug Name DrugTier

RequirementsLimits

IFEX SOLR 3 GM 6 PA







melphalan tabs 1





6

PA SP








YONDELIS SOLR 6


ZEPZELCA SOLR 6

Antimetabolites


35

Drug Name DrugTier

RequirementsLimits





















6


6 PA



Drug Name DrugTier

RequirementsLimits


6


6

PA


6

INFUGEM SOLN 6






PURIXAN SUSP 6 PA




XATMEP SOLN 6 PA



CYRAMZA SOLN 6 PA



daily)


36

Drug Name DrugTier

RequirementsLimits








daily)

MVASI SOLN 6 PA



ZIRABEV SOLN 6 PA



HERZUMA SOLR 6

KANJINTI SOLR 6

OGIVRI SOLR 6

ONTRUZANT SOLR 6



TUKYSA TABS 6 PA




BAVENCIO SOLN 6

Drug Name DrugTier

RequirementsLimits

BESPONSA SOLR 6

BLENREP SOLR 6

BLINCYTO SOLR 6 PA

DARZALEX SOLN 6

EMPLICITI SOLR 6

ENHERTU SOLR 6

GAZYVA SOLN 6 PA

IMFINZI SOLN 6

KADCYLA SOLR 6 PA

KEYTRUDA SOLN 6 PA

LIBTAYO SOLN 6

LUMOXITI SOLR 6

MONJUVI SOLR 6

MYLOTARG SOLR 6

OPDIVO SOLN 6 PA

PADCEV SOLR 6


POTELIGEO SOLN 6


RUXIENCE SOLN 6

SARCLISA SOLN 6

TECENTRIQ SOLN 6

TRUXIMA SOLN 6

UNITUXIN SOLN 6

YERVOY SOLN 6 PA SP


37

Drug Name DrugTier

RequirementsLimits



VENCLEXTA TABS 6 PA


KYMRIAH SUSP 6 PA

PROVENGE SUSP 6 PA

TECARTUS SUSP 6

YESCARTA SUSP 6





IRESSA TABS 6

PORTRAZZA SOLN 6

TAGRISSO TABS 6 PA




VIZIMPRO TABS 6 PA


DAURISMO TABS 6 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP






EMCYT CAPS 6 PA SP

ERLEADA TABS 6 PA









6

letrozole tabs 1


38

Drug Name DrugTier

RequirementsLimits



6





ea daily) SP






NUBEQA TABS 6 PA

SOLTAMOX SOLN 6 PA




VANTAS KIT 6 PA


YONSA TABS 6 PA





daily)

Drug Name DrugTier

RequirementsLimits




daily)

LARTRUVO SOLN 6














6


6




39

Drug Name DrugTier

RequirementsLimits




6 PA


6 PA SP




6 PA SP


6 PA



JELMYTO SOLR 6










INQOVI TABS 6

Drug Name DrugTier

RequirementsLimits




LONSURF TABS 6 PA

PHESGO SOLN 6


VYXEOS SUSR 6







ALIQOPA SOLR 6



BALVERSA TABS 6 PA

BELEODAQ SOLR 6 PA



daily) SP


BRAFTOVI CAPS 6 PA

BRUKINSA CAPS 6 PA

CABOMETYX TABS 6 PA

CALQUENCE CAPS 6 PA


40

Drug Name DrugTier

RequirementsLimits





COPIKTRA CAPS 6 PA

COTELLIC TABS 6 PA


FARYDAK CAPS 6 PA


daily) SP

IBRANCE CAPS 6 PA

IBRANCE TABS 6 PA


daily)


IDHIFA TABS 6 PA



daily)



6 PA QL(1 eadaily)

INREBIC CAPS 6 PA




daily) SP

KISQALI TBPK 6 PA

Drug Name DrugTier

RequirementsLimits

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 6 PA


LORBRENA TABS 6 PA




MEKTOVI TABS 6 PA

NERLYNX TABS 6 PA







QINLOCK TABS 6 PA

RETEVMO CAPS 6 PA



ROZLYTREK CAPS 6 PA


RYDAPT CAPS 6 PA



41

Drug Name DrugTier

RequirementsLimits



daily) SP


TABRECTA TABS 6 PA


TALZENNA CAPS 6 PA


daily) SP


TAZVERIK TABS 6 PA


TIBSOVO TABS 6 PA


ml daily) SP



daily) SP


VERZENIO TABS 6 PA

VITRAKVI CAPS 6 PA

VITRAKVI SOLN 6 PA



XOSPATA TABS 6 PA




Drug Name DrugTier

RequirementsLimits



ZYKADIA TABS 6


ASPARLAS SOLN 6






LUTATHERA SOLN 6

QUADRAMET SOLN 6 PA


XOFIGO SOLN 6 PA


ALFERON N SOLN 6 PA






ELZONRIS SOLN 6



42

Drug Name DrugTier

RequirementsLimits

hydroxyurea caps 1





NIPENT SOLR 6 PA SP








UVADEX SOLN 6 PA SP


ELITEK SOLR 6 PA




ETHYOL SOLR 6


KHAPZORY SOLR 6



1

Drug Name DrugTier

RequirementsLimits





mesna soln 6 PA



TOTECT SOLR 6 PA



Mitotic Inhibitors











6 PA




43

Drug Name DrugTier

RequirementsLimits









MARQIBO SUSP 6 PA


6 PA SP


6 PA


6 PA SP









6 PA SP

Drug Name DrugTier

RequirementsLimits


6 PA





ONIVYDE INJ 6




6 PA


TRODELVY SOLR 6



carbidopa tabs 1










44

Drug Name DrugTier

RequirementsLimits



tolcapone tabs 1





APOKYN SOCT 4 PA








NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)


1

Drug Name DrugTier

RequirementsLimits


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


1


45

Drug Name DrugTier

RequirementsLimits


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1









Drug Name DrugTier

RequirementsLimits


Benzisoxazoles




NF QL(1 ea daily)








NF

QL(4 ea daily)



1 QL(4 ea daily)


1 QL(2 ea daily)


NF QL(0036 mldaily)


NF QL(0036 mldaily)




46

Drug Name DrugTier

RequirementsLimits



haloperidol tabs 1




















Drug Name DrugTier

RequirementsLimits










3 PA QL(2 eadaily)


daily)



NF





NF



NF




NF QL(2 ea daily)


NF QL(4 ea daily)


NF QL(2 ea daily)


47

Drug Name DrugTier

RequirementsLimits




1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1



Drug Name DrugTier

RequirementsLimits









3

QL(1 ea daily)

















48

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(1 ea daily)



1



0 QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP





Drug Name DrugTier

RequirementsLimits







NF QL(125 mldaily)


2 QL(4 ea daily)







NF QL(4 ea daily)











49

Drug Name DrugTier

RequirementsLimits













NF QL(1 ea daily)



RUKOBIA TB12 4 PA









Drug Name DrugTier

RequirementsLimits




2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)














50

Drug Name DrugTier

RequirementsLimits




NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP

Drug Name DrugTier

RequirementsLimits




ml daily) SP










daily)



ZEPATIER TABS 4 PA

Herpes Agents









51

Drug Name DrugTier

RequirementsLimits








NF QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


NF



NF



Alpha-Beta Blockers

carvedilol tabs 1






atenolol tabs 1




daily)






52

Drug Name DrugTier

RequirementsLimits









nadolol tabs 1

pindolol tabs 1













Drug Name DrugTier

RequirementsLimits



NF







1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1




53

Drug Name DrugTier

RequirementsLimits




NF






NF



1



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





Drug Name DrugTier

RequirementsLimits


BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents











3 PA









daily) SP


54

Drug Name DrugTier

RequirementsLimits




daily)





NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP






Drug Name DrugTier

RequirementsLimits




cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1






cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1


55

Drug Name DrugTier

RequirementsLimits

cefdinir susr 1











NF ST


cefepime hcl solr 1



TEFLARO SOLR 3




NF




Drug Name DrugTier

RequirementsLimits



0


NF


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0







56

Drug Name DrugTier

RequirementsLimits








NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF



Drug Name DrugTier

RequirementsLimits




NF


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF




57

Drug Name DrugTier

RequirementsLimits







NF






NF





NF




1



1

Drug Name DrugTier

RequirementsLimits

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA






NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1


58

Drug Name DrugTier

RequirementsLimits

prednisone tabs 1

prednisone tbpk 1






NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)


1 QL(2 ea daily)


1 QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics






59

Drug Name DrugTier

RequirementsLimits






12 yrs old)





NF





yrs old)














12 yrs old)

Drug Name DrugTier

RequirementsLimits



yrs old)










12 yrs old)




12 yrs old)



NF












60

Drug Name DrugTier

RequirementsLimits




























VEREGEN OINT 3



Drug Name DrugTier

RequirementsLimits




daily) RXOTC




mupirocin oint 1















ERTACZO CREA 3


61

Drug Name DrugTier

RequirementsLimits


EXELDERM SOLN 3


JUBLIA SOLN 3 PA










NF RXOTC



NF





Drug Name DrugTier

RequirementsLimits






NF













62

Drug Name DrugTier

RequirementsLimits





OXISTAT LOTN 2







NF







Drug Name DrugTier

RequirementsLimits




PANRETIN GEL 6

PICATO GEL 0015 6


PICATO GEL 005 6



VALCHLOR GEL 6 PA







63

Drug Name DrugTier

RequirementsLimits













daily)



NF QL(4 ea daily)






ml daily)

Drug Name DrugTier

RequirementsLimits


ml daily) SP


TAZORAC CREA 005 2













Burn Products









64

Drug Name DrugTier

RequirementsLimits

amcinonide crea 1


amcinonide lotn 3

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)


Drug Name DrugTier

RequirementsLimits





CLODERM CREA 3


CLODERM PUMP CREA 3






NF



NF











65

Drug Name DrugTier

RequirementsLimits


NF


NF






















Drug Name DrugTier

RequirementsLimits

HALOG OINT 3 PA














daily)





NF

RXOTC


daily)



PSORCON CREA 2 PA


66

Drug Name DrugTier

RequirementsLimits





NF

ST


3

ST







1



1


1






Drug Name DrugTier

RequirementsLimits




NF RXOTC


NF RXOTC











2 yrs old)



2 yrs old)



podofilox soln 1



67

Drug Name DrugTier

RequirementsLimits








SYNERA PTCH 3




Rosacea Agents




NF



NF





Drug Name DrugTier

RequirementsLimits






EURAX CREA 3




lindane sham 1

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS


daily)


68

Drug Name DrugTier

RequirementsLimits

THYROGEN SOLR 3


Diagnostic Tests

CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1





1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits









NF



NF


NF


NF









69

Drug Name DrugTier

RequirementsLimits


furosemide soln 1

furosemide tabs 1


torsemide tabs 1


















daily)

Drug Name DrugTier

RequirementsLimits





NF PA SP










4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA


70

Drug Name DrugTier

RequirementsLimits

XGEVA SOLN 4 PA SP





Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



NF PA







Drug Name DrugTier

RequirementsLimits



4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA










Metabolic Modifiers


71

Drug Name DrugTier

RequirementsLimits




calcitriol caps 1

calcitriol soln 1










NF


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP





72

Drug Name DrugTier

RequirementsLimits




cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP

JYNARQUE TBPK 4 PA


daily) SP




CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2

Drug Name DrugTier

RequirementsLimits




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2


daily)


73

Drug Name DrugTier

RequirementsLimits



1


BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA









levofloxacin soln 1

levofloxacin tabs 1



ofloxacin tabs 1





Drug Name DrugTier

RequirementsLimits




ursodiol caps 1

ursodiol tabs 1


daily)








AVSOLA SOLR 4 PA







DIPENTUM CAPS 2


74

Drug Name DrugTier

RequirementsLimits



















alvimopan caps 1




Drug Name DrugTier

RequirementsLimits



NF


PHOSLYRA SOLN 2





VELPHORO CHEW 3 PA



1



NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1



75

Drug Name DrugTier

RequirementsLimits



ELMIRON CAPS 2












Urinary Analgesics





Gout Agents

allopurinol tabs 1




Drug Name DrugTier

RequirementsLimits

KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA


TAVALISSE TABS 4 PA




TAKHZYRO SOLN 4 PA






76

Drug Name DrugTier

RequirementsLimits

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




REOPRO SOLN 3

ZONTIVITY TABS 3 PA







VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates

Drug Name DrugTier

RequirementsLimits




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA






4 PA



3

PA SP



daily)


77

Drug Name DrugTier

RequirementsLimits



4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










NF PA






Drug Name DrugTier

RequirementsLimits





1










estazolam tabs 1

eszopiclone tabs 1







triazolam tabs 1


78

Drug Name DrugTier

RequirementsLimits








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives




CLENPIQ SOLN 3 PA


NF


0

Drug Name DrugTier

RequirementsLimits


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1









NF


NF


79

Drug Name DrugTier

RequirementsLimits


NF


Azithromycin












NF






daily)





Clarithromycin



Drug Name DrugTier

RequirementsLimits



NF


NF


3





1


Fidaxomicin




CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0



80

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)







0 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits





0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)



0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


81

Drug Name DrugTier

RequirementsLimits


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)

Drug Name DrugTier

RequirementsLimits












1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


82

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1












1

Drug Name DrugTier

RequirementsLimits










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)












daily)


83

Drug Name DrugTier

RequirementsLimits







1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



daily)








1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


84

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1












daily)



daily)



Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1


1


1


1



1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)







1



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)









1


1 QL(66667 eadaily)





daily)


86

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



daily)










daily)







daily)


Drug Name DrugTier

RequirementsLimits






daily)








LANZO MISC 1





1 QL(66667 eadaily)







87

Drug Name DrugTier

RequirementsLimits







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)









1 QL(66667 eadaily)



1

QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)










daily)


88

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1




daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1 QL(66667 eadaily)










89

Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)







1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


90

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)













daily)

SURE-PEN MISC 1



daily)


91

Drug Name DrugTier

RequirementsLimits










1







1








daily)

Drug Name DrugTier

RequirementsLimits







daily)



1 QL(66667 eadaily)







daily)






daily)




daily)


92

Drug Name DrugTier

RequirementsLimits



daily)














1 QL(66667 eadaily)








Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)







1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


93

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)








Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)









Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


97

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


98

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


99

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)






101

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






102

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




103

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


104

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


105

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


107

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




108

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






109

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






111

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


112

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


113

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


114

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)

















Drug Name DrugTier

RequirementsLimits




NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists












115

Drug Name DrugTier

RequirementsLimits




NF



NF



NF



NF



NF
















Drug Name DrugTier

RequirementsLimits





sumatriptan soln 1





















116

Drug Name DrugTier

RequirementsLimits








1






NF



NF


1


ISOLYTE-S SOLN 1

Drug Name DrugTier

RequirementsLimits



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1

ringers soln 1


117

Drug Name DrugTier

RequirementsLimits









1



1


1





1



Drug Name DrugTier

RequirementsLimits





daily) SP







ATGAM INJ 4 PA SP

AZASAN TABS 3




NF


NF

cyclosporine caps 1



cyclosporine soln 1





118

Drug Name DrugTier

RequirementsLimits





NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1



NF




Drug Name DrugTier

RequirementsLimits



Lymphatic Agents

SYLVANT SOLR 6 PA









DEBACTEROL SOLN 2


NF

Dental Products







119

Drug Name DrugTier

RequirementsLimits


MULTIVITAMINS











2

QL(1 ea daily)RXOTC










Drug Name DrugTier

RequirementsLimits



2

QL(1 ea daily)


2

QL(1 ea daily)RXOTC







120

Drug Name DrugTier

RequirementsLimits







2 QL(1 ea daily)





RXOTC



RXOTC





carisoprodol tabs 1






Drug Name DrugTier

RequirementsLimits











Nasal Antiallergy






Nasal Steroids



NF



NF



121

Drug Name DrugTier

RequirementsLimits






NF


NF






riluzole tabs 3


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3

Drug Name DrugTier

RequirementsLimits


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1







tropicamide soln 1



122

Drug Name DrugTier

RequirementsLimits




NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF







KLARITY-A SOLN 3



NATACYN SUSP 2


Drug Name DrugTier

RequirementsLimits








trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA





OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA


DUREZOL EMUL 3 PA


FML FORTE SUSP 3 PA


123

Drug Name DrugTier

RequirementsLimits


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF





NF

PRED MILD SUSP 3 PA




3


NF


Ophthalmics - Misc

Drug Name DrugTier

RequirementsLimits


NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA














LASTACAFT SOLN 3 PA






124

Drug Name DrugTier

RequirementsLimits



ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2








Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3

Drug Name DrugTier

RequirementsLimits





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins


125

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1











1



NF

Drug Name DrugTier

RequirementsLimits


NF


NF



NF


NF


NF










NF PA





126

Drug Name DrugTier

RequirementsLimits



NF





disulfiram tabs 1





NF QL(2 ea daily)


NF QL(1 ea daily)










Drug Name DrugTier

RequirementsLimits





NF





Fibromyalgia Agents







daily) SP


daily) SP

AUBAGIO TABS 4 PA







127

Drug Name DrugTier

RequirementsLimits







GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA





ml daily)







NF PA

Drug Name DrugTier

RequirementsLimits



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)






NUEDEXTA CAPS 3 PA


pimozide tabs 1



Smoking Deterrents









128

Drug Name DrugTier

RequirementsLimits




NF





0


NICOTROL NS SOLN 0


NF QL(2 ea daily)


TEGSEDI SOSY 4 PA











daily)

Drug Name DrugTier

RequirementsLimits








Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines











129

Drug Name DrugTier

RequirementsLimits






NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)




1





Drug Name DrugTier

RequirementsLimits




WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0











NF





130

Drug Name DrugTier

RequirementsLimits




1







NF RXOTC







1 QL(40 ml daily)





NF RXOTC



Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)










RXOTC MP


131

Drug Name DrugTier

RequirementsLimits



1 QL(4 ea daily)


NF QL(1 ea daily)


NF







NF

RXOTC










Drug Name DrugTier

RequirementsLimits









MYRBETRIQ TB24 3 PA




NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines


MENACTRA INJ 0

MENQUADFI INJ 0

MENVEO SOLR 0

PNEUMOVAX 23 INJ 0



132

Drug Name DrugTier

RequirementsLimits

PREVNAR 13 SUSP 0

Viral Vaccines













ENGERIX-B INJ 0


ENGERIX-B SUSP 0






Drug Name DrugTier

RequirementsLimits












0



0



0



0



0



0



0



133

Drug Name DrugTier

RequirementsLimits


0



0



0



0



0



0











0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0














134

Drug Name DrugTier

RequirementsLimits

SHINGRIX SUSR 0





ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3



NF

Drug Name DrugTier

RequirementsLimits






PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF







135

Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




136










Index 1








Index 2













Index 3




127 52

122 132

15 16 42 56 38 35 54 48 10

125 79

32 52 37 39

123 37 70 26

130 40 54


83

83



40 122




Index 4





32 34 36 41 30 63

131 72 17 17 44 45

45 28 35

83 53 53 53 31



52 73 77 40


83

96


56 56 55 56





55 55 56 55 56 56 55 55

4 4

58 21

118 20 55 77


Index 5









Index 6




39 122

41 15 31 69 27 30 48 13


23 17 31 31



124 68 11 11


2 77 13

119 61

135

61 47 47 83 33

6 6

44 79 74 76 76 76




29 29 29


127128 41 65


35 34 24



52 53 55 58 10 58

125


118

118 78 22 29 36


Index 7


36 130 132

51 115

42 36 39

128 14 10

121 121

11 11 11 33

132 37 40 39




39 38

4 2

72 119

36 2526

26 73 48 74

129 6

64 20 20 20 20

118




73 58 38

57


117

117 1718


74 28 25 66

Index 8




Index 9






Index 10




51 75 58 54


85 46 27 38




136 128 115 115

38 38 38




Index 11








19 19

4 53 38 80 73


85 85

5 8 6 8





famotidine 131

Index 12




100

100

100

85 115 116

77 38








4 124

38 66

122 15



Index 13






100

100




101

101





Index 14




Index 15












Index 16








Index 17



49 51 49 18

87

87 87

87 87

87

87

87


87

104

104

104

104

104

104






131 75 87 41 39 70

124 125

46


37

37 54 38 43 35 77 39

Index 18












Index 19



62 62



88


62 75 30 29 17 47 74




127 62

125 72


20 79 27 21


88

88




Index 20





1 69 12

130 10

121 4


73 129 130

33 45 77 56




57 20 68

132 76 40 40


Index 21



516 106


88


88


89

23G18MM MS CONTIN

89 7




Index 22


49 41

131 131

57 136

30 136 136

30 53

128 128 129








12 12 12

120



32 124 121

66 29

Index 23



23 79 71

5 125

68 126

35 9 5 7

13 77 18

123 63 63




64 132




7

9 9 7 7

24 44 37 46 26



7 37 55 68 58 54 72

129 121

58





Index 24




Index 25







Index 26














Index 27


122 122

52 117 119

4 70 46 46 46

3 3

50 37 40

127 116 121

72 41 45 30

134 134

8 79 41 41 76 19 50 37 34





120 6

73 119

73 67 47

72 37

127


Index 28







POWDER 129 516 109

Index 29




Index 30













Index 31





Index 32







Index 33






Index 34




115

115

115



33


115 39

135 135

27 29 33 31 33 38 64 42 54 75 61


44 44 50 50 50 51 13 26

136 121

42 93

93 73 38



38 22 54 15 54 61 54 54 42


121 61 43 28 51 42

115 77 63



132 28 54


55 55 29




40

93


11

11



Index 35



39

39

ZESTRIL ZETIA

31 30



39

39

ZIAC ZIAGEN

33 51


21 121 130


39

39


51 78 14


81

81


8 39 24


125 46 37


81

81


79 80

127


123 80 80




30 26

8 39 71 71 71 71 42

116 22 79 71

116 117

64 19 19 77 71

119 135 126

5264 129

67 67

Index 36


Index 37













AMB19-AZ-HP-1000



















Classes



AMEBICIDES








































DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

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