Arizona

4-Tier Drug List The 4-Tier Drug List includes a list of drugs covered by Health Net This drug list is for Arizona The drug list is updated often and may change To get the most up-to-date information you may view the latest drug list on our website at wwwhealthnetcom or call us at the toll-free telephone number on your Health Net ID card

Welcome to Health Net

What is the 4-Tier Drug List The 4-Tier Drug List or formulary is a list of covered drugs used to treat common diseases or health problems The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included The committee reviews new drugs and new information about existing drugs and chooses drugs based on Safety Effectiveness Side effects and Value (If two drugs are equally effective the less costly drug will be preferred)

How much will I pay for my drugs To figure out how much you will pay for a drug the abbreviations in the table below appear in the Drug Tier column on the drug list The copayment or coinsurance levels are defined in the table below If you do not know your copayment or coinsurance for each tier please refer to your Summary of Benefits or other plan documents

Abbreviation Description 1 Low-cost preferred generic or brand-name drugs 2 Moderate-cost preferred generic or brand-name drugs or

preferred insulin in vials 3 Preferred generic or brand-name drugs not included in a lower

level on the drug list 4 Non-preferred drugs brand-name drugs with generics in a lower

level compounded prescription drugs self-injectable drugs drugs with preferred generic equivalents at lower tiers and newly released drugs

J5 Covered injectable drugs You may be required to obtain these drugs from a Specialty Pharmacy Prior authorization may be required

O Oral or patient-administered cancer treatment drugs PV Preventive benefit drugs These drugs must be covered at no cost

to members under the Affordable Care Act A deductible does not apply To get a brand drug that has a generic available you pay the difference in cost between the brand and generic drugs

How do I use the drug list Look for your drug in the index at the end of this booklet The index lists all of the drugs on the drug list Both brand name drugs and generic drugs are listed in the index Next to your drug you will see the page number where you can find your drug

What if my drug is not on the drug list If your drug is not on the drug list call us at the telephone number on your Health Net ID card and ask if your drug is covered If your drug is not covered you can ask your doctor to prescribe a similar drug that is

ii

covered If your doctor feels you need to have the drug that is not covered your doctor can ask us to make an exception

What are generic drugs A generic drug contains the same active ingredient and works the same way as the brand name drug Generic drugs are safe and effective and generally cost less

Generic drugs are available on the drug list at Tier 1 If you request a brand name drug that has an available generic version you may pay a higher cost share

Are there any limits on my drug coverage Some drugs have limits on coverage The table below provides a description of abbreviations that may appear in the Limits column on the drug list

Abbreviation Definition Description AL Age Limit These drugs may require prior authorization if your age does

not fall within manufacturer FDA or clinical recommendations PA Prior Authorization These drugs require prior authorization for coverage

effectiveness or safety reasons This means that your doctor must request approval from Health Net before the drug will be covered

QL Quantity Limit These drugs have a limit on the amount that will be covered Your doctor must request approval for a higher quantity of the drug from Health Net

RXOTC Prescription amp Over-the-Counter (OTC)

Certain drugs are available both in a prescription form and in an OTC form Only prescription drugs are covered by your plan with the exception of some insulins insulin supplies and some covered preventive drugs

ST Step Therapy You must first try another specific drug(s) before these drugs will be covered

How can I get an exception to the rules for drug coverage Your doctor can ask for an exception to our rules for drug coverage

Your doctor can ask us to cover your drug even if it is not on the drug list If we approve an exception request for a drug not on the drug list the non-preferred brand tier (Tier 3) or Specialty copaymentcoinsurance will apply

Your doctor can ask us to make an exception for limits on your drug For example if your drug has a quantity limit of 1 tablet per day your doctor can ask us to cover more

To request an exception your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-977-4170

Can I go to any pharmacy To get the best benefit you should use pharmacies that are in the network These pharmacies have a contract with Health Net Most chain pharmacies and many independent pharmacies are in the network To find a

iii

pharmacy near you visit our website at wwwhealthnetcom or call us at the telephone number on your Health Net ID card

If you fill your prescription at an out-of-network pharmacy the pharmacy may not be able to bill Health Net online so you may have to pay the full cost of your drug Unless it is an emergency your out-ofshynetwork prescription drug may not be covered

Some injectable and high cost drugs may be considered ldquospecialty drugsrdquo Unless otherwise noted these drugs must be obtained from one of Health Netrsquos Specialty Pharmacies

Can I use a mail order pharmacy You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs Maintenance drugs are those that you take daily and are needed for a long term condition To use the mail order pharmacy your doctor must provide new prescriptions that allow up to a 90-day supply of each drug Mail order forms are available on our website at wwwhealthnetcom or you may call us at the telephone number on your Health Net ID card to request a form

How can I save money on my prescription drugs You can save time and money with these simple steps Ask your doctor about generic drugs that may work for you Fill prescriptions at Health Net participating pharmacies Be sure your doctor prescribes drugs on the drug list

iv

covered If your doctor feels you need to have the drug that is not covered your doctor can ask us to make an exception

What are generic drugs A generic drug contains the same active ingredient and works the same way as the brand name drug Generic drugs are safe and effective and generally cost less

Generic drugs are available on the drug list at Tier 1 If you request a brand name drug that has an available generic version you may pay a higher cost share

Are there any limits on my drug coverage Some drugs have limits on coverage The table below provides a description of abbreviations that may appear in the Limits column on the drug list

Abbreviation Definition Description AL Age Limit These drugs may require prior authorization if your age does

not fall within manufacturer FDA or clinical recommendations PA Prior Authorization These drugs require prior authorization for coverage

effectiveness or safety reasons This means that your doctor must request approval from Health Net before the drug will be covered

QL Quantity Limit These drugs have a limit on the amount that will be covered Your doctor must request approval for a higher quantity of the drug from Health Net

RXOTC Prescription amp Over-the-Counter (OTC)

Certain drugs are available both in a prescription form and in an OTC form Only prescription drugs are covered by your plan with the exception of some insulins insulin supplies and some covered preventive drugs

ST Step Therapy You must first try another specific drug(s) before these drugs will be covered

How can I get an exception to the rules for drug coverage Your doctor can ask for an exception to our rules for drug coverage

Your doctor can ask us to cover your drug even if it is not on the drug list If we approve an exception request for a drug not on the drug list the non-preferred brand tier (Tier 3) or Specialty copaymentcoinsurance will apply

Your doctor can ask us to make an exception for limits on your drug For example if your drug has a quantity limit of 1 tablet per day your doctor can ask us to cover more

To request an exception your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-977-4170

Can I go to any pharmacy To get the best benefit you should use pharmacies that are in the network These pharmacies have a contract with Health Net Most chain pharmacies and many independent pharmacies are in the network To find a

iii

pharmacy near you visit our website at wwwhealthnetcom or call us at the telephone number on your Health Net ID card

If you fill your prescription at an out-of-network pharmacy the pharmacy may not be able to bill Health Net online so you may have to pay the full cost of your drug Unless it is an emergency your out-ofshynetwork prescription drug may not be covered

Some injectable and high cost drugs may be considered ldquospecialty drugsrdquo Unless otherwise noted these drugs must be obtained from one of Health Netrsquos Specialty Pharmacies

Can I use a mail order pharmacy You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs Maintenance drugs are those that you take daily and are needed for a long term condition To use the mail order pharmacy your doctor must provide new prescriptions that allow up to a 90-day supply of each drug Mail order forms are available on our website at wwwhealthnetcom or you may call us at the telephone number on your Health Net ID card to request a form

How can I save money on my prescription drugs You can save time and money with these simple steps Ask your doctor about generic drugs that may work for you Fill prescriptions at Health Net participating pharmacies Be sure your doctor prescribes drugs on the drug list

iv

pharmacy near you visit our website at wwwhealthnetcom or call us at the telephone number on your Health Net ID card

If you fill your prescription at an out-of-network pharmacy the pharmacy may not be able to bill Health Net online so you may have to pay the full cost of your drug Unless it is an emergency your out-ofshynetwork prescription drug may not be covered

Some injectable and high cost drugs may be considered ldquospecialty drugsrdquo Unless otherwise noted these drugs must be obtained from one of Health Netrsquos Specialty Pharmacies

Can I use a mail order pharmacy You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs Maintenance drugs are those that you take daily and are needed for a long term condition To use the mail order pharmacy your doctor must provide new prescriptions that allow up to a 90-day supply of each drug Mail order forms are available on our website at wwwhealthnetcom or you may call us at the telephone number on your Health Net ID card to request a form

How can I save money on my prescription drugs You can save time and money with these simple steps Ask your doctor about generic drugs that may work for you Fill prescriptions at Health Net participating pharmacies Be sure your doctor prescribes drugs on the drug list

iv

Health Net of Arizona Inc and Health Net Life Insurance Company (ldquoHealth Netrdquo) complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Health Net does not exclude people or treat them differently because of race color national origin age disability or sex

Health Net bull Provides free aids and services to people with disabilities to communicate effectively with us such as qualified sign language interpreters and written information in other formats (large print accessible electronic formats other formats)

bull Provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages

If you need these services contact Health Nets Customer Contact Center at IndividualFamily Plans 1-888-926-5057 (TTY 711) Arizona Marketplace Small Group Plans 1-888-926-5122 (TTY 711) Small Business Group plans and Large Employer Group Plans 1-800-289-2818 (TTY 711)

If you believe that Health Net has 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 by calling the number above and telling them you need help filing a grievance Health Nets Customer Contact Center is available to help you

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 (TDD 1-800ndash537ndash7697)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

EnglishNo Cost Language Services You can get an interpreter You can get documents read to you and some sent to you in your language For help call us at the number listed on your ID card Individual amp Family Planmembers please call 1-888-926-5057 (TTY 711) Small Business members please call 1-888-926-5122 (TTY 711) Employer group members please call 1-800-289-2818 (TTY 711)

Arabic

Chinese免費語言服務您可使用口譯員您可請人將文件內容唸給您聽如需協助請致電您會員卡上所列

的電話號碼與我們聯絡個人與家庭計畫的會員請致電 1-888-926-5057 (TTY 711) 小型企業的會員請致

電 1-888-926-5122 (TTY 711) 雇主團體的會員請致電 1-800-289-2818 (TTY 711)

French Aucun service linguistique avec coucirct Vous pouvez obtenir un interpregravete Les documents peuvent ecirctre lus pour vous Pour obtenir de lrsquoaide appelez-nous au numeacutero figurant sur votre carte drsquoidentiteacute Membres desprogrammes pour particuliers et familles veuillez composer le 1-888-926-5057 (TTY 711) Membres des programmes pour petites entreprises veuillez composer le 1-888-926-5122 (TTY 711) Membres du groupe drsquoemployeurs veuillez composer le 1-800-289-2818 (TTY 711)

German Kostenloser Sprachendienst Dolmetscher sind verfuumlgbar Dokumente koumlnnen Ihnen vorgelesen werden Wenn Sie Hilfe benoumltigen rufen Sie uns unter der Nummer auf Ihrer ID-Karte an Mitglieder von Einzel- und Familienpolicen rufen bitte unter 1-888-926-5057 (TTY 711) an Kleinunternehmen-Mitglieder rufen bitte unter 1-888-926-5122 (TTY 711) an Arbeitgeber-Gruppenmitglieder rufen bitte unter 1-800-289-2818 (TTY 711) an

Japanese無料の言語サービス通訳をご利用いただけます文書をお読みします援助が必要な場合はIDカードに記載されている番号までお電話ください個人および家族向けプランのメンバーの方は 1-888-926-5057 (TTY 711) まで小規模企業メンバーの方は1-888-926-5122 (TTY 711)までお電話ください雇用主を通じた団体保険のメンバーの方は1-800-289-2818 (TTY 711) までお電話ください

Korean 무료 언어 서비스 통역 서비스를 받을 수 있습니다 문서 낭독 서비스를 받으실 수 있습니다

도움을 원하시면 보험 ID에 수록된 번호로 전화해 주십시오 개인 및 가족 계획가입자분은

1-888-926-5057 (TTY 711) 번으로 전화해 주시고 소기업가입자분은 1-888-926-5122 (TTY 711) 번으로

전화해 주십시오 고용주 그룹 가입자분은 1-800-289-2818 (TTY 711) 번으로 전화해 주십시오

خدمات اللغة مجانية يمكنك الحصول على مترجم فوري ويمكنك الحصول على وثائق مقروءة لك للحصول على المساعدة اتصل بنا على( ويرجى1-888-926-5057 )TTY 711الرقم الموجود على بطاقة الهوية يرجى من أعضاء خطة الأفراد والعائلة الاتصال على الرقم

( يرجى من أعضاء مجموعة أصحاب العمل الاتصال1-888-926-5122 )TTY 711من أعضاء الأعمال الصغيرة الاتصال على الرقم TTY 711(2818-289-800-1 )على الرقم

Navajo Saad Bee k1 Ersquoeyeed Trsquo11 J77krsquoe Atarsquo halnersquo7g77 h0l= Trsquo11 h0 hazaad krsquoehj7 naaltsoos hachrsquo8rsquo w0ltah d00 [arsquo da hachrsquo8rsquo 4lrsquo88hSh7k1 arsquodoowo[ n7n7zingo naaltsoos bee n47horsquod0lzin7g77 bik1arsquogi b44sh

bee hanersquo7 bik11rsquo 1aj8rsquo hod77lnih Trsquo11 h0 d00 harsquo1[ch7n7 bi[ hakrsquo4rsquo4stirsquo7g77 koj8rsquo hojilnih

1-888-926-5057 (TTY 711) Small business dei[n7n7j7 atah n7l98go 47 koj8rsquo h0lnersquo 1-888-926-5122 (TTY 711) Employer group-j7 atah n7l98go 47 koj8rsquo hod77lnih 1-800-289-2818 (TTY 711)

Persian (Farsi) با شمارهکسب اطلاعات با ما به شماره ای که در کارت شناسايی شما قيد شده تماس بگيريد اعضای برنامه انفرادی و خانواده لطفا

TTY 711( 1-888-926-5057تماس بگ )د اعضای واحد بازرگانی کوچک با شمارهيريTTY 711( 1-888-926-5122تماس بگ )با شماره د اعضای گروه کارفرما لطفايري TTY 711( 1-800-289-2818تماس )

د يريبگ

Russian Бесплатная помощь переводчиков Вы можете получить помощь устного переводчика Вам могут прочитать документы За помощью обращайтесь к нам по телефону приведенному на вашейидентификационной карточке участника плана Участники планов для семей и частных лиц звоните по телефону 1-888-926-5057 (TTY 711) Участники планов для малых предприятий звоните по телефону 1-888-926-5122 (TTY 711) Участники групповых планов предоставляемых работодателем звоните по телефону 1-800-289-2818 (TTY 711)

Serbo-Croatian Besplatne jezičke usluge Možemo vam obezbediti tumača Možemo vam pročitati vaše dokumente Ukolikovam je potrebna pomoć nazovite broj napisan na vašoj zdravstvenoj kartici Molimo članove individualnog iporodičnog plana da nazovu 1-888-926-5057 (TTY 711) molimo članove malog preduzeća da nazovu 1-888-926-5122 (TTY 711) Molimo članove grupe osigurane preko poslodavca da nazovu 1-800-289-2818 (TTY 711)

SpanishServicios de idiomas sin costo Puede solicitar un inteacuterprete Puede obtener el servicio de lectura dedocumentos Para obtener ayuda llaacutemenos al nuacutemero que aparece en su tarjeta de identificacioacuten Los afiliadosde planes individuales y familiares deben llamar al 1-888-926-5057 (TTY 711) los afiliados de pequentildeas empresas deben llamar al 1-888-926-5122 (TTY 711) Los afiliados del grupo del empleador deben llamar al 1-800-289-2818 (TTY 711)

ܢ ܠܐ ܬܚ ܫܡܠSyriac (Assyrian)

ܐܪܬܝܗܐܩ ܟܬܘ ܦܐ ܛܫܕܛܬ ܡܐܢܡܬܕܚܕܗܬ ܡܐ( ܢ ܓܝ ܪܓܟܘܐܠܘܨܘܦ ܕܐܬ ܒܠܬܨ ܪܥ)ܕܠܢ ܡܐ ܠܐܡܣܒܢ ܬܕܒܐ ܕܗܢܝܐ ܪܨܘܦ ܕܗܝܐ ܬܩܥܐܡܢܝܢܥܢܠ

ܩܐܪܝܩܝܫܝܪ ܢܝܢܥܢ ܪܝܩܢܘ ܐܡܠ ܘܡܘܟܐܐ ܬܘܝܡܦܟܬܘܘܝܦܠ ܝܪܫܐ ܡܠ ܪܝܩ

1-888-926-5057(TTY 711) 5122-926-888-1ܠ ܥܢܘܡܪܝܩܢܘܘܟܠܐܡܣܒܢܐܐܪܬܘܙܥܐ ܬܪܘܓܕܬܐ ܬܘܪܡ(TTY 711)

)TTY 711( ܐܢܝܢܡܠ ܥܢܘܡܪܝܩܢܘܘܟܠܐܡܣܒܢܐܐ ܚܠܕܦܐ ܢܚܠܦܕܡܐ ܬܣܕܕܐ ܡܕܗ 1-800-289-2818

TagalogWalang Bayad na Mga Serbisyo sa Wika Makakakuha kayo ng isang interpreter Makakakuha kayo ng mga dokumento na babasahin sa inyo Para sa tulong tawagan kami sa nakalistang numero sa inyong ID cardPara sa mga miyembro ng Plano para sa Indibiduwal at Pamilya mangyaring tawagan ang1-888-926-5057 (TTY 711) Para sa mga miyembro na Maliit na Negosyo mangyaring tawagan ang 1-888-926-5122 (TTY 711) Para sa mga miyembro ng grupo ng empleyado mangyaring tawagan ang 1-800-289-2818 (TTY 711)

Thai ไมมคาบรการดานภาษา คณสามารถใชลามได คณสามารถใหอานเอกสารใหฟงได สาหรบความชวยเหลอ โทรหาเราตาม

หมายเลขทใหไวบนบตรประจาตวของคณ สมาชกแผนบคคลและครอบครว กรณาโทร 1-888-926-5057 (TTY 711) สมาชก

ธรกจขนาดเลก กรณาโทร 1-888-926-5122 (TTY 711) สมาชกกลมนายจาง กรณาโทร 1-800-289-2818 (TTY 711)

Vietnamese Caacutec Dịch Vụ Ngocircn Ngữ Miễn Phiacute Quyacute vị coacute thể coacute một phiecircn dịch viecircn Quyacute vị coacute thể yecircu cầu được đọc cho nghe tagravei liệu Để nhận trợ giuacutep hatildey gọi cho chuacuteng tocirci theo số được liệt kecirc trecircn thẻ ID của quyacute vị Caacutec thagravenh viecircn của Chương Trigravenh Caacute Nhacircn amp Gia Đigravenh vui lograveng gọi số 1-888-926-5057 (TTY 711) Caacutec thagravenh viecircn thuộc Doanh Nghiệp Nhỏ vui lograveng gọi số 1-888-926-5122 (TTY 711) Caacutec thagravenh viecircn thuộc chương trigravenh theo nhoacutem của chủ sử dụng lao động vui lograveng gọi số 1-800-289-2818 (TTY 711)

Health Net of Arizona Inc underwrites benefits for HMO plans and Health Net Life Insurance Company underwrites benefits for PPO and indemnity plans and for life insurance coverage Health Net of Arizona Inc and Health Net Life Insurance Company are subsidiaries of Health Net Inc All rights reserved

AZ Commercial On and Off-Exchange Member Notice of Language Assistance

FLY007786EH00 (0616)

Drug Name DrugTier

RequirementsLimits

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to TreatADHD Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine-Dextroamphetamine)

4

ADDERALL XR CP24 (Use Amphetamine-Dextroamphetamine)

4

ADZENYS XR-ODT TBED 4 PA

amphetamine sulfate tabs 4 PA

amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg25mg-25mg-25mg-25mg 75mg-75mg-75mg-75mg 125mg-125mg-125mg-125mg375mg-375mg-375mg-375mg 625mg-625mg-625mg-625mg

1

amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg25mg-25mg-25mg-25mg 75mg-75mg-75mg-75mg 125mg-125mg-125mg-125mg375mg-375mg-375mg-375mg 1875mg-1875mg-1875mg-1875mg 3125mg-3125mg-3125mg-3125mg

2

DESOXYN TABS (Use Methamphetamine HCl) 4

DEXEDRINE CP24 (Use DextroamphetamineSulfate)

4

dextroamphetamine sulfatecp24 5 mg 10 mg 15 mg 2

dextroamphetamine sulfatesoln 5 mg5ml 4

dextroamphetamine sulfatetabs 5 mg 10 mg 2

Drug Name DrugTier

RequirementsLimits

DYANAVEL XR SUER 4 PA QL(8 mldaily)

EVEKEO TABS (Use Amphetamine Sulfate) 4 PA

methamphetamine hcl tabs 4

PROCENTRA SOLN (Use DextroamphetamineSulfate)

4

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

3

VYVANSE CHEW 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG

3 QL(1 ea daily)

ZENZEDI TABS 4 PA

Analeptics caffeine citrate soln 1

Attention-DeficitHyperactivity Disorder (ADHD) atomoxetine hcl caps 10mg 18 mg 25 mg 40 mg 3 QL(2 ea daily)

atomoxetine hcl caps 60mg 80 mg 100 mg 3 QL(1 ea daily)

clonidine hcl (adhd) tb12 2 QL(4 ea daily)

guanfacine hcl (adhd) tb24 2 QL(1 ea daily)

INTUNIV TB24 (Use Guanfacine HCl (ADHD)) 4 QL(1 ea daily)

KAPVAY TB12 (Use Clonidine HCl (ADHD)) 4 QL(4 ea daily)

STRATTERA CAPS 10 MG 18 MG 25 MG 40 MG (Use Atomoxetine HCl)

4 QL(2 ea daily)

STRATTERA CAPS 60 MG 80 MG 100 MG (Use Atomoxetine HCl)

4 QL(1 ea daily)

Stimulants - Misc

APTENSIO XR CP24 4 PA QL(1 eadaily)

armodafinil tabs 3 PA

CONCERTA TBCR (Use Methylphenidate HCl) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

1

Drug Name DrugTier

RequirementsLimits

DAYTRANA PTCH 4

dexmethylphenidate hclcp24 5 mg 10 mg 15 mg20 mg 25 mg 30 mg 35mg 40 mg

4

dexmethylphenidate hcltabs 5 mg 10 mg 25 mg 1

FOCALIN TABS (Use Dexmethylphenidate HCl) 4

FOCALIN XR CP24 (Use Dexmethylphenidate HCl) 4

METADATE CD CPCR 10 MG 20 MG 30 MG (Use Methylphenidate HCl)

4 QL(1 ea daily)

METADATE CD CPCR 40 MG 50 MG 60 MG (Use Methylphenidate HCl)

4

METHYLIN CHEW 25 MG (Use Methylphenidate HCl) 4

METHYLIN CHEW 5 MG 10 MG (Use Methylphenidate HCl)

3

METHYLIN SOLN 5 MG5ML 10 MG5ML (Use Methylphenidate HCl)

4

methylphenidate hcl chew25 mg 4

methylphenidate hcl chew5 mg 10 mg 3

methylphenidate hcl cp2410 mg 4 QL(1 ea daily)

methylphenidate hcl cp2420 mg 30 mg 40 mg 3 QL(1 ea daily)

methylphenidate hcl cpcr10 mg 20 mg 30 mg 4 QL(1 ea daily)

methylphenidate hcl cpcr40 mg 50 mg 60 mg 4

methylphenidate hcl soln 5mg5ml 10 mg5ml 2

methylphenidate hcl tabs 5mg 10 mg 20 mg 1

methylphenidate hcl tb2427 mg 36 mg 54 mg 2

methylphenidate hcl tbcr 10mg 20 mg 1

Drug Name DrugTier

RequirementsLimits

methylphenidate hcl tbcr 18mg 27 mg 36 mg 54 mg 2

METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24

4 QL(1 ea daily)

METHYLPHENIDATE HYDROCHLORIDE ER TB24

4

modafinil tabs 4 ST

NUVIGIL TABS (Use Armodafinil) 4 PA

PROVIGIL TABS (Use Modafinil) 4 ST

QUILLICHEW ER CHER 4 PA

QUILLIVANT XR SUSR 4 PA QL(12 mldaily)

RITALIN LA CP24 (Use Methylphenidate HCl) 4 QL(1 ea daily)

RITALIN TABS (Use Methylphenidate HCl) 4

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections Aminoglycosides ARIKAYCE SUSP 4 PA

BETHKIS NEBU 4 Specialty Tier 3May Apply

GENTAMICIN SULFATE09 SODIUMCHLORIDE SOLN

3

KITABIS PAK NEBU 4

Specialty MayApply BrandTier 3 Generic Tier 1

neomycin sulfate tabs 1

paromomycin sulfate caps 2

TOBI NEBU (Use Tobramycin) 4

Specialty MayApply BrandTier 3 Generic Tier 1

TOBI PODHALER CAPS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

2

Drug Name DrugTier

RequirementsLimits

TOBRAMYCIN NEBU 4

Specialty MayApply BrandTier 3 Generic Tier 1

tobramycin nebu 1

Specialty MayApply BrandTier 3 Generic Tier 1

TOBRAMYCIN SULFATE SOLN 40 MGML J PA

tobramycin sulfate soln 40mgml 80 mg2ml 12gm30ml

J PA

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain Swelling Muscle and JointConditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

J PA SpecialtyTier 2 MayApply

HUMIRA PEN PNKT J PA SpecialtyTier 2 MayApply

HUMIRA PEN-CDUCHSSTARTER PNKT J

PA SpecialtyTier 2 MayApply

HUMIRA PEN-PSUVSTARTER PNKT J

PA SpecialtyTier 2 MayApply

HUMIRA PSKT J PA SpecialtyTier 2 MayApply

SIMPONI SOAJ J PA SpecialtyTier 2 MayApply

SIMPONI SOSY J PA SpecialtyTier 2 MayApply

Antirheumatic - Enzyme Inhibitors

XELJANZ TABS 4 PA SpecialtyTier 2 MayApply

XELJANZ XR TB24 4 PA

Antirheumatic Antimetabolites

Drug Name DrugTier

RequirementsLimits

OTREXUP SOAJ 10 MG04ML 15 MG04ML20 MG04ML 25MG04ML 75 MG04ML125 MG04ML

J

PA SpecialtyTier 2 MayApply

OTREXUP SOAJ 175 MG04ML 225 MG04ML J PA

RASUVO SOAJ J PA SpecialtyTier 2 MayApply

Gold Compounds RIDAURA CAPS 3

Interleukin-1 Blockers

ARCALYST SOLR J PA SpecialtyTier 4 MayApply

Interleukin-1beta Blockers

ILARIS SOLN J PA SpecialtyTier 3 MayApply

Interleukin-6 Receptor Inhibitors

ACTEMRA SOSY J PA SpecialtyTier 2 MayApply

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Use Naproxen Sodium) 4

ARTHROTEC 50 TBEC (Use Diclofenac wMisoprostol)

4

ARTHROTEC 75 TBEC (Use Diclofenac wMisoprostol)

4

CELEBREX CAPS (Use Celecoxib) 4 AL(At least 60

yrs old)

celecoxib caps 3 AL(At least 60yrs old)

DAYPRO TABS (Use Oxaprozin) 4

diclofenac potassium tabs 2

diclofenac sodium tb24 100 mg 1

diclofenac sodium tbec 25 mg 50 mg 75 mg 2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

3

Drug Name DrugTier

RequirementsLimits

diclofenac w misoprostoltbec 4

DUEXIS TABS 4 PA

EC-NAPROSYN TBEC (Use Naproxen) 4

etodolac caps 2

etodolac tabs 2

etodolac tb24 2

FELDENE CAPS (Use Piroxicam) 4

FENOPROFEN CALCIUM CAPS 200 MG 400 MG 4

fenoprofen calcium tabs600 mg 1

FENORTHO CAPS 4

flurbiprofen tabs 100 mg 1

flurbiprofen tabs 50 mg 2

ibuprofen tabs 1

INDOCIN SUPP 4

INDOCIN SUSP 4

indomethacin caps 1

indomethacin cpcr 1

KETOPROFEN CAPS 25 MG 4 PA

ketoprofen caps 50 mg 75 mg 1

KETOPROFEN CAPS 50 MG 75 MG 4

ketoprofen cp24 200 mg 3

ketorolac tromethamine tabs 1

QL(20 ea per180 daysretail20 ea per180 days mail)

LODINE TABS (Use Etodolac) 4

Drug Name DrugTier

RequirementsLimits

MECLOFENAMATE SODIUM CAPS 4

mefenamic acid caps 4

meloxicam tabs 15 mg 1 QL(1 ea daily)

meloxicam tabs 75 mg 1 QL(2 ea daily)

MOBIC TABS 15 MG (Use Meloxicam) 4 QL(1 ea daily)

MOBIC TABS 75 MG (Use Meloxicam) 4 QL(2 ea daily)

nabumetone tabs 2

NALFON CAPS 400 MG 4

NALFON TABS 600 MG (Use Fenoprofen Calcium) 4 PA

NAPRELAN TB24 375 MG 500 MG (Use NaproxenSodium)

4

NAPRELAN TB24 750 MG 4

NAPROSYN SUSP (Use Naproxen) 4

NAPROSYN TABS (Use Naproxen) 4

naproxen sodium tabs 275mg 550 mg 1

naproxen sodium tb24 375mg 500 mg 4

naproxen susp 125 mg5ml 1

naproxen tabs 250 mg 375mg 500 mg 1

naproxen tbec 375 mg 500 mg 2

oxaprozin tabs 1

piroxicam caps 1

PONSTEL CAPS (Use Mefenamic Acid) 4

PREVIDOLRX ANALGESIC PAK THPK 4 PA

SPRIX SOLN 4 QL(1 ea daily5day(s) limit)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

4

Drug Name DrugTier

RequirementsLimits

sulindac tabs 1

TIVORBEX CAPS 4 ST QL(3 eadaily)

TOLMETIN SODIUM CAPS 400 MG 4

tolmetin sodium tabs 200 mg 2

TOLMETIN SODIUM TABS 600 MG 4

VIMOVO TBEC 4 PA

VIVLODEX CAPS 4 PA

YBUPHEN TBPK 4 PA

ZIPSOR CAPS 4 ST QL(4 eadaily7 day(s)limit)

ZORVOLEX CAPS 4 ST QL(3 eadaily)

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS 4 PA SpecialtyTier 2 MayApply

OTEZLA TBPK 4 PA SpecialtyTier 2 MayApply

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) 4

leflunomide tabs 1

Selective Costimulation Modulators

ORENCIA CLICKJECT SOAJ J

PA SpecialtyTier 2 MayApply

ORENCIA SOSY J PA SpecialtyTier 2 MayApply

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL SOLR J PA SpecialtyTier 2 MayApply

Drug Name DrugTier

RequirementsLimits

ENBREL SOSY J PA SpecialtyTier 2 MayApply

ENBREL SURECLICK SOAJ J

PA SpecialtyTier 2 MayApply

ANALGESICS - NonNarcotic - Drugs to TreatPain Muscle and Joint Conditions Analgesic Combinations ALLZITAL TABS 4 PA

butalbital-acetaminophentabs 300mg-50mg 4

butalbital-acetaminophentabs 325mg-50mg 2

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

4

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

1

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

1

butalbital-aspirin-caffeine caps 1

BUTALBITALACETAMINOPHEN CAPS 4 PA

BUTALBITALASPIRINCAFFEINE TABS 4

DURAXIN CAPS 4

ESGIC TABS (Use Butalbital-Acetaminophen-Caffeine)

4

FIORICET CAPS (Use Butalbital-Acetaminophen-Caffeine)

4

FIORINAL CAPS (Use Butalbital-Aspirin-Caffeine) 4

TENCON TABS 4

VANATOL LQ SOLN 4

VANATOL S SOLN 4

Salicylates You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

5

Drug Name DrugTier

RequirementsLimits

choline amp mag salicylateliqd 2

diflunisal tabs 2

DISALCID TABS (Use Salsalate) 4

salsalate tabs 1

ANALGESICS - OPIOID - Drugs to Treat PainMuscle and Joint Conditions Opioid Agonists ABSTRAL SUBL 4 PA

ACTIQ LPOP (Use Fentanyl Citrate) 4 PA QL(3 ea

daily) codeine sulfate tabs 15 mg30 mg 60 mg 1

CODEINE SULFATE TABS 30 MG 60 MG (Use Codeine Sulfate)

4

CONZIP CP24 4

DEMEROL TABS (Use Meperidine HCl) 4

DILAUDID LIQD (Use Hydromorphone HCl) 4

DILAUDID TABS (Use Hydromorphone HCl) 4

DOLOPHINE TABS (Use Methadone HCl) 4

DURAGESIC PT72 (Use Fentanyl) 4

Limit 10 permonthQL(034ea daily)

EMBEDA CPCR 4 PA

EXALGO T24A 32 MG (Use Hydromorphone HCl) 4 QL(2 ea daily)

EXALGO T24A 8 MG 12 MG 16 MG (Use Hydromorphone HCl)

4 QL(4 ea daily)

fentanyl citrate lpop bu 200mcg 400 mcg 600 mcg800 mcg 1200 mcg 1600 mcg

1

PA QL(3 eadaily)

FENTANYL CITRATE SOSY IJ 50 MCG5ML 4 PA

Drug Name DrugTier

RequirementsLimits

FENTANYL CITRATE SOSY IV 1500 MCG30ML2750 MCG55ML

4 PA

FENTANYL CITRATESODIUMCHLORIDE SOSY

4 PA

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

2 Limit 10 permonthQL(034ea daily)

fentanyl pt72 375 mcghr625 mcghr 875 mcghr 4

Limit 10 permonthQL(034ea daily)

FENTORA TABS 4 PA

hydromorphone hcl liqd 1mgml 4

hydromorphone hcl t24a 32 mg 4 QL(2 ea daily)

hydromorphone hcl t24a8mg 8 mg 12 mg 16 mg 2 QL(4 ea daily)

hydromorphone hcl tabs 2mg 4 mg 8 mg 1

HYSINGLA ER T24A 4 PA

IONSYS PTCH 4 PA

KADIAN CP24 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 80 MG 100 MG (Use Morphine Sulfate)

4

KADIAN CP24 200 MG 4

LAZANDA SOLN 4 PA

levorphanol tartrate tabs 4 PA

meperidine hcl soln 2

meperidine hcl tabs 2

methadone hcl conc 10 mgml 2

methadone hcl soln 10 mg5ml 1

methadone hcl soln 5 mg5ml 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

6

Drug Name DrugTier

RequirementsLimits

METHADONE HCL SOLN 5 MG5ML (Use Methadone HCl)

4

methadone hcl tabs 5 mg10 mg 1

methadone hcl tbso 40 mg 2

morphine sulfate cp24 or10 mg 20 mg 30 mg 50mg 60 mg 80 mg 100 mg

3

morphine sulfate cp24 or40 mg 4

MORPHINE SULFATE ER CP24 2 QL(1 ea daily)

morphine sulfate soln or 20mgml 10 mg5ml 20mg5ml 100 mg5ml

2

morphine sulfate supp re20 mg 1

MORPHINE SULFATE SUPP RE 5 MG 10 MG 30 MG

4

morphine sulfate tabs or 15mg 30 mg 2

morphine sulfate tbcr or 15mg 30 mg 60 mg 100 mg200 mg

3

MORPHINE SULFATESODIUMCHLORIDE SOSY

4 PA

MS CONTIN TBCR (Use Morphine Sulfate) 4

NUCYNTA ER TB12 2 QL(2 ea daily)

NUCYNTA TABS 2

OPANA ER (CRUSH RESISTANT) T12A 2 QL(2 ea daily)

OPANA TABS (Use Oxymorphone HCl) 4

OXAYDO TABA 4 QL(4 ea daily)

oxycodone hcl caps 5 mg 1

oxycodone hcl conc 100mg5ml 2

Drug Name DrugTier

RequirementsLimits

OXYCODONE HCL ER T12A 4 PA QL(3 ea

daily) oxycodone hcl soln 5mg5ml 2

oxycodone hcl tabs 5 mg10 mg 15 mg 20 mg 30 mg

1

OXYCONTIN T12A 4 PA QL(3 eadaily)

oxymorphone hcl tabs 5mg 10 mg 1

oxymorphone hcl tb12 5mg 10 mg 15 mg 20 mg30 mg 40 mg 75 mg

1 QL(2 ea daily)

ROXICODONE TABS (Use Oxycodone HCl) 4

ROXYBOND TABA 4 QL(4 ea daily)

SUBSYS LIQD 4 PA

TRAMADOL HCL ER CP24 4

tramadol hcl tabs 50 mg 1 QL(8 ea daily)

tramadol hcl tb24 100 mg200 mg 300 mg 4

tramadol hcl tb24 100 mg200 mg 300 mg 4 QL(1 ea daily)

ULTRAM TABS (Use Tramadol HCl) 4 QL(8 ea daily)

XTAMPZA ER C12A 4 PA

ZOHYDRO ER C12A 4 PA

Opioid Combinations acetaminophen w codeinesoln 1

acetaminophen w codeinetabs 1

ASPIRIN-CAFFEINE-DIHYDROCODEINE CAPS 4

butalbital-acetaminophen-caffeine w codeine caps300mg-50mg-40mg-30mg

4

butalbital-acetaminophen-caffeine w codeine caps325mg-50mg-40mg-30mg

2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

7

Drug Name DrugTier

RequirementsLimits

butalbital-aspirin-caffeinewcod caps 2

CAPITALCODEINE SUSP 4

FIORICETCODEINECAPS (Use Butalbital-Acetaminophen-Caffeinew Codeine)

4

FIORINALCODEINE 3CAPS (Use Butalbital-Aspirin-Caffeine wCod)

4

HYDROCODONE BITARTRATEACETAMINOPHEN SOLN

4

hydrocodone-acetaminophen soln10mg15ml-325mg15ml

4

hydrocodone-acetaminophen soln25mg5ml-108mg5ml5mg10ml-217mg10ml75mg15ml-325mg15ml

1

hydrocodone-acetaminophen tabs25mg-325mg

4

hydrocodone-acetaminophen tabs 5mg-300mg 10mg-300mg75mg-300mg

2

hydrocodone-acetaminophen tabs 5mg-325mg 10mg-325mg75mg-325mg

1

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

1

hydrocodone-ibuprofentabs 200mg-75mg 2

LORTAB ELIX 4

MEPERIDINE HCLPROMETHAZINEHCL CAPS

4

NALOCET TABS 3

NORCO TABS (Use Hydrocodone-Acetaminophen)

4

Drug Name DrugTier

RequirementsLimits

oxycodone wacetaminophen tabs 1

OXYCODONEACETAMINOPHEN SOLN 4

OXYCODONEIBUPROFEN TABS 4

PERCOCET TABS (Use Oxycodone wAcetaminophen)

4

PRIMLEV TABS 3

REPREXAIN TABS (Use Hydrocodone-Ibuprofen) 4

SYNALGOS-DC CAPS 4

tramadol-acetaminophentabs 2

TYLENOLCODEINE 3TABS (Use Acetaminophenw Codeine)

4

TYLENOLCODEINE 4TABS (Use Acetaminophenw Codeine)

4

ULTRACET TABS (Use Tramadol-Acetaminophen) 4

VERDROCET TABS 4

XARTEMIS XR TBCR 4 PA

XODOL TABS (Use Hydrocodone-Acetaminophen)

4

ZAMICET SOLN 4

Opioid Partial Agonists BELBUCA FILM 4 QL(2 ea daily)

BUNAVAIL FILM 4 PA

buprenorphine hcl subl 2 PA

buprenorphine hcl-naloxone hcl dihydrate film 4 PA

buprenorphine hcl-naloxone hcl dihydrate subl 4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

8

Drug Name DrugTier

RequirementsLimits

buprenorphine ptwk 5mcghr 10 mcghr 15mcghr 20 mcghr

4 Limit 4 permonthQL(015ea daily)

BUPRENORPHINE PTWK 5 MCGHR 10 MCGHR15 MCGHR 20 MCGHR75 MCGHR

4

Limit 4 permonthQL(015ea daily)

butorphanol tartrate soln 4 QL(6 ml per fillretail18 ml perfill mail)

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

4

Limit 4 permonthQL(015ea daily)

BUTRANS PTWK 75 MCGHR 4

Limit 4 permonthQL(015ea daily)

pentazocine w naloxonetabs 2

SUBOXONE FILM 4 PA

ZUBSOLV SUBL 4 PA

ANDROGENS-ANABOLIC - Drugs to RegulateHormones Anabolic Steroids ANADROL-50 TABS 4

OXANDRIN TABS (Use Oxandrolone) 4

oxandrolone tabs 4

Androgens

ANDRODERM PT24 4 ST QL(1 eadaily)

ANDROGEL GEL 25 MG25GM 405MG25GM 2025MG125GM (Use Testosterone)

3

QL(10 gmdaily)

ANDROGEL GEL 50 MG5GM 3 QL(10 gm

daily) ANDROGEL PUMP GEL (Use Testosterone) 3 QL(10 gm

daily) ANDROID CAPS (Use Methyltestosterone) 4

Drug Name DrugTier

RequirementsLimits

ANDROXY TABS 3

AXIRON SOLN (Use Testosterone) 4 ST QL(6 ml

daily)

danazol caps 3

FIRST-TESTOSTERONE OINT 4 PA

FORTESTA GEL (Use Testosterone) 4

PA Limit 1 permonthQL(35gm daily)

METHITEST TABS 4

METHYLTESTOSTERONE CAPS 4

NATESTO GEL 4

PA Limit 21 grams permonthQL(074gm daily)

STRIANT MISC 4 QL(2 ea daily)

TESTIM GEL (Use Testosterone) 4 PA QL(10 gm

daily)

TESTONE CIK KIT J PA SpecialtyTier 1 MayApply

testosterone gel 1 4 PA QL(10 gmdaily)

testosterone gel 1 4 PA

testosterone gel 1 50mg5gm 25 mg25gm 1 QL(10 gm

daily) TESTOSTERONE GEL 1 50 MG5GM 25MG25GM

4 PA QL(10 gmdaily)

testosterone gel 162 405 mg25gm 2025mg125gm

3 QL(10 gmdaily)

testosterone gel 10 mgact 4 PA Limit 1 permonthQL(35gm daily)

TESTOSTERONE PUMP GEL 4 PA QL(10 gm

daily)

testosterone soln 30 mgact 4 ST QL(6 mldaily)

TESTRED CAPS (Use Methyltestosterone) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

9

Drug Name DrugTier

RequirementsLimits

VOGELXO GEL 4 PA QL(10 gmdaily)

VOGELXO PUMP GEL 4 PA QL(10 gmdaily)

XYOSTED SOAJ 4 PA

ANORECTAL AGENTS - Rectal Drugs to TreatPain Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone(Intrarectal))

4

CORTIFOAM FOAM 3

hydrocortisone (intrarectal) enem 1

UCERIS FOAM RE 2 MGACT 4 PA

Rectal Combinations ANALPRAM HC CREA (Use HydrocortisoneAcetate w Pramoxine)

4

ANALPRAM HC SINGLES CREA (Use HydrocortisoneAcetate w Pramoxine)

4

ANALPRAM-HC CREA 1-1 (Use Hydrocortisone Acetate wPramoxine)

4

ANALPRAM-HC LOTN 1-25 3

hydrocortisone acetate wpramoxine crea 1-1 1

hydrocortisone acetate wpramoxine crea 1-25 2

lidocaine-hydrocortisoneacetate (rectal) kit 1

PROCORT CREA 4

PROCTOFOAM HC FOAM 3

Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) 4

hydrocortisone (rectal) crea 1

Drug Name DrugTier

RequirementsLimits

hydrocortisone acetate(rectal) supp 1

PROCTOCORT SUPP (Use HydrocortisoneAcetate (Rectal))

4

Vasodilating Agents RECTIV OINT 4

ANTHELMINTICS - Drugs to Treat WormInfections Anthelmintics albendazole tabs 1

ALBENZA TABS (Use Albendazole) 3

BILTRICIDE TABS (Use Praziquantel) 3

EMVERM CHEW 3

ivermectin tabs 1

praziquantel tabs 1

STROMECTOL TABS (Use Ivermectin) 4

ANTI-INFECTIVE AGENTS - MISC - Drugs toTreat Bacterial Infections Anti-infective Agents - Misc FLAGYL CAPS (Use Metronidazole) 4

FLAGYL TABS (Use Metronidazole) 4

IMPAVIDO CAPS 4

metronidazole caps 1

metronidazole in nacl soln 3

metronidazole tabs 1

NEBUPENT SOLR 2

PRIMSOL SOLN 3

TINDAMAX TABS (Use Tinidazole) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

10

Drug Name DrugTier

RequirementsLimits

tinidazole tabs 4

trimethoprim tabs 1

TRIMPEX SOLN 3

XIFAXAN TABS 4 PA

Anti-infective Misc - Combinations BACTRIM DS TABS (Use Sulfamethoxazole-Trimethoprim)

4

BACTRIM TABS (Use Sulfamethoxazole-Trimethoprim)

4

sulfamethoxazole-trimethoprim susp 1

sulfamethoxazole-trimethoprim tabs 1

Antiprotozoal Agents ALINIA SUSR 4

ALINIA TABS 4

atovaquone susp 1

MEPRON SUSP (Use Atovaquone) 4

Carbapenems DORIBAX SOLR 3

DORIPENEM SOLR 3

meropenem solr 3

MERREM SOLR (Use Meropenem) 3

Glycopeptides VANCOMYCIN HYDROCHLORIDE SOLR 4 PA

VANCOMYCIN HYDROCHLORIDEDEXTROSE SOLN

4 PA

Glycylcyclines TIGECYCLINE SOLR 3

Drug Name DrugTier

RequirementsLimits

tigecycline solr 3

TYGACIL SOLR (Use Tigecycline) 3

Leprostatics dapsone tabs 1

Lincosamides CLEOCIN CAPS OR 75 MG 150 MG 300 MG (Use Clindamycin HCl)

4

CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin PalmitateHydrochloride)

4

clindamycin hcl caps 1

clindamycin palmitatehydrochloride solr 1

Oxazolidinones linezolid susr 2

linezolid tabs 2

SIVEXTRO TABS 2 QL(6 ea per 90days retail)

ZYVOX SUSR (Use Linezolid) 4

ZYVOX TABS (Use Linezolid) 4

Streptogramins SYNERCID SOLR 3

ANTIANGINAL AGENTS - Drugs to Treat ChestPain Antianginals-Other RANEXA TB12 4

Nitrates DILATRATE SR CPCR 4

ISORDIL TITRADOSE TABS 40 MG 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

11

Drug Name DrugTier

RequirementsLimits

ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate)

4

ISOSORBIDE DINITRATE ER TBCR 4

isosorbide dinitrate tabs 1

isosorbide mononitrate tabs 10 mg 20 mg 2

isosorbide mononitrate tb24 30 mg 60 mg 120 mg 1

NITRO-BID OINT 3

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

4

NITRO-DUR PT24 03 MGHR 08 MGHR 2

nitroglycerin cpcr 1

NITROGLYCERIN LINGUAL AERS 4

nitroglycerin pt24 1

nitroglycerin soln 1

nitroglycerin subl 1

NITROLINGUAL PUMPSPRAY SOLN (Use Nitroglycerin)

4

NITROMIST AERS 4

NITROSTAT SUBL (Use Nitroglycerin) 3

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc buspirone hcl tabs 5 mg10 mg 15 mg 30 mg 2

buspirone hcl tabs 75 mg 3

hydroxyzine hcl syrp 1

hydroxyzine hcl tabs 1

Drug Name DrugTier

RequirementsLimits

hydroxyzine pamoate caps 1

meprobamate tabs 2

VISTARIL CAPS (Use Hydroxyzine Pamoate) 4

Benzodiazepines ALPRAZOLAM INTENSOL CONC 3

alprazolam tabs 025 mg05 mg 1 mg 2 mg 1

alprazolam tb24 05 mg 1mg 2 mg 3 mg 1

alprazolam tbdp 025 mg05 mg 1 mg 2 mg 4

ATIVAN TABS (Use Lorazepam) 4 PA

chlordiazepoxide hcl caps 1

clorazepate dipotassiumtabs 2

diazepam conc or 5 mgml 4

DIAZEPAM SOLN OR 5 MG5ML 4

diazepam tabs or 2 mg 5mg 10 mg 1

lorazepam conc 2 mgml 4

lorazepam tabs 05 mg 1mg 2 mg 1

oxazepam caps 10 mg 15mg 30 mg 1

OXAZEPAM CAPS 30 MG 4

TRANXENE T TABS (Use Clorazepate Dipotassium) 4

VALIUM TABS (Use Diazepam) 4

XANAX TABS (Use Alprazolam) 4

XANAX XR TB24 (Use Alprazolam) 4

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms Antiarrhythmics Type I-A

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

12

Drug Name DrugTier

RequirementsLimits

disopyramide phosphate caps 2

NORPACE CAPS (Use Disopyramide Phosphate) 4

NORPACE CR CP12 100 MG 3

NORPACE CR CP12 150 MG 4

quinidine gluconate tbcr 2

QUINIDINE SULFATE TABS 4

Antiarrhythmics Type I-B mexiletine hcl caps 150 mg 2

mexiletine hcl caps 200mg 250 mg 1

Antiarrhythmics Type I-C flecainide acetate tabs 2

propafenone hcl cp12 225mg 325 mg 2

propafenone hcl cp12 425 mg 3

propafenone hcl tabs 150mg 225 mg 300 mg 2

RYTHMOL SR CP12 (Use Propafenone HCl) 4

Antiarrhythmics Type III amiodarone hcl tabs 1

dofetilide caps 3

MULTAQ TABS 3

TIKOSYN CAPS (Use Dofetilide) 3

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu 1

Antiasthmatic - Monoclonal Antibodies NUCALA SOLR J PA

Drug Name DrugTier

RequirementsLimits

XOLAIR SOLR J PA SpecialtyTier 3 MayApply

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 2

Limit 2 inhalers permonthQL(086gm daily)

INCRUSE ELLIPTA AEPB 2 QL(1 ea daily)

ipratropium bromide soln 1

SEEBRI NEOHALER CAPS 4 QL(2 ea daily)

SPIRIVA HANDIHALER CAPS 2 QL(1 ea daily)

SPIRIVA RESPIMAT AERS 2

Limit 1 inhaler permonthQL(014gm daily)

TUDORZA PRESSAIR AEPB 4

ST Limit 1 inhaler permonthQL(004ea daily)

YUPELRI SOLN 4 PA

Leukotriene Modulators ACCOLATE TABS (Use Zafirlukast) 4

montelukast sodium chew 4 mg 1

QL(1 ea daily)AL(Up to 12 yrsold )

montelukast sodium chew 5 mg 1

QL(1 ea daily)AL(Up to 14 yrsold )

montelukast sodium pack 4 mg 1

QL(1 ea daily)AL(Up to 12 yrsold )

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

SINGULAIR CHEW 4 MG (Use Montelukast Sodium) 4

QL(1 ea daily)AL(Up to 12 yrsold )

SINGULAIR CHEW 5 MG (Use Montelukast Sodium) 4

QL(1 ea daily)AL(Up to 14 yrsold )

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

13

Drug Name DrugTier

RequirementsLimits

SINGULAIR PACK 4 MG (Use Montelukast Sodium) 4

QL(1 ea daily)AL(Up to 12 yrsold )

SINGULAIR TABS 10 MG (Use Montelukast Sodium) 4 QL(1 ea daily)

zafirlukast tabs 1

zileuton tb12 4 ST

ZYFLO CR TB12 (Use Zileuton) 4 ST

ZYFLO TABS 4 ST

Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TABS 4 QL(1 ea daily)

Steroid Inhalants

AEROSPAN AERS 2

Limit 2 inhalers permonthQL(06gm daily)

ALVESCO AERS 4

Limit 2 inhalers permonthQL(041gm daily)

ARNUITY ELLIPTA AEPB 2 QL(1 ea daily)

ASMANEX HFA AERO 2

Limit 1 inhaler permonthQL(044gm daily)

ASMANEX TWISTHALER 120 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

ASMANEX TWISTHALER 14 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

ASMANEX TWISTHALER 30 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

ASMANEX TWISTHALER 60 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

Drug Name DrugTier

RequirementsLimits

ASMANEX TWISTHALER 7 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

budesonide (inhalation)susp 025 mg2ml 2 QL(8 ml daily)

budesonide (inhalation)susp 05 mg2ml 1 mg2ml 2 QL(4 ml daily)

FLOVENT DISKUS AEPB 100 MCGBLIST 2 QL(20 ea daily)

FLOVENT DISKUS AEPB 250 MCGBLIST 2 QL(8 ea daily)

FLOVENT DISKUS AEPB 50 MCGBLIST 2 QL(40 ea daily)

FLOVENT HFA AERO 110 MCGACT 220 MCGACT 2

Limit 2 inhalers permonthQL(08gm daily)

FLOVENT HFA AERO 44 MCGACT 2

Limit 1 inhaler permonthQL(036gm daily)

PULMICORT FLEXHALER AEPB 180 MCGACT 2

Limit 2 inhalers permonthQL(007ea daily)

PULMICORT FLEXHALER AEPB 90 MCGACT 2

Limit 4 inhalers permonthQL(027ea daily)

PULMICORT SUSP 025 MG2ML (Use Budesonide (Inhalation))

4 QL(8 ml daily)

PULMICORT SUSP 05 MG2ML 1 MG2ML (Use Budesonide (Inhalation))

4 QL(4 ml daily)

QVAR AERS 40 MCGACT 2

Limit 3 Inhalers per Month-73g pkg Limit2 Inhalers perMonth-87 pkgQL(058gm daily)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

14

Drug Name DrugTier

RequirementsLimits

QVAR AERS 80 MCGACT 2

Limit 2 Inhalers per Month-73g pkg 1Inhaler perMonth-87 pkgQL(029gm daily)

Sympathomimetics ADVAIR DISKUS AEPB 2 QL(2 ea daily)

ADVAIR HFA AERO 2

Limit 1 inhaler permonthQL(04gm daily)

AIRDUO RESPICLICK 5514 AEPB 4 QL(004 ea

daily) ALBUTEROL SULFATE ER TB12 4

albuterol sulfate nebu in 063 mg3ml 0083 05 125 mg3ml

1

albuterol sulfate syrp or 2mg5ml 1

albuterol sulfate tabs or 2 mg 4 mg 1

albuterol sulfate tb12 or 4 mg 8 mg 2

ANORO ELLIPTA AEPB 2 QL(2 ea daily)

ARCAPTA NEOHALER CAPS 4 QL(1 ea daily)

BEVESPI AEROSPHERE AERO 4 QL(036 gm

daily)

BREO ELLIPTA AEPB 2 QL(2 ea daily)

BROVANA NEBU 4

COMBIVENT RESPIMAT AERS 4

Limit 1 inhaler permonthQL(02gm daily)

DULERA AERO 2

Limit 1 inhaler permonthQL(045gm daily)

ipratropium-albuterol soln 1

Drug Name DrugTier

RequirementsLimits

levalbuterol hcl nebu 1

levalbuterol tartrate aero 2

metaproterenol sulfate syrp 1

metaproterenol sulfate tabs 1

PERFOROMIST NEBU 3 QL(4 ml daily)

PROAIR HFA AERS 4

PROAIR RESPICLICK AEPB 4

PROVENTIL HFA AERS 2

SEREVENT DISKUS AEPB 2 QL(2 ea daily)

STIOLTO RESPIMAT AERS 2

Limit 1 inhaler permonthQL(014gm daily)

STRIVERDI RESPIMAT AERS 2

Limit 1 inhaler permonthQL(014gm daily)

SYMBICORT AERO 2

Limit 1 inhaler permonthQL(034gm daily)

terbutaline sulfate tabs 2

UTIBRON NEOHALER CAPS 4 QL(2 ea daily)

VENTOLIN HFA AERS 4

VOSPIRE ER TB12 (Use Albuterol Sulfate) 4

XOPENEX CONCENTRATE NEBU (Use Levalbuterol HCl)

4

XOPENEX HFA AERO 2

XOPENEX NEBU (Use Levalbuterol HCl) 4

Xanthines aminophylline soln 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

15

Drug Name DrugTier

RequirementsLimits

ELIXOPHYLLIN ELIX 4

THEO-24 CP24 3

theophylline soln 80mg15ml 4

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) 4

warfarin sodium tabs 1

Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS 2

ELIQUIS TABS 2

SAVAYSA TABS 4

XARELTO STARTER PACK TBPK 2

XARELTO TABS 2

Heparins And Heparinoid-Like Agents

ARIXTRA SOLN 5 MG04ML 10 MG08ML25 MG05ML (Use Fondaparinux Sodium)

J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

ARIXTRA SOLN 75 MG06ML (Use Fondaparinux Sodium)

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

enoxaparin sodium soln ij300 mg3ml J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

Drug Name DrugTier

RequirementsLimits

enoxaparin sodium soln sc100 mgml 30 mg03ml40 mg04ml 60 mg06ml80 mg08ml 120 mg08ml

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

enoxaparin sodium soln sc150 mgml J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

fondaparinux sodium soln 5mg04ml 10 mg08ml 25mg05ml

J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

fondaparinux sodium soln75 mg06ml J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

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

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

FRAGMIN SOLN 95000 UNIT38ML J QL(20 ml per

10 days retail)

heparin (porcine) in sodiumchloride soln J

PA SpecialtyTier 1 MayApply

HEPARIN LOCK FLUSH SOLN J

PA SpecialtyTier 1 MayApply

heparin sod (porcine) ind5w soln J

PA SpecialtyTier 1 MayApply

heparin sodium (porcine)lock flush amp nacl lock flush kit

J PA SpecialtyTier 1 MayApply

heparin sodium (porcine)lock flush soln J

PA SpecialtyTier 1 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

16

Drug Name DrugTier

RequirementsLimits

heparin sodium (porcine)soln J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUM SOSY IV 4 PA

HEPARIN SODIUMD5WSOLN J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMDEXTROSESOLN

J PA SpecialtyTier 1 MayApply

HEPARIN SODIUMNACL045 SOLN J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMSODIUMCHLORIDE 09 SOLN (Use Heparin (Porcine) in Sodium Chloride)

J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMSODIUMCHLORIDE SOLN IJ 2UNITML-09

J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMSODIUMCHLORIDE SOSY IV 100UNIT50ML-09

4

PA SpecialtyTier 1 MayApply

LOVENOX SOLN IJ 300 MG3ML (Use EnoxaparinSodium)

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

LOVENOX SOLN SC 100 MGML 30 MG03ML 40MG04ML 60 MG06ML80 MG08ML 120MG08ML (Use Enoxaparin Sodium)

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

LOVENOX SOLN SC 150 MGML (Use EnoxaparinSodium)

J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

SASH KIT FOR FLUSHING VASCULAR ACCESS DEVICES KIT

J PA SpecialtyTier 1 MayApply

Thrombin Inhibitors

Drug Name DrugTier

RequirementsLimits

IPRIVASK SOLR J

Specialty Tier 1MayApplyQL(24 eaper 12 daysretail)

PRADAXA CAPS 4

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists FYCOMPA SUSP 4

FYCOMPA TABS 4

Anticonvulsants - Benzodiazepines clobazam susp 4

clobazam tabs 4

clonazepam tabs 05 mg 1mg 2 mg 1

clonazepam tbdp 0125mg 025 mg 05 mg 1 mg2 mg

2

DIASTAT ACUDIAL GEL 10 MG 2

Limit 4 boxes (8 syringes) per30 days

DIASTAT ACUDIAL GEL 20 MG 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

DIASTAT PEDIATRIC GEL 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

diazepam (anticonvulsant)gel 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

DIAZEPAM GEL RE 20 MG 25 MG 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

17

Drug Name DrugTier

RequirementsLimits

DIAZEPAM RECTAL GEL GEL 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

KLONOPIN TABS (Use Clonazepam) 4

ONFI SUSP (Use Clobazam) 4

ONFI TABS (Use Clobazam) 4

SYMPAZAN FILM 4 PA

Anticonvulsants - Misc APTIOM TABS 200 MG 400 MG 600 MG 4 QL(2 ea daily)

APTIOM TABS 800 MG 4 QL(1 ea daily)

BANZEL SUSP 3

BANZEL TABS 3

BRIVIACT SOLN 4 PA

BRIVIACT TABS 4 PA

carbamazepine chew 100 mg 1

carbamazepine cp12 100mg 200 mg 300 mg 1

carbamazepine susp 100mg5ml 1

carbamazepine tabs 200 mg 1

carbamazepine tb12 100 mg 1

carbamazepine tb12 200mg 400 mg 2

CARBATROL CP12 (Use Carbamazepine) 4

EPIDIOLEX SOLN 4 PA

gabapentin caps 2

gabapentin soln 2

Drug Name DrugTier

RequirementsLimits

gabapentin tabs 2

KEPPRA SOLN (Use Levetiracetam) 4

KEPPRA TABS (Use Levetiracetam) 4

KEPPRA XR TB24 (Use Levetiracetam) 4

LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine)

4

LAMICTAL ODT KIT 4 PA

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

4 PA

LAMICTAL STARTERNOTTAKING CARBAMAZEPINE KIT (Use Lamotrigine)

4

LAMICTAL STARTERTAKINGCARBAMAZEPINENOTTAKING VALPROATE KIT (Use Lamotrigine)

4

LAMICTAL STARTERTAKINGVALPROATE KIT (Use Lamotrigine)

4

LAMICTAL TABS (Use Lamotrigine) 4

LAMICTAL XR KIT 4 PA

LAMICTAL XR TB24 25 MG 50 MG 100 MG 200 MG 250 MG 300 MG (Use Lamotrigine)

4

PA

lamotrigine chew 5 mg 25 mg 3

lamotrigine kit 4 PA

lamotrigine kit 25 mg 4

lamotrigine tabs 25 mg100 mg 150 mg 200 mg 1

lamotrigine tb24 25 mg 50mg 100 mg 200 mg 250mg 300 mg

4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

18

Drug Name DrugTier

RequirementsLimits

lamotrigine tbdp 25 mg 50mg 100 mg 200 mg 4 PA

levetiracetam soln 100 mgml 500 mg5ml 2

levetiracetam tabs 250 mg500 mg 750 mg 1000 mg 3

levetiracetam tb24 500 mg750 mg 3

LYRICA CAPS 150 MG 225 MG 300 MG 4 PA QL(2 ea

daily) LYRICA CAPS 25 MG 50 MG 75 MG 100 MG 200 MG

4 PA QL(3 eadaily)

LYRICA SOLN 20 MGML 4 PA QL(30 mldaily)

MYSOLINE TABS (Use Primidone) 4

NEURONTIN CAPS (Use Gabapentin) 4

NEURONTIN SOLN (Use Gabapentin) 4

NEURONTIN TABS (Use Gabapentin) 4

oxcarbazepine susp 3

oxcarbazepine tabs 3

OXTELLAR XR TB24 4 ST

POTIGA TABS 4

primidone tabs 1

QUDEXY XR CS24 4 PA

SPRITAM TB3D 4 PA

TEGRETOL SUSP (Use Carbamazepine) 4

TEGRETOL TABS (Use Carbamazepine) 4

TEGRETOL-XR TB12 100 MG (Use Carbamazepine) 3

TEGRETOL-XR TB12 200 MG 400 MG (Use Carbamazepine)

4

Drug Name DrugTier

RequirementsLimits

TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate)

4

TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate)

3

TOPAMAX TABS (Use Topiramate) 4

topiramate cpsp 15 mg 25 mg 3

TOPIRAMATE ER CS24 4 PA

topiramate tabs 25 mg 50mg 100 mg 200 mg 2

TRILEPTAL SUSP (Use Oxcarbazepine) 4

TRILEPTAL TABS (Use Oxcarbazepine) 4

TROKENDI XR CP24 4 PA

VIMPAT SOLN 2

VIMPAT TABS 2

ZONEGRAN CAPS (Use Zonisamide) 4

zonisamide caps 3

Carbamates felbamate susp 3

felbamate tabs 3

FELBATOL SUSP (Use Felbamate) 4

FELBATOL TABS (Use Felbamate) 4

GABA Modulators GABITRIL TABS 12 MG 16 MG (Use TiagabineHCl)

3

GABITRIL TABS 2 MG 4 MG (Use Tiagabine HCl) 4

SABRIL PACK (Use Vigabatrin) 3

SABRIL TABS 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

19

Drug Name DrugTier

RequirementsLimits

tiagabine hcl tabs 12 mg16 mg 3

tiagabine hcl tabs 2 mg 4 mg 1

vigabatrin pack 3

Hydantoins DILANTIN CAPS 100 MG (Use Phenytoin SodiumExtended)

4

DILANTIN CAPS 30 MG 4

DILANTIN INFATABS CHEW (Use Phenytoin) 4

DILANTIN-125 SUSP (Use Phenytoin) 4

PEGANONE TABS 4

PHENYTEK CAPS (Use Phenytoin SodiumExtended)

4

phenytoin chew 1

phenytoin sodium extendedcaps 100 mg 1

phenytoin sodium extendedcaps 200 mg 300 mg 4

phenytoin susp 1

Succinimides CELONTIN CAPS 3

ethosuximide caps 2

ethosuximide soln 2

ZARONTIN CAPS (Use Ethosuximide) 4

ZARONTIN SOLN (Use Ethosuximide) 4

Valproic Acid DEPAKENE CAPS (Use Valproic Acid) 4

DEPAKENE SOLN (Use Valproate Sodium) 4

Drug Name DrugTier

RequirementsLimits

DEPAKOTE ER TB24 (Use Divalproex Sodium) 4

DEPAKOTE SPRINKLES CSDR (Use DivalproexSodium)

4

DEPAKOTE TBEC (Use Divalproex Sodium) 4

divalproex sodium csdr 125 mg 1

divalproex sodium tb24 250mg 500 mg 2

divalproex sodium tbec 125mg 250 mg 500 mg 1

valproate sodium soln 1

valproic acid caps 1

ANTIDEPRESSANTS - Drugs to TreatDepression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 2

mirtazapine tbdp 2

REMERON SOLTAB TBDP (Use Mirtazapine) 4

REMERON TABS (Use Mirtazapine) 4

Antidepressants - Misc

APLENZIN TB24 4 PA QL(1 eadaily)

bupropion hcl tabs 2

bupropion hcl tb12 2

bupropion hcl tb24 2

BUPROPION HYDROCHLORIDE ER TB24

4 ST QL(1 eadaily)

FORFIVO XL TB24 4 ST QL(1 eadaily)

maprotiline hcl tabs 25 mg 2

MAPROTILINE HCL TABS 50 MG 75 MG 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

20

Drug Name DrugTier

RequirementsLimits

WELLBUTRIN SR TB12 (Use Bupropion HCl) 4

WELLBUTRIN XL TB24 (Use Bupropion HCl) 4 PA

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 4

MARPLAN TABS 3

NARDIL TABS (Use Phenelzine Sulfate) 3

PARNATE TABS (Use Tranylcypromine Sulfate) 4

phenelzine sulfate tabs 3

tranylcypromine sulfatetabs 2

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

4 QL(4 ea daily)

CELEXA TABS 20 MG (Use CitalopramHydrobromide)

4 QL(2 ea daily)

CELEXA TABS 40 MG (Use CitalopramHydrobromide)

4 QL(1 ea daily)

citalopram hydrobromidesoln 10 mg5ml 1 QL(20 ml daily)

citalopram hydrobromidetabs 10 mg 1 QL(4 ea daily)

citalopram hydrobromidetabs 20 mg 1 QL(2 ea daily)

citalopram hydrobromidetabs 40 mg 1 QL(1 ea daily)

escitalopram oxalate soln 1

escitalopram oxalate tabs 1

FLUOXETINE DR CPDR 4

fluoxetine hcl caps 10 mg20 mg 40 mg 1

fluoxetine hcl soln 20 mg5ml 2

Drug Name DrugTier

RequirementsLimits

fluoxetine hcl tabs 10 mg20 mg 1

fluoxetine hcl tabs 60 mg 4 ST QL(1 eadaily)

FLUOXETINE HYDROCHLORIDE TABS 4 ST QL(1 ea

daily) FLUOXETINE HYDROCHLORIDE TABS (Use Fluoxetine HCl)

4 ST QL(1 eadaily)

fluvoxamine maleate cp24100 mg 150 mg 1

fluvoxamine maleate tabs 25 mg 50 mg 100 mg 2

LEXAPRO SOLN (Use Escitalopram Oxalate) 4

LEXAPRO TABS (Use Escitalopram Oxalate) 4

paroxetine hcl tabs 1

paroxetine hcl tb24 1

PAXIL CR TB24 (Use Paroxetine HCl) 4

PAXIL SUSP 10 MG5ML 4

PAXIL TABS 10 MG 20 MG 30 MG 40 MG (Use Paroxetine HCl)

4

PEXEVA TABS 10 MG 4

PEXEVA TABS 20 MG 30 MG 40 MG 4 QL(1 ea daily)

PROZAC CAPS (Use Fluoxetine HCl) 4

PROZAC WEEKLY CPDR (Use Fluoxetine HCl) 4

sertraline hcl conc 1

sertraline hcl tabs 1

ZOLOFT CONC (Use Sertraline HCl) 4

ZOLOFT TABS (Use Sertraline HCl) 4

Serotonin Modulators nefazodone hcl tabs 2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

21

Drug Name DrugTier

RequirementsLimits

NEFAZODONE HYDROCHLORIDE TABS 4

trazodone hcl tabs 1

TRINTELLIX TABS 4 ST QL(1 eadaily)

VIIBRYD STARTER PACK KIT 4 PA

VIIBRYD TABS 4 ST

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use Duloxetine HCl) 4

DESVENLAFAXINE ER TB24 50 MG 100 MG 4 ST QL(1 ea

daily) DESVENLAFAXINE ER TB24 50 MG 100 MG 4 ST

desvenlafaxine succinate tb24 2

duloxetine hcl cpep 20 mg30 mg 60 mg 2

duloxetine hcl cpep 40 mg 4 PA

EFFEXOR XR CP24 (Use Venlafaxine HCl) 4 QL(1 ea daily)

FETZIMA CP24 20 MG 4 ST QL(2 eadaily)

FETZIMA CP24 40 MG 80 MG 120 MG 4 ST QL(1 ea

daily) FETZIMA TITRATION PACK C4PK 4 ST

KHEDEZLA TB24 4 ST QL(1 eadaily)

PRISTIQ TB24 (Use Desvenlafaxine Succinate) 4

venlafaxine hcl cp24 75mg 150 mg 375 mg 1 QL(1 ea daily)

venlafaxine hcl tabs 25 mg50 mg 75 mg 100 mg375 mg

2

venlafaxine hcl tb24 75 mg150 mg 225 mg 375 mg 4

Tricyclic Agents amitriptyline hcl tabs 1

Drug Name DrugTier

RequirementsLimits

AMOXAPINE TABS 4

ANAFRANIL CAPS (Use Clomipramine HCl) 4

clomipramine hcl caps 1

desipramine hcl tabs 1

doxepin hcl caps 1

doxepin hcl conc 1

ELAVIL TABS (Use Amitriptyline HCl) 4

imipramine hcl tabs 1

imipramine pamoate caps100 mg 150 mg 4

imipramine pamoate caps125 mg 3

imipramine pamoate caps75 mg 1

NORPRAMIN TABS (Use Desipramine HCl) 4

nortriptyline hcl caps 1

nortriptyline hcl soln 1

PAMELOR CAPS (Use Nortriptyline HCl) 4

protriptyline hcl tabs 1

SURMONTIL CAPS (Use Trimipramine Maleate) 4

TOFRANIL TABS (Use Imipramine HCl) 4

trimipramine maleate caps 4

ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors acarbose tabs 2

GLYSET TABS (Use Miglitol) 3

miglitol tabs 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

22

Drug Name DrugTier

RequirementsLimits

PRECOSE TABS (Use Acarbose) 4

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN J PA SpecialtyTier 1 MayApply

SYMLINPEN 60 SOPN J PA SpecialtyTier 1 MayApply

Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl-Metformin HCl)

4

ACTOPLUS MET XR TB24 15MG-1000MG 4 QL(2 ea daily)

ACTOPLUS MET XR TB24 30MG-1000MG 4 QL(1 ea daily)

ALOGLIPTINMETFORMINHCL TABS 4

ALOGLIPTINPIOGLITAZONE TABS 4

DUETACT TABS (Use Pioglitazone HCl-Glimepiride)

4

glipizide-metformin hcl tabs 2

GLUCOVANCE TABS (Use Glyburide-Metformin) 4

glyburide-metformin tabs 2

GLYXAMBI TABS 3

INVOKAMET TABS 3

INVOKAMET XR TB24 3

JANUMET TABS 3

JANUMET XR TB24 3

JENTADUETO TABS 3

JENTADUETO XR TB24 3

KAZANO TABS 4

Drug Name DrugTier

RequirementsLimits

KOMBIGLYZE XR TB24 4

OSENI TABS 4

pioglitazone hcl-glimepiridetabs 1

pioglitazone hcl-metforminhcl tabs 2

REPAGLINIDEMETFORMIN HYDROCHLORIDE TABS

4

SYNJARDY TABS 3

XIGDUO XR TB24 4

Biguanides FORTAMET TB24 (Use Metformin HCl) 4

GLUCOPHAGE TABS (Use Metformin HCl) 4

GLUCOPHAGE XR TB24 (Use Metformin HCl) 4

GLUMETZA TB24 (Use Metformin HCl) 4 PA

metformin hcl tabs 500 mg850 mg 1000 mg 1

metformin hcl tb24 500 mg1000 mg 2

metformin hcl tb24 500 mg1000 mg 4 PA

metformin hcl tb24 500 mg750 mg 1

METFORMIN HYDROCHLORIDE SOLN 4

RIOMET SOLN 4

Diabetic Other GLUCAGEN HYPOKIT SOLR J Specialty Tier 1

May Apply GLUCAGON EMERGENCY KIT KIT J Specialty Tier 1

May Apply

KORLYM TABS 4 PA SpecialtyTier 3 MayApply

PROGLYCEM SUSP 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

23

Drug Name DrugTier

RequirementsLimits

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ALOGLIPTIN TABS 4

JANUVIA TABS 3

NESINA TABS 4

ONGLYZA TABS 4

TRADJENTA TABS 3

Dopamine Receptor Agonists - Antidiabetic CYCLOSET TABS 4

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON PEN PEN J PA SpecialtyTier 1 MayApply

BYDUREON SRER J PA SpecialtyTier 1 MayApply

BYETTA SOPN J PA SpecialtyTier 1 MayApply

TANZEUM PEN J PA SpecialtyTier 1 MayApply

TRULICITY SOPN J PA SpecialtyTier 1 MayApply

VICTOZA SOPN J PA SpecialtyTier 1 MayApply

Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) 4

AVANDIA TABS 3

pioglitazone hcl tabs 2

Insulin

ADMELOG SOLN 4

PA Limit 45mls permonthQL(15ml daily)

Drug Name DrugTier

RequirementsLimits

ADMELOG SOLOSTAR SOPN 4

PA Limit 45mls permonthQL(15ml daily)

AFREZZA POWD 4 PA

AFREZZA POWD 4 UNIT 8 UNIT 12 UNIT 4 PA QL(3 ea

daily)

APIDRA SOLN 4 PA

APIDRA SOLOSTAR SOPN 4 PA

BASAGLAR KWIKPEN SOPN 4 PA

FIASP FLEXTOUCH SOPN 4

PA Limit 45mls permonthQL(15ml daily)

FIASP SOLN 4

PA Limit 45mls permonthQL(15ml daily)

HUMALOG JUNIOR KWIKPEN SOPN 2

Limit 45mls permonthQL(15ml daily)

HUMALOG KWIKPEN SOPN 100 UNITML 2

Limit 45mls permonthQL(15ml daily)

HUMALOG KWIKPEN SOPN 200 UNITML 2

Limit 24mls permonthQL(08ml daily)

HUMALOG MIX 5050KWIKPEN SUPN 2

Limit 45mls permonthQL(15ml daily)

HUMALOG MIX 5050SUSP 2

Limit 45mls permonthQL(15ml daily)

HUMALOG MIX 7525KWIKPEN SUPN 2

Limit 45mls permonthQL(15ml daily)

HUMALOG MIX 7525SUSP 2

Limit 45mls permonthQL(15ml daily)

HUMALOG SOCT 2 Limit 45mls permonthQL(15ml daily)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

24

Drug Name DrugTier

RequirementsLimits

HUMALOG SOLN 2 Limit 45mls permonthQL(15ml daily)

HUMULIN 7030 KWIKPENSUPN 2

HUMULIN 7030 SUSP 2 Limit 45mls permonthQL(15ml daily)

HUMULIN 7030 SUSP 2 Limit 40mls permonthQL(134ml daily)

HUMULIN N KWIKPEN SUPN 2

Limit 45mls permonthQL(15ml daily)

HUMULIN N SUSP 2 Limit 40mls permonthQL(134ml daily)

HUMULIN N SUSP 2 Limit 45mls permonthQL(15ml daily)

HUMULIN R SOLN 2 Limit 45mls permonthQL(15ml daily)

HUMULIN R SOLN 2 Limit 40mls permonthQL(134ml daily)

HUMULIN R U-500 (CONCENTRATED) SOLN 2

Limit 40mls permonthQL(134ml daily)

HUMULIN R U-500 KWIKPEN SOPN 2

Limit 40mls permonthQL(134ml daily)

LANTUS SOLN 3 Limit 45mls permonthQL(15ml daily)

LANTUS SOLOSTAR SOPN 3

Limit 45mls permonthQL(15ml daily)

LEVEMIR FLEXTOUCH SOPN 3

Limit 45mls permonthQL(15ml daily)

LEVEMIR SOLN 3 Limit 45mls permonthQL(15ml daily)

NOVOLIN 7030 RELIONSUSP 4

PA Limit 40mls permonthQL(134ml daily)

Drug Name DrugTier

RequirementsLimits

NOVOLIN 7030 SUSP 3

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN N RELION SUSP 4

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN N SUSP 4

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN R RELION SOLN 4

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN R SOLN 3

PA Limit 40mls permonthQL(134ml daily)

NOVOLOG FLEXPEN SOPN 4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG MIX 7030PREFILLED FLEXPEN SUPN

4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG MIX 7030SUSP 4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG PENFILL SOCT 4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG SOLN 4

PA Limit 45mls permonthQL(15ml daily)

TOUJEO MAX SOLOSTAR SOPN 3 QL(05 ml

daily) TOUJEO SOLOSTAR SOPN 3 QL(05 ml

daily)

TRESIBA FLEXTOUCH SOPN 100 UNITML 3

Limit 45mls permonthQL(15ml daily)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

25

Drug Name DrugTier

RequirementsLimits

TRESIBA FLEXTOUCH SOPN 200 UNITML 3

Limit 27mls permonthQL(09ml daily)

Meglitinide Analogues nateglinide tabs 2

PRANDIN TABS 05 MG (Use Repaglinide) 3

PRANDIN TABS 1 MG 2 MG (Use Repaglinide) 4

repaglinide tabs 05 mg 3

repaglinide tabs 1 mg 2 mg 2

STARLIX TABS (Use Nateglinide) 4

Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS 4

INVOKANA TABS 3

JARDIANCE TABS 3

Sulfonylureas AMARYL TABS (Use Glimepiride) 4

chlorpropamide tabs 1

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

GLUCOTROL TABS (Use Glipizide) 4

GLUCOTROL XL TB24 (Use Glipizide) 4

glyburide micronized tabs 1

glyburide tabs 1

GLYNASE TABS (Use Glyburide Micronized) 4

TOLAZAMIDE TABS 250 MG 4

Drug Name DrugTier

RequirementsLimits

tolazamide tabs 500 mg 1

TOLBUTAMIDE TABS 4

ANTIDIARRHEALPROBIOTIC AGENTS - Drugsto Treat Diarrhea Antidiarrheal - Chloride Channel Antagonists

MYTESI TBEC 4 PA QL(2 eadaily)

Antiperistaltic Agents diphenoxylate w atropineliqd 1

diphenoxylate w atropinetabs 1

LOMOTIL TABS (Use Diphenoxylate w Atropine) 4

MOTOFEN TABS 2

opium tincture tinc 4

paregoric tinc 2

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents CHEMET CAPS 2

EXJADE TBSO 2 PA SpecialtyTier 3 MayApply

FERRIPROX SOLN 4 Specialty Tier 3May Apply

FERRIPROX TABS 4 Specialty Tier 3May Apply

JADENU TABS 2

PA SpecialtyTier 3 MayApply - Directto Acaria Specialty

Antidotes and Specific Antagonists CETYLEV TBEF 4 PA

RADIOGARDASE CAPS 4 PA

VISTOGARD PACK 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

26

Drug Name DrugTier

RequirementsLimits

Opioid Antagonists

EVZIO SOAJ J PA SpecialtyTier 3 MayApply

naltrexone hcl tabs 2

NALTREXONE IMPL 4 PA

NARCAN LIQD 4 QL(4 ea per 30days retail)

VIVITROL SUSR J PA SpecialtyTier 3 MayApply

ANTIEMETICS - Drugs to Treat Nausea andVomiting 5-HT3 Receptor Antagonists ALOXI SOLN (Use Palonosetron HCl) 3

ANZEMET TABS 4 PA

granisetron hcl tabs 4 PA QL(2 eadaily)

ondansetron hcl soln 4 mg5ml 3 QL(5 ml daily)

ondansetron hcl tabs 24 mg 3

QL(31 ea per30 daysretail93 ea per90 days mail)

ondansetron hcl tabs 4 mg8 mg 3

Limit 30 permonthQL(1 eadaily)

ondansetron tbdp 3

QL(31 ea per30 daysretail93 ea per90 days mail)

palonosetron hcl soln 3

PALONOSETRON HYDROCHLORIDE SOLN 3

SANCUSO PTCH 4 QL(1 ea per 30days retail)

SUSTOL PRSY J PA SpecialtyTier 3 MayApply

Drug Name DrugTier

RequirementsLimits

ZOFRAN ODT TBDP (Use Ondansetron) 4

QL(31 ea per30 daysretail93 ea per90 days mail)

ZOFRAN SOLN 4 MG5ML(Use Ondansetron HCl) 4 QL(5 ml daily)

ZOFRAN TABS 4 MG 8 MG (Use Ondansetron HCl)

4 Limit 30 permonthQL(1 eadaily)

ZUPLENZ FILM 4 QL(10 ea per30 days retail)

Antiemetics - Anticholinergic scopolamine pt72 1

TIGAN CAPS (Use Trimethobenzamide HCl) 4

TRANSDERM-SCOP PT72 2

TRANSDERM-SCOP PT72 (Use Scopolamine) 3

trimethobenzamide hcl caps 1

Antiemetics - Miscellaneous

AKYNZEO CAPS 4 QL(2 ea per 28days retail)

CESAMET CAPS 4 PA

DICLEGIS TBEC 4 QL(4 ea daily)

dronabinol caps 3

MARINOL CAPS (Use Dronabinol) 4

Substance PNeurokinin 1 (NK1) Receptor aprepitant caps 4

EMEND CAPS 40 MG 80 MG 125 MG (Use Aprepitant)

4

EMEND SUSR 125 MG 4 PA

EMEND TRIPACK CAPS (Use Aprepitant) 4

VARUBI TABS 4 QL(4 ea per fillretail)

ANTIFUNGALS - Drugs to Treat Fungal Infections

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

27

Drug Name DrugTier

RequirementsLimits

Antifungals ANCOBON CAPS (Use Flucytosine) 4

BIO-STATIN CAPS 4

flucytosine caps 4

GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) 4

griseofulvin microsize susp125 mg5ml 1

griseofulvin microsize tabs500 mg 3

griseofulvin ultramicrosizetabs 2

LAMISIL TABS (Use Terbinafine HCl) 4 QL(90 ea per

365 days retail)

nystatin tabs 1

terbinafine hcl tabs 1 QL(90 ea per365 days retail)

Imidazole-Related Antifungals CRESEMBA CAPS 4

DIFLUCAN SUSR (Use Fluconazole) 4

DIFLUCAN TABS (Use Fluconazole) 4

fluconazole susr 1

fluconazole tabs 1

itraconazole caps 100 mg 3 PA

itraconazole soln 10 mgml 3

ketoconazole tabs 1

NOXAFIL SUSP 4

NOXAFIL TBEC 4

ONMEL TABS 4 PA

SPORANOX CAPS 100 MG (Use Itraconazole) 4 PA

Drug Name DrugTier

RequirementsLimits

SPORANOX PULSEPAK CAPS (Use Itraconazole) 4 PA

SPORANOX SOLN 10 MGML (Use Itraconazole) 3

TOLSURA CAPS 4 PA

VFEND SUSR (Use Voriconazole) 4

VFEND TABS (Use Voriconazole) 4

voriconazole susr 1

voriconazole tabs 1

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines BROMPHENIRAMINE TANNATE CHEW 4

RYCLORA SYRP 4

Antihistamines - Ethanolamines carbinoxamine maleate soln 4 mg5ml 1

carbinoxamine maleate tabs 4 mg 4

diphenhydramine hcl caps 1 RXOTC

KARBINAL ER SUER 4

Antihistamines - Phenothiazines promethazine hcl soln or625 mg5ml 4

promethazine hcl supp re25 mg 50 mg 125 mg 2

promethazine hcl syrp or625 mg5ml 4

promethazine hcl tabs or25 mg 50 mg 125 mg 1

Antihistamines - Piperidines cyproheptadine hcl syrp 1

cyproheptadine hcl tabs 1

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

28

Drug Name DrugTier

RequirementsLimits

Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs 10mg-10mg 10mg-20mg40mg-10mg

1

ezetimibe-simvastatin tabs 80mg-10mg 1 PA

VYTORIN TABS 10MG-10MG 10MG-20MG 40MG-10MG (Use Ezetimibe-Simvastatin)

3

VYTORIN TABS 80MG-10MG (Use Ezetimibe-Simvastatin)

3 PA

Antihyperlipidemics - Misc

KYNAMRO SOSY J PA SpecialtyTier 2 MayApply

LOVAZA CAPS (Use Omega-3-acid EthylEsters)

4

omega-3-acid ethyl esters caps 1

VASCEPA CAPS 4 ST

Bile Acid Sequestrants cholestyramine light pack 2

cholestyramine light powd 2

cholestyramine pack 2

cholestyramine powd 2

colesevelam hcl pack 4

colesevelam hcl tabs 4

COLESTID FLAVORED GRAN (Use Colestipol HCl) 4

COLESTID FLAVORED PACK (Use Colestipol HCl) 4

COLESTID GRAN (Use Colestipol HCl) 4

COLESTID PACK (Use Colestipol HCl) 4

COLESTID TABS (Use Colestipol HCl) 4

Drug Name DrugTier

RequirementsLimits

colestipol hcl gran 1

colestipol hcl pack 1

colestipol hcl tabs 1

QUESTRAN LIGHT POWD (Use Cholestyramine Light) 4

QUESTRAN PACK (Use Cholestyramine) 4

QUESTRAN POWD (Use Cholestyramine) 4

WELCHOL PACK (Use Colesevelam HCl) 4

WELCHOL TABS (Use Colesevelam HCl) 4

Fibric Acid Derivatives ANTARA CAPS 4

choline fenofibrate cpdr 2

FENOFIBRATE CAPS 150 MG 4

FENOFIBRATE CAPS 50 MG 3

fenofibrate micronized caps 1

FENOFIBRATE TABS 160 MG 4

fenofibrate tabs 40 mg 120 mg 3 PA

fenofibrate tabs 48 mg 145 mg 2

fenofibrate tabs 54 mg 160 mg 1

FENOFIBRIC ACID TABS 4

FENOGLIDE TABS (Use Fenofibrate) 3 PA

FIBRICOR TABS 4

gemfibrozil tabs 1

LIPOFEN CAPS 150 MG 4

LIPOFEN CAPS 50 MG 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

29

Drug Name DrugTier

RequirementsLimits

LOFIBRA CAPS (Use Fenofibrate Micronized) 4

LOPID TABS (Use Gemfibrozil) 4

TRICOR TABS (Use Fenofibrate) 4

TRIGLIDE TABS 4

TRILIPIX CPDR (Use Choline Fenofibrate) 4

HMG CoA Reductase Inhibitors ALTOPREV TB24 4

atorvastatin calcium tabs 1 QL(1 ea daily)

CRESTOR TABS 40 MG (Use Rosuvastatin Calcium)

4

CRESTOR TABS 5 MG 10 MG 20 MG (Use Rosuvastatin Calcium)

4 QL(1 ea daily)

fluvastatin sodium caps 20mg 40 mg 1

fluvastatin sodium tb24 80 mg 2

LESCOL XL TB24 (Use Fluvastatin Sodium) 4

LIPITOR TABS (Use Atorvastatin Calcium) 4 QL(1 ea daily)

LIVALO TABS 4 QL(1 ea daily)

lovastatin tabs 1

$0 copay forGeneric onlyage 40 to75QL(1 eadaily) AL(Atleast 40 yrs old- Up to 75 yrsold) PV

MEVACOR TABS (Use Lovastatin) 4

$0 copay forGeneric onlyage 40 to75QL(1 eadaily) AL(Atleast 40 yrs old- Up to 75 yrsold) PV

Drug Name DrugTier

RequirementsLimits

PRAVACHOL TABS (Use Pravastatin Sodium) 4 QL(1 ea daily)

pravastatin sodium tabs 1 QL(1 ea daily)

rosuvastatin calcium tabs 40 mg 2

rosuvastatin calcium tabs 5 mg 10 mg 20 mg 2 QL(1 ea daily)

simvastatin tabs 1

ZOCOR TABS (Use Simvastatin) 4

Intestinal Cholesterol Absorption Inhibitors ezetimibe tabs 1

ZETIA TABS (Use Ezetimibe) 3

Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS 30 MG 40 MG 60 MG 4 PA

JUXTAPID CAPS 5 MG 10 MG 20 MG 4

PA SpecialtyTier 4 MayApply

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1

NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) 4

Proprotein Convertase SubtilisinKexin Type 9

PRALUENT SOPN J PA SpecialtyTier 3 MayApply

PRALUENT SOSY J PA SpecialtyTier 3 MayApply

REPATHA PUSHTRONEX SYSTEM SOCT J

PA SpecialtyTier 3 MayApply

REPATHA SOSY J PA SpecialtyTier 3 MayApply

REPATHA SURECLICK SOAJ J

PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

30

Drug Name DrugTier

RequirementsLimits

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) 4

ACEON TABS (Use Perindopril Erbumine) 4

ALTACE CAPS (Use Ramipril) 4

benazepril hcl tabs 1

captopril tabs 1

enalapril maleate tabs 1

EPANED SOLR 4 QL(5 ml daily)

fosinopril sodium tabs 1

lisinopril tabs 1

LOTENSIN TABS (Use Benazepril HCl) 4

MAVIK TABS (Use Trandolapril) 4

moexipril hcl tabs 1

perindopril erbumine tabs 1

PRINIVIL TABS (Use Lisinopril) 4

quinapril hcl tabs 1

ramipril caps 2

trandolapril tabs 2

VASOTEC TABS (Use Enalapril Maleate) 4

ZESTRIL TABS (Use Lisinopril) 4

Agents for Pheochromocytoma DEMSER CAPS 4

DIBENZYLINE CAPS (Use Phenoxybenzamine HCl) 3

Drug Name DrugTier

RequirementsLimits

phenoxybenzamine hcl caps 3

Angiotensin II Receptor Antagonists ATACAND TABS (Use Candesartan Cilexetil) 4

AVAPRO TABS (Use Irbesartan) 4

BENICAR TABS (Use Olmesartan Medoxomil) 3

candesartan cilexetil tabs 1

COZAAR TABS (Use Losartan Potassium) 4

DIOVAN TABS (Use Valsartan) 4

EDARBI TABS 4

EPROSARTAN MESYLATE TABS 4

irbesartan tabs 1

losartan potassium tabs 1

MICARDIS TABS (Use Telmisartan) 4

olmesartan medoxomil tabs 3

telmisartan tabs 1

valsartan tabs 2

Antiadrenergic Antihypertensives CARDURA TABS (Use Doxazosin Mesylate) 4

CATAPRES TABS (Use Clonidine HCl) 4

clonidine hcl tabs 1

doxazosin mesylate tabs 1

guanfacine hcl tabs 1

methyldopa tabs 1

MINIPRESS CAPS (Use Prazosin HCl) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

31

Drug Name DrugTier

RequirementsLimits

prazosin hcl caps 1

TENEX TABS (Use Guanfacine HCl) 4

terazosin hcl caps 1

Antihypertensive Combinations ACCURETIC TABS (Use Quinapril-Hydrochlorothiazide)

4

amlodipine besylate-benazepril hcl caps 1

amlodipine besylate-olmesartan medoxomil tabs 3 ST

amlodipine besylate-valsartan tabs 3

amlodipine-valsartan-hydrochlorothiazide tabs 3

ATACAND HCT TABS (Use Candesartan Cilexetil-Hydrochlorothiazide)

4

atenolol amp chlorthalidone tabs 1

AVALIDE TABS (Use Irbesartan-Hydrochlorothiazide)

4

AZOR TABS (Use Amlodipine Besylate-Olmesartan Medoxomil)

3 ST

benazepril amphydrochlorothiazide tabs 1

BENICAR HCT TABS (Use Olmesartan Medoxomil-Hydrochlorothiazide)

3

bisoprolol amphydrochlorothiazide tabs 1

BYVALSON TABS 4

candesartan cilexetil-hydrochlorothiazide tabs 1

captopril amphydrochlorothiazide tabs 1

CLORPRES TABS 3

CORZIDE TABS 40MG-5MG (Use Nadolol amp Bendroflumethiazide)

4

Drug Name DrugTier

RequirementsLimits

CORZIDE TABS 80MG-5MG 4

DIOVAN HCT TABS (Use Valsartan-Hydrochlorothiazide)

4

DUTOPROL TB24 4

EDARBYCLOR TABS 4

enalapril maleate amphydrochlorothiazide tabs 1

EXFORGE HCT TABS (Use Amlodipine-Valsartan-Hydrochlorothiazide)

3

EXFORGE TABS (Use Amlodipine Besylate-Valsartan)

3

fosinopril sodium amphydrochlorothiazide tabs 2

HYZAAR TABS (Use Losartan Potassium amp Hydrochlorothiazide)

4

irbesartan-hydrochlorothiazide tabs 1

lisinopril amphydrochlorothiazide tabs 1

LOPRESSOR HCT TABS (Use Metoprolol ampHydrochlorothiazide)

4

losartan potassium amphydrochlorothiazide tabs 1

LOTENSIN HCT TABS (Use Benazepril ampHydrochlorothiazide)

4

LOTREL CAPS (Use Amlodipine Besylate-Benazepril HCl)

4

methyldopa amphydrochlorothiazide tabs 1

metoprolol amphydrochlorothiazide tabs 2

METOPROLOL SUCCINATE ERHYDROCHLOROTHIAZIDE TB24

4

METOPROLOLHYDROCHLOROTHIAZIDE TABS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

32

Drug Name DrugTier

RequirementsLimits

MICARDIS HCT TABS (Use Telmisartan-Hydrochlorothiazide)

4

moexipril-hydrochlorothiazide tabs 2

MOEXIPRILHYDROCHLOROTHIAZIDE TABS 4

nadolol amp bendroflumethiazide tabs 4

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

3 ST

olmesartan medoxomil-hydrochlorothiazide tabs 3

PRESTALIA TABS 4 ST

propranolol amphydrochlorothiazide tabs 1

quinapril-hydrochlorothiazide tabs 2

TARKA TBCR (Use Trandolapril-VerapamilHCl)

4

TEKTURNA HCT TABS 4 ST

telmisartan-amlodipine tabs 1

telmisartan-hydrochlorothiazide tabs 1

TENORETIC 100 TABS (Use Atenolol amp Chlorthalidone)

4

TENORETIC 50 TABS (Use Atenolol amp Chlorthalidone)

4

trandolapril-verapamil hcltbcr 4

TRANDOLAPRILVERAPAMIL HCL ER TBCR 4

TRIBENZOR TABS (Use Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)

3

ST

TWYNSTA TABS (Use Telmisartan-Amlodipine) 4

valsartan-hydrochlorothiazide tabs 2

Drug Name DrugTier

RequirementsLimits

VASERETIC TABS (Use Enalapril Maleate ampHydrochlorothiazide)

4

ZESTORETIC TABS (Use Lisinopril ampHydrochlorothiazide)

4

ZIAC TABS (Use Bisoprololamp Hydrochlorothiazide) 4

Antihypertensives - Misc VECAMYL TABS 4

Direct Renin Inhibitors TEKTURNA TABS 4 ST

Selective Aldosterone Receptor Antagonists eplerenone tabs 4

INSPRA TABS (Use Eplerenone) 4

Vasodilators hydralazine hcl tabs 1

minoxidil tabs 2

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations atovaquone-proguanil hcltabs 3

COARTEM TABS 2

MALARONE TABS (Use Atovaquone-Proguanil HCl) 4

Antimalarials ARAKODA TABS 4 PA

CHLOROQUINE PHOSPHATE TABS 250 MG

4

chloroquine phosphate tabs500 mg 2

DARAPRIM TABS 2 PA

hydroxychloroquine sulfatetabs 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

33

Drug Name DrugTier

RequirementsLimits

MEFLOQUINE HCL TABS 4

mefloquine hcl tabs 3

PLAQUENIL TABS (Use HydroxychloroquineSulfate)

4

PRIMAQUINE PHOSPHATE TABS 2

QUALAQUIN CAPS (Use Quinine Sulfate) 4

QL(42 ea per365 daysretail42 ea per365 days mail)

quinine sulfate caps 4

QL(42 ea per365 daysretail42 ea per365 days mail)

ANTIMYASTHENICCHOLINERGIC AGENTS

AntimyasthenicCholinergic Agents GUANIDINE HCL TABS 3

MESTINON SYRP 60 MG5ML 4 PA

MESTINON TABS 60 MG (Use PyridostigmineBromide)

4

MESTINON TIMESPAN TBCR (Use PyridostigmineBromide)

4

pyridostigmine bromidetabs 60 mg 2

pyridostigmine bromidetbcr 180 mg 4

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Anti TB Combinations RIFAMATE CAPS 4

RIFATER TABS 3

Antimycobacterial Agents CYCLOSERINE CAPS 4

ethambutol hcl tabs 1

Drug Name DrugTier

RequirementsLimits

ISONIAZID SYRP 50 MG5ML 4

isoniazid tabs 100 mg 300 mg 1

MYAMBUTOL TABS (Use Ethambutol HCl) 4

MYCOBUTIN CAPS (Use Rifabutin) 3

PASER PACK 4

PRIFTIN TABS 4

pyrazinamide tabs 2

rifabutin caps 3

RIFADIN CAPS (Use Rifampin) 4

rifampin caps 2

SIRTURO TABS 4

TRECATOR TABS 4

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS (Use Melphalan) 3

carboplatin soln J PA

CISPLATIN SOLN 200 MG200ML J PA

cisplatin soln 50 mg50ml100 mg100ml J PA

cyclophosphamide caps or25 mg 4 PA

CYCLOPHOSPHAMIDE CAPS OR 25 MG (Use Cyclophosphamide)

4 PA

cyclophosphamide caps or50 mg 4

CYCLOPHOSPHAMIDE CAPS OR 50 MG (Use Cyclophosphamide)

4

cyclophosphamide solr ij 1gm 2 gm 500 mg J PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

34

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 10 MG 40 MG 100 MG (Use Lomustine)

4

GLEOSTINE CAPS 5 MG 4

HEXALEN CAPS 2

IFEX SOLR (Use Ifosfamide) J PA

ifosfamide soln J PA

ifosfamide solr J PA

LEUKERAN TABS 2

melphalan tabs 1

MUSTARGEN SOLR J PA

MYLERAN TABS 2

oxaliplatin soln J PA

TEMODAR CAPS OR 250 MG (Use Temozolomide) 4 Specialty Tier 2

May Apply TEMODAR CAPS OR 5 MG 20 MG 100 MG 140 MG 180 MG (Use Temozolomide)

4

Specialty MayApply BrandTier 4 Generic Tier 1

TEMODAR SOLR IV 100 MG J PA

temozolomide caps 250 mg 1 Specialty Tier 2May Apply

temozolomide caps 5 mg20 mg 100 mg 140 mg180 mg

1

Specialty MayApply BrandTier 4 Generic Tier 1

TEPADINA SOLR J PA

thiotepa solr J PA

TREANDA SOLR J PA

Antimetabolites azacitidine susr J PA

capecitabine tabs 2

Drug Name DrugTier

RequirementsLimits

cladribine soln J PA

cytarabine soln J PA

CYTARABINEAQUEOUS SOLN J PA

DACOGEN SOLR (Use Decitabine) J PA

decitabine solr J PA

DEPOCYT SUSP J PA

floxuridine solr J PA

fludarabine phosphate soln J PA

fludarabine phosphate solr J PA

fluorouracil soln iv 1 gm20ml 5 gm100ml 25gm50ml 500 mg10ml

J PA

FOLOTYN SOLN J PA

gemcitabine hcl soln J PA

gemcitabine hcl solr J PA

GEMZAR SOLR (Use Gemcitabine HCl) J PA

mercaptopurine tabs 2

methotrexate sodium soln ij1 gm40ml 50 mg2ml 200mg8ml 250 mg10ml

J PA SpecialtyTier 1 MayApply

METHOTREXATE SODIUM SOLN IJ 250 MG10ML

J PA SpecialtyTier 1 MayApply

methotrexate sodium solr ij1 gm J

PA SpecialtyTier 1 MayApply

methotrexate sodium tabs or 25 mg 1

PURIXAN SUSP 4 AL(Up to 13 yrsold )

TABLOID TABS 2

TREXALL TABS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

35

Drug Name DrugTier

RequirementsLimits

VIDAZA SUSR (Use Azacitidine) J PA

XELODA TABS (Use Capecitabine) 4

Antineoplastic - Angiogenesis Inhibitors AVASTIN SOLN J PA

CYRAMZA SOLN J PA

ZALTRAP SOLN J PA

Antineoplastic - Antibodies ADCETRIS SOLR J PA

ARZERRA CONC J PA

BLINCYTO SOLR J PA

ERBITUX SOLN J PA

GAZYVA SOLN J PA

KADCYLA SOLR J PA

KEYTRUDA SOLN J PA SpecialtyTier 3 MayApply

OPDIVO SOLN J PA

PERJETA SOLN J PA

POTELIGEO SOLN 4 PA

RITUXAN SOLN J PA

VECTIBIX SOLN J PA

YERVOY SOLN J PA

ZEVALIN Y-90 KIT J PA

Antineoplastic - BCL-2 Inhibitors

VENCLEXTA STARTING PACK TBPK 2

PA SpecialtyTier 3 MayApply

VENCLEXTA TABS 2 PA SpecialtyTier 3 MayApply

Drug Name DrugTier

RequirementsLimits

Antineoplastic - Cellular Immunotherapy PROVENGE SUSP J PA

Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO TABS 4 PA

ERIVEDGE CAPS 2 Specialty Tier 2May Apply

ODOMZO CAPS 2 Specialty Tier 2May Apply

Antineoplastic - Hormonal and Related Agents

abiraterone acetate tabs 1 PA SpecialtyTier 2 MayApply

anastrozole tabs 2 AL(At least 40yrs old)

ARIMIDEX TABS (Use Anastrozole) 4 AL(At least 40

yrs old) AROMASIN TABS (Use Exemestane) 4 AL(At least 40

yrs old)

bicalutamide tabs 1

CASODEX TABS (Use Bicalutamide) 4

DEPO-PROVERA SUSP J PA

EMCYT CAPS 2

exemestane tabs 2 AL(At least 40yrs old)

FARESTON TABS 2

FASLODEX SOLN J PA

FEMARA TABS (Use Letrozole) 4 AL(At least 40

yrs old)

FIRMAGON SOLR J PA

flutamide caps 3

letrozole tabs 2 AL(At least 40yrs old)

leuprolide acetate kit J PA

LEUPROLIDE ACETATEBUPIVACAINEHYDROCHLORIDE SOLN

4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

36

Drug Name DrugTier

RequirementsLimits

LUPRON DEPOT (1-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LUPRON DEPOT (3-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LUPRON DEPOT (4-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LYSODREN TABS 2

MEGACE ORAL SUSP (Use Megestrol Acetate) 4

megestrol acetate susp 40mgml 400 mg10ml 2

megestrol acetate tabs 20mg 40 mg 1

NILANDRON TABS (Use Nilutamide) 3

nilutamide tabs 1

SOLTAMOX SOLN 4

tamoxifen citrate tabs 1 PV

TRELSTAR MIXJECT SUSR J PA

TRELSTAR SUSR J PA

VANTAS KIT J PA

XTANDI CAPS 4 PA SpecialtyTier 2 MayApply

ZOLADEX IMPL J PA

ZYTIGA TABS (Use Abiraterone Acetate) 3

PA SpecialtyTier 2 MayApply

Antineoplastic - Immunomodulators

POMALYST CAPS 4 Specialty Tier 2May Apply

Antineoplastic Antibiotics bleomycin sulfate solr J PA

ELLENCE SOLN (Use Epirubicin HCl) J PA

Drug Name DrugTier

RequirementsLimits

epirubicin hcl soln J PA

IDAMYCIN PFS SOLN (Use Idarubicin HCl) J PA

idarubicin hcl soln J PA

mitomycin solr J PA

mitoxantrone hcl conc J PA

VALSTAR SOLN J PA

Antineoplastic Combinations

LONSURF TABS 2 PA SpecialtyTier 2 MayApply

Antineoplastic Enzyme Inhibitors AFINITOR DISPERZ TBSO 4 PA

AFINITOR TABS 4 PA SpecialtyTier 2 MayApply

ALECENSA CAPS 2 PA SpecialtyTier 2 MayApply

BELEODAQ SOLR J PA

BOSULIF TABS 4 PA SpecialtyTier 2 MayApply

BRAFTOVI CAPS 2 PA

CABOMETYX TABS 2 PA

CAPRELSA TABS 2 Specialty Tier 4May Apply

COMETRIQ KIT 4 Specialty Tier 2May Apply

COPIKTRA CAPS 4 PA

COTELLIC TABS 2 PA SpecialtyTier 2 MayApply

FARYDAK CAPS 2 PA SpecialtyTier 2 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

37

Drug Name DrugTier

RequirementsLimits

GILOTRIF TABS 20 MG 30 MG 2

PA SpecialtyTier 3 MayApply

GILOTRIF TABS 40 MG 2 PA

GLEEVEC TABS (Use Imatinib Mesylate) 4

PA SpecialtyTier 2 MayApply - Directto Acaria Specialty

IBRANCE CAPS 2

PA SpecialtyTier 2 MayApply - Directto Acaria Specialty

ICLUSIG TABS 4 PA SpecialtyTier 2 MayApply

IDHIFA TABS 4 PA

imatinib mesylate tabs 100mg 400 mg 1

imatinib mesylate tabs 400 mg 1 Specialty Tier 2

May Apply

IMBRUVICA CAPS 70 MG 140 MG 2

PA SpecialtyTier 2 MayApply

IMBRUVICA TABS 140 MG 280 MG 420 MG 560 MG

2

PA SpecialtyTier 2 MayApplyQL(1 eadaily)

INLYTA TABS 4 PA SpecialtyTier 2 MayApply

IRESSA TABS 2 Specialty Tier 2May Apply

ISTODAX (OVERFILL) SOLR J PA

JAKAFI TABS 2 Specialty Tier 3May Apply

KYPROLIS SOLR J PA

LENVIMA 10 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 12MG DAILY DOSE CPPK 4 PA

Drug Name DrugTier

RequirementsLimits

LENVIMA 14 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 18 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 20 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 24 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 4 MG DAILY DOSE CPPK 4 PA

LENVIMA 8 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LORBRENA TABS 4 PA

LYNPARZA CAPS 50 MG 2 PA SpecialtyTier 2 MayApply

LYNPARZA TABS 100 MG 150 MG 4 PA

MEKINIST TABS 2 PA SpecialtyTier 3 MayApply

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

PA SpecialtyTier 2 MayApply - Directto Acaria Specialty

NINLARO CAPS 2 PA

ROMIDEPSIN SOLR J PA

RUBRACA TABS 2 PA SpecialtyTier 3 MayApply

SPRYCEL TABS 3 PA SpecialtyTier 2 MayApply

STIVARGA TABS 4 PA SpecialtyTier 2 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

38

Drug Name DrugTier

RequirementsLimits

SUTENT CAPS 25 MG 50 MG 125 MG 2 Specialty Tier 2

May Apply

SUTENT CAPS 375 MG 2

TAFINLAR CAPS 2 PA SpecialtyTier 3 MayApply

TAGRISSO TABS 2 PA SpecialtyTier 3 MayApply

TALZENNA CAPS 4 PA

TARCEVA TABS 2 PA SpecialtyTier 2 MayApply

TASIGNA CAPS 2 PA SpecialtyTier 2 MayApply

temsirolimus soln J PA

TIBSOVO TABS 4 PA

TORISEL SOLN (Use Temsirolimus) J PA

TYKERB TABS 2 Specialty Tier 2May Apply

VELCADE SOLR J PA

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

VIZIMPRO TABS 4 PA

VOTRIENT TABS 2 Specialty Tier 2May Apply

XALKORI CAPS 2 PA SpecialtyTier 2 MayApply

XOSPATA TABS 4 PA

ZELBORAF TABS 2 PA SpecialtyTier 2 MayApply

ZOLINZA CAPS 4 PA SpecialtyTier 2 MayApply

Drug Name DrugTier

RequirementsLimits

ZYDELIG TABS 2 PA SpecialtyTier 2 MayApply

ZYKADIA CAPS 4 PA SpecialtyTier 2 MayApply

Antineoplastic Enzymes ERWINAZE SOLR J PA

ONCASPAR SOLN J PA

Antineoplastic Radiopharmaceuticals METASTRON SOLN J PA

XOFIGO SOLN J PA

Antineoplastics Misc

ACTIMMUNE SOLN J PA SpecialtyTier 3 MayApply

ALFERON N SOLN J PA SpecialtyTier 3 MayApply

bexarotene caps 1

dacarbazine solr J PA

HYDREA CAPS (Use Hydroxyurea) 4

hydroxyurea caps 1

INTRON A SOLN J PA SpecialtyTier 3 MayApply

INTRON A SOLR J PA SpecialtyTier 3 MayApply

INTRON A WDILUENTSOLR J

PA SpecialtyTier 3 MayApply

MATULANE CAPS 2 Specialty Tier 1May Apply

NIPENT SOLR J PA

SYLATRON KIT J PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

39

Drug Name DrugTier

RequirementsLimits

SYNRIBO SOLR J PA SpecialtyTier 2 MayApply

TARGRETIN CAPS OR 75 MG (Use Bexarotene) 4

tretinoin (chemotherapy) caps 2

Chemotherapy RescueAntidote Agents dexrazoxane solr J PA

FUSILEV SOLR (Use Levoleucovorin Calcium) J PA

KHAPZORY SOLR 4 PA

LEUCOVORIN CALCIUM SOLN IJ 500 MG50ML 4 PA

leucovorin calcium solr ij 50mg 100 mg 200 mg 350mg 500 mg

J PA

LEUCOVORIN CALCIUM TABS OR 10 MG 15 MG 4

leucovorin calcium tabs or 5 mg 25 mg 2

levoleucovorin calcium soln J PA

levoleucovorin calcium solr J PA

mesna soln J PA

MESNEX SOLN IV 100 MGML (Use Mesna) J PA

MESNEX TABS OR 400 MG 2

TOTECT SOLR J PA

VORAXAZE SOLR J PA

ZINECARD SOLR (Use Dexrazoxane) J PA

Mitotic Inhibitors DOCEFREZ SOLR J PA

DOCETAXEL CONC 20 MGML 80 MG2ML 80MG4ML 140 MG7ML160 MG8ML

J

PA

Drug Name DrugTier

RequirementsLimits

docetaxel conc 20 mgml80 mg4ml J PA

docetaxel soln 20 mg2ml80 mg8ml 160 mg16ml J PA

DOCETAXEL SOLN 20 MG2ML 80 MG8ML 160MG16ML

J PA

DOCETAXEL SOLN 20 MG2ML 80 MG8ML 160MG16ML (Use Docetaxel)

J PA

etoposide caps or 50 mg 2

etoposide soln iv 1gm50ml 100 mg5ml 500mg25ml

J PA

HALAVEN SOLN J PA

JEVTANA SOLN J PA

MARQIBO SUSP J PA

NAVELBINE SOLN (Use Vinorelbine Tartrate) J PA

PACLITAXEL CONC 150 MG25ML J PA

paclitaxel conc 30 mg5ml300 mg50ml 100mg167ml

J PA

TAXOL CONC (Use Paclitaxel) J PA

TAXOTERE CONC (Use Docetaxel) J PA

vinorelbine tartrate soln J PA

Topoisomerase I Inhibitors CAMPTOSAR SOLN 300 MG15ML J PA

CAMPTOSAR SOLN 40 MG2ML 100 MG5ML(Use Irinotecan HCl)

J PA

HYCAMTIN CAPS OR 025 MG 1 MG 4

HYCAMTIN SOLR IV 4 MG (Use Topotecan HCl) J PA

irinotecan hcl soln J PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

40

Drug Name DrugTier

RequirementsLimits

IRINOTECAN SOLN J PA

TOPOTECAN HCL SOLN 4 MG4ML J PA

topotecan hcl soln 4mg4ml J PA

TOPOTECAN HCL SOLN 4 MG4ML (Use TopotecanHCl)

J PA

topotecan hcl solr 4 mg J PA

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease Antiparkinson Adjuvants carbidopa tabs 4

LODOSYN TABS (Use Carbidopa) 4

Antiparkinson Anticholinergics benztropine mesylate tabs 1

trihexyphenidyl hcl elix 1

trihexyphenidyl hcl tabs 1

Antiparkinson COMT Inhibitors COMTAN TABS (Use Entacapone) 4

entacapone tabs 4

TASMAR TABS (Use Tolcapone) 4

tolcapone tabs 4

Antiparkinson Dopaminergics amantadine hcl caps 1

amantadine hcl syrp 1

amantadine hcl tabs 1

bromocriptine mesylate caps 3

bromocriptine mesylatetabs 3

Drug Name DrugTier

RequirementsLimits

carbidopa-levodopa tabs10mg-100mg 25mg-100mg 25mg-250mg

2

carbidopa-levodopa tbcr25mg-100mg 50mg-200mg

2

carbidopa-levodopa tbdp10mg-100mg 25mg-100mg 25mg-250mg

4

carbidopa-levodopa-entacapone tabs 1

CARBIDOPALEVODOPAENTACAPONE TABS 3

DUOPA SUSP 4 Specialty Tier 3May Apply

MIRAPEX ER TB24 0375 MG 075 MG 3 MG 15 MG 45 MG 225 MG (Use PramipexoleDihydrochloride)

4

MIRAPEX ER TB24 375 MG (Use PramipexoleDihydrochloride)

4 PA

MIRAPEX TABS (Use PramipexoleDihydrochloride)

4

NEUPRO PT24 4

PARLODEL CAPS (Use Bromocriptine Mesylate) 4

PARLODEL TABS (Use Bromocriptine Mesylate) 4

pramipexoledihydrochloride tabs 0125mg 025 mg 05 mg 1 mg15 mg

3

pramipexoledihydrochloride tabs 075 mg

2

pramipexoledihydrochloride tb24 0375mg 075 mg 3 mg 15 mg45 mg 225 mg

4

pramipexoledihydrochloride tb24 375 mg

4 PA

REQUIP TABS (Use Ropinirole Hydrochloride) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

41

Drug Name DrugTier

RequirementsLimits

REQUIP XL TB24 (Use Ropinirole Hydrochloride) 4

ropinirole hydrochloridetabs 2

ropinirole hydrochloridetb24 2

RYTARY CPCR 4 PA

SINEMET CR TBCR (Use Carbidopa-Levodopa) 4

SINEMET TABS (Use Carbidopa-Levodopa) 4

STALEVO 100 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 125 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 150 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 200 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 50 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 75 TABS (Use Carbidopa-Levodopa-Entacapone)

4

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Use Rasagiline Mesylate) 3

ELDEPRYL CAPS (Use Selegiline HCl) 4

rasagiline mesylate tabs 3

selegiline hcl caps 2

selegiline hcl tabs 2

ZELAPAR TBDP 4

ANTIPSYCHOTICSANTIMANIC AGENTS -Drugs to Treat Mood Disorders Antimanic Agents

Drug Name DrugTier

RequirementsLimits

lithium carbonate caps 1

lithium carbonate tabs 1

lithium carbonate tbcr 1

LITHIUM SOLN 4

LITHOBID TBCR (Use Lithium Carbonate) 4

Antipsychotics - Misc EQUETRO CP12 4

GEODON CAPS (Use Ziprasidone HCl) 4

LATUDA TABS 120 MG 4 PA QL(1 eadaily)

LATUDA TABS 20 MG 4 PA

LATUDA TABS 40 MG 60 MG 80 MG 4 PA QL(2 ea

daily)

NUPLAZID CAPS 34 MG 4 PA QL(1 eadaily)

NUPLAZID TABS 10 MG 4 PA QL(1 eadaily)

NUPLAZID TABS 17 MG 4 PA

VRAYLAR CAPS 4 PA

VRAYLAR CPPK 4 PA

ziprasidone hcl caps 1

Benzisoxazoles FANAPT TABS 4 PA

FANAPT TITRATION PACK TABS 4 PA

INVEGA SUSTENNA SUSP J

PA SpecialtyTier 2 MayApply

INVEGA TB24 (Use Paliperidone) 4

INVEGA TRINZA SUSP J PA SpecialtyTier 2 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

42

Drug Name DrugTier

RequirementsLimits

paliperidone tb24 4

PERSERIS PRSY 4 PA

RISPERDAL M-TAB TBDP (Use Risperidone) 4

RISPERDAL SOLN (Use Risperidone) 4

RISPERDAL TABS (Use Risperidone) 4

RISPERIDONE ODT TBDP 4

risperidone soln 1 mgml 1

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

1

risperidone tbdp 025 mg 4

risperidone tbdp 05 mg 1mg 2 mg 3 mg 4 mg 1

Butyrophenones haloperidol lactate conc 1

haloperidol tabs 1

Dibenzapines CLOZAPINE ODT TBDP 4

clozapine tabs 25 mg 50mg 100 mg 200 mg 2

clozapine tbdp 25 mg 100mg 125 mg 4

CLOZARIL TABS (Use Clozapine) 4

FAZACLO TBDP 150 MG 200 MG 4

FAZACLO TBDP 25 MG 100 MG 125 MG (Use Clozapine)

4

loxapine succinate caps 2

olanzapine tabs 5 mg 10mg 15 mg 20 mg 25 mg75 mg

1

olanzapine tbdp 5 mg 10mg 15 mg 20 mg 4

Drug Name DrugTier

RequirementsLimits

quetiapine fumarate tabs25 mg 50 mg 100 mg 200mg 300 mg 400 mg

1

quetiapine fumarate tb2450 mg 150 mg 200 mg300 mg 400 mg

4 PA

SAPHRIS SUBL 4 PA

SEROQUEL TABS (Use Quetiapine Fumarate) 4

SEROQUEL XR TB24 (Use Quetiapine Fumarate) 4 PA

VERSACLOZ SUSP 4 QL(18 ml daily)

ZYPREXA TABS (Use Olanzapine) 4

ZYPREXA ZYDIS TBDP (Use Olanzapine) 4

Dihydroindolones MOLINDONE HYDROCHLORIDE TABS 3

Phenothiazines chlorpromazine hcl tabs 1

fluphenazine hcl conc 1

fluphenazine hcl elix 1

fluphenazine hcl tabs 1

perphenazine tabs 1

prochlorperazine maleatetabs 1

prochlorperazine supp 1

thioridazine hcl tabs 1

trifluoperazine hcl tabs 1

Quinolinone Derivatives ABILIFY MYCITE TABS 4 PA

ABILIFY TABS (Use Aripiprazole) 4

aripiprazole soln 1 mgml 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

43

Drug Name DrugTier

RequirementsLimits

aripiprazole tabs 2 mg 5mg 10 mg 15 mg 20 mg30 mg

1

aripiprazole tbdp 10 mg 15 mg 4

REXULTI TABS 4 PA

Thioxanthenes thiothixene caps 1

ANTISEPTICS amp DISINFECTANTS

Chlorine Antiseptics CHLORHEXIDINE GLUCONATE SOLN 3

Iodine Antiseptics IODOFLEX PADS 3

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 1

abacavir sulfate tabs 1

abacavir sulfate-lamivudine tabs 1

abacavir sulfate-lamivudine-zidovudine tabs 1

APTIVUS CAPS 2

APTIVUS SOLN 2

atazanavir sulfate caps 1

ATRIPLA TABS 2 ST

COMBIVIR TABS (Use Lamivudine-Zidovudine) 4

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 4 PA

DESCOVY TABS 2

Drug Name DrugTier

RequirementsLimits

didanosine cpdr 2

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

EPIVIR SOLN (Use Lamivudine) 4

EPIVIR TABS (Use Lamivudine) 4

EPZICOM TABS (Use Abacavir Sulfate-Lamivudine)

3

EVOTAZ TABS 2

fosamprenavir calcium tabs 1

FUZEON SOLR J PA SpecialtyTier 2 MayApply

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS PACK 2

ISENTRESS TABS 2

KALETRA SOLN 400MG5ML-100MG5ML(Use Lopinavir-Ritonavir)

3

KALETRA TABS 100MG-25MG 200MG-50MG 2

lamivudine soln 1

lamivudine tabs 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

44

Drug Name DrugTier

RequirementsLimits

lamivudine-zidovudine tabs 1

LEXIVA SUSP 50 MGML 2

LEXIVA TABS 700 MG (Use FosamprenavirCalcium)

3

lopinavir-ritonavir soln 1

nevirapine tabs 200 mg 1

nevirapine tb24 100 mg400 mg 2

NORVIR CAPS 100 MG 2

NORVIR PACK 100 MG 4

NORVIR SOLN 80 MGML 2

NORVIR TABS 100 MG (Use Ritonavir) 3

PIFELTRO TABS 4 PA

PREZCOBIX TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

RETROVIR CAPS (Use Zidovudine) 4

RETROVIR SYRP (Use Zidovudine) 4

REYATAZ CAPS 150 MG 200 MG 300 MG (Use Atazanavir Sulfate)

3

REYATAZ PACK 50 MG 2

ritonavir tabs 1

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

Drug Name DrugTier

RequirementsLimits

SUSTIVA CAPS (Use Efavirenz) 3

SUSTIVA TABS (Use Efavirenz) 3

SYMTUZA TABS 4 ST

tenofovir disoproxilfumarate tabs 1

TIVICAY TABS 2

TRIUMEQ TABS 2

TRIZIVIR TABS (Use Abacavir Sulfate-Lamivudine-Zidovudine)

4

TRUVADA TABS 2

TYBOST TABS 2

VIDEX EC CPDR 125 MG 4

VIDEX EC CPDR 200 MG 250 MG 400 MG (Use Didanosine)

4

VIDEXPEDIATRIC SOLR 2

VIRACEPT TABS 2

VIRAMUNE TABS (Use Nevirapine) 4

VIRAMUNE XR TB24 (Use Nevirapine) 4

VIREAD POWD 40 MGGM 3

VIREAD TABS 150 MG 200 MG 250 MG 2

VIREAD TABS 300 MG (Use Tenofovir DisoproxilFumarate)

3

VITEKTA TABS 2

ZERIT CAPS 15 MG 20 MG 30 MG 40 MG (Use Stavudine)

4

ZERIT SOLR 1 MGML 4

ZIAGEN SOLN 20 MGML(Use Abacavir Sulfate) 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

45

Drug Name DrugTier

RequirementsLimits

ZIAGEN TABS 300 MG (Use Abacavir Sulfate) 4

zidovudine caps 100 mg 2

zidovudine syrp 50 mg5ml 2

zidovudine tabs 300 mg 1

CMV Agents VALCYTE SOLR 50 MGML (Use ValganciclovirHCl)

3 QL(21 ml daily)

VALCYTE TABS 450 MG (Use Valganciclovir HCl) 4

valganciclovir hcl solr 50mgml 1 QL(21 ml daily)

valganciclovir hcl tabs 450 mg 2

Hepatitis Agents adefovir dipivoxil tabs 1

BARACLUDE SOLN 005 MGML 2

BARACLUDE TABS 05 MG 1 MG (Use Entecavir) 4 PA

COPEGUS TABS (Use Ribavirin (Hepatitis C)) 4 PA

DAKLINZA TABS 4 PA SpecialtyTier 3 MayApply

entecavir tabs 1

EPCLUSA TABS 4 PA SpecialtyTier 3 MayApply

EPIVIR HBV SOLN 5 MGML 4

EPIVIR HBV TABS 100 MG (Use Lamivudine (HBV))

4

HARVONI TABS 4 PA SpecialtyTier 3 MayApply

HEPSERA TABS 2

lamivudine (hbv) tabs 1

Drug Name DrugTier

RequirementsLimits

LEDIPASVIRSOFOSBUVIR TABS 4

PA SpecialtyTier 3 MayApply

MODERIBA 1200 DOSE PACK TABS 4 PA

MODERIBA 800 DOSE PACK TABS 3 PA

OLYSIO CAPS 4 PA SpecialtyTier 3 MayApply

PEG-INTRON REDIPEN KIT J

PA SpecialtyTier 2 MayApply

PEGASYS PROCLICK SOLN J

PA SpecialtyTier 2 MayApply

PEGASYS SOLN J PA SpecialtyTier 2 MayApply

PEGINTRON KIT J PA SpecialtyTier 2 MayApply

REBETOL CAPS 200 MG (Use Ribavirin (HepatitisC))

4 PA

REBETOL SOLN 40 MGML 3 PA

RIBASPHERE RIBAPAK TABS 400 MG 3 PA

RIBASPHERE RIBAPAK TABS 600 MG 4 PA

RIBASPHERE TABS 3 PA

ribavirin (hepatitis c) caps 3 PA

ribavirin (hepatitis c) tabs 3 PA

SOFOSBUVIRVELPATASVIR TABS 4

PA SpecialtyTier 3 MayApply

SOVALDI TABS 4 PA SpecialtyTier 3 MayApply

TECHNIVIE TABS 4 PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

46

Drug Name DrugTier

RequirementsLimits

VIEKIRA PAK TBPK 4 PA SpecialtyTier 3 MayApply

VIEKIRA XR TB24 4 PA SpecialtyTier 3 MayApply

ZEPATIER TABS 4 PA SpecialtyTier 3 MayApply

Herpes Agents acyclovir caps 1

acyclovir sodium soln 3

acyclovir susp 1

acyclovir tabs 1

famciclovir tabs 3

FAMVIR TABS (Use Famciclovir) 4

SITAVIG TABS 4 PA

valacyclovir hcl tabs 2

VALTREX TABS (Use Valacyclovir HCl) 4

ZOVIRAX CAPS OR 200 MG (Use Acyclovir) 4

ZOVIRAX SUSP OR 200 MG5ML (Use Acyclovir) 4

ZOVIRAX TABS OR 400 MG 800 MG (Use Acyclovir)

4

Influenza Agents FLUMADINE TABS (Use Rimantadine Hydrochloride)

4

oseltamivir phosphate caps30 mg 45 mg 4

QL(10 ea perfill retail10 ea per fill mail)

oseltamivir phosphate caps75 mg 4

Drug Name DrugTier

RequirementsLimits

oseltamivir phosphate susr6 mgml 4

QL(120 ml per30 days retail)AL(At least 1yrs old - Up to12 yrs old)

RELENZA DISKHALER AEPB 4 QL(20 ea per

fill retail) rimantadine hydrochloridetabs 2

TAMIFLU CAPS 30 MG 45 MG (Use Oseltamivir Phosphate)

4 QL(10 ea perfill retail10 ea per fill mail)

TAMIFLU CAPS 75 MG (Use Oseltamivir Phosphate)

4

TAMIFLU SUSR 6 MGML(Use Oseltamivir Phosphate)

4

QL(120 ml per30 days retail)AL(At least 1yrs old - Up to12 yrs old)

XOFLUZA TBPK 4 PA QL(2 eaper fill retail)

Respiratory Syncytial Virus (RSV) Agents ribavirin solr 3

VIRAZOLE SOLR (Use Ribavirin) 3

BETA BLOCKERS - Drugs to Treat High BloodPressure Alpha-Beta Blockers carvedilol phosphate cp24 4

carvedilol tabs 1

COREG CR CP24 (Use Carvedilol Phosphate) 4

COREG TABS (Use Carvedilol) 4

labetalol hcl tabs 1

LABETALOL HYDROCHLORIDESODIUM CHLORIDE SOLN

4 PA

Beta Blockers Cardio-Selective acebutolol hcl caps 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

47

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

betaxolol hcl tabs 2

bisoprolol fumarate tabs 2

BYSTOLIC TABS 4

KAPSPARGO SPRINKLE CS24 4 PA

LOPRESSOR TABS (Use Metoprolol Tartrate) 4

metoprolol succinate tb24 2

metoprolol tartrate tabs 25 mg 1 QL(2 ea daily)

metoprolol tartrate tabs 50mg 100 mg 1

METOPROLOL TARTRATE TABS 75 MG 375 MG

4 PA

SECTRAL CAPS (Use Acebutolol HCl) 4

TENORMIN TABS (Use Atenolol) 4

TOPROL XL TB24 (Use Metoprolol Succinate) 4

ZEBETA TABS (Use Bisoprolol Fumarate) 4

Beta Blockers Non-Selective BETAPACE AF TABS (Use Sotalol HCl (AFIBAFL)) 4

BETAPACE TABS (Use Sotalol HCl) 4

CORGARD TABS (Use Nadolol) 4

HEMANGEOL SOLN 4 AL(Up to 1 yrsold )

INDERAL LA CP24 (Use Propranolol HCl) 4

INDERAL XL CP24 4

INNOPRAN XL CP24 4

nadolol tabs 1

Drug Name DrugTier

RequirementsLimits

pindolol tabs 1

propranolol hcl cp24 60 mg 2

propranolol hcl cp24 80mg 120 mg 160 mg 1

PROPRANOLOL HCL SOLN 20 MG5ML 40MG5ML

4

propranolol hcl tabs 10 mg20 mg 40 mg 60 mg 80 mg

1

sotalol hcl (afibafl) tabs 2

sotalol hcl tabs 2

SOTYLIZE SOLN 4

timolol maleate tabs 1

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure Calcium Channel Blockers ADALAT CC TB24 (Use Nifedipine) 4

amlodipine besylate tabs 1 QL(1 ea daily)

CALAN SR TBCR (Use Verapamil HCl) 4

CALAN TABS (Use Verapamil HCl) 4

CARDIZEM CD CP24 (Use Diltiazem HCl Coated Beads)

4

CARDIZEM LA TB24 120 MG 4

CARDIZEM LA TB24 180 MG 240 MG 300 MG 360 MG 420 MG (Use Diltiazem HCl Coated Beads)

4

CARDIZEM TABS (Use Diltiazem HCl) 4

diltiazem hcl coated beads cp24 120 mg 180 mg 240mg 300 mg 360 mg

2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

48

Drug Name DrugTier

RequirementsLimits

diltiazem hcl coated beads tb24 180 mg 240 mg 300mg 360 mg 420 mg

1

diltiazem hcl cp12 1

diltiazem hcl cp24 1

diltiazem hcl extended release beads cp24 2

diltiazem hcl tabs 1

DILTIAZEM HYDROCHLORIDE SOSY 4 PA

felodipine tb24 2

isradipine caps 25 mg 1

isradipine caps 5 mg 3

nicardipine hcl caps 2

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 2 QL(12 eadaily21 day(s)limit)

NISOLDIPINE ER TB24 4

nisoldipine tb24 17 mg 34mg 85 mg 255 mg 2

nisoldipine tb24 20 mg 40 mg 1 QL(1 ea daily)

NORVASC TABS (Use Amlodipine Besylate) 4 QL(1 ea daily)

NYMALIZE SOLN 4

PROCARDIA CAPS (Use Nifedipine) 4

PROCARDIA XL TB24 (Use Nifedipine) 4

SULAR TB24 (Use Nisoldipine) 4

TIAZAC CP24 (Use Diltiazem HCl Extended Release Beads)

4

Drug Name DrugTier

RequirementsLimits

verapamil hcl cp24 1

VERAPAMIL HCL SR CP24 4

verapamil hcl tabs 1

verapamil hcl tbcr 1

VERELAN CP24 120 MG 180 MG 240 MG (Use Verapamil HCl)

4

VERELAN CP24 360 MG 4

VERELAN PM CP24 (Use Verapamil HCl) 4

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm Cardiac Glycosides digoxin soln 1

digoxin tabs 1

LANOXIN TABS 125 MCG 250 MCG (Use Digoxin) 4

LANOXIN TABS 625 MCG 1875 MCG 4

CARDIOVASCULAR AGENTS - MISC - Drugs toTreat Heart and Circulation Conditions Cardiovascular Agents Misc - Combinations amlodipine besylate-atorvastatin calcium tabs 3

BIDIL TABS 4

CADUET TABS (Use Amlodipine Besylate-Atorvastatin Calcium)

4

ENTRESTO TABS 4 PA

Peripheral Vasodilators isoxsuprine hcl tabs 10 mg 1

ISOXSUPRINE HCL TABS 20 MG 4

Prostaglandin Vasodilators

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

49

Drug Name DrugTier

RequirementsLimits

epoprostenol sodium solr J PA SpecialtyTier 4 MayApply

FLOLAN SOLR (Use Epoprostenol Sodium) J

PA SpecialtyTier 4 MayApply

ORENITRAM TBCR 4 PA

TYVASO REFILL SOLN 4 PA SpecialtyTier 4 MayApply

TYVASO SOLN 4 PA SpecialtyTier 4 MayApply

TYVASO STARTER SOLN 4 PA SpecialtyTier 4 MayApply

VELETRI SOLR J PA SpecialtyTier 4 MayApply

VENTAVIS SOLN 10 MCGML 4

PA SpecialtyTier 4 MayApply

VENTAVIS SOLN 20 MCGML 4 PA

Pulmonary Hypertension - Endothelin Receptor

LETAIRIS TABS 3 PA SpecialtyTier 2 MayApply

OPSUMIT TABS 4 PA SpecialtyTier 3 MayApply

TRACLEER TABS 3

PA PA Required todirect to Caremark Specialty -Specialty Tier 2May Apply

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (Use Tadalafil (PulmonaryHypertension))

3 PA SpecialtyTier 1 MayApply

REVATIO SUSR 10 MGML 4

PA SpecialtyTier 1 MayApply

Drug Name DrugTier

RequirementsLimits

REVATIO TABS 20 MG (Use Sildenafil Citrate (Pulmonary Hypertension))

4 PA SpecialtyTier 1 MayApply

sildenafil citrate (pulmonaryhypertension) tabs 4

PA SpecialtyTier 1 MayApply

tadalafil (pulmonaryhypertension) tabs 3

PA SpecialtyTier 1 MayApply

Pulmonary Hypertension - Prostacyclin Receptor

UPTRAVI TABS 4 PA SpecialtyTier 3 MayApply

UPTRAVI TBPK 4 PA SpecialtyTier 3 MayApply

Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 4 PA

Sinus Node Inhibitors CORLANOR TABS 4 ST

CEPHALOSPORINS - Drugs to Treat BacterialInfections Cephalosporins - 1st Generation cefadroxil caps 500 mg 1

cefadroxil susr 250 mg5ml 2

cefadroxil susr 500 mg5ml 1

cefadroxil tabs 1 gm 2

cephalexin caps 250 mg500 mg 1

cephalexin caps 750 mg 4

cephalexin susr 125mg5ml 250 mg5ml 1

CEPHALEXIN TABS 250 MG 500 MG 4

KEFLEX CAPS (Use Cephalexin) 4

Cephalosporins - 2nd Generation cefaclor caps 250 mg 500 mg 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

50

Drug Name DrugTier

RequirementsLimits

CEFACLOR ER TB12 4

cefaclor susr 125 mg5ml250 mg5ml 375 mg5ml 1

CEFACLOR SUSR 250 MG5ML 375 MG5ML 4

cefprozil susr 2

cefprozil tabs 2

CEFTIN SUSR 4

cefuroxime axetil tabs 1

Cephalosporins - 3rd Generation CEDAX CAPS 4

CEDAX SUSR 4

cefdinir caps 300 mg 2

cefdinir susr 125 mg5ml250 mg5ml 1

CEFDITOREN PIVOXIL TABS 200 MG 400 MG 4

cefixime susr 3

cefpodoxime proxetil susr 2

cefpodoxime proxetil tabs 2

CEFTIBUTEN CAPS 4

CEFTIBUTEN SUSR 4

SPECTRACEF TABS 4

SUPRAX CAPS 400 MG 3

SUPRAX CHEW 100 MG 200 MG 4

SUPRAX SUSR 100 MG5ML 200 MG5ML(Use Cefixime)

4

SUPRAX SUSR 500 MG5ML 4

TAZICEF SOLN 3

Drug Name DrugTier

RequirementsLimits

CHEMICALS

Acids Bases amp Buffers POTASSIUM HYDROXIDE SOLN 3

SODIUM HYDROXIDE SOLN 3

Bulk Chemicals - Cs CROSCARMELLOSE SODIUM POWD 4 PA

Bulk Chemicals - Hs

HEPARIN SODIUM POWD XX J

PA SpecialtyTier 1 MayApply

Bulk Chemicals - Ns N-ACETYL-L-CARNOSINE POWD 4 PA

Bulk Chemicals - Ts TRICHLOROACETIC ACID SOLN 3

CONTRACEPTIVES - Drugs to PreventPregnancy Combination Contraceptives - Oral BEYAZ TABS (Use Drospirenone-EthinylEstradiol-Levomefolate Calcium)

3

PV

BREVICON-28 TABS (Use Norethindrone amp Eth Estradiol)

4 PV

CYCLESSA TABS (Use Desogestrel-EthinylEstradiol (Triphasic))

4 PV

DESOGEN TABS (Use Desogestrel amp EthinylEstradiol)

4 PV

desogestrel amp ethinylestradiol tabs 1 PV

desogestrel-ethinylestradiol (biphasic) tabs 1 PV

desogestrel-ethinylestradiol (triphasic) tabs 1 PV

drospirenone-ethinylestradiol tabs 1 PV

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

51

Drug Name DrugTier

RequirementsLimits

drospirenone-ethinylestradiol-levomefolate calcium tabs

1 PV

ESTROSTEP FE TABS (Use Norethindrone Acetate-Ethinyl Estradiol-Fe)

4

PV

ethynodiol diacet amp ethestrad tabs 1 PV

FEMCON FE CHEW (Use Norethindrone amp EthinylEstradiol-Fe)

4 PV

GENERESS FE CHEW (Use Norethindrone amp Ethinyl Estradiol-Fe)

4 QL(1 ea daily)PV

levonorgestrel amp ethestradiol tabs 1 QL(1 ea daily)

PV levonorgestrel-eth estradiol(triphasic) tabs 1 QL(1 ea daily)

PV

levonorgestrel-ethinylestradiol (91-day) tabs 1

QL(90 ea perfill retail90 ea per fill mail) PV

levonorgestrel-ethinylestradiol (91-day) tabs 1

QL(91 ea perfill retail91 ea per fill mail) PV

levonorgestrel-ethinylestradiol (91-day) tabs 4

QL(90 ea perfill retail90 ea per fill mail) PV

levonorgestrel-ethinylestradiol (continuous) tabs 4 PV

LO LOESTRIN FE TABS 4 PV

LOESTRIN 1530-21TABS (Use Norethindrone Acet amp Eth Estra)

4 PV

LOESTRIN 120-21 TABS(Use Norethindrone Acet amp Eth Estra)

4 PV

LOESTRIN FE 1530TABS (Use Norethin Acet amp Estrad-Fe)

4 PV

LOESTRIN FE 120 TABS(Use Norethin Acet amp Estrad-Fe)

4 PV

LOSEASONIQUE TABS (Use Levonorgestrel-Ethinyl Estradiol (91-Day))

4 QL(90 ea perfill retail90 ea per fill mail) PV

Drug Name DrugTier

RequirementsLimits

MINASTRIN 24 FE CHEW (Use Norethin Acet amp Estrad-Fe)

3 PV

MIRCETTE TABS (Use Desogestrel-EthinylEstradiol (Biphasic))

4 PV

NATAZIA TABS 2 QL(1 ea daily)PV

NECON 1011-28 TABS 2 PV

norethin acet amp estrad-fe chew 1 PV

norethin acet amp estrad-fe tabs 1 PV

norethindrone amp eth estradiol tabs 1 PV

norethindrone amp ethinylestradiol-fe chew 04mg-35mcg

1 PV

norethindrone amp ethinylestradiol-fe chew 75mg-08mg-25mcg

1 QL(1 ea daily)PV

norethindrone amp mestranol tabs 1 PV

norethindrone acet amp eth estra tabs 1 PV

norethindrone acetate-ethinyl estradiol-fe tabs 4 PV

norethindrone-eth estradiol (triphasic) tabs 1 PV

norgestimate-ethinylestradiol (triphasic) tabs 1 PV

norgestimate-ethinylestradiol tabs 1 PV

norgestrel amp ethinylestradiol tabs 1 PV

NORINYL 1+35 TABS (Use Norethindrone amp Eth Estradiol)

4 PV

ORTHO TRI-CYCLEN LO TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

3

PV

ORTHO TRI-CYCLEN TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

4

PV

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

52

Drug Name DrugTier

RequirementsLimits

ORTHO-CYCLEN TABS (Use Norgestimate-EthinylEstradiol)

4 PV

ORTHO-NOVUM 135TABS (Use Norethindrone amp Eth Estradiol)

4 PV

ORTHO-NOVUM 777TABS (Use Norethindrone-Eth Estradiol (Triphasic))

4 PV

OVCON-35 TABS (Use Norethindrone amp Eth Estradiol)

4 PV

QUARTETTE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))

4 QL(90 ea perfill retail90 ea per fill mail) PV

SAFYRAL TABS (Use Drospirenone-EthinylEstradiol-Levomefolate Calcium)

3

PV

SEASONIQUE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))

4 QL(91 ea perfill retail91 ea per fill mail) PV

TRI-NORINYL 28 TABS (Use Norethindrone-Eth Estradiol (Triphasic))

4 PV

YASMIN 28 TABS (Use Drospirenone-EthinylEstradiol)

4 PV

YAZ TABS (Use Drospirenone-EthinylEstradiol)

4 PV

Combination Contraceptives - Transdermal XULANE PTWK 2 PV

Combination Contraceptives - Vaginal NUVARING RING 2 PV

Emergency Contraceptives ELLA TABS 4 PV

levonorgestrel (emergencyoc) tabs 1 PV

PLAN B ONE-STEP TABS (Use Levonorgestrel(Emergency OC))

4 PV

Progestin Contraceptives - IUD

Drug Name DrugTier

RequirementsLimits

LILETTA IUD 4 QL(1 ea per365 daysretail) PV

MIRENA IUD 4 PV

SKYLA IUD 4 PV

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSY (Use MedroxyprogesteroneAcetate (Contraceptive))

3

PV

DEPO-SUBQ PROVERA 104 SUSY 3 PV

medroxyprogesteroneacetate (contraceptive) susy

1 PV

Progestin Contraceptives - Oral NOR-QD TABS (Use Norethindrone (Contraceptive))

4 PV

norethindrone (contraceptive) tabs 1 PV

ORTHO MICRONOR TABS (Use Norethindrone (Contraceptive))

4 PV

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions Glucocorticosteroids budesonide cpep 3 mg 2

budesonide tb24 9 mg 4 PA

CORTEF TABS (Use Hydrocortisone) 4

cortisone acetate tabs 1

dexamethasone elix 05 mg5ml 1

DEXAMETHASONE INTENSOL CONC 4

DEXAMETHASONE SOLN 05 MG5ML 4

dexamethasone tabs 075 mg 05 mg 4 mg 6 mg15 mg

1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

53

Drug Name DrugTier

RequirementsLimits

DEXAMETHASONE TABS 1 MG 2 MG 4

dexamethasone tbpk 15 mg 4

DEXPAK 10 DAY TBPK (Use Dexamethasone) 4

DEXPAK 13 DAY TBPK (Use Dexamethasone) 4

DEXPAK 6 DAY TBPK (Use Dexamethasone) 4

ENTOCORT EC CPEP (Use Budesonide) 4

hydrocortisone tabs 1

MEDROL DOSEPAK TBPK (Use Methylprednisolone) 4

MEDROL TABS 2 MG 4

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

4

methylprednisolone tabs 1

methylprednisolone tbpk 1

MILLIPRED DP TBPK 4

MILLIPRED SOLN 10 MG5ML (Use Prednisolone Sodium Phosphate)

4

MILLIPRED TABS 5 MG 4

ORAPRED ODT TBDP (Use Prednisolone Sodium Phosphate)

4

PEDIAPRED SOLN (Use Prednisolone Sodium Phosphate)

4

prednisolone sodiumphosphate soln or 10mg5ml 20 mg5ml

4

PREDNISOLONE SODIUM PHOSPHATE SOLN OR 25 MG5ML

4

prednisolone sodiumphosphate soln or 5mg5ml 15 mg5ml

1

Drug Name DrugTier

RequirementsLimits

prednisolone sodiumphosphate tbdp or 10 mg15 mg 30 mg

4

PREDNISOLONE SOLN 4

prednisolone soln 1

prednisolone syrp 1

PREDNISONE INTENSOL CONC 2

PREDNISONE SOLN 5 MG5ML 4

prednisone tabs 1 mg 5mg 10 mg 20 mg 25 mg 1

PREDNISONE TABS 50 MG 4

prednisone tbpk 5 mg 10 mg 1

RAYOS TBEC 4 PA

TAPERDEX 12-DAY TBPK 4

TAPERDEX 6-DAY TBPK 4

UCERIS TB24 OR 9 MG (Use Budesonide) 4 PA

VERIPRED 20 SOLN (Use Prednisolone Sodium Phosphate)

4

ZODEX 12-DAY TBPK 4

ZODEX 6-DAY TBPK 4

Mineralocorticoids fludrocortisone acetate tabs 2

COUGHCOLDALLERGY - Drugs to TreatCough Cold and Allergy Symptoms Antitussives benzonatate caps 100 mg200 mg 1

benzonatate caps 150 mg 4

hydrocodone whomatropine syrp 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

54

Drug Name DrugTier

RequirementsLimits

hydrocodone whomatropine tabs 1

TESSALON PERLES CAPS (Use Benzonatate) 4

CoughColdAllergy Combinations ACTIDOM DMX LIQD 4

ALAHIST DM LIQD (Use Phenylephrine-Brompheniramine-DM)

4

AP-HIST DM LIQD 4

CLARINEX-D 12 HOUR TB12 3

CODITUSSIN AC LIQD 3

DALLERGY LIQD 4

DECON-G LIQD 3

DOMETUSS-DMX LIQD 4

FLOWTUSS SOLN 4

guaifenesin-codeine liqd 1

guaifenesin-codeine soln 1

guaifenesin-codeine syrp 1

HYCOFENIX SOLN 4 PA

HYDROCODONE BITARTRATECHLORPHENIRAMINE MALEATEPSESOLN

4

PA

HYDROCODONE BITARTRATEGUAIFENESIN SOLN

4

hydrocodone polistirex-chlorpheniramine polistirex suer

4

QL(300 ml per31 daysretail900 ml per 93 daysmail)

LOHIST-DM SYRP 4

M-CLEAR WC SOLN 4

Drug Name DrugTier

RequirementsLimits

NORTUSS-EX LIQD 4

OBREDON SOLN 4

phenylephrine w dm-ggliqd 1 RXOTC

phenylephrine-brompheniramine-dm liqd 1

PHENYLEPHRINEGUAIFENESIN LIQD 4

PHENYLHISTINE DH LIQD 4

promethazine ampphenylephrine soln 1

promethazine wcodeinesoln 1

promethazine wcodeine syrp 1

promethazine-dm syrp 1

promethazine-phenylephrine-codeine syrp 1

PROMETHAZINEPHENYLEPHRINE SYRP 4

PROMETHAZINEPHENYLEPHRINECODEINE SYRP 4

pseudoephed-bromphen-dm syrp 1

pseudoephed-cpm whydrocod soln 4 PA

REZIRA SOLN 4

SEMPREX-D CAPS 4

TUSNEL TABS 3

TUSSICAPS CP12 4

TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER (Use HydrocodonePolistirex-ChlorpheniraminePolistirex)

4

QL(300 ml per31 daysretail900 ml per 93 daysmail)

TUZISTRA XR SUER 4 PA

VITUZ SOLN 4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

55

Drug Name DrugTier

RequirementsLimits

ZUTRIPRO SOLN (Use Pseudoephed-CPM wHydrocod)

4 PA

Expectorants guaifenesin tabs 1

Misc Respiratory Inhalants HYPER-SAL NEBU (Use Sodium Chloride (Inhalant)) 4

HYPERSAL NEBU 35 4

HYPERSAL NEBU 7 (Use Sodium Chloride (Inhalant))

4

NEBUSAL NEBU 4

sodium chloride (inhalant)nebu 1

Mucolytics acetylcysteine soln 2

DERMATOLOGICALS - Drugs to Treat SkinConditions Acne Products ABSORICA CAPS 10 MG 20 MG 30 MG 40 MG 4 PA

ABSORICA CAPS 25 MG 35 MG 4

ACANYA GEL 4 PA

ACZONE GEL 5 (Use Dapsone (Topical)) 4 PA

ACZONE GEL 75 4 PA QL(2 gmdaily)

adapalene crea 01 3

adapalene gel 01 3 RXOTC

adapalene gel 03 3

ADAPALENE LOTN 01 4 Limit 59mls permonthQL(197ml daily)

Drug Name DrugTier

RequirementsLimits

adapalene-benzoylperoxide gel 4

Limit 45gms permonthQL(15gm daily)

ALTRENO LOTN 4 PA

ATRALIN GEL (Use Tretinoin) 4

Limit 45gms permonthQL(15gm daily)AL(Up to 46 yrsold )

AZELEX CREA 3

BENZACLIN GEL (Use Clindamycin Phosphate-Benzoyl Peroxide)

4

BENZACLIN WITH PUMP GEL (Use ClindamycinPhosphate-BenzoylPeroxide)

4

BENZAMYCIN GEL (Use Benzoyl Peroxide-Erythromycin)

4

benzoyl peroxide bar 10 3

BENZOYL PEROXIDE CLEANSER LOTN 4

benzoyl peroxide crea 10 4

benzoyl peroxide liqd 4 7 4

benzoyl peroxide lotn 6 4

benzoyl peroxide misc 6 4 RXOTC

benzoyl peroxide-erythromycin gel 2

CLEOCIN-T GEL (Use Clindamycin Phosphate(Topical))

4

CLEOCIN-T LOTN (Use Clindamycin Phosphate(Topical))

4

CLEOCIN-T SOLN (Use Clindamycin Phosphate(Topical))

4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

56

Drug Name DrugTier

RequirementsLimits

CLEOCIN-T SWAB (Use Clindamycin Phosphate(Topical))

4

CLINDAGEL GEL (Use Clindamycin Phosphate(Topical))

4 PA

clindamycin phosphate(topical) foam 4

clindamycin phosphate(topical) gel 1

clindamycin phosphate(topical) lotn 1

clindamycin phosphate(topical) soln 1

clindamycin phosphate(topical) swab 1

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

3

clindamycin phosphate-benzoyl peroxide gel 4

clindamycin phosphate-tretinoin gel 4 QL(1 gm daily)

CLINDAMYCIN PHOSPHATEBENZOYLPEROXIDE GEL

4 PA

dapsone (topical) gel 4 PA

DIFFERIN CREA 01 (Use Adapalene) 4

DIFFERIN GEL 01 (Use Adapalene) 4 RXOTC

DIFFERIN GEL 03 (Use Adapalene) 4

DIFFERIN LOTN 01 4 Limit 59mls permonthQL(197ml daily)

DUAC GEL (Use Clindamycin Phosphate-Benzoyl Peroxide(Refrigerate))

4

EPIDUO FORTE GEL 4

PA Limit 45gms permonthQL(15gm daily)

Drug Name DrugTier

RequirementsLimits

EPIDUO GEL (Use Adapalene-BenzoylPeroxide)

4

Limit 45gms permonthQL(15gm daily)

ERYGEL GEL (Use Erythromycin (Acne Aid)) 4

erythromycin (acne aid) gel 1

erythromycin (acne aid)pads 1

erythromycin (acne aid)soln 1

EVOCLIN FOAM (Use Clindamycin Phosphate(Topical))

4

FABIOR FOAM 4

Limit 50gms permonthQL(167gm daily)AL(Up to 46 yrsold )

isotretinoin caps 10 mg 20mg 30 mg 40 mg 1

isotretinoin caps 10 mg 20mg 30 mg 40 mg 3

isotretinoin caps 30 mg 4

isotretinoin caps 30 mg 40 mg 1

Limited to 5 months of treatment

KLARON LOTN (Use Sulfacetamide Sodium (Acne))

4

ONEXTON GEL 4 PA

PANOXYL-4 CREAMY WASH LIQD (Use BenzoylPeroxide)

4

RETIN-A CREA (Use Tretinoin) 4 AL(Up to 46 yrs

old ) RETIN-A GEL (Use Tretinoin) 4 AL(Up to 46 yrs

old ) RETIN-A MICRO GEL 004 (Use Tretinoin Microsphere)

3 QL(067 gmdaily) AL(Up to46 yrs old )

RETIN-A MICRO GEL 004 (Use Tretinoin Microsphere)

4 QL(067 gmdaily) AL(Up to46 yrs old )

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

57

Drug Name DrugTier

RequirementsLimits

RETIN-A MICRO GEL 01 (Use Tretinoin Microsphere)

4

Limit 20gms permonthQL(067gm daily)AL(Up to 46 yrsold )

RETIN-A MICRO PUMP GEL 004 (Use Tretinoin Microsphere)

4 QL(067 gmdaily) AL(Up to46 yrs old )

RETIN-A MICRO PUMP GEL 008 4

PA Limit 50gms permonthQL(17gm daily)

RETIN-A MICRO PUMP GEL 01 (Use Tretinoin Microsphere)

2

Limit 50gms permonthQL(17gm daily)AL(Up to 46 yrsold )

RIAX FOAM 4

ROSULA LIQD 45-10 4 PA

ROSULA PADS 5-10 4 QL(30 ea perfill retail)

SODIUM SULFACETAMIDESULFUR LOTN

4 QL(25 gm perfill retail)

SODIUM SULFACETAMIDESULFUR SUSP

4

sulfacetamide sodium (acne) lotn 1

sulfacetamide sodium wsulfur liqd 4-9 1

sulfacetamide sodium wsulfur pads 4-10 4-4-10-10

4

sulfacetamide sodium wsulfur susp 4-8 1

SUMAXIN PADS (Use Sulfacetamide Sodium wSulfur)

4

SUMAXIN TS SUSP (Use Sulfacetamide Sodium wSulfur)

4

Drug Name DrugTier

RequirementsLimits

SUMAXIN WASH LIQD (Use Sulfacetamide Sodium w Sulfur)

4

TRETIN-X CREA 4 PA

tretinoin crea 0025 005 01 2 AL(Up to 46 yrs

old ) tretinoin gel 0025 001 2 AL(Up to 46 yrs

old )

tretinoin gel 005 4

Limit 45gms permonthQL(15gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel004 2

QL(067 gmdaily) AL(Up to46 yrs old )

tretinoin microsphere gel01 1

Limit 50gms permonthQL(17gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel01 1

Limit 20gms permonthQL(06749 gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel01 1

Limit 45gms permonthQL(15gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel01 1

Limit 20gms permonthQL(067gm daily)AL(Up to 46 yrsold )

VELTIN GEL 4 QL(1 gm daily)

ZIANA GEL (Use Clindamycin Phosphate-Tretinoin)

4 QL(1 gm daily)

Agents for External Genital and Perianal Warts

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

58

Drug Name DrugTier

RequirementsLimits

VEREGEN OINT 4

Anti-inflammatory Agents - Topical DFSMSMENTHCAP PAKKIT 4 PA

diclofenac sodium (topical)gel 1 1

diclofenac sodium (topical)soln 15 2 QL(5 ml daily)

FLECTOR PTCH 4

PENNSAID SOLN 4 PA QL(4 gmdaily)

VOLTAREN GEL (Use Diclofenac Sodium (Topical))

3

VOPAC MDS KIT 4 PA

Antibiotics - Topical ALTABAX OINT 4

BACTROBAN CREA (Use Mupirocin Calcium(Topical))

4

CORTISPORIN CREA 3

CORTISPORIN OINT 3

gentamicin sulfate (topical) crea 1

gentamicin sulfate (topical)oint 1

mupirocin calcium (topical) crea 1

mupirocin oint 1

NEO-SYNALAR CREA 4 PA

XEPI CREA 4 PA

Antifungals - Topical ciclopirox gel 077 2

ciclopirox olamine crea 2

ciclopirox olamine susp 2

Drug Name DrugTier

RequirementsLimits

ciclopirox sham 1 2

ciclopirox soln 8 1

clotrimazole wbetamethasone crea 2

clotrimazole wbetamethasone lotn 2 QL(1 ml daily)

econazole nitrate crea 1

ECOZA FOAM 4

Limit 70gms permonthQL(25gm daily)

ERTACZO CREA 4 PA

EXELDERM CREA 4

EXELDERM SOLN 4

EXTINA FOAM (Use Ketoconazole (Topical)) 4

iodoquinol-hc crea 2

JUBLIA SOLN 4 PA

KERYDIN SOLN 4 PA

ketoconazole (topical) crea 2

ketoconazole (topical) foam 4

ketoconazole (topical)sham 1

LOPROX CREA (Use Ciclopirox Olamine) 4

LOPROX SHAMPOO SHAM (Use Ciclopirox) 4

LOPROX SUSP (Use Ciclopirox Olamine) 4

LOTRISONE CREA (Use Clotrimazole wBetamethasone)

4

LULICONAZOLE CREA 4

LUZU CREA 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

59

Drug Name DrugTier

RequirementsLimits

MICONAZOLE NITRATEZINCOXIDEWHITEPETROLATUM OINT

4

naftifine hcl crea 4

NAFTIN CREA 2 (Use Naftifine HCl) 4

NAFTIN GEL 1 2 4

NIZORAL SHAM (Use Ketoconazole (Topical)) 4

nystatin (topical) crea 1

nystatin (topical) oint 1

nystatin (topical) powd 2

nystatin-triamcinolone crea 1

nystatin-triamcinolone oint 1

oxiconazole nitrate crea 4

OXISTAT CREA (Use Oxiconazole Nitrate) 4

OXISTAT LOTN 4

PENLAC NAIL LACQUER SOLN (Use Ciclopirox) 4

VUSION OINT 4

XOLEGEL GEL 4

Antineoplastic or Premalignant Lesion Agents -CARAC CREA 4

diclofenac sodium (actinickeratoses) gel 4 PA

EFUDEX CREA (Use Fluorouracil (Topical)) 4

FLUOROPLEX CREA 4

fluorouracil (topical) crea 1

FLUOROURACIL CREA EX 05 4

Drug Name DrugTier

RequirementsLimits

FLUOROURACIL SOLN EX 2 5 4

LEVULAN KERASTICK SOLR 4 PA

PANRETIN GEL 4 PA

PICATO GEL 4

SOLARAZE GEL (Use Diclofenac Sodium (ActinicKeratoses))

4 PA

TARGRETIN GEL EX 1 4

TOLAK CREA 4 PA

VALCHLOR GEL 4 PA SpecialtyTier 2 MayApply

Antipruritics - Topical doxepin hcl (antipruritic) crea 4

PRUDOXIN CREA 4

ZONALON CREA 4

ZONALON CREA 4 PA

Antipsoriatics acitretin caps 2

calcipotriene crea 3

calcipotriene oint 3

calcipotriene soln 3

calcitriol (topical) oint 3

Limit 100gms permonthQL(34gm daily)

COSENTYX SENSOREADY PEN SOAJ J

PA SpecialtyTier 2 MayApply

COSENTYX SOSY J PA SpecialtyTier 2 MayApply

DOVONEX CREA (Use Calcipotriene) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

60

Drug Name DrugTier

RequirementsLimits

ILUMYA SOSY J PA SpecialtyTier 3 MayApply

methoxsalen rapid caps 3

OXSORALEN ULTRA CAPS (Use Methoxsalen Rapid)

3

SORIATANE CAPS (Use Acitretin) 4

SORILUX FOAM 4 QL(4 gm daily)

STELARA SOLN J PA SpecialtyTier 2 MayApply

STELARA SOSY J PA SpecialtyTier 2 MayApply

TALTZ SOAJ J PA SpecialtyTier 3 MayApply

TALTZ SOSY J PA SpecialtyTier 3 MayApply

tazarotene crea 3 QL(1 gm daily)AL(Up to 46 yrsold )

TAZORAC CREA 005 3 QL(1 gm daily)AL(Up to 46 yrsold )

TAZORAC CREA 01 (Use Tazarotene) 3

QL(1 gm daily)AL(Up to 46 yrsold )

TAZORAC GEL 005 01 3

QL(1 gm daily)AL(Up to 46 yrsold )

VECTICAL OINT (Use Calcitriol (Topical)) 3

Limit 100gms permonthQL(34gm daily)

ZITHRANOL SHAM 4 PA

Antiseborrheic Products GLYCOLIC ACID 70 HIGH PURITY SOLN 3 RXOTC

GLYCOLIC ACID SOLN 3 RXOTC

Drug Name DrugTier

RequirementsLimits

selenium sulfide lotn 25 1

selenium sulfide sham 225 4 MO

SODIUM SULFACETAMIDE WASH LIQD

4

Antivirals - Topical acyclovir topical oint 4

DENAVIR CREA 4

Limited to 5 gms permonthQL(017gm daily)

XERESE CREA 4

PA Limit 5gms permonthQL(017gm daily)

ZOVIRAX CREA EX 5 4 PA QL(5 gmper 30 daysretail)

ZOVIRAX OINT EX 5 (Use Acyclovir Topical) 4

Burn Products mafenide acetate pack 4

SILVADENE CREA (Use Silver Sulfadiazine) 4

silver sulfadiazine crea 1

SULFAMYLON CREA 85 MGGM 4

SULFAMYLON PACK 5 (Use Mafenide Acetate) 4

Cauterizing Agents SILVER NITRATE OINT 4

SILVER NITRATE SOLN 4

Corticosteroids - Topical ACLOVATE CREA (Use Alclometasone Dipropionate)

4

ALA SCALP LOTN 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

61

Drug Name DrugTier

RequirementsLimits

alclometasone dipropionate crea 2

alclometasone dipropionateoint 2

AMCINONIDE CREA 4

AMCINONIDE LOTN 3

AMCINONIDE OINT 3

APEXICON E CREA 3

AUGMENTED BETAMETHASONE DIPROPIONATE GEL

4

betamethasone dipropionate (topical) crea 1

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint 1

betamethasone dipropionate augmented crea

1

betamethasone dipropionate augmentedgel

1

betamethasone dipropionate augmentedlotn

1

betamethasone dipropionate augmentedoint

2

betamethasone valerate crea 01 1

betamethasone valerate foam 012 4

betamethasone valerate lotn 01 1

betamethasone valerate oint 01 1

BRYHALI LOTN 4 PA

calcipotriene-betamethasone dipropionate oint

3 ST QL(2 gmdaily)

Drug Name DrugTier

RequirementsLimits

CAPEX SHAM 4

clobetasol propionate crea 1

clobetasol propionateemollient base crea 1

clobetasol propionateemulsion foam 4

clobetasol propionate foam 4

clobetasol propionate gel 1

clobetasol propionate liqd 4

clobetasol propionate lotn 4

clobetasol propionate oint 1

clobetasol propionate sham 2

clobetasol propionate soln 1

CLOBEX LIQD (Use Clobetasol Propionate) 4

CLOBEX LOTN (Use Clobetasol Propionate) 4

CLOBEX SHAM (Use Clobetasol Propionate) 4

CLOCORTOLONE PIVALATE CREA 4

CLOCORTOLONE PIVALATE PUMP CREA 4

CLODERM CREA 4

CLODERM PUMP CREA 4

CORDRAN CREA 0025 4 PA

CORDRAN CREA 005 (Use Flurandrenolide) 4

CORDRAN LOTN 005 (Use Flurandrenolide) 4 PA

CORDRAN OINT 005 (Use Flurandrenolide) 4 PA

CORDRAN TAPE 4 MCGSQCM 4

CUTIVATE LOTN (Use Fluticasone Propionate) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

62

Drug Name DrugTier

RequirementsLimits

DERMA-SMOOTHEFSBODY OIL (Use Fluocinolone Acetonide)

4

DERMA-SMOOTHEFSSCALP OIL (Use Fluocinolone Acetonide)

4

DERMATOP CREA (Use Prednicarbate) 4

DERMATOP OINT (Use Prednicarbate) 4

DESONATE GEL 4

desonide crea 1

desonide lotn 1

desonide oint 1

DESOWEN CREA (Use Desonide) 4

DESOWEN LOTN (Use Desonide) 4

desoximetasone crea 005 025 1

desoximetasone gel 005 1

desoximetasone liqd 025 4 ST

desoximetasone oint 005 4

desoximetasone oint 025 1

diflorasone diacetate crea 3

diflorasone diacetate oint 3

DIPROLENE AF CREA (Use Betamethasone Dipropionate Augmented)

4

DIPROLENE LOTN (Use Betamethasone Dipropionate Augmented)

4

DIPROLENE OINT (Use Betamethasone Dipropionate Augmented)

4

ELOCON CREA (Use Mometasone Furoate) 4

Drug Name DrugTier

RequirementsLimits

ELOCON OINT (Use Mometasone Furoate) 4

ENSTILAR FOAM 4 PA

EPIFOAM FOAM 4

fluocinolone acetonide crea 0025 001 1

fluocinolone acetonide oil 001 2

fluocinolone acetonide oint 0025 1

fluocinolone acetonide soln 001 1

fluocinonide crea 005 1

fluocinonide crea 01 4

fluocinonide emulsified base crea 1

fluocinonide gel 005 1

fluocinonide oint 005 1

fluocinonide soln 005 1

flurandrenolide crea 4

flurandrenolide lotn 4 PA

flurandrenolide oint 4 PA

fluticasone propionate crea005 1 QL(30 gm per

fill retail) fluticasone propionate lotn005 4

fluticasone propionate oint0005 1 QL(30 gm per

fill retail) halobetasol propionate crea 1

halobetasol propionate oint 1

HALOG CREA 4

HALOG OINT 4

hydrocortisone (topical)crea 25 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

63

Drug Name DrugTier

RequirementsLimits

hydrocortisone (topical)lotn 25 1

hydrocortisone (topical)oint 25 1

hydrocortisone (topical)soln 1 3

hydrocortisone butyrate crea 1

hydrocortisone butyratehydrophilic lipo base crea 1

hydrocortisone butyratelotn 4 PA

hydrocortisone butyrateoint 1

hydrocortisone butyratesoln 1

hydrocortisone valerate crea 1

hydrocortisone valerateoint 1

KENALOG AERS (Use Triamcinolone Acetonide (Topical))

4

LEXETTE FOAM 4 PA

LOCOID CREA (Use Hydrocortisone Butyrate) 4

LOCOID LIPOCREAM CREA (Use HydrocortisoneButyrate Hydrophilic LipoBase)

4

LOCOID LOTN (Use Hydrocortisone Butyrate) 4 PA

LOCOID OINT (Use Hydrocortisone Butyrate) 4

LOCOID SOLN (Use Hydrocortisone Butyrate) 4

LUXIQ FOAM (Use Betamethasone Valerate) 4

mometasone furoate crea 1

mometasone furoate oint 1

mometasone furoate soln 1

OLUX FOAM (Use Clobetasol Propionate) 4

Drug Name DrugTier

RequirementsLimits

OLUX-E FOAM (Use Clobetasol PropionateEmulsion)

4

PANDEL CREA 4

PRAMOSONE CREA 1-1 4

PRAMOSONE CREA 1-25 (Use Pramoxine-HC) 4

PRAMOSONE E CREA 4

PRAMOSONE LOTN 1-1 1-25 2

PRAMOSONE OINT 1-1 2

PRAMOSONE OINT 1-25 4

pramoxine-hc crea 1

PREDNICARBATE CREA 4

prednicarbate crea 1

PREDNICARBATE OINT 4

PSORCON CREA 4

SERNIVO EMUL 4 PA

SYNALAR CREA (Use Fluocinolone Acetonide) 4

SYNALAR OINT (Use Fluocinolone Acetonide) 4

SYNALAR SOLN (Use Fluocinolone Acetonide) 4

TACLONEX OINT (Use Calcipotriene-Betamethasone Dipropionate)

3

ST QL(2 gmdaily)

TACLONEX SUSP 4 ST QL(2 gmdaily)

TEMOVATE CREA (Use Clobetasol Propionate) 4

TEMOVATE E CREA (Use Clobetasol PropionateEmollient Base)

4

TEMOVATE OINT (Use Clobetasol Propionate) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

64

Drug Name DrugTier

RequirementsLimits

TEXACORT SOLN 4

TOPICORT CREA 005 025 (Use Desoximetasone)

4

TOPICORT GEL 005 (Use Desoximetasone) 4

TOPICORT LIQD 025 (Use Desoximetasone) 4 ST

TOPICORT OINT 005 025 (Use Desoximetasone)

4

triamcinolone acetonide (topical) aers 0147 mggm 3

triamcinolone acetonide (topical) crea 0025 01 05

1

triamcinolone acetonide (topical) lotn 0025 01

1

triamcinolone acetonide (topical) oint 0025 01 05

1

TRIANEX OINT 3

TRIDESILON CREA (Use Desonide) 4

ULTRAVATE CREA (Use Halobetasol Propionate) 4

ULTRAVATE LOTN 4 PA

ULTRAVATE OINT (Use Halobetasol Propionate) 4

VANOS CREA (Use Fluocinonide) 4

VERDESO FOAM 3

WESTCORT OINT (Use Hydrocortisone Valerate) 4

EmollientKeratolytic Agents urea crea 40 1 RXOTC

urea crea 41 4

urea gel 40 2

Drug Name DrugTier

RequirementsLimits

urea lotn 40 1

UTOPIC CREA (Use Urea) 4

Emollients lactic acid (ammoniumlactate) lotn 4

Enzymes - Topical SANTYL OINT 4

Immunomodulating Agents - Topical ALDARA CREA (Use Imiquimod) 4

imiquimod crea 1

IMIQUIMOD PUMP CREA 4

PA Limit 2 bottles per 28daysQL(28 gmper 28 daysretail)

ZYCLARA CREA 4

PA Limit 2 bottles per 28daysQL(28 gmper 28 daysretail)

ZYCLARA PUMP CREA 25 4

PA Limit 2 bottles per 28daysQL(06gm daily)

ZYCLARA PUMP CREA 375 4

PA Limit 2 bottles per 28daysQL(28 gmper 28 daysretail)

Immunosuppressive Agents - Topical ELIDEL CREA 4 PA

PROTOPIC OINT (Use Tacrolimus (Topical)) 4

tacrolimus (topical) oint 3

KeratolyticAntimitotic Agents CONDYLOX GEL 3

CONDYLOX SOLN (Use Podofilox) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

65

Drug Name DrugTier

RequirementsLimits

podofilox soln 3

SALEX SHAM (Use Salicylic Acid) 4

salicylic acid crea 6 1

salicylic acid liqd 26 4

salicylic acid lotn 6 1

salicylic acid sham 6 1

salicylic acid soln 26 4

Local Anesthetics - Topical AFTERTEST TOPICAL PAIN RELIEF STCK 3 QL(1 ml per

365 days retail)

CETACAINE AERO 4

lidocaine hcl crea ex 3 2 RXOTC

lidocaine hcl soln ex 4 1

lidocaine oint 2

lidocaine ptch 2 QL(3 ea daily)

lidocaine-prilocaine crea 2

lidocaine-prilocaine kit 4

LIDODERM PTCH (Use Lidocaine) 4 QL(3 ea daily)

LIDOPIN CREA 4 PA

LIDOVEX CREA 4 PA

pramoxine hcl gel 3 RXOTC

SYNERA PTCH 4

ZTLIDO PTCH 4 PA

Misc Topical DRYSOL SOLN 4

QBREXZA PADS 4 PA

Drug Name DrugTier

RequirementsLimits

Rosacea Agents

azelaic acid gel 3

QL(50 gm per30 daysretail150 gmper 90 daysmail)

DOXYCYCLINE CPDR 4 PA

FINACEA FOAM 4

FINACEA GEL (Use Azelaic Acid) 3

QL(50 gm per30 daysretail150 gmper 90 daysmail)

METROCREAM CREA (Use Metronidazole (Topical))

4

METROGEL GEL (Use Metronidazole (Topical)) 4

METROLOTION LOTN (Use Metronidazole (Topical))

4

metronidazole (topical)crea 075 2

metronidazole (topical) gel075 2

metronidazole (topical) gel1 1

metronidazole (topical) lotn075 2

MIRVASO GEL 4 PA

NORITATE CREA 4 PA

ORACEA CPDR 4 PA

SOOLANTRA CREA 4 PA QL(1 gmdaily)

Scabicides amp Pediculicides ELIMITE CREA (Use Permethrin) 4

LINDANE SHAM 4

lindane sham 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

66

Drug Name DrugTier

RequirementsLimits

malathion lotn 3 QL(59 ml perfill retail)

NATROBA SUSP 4

OVIDE LOTN (Use Malathion) 4 QL(59 ml per

fill retail)

permethrin crea 1

SKLICE LOTN 4

SPINOSAD SUSP 4

SULFURATED LIME SOLN 3

ULESFIA LOTN 4

Wound Care Products LURADROX GEL 4 PA

REGRANEX GEL 4

DIAGNOSTIC PRODUCTS

Diagnostic Radiopharmaceuticals AXUMIN SOLN 4 PA

Diagnostic Tests CHEK-STIX COMBO PAK URINALYSIS CONTROL STRP

2

CHEK-STIX CONTROL STRP 2

CHEMSTRIP-K STRP 2

CONTOUR NEXT BLOOD GLUCOSE TEST STRP 4 PA RXOTC

DIATHRIVE BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP

2

Limit 200 permonthQL(667ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

FREESTYLE INSULINX BLOODGLUCOSE TEST STRP

2

Limit 200 permonthQL(667ea daily)RXOTC

FREESTYLE LITE TEST STRIPS STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

FREESTYLE TEST STRIPS STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

KETOCARE STRP 2

KETONE TEST STRIPS STRP 2

KETOSTIX STRP 2

ONETOUCH ULTRA BLUE STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

ONETOUCH VERIO TEST STRIPS STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP

2

Limit 200 permonthQL(667ea daily)RXOTC

PREFERRED GLUCOMETER SUPPLIES AND STRIPS

2 Limit 200 permonth

PRO VOICE V8V9BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

RELION KETONE STRP 2

RELION KETONE TEST STRIPS STRP 2

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

67

Drug Name DrugTier

RequirementsLimits

Digestive Enzymes CREON CPEP 3

PANCREAZE CPEP 4

PERTZYE CPEP 4

SUCRAID SOLN 2 Specialty Tier 3May Apply

VIOKACE TABS 4

ZENPEP CPEP 3

DIURETICS - Drugs to Treat Heart CirculationConditions and Blood Pressure Carbonic Anhydrase Inhibitors acetazolamide cp12 1

acetazolamide tabs 1

DIAMOX CP12 (Use Acetazolamide) 4

KEVEYIS TABS 4 PA SpecialtyTier 3 MayApply

methazolamide tabs 2

NEPTAZANE TABS (Use Methazolamide) 4

Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Use Spironolactone ampHydrochlorothiazide)

4

ALDACTAZIDE TABS 50MG-50MG 4

amiloride amp hydrochlorothiazide tabs 1

DYAZIDE CAPS (Use Triamterene amp Hydrochlorothiazide)

4

MAXZIDE TABS (Use Triamterene amp Hydrochlorothiazide)

4

MAXZIDE-25 TABS (Use Triamterene amp Hydrochlorothiazide)

4

Drug Name DrugTier

RequirementsLimits

spironolactone amphydrochlorothiazide tabs 1

triamterene amp hydrochlorothiazide caps 1

triamterene amp hydrochlorothiazide tabs 1

TRIAMTERENEHYDROCHLOROTHIAZIDE CAPS 4

Loop Diuretics bumetanide tabs 1

BUMEX TABS (Use Bumetanide) 4

DEMADEX TABS (Use Torsemide) 4

EDECRIN TABS (Use Ethacrynic Acid) 3 ST

ethacrynic acid tabs 3 ST

furosemide soln 10 mgml 1

FUROSEMIDE SOLN 8 MGML 4

furosemide tabs 20 mg 40mg 80 mg 1

LASIX TABS (Use Furosemide) 4

torsemide tabs 1

Potassium Sparing Diuretics ALDACTONE TABS (Use Spironolactone) 4

amiloride hcl tabs 2

DYRENIUM CAPS 2

spironolactone tabs 2

Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG 4

chlorothiazide tabs 500 mg 1

chlorthalidone tabs 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

68

Drug Name DrugTier

RequirementsLimits

DIURIL SUSP 4

hydrochlorothiazide caps 1

hydrochlorothiazide tabs 1

indapamide tabs 1

methyclothiazide tabs 1

metolazone tabs 2

MICROZIDE CAPS (Use Hydrochlorothiazide) 4

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

ACTONEL TABS 150 MG (Use Risedronate Sodium) 4

QL(1 ea per 28days retail3 eaper 84 daysmail)

ACTONEL TABS 35 MG (Use Risedronate Sodium) 4 QL(4 ea per 30

days retail) ACTONEL TABS 5 MG 30 MG (Use Risedronate Sodium)

4

ALENDRONATE SODIUM SOLN 70 MG75ML 4

alendronate sodium tabs 5 mg 10 mg 35 mg 40 mg 1

alendronate sodium tabs 70 mg 1

QL(4 ea per fillretail12 ea perfill mail)

ATELVIA TBEC (Use Risedronate Sodium) 4

BINOSTO TBEF 4

BONIVA SOLN IV 3 MG3ML (Use Ibandronate Sodium)

J PA SpecialtyTier 3 MayApply

BONIVA TABS OR 150 MG (Use Ibandronate Sodium) 4 QL(1 ea per 30

days retail)

calcitonin (salmon) soln 2

etidronate disodium tabs 3

Drug Name DrugTier

RequirementsLimits

FORTEO SOLN J PA SpecialtyTier 2 MayApply

FOSAMAX PLUS D TABS 4

FOSAMAX TABS (Use Alendronate Sodium) 4

QL(4 ea per fillretail12 ea perfill mail)

ibandronate sodium soln iv 3 mg3ml J

PA SpecialtyTier 3 MayApply

ibandronate sodium tabs or 150 mg 1 QL(1 ea per 30

days retail) MIACALCIN SOLN IJ 200 UNITML J PA

MIACALCIN SOLN NA 200 UNITACT (Use Calcitonin (Salmon))

4

NATPARA CART J PA SpecialtyTier 3 MayApply

PROLIA SOLN J PA SpecialtyTier 3 MayApply

RECLAST SOLN (Use Zoledronic Acid) J

PA SpecialtyTier 3 MayApply

risedronate sodium tabs 150 mg 4

QL(1 ea per 28days retail3 eaper 84 daysmail)

risedronate sodium tabs 35 mg 4 QL(4 ea per 30

days retail) risedronate sodium tabs 5 mg 30 mg 4

risedronate sodium tbec 35 mg 1

XGEVA SOLN J PA SpecialtyTier 3 MayApply

zoledronic acid soln J PA SpecialtyTier 3 MayApply

Corticotropin

HP ACTHAR GEL J PA SpecialtyTier 4 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

69

Drug Name DrugTier

RequirementsLimits

GnRHLHRH Antagonists ORILISSA TABS 4 PA

Growth Hormone Receptor Antagonists

SOMAVERT SOLR 10 MG 15 MG 20 MG 25 MG J

PA SpecialtyTier 3 MayApply

SOMAVERT SOLR 30 MG J PA

Growth Hormones

GENOTROPIN MINIQUICK SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

GENOTROPIN SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

HUMATROPE COMBO PACK SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

HUMATROPE SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

NORDITROPIN FLEXPRO SOLN 10 MG15ML J

PA SpecialtyMay ApplyHumatrope Tier2 OmnitropeTier 2 NutropinTier 3 Genotropin Tier3

NORDITROPIN FLEXPRO SOLN 30 MG3ML 15MG15ML

J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

Drug Name DrugTier

RequirementsLimits

NORDITROPIN FLEXPRO SOLN 5 MG15ML J

PA SpecialtyTier 2 MayApply

NUTROPIN AQ NUSPIN 10 SOLN J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

NUTROPIN AQ NUSPIN 20 SOLN J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

NUTROPIN AQ NUSPIN 5 SOLN J

PA SpecialtyTier 3 MayApply

OMNITROPE SOLN 10 MG15ML J

PA SpecialtyMay ApplyHumatrope Tier2 OmnitropeTier 2 NutropinTier 3 Genotropin Tier3

OMNITROPE SOLN 5 MG15ML J

PA SpecialtyTier 2 MayApply

OMNITROPE SOLR 58 MG J

PA SpecialtyMay ApplyHumatrope Tier2 OmnitropeTier 2 NutropinTier 3 Genotropin Tier3

SAIZEN CLICKEASY SOLR J

PA SpecialtyTier 3 MayApply

SAIZEN SOLR J PA SpecialtyTier 3 MayApply

SAIZENPREP RECONSTITUTIONKIT SOLR

J PA SpecialtyTier 3 MayApply

SEROSTIM SOLR J PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

70

Drug Name DrugTier

RequirementsLimits

ZOMACTON SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

ZORBTIVE SOLR J PA SpecialtyTier 3 MayApply

Hormone Receptor Modulators EVISTA TABS (Use Raloxifene HCl) 4 PV

OSPHENA TABS 4

raloxifene hcl tabs 1 PV

Insulin-Like Growth Factors (Somatomedins)

INCRELEX SOLN J PA SpecialtyTier 3 MayApply

LHRHGnRH Agonist Analog Pituitary

LUPANETA PACK KIT J PA SpecialtyTier 2 MayApply

LUPRON DEPOT-PED (1-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LUPRON DEPOT-PED (3-MONTH) KIT J

PA SpecialtyTier 3 MayApply

SYNAREL SOLN 3

Metabolic Modifiers BUPHENYL POWD 3 GMTSP (Use Sodium Phenylbutyrate)

4 Specialty Tier 4May Apply

BUPHENYL TABS 500 MG (Use Sodium Phenylbutyrate)

4

calcitriol caps 1

CARBAGLU TABS 3 Specialty Tier 2May Apply

CARNITOR SF SOLN (Use Levocarnitine (MetabolicModifiers))

4

Drug Name DrugTier

RequirementsLimits

CARNITOR SOLN 1 GM10ML (Use Levocarnitine (MetabolicModifiers))

4

CARNITOR TABS 330 MG (Use Levocarnitine (Metabolic Modifiers))

4 RXOTC

doxercalciferol caps 4

GALAFOLD CAPS 4 PA

HECTOROL CAPS (Use Doxercalciferol) 4

KUVAN PACK 2 Specialty Tier 2May Apply

KUVAN TBSO 2 Specialty Tier 2May Apply

levocarnitine (metabolicmodifiers) soln 1 gm10ml 1

levocarnitine (metabolicmodifiers) tabs 330 mg 1 RXOTC

MYALEPT SOLR J PA SpecialtyTier 3 MayApply

ORFADIN CAPS 2 MG 5 MG 10 MG 20 MG 4 Specialty Tier 4

May Apply

ORFADIN SUSP 4 MGML 4 PA SpecialtyTier 4 MayApply

paricalcitol caps 2

RAVICTI LIQD 4 PA SpecialtyTier 4 MayApply

REVCOVI SOLN J PA SpecialtyTier 3 MayApply

ROCALTROL CAPS (Use Calcitriol) 4

SENSIPAR TABS 4

sodium phenylbutyratepowd 3 gmtsp 4 Specialty Tier 4

May Apply sodium phenylbutyrate tabs500 mg 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

71

Drug Name DrugTier

RequirementsLimits

STRENSIQ SOLN J PA SpecialtyTier 3 MayApply

XURIDEN PACK 4

ZEMPLAR CAPS (Use Paricalcitol) 4

Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCGML (Use Desmopressin Acetate)

4

DDAVP SOLN NA 001 4

DDAVP SOLN NA 001 (Use DesmopressinAcetate Spray)

4

DDAVP TABS OR 01 MG 02 MG (Use Desmopressin Acetate)

4

desmopressin acetate solnij 4 mcgml 3

desmopressin acetatespray refrigerated soln 3

desmopressin acetatespray soln 3

desmopressin acetate tabsor 01 mg 02 mg 2

NOCDURNA SUBL 4 PA

STIMATE SOLN 4

VASOPRESSINDEXTROSE SOLN 4 PA

Prolactin Inhibitors cabergoline tabs 2

Somatostatic Agents

octreotide acetate soln J

PA SpecialtyMay ApplyBrand Tier 2 Generic Tier 1

SANDOSTATIN SOLN (Use Octreotide Acetate) J

PA SpecialtyMay ApplyBrand Tier 2 Generic Tier 1

Drug Name DrugTier

RequirementsLimits

SIGNIFOR SOLN J PA SpecialtyTier 4 MayApply

SOMATULINE DEPOT SOLN 120 MG05ML J

PA SpecialtyMay ApplyBrand Tier 4 Generic Tier 1

SOMATULINE DEPOT SOLN 60 MG02ML 90MG03ML

J PA SpecialtyTier 2 MayApply

Vasopressin Receptor Antagonists

SAMSCA TABS 3

Specialty Tier 2MayApplyQL(1 eadaily)

ESTROGENS - Hormone ReplacementModifyingDrugs Estrogen Combinations ACTIVELLA TABS (Use Estradiol amp Norethindrone Acetate)

4

ANGELIQ TABS 4

CLIMARA PRO PTWK 2

QL(4 ea per 30days retail12ea per 90 daysmail)

COMBIPATCH PTTW 4

DUAVEE TABS 4

esterified estrogens ampmethyltestosterone tabs0625mg-125mg

1

esterified estrogens ampmethyltestosterone tabs125mg-25mg

2

estradiol amp norethindrone acetate tabs 1

FEMHRT LOW DOSE TABS (Use Norethindrone Acetate-Ethinyl Estradiol)

4

norethindrone acetate-ethinyl estradiol tabs 1

PREFEST TABS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

72

Drug Name DrugTier

RequirementsLimits

PREMPHASE TABS 2 QL(1 ea daily)

PREMPRO TABS 2 QL(1 ea daily)

Estrogens

ALORA PTTW 4

QL(8 ea per 28days retail24ea per 84 daysmail)

CLIMARA PTWK (Use Estradiol) 4

QL(8 ea per 28days retail24ea per 84 daysmail)

DIVIGEL GEL 4

ELESTRIN GEL 4

ESTRACE TABS OR 05 MG 1 MG 2 MG (Use Estradiol)

4

estradiol pttw td 00375mg24hr 0025 mg24hr0075 mg24hr 005mg24hr 01 mg24hr

1

QL(8 ea per 28days retail24ea per 84 daysmail)

estradiol ptwk td 0025mg24hr 0075 mg24hr005 mg24hr 006mg24hr 01 mg24hr 375mcg24hr

1

QL(8 ea per 28days retail24ea per 84 daysmail)

estradiol tabs or 05 mg 1mg 2 mg 1

ESTROGEL GEL 4

ESTROPIPATE TABS 075 MG 15 MG 4

estropipate tabs 3 mg 1

EVAMIST SOLN 4

MENEST TABS 4

MENOSTAR PTWK 4

QL(8 ea per 28days retail24ea per 84 daysmail)

Drug Name DrugTier

RequirementsLimits

MINIVELLE PTTW (Use Estradiol) 4

QL(8 ea per 28days retail24ea per 84 daysmail)

PREMARIN TABS OR 0625 MG 045 MG 03 MG 09 MG 125 MG

2

VIVELLE-DOT PTTW (Use Estradiol) 4

QL(8 ea per 28days retail24ea per 84 daysmail)

FLUOROQUINOLONES - Drugs to Treat BacterialInfections Fluoroquinolones AVELOX ABC PACK TABS (Use Moxifloxacin HCl) 4

AVELOX TABS (Use Moxifloxacin HCl) 4

CIPRO SUSR 5 GM100ML 4

CIPRO SUSR 500 MG5ML(Use Ciprofloxacin) 4

CIPRO TABS 250 MG 500 MG (Use CiprofloxacinHCl)

4

CIPRO XR TB24 (Use Ciprofloxacin-CiprofloxacinHCl)

4

QL(14 ea per30 daysretail42 ea per90 days mail)

CIPROFLOXACIN ER TB24 4

QL(14 ea per30 daysretail42 ea per90 days mail)

CIPROFLOXACIN HCL TABS 100 MG 4

ciprofloxacin hcl tabs 250mg 500 mg 750 mg 1

ciprofloxacin susr 4

FACTIVE TABS 4 PA QL(7 eaper 30 daysretail)

LEVAQUIN TABS (Use Levofloxacin) 4 QL(14 ea per

fill retail)

levofloxacin soln 25 mgml 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

73

Drug Name DrugTier

RequirementsLimits

levofloxacin tabs 250 mg500 mg 750 mg 1 QL(14 ea per

fill retail)

moxifloxacin hcl tabs 2

OFLOXACIN TABS 300 MG 2

ofloxacin tabs 400 mg 3

GASTROINTESTINAL AGENTS - MISC -Miscellaneous Gastrointestinal Drugs Agents for Chronic Idiopathic Constipation (CIC) TRULANCE TABS 4 PA

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS 4 PA SpecialtyTier 3 MayApply

Farnesoid X Receptor (FXR) Agonists OCALIVA TABS 4 PA

Gallstone Solubilizing Agents ACTIGALL CAPS (Use Ursodiol) 4

CHENODAL TABS 4 PA

URSO 250 TABS (Use Ursodiol) 4

URSO FORTE TABS (Use Ursodiol) 4

ursodiol caps 3

ursodiol tabs 3

Gastrointestinal Antiallergy Agents cromolyn sodium(mastocytosis) conc 1

GASTROCROM CONC (Use Cromolyn Sodium(Mastocytosis))

4

Gastrointestinal Chloride Channel Activators AMITIZA CAPS 3

Gastrointestinal Stimulants metoclopramide hcl soln 1

Drug Name DrugTier

RequirementsLimits

metoclopramide hcl tabs 1

METOCLOPRAMIDE ODT TBDP 4

REGLAN TABS (Use Metoclopramide HCl) 4

Inflammatory Bowel Agents APRISO CP24 4 PA

ASACOL HD TBEC 4 PA

ASACOL HD TBEC (Use Mesalamine) 4 PA

AZULFIDINE EN-TABS TBEC (Use Sulfasalazine) 4

AZULFIDINE TABS (Use Sulfasalazine) 4

balsalazide disodium caps 1

CANASA SUPP 3

CIMZIA KIT J PA SpecialtyTier 3 MayApply

CIMZIA STARTER KIT KIT J PA SpecialtyTier 3 MayApply

COLAZAL CAPS (Use Balsalazide Disodium) 4

DELZICOL CPDR 4 PA

DIPENTUM CAPS 4

GIAZO TABS 4 PA QL(6 eadaily)

LIALDA TBEC (Use Mesalamine) 3

mesalamine enem 3

mesalamine tbec 3

PENTASA CPCR 4 PA

REMICADE SOLR J PA SpecialtyTier 2 MayApply

SFROWASA ENEM 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

74

Drug Name DrugTier

RequirementsLimits

sulfasalazine tabs 1

sulfasalazine tbec 1

Intestinal Acidifiers lactulose (encephalopathy)soln 1

Irritable Bowel Syndrome (IBS) Agents alosetron hcl tabs 4

LINZESS CAPS 3

LOTRONEX TABS (Use Alosetron HCl) 4

VIBERZI TABS 4 PA SpecialtyTier 3 MayApply

Peripheral Opioid Receptor Antagonists ENTEREG CAPS 3

MOVANTIK TABS 4

RELISTOR SOLN SC 8 MG04ML 12 MG06ML J

PA SpecialtyTier 3 MayApply

RELISTOR TABS OR 150 MG 4

PA SpecialtyTier 3 MayApply

Phosphate Binder Agents AURYXIA TABS 4 PA

calcium acetate (phosphatebinder) caps 1

calcium acetate (phosphatebinder) tabs 1 RXOTC

ELIPHOS TABS (Use Calcium Acetate (Phosphate Binder))

4 RXOTC

FOSRENOL CHEW 500 MG 750 MG 1000 MG (Use Lanthanum Carbonate)

4

FOSRENOL PACK 750 MG 1000 MG 4

lanthanum carbonate chew 4

Drug Name DrugTier

RequirementsLimits

PHOSLYRA SOLN 4

RENAGEL TABS 4 PA

RENVELA PACK (Use Sevelamer Carbonate) 4

RENVELA TABS (Use Sevelamer Carbonate) 4

sevelamer carbonate pack 4

sevelamer carbonate tabs 4

VELPHORO CHEW 4 PA

Short Bowel Syndrome (SBS) Agents

GATTEX KIT J PA SpecialtyTier 4 MayApply

GENERAL ANESTHETICS

Anesthetics - Misc KETAMINE HYDROCHLORIDE SOSY 4 PA

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System Acidifiers K-PHOS NO 2 TABS 4

Alkalinizers ORACIT SOLN 2

pot amp sod citrates wcitricac soln 1

pot amp sod citrates wcitric ac syrp 1

potassium citrate(alkalinizer) tbcr 15 meq 4

potassium citrate(alkalinizer) tbcr 540 mg1080 mg

1

potassium citrate-citric acidpack 3300mg-1002mg 2

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Arizona 4-Tier Drug List Updated January 1 2019

75

Drug Name DrugTier

RequirementsLimits

potassium citrate-citric acidsoln 1100mg5ml-334mg5ml 1100mg5ml-1100mg5ml-334mg5ml-334mg5ml

1

RXOTC

POTASSIUM CITRATESODIUMCITRATECITRIC ACID SOLN

4

SHOHLS SOLUTION MODIFIED SOLN (Use Sodium Citrate amp Citric Acid)

4

RXOTC

sodium citrate amp citric acid soln 1 RXOTC

TRICITRATES SOLN 4

UROCIT-K 10 TBCR (Use Potassium Citrate (Alkalinizer))

4

UROCIT-K 15 TBCR (Use Potassium Citrate (Alkalinizer))

4

UROCIT-K 5 TBCR (Use Potassium Citrate (Alkalinizer))

4

Cystinosis Agents CYSTAGON CAPS 4

PROCYSBI CPDR 4

Genitourinary Irrigants sodium chloride (guirrigant) soln 1

Interstitial Cystitis Agents ELMIRON CAPS 4 QL(3 ea daily)

Prostatic Hypertrophy Agents alfuzosin hcl tb24 1

AVODART CAPS (Use Dutasteride) 4 AL(At least 40

yrs old)

CARDURA XL TB24 4

dutasteride caps 1 AL(At least 40yrs old)

Drug Name DrugTier

RequirementsLimits

dutasteride-tamsulosin hcl caps 2

finasteride tabs 2 AL(At least 40yrs old)

FLOMAX CAPS (Use Tamsulosin HCl) 4

JALYN CAPS (Use Dutasteride-Tamsulosin HCl)

4

PROSCAR TABS (Use Finasteride) 4 AL(At least 40

yrs old)

RAPAFLO CAPS 4 MG 4

RAPAFLO CAPS 4 MG 8 MG (Use Silodosin) 4

silodosin caps 4

tamsulosin hcl caps 1

UROXATRAL TB24 (Use Alfuzosin HCl) 4

Urinary Analgesics phenazopyridine hcl tabs 1

PYRIDIUM TABS (Use Phenazopyridine HCl) 4

Urinary Stone Agents LITHOSTAT TABS 4

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w probenecidtabs 2

Gout Agents allopurinol tabs 1

COLCHICINE CAPS 4

COLCHICINE TABS 4 PA

colchicine tabs 4

COLCRYS TABS 4

MITIGARE CAPS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

76

Drug Name DrugTier

RequirementsLimits

ULORIC TABS 3

ZURAMPIC TABS 4 PA

ZYLOPRIM TABS (Use Allopurinol) 4

Uricosurics probenecid tabs 1

HEMATOLOGICAL AGENTS - MISC - Drugs toTreat Blood Disorders Antihemophilic Products ADVATE SOLR 250 UNIT 500 UNIT 1000 UNIT 1500 UNIT 2000 UNIT 3000 UNIT

J

PA SpecialtyTier 4 MayApply

ADVATE SOLR 4000 UNIT J PA

ALPHANATEVONWILLEBRANDFACTOR COMPLEXHUMAN SOLR2000 UNIT

J

PA

ALPHANATEVONWILLEBRANDFACTOR COMPLEXHUMAN SOLR250 UNIT 500 UNIT 1000 UNIT 1500 UNIT

J

PA SpecialtyTier 4 MayApply

ALPHANINE SD SOLR J PA SpecialtyTier 4 MayApply

ALPROLIX SOLR J PA

BEBULIN SOLR J PA SpecialtyTier 4 MayApply

BENEFIX KIT J PA SpecialtyTier 4 MayApply

CORIFACT KIT J PA

ELOCTATE SOLR J PA SpecialtyTier 4 MayApply

FEIBA SOLR J PA SpecialtyTier 4 MayApply

Drug Name DrugTier

RequirementsLimits

HELIXATE FS KIT 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

HELIXATE FS KIT 3000 UNIT J PA

HEMOFIL M SOLR J PA SpecialtyTier 4 MayApply

HUMATE-P SOLR J PA SpecialtyTier 4 MayApply

IDELVION SOLR J PA

IXINITY SOLR 250 UNIT 500 UNIT 1000 UNIT 1500 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

IXINITY SOLR 3000 UNIT J PA

KOATE SOLR J PA SpecialtyTier 4 MayApply

KOATE-DVI SOLR J PA SpecialtyTier 4 MayApply

KOGENATE FS BIO-SET KIT 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

KOGENATE FS BIO-SET KIT 3000 UNIT J PA

KOGENATE FS KIT 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

KOGENATE FS KIT 3000 UNIT J PA

KOVALTRY SOLR 2000 UNIT 3000 UNIT J PA

KOVALTRY SOLR 250 UNIT 500 UNIT 1000 UNIT

J PA SpecialtyTier 4 MayApply

MONOCLATE-P KIT J PA SpecialtyTier 4 MayApply

MONONINE SOLR J PA SpecialtyTier 4 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

77

Drug Name DrugTier

RequirementsLimits

NOVOEIGHT SOLR 1500 UNIT 2000 UNIT 3000 UNIT

J PA

NOVOEIGHT SOLR 250 UNIT 500 UNIT 1000 UNIT

J PA SpecialtyTier 4 MayApply

NOVOSEVEN RT SOLR J PA

OBIZUR SOLR J PA SpecialtyTier 4 MayApply

PROFILNINE SD SOLR 1000 UNIT J PA

PROFILNINE SD SOLR 500 UNIT 1500 UNIT J

PA SpecialtyTier 4 MayApply

PROFILNINE SOLR 1000 UNIT J PA

PROFILNINE SOLR 500 UNIT 1500 UNIT J

PA SpecialtyTier 4 MayApply

RECOMBINATE SOLR J PA SpecialtyTier 4 MayApply

RIXUBIS SOLR 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

RIXUBIS SOLR 3000 UNIT J PA

WILATE KIT J PA SpecialtyTier 4 MayApply

XYNTHA KIT J PA

XYNTHA SOLOFUSE KIT J PA

Bradykinin B2 Receptor Antagonists

FIRAZYR SOLN J Specialty Tier 2May Apply

Complement Inhibitors

CINRYZE SOLR J PA SpecialtyTier 3 MayApply

RUCONEST SOLR J PA

Hematorheologic Agents

Drug Name DrugTier

RequirementsLimits

pentoxifylline tbcr 2

Plasma Proteins ALBUMINEX SOLN 4 PA

Platelet Aggregation Inhibitors AGGRENOX CP12 (Use Aspirin-Dipyridamole) 4

AGRYLIN CAPS (Use Anagrelide HCl) 4

anagrelide hcl caps 3

aspirin-dipyridamole cp12 4

BRILINTA TABS 3

cilostazol tabs 100 mg 2

cilostazol tabs 50 mg 1

clopidogrel bisulfate tabs300 mg 2

clopidogrel bisulfate tabs75 mg 2 QL(1 ea daily)

dipyridamole tabs 1

EFFIENT TABS (Use Prasugrel HCl) 4

PLAVIX TABS 300 MG (Use Clopidogrel Bisulfate) 4

PLAVIX TABS 75 MG (Use Clopidogrel Bisulfate) 4 QL(1 ea daily)

prasugrel hcl tabs 2

ZONTIVITY TABS 3

Protamine PROTAMINE SULFATE SOLN 3

Thrombolytic Enzymes ACTIVASE SOLR 3

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders Agents for Gaucher Disease

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Arizona 4-Tier Drug List Updated January 1 2019

78

Drug Name DrugTier

RequirementsLimits

CERDELGA CAPS 4 PA SpecialtyTier 3 MayApply

miglustat caps 3 PA SpecialtyTier 4 MayApply

ZAVESCA CAPS (Use Miglustat) 3

PA SpecialtyTier 4 MayApply

Agents for Sickle Cell Anemia DROXIA CAPS 2

SIKLOS TABS 4 PA

Cobalamins

cyanocobalamin soln J PA SpecialtyTier 1 MayApply

NASCOBAL SOLN 4

Folic AcidFolates folic acid tabs 1 RXOTC

Hematopoietic Growth Factors ARANESP ALBUMIN FREE SOLN 25 MCGML40 MCGML 60 MCGML100 MCGML 200MCGML 300 MCGML

J

PA SpecialtyTier 3 MayApply

ARANESP ALBUMIN FREE SOSY 10 MCG04ML

J PA

ARANESP ALBUMIN FREE SOSY 500 MCGML40 MCG04ML 60MCG03ML 100MCG05ML 150MCG03ML 200MCG04ML 25MCG042ML 300MCG06ML

J

PA SpecialtyTier 3 MayApply

EPOGEN SOLN J

PA SpecialtyMay ApplyProcrit Tier 2 Epogen Tier 3

FULPHILA SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

GRANIX SOSY J PA SpecialtyTier 3 MayApply

LEUKINE SOLR J PA SpecialtyTier 3 List MayApply

MIRCERA SOSY J PA SpecialtyTier 3 MayApply

MULPLETA TABS 4 PA

NEULASTA ONPRO KIT PSKT J

PA SpecialtyTier 3 MayApply

NEULASTA SOSY J PA SpecialtyTier 3 MayApply

NEUPOGEN SOLN J PA SpecialtyTier 3 MayApply

NEUPOGEN SOSY J PA SpecialtyTier 3 MayApply

NIVESTYM SOSY 4 PA

PROCRIT SOLN 2000 UNITML 3000 UNITML4000 UNITML 10000UNITML 20000 UNITML40000 UNITML

J

PA SpecialtyMay ApplyProcrit Tier 2 Epogen Tier 3

PROMACTA TABS 25 MG 50 MG 125 MG 4 PA

PROMACTA TABS 75 MG 4 PA SpecialtyTier 2 MayApply

UDENYCA SOSY 4 PA

ZARXIO SOSY J PA SpecialtyTier 3 MayApply

Hematopoietic Mixtures ferrous fumarate-folic acid tabs 1

Stem Cell Mobilizers MOZOBIL SOLN J PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

79

Drug Name DrugTier

RequirementsLimits

HEMOSTATICS - Drugs to Stop BleedingTreatBlood Disorders Hemostatics - Systemic AMICAR SOLN 025 GMML 4

AMICAR TABS 500 MG 1000 MG (Use Aminocaproic Acid)

4

aminocaproic acid tabs1000 mg 4 PA

aminocaproic acid tabs 500 mg 3

LYSTEDA TABS (Use Tranexamic Acid) 4

QL(30 ea per30 daysretail90 ea per90 days mail)

tranexamic acid tabs 1

QL(30 ea per30 daysretail90 ea per90 days mail)

HYPNOTICSSEDATIVESSLEEP DISORDERAGENTS Barbiturate Hypnotics BUTISOL SODIUM TABS 4

phenobarbital elix 1

phenobarbital soln 1

phenobarbital tabs 1

SECONAL SODIUM CAPS 4

Hypnotics - Tricyclic Agents

SILENOR TABS 4 ST QL(1 eadaily)

Non-Barbiturate Hypnotics AMBIEN CR TBCR (Use Zolpidem Tartrate) 4 QL(1 ea daily)

AMBIEN TABS (Use Zolpidem Tartrate) 4 QL(1 ea daily)

DORAL TABS 4

EDLUAR SUBL 4 PA

Drug Name DrugTier

RequirementsLimits

estazolam tabs 1

eszopiclone tabs 4 QL(1 ea daily)

FLURAZEPAM HCL CAPS 15 MG 4

flurazepam hcl caps 30 mg 1

HALCION TABS (Use Triazolam) 4

INTERMEZZO SUBL (Use Zolpidem Tartrate) 4 PA

LUNESTA TABS (Use Eszopiclone) 4 QL(1 ea daily)

midazolam hcl syrp 1

MIDAZOLAMSODIUMCHLORIDE SOLN 4 PA

QUAZEPAM TABS 4

RESTORIL CAPS (Use Temazepam) 4

SONATA CAPS (Use Zaleplon) 4 QL(1 ea daily)

temazepam caps 1

triazolam tabs 1

zaleplon caps 1 QL(1 ea daily)

zolpidem tartrate subl sl 35mg 175 mg 4 PA

zolpidem tartrate tabs or 5mg 10 mg 1 QL(1 ea daily)

zolpidem tartrate tbcr or125 mg 625 mg 4 QL(1 ea daily)

ZOLPIMIST SOLN 4

ST Limit 1 bottle permonthQL(026ml daily)

Orexin Receptor Antagonists

BELSOMRA TABS 3 ST QL(1 eadaily)

Selective Melatonin Receptor Agonists

HETLIOZ CAPS 4 PA SpecialtyTier 3 MayApply

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Arizona 4-Tier Drug List Updated January 1 2019

80

Drug Name DrugTier

RequirementsLimits

ROZEREM TABS 4 ST QL(1 eadaily)

LAXATIVES - Bowel Treatment Drugs

Laxative Combinations bisacodyl-peg 3350-potchloride-sod bicarb-sod chloride kit

4 AL(At least 50yrs old - Up to74 yrs old) PV

COLYTE-FLAVOR PACKS SOLR (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

4

AL(At least 50yrs old - Up to74 yrs old) PV

GOLYTELY SOLR 2271GM-215GM-553GM-282GM-636GM

4

PA AL(At least50 yrs old - Upto 74 yrs old)PV

GOLYTELY SOLR 236GM-2274GM-586GM-297GM-674GM (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

4

AL(At least 50yrs old - Up to74 yrs old) PV

MOVIPREP SOLR 4 AL(At least 50yrs old - Up to74 yrs old) PV

NULYTELYFLAVORPACKS SOLR (Use PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)

4

AL(At least 50yrs old - Up to74 yrs old) PV

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

2

AL(At least 50yrs old - Up to74 yrs old) PV

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr 240gm-2272gm-584gm-298gm-672gm

1

AL(At least 50yrs old - Up to74 yrs old) PV

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

1 AL(At least 50yrs old - Up to74 yrs old) PV

PLENVU SOLR 4 PA

PREPOPIK PACK 4

PA AL(At least50 yrs old - Upto 74 yrs old)PV

Drug Name DrugTier

RequirementsLimits

SUPREP BOWEL PREP KIT SOLN 4

AL(At least 50yrs old - Up to74 yrs old) PV

Laxatives - Miscellaneous KRISTALOSE PACK 10 GM (Use Lactulose) 3

KRISTALOSE PACK 20 GM 2

lactulose pack 1

lactulose soln 1

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing Local Anesthetics - Amides BUPIVACAINE HYDROCHLORIDE SOSY 4 PA

BUPIVACAINE HYDROCHLORIDEDEXTROSE SOSY

4 PA

EXPAREL SUSP 4 PA

ROPIVACAINE HYDROCHLORIDESODIUM CHLORIDE SOLN

4 PA

MACROLIDES - Drugs to Treat BacterialInfections Azithromycin azithromycin pack 1 gm 1

azithromycin susr 100mg5ml 200 mg5ml 2

azithromycin tabs 250 mg500 mg 600 mg 2

ZITHROMAX PACK (Use Azithromycin) 4

ZITHROMAX SUSR (Use Azithromycin) 4

ZITHROMAX TABS (Use Azithromycin) 4

ZITHROMAX TRI-PAK TABS (Use Azithromycin) 4

ZITHROMAX Z-PAK TABS (Use Azithromycin) 4

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Arizona 4-Tier Drug List Updated January 1 2019

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Drug Name DrugTier

RequirementsLimits

ZMAX SUSR 4 PA QL(1 eadaily)

Clarithromycin BIAXIN TABS (Use Clarithromycin) 4

CLARITHROMYCIN SUSR 125 MG5ML 250 MG5ML 4

clarithromycin susr 125mg5ml 250 mg5ml 2

clarithromycin tabs 250 mg500 mg 1

clarithromycin tb24 500 mg 2

Erythromycins EES GRANULES SUSR (Use ErythromycinEthylsuccinate)

4

ERY-TAB TBEC 4

ERYPED 200 SUSR (Use ErythromycinEthylsuccinate)

4

ERYPED 400 SUSR 4

ERYTHROCIN STEARATE TABS 4

erythromycin base cpep 1

erythromycin base tabs 1

erythromycinethylsuccinate susr 200mg5ml

4

erythromycinethylsuccinate tabs 400 mg 1

PCE TBEC 3

Fidaxomicin DIFICID TABS 4

MEDICAL DEVICES AND SUPPLIES

Contraceptives CAYA DPRH 2 PV

Drug Name DrugTier

RequirementsLimits

FEMCAP DEVI 3 PV

FEMCAP DEVI 4 PV

OMNIFLEX DIAPHRAGM DPRH 2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 60 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 65 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 70 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 75 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 80 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 85 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 90 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 95 DPRH

2 PV

Diabetic Supplies EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI

4 PA

EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT

4 PA RXOTC

FREESTYLE LIBRE 14 DAYREADERFLASHMONITORING SYSTEM DEVI

4

PA

FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM KIT

2

RXOTC

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

82

Drug Name DrugTier

RequirementsLimits

GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC DEVI

3

QL(0002 eadaily) B NT

HW EMBRACE PRO BLOOD GLUCOSE METER DEVI

4 PA

HW EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI

4 PA

HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT

4

PA RXOTC

LANCETS AND LANCET DEVICES 2

PRO VOICE V8 BLOOD GLUCOSE MONITORING SYSTEM DEVI

4 PA

PRO VOICE V9 BLOOD GLUCOSE MONITORING SYSTEM DEVI

4 PA

Parenteral Therapy Supplies AUTOPEN DEVI 4 RXOTC

BD PEN MINI MISC 4 RXOTC

BD PEN MISC 4 RXOTC

HUMAPEN LUXURA HD DEVI 4 RXOTC

INPEN 100BLUELILLYDEVI 4 RXOTC

INPEN 100BLUENOVODEVI 4 RXOTC

INPEN 100GRAYLILLYDEVI 4 RXOTC

INPEN 100GREYNOVODEVI 4 RXOTC

INPEN 100PINKLILLYDEVI 4 RXOTC

INPEN 100PINKNOVODEVI 4 RXOTC

INSULIN SYRINGES AND PEN NEEDLES 2

Drug Name DrugTier

RequirementsLimits

KMART VALU PLUS INSULIN SYRINGE03ML30GMISC

2

KMART VALU PLUS INSULIN SYRINGE05ML29GMISC

2

KMART VALU PLUS INSULIN SYRINGE05ML30GMISC

2

NOVOPEN ECHO DEVI 4 RXOTC

Respiratory Therapy Supplies NASONEB NASAL NEBULIZER REPLACEMENT MISC

3 RXOTC

NASONEB NASAL NEBULIZER STARTER KIT MISC

3 RXOTC

PARI SINUSTAR NASAL AEROSOL DELIVERY SYSTEM MISC

3 RXOTC

PARI SINUSTAR NASAL NEBULIZER MISC 3 RXOTC

SPACERAEROSOL-HOLDING CHAMBER 2

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches Migraine Combinations CAFERGOT TABS (Use Ergotamine w Caffeine) 4

ergotamine w caffeine tabs 2

ISOMETHEPTENE MUCATECAFFEINEACETAMINOPHEN TABS

4

isometheptene-caffeine-acetaminophen tabs 2

isometheptene-dichloralphenazone-acetaminophen caps

1

ISOMETHEPTENEDICHLORALPHENAZONEACETAMINOPHEN CAPS

4

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Arizona 4-Tier Drug List Updated January 1 2019

83

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

QL(12 ea per30 daysretail36 ea per90 days mail)

PRODRIN TABS (Use Isometheptene-Caffeine-Acetaminophen)

4

sumatriptan-naproxensodium tabs 4

PA QL(9 eaper fill retail27ea per fill mail9ea per 30 daysretail27 ea per90 days mail)

TREXIMET TABS (Use Sumatriptan-NaproxenSodium)

4

PA QL(9 eaper fill retail27ea per fill mail9ea per 30 daysretail27 ea per90 days mail)

Migraine Products - NSAIDs

CAMBIA PACK 4 PA Limit 9 permonthQL(03ea daily)

Migraine Products DHE 45 SOLN (Use DihydroergotamineMesylate)

J PA SpecialtyTier 1 MayApply

dihydroergotaminemesylate soln ij 1 mgml J

PA SpecialtyTier 1 MayApply

dihydroergotaminemesylate soln na 4 mgml 4

ERGOMAR SUBL 4

MIGRANAL SOLN 4

Serotonin Agonists

almotriptan malate tabs 3

QL(6 ea per 30days retail18ea per 90 daysmail)

AMERGE TABS (Use Naratriptan HCl) 4

QL(9 ea per 30days retail27ea per 90 daysmail)

Drug Name DrugTier

RequirementsLimits

AXERT TABS (Use Almotriptan Malate) 4

QL(6 ea per 30days retail18ea per 90 daysmail)

eletriptan hydrobromidetabs 4

QL(6 ea per fillretail6 ea per30 daysretail18 ea per90 days mail)

FROVA TABS (Use Frovatriptan Succinate) 4

QL(9 ea per 30days retail18ea per 90 daysmail)

frovatriptan succinate tabs 4

QL(9 ea per 30days retail18ea per 90 daysmail)

IMITREX SOLN NA 5 MGACT 20 MGACT (Use Sumatriptan)

4

Limit 6 sprays permonthQL(023ea daily)

IMITREX SOLN SC 6 MG05ML (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

IMITREX STATDOSE REFILL SOCT (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

IMITREX STATDOSE SYSTEM SOAJ 4 MG05ML (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

IMITREX STATDOSE SYSTEM SOAJ 6 MG05ML (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper 30 daysretail)

IMITREX TABS OR 25 MG 50 MG 100 MG (Use Sumatriptan Succinate)

4 QL(035 eadaily)

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Arizona 4-Tier Drug List Updated January 1 2019

84

Drug Name DrugTier

RequirementsLimits

MAXALT TABS (Use Rizatriptan Benzoate) 4

QL(9 ea per 30days retail27ea per 90 daysmail)

MAXALT-MLT TBDP (Use Rizatriptan Benzoate) 4

QL(9 ea per 30days retail27ea per 90 daysmail)

naratriptan hcl tabs 3

QL(9 ea per 30days retail27ea per 90 daysmail)

ONZETRA XSAIL EXHP 4 PA

RELPAX TABS (Use Eletriptan Hydrobromide) 4

QL(6 ea per fillretail6 ea per30 daysretail18 ea per90 days mail)

rizatriptan benzoate tabs 2

QL(9 ea per 30days retail27ea per 90 daysmail)

rizatriptan benzoate tbdp 2

QL(9 ea per 30days retail27ea per 90 daysmail)

sumatriptan soln 2

Limit 6 sprays permonthQL(023ea daily)

sumatriptan succinate soajsc 4 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

sumatriptan succinate soajsc 6 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper 30 daysretail)

sumatriptan succinate soctsc 4 mg05ml 6 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

Drug Name DrugTier

RequirementsLimits

sumatriptan succinate solnsc 6 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

SUMATRIPTAN SUCCINATE SOSY SC 6 MG05ML

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

sumatriptan succinate tabsor 25 mg 50 mg 100 mg 2 QL(035 ea

daily)

SUMAVEL DOSEPRO SOTJ J

PA SpecialtyTier 3 MayApply

ZEMBRACE SYMTOUCH SOAJ J PA

zolmitriptan tabs 4

QL(6 ea per 30days retail18ea per 90 daysmail)

zolmitriptan tbdp 4

QL(6 ea per 30days retail18ea per 90 daysmail)

ZOMIG SOLN NA 5 MG 25 MG 4

QL(6 ea per 30days retail18ea per 90 daysmail)

ZOMIG TABS OR 5 MG 25 MG (Use Zolmitriptan) 4

QL(6 ea per 30days retail18ea per 90 daysmail)

ZOMIG ZMT TBDP (Use Zolmitriptan) 4

QL(6 ea per 30days retail18ea per 90 daysmail)

MINERALS amp ELECTROLYTES

Calcium CALCIUM GLUCONATE SOSY 4 PA

Electrolyte Mixtures IONOSOL-BDEXTROSE5 SOLN 3

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Arizona 4-Tier Drug List Updated January 1 2019

85

Drug Name DrugTier

RequirementsLimits

IONOSOL-MBDEXTROSE5 SOLN 3

ISOLYTE-PDEXTROSE5 SOLN 3

ISOLYTE-S PH 74 SOLN 3

ISOLYTE-S SOLN 3

KCL 03D5WNACL09 SOLN 3

NORMOSOL -R SOLN 3

NORMOSOL-M IN D5W SOLN 3

NORMOSOL-R IN D5W SOLN 3

NORMOSOL-R SOLN 3

PLASMA-LYTE A SOLN 3

PLASMA-LYTE-148 SOLN 3

PLASMA-LYTE-56D5WSOLN 3

potassium chloride indextrose amp sodium chloride soln

3

Fluoride FLUORABON SOLN 4 PV

LOZI-FLUR LOZG 2

LURIDE SOLN (Use Sodium Fluoride) 4 PV

sodium fluoride chew 025 mg 05 mg 1 mg 22 mg 1 PV

sodium fluoride soln 0125 mgdrop 3 PV

sodium fluoride soln 025 mgdrop 05 mgml 1 PV

SODIUM FLUORIDE TABS 05 MG 4 PV

sodium fluoride tabs 1 mg 1

Iodine Products IODINE STRONG SOLN 3

Drug Name DrugTier

RequirementsLimits

Magnesium MAGNEBIND 400 TABS 3

Phosphate K-PHOS NEUTRAL TABS (Use Pot PhosphateMonobasic w SodPhosphate Dibasic ampMonobasic)

4

K-PHOS TABS 3

pot phosphate monobasicw sod phosphate dibasic ampmonobasic tabs

2

POTASSIUM PHOSPHATESDEXTROSE SOLN

4 PA

POTASSIUM PHOSPHATESSODIUMCHLORIDE SOLN

4 PA

SODIUM PHOSPHATESODIUMCHLORIDE SOLN

4 PA

Potassium EFFER-K TBEF 3

K-BICARB CAPS 4

K-TAB TBCR 10 MEQ (Use Potassium Chloride) 4

K-TAB TBCR 20 MEQ 4

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 4

KLOR-CON25 PACK 4

MICRO-K CPCR (Use Potassium Chloride) 4

potassium bicarb amp chloridetbef 2

potassium bicarbonate tbef 1

potassium chloride cpcr or8 meq 10 meq 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

86

Drug Name DrugTier

RequirementsLimits

POTASSIUM CHLORIDE ER TBCR 20 MEQ 4

POTASSIUM CHLORIDE ER TBCR 8 MEQ 2

potassium chloridemicroencapsulated crystalser tbcr

1

potassium chloride pack or20 meq 1

POTASSIUM CHLORIDE SOSY IV 10 MEQ5ML 4 PA

potassium chloride tbcr or8 meq 10 meq 1

Trace Minerals THE LIQUILIFT TRACE KIT KIT 4 PA

Zinc GALZIN CAPS 4

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS 3 PA

DEPEN TITRATABS TABS 4

SYPRINE CAPS (Use Trientine HCl) 4

PA SpecialtyTier 1 MayApply

trientine hcl caps 4 PA SpecialtyTier 1 MayApply

Enzymes

XIAFLEX SOLR J PA SpecialtyTier 3 MayApply

Immunomodulators REVLIMID CAPS 20 MG 25 MG 4 PA

REVLIMID CAPS 5 MG 10 MG 15 MG 25 MG 4

PA SpecialtyTier 2 MayApply

THALOMID CAPS 4 Specialty Tier 2May Apply

Immunosuppressive Agents

Drug Name DrugTier

RequirementsLimits

ASTAGRAF XL CP24 4 PA

AZASAN TABS 4

azathioprine tabs 2

CELLCEPT CAPS (Use Mycophenolate Mofetil) 4

CELLCEPT SUSR (Use Mycophenolate Mofetil) 4

CELLCEPT TABS (Use Mycophenolate Mofetil) 4

cyclosporine caps 2

cyclosporine modified (formicroemulsion) caps 25mg 100 mg

2

cyclosporine modified (formicroemulsion) caps 50 mg 1

cyclosporine modified (formicroemulsion) soln 100mgml

2

ENVARSUS XR TB24 4 ST

IMURAN TABS (Use Azathioprine) 4

mycophenolate mofetil caps 2

mycophenolate mofetil susr 2

mycophenolate mofetil tabs 2

mycophenolate sodiumtbec 1

MYFORTIC TBEC (Use Mycophenolate Sodium) 4

NEORAL CAPS (Use Cyclosporine Modified (ForMicroemulsion))

4

NEORAL SOLN (Use Cyclosporine Modified (ForMicroemulsion))

4

PROGRAF CAPS (Use Tacrolimus) 4

RAPAMUNE SOLN 1 MGML 2

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Arizona 4-Tier Drug List Updated January 1 2019

87

Drug Name DrugTier

RequirementsLimits

RAPAMUNE TABS 05 MG 1 MG 2 MG (Use Sirolimus)

4

SANDIMMUNE CAPS 25 MG 100 MG (Use Cyclosporine)

4

SANDIMMUNE SOLN 100 MGML 4

sirolimus tabs 1

tacrolimus caps 2

ZORTRESS TABS 2

Potassium Removing Agents LOKELMA PACK 4 PA

sodium polystyrenesulfonate susp or 15gm60ml

2

sodium polystyrenesulfonate susp re 30gm120ml 50 gm200ml

1

VELTASSA PACK 4 ST

MOUTHTHROATDENTAL AGENTS

Anesthetics Topical Oral FIRST-MOUTHWASH BLM SUSP 4

lidocaine hcl (mouth-throat)soln 1

LIDOCAINE HCL SOLN MT 4 3

Anti-infectives - Throat clotrimazole lozg 3

clotrimazole troc 3

nystatin (mouth-throat) susp 1

ORAVIG TABS 4

Dental Products NAFRINSE DAILYACIDULATEDSOLR

3

Drug Name DrugTier

RequirementsLimits

NAFRINSE DAILYNEUTRAL SOLR 3

Steroids - MouthThroat triamcinolone acetonide (mouth) pste 1

Throat Products - Misc cevimeline hcl caps 4

EVOXAC CAPS (Use Cevimeline HCl) 4

pilocarpine hcl (oral) tabs 2

SALAGEN TABS (Use Pilocarpine HCl (Oral)) 4

MULTIVITAMINS

Prenatal Vitamins prenatal w calciumcarbonate-vit b6-vit b12-folic acid tabs

1

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms Central Muscle Relaxants AMRIX CP24 4

baclofen tabs 10 mg 20 mg 1

BACLOFEN TABS 5 MG 4

carisoprodol tabs 250 mg 2

carisoprodol tabs 350 mg 1

CHLORZOXAZONE TABS 250 MG 2

CHLORZOXAZONE TABS 500 MG 4

cyclobenzaprine hcl tabs 1

FEXMID TABS (Use Cyclobenzaprine HCl) 3

LORZONE TABS 4

METAXALONE TABS 400 MG 4

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Arizona 4-Tier Drug List Updated January 1 2019

88

Drug Name DrugTier

RequirementsLimits

metaxalone tabs 800 mg 4

methocarbamol tabs 1

orphenadrine citrate tb12 2

PARAFON FORTE DSC TABS (Use Chlorzoxazone)

4

ROBAXIN TABS (Use Methocarbamol) 4

ROBAXIN-750 TABS (Use Methocarbamol) 4

SKELAXIN TABS (Use Metaxalone) 4

SOMA TABS (Use Carisoprodol) 4

tizanidine hcl tabs 1

ZANAFLEX TABS (Use Tizanidine HCl) 4

Direct Muscle Relaxants DANTRIUM CAPS (Use Dantrolene Sodium) 4

dantrolene sodium caps 3

Muscle Relaxant Combinations carisoprodol w aspirin ampcodeine tabs 2

carisoprodol w aspirin tabs 2

CYCLOGABA10300PACK THPK 4 PA

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus Nasal Agent Combinations

DYMISTA SUSP 4

Limit 1 bottle permonthQL(077gm daily)

Nasal Agents - Misc TICASPRAY THPK 4 PA

Nasal Anti-infectives

Drug Name DrugTier

RequirementsLimits

BACTROBAN NASAL OINT 2

Nasal Antiallergy ASTEPRO SOLN (Use Azelastine HCl) 4

azelastine hcl soln 1

olopatadine hcl (nasal) soln 4

PATANASE SOLN (Use Olopatadine HCl (Nasal)) 4

Nasal Anticholinergics ipratropium bromide (nasal)soln 1

Nasal Steroids BECONASE AQ SUSP 4

budesonide (nasal) susp 2

QL(9 ml per 30days retail26ml per 90 daysmail) RXOTC

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use Fluticasone Propionate (Nasal))

4

RXOTC

FLONASE ALLERGY RELIEF SUSP (Use Fluticasone Propionate(Nasal))

4

RXOTC

FLONASE SENSIMIST SUSP 4 RXOTC

FLUNISOLIDE SOLN 4

fluticasone propionate(nasal) susp 1 RXOTC

mometasone furoate (nasal) susp 1

QL(34 gm perfill retail34 gmper 30 daysretail)

NASONEX SUSP (Use Mometasone Furoate (Nasal))

3

QL(34 gm perfill retail34 gmper 30 daysretail)

OMNARIS SUSP 4 Limit 1 permonthQL(042gm daily)

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Arizona 4-Tier Drug List Updated January 1 2019

89

Drug Name DrugTier

RequirementsLimits

QNASL AERS 4

Limit 1 inhaler permonthQL(03gm daily)

QNASL CHILDRENS AERS 4

Limit 1 inhaler permonthQL(017gm daily)

RHINOCORT AQUA SUSP (Use Budesonide (Nasal)) 4

QL(9 ml per 30days retail26ml per 90 daysmail) RXOTC

VERAMYST SUSP 4 RXOTC

ZETONNA AERS 4

Limit 1 inhaler permonthQL(03gm daily)

Sympathomimetic Decongestants ADRENALIN SOLN 4

TYZINE PEDIATRIC NASAL DROPS SOLN 3

NEUROMUSCULAR AGENTS - Drugs toRelaxParalyze Muscles ALS Agents RILUTEK TABS (Use Riluzole) 4

riluzole tabs 3

TIGLUTIK SUSP 4 PA

NUTRIENTS

Carbohydrates alcohol soln 3

Lipids OMEGAVEN EMUL 4 PA

Proteins FREAMINE HBC 69 SOLN 3

L-TRYPTOPHAN CAPS 3 RXOTC

Drug Name DrugTier

RequirementsLimits

NEPHRAMINE SOLN 3

PROCALAMINE SOLN 3

PROSOL SOLN 3

TRYPTOPHAN CAPS 3 RXOTC

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Beta-blockers - Ophthalmic BETAGAN SOLN (Use Levobunolol HCl) 4

betaxolol hcl (ophth) soln 2

BETIMOL SOLN 2

BETOPTIC-S SUSP 3

carteolol hcl (ophth) soln 2

CARTEOLOL HCL SOLN 4

COMBIGAN SOLN 4

COSOPT PF SOLN (Use Dorzolamide HCl-Timolol Maleate)

4

COSOPT SOLN (Use Dorzolamide HCl-Timolol Maleate)

4

dorzolamide hcl-timolol maleate soln 2-05223mgml-68mgml

2

dorzolamide hcl-timolol maleate soln 20mgml-5mgml

4

DORZOLAMIDE HCLTIMOLOL MALEATESOLN

4

ISTALOL SOLN 4

ISTALOL SOLN (Use Timolol Maleate (Ophth)) 4

levobunolol hcl soln 1

METIPRANOLOL SOLN 4

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Arizona 4-Tier Drug List Updated January 1 2019

90

Drug Name DrugTier

RequirementsLimits

timolol maleate (ophth)solg 025 05 2

timolol maleate (ophth)soln 025 05 1

timolol maleate (ophth)soln 05 4

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG

4

TIMOLOLBRIMONIDEDORZOLAMIDE SOLN 4 PA

TIMOLOLBRIMONIDINEDORZOLAMIDELATANOPROST SOLN

4 PA

TIMOLOLDORZOLAMIDELATANOPROST SOLN 4 PA

TIMOLOLLATANOPROSTSOLN 4 PA

TIMOPTIC OCUDOSE SOLN 4

TIMOPTIC SOLN (Use Timolol Maleate (Ophth)) 4

TIMOPTIC-XE SOLG 025 (Use Timolol Maleate (Ophth))

4

TIMOPTIC-XE SOLG 025 05 4

Cycloplegic Mydriatics ATROPINE SULFATE OINT OP 1 2

ATROPINE SULFATE SOLN OP 1 4

ATROPINE SULFATESODIUMCHLORIDE SOLN

2

CYCLOGYL SOLN (Use Cyclopentolate HCl) 4

CYCLOMYDRIL SOLN 4

cyclopentolate hcl soln 05 2 4

cyclopentolate hcl soln 1 1

homatropine hbr soln 1

ISOPTO ATROPINE SOLN 4

Drug Name DrugTier

RequirementsLimits

MYDRIACYL SOLN (Use Tropicamide) 4

tropicamide soln 2

TROPICAMIDEPROPARACAINEPHENYLEPHRINEKETOROLAC SOLN

4 PA

Miotics ISOPTO CARPINE SOLN (Use Pilocarpine HCl) 4

PHOSPHOLINE IODIDE SOLR 3

pilocarpine hcl soln 1

Ophthalmic - Angiogenesis Inhibitors

LUCENTIS SOSY J PA SpecialtyTier 4 MayApply

Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 01 3

ALPHAGAN P SOLN 015 (Use Brimonidine Tartrate)

4

apraclonidine hcl soln 3

BRIMONIDEDORZOLAMIDE P-F SOLN 4 PA

brimonidine tartrate soln 2

IOPIDINE SOLN 05 (Use Apraclonidine HCl) 4

IOPIDINE SOLN 1 4

SIMBRINZA SUSP 4

Ophthalmic Anti-infectives

AZASITE SOLN 4

Limit 25mls permonthQL(018ml daily14day(s) limit)

BACITRACIN OINT 4

bacitracin-polymyxin b(ophth) oint 1

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Arizona 4-Tier Drug List Updated January 1 2019

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Drug Name DrugTier

RequirementsLimits

BESIVANCE SUSP 4

BETADINE OPHTHALMIC PREP SOLN 4

BLEPH-10 SOLN (Use Sulfacetamide Sodium (Ophth))

4

CILOXAN OINT 4

CILOXAN SOLN (Use Ciprofloxacin HCl (Ophth)) 4

ciprofloxacin hcl (ophth)soln 2

erythromycin (ophth) oint 1

gatifloxacin (ophth) soln 1

GENTAK OINT 4

gentamicin sulfate (ophth)oint 1

gentamicin sulfate (ophth)soln 1

levofloxacin (ophth) soln 4

MOXEZA SOLN 2

moxifloxacin hcl (ophth)soln 1

NATACYN SUSP 4

neomycin-bacitracin zn-polymyxin oint 1

neomycin-polymyxin-gramicidin soln 2

NEOSPORIN SOLN (Use Neomycin-Polymyxin-Gramicidin)

4

OCUFLOX SOLN (Use Ofloxacin (Ophth)) 4 QL(5 ml per fill

retail)

ofloxacin (ophth) soln 2 QL(5 ml per fillretail)

polymyxin b-trimethoprimsoln 1

POLYTRIM SOLN (Use Polymyxin B-Trimethoprim) 4

Drug Name DrugTier

RequirementsLimits

sulfacetamide sodium (ophth) soln 1

SULFACETAMIDE SODIUM OINT 3

tobramycin (ophth) soln 1

TOBREX OINT 4

TOBREX SOLN (Use Tobramycin (Ophth)) 4

trifluridine soln 3

VIGAMOX SOLN (Use Moxifloxacin HCl (Ophth)) 3

VIROPTIC SOLN (Use Trifluridine) 4

ZIRGAN GEL 4

ZYMAXID SOLN (Use Gatifloxacin (Ophth)) 4

Ophthalmic Decongestants phenylephrine hcl (ophth)soln 1

Ophthalmic Immunomodulators CEQUA SOLN 4 PA

RESTASIS EMUL 4

RESTASIS MULTIDOSE EMUL 4

Ophthalmic Local Anesthetics AKTEN GEL 4

ALCAINE SOLN (Use Proparacaine HCl) 4

proparacaine hcl soln 2

tetracaine hcl (ophth) soln 4

Ophthalmic Nerve Growth Factors OXERVATE SOLN 4 PA

Ophthalmic Steroids ALREX SUSP 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

92

Drug Name DrugTier

RequirementsLimits

bacitracin-poly-neomycin-hc oint 1

BLEPHAMIDE SOP OINT 4

BLEPHAMIDE SUSP 4

DEXAMETHASONE SODIUM PHOSPHATE SOLN

4

DUREZOL EMUL 4

FLAREX SUSP 2

fluorometholone (ophth) susp 1

FML FORTE SUSP 4 Limit 5mls permonthQL(017ml daily)

FML LIQUIFILM SUSP (Use Fluorometholone (Ophth))

4

FML OINT 4

INVELTYS SUSP 4 PA

LOTEMAX GEL 4

LOTEMAX OINT 4

LOTEMAX SUSP 4

MAXIDEX SUSP 4

MAXITROL OINT (Use Neomycin-Polymy-Dexameth)

4

MAXITROL SUSP (Use Neomycin-Polymy-Dexameth)

4

neomycin-polymy-dexameth oint 1

neomycin-polymy-dexameth susp 1

neomycin-polymyxin-hc(ophth) susp 1

OMNIPRED SUSP (Use Prednisolone Acetate (Ophth))

4

Drug Name DrugTier

RequirementsLimits

PRED FORTE SUSP (Use Prednisolone Acetate (Ophth))

4

PRED MILD SUSP 4

PRED-G SOP OINT 4

PRED-G SUSP 3

prednisolone acetate(ophth) susp 1

PREDNISOLONE ACETATE P-F SUSP 4

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1

4

PREDNISOLONE SODIUM PHOSPHATEBROMFENAC SOLN

4 PA

PREDNISOLONE SODIUM PHOSPHATEGATIFLOXACIN SOLN

4 PA

PREDNISOLONE SODIUM PHOSPHATEGATIFLOXACINBROMFENAC SOLN

4 PA

PREDNISOLONEMOXIFLOXACIN SOLN 4 PA

PREDNISOLONEMOXIFLOXACINBROMFENACSOLN

4 PA

PREDNISOLONEMOXIFLOXACINKETOROLACSOLN

4 PA

sulfacetamide sod-prednisolone soln 1

TOBRADEX OINT 4

TOBRADEX ST SUSP 4

TOBRADEX SUSP (Use Tobramycin-Dexamethasone)

4 QL(5 ml per fillretail5 ml per30 days retail)

tobramycin-dexamethasone susp 1

QL(5 ml per fillretail5 ml per30 days retail)

YUTIQ IMPL 4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

93

Drug Name DrugTier

RequirementsLimits

ZYLET SUSP 4 Limit 5mls permonthQL(017ml daily)

Ophthalmics - Misc ACULAR LS SOLN (Use Ketorolac Tromethamine (Ophth))

4

ACULAR SOLN (Use Ketorolac Tromethamine (Ophth))

4

ACUVAIL SOLN 4

ALOCRIL SOLN 4

ALOMIDE SOLN 3

azelastine hcl (ophth) soln 2

AZOPT SUSP 2

BEPREVE SOLN 4

ST Limit 10 permonthQL(034ml daily)

bromfenac sodium (ophth)soln 1

BROMFENAC SOLN 4

CHONDROITIN SULFATE SOLN 4 PA

cromolyn sodium (ophth)soln 2

CYSTARAN SOLN 4 Limit 30mls permonthQL(133ml daily)

diclofenac sodium (ophth)soln 2

DORZOLAMIDE HCL SOLN 4

dorzolamide hcl soln 1

ELESTAT SOLN (Use Epinastine HCl (Ophth)) 4

EMADINE SOLN 4

epinastine hcl (ophth) soln 2

Drug Name DrugTier

RequirementsLimits

fluorescein sodium topical strp 3

fluorescein w benoxinatesoln 3

fluorescein w proparacainesoln 3

flurbiprofen sodium soln 2

FUL-GLO STRP 3

ILEVRO SUSP 4

ketorolac tromethamine (ophth) soln 3

LASTACAFT SOLN 4 ST

NEVANAC SUSP 4

OCUFEN SOLN (Use Flurbiprofen Sodium) 4

olopatadine hcl soln 01 2

olopatadine hcl soln 02 2

Limit 25mls permonthQL(009ml daily)

PAREMYD SOLN 3

PATADAY SOLN (Use Olopatadine HCl) 4

Limit 25mls permonthQL(009ml daily)

PATANOL SOLN (Use Olopatadine HCl) 4

PAZEO SOLN 4

ST Limit 1 bottle permonthQL(0084 ml daily)

PROLENSA SOLN 4

TRUSOPT SOLN (Use Dorzolamide HCl) 4

Prostaglandins - Ophthalmic

bimatoprost soln 3

QL(5 ml per 30days retail15ml per 90 daysmail)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

94

Drug Name DrugTier

RequirementsLimits

LATANOPROST SOLN 4

Limit 25mls permonthQL(009ml daily)

latanoprost soln 2

Limit 25mls permonthQL(009ml daily)

LUMIGAN SOLN 3

Limit 25mls permonthQL(009ml daily)

RESCULA SOLN 4

Limit 1 bottle permonthQL(017ml daily)

TRAVATAN Z SOLN 3

QL(3 ml per 30days retail8 mlper 90 daysmail)

XALATAN SOLN (Use Latanoprost) 4

Limit 25mls permonthQL(009ml daily)

XELPROS EMUL 4 PA

ZIOPTAN SOLN 4 QL(1 ea daily)

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous acetic acid (otic) soln 1

acetic acid-aluminum acetate soln 1

Otic Anti-infectives CETRAXAL SOLN (Use Ciprofloxacin HCl (Otic)) 4

ciprofloxacin hcl (otic) soln 1

FLOXIN OTIC SOLN (Use Ofloxacin (Otic)) 4

ofloxacin (otic) soln 2

OTIPRIO SUSP 4 PA

Otic Combinations

Drug Name DrugTier

RequirementsLimits

CIPRO HC SUSP 3

CIPRODEX SUSP 3

COLY-MYCIN S SUSP 4

neomycin-polymyxin-hc(otic) soln 1

neomycin-polymyxin-hc(otic) susp 1

OTOVEL SOLN 4 Limit 14mls permonthQL(05ea daily)

PRAMOTIC LIQD 4

Otic Steroids DERMOTIC OIL (Use Fluocinolone Acetonide (Otic))

4

fluocinolone acetonide (otic) oil 1

hydrocortisone waceticacid soln 4

OXYTOCICS - Drugs to PreventControl UterineBleeding AbortifacientsAgents for Cervical Ripening PROSTIN E2 SUPP 3

Oxytocics methylergonovine maleatesoln ij 02 mgml 3

methylergonovine maleatetabs or 02 mg 2

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem Antitoxins-Antivenins ANAVIP SOLR 4 PA

Passive Immunizing Agents - Combinations HYQVIA KIT J PA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

95

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 250 mg500 mg 1

AMPICILLIN CAPS 500 MG 2

ampicillin susr 125 mg5ml250 mg5ml 1

MOXATAG TB24 4

Natural Penicillins penicillin v potassium solr125 mg5ml 250 mg5ml 1

PENICILLIN V POTASSIUM SOLR 125 MG5ML 250 MG5ML

2

penicillin v potassium tabs250 mg 4

penicillin v potassium tabs500 mg 1

Penicillin Combinations amoxicillin amp potclavulanate susr 1

amoxicillin amp potclavulanate tabs 1

amoxicillin amp potclavulanate tb12 1

AMOXICILLINCLAVULANATE POTASSIUM CHEW 4

AMPICILLIN-SULBACTAM SOLR 3

AUGMENTIN ES-600 SUSR (Use Amoxicillin amp Pot Clavulanate)

4

AUGMENTIN SUSR 125MG5ML-3125MG5ML 2

AUGMENTIN SUSR 250MG5ML-625MG5ML(Use Amoxicillin amp Pot Clavulanate)

4

Drug Name DrugTier

RequirementsLimits

AUGMENTIN TABS 500MG-125MG 875MG-125MG (Use Amoxicillin amp Pot Clavulanate)

4

AUGMENTIN XR TB12 (Use Amoxicillin amp Pot Clavulanate)

4

Penicillinase-Resistant Penicillins dicloxacillin sodium caps 1

PROGESTINS - Hormone ReplacementModifyingDrugs Progestins AYGESTIN TABS (Use Norethindrone Acetate) 4

MAKENA SOAJ J PA SpecialtyTier 2 MayApply

medroxyprogesteroneacetate tabs 1

MEGACE ES SUSP (Use Megestrol Acetate(Appetite))

4

megestrol acetate(appetite) susp 4

norethindrone acetate tabs 2

progesterone micronized caps 4 QL(2 ea daily)

PROMETRIUM CAPS (Use Progesterone Micronized) 4 QL(2 ea daily)

PROVERA TABS (Use MedroxyprogesteroneAcetate)

4

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental andEmotional Conditions Agents for Chemical Dependency acamprosate calcium tbec 2

ANTABUSE TABS (Use Disulfiram) 4

disulfiram tabs 1

Anti-Cataplectic Agents

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

96

Drug Name DrugTier

RequirementsLimits

XYREM SOLN 4 PA SpecialtyTier 3 MayApply

Antidementia Agents ARICEPT TABS (Use Donepezil Hydrochloride) 4 QL(1 ea daily)

donepezil hydrochloridetabs 23 mg 1 QL(1 ea daily)

donepezil hydrochloridetabs 5 mg 10 mg 2 QL(1 ea daily)

donepezil hydrochloridetbdp 5 mg 10 mg 2 QL(1 ea daily)

EXELON PT24 (Use Rivastigmine) 4

galantamine hydrobromidecp24 8 mg 16 mg 24 mg 1

GALANTAMINE HYDROBROMIDE SOLN 4 MGML

4

galantamine hydrobromidetabs 4 mg 8 mg 12 mg 1

memantine hcl cp24 7 mg14 mg 21 mg 28 mg 4 PA

memantine hcl soln 2 mgml 1

memantine hcl tabs 5 mg10 mg 1

NAMENDA SOLN (Use Memantine HCl) 4

NAMENDA TABS (Use Memantine HCl) 4

NAMENDA TITRATION PAK TABS (Use Memantine HCl)

4

NAMENDA XR CP24 (Use Memantine HCl) 4 PA

NAMENDA XR TITRATION PACK CP24 4 PA

NAMZARIC CP24 4 PA

RAZADYNE ER CP24 (Use Galantamine Hydrobromide)

4

RAZADYNE TABS (Use Galantamine Hydrobromide)

4

Drug Name DrugTier

RequirementsLimits

rivastigmine pt24 3

rivastigmine tartrate caps 3

Combination Psychotherapeutics CHLORDIAZEPOXIDEAMITRIPTYLINE TABS 4

olanzapine-fluoxetine hcl caps 4

perphenazine-amitriptylinetabs 1

PERPHENAZINEAMITRIPTYLINE TABS 4

SYMBYAX CAPS (Use Olanzapine-Fluoxetine HCl) 4

Fibromyalgia Agents

SAVELLA TABS 4 PA QL(2 eadaily)

SAVELLA TITRATION PACK MISC 4 PA

Movement Disorder Drug Therapy

INGREZZA CAPS 4 PA SpecialtyTier 3 MayApply

tetrabenazine tabs 4 Specialty Tier 2May Apply

XENAZINE TABS (Use Tetrabenazine) 4 Specialty Tier 2

May Apply Multiple Sclerosis Agents

AMPYRA TB12 (Use Dalfampridine) 3

PA SpecialtyTier 1 MayApply

AUBAGIO TABS 4 PA SpecialtyTier 2 MayApply

AVONEX KIT J PA SpecialtyTier 2 MayApply

AVONEX PEN AJKT J PA SpecialtyTier 2 MayApply

AVONEX PSKT J PA SpecialtyTier 2 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

97

Drug Name DrugTier

RequirementsLimits

BETASERON KIT J PA SpecialtyTier 2 MayApply

COPAXONE SOSY (Use Glatiramer Acetate) J

PA SpecialtyTier 2 MayApply

dalfampridine tb12 1 PA SpecialtyTier 1 MayApply

EXTAVIA KIT J PA SpecialtyTier 2 MayApply

GILENYA CAPS 4 PA SpecialtyTier 2 MayApply

glatiramer acetate sosy J PA SpecialtyTier 2 MayApply

PLEGRIDY SOPN J PA SpecialtyTier 2 MayApply

PLEGRIDY SOSY J PA SpecialtyTier 2 MayApply

PLEGRIDY STARTER PACK SOPN J

PA SpecialtyTier 2 MayApply

PLEGRIDY STARTER PACK SOSY J

PA SpecialtyTier 2 MayApply

REBIF REBIDOSE SOAJ J PA SpecialtyTier 2 MayApply

REBIF REBIDOSE TITRATIONPACK SOAJ J

PA SpecialtyTier 2 MayApply

REBIF SOSY J PA SpecialtyTier 2 MayApply

REBIF TITRATION PACK SOSY J

PA SpecialtyTier 2 MayApply

TECFIDERA CPDR 4 PA SpecialtyTier 2 MayApply

TECFIDERA STARTER PACK MISC 4

PA SpecialtyTier 2 MayApply

Drug Name DrugTier

RequirementsLimits

ZINBRYTA SOSY J PA SpecialtyTier 3 MayApply

Postherpetic Neuralgia (PHN)Neuropathic Pain GRALISE STARTER MISC 4 PA

GRALISE TABS 4 PA

LYRICA CR TB24 165 MG 825 MG 4 PA QL(1 ea

daily)

LYRICA CR TB24 330 MG 4 PA QL(2 eadaily)

Premenstrual Dysphoric Disorder (PMDD) Agents FLUOXETINE CAPS 10 MG 4 QL(1 ea daily)

FLUOXETINE CAPS 20 MG 3

fluoxetine hcl (pmdd) tabs 4

SARAFEM TABS (Use Fluoxetine HCl (PMDD)) 4

Pseudobulbar Affect (PBA) Agents NUEDEXTA CAPS 4 PA

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS 4

ORAP TABS (Use Pimozide) 3

pimozide tabs 3

Restless Leg Syndrome (RLS) Agents HORIZANT TBCR 4 QL(1 ea daily)

Smoking Deterrents bupropion hcl (smokingdeterrent) tb12 1 PV

CHANTIX CONTINUING MONTHPAK TABS 2 PV

CHANTIX STARTING MONTH PAK TABS 2 PV

CHANTIX TABS 2 PV

NICODERM CQ PT24 (Use Nicotine) 4 PV

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

98

Drug Name DrugTier

RequirementsLimits

nicotine pt24 1 PV

NICOTROL INHALER INHA 4 PV

NICOTROL NS SOLN 4 PV

ZYBAN TB12 (Use Bupropion HCl (SmokingDeterrent))

4 PV

Vasomotor Symptom Agents BRISDELLE CAPS (Use Paroxetine Mesylate(Vasomotor))

4

paroxetine mesylate(vasomotor) caps 4

RESPIRATORY AGENTS - MISC - Drugs toTreat Lung Conditions Cystic Fibrosis Agents KALYDECO PACK 50 MG 75 MG 2 PA

KALYDECO TABS 150 MG 2 PA SpecialtyTier 3 MayApply

ORKAMBI PACK 100MG-125MG 150MG-188MG 4 PA

ORKAMBI TABS 100MG-125MG 200MG-125MG 2

PA SpecialtyTier 3 MayApply

PULMOZYME SOLN 4 Specialty Tier 3May Apply

Pulmonary Fibrosis Agents

ESBRIET CAPS 4 PA SpecialtyTier 3 MayApply

ESBRIET TABS 4 PA SpecialtyTier 3 MayApply

OFEV CAPS 4 PA SpecialtyTier 3 MayApply

SULFONAMIDES - Drugs to Treat BacterialInfections Sulfonamides SULFADIAZINE TABS 4

Drug Name DrugTier

RequirementsLimits

TETRACYCLINES - Drugs to Treat BacterialInfections Aminomethylcyclines NUZYRA SOLR 4 PA

NUZYRA TABS 4 PA

Tetracyclines ACTICLATE TABS (Use Doxycycline Hyclate) 4 PA

ADOXA PAK 1100 TABS(Use Doxycycline(Monohydrate))

4

ADOXA PAK 1150 TABS(Use Doxycycline(Monohydrate))

4

ADOXA PAK 2100 TABS(Use Doxycycline(Monohydrate))

4

ADOXA TABS (Use Doxycycline(Monohydrate))

4

demeclocycline hcl tabs 4

DORYX MPC TBEC 4 PA

DORYX TBEC (Use Doxycycline Hyclate) 4 PA

doxycycline (monohydrate)caps 50 mg 100 mg 1

doxycycline (monohydrate)caps 75 mg 150 mg 3

doxycycline (monohydrate)susr 25 mg5ml 1

doxycycline (monohydrate)tabs 50 mg 75 mg 100mg 150 mg

3

doxycycline hyclate caps50 mg 100 mg 1

doxycycline hyclate tabs 20mg 100 mg 1

DOXYCYCLINE HYCLATE TABS 50 MG 4 PA

doxycycline hyclate tabs 75mg 150 mg 4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

99

Drug Name DrugTier

RequirementsLimits

doxycycline hyclate tbec 50mg 200 mg 4 PA

doxycycline hyclate tbec 75mg 100 mg 150 mg 4 ST

MINOCIN CAPS (Use Minocycline HCl) 4 PA

minocycline hcl caps 50mg 75 mg 100 mg 1

minocycline hcl tb24 45mg 65 mg 90 mg 115 mg135 mg

4 PA

MINOCYCLINE HYDROCHLORIDEER TB24

4 PA

MINOLIRA TB24 4 PA

MONODOX CAPS 100 MG (Use Doxycycline(Monohydrate))

3

MONODOX CAPS 75 MG (Use Doxycycline(Monohydrate))

4

SOLODYN TB24 55 MG 80 MG 105 MG 4 PA

SOLODYN TB24 65 MG 115 MG (Use MinocyclineHCl)

4 PA

TARGADOX TABS 4 PA

tetracycline hcl caps 1

VIBRAMYCIN CAPS 100 MG (Use DoxycyclineHyclate)

4

VIBRAMYCIN SUSR 25 MG5ML (Use Doxycycline(Monohydrate))

4

VIBRAMYCIN SYRP 50 MG5ML 4

THYROID AGENTS - Drugs to Regulate ThyroidHormones Antithyroid Agents methimazole tabs 1

propylthiouracil tabs 1

Drug Name DrugTier

RequirementsLimits

TAPAZOLE TABS (Use Methimazole) 4

Thyroid Hormones ARMOUR THYROID TABS 15 MG 30 MG 60 MG 90 MG 120 MG (Use Thyroid)

4

ARMOUR THYROID TABS 180 MG 240 MG 300 MG 4

CYTOMEL TABS (Use Liothyronine Sodium) 4

levothyroxine sodium tabs 1

liothyronine sodium tabs 1

NATURE-THROID NT-25 TABS 4

NATURE-THROID TABS 1625 MG 3

NATURE-THROID TABS 65 MG 130 MG 195 MG 260 MG 325 MG 325 MG 975 MG 4875 MG 8125 MG 11375 MG 14625 MG

4

SYNTHROID TABS (Use Levothyroxine Sodium) 4

thyroid tabs 1

THYROLAR-1 TABS 2

THYROLAR-12 TABS 2

THYROLAR-14 TABS 2

THYROLAR-2 TABS 2

THYROLAR-3 TABS 2

TIROSINT CAPS 4

WESTHROID TABS 4

WP THYROID TABS 1625 MG 3

WP THYROID TABS 65 MG 130 MG 325 MG 975 MG 4875 MG 8125 MG 11375 MG

4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

100

Drug Name DrugTier

RequirementsLimits

ULCER DRUGS - Drugs to Treat Bowel Intestineand Stomach Conditions Antispasmodics ANASPAZ TBDP (Use Hyoscyamine Sulfate) 4

ATROPINE SULFATE SOSY IV 12 MG3ML 4 PA

BELLADONNA ALKALOIDS amp OPIUM SUPP

4

BENTYL CAPS (Use Dicyclomine HCl) 4

chlordiazepoxide hcl-clidinium bromide caps 1

CUVPOSA SOLN 3

dicyclomine hcl caps 1

dicyclomine hcl soln 1

dicyclomine hcl tabs 1

DONNATAL ELIX (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)

4

DONNATAL TABS (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)

4

GLYCATE TABS 4 PA

GLYCOPYRROLATE SOSY IJ 06 MG3ML 1MG5ML

4 PA

glycopyrrolate tabs or 1mg 2 mg 1

GLYCOPYRROLATE TABS OR 15 MG 4 PA

hyoscyamine sulfate elix 1

hyoscyamine sulfate soln 1

hyoscyamine sulfate subl 1

hyoscyamine sulfate tabs 1

Drug Name DrugTier

RequirementsLimits

hyoscyamine sulfate tbdp 1

LEVSIN TABS (Use Hyoscyamine Sulfate) 4

LEVSINSL SUBL (Use Hyoscyamine Sulfate) 4

LIBRAX CAPS (Use Chlordiazepoxide HCl-Clidinium Bromide)

4 PA

methscopolamine bromidetabs 2

phenobarbital-hyoscyamine-atropine-scopolamine elix01037mg5ml-00065mg5ml-00194mg5ml-162mg5ml

1

phenobarbital-hyoscyamine-atropine-scopolamine tabs01037mg-00065mg-00194mg-162mg

4

PROPANTHELINE BROMIDE TABS 4

ROBINUL FORTE TABS (Use Glycopyrrolate) 4

ROBINUL TABS (Use Glycopyrrolate) 4

H-2 Antagonists CIMETIDINE HCL SOLN 4

cimetidine tabs 1

famotidine susr 40 mg5ml 1

famotidine tabs 20 mg 1 RXOTC

famotidine tabs 40 mg 1

nizatidine caps 150 mg300 mg 1

NIZATIDINE SOLN 15 MGML 4

PEPCID AC MAXIMUM STRENGTH TABS (Use Famotidine)

4 RXOTC

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

101

Drug Name DrugTier

RequirementsLimits

PEPCID SUSR 40 MG5ML(Use Famotidine) 4

PEPCID TABS 20 MG (Use Famotidine) 4 RXOTC

PEPCID TABS 40 MG (Use Famotidine) 4

ranitidine hcl caps 150 mg300 mg 1

ranitidine hcl syrp 15mgml 75 mg5ml 150mg10ml

1

ranitidine hcl tabs 150 mg 1 RXOTC

ranitidine hcl tabs 300 mg 1

ZANTAC 150 MAXIMUM STRENGTH TABS (Use Ranitidine HCl)

4 RXOTC

ZANTAC TABS 150 MG (Use Ranitidine HCl) 4 RXOTC

ZANTAC TABS 300 MG (Use Ranitidine HCl) 4

Misc Anti-Ulcer CARAFATE SUSP 1 GM10ML 4

CARAFATE TABS 1 GM (Use Sucralfate) 4

sucralfate tabs 1

Proton Pump Inhibitors ACIPHEX SPRINKLE CPSP 4 PA

ACIPHEX TBEC (Use Rabeprazole Sodium) 4 PA

DEXILANT CPDR 4 PA

esomeprazole magnesiumcpdr 20 mg 4 PA RXOTC

esomeprazole magnesiumcpdr 40 mg 4 PA

ESOMEPRAZOLE STRONTIUM CPDR 493 MG 2465 MG

4 PA QL(1 eadaily)

FIRST-LANSOPRAZOLE SUSP 4

Drug Name DrugTier

RequirementsLimits

FIRST-OMEPRAZOLE SUSP 4

lansoprazole cpdr 15 mg 1 QL(1 ea daily)RXOTC

lansoprazole cpdr 15 mg 1 RXOTC

lansoprazole cpdr 30 mg 1

lansoprazole tbdp 15 mg30 mg 4

QL(1 ea daily)AL(Up to 12 yrsold )

NEXIUM 24HR CLEAR MINIS CPDR (Use Esomeprazole Magnesium)

4 PA RXOTC

NEXIUM 24HR CPDR (Use Esomeprazole Magnesium) 4 PA RXOTC

NEXIUM CPDR 20 MG (Use EsomeprazoleMagnesium)

4 PA RXOTC

NEXIUM CPDR 40 MG (Use EsomeprazoleMagnesium)

4 PA

NEXIUM PACK 5 MG 10 MG 20 MG 40 MG 25 MG

4 PA

OMEPRAZOLE + SYRSPEND SFALKA SUSP

4

omeprazole cpdr 10 mg 40 mg 1

omeprazole cpdr 20 mg 1 RXOTC

pantoprazole sodium tbec 1

PREVACID CPDR 15 MG (Use Lansoprazole) 4 RXOTC

PREVACID CPDR 30 MG (Use Lansoprazole) 4

PREVACID SOLUTAB TBDP (Use Lansoprazole) 4

QL(1 ea daily)AL(Up to 12 yrsold )

PROTONIX PACK 40 MG 4 QL(1 ea daily)

PROTONIX TBEC 20 MG 40 MG (Use PantoprazoleSodium)

4

rabeprazole sodium tbec 4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

102

Drug Name DrugTier

RequirementsLimits

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use Misoprostol) 4

misoprostol tabs 2

Ulcer Therapy Combinations

amoxicillin-clarithromycinw lansoprazole misc 1

QL(112 ea per365 daysretail112 ea per 365 daysmail)

OMECLAMOX-PAK MISC 4

omeprazole-sodiumbicarbonate caps 20mg-1100mg

4 PA RXOTC

omeprazole-sodiumbicarbonate caps 40mg-1100mg

4 PA

omeprazole-sodiumbicarbonate pack 20mg-1680mg 40mg-1680mg

4 PA

PREVPAC MISC (Use Amoxicillin-Clarithromycinw Lansoprazole)

4

QL(112 ea per365 daysretail112 ea per 365 daysmail)

PYLERA CAPS 4 QL(120 ea per10 days retail)

ZEGERID CAPS 20MG-1100MG (Use Omeprazole-SodiumBicarbonate)

4

PA RXOTC

ZEGERID CAPS 40MG-1100MG (Use Omeprazole-SodiumBicarbonate)

4

PA

ZEGERID PACK 20MG-1680MG 40MG-1680MG (Use Omeprazole-SodiumBicarbonate)

4

PA

URINARY ANTI-INFECTIVES - Drugs to TreatBladderKidney Infections Urinary Anti-infective Combinations HYOPHEN TABS 4

Drug Name DrugTier

RequirementsLimits

methenamine-hyosc-methylene blue-benzoicacid-phenyl sal tabs

4

methenamine-hyosc-methylene blue-sod phos-phenyl sal caps

3

Urinary Anti-infectives FURADANTIN SUSP (Use Nitrofurantoin) 4

HIPREX TABS (Use Methenamine Hippurate) 4

MACROBID CAPS (Use Nitrofurantoin MonohydMacro)

4

MACRODANTIN CAPS (Use Nitrofurantoin Macrocrystal)

4

methenamine hippuratetabs 2

methenamine mandelate tabs 05 gm 1 gm 2

methenamine mandelate tabs 500 mg 4 PA

MONUROL PACK 4

nitrofurantoin macrocrystal caps 1

nitrofurantoin monohyd macro caps 2

nitrofurantoin susp 2

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms Urinary Antispasmodic - Antimuscarinics darifenacin hydrobromidetb24 4

DETROL LA CP24 (Use Tolterodine Tartrate) 4 QL(1 ea daily)

DETROL TABS (Use Tolterodine Tartrate) 4

DITROPAN XL TB24 (Use Oxybutynin Chloride) 4

ENABLEX TB24 (Use Darifenacin Hydrobromide) 4

GELNIQUE GEL 4

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103

Drug Name DrugTier

RequirementsLimits

GELNIQUE PUMP GEL 4

oxybutynin chloride syrp 5mg5ml 1

oxybutynin chloride tabs 5 mg 1

oxybutynin chloride tb24 5mg 10 mg 15 mg 2

OXYTROL FOR WOMEN PTTW 4 RXOTC

OXYTROL PTTW 4 RXOTC

tolterodine tartrate cp24 2mg 4 mg 1 QL(1 ea daily)

tolterodine tartrate tabs 1 mg 2 mg 1

TOVIAZ TB24 3

trospium chloride cp24 60 mg 2

trospium chloride tabs 20 mg 1

VESICARE TABS 4

Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 4 QL(1 ea daily)

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs 5 mg 10 mg 25 mg 4

bethanechol chloride tabs 50 mg 1

URECHOLINE TABS (Use Bethanechol Chloride) 4

Urinary Antispasmodics - Direct Muscle Relaxants flavoxate hcl tabs 2

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones Miscellaneous Vaginal Products FEM PH GEL 4

RELAGARD GEL 4

Vaginal Anti-infectives

Drug Name DrugTier

RequirementsLimits

AVC CREA 4

CLEOCIN CREA VA 2 (Use ClindamycinPhosphate Vaginal)

4

CLEOCIN SUPP VA 100 MG 4

clindamycin phosphatevaginal crea 2

CLINDESSE CREA 3

GYNAZOLE-1 CREA 4

METROGEL-VAGINAL GEL (Use Metronidazole Vaginal)

4

metronidazole vaginal gel 1

MICONAZOLE 3 SUPP 3

NUVESSA GEL 4 PA

TERAZOL 7 CREA (Use Terconazole Vaginal) 4

TERCONAZOLE CREA 4

terconazole vaginal crea 1

terconazole vaginal supp 1

Vaginal Estrogens ESTRACE CREA VA 01 MGGM (Use Estradiol Vaginal)

3

estradiol vaginal crea 01mggm 3

estradiol vaginal tabs 10 mcg 3 QL(90 ea per

fill retail)

ESTRING RING 4 QL(1 ea per 83days retail)

FEMRING RING 4 QL(90 ea perfill retail)

PREMARIN CREA VA 0625 MGGM 2 GL

VAGIFEM TABS (Use Estradiol Vaginal) 3 QL(90 ea per

fill retail) Vaginal Progestins

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Drug Name DrugTier

RequirementsLimits

CRINONE GEL 4

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions Anaphylaxis Therapy Agents

ADRENACLICK SOAJ 5

Specialty Tier 1MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

AUVI-Q SOAJ J

PA SpecialtyTier 1 MayApplyQL(4 eaper 30 daysretail)2 rtl packlmt per fill

epinephrine (anaphylaxis)soaj 015 mg015ml 015mg03ml 03 mg03ml

5

Specialty Tier 1MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

epinephrine (anaphylaxis)soaj 03 mg03ml 4 PA

EPIPEN 2-PAK SOAJ (Use Epinephrine (Anaphylaxis)) 5

PA SpecialtyTier 1 MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

EPIPEN-JR 2-PAK SOAJ 5

PA SpecialtyTier 1 MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

Neurogenic Orthostatic Hypotension (NOH) -NORTHERA CAPS 4 PA

Vasopressors dobutamine hcl soln 3

dobutamine in d5w soln 3

dopamine hcl soln 40mgml 3

Drug Name DrugTier

RequirementsLimits

DOPAMINE HCL SOLN 80 MGML 160 MGML 3

dopamine in d5w soln 3

EPHEDRINE SULFATE SOSY 4 PA

EPINEPHRINE SOSY 4 PA

midodrine hcl tabs 3

NOREPINEPHRINESODIUM CHLORIDE SOLN 4 PA

PHENYLEPHRINE HYDROCHLORIDE SOSY 4 PA

PHENYLEPHRINE HYDROCHLORIDESODIUM CHLORIDE SOLN

4 PA

VITAMINS

Oil Soluble Vitamins DRISDOL CAPS (Use Ergocalciferol) 4

ergocalciferol caps 1

MEPHYTON TABS (Use Phytonadione) 3

phytonadione tabs 1

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Arizona 4-Tier Drug List Updated January 1 2019

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Indexabacavir sulfate 44 abacavir sulfate-lamivudine 44 abacavir sulfate-lamivudine-zidovudine 44 ABILIFY 43 ABILIFY MYCITE 43 abiraterone acetate 36 ABSORICA 56 ABSTRAL 6 acamprosate calcium 96 ACANYA 56 acarbose 22 ACCOLATE 13 ACCUPRIL 31 ACCURETIC 32 acebutolol hcl 47 ACEON 31 acetaminophen w codeine 7 acetazolamide 68 acetic acid (otic) 95 acetic acid-aluminumacetate 95 acetylcysteine 56 ACIPHEX 102 ACIPHEX SPRINKLE 102 acitretin 60 ACLOVATE 61 ACTEMRA 3 ACTICLATE 99 ACTIDOM DMX 55 ACTIGALL 74 ACTIMMUNE 39 ACTIQ 6 ACTIVASE 78 ACTIVELLA 72 ACTONEL 69 ACTOPLUS MET 23 ACTOPLUS MET XR 23 ACTOS 24 ACULAR 94 ACULAR LS 94 ACUVAIL 94 acyclovir 47 acyclovir sodium 47 acyclovir topical 61 ACZONE 56 ADALAT CC 48

adapalene 56 ADAPALENE 56 adapalene-benzoylperoxide 56 ADCETRIS 36 ADCIRCA 50 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 46 ADEMPAS 50 ADMELOG 24 ADMELOG SOLOSTAR 24 ADOXA 99 ADOXA PAK 1100 99 ADOXA PAK 1150 99 ADOXA PAK 2100 99 ADRENACLICK 105 ADRENALIN 90 ADVAIR DISKUS 15 ADVAIR HFA 15 ADVATE 77 ADZENYS XR-ODT 1 AEROSPAN 14 AFINITOR 37 AFINITOR DISPERZ 37 AFREZZA 24 AFTERTEST TOPICAL PAINRELIEF 66 AGGRENOX 78 AGRYLIN 78 AIRDUO RESPICLICK5514 15 AKTEN 92 AKYNZEO 27 ALA SCALP 61 ALAHIST DM 55 albendazole 10 ALBENZA 10 ALBUMINEX 78 albuterol sulfate 15 ALBUTEROL SULFATEER 15 ALCAINE 92 alclometasonedipropionate 62 alcohol 90 ALDACTAZIDE 68 ALDACTONE 68

ALDARA 65 ALECENSA 37 ALENDRONATE SODIUM 69 alendronate sodium 69 ALFERON N 39 alfuzosin hcl 76 ALINIA 11 ALKERAN 34 allopurinol 76 ALLZITAL 5 almotriptan malate 84 ALOCRIL 94 ALOGLIPTIN 24 ALOGLIPTINMETFORMINHCL 23 ALOGLIPTINPIOGLITAZONE

23 ALOMIDE 94 ALORA 73 alosetron hcl 75 ALOXI 27 ALPHAGAN P 91 ALPHANATEVONWILLEBRANDFACTORCOMPLEXHUMAN 77 ALPHANINE SD 77 alprazolam 12 ALPRAZOLAM INTENSOL 12 ALPROLIX 77 ALREX 92 ALTABAX 59 ALTACE 31 ALTOPREV 30 ALTRENO 56 ALVESCO 14 amantadine hcl 41 AMARYL 26 AMBIEN 80 AMBIEN CR 80 AMCINONIDE 62 AMERGE 84 AMICAR 80 amiloride amphydrochlorothiazide 68 amiloride hcl 68 aminocaproic acid 80 aminophylline 15 amiodarone hcl 13

Index 1

AMITIZA 74 ANZEMET 27 atazanavir sulfate 44 amitriptyline hcl 22 AP-HIST DM 55 ATELVIA 69 amlodipine besylate 48 amlodipine besylate-atorvastatincalcium 49 amlodipine besylate-benazeprilhcl 32

APEXICON E APIDRA APIDRA SOLOSTAR APLENZIN

62 24 24 20

atenolol atenolol amp chlorthalidone ATIVAN atomoxetine hcl

48 32 12 1

amlodipine besylate-olmesartanmedoxomil 32 amlodipine besylate-valsartan 32

apraclonidine hcl aprepitant APRISO

91 27 74

atorvastatin calcium atovaquone atovaquone-proguanil hcl

30 11 33

amlodipine-valsartan-hydrochlorothiazide 32 AMOXAPINE 22 amoxicillin 96 amoxicillin amp pot clavulanate 96 amoxicillin-clarithromycin wlansoprazole 103 AMOXICILLINCLAVULANATEPOTASSIUM 96 amphetamine sulfate 1 amphetamine-dextroamphetamine 1 ampicillin 96 AMPICILLIN 96 ampicillin 96 AMPICILLIN-SULBACTAM 96 AMPYRA 97 AMRIX 88 ANADROL-50 9 ANAFRANIL 22 anagrelide hcl 78 ANALPRAM HC 10 ANALPRAM HC SINGLES 10 ANALPRAM-HC 10 ANAPROX DS 3 ANASPAZ 101 anastrozole 36 ANAVIP 95 ANCOBON 28 ANDRODERM 9 ANDROGEL 9 ANDROGEL PUMP 9 ANDROID 9 ANDROXY 9 ANGELIQ 72 ANORO ELLIPTA 15 ANTABUSE 96 ANTARA 29 ANUSOL-HC 10

APTENSIO XR 1 APTIOM 18 APTIVUS 44 ARAKODA 33 ARANESP ALBUMIN FREE 79 ARAVA 5 ARCALYST 3 ARCAPTA NEOHALER 15 ARICEPT 97 ARIKAYCE 2 ARIMIDEX 36 aripiprazole 4344 ARIXTRA 16 armodafinil 1 ARMOUR THYROID 100 ARNUITY ELLIPTA 14 AROMASIN 36 ARTHROTEC 50 3 ARTHROTEC 75 3 ARZERRA 36 ASACOL HD 74 ASMANEX HFA 14 ASMANEX TWISTHALER 120 METERED DOSES 14 ASMANEX TWISTHALER 14 METERED DOSES 14 ASMANEX TWISTHALER 30 METERED DOSES 14 ASMANEX TWISTHALER 60 METERED DOSES 14 ASMANEX TWISTHALER 7 METERED DOSES 14 ASPIRIN-CAFFEINE-DIHYDROCODEINE 7 aspirin-dipyridamole 78 ASTAGRAF XL 87 ASTEPRO 89 ATACAND 31 ATACAND HCT 32

ATRALIN 56 ATRIPLA 44 ATROPINE SULFATE 91101 ATROPINE SULFATESODIUMCHLORIDE 91 ATROVENT HFA 13 AUBAGIO 97 AUGMENTED BETAMETHASONE DIPROPIONATE 62 AUGMENTIN 96 AUGMENTIN ES-600 96 AUGMENTIN XR 96 AURYXIA 75 AUTOPEN 83 AUVI-Q 105 AVALIDE 32 AVANDIA 24 AVAPRO 31 AVASTIN 36 AVC 104 AVELOX 73 AVELOX ABC PACK 73 AVODART 76 AVONEX 97 AVONEX PEN 97 AXERT 84 AXIRON 9 AXUMIN 67 AYGESTIN 96 azacitidine 35 AZASAN 87 AZASITE 91 azathioprine 87 azelaic acid 66 azelastine hcl 89 azelastine hcl (ophth) 94 AZELEX 56

Index 2

AZILECT 42 BETADINE OPHTHALMIC BROMFENAC 94 azithromycin 81 AZOPT 94 AZOR 32 AZULFIDINE 74 AZULFIDINE EN-TABS 74 BACITRACIN 91 bacitracin-poly-neomycin-hc 93 bacitracin-polymyxin b(ophth) 91 baclofen 88

PREP 92 BETAGAN 90 betamethasone dipropionate(topical) 62 betamethasone dipropionateaugmented 62 betamethasone valerate 62 BETAPACE 48 BETAPACE AF 48 BETASERON 98 betaxolol hcl 48

bromfenac sodium (ophth) bromocriptine mesylate BROMPHENIRAMINE TANNATE BROVANA BRYHALI budesonide budesonide (inhalation) budesonide (nasal) bumetanide

94 41

28 15 62 53 14 89 68

BACLOFEN BACTRIM

88 11

betaxolol hcl (ophth) bethanechol chloride

90 104

BUMEX BUNAVAIL

68 8

BACTRIM DS 11 BETHKIS 2 BUPHENYL 71 BACTROBAN BACTROBAN NASAL balsalazide disodium BANZEL

59 89 74 18

BETIMOL 90 BETOPTIC-S 90 BEVESPI AEROSPHERE 15 bexarotene 39

BUPIVACAINE HYDROCHLORIDE 81 BUPIVACAINE HYDROCHLORIDEDEXTROSE

81 BARACLUDE 46 BEYAZ 51 buprenorphine 9 BASAGLAR KWIKPEN 24 BIAXIN 82 BUPRENORPHINE 9 BD PEN 83 BD PEN MINI 83 BEBULIN 77 BECONASE AQ 89 BELBUCA 8 BELEODAQ 37 BELLADONNA ALKALOIDS amp OPIUM 101

bicalutamide BIDIL BILTRICIDE bimatoprost BINOSTO BIO-STATIN bisacodyl-peg 3350-potchloride-sod bicarb-sod

36 49 10 94 69 28

buprenorphine hcl 8 buprenorphine hcl-naloxone hcldihydrate 8 bupropion hcl 20 bupropion hcl (smokingdeterrent) 98 BUPROPION HYDROCHLORIDE ER 20 buspirone hcl 12

BELSOMRA benazepril amphydrochlorothiazide benazepril hcl BENEFIX BENICAR BENICAR HCT BENTYL BENZACLIN BENZACLIN WITH PUMP BENZAMYCIN

80

32 31 77 31 32

101 56 56 56

chloride bisoprolol amphydrochlorothiazide bisoprolol fumarate bleomycin sulfate BLEPH-10 BLEPHAMIDE BLEPHAMIDE SOP BLINCYTO BONIVA BOSULIF

81

32 48 37 92 93 93 36 69 37

butalbital-acetaminophen 5 butalbital-acetaminophen-caffeine 5 butalbital-acetaminophen-caffeine w codeine 7 butalbital-aspirin-caffeine 5 butalbital-aspirin-caffeinewcod 8 BUTALBITALACETAMINOPHEN

5 BUTALBITALASPIRINCAFFEINE 5 BUTISOL SODIUM 80

benzonatate benzoyl peroxide BENZOYL PEROXIDE CLEANSER benzoyl peroxide-erythromycin benztropine mesylate

54 56

56

56 41

BRAFTOVI 37 BREO ELLIPTA 15 BREVICON-28 51 BRILINTA 78 BRIMONIDEDORZOLAMIDEP-F 91 brimonidine tartrate 91

butorphanol tartrate BUTRANS BYDUREON BYDUREON PEN BYETTA BYSTOLIC

9 9

24 24 24 48

BEPREVE 94 BYVALSON 32BRISDELLE 99 BESIVANCE 92 cabergoline 72BRIVIACT 18

Index 3

CABOMETYX 37 CADUET 49 CAFERGOT 83 caffeine citrate 1 CALAN 48 CALAN SR 48 calcipotriene 60 calcipotriene-betamethasonedipropionate 62 calcitonin (salmon) 69 calcitriol 71 calcitriol (topical) 60 calcium acetate (phosphatebinder) 75 CALCIUM GLUCONATE 85 CAMBIA 84 CAMPTOSAR 40 CANASA 74 candesartan cilexetil 31 candesartan cilexetil-hydrochlorothiazide 32 capecitabine 35 CAPEX 62 CAPITALCODEINE 8 CAPRELSA 37 captopril 31 captopril amphydrochlorothiazide 32 CARAC 60 CARAFATE 102 CARBAGLU 71 carbamazepine 18 CARBATROL 18 carbidopa 41 carbidopa-levodopa 41 carbidopa-levodopa-entacapone

41 CARBIDOPALEVODOPAENTACAPONE 41 carbinoxamine maleate 28 carboplatin 34 CARDIZEM 48 CARDIZEM CD 48 CARDIZEM LA 48 CARDURA 31 CARDURA XL 76 carisoprodol 88 carisoprodol w aspirin 89

carisoprodol w aspirin ampcodeine 89 CARNITOR 71 CARNITOR SF 71 CARTEOLOL HCL 90 carteolol hcl (ophth) 90 carvedilol 47 carvedilol phosphate 47 CASODEX 36 CATAPRES 31 CAYA 82 CEDAX 51 cefaclor 5051 CEFACLOR 51 CEFACLOR ER 51 cefadroxil 50 cefdinir 51 CEFDITOREN PIVOXIL 51 cefixime 51 cefpodoxime proxetil 51 cefprozil 51 CEFTIBUTEN 51 CEFTIN 51 cefuroxime axetil 51 CELEBREX 3 celecoxib 3 CELEXA 21 CELLCEPT 87 CELONTIN 20 cephalexin 50 CEPHALEXIN 50 CEQUA 92 CERDELGA 79 CESAMET 27 CETACAINE 66 CETRAXAL 95 CETYLEV 26 cevimeline hcl 88 CHANTIX 98 CHANTIX CONTINUINGMONTHPAK 98 CHANTIX STARTING MONTHPAK 98 CHEK-STIX COMBO PAKURINALYSIS CONTROL 67 CHEK-STIX CONTROL 67 CHEMET 26 CHEMSTRIP-K 67

CHENODAL 74 chlordiazepoxide hcl 12 chlordiazepoxide hcl-clidiniumbromide 101 CHLORDIAZEPOXIDEAMITRIPTYLINE 97 CHLORHEXIDINEGLUCONATE 44 CHLOROQUINEPHOSPHATE 33 chloroquine phosphate 33 CHLOROTHIAZIDE 68 chlorothiazide 68 chlorpromazine hcl 43 chlorpropamide 26 chlorthalidone 68 CHLORZOXAZONE 88 CHOLBAM 74 cholestyramine 29 cholestyramine light 29 choline amp mag salicylate 6 choline fenofibrate 29 CHONDROITIN SULFATE 94 ciclopirox 59 ciclopirox olamine 59 cilostazol 78 CILOXAN 92 cimetidine 101 CIMETIDINE HCL 101 CIMZIA 74 CIMZIA STARTER KIT 74 CINRYZE 78 CIPRO 73 CIPRO HC 95 CIPRO XR 73 CIPRODEX 95 ciprofloxacin 73 CIPROFLOXACIN ER 73 CIPROFLOXACIN HCL 73 ciprofloxacin hcl 73 ciprofloxacin hcl (ophth) 92 ciprofloxacin hcl (otic) 95 CISPLATIN 34 cisplatin 34 citalopram hydrobromide 21 cladribine 35 CLARINEX-D 12 HOUR 55 CLARITHROMYCIN 82

Index 4

clarithromycin 82 codeine sulfate 6 COUMADIN 16 CLEOCIN 11104 CODEINE SULFATE 6 COZAAR 31 CLEOCIN PEDIATRIC CODITUSSIN AC 55 CREON 68 GRANULES 11 COLAZAL 74 CRESEMBA 28CLEOCIN-T 56 COLCHICINE 76 CRESTOR 30CLIMARA 73 colchicine 76 CRINONE 105CLIMARA PRO 72 colchicine w probenecid 76 CRIXIVAN 44CLINDAGEL 57 COLCRYS 76 cromolyn sodium 13clindamycin hcl 11 colesevelam hcl 29 cromolyn sodiumclindamycin palmitate (mastocytosis) 74COLESTID 29hydrochloride 11 cromolyn sodium (ophth) 94clindamycin phosphate COLESTID FLAVORED 29 CROSCARMELLOSE(topical) 57 colestipol hcl 29 SODIUM 51clindamycin phosphate COLY-MYCIN S 95 CUPRIMINE 87vaginal 104 clindamycin phosphate-benzoyl COLYTE-FLAVOR PACKS81 CUTIVATE 62 peroxide 57 COMBIGAN 90 CUVPOSA 101clindamycin phosphate-benzoyl COMBIPATCH 72 cyanocobalamin 79peroxide (refrigerate) 57 clindamycin phosphate- COMBIVENT RESPIMAT 15 CYCLESSA 51 tretinoin 57 COMBIVIR 44 CYCLOGABA10300 PACK 89 CLINDAMYCIN COMETRIQ 37 cyclobenzaprine hcl 88PHOSPHATEBENZOYL COMPLERA 44 CYCLOGYL 91PEROXIDE 57 CLINDESSE 104 COMTAN 41 CYCLOMYDRIL 91 clobazam 17 CONCERTA 1 cyclopentolate hcl 91 clobetasol propionate 62 CONDYLOX 65 cyclophosphamide 34 clobetasol propionate emollient CONTOUR NEXT BLOOD CYCLOPHOSPHAMIDE 34

GLUCOSE TEST 67base 62 cyclophosphamide 34clobetasol propionate CONZIP 6 CYCLOPHOSPHAMIDE 34emulsion 62 COPAXONE 98

CLOBEX 62 cyclophosphamide 34COPEGUS 46 CLOCORTOLONE CYCLOSERINE 34COPIKTRA 37PIVALATE 62 CYCLOSET 24CORDRAN 62CLOCORTOLONE PIVALATE cyclosporine 87PUMP 62 COREG 47 cyclosporine modified (forCLODERM 62 COREG CR 47 microemulsion) 87 CLODERM PUMP 62 CORGARD 48 CYMBALTA 22 clomipramine hcl 22 CORIFACT 77 cyproheptadine hcl 28 clonazepam 17 CORLANOR 50 CYRAMZA 36 clonidine hcl 31 53 76CORTEF CYSTAGON clonidine hcl (adhd) 1 CORTENEMA 10 CYSTARAN 94 clopidogrel bisulfate 78 CORTIFOAM 10 cytarabine 35 clorazepate dipotassium 12 cortisone acetate 53 CYTARABINEAQUEOUS 35 CLORPRES 32 CORTISPORIN 59 CYTOMEL 100 clotrimazole 88 32 103CORZIDE CYTOTEC clotrimazole w COSENTYX 60 DHE 45 84betamethasone 59 COSENTYX SENSOREADY dacarbazine 39clozapine 43 PEN 60 DACOGEN 35CLOZAPINE ODT 43 COSOPT 90

DAKLINZA 46CLOZARIL 43 COSOPT PF 90 dalfampridine 98COARTEM 33 COTELLIC 37

Index 5

DALIRESP 14 desogestrel-ethinyl estradiol diclofenac sodium (ophth) 94 (biphasic) 51DALLERGY 55 diclofenac sodium (topical) 59desogestrel-ethinyl estradiol

danazol 9 diclofenac w misoprostol 4(triphasic) 51 DANTRIUM 89 DESONATE 63 dicloxacillin sodium 96 dantrolene sodium 89 desonide 63 dicyclomine hcl 101 dapsone 11 DESOWEN 63 didanosine 44 dapsone (topical) 57 desoximetasone 63 DIFFERIN 57 DARAPRIM 33 DESOXYN 1 DIFICID 82 darifenacin hydrobromide 103 DESVENLAFAXINE ER 22 diflorasone diacetate 63 DAURISMO 36 desvenlafaxine succinate 22 DIFLUCAN 28 DAYPRO 3 DETROL 103 diflunisal 6 DAYTRANA 2 DETROL LA 103 digoxin 49 DDAVP 72 dexamethasone 53 dihydroergotamine mesylate 84 decitabine 35 DEXAMETHASONE 53 DILANTIN 20 DECON-G 55 dexamethasone 53 DILANTIN INFATABS 20 DELSTRIGO 44 DEXAMETHASONE 54 DILANTIN-125 20 DELZICOL 74 dexamethasone 54 DILATRATE SR 11 DEMADEX 68 DEXAMETHASONE DILAUDID 6 demeclocycline hcl DEMEROL DEMSER DENAVIR

99 6

31 61

INTENSOL 53 DEXAMETHASONE SODIUM PHOSPHATE 93 DEXEDRINE 1 DEXILANT 102

diltiazem hcl 49 diltiazem hcl coated beads 4849 diltiazem hcl extended release beads 49

DEPAKENE 20 DEPAKOTE 20 DEPAKOTE ER 20 DEPAKOTE SPRINKLES 20 DEPEN TITRATABS 87 DEPO-PROVERA 36 DEPO-PROVERA CONTRACEPTIVE 53 DEPO-SUBQ PROVERA 104 53 DEPOCYT 35 DERMA-SMOOTHEFSBODY 63 DERMA-SMOOTHEFSSCALP 63 DERMATOP 63 DERMOTIC 95 DESCOVY 44 desipramine hcl 22 desmopressin acetate 72 desmopressin acetate spray 72 desmopressin acetate sprayrefrigerated 72 DESOGEN 51 desogestrel amp ethinylestradiol 51

dexmethylphenidate hcl 2 DEXPAK 10 DAY 54 DEXPAK 13 DAY 54 DEXPAK 6 DAY 54 dexrazoxane 40 dextroamphetamine sulfate 1 DFSMSMENTHCAPPAK 59 DIAMOX 68 DIASTAT ACUDIAL 17 DIASTAT PEDIATRIC 17 DIATHRIVE BLOOD GLUCOSE TEST STRIPS 67 diazepam 12 DIAZEPAM 12 diazepam 12 DIAZEPAM 17 diazepam (anticonvulsant) 17 DIAZEPAM RECTAL GEL 18 DIBENZYLINE 31 DICLEGIS 27 diclofenac potassium 3 diclofenac sodium 3 diclofenac sodium (actinickeratoses) 60

DILTIAZEM HYDROCHLORIDE DIOVAN DIOVAN HCT DIPENTUM diphenhydramine hcl diphenoxylate w atropine DIPROLENE DIPROLENE AF dipyridamole DISALCID disopyramide phosphate disulfiram DITROPAN XL DIURIL divalproex sodium DIVIGEL dobutamine hcl dobutamine in d5w DOCEFREZ DOCETAXEL docetaxel DOCETAXEL dofetilide

49 31 32 74 28 26 63 63 78 6

13 96

103 69 20 73

105 105 40 40 40 40 13

Index 6

DOLOPHINE 6 DUTOPROL 32 EMTRIVA 44 DOMETUSS-DMX 55 DYANAVEL XR 1 EMVERM 10 donepezil hydrochloride 97 DONNATAL 101 dopamine hcl 105 DOPAMINE HCL 105 dopamine in d5w 105 DORAL 80 DORIBAX 11 DORIPENEM 11 DORYX 99 DORYX MPC 99 DORZOLAMIDE HCL 94 dorzolamide hcl 94 dorzolamide hcl-timolol maleate 90 DORZOLAMIDE HCLTIMOLOLMALEATE 90 DOVONEX 60 doxazosin mesylate 31 doxepin hcl 22 doxepin hcl (antipruritic) 60 doxercalciferol 71 DOXYCYCLINE 66 doxycycline (monohydrate) 99 doxycycline hyclate 99 DOXYCYCLINE HYCLATE 99 doxycycline hyclate 99100 DRISDOL 105 dronabinol 27 drospirenone-ethinylestradiol 51 drospirenone-ethinyl estradiol-levomefolate calcium 52 DROXIA 79 DRYSOL 66 DUAC 57 DUAVEE 72 DUETACT 23 DUEXIS 4 DULERA 15 duloxetine hcl 22 DUOPA 41 DURAGESIC 6 DURAXIN 5 DUREZOL 93 dutasteride 76 dutasteride-tamsulosin hcl 76

DYAZIDE 68 DYMISTA 89 DYRENIUM 68 EES GRANULES 82 EC-NAPROSYN 4 econazole nitrate 59 ECOZA 59 EDARBI 31 EDARBYCLOR 32 EDECRIN 68 EDLUAR 80 EDURANT 44 efavirenz 44 EFFER-K 86 EFFEXOR XR 22 EFFIENT 78 EFUDEX 60 ELAVIL 22 ELDEPRYL 42 ELESTAT 94 ELESTRIN 73 eletriptan hydrobromide 84 ELIDEL 65 ELIMITE 66 ELIPHOS 75 ELIQUIS 16 ELIQUIS STARTER PACK 16 ELIXOPHYLLIN 16 ELLA 53 ELLENCE 37 ELMIRON 76 ELOCON 63 ELOCTATE 77 EMADINE 94 EMBEDA 6 EMBRACE TALK BLOOD GLUCOSE MONITOR 82 EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM 82 EMBRACE TALK BLOOD GLUCOSE TEST STRIPS 67 EMCYT 36 EMEND 27 EMEND TRIPACK 27 EMSAM 21

ENABLEX 103 enalapril maleate 31 enalapril maleate amphydrochlorothiazide 32 ENBREL 5 ENBREL SURECLICK 5 enoxaparin sodium 16 ENSTILAR 63 entacapone 41 entecavir 46 ENTEREG 75 ENTOCORT EC 54 ENTRESTO 49 ENVARSUS XR 87 EPANED 31 EPCLUSA 46 EPHEDRINE SULFATE 105 EPIDIOLEX 18 EPIDUO 57 EPIDUO FORTE 57 EPIFOAM 63 epinastine hcl (ophth) 94 EPINEPHRINE 105 epinephrine (anaphylaxis) 105 EPIPEN 2-PAK 105 EPIPEN-JR 2-PAK 105 epirubicin hcl 37 EPIVIR 44 EPIVIR HBV 46 eplerenone 33 EPOGEN 79 epoprostenol sodium 50 EPROSARTAN MESYLATE 31 EPZICOM 44 EQUETRO 42 ERBITUX 36 ergocalciferol 105 ERGOLOID MESYLATES 98 ERGOMAR 84 ergotamine w caffeine 83 ERIVEDGE 36 ERTACZO 59 ERWINAZE 39 ERY-TAB 82

Index 7

ERYGEL 57 EXFORGE HCT 32 FETZIMA 22 ERYPED 200 82 EXJADE 26 FETZIMA TITRATION PACK22 ERYPED 400 82 EXPAREL 81 FEXMID 88 ERYTHROCIN STEARATE 82 EXTAVIA 98 FIASP 24 erythromycin (acne aid) 57 EXTINA 59 FIASP FLEXTOUCH 24 erythromycin (ophth) 92 ezetimibe 30 FIBRICOR 29 erythromycin base 82 ezetimibe-simvastatin 29 FINACEA 66 erythromycin ethylsuccinate 82 FABIOR 57 finasteride 76 ESBRIET 99 FACTIVE 73 FIORICET 5 escitalopram oxalate 21 famciclovir 47 FIORICETCODEINE 8 ESGIC 5 famotidine 101 FIORINAL 5 esomeprazole magnesium 102 FAMVIR 47 FIORINALCODEINE 3 8 ESOMEPRAZOLE FANAPT 42 FIRAZYR 78 STRONTIUM 102 FANAPT TITRATION FIRMAGON 36estazolam 80 PACK 42 FIRST-LANSOPRAZOLE 102esterified estrogens amp FARESTON 36 FIRST-MOUTHWASH BLM 88methyltestosterone 72 FARXIGA 26ESTRACE 73104 FIRST-OMEPRAZOLE 102

FARYDAK 37estradiol 73 FIRST-TESTOSTERONE 9

FASLODEX 36estradiol amp norethindrone FLAGYL 10FAZACLO 43acetate 72 FLAREX 93

estradiol vaginal 104 FEIBA 77 flavoxate hcl 104 ESTRING 104 felbamate 19 flecainide acetate 13 ESTROGEL 73 FELBATOL 19 FLECTOR 59 ESTROPIPATE 73 FELDENE 4 FLOLAN 50 estropipate 73 felodipine 49 FLOMAX 76 ESTROSTEP FE 52 FEM PH 104 FLONASE ALLERGY eszopiclone 80 FEMARA 36 RELIEF 89 ethacrynic acid 68 FEMCAP 82 FLONASE ALLERGY RELIEF

CHILDRENS 89ethambutol hcl 34 FEMCON FE 52 FLONASE SENSIMIST 89

ethosuximide 20 FEMHRT LOW DOSE 72 FLOVENT DISKUS 14ethynodiol diacet amp eth FEMRING 104 FLOVENT HFA 14estrad 52 FENOFIBRATE 29

etidronate disodium 69 FLOWTUSS 55fenofibrate 29 etodolac 4 FLOXIN OTIC 95fenofibrate micronized 29 etoposide 40 floxuridine 35FENOFIBRIC ACID 29 EVAMIST 73 fluconazole 28FENOGLIDE 29 EVEKEO 1 flucytosine 28FENOPROFEN CALCIUM 4 EVISTA 71 fludarabine phosphate 35fenoprofen calcium 4 EVOCLIN 57 fludrocortisone acetate 54FENORTHO 4 EVOTAZ 44 FLUMADINE 47fentanyl 6 EVOXAC 88 FLUNISOLIDE 89fentanyl citrate 6 EVZIO 27 fluocinolone acetonide 63FENTANYL CITRATE 6 EXALGO 6 fluocinolone acetonide (otic) 95FENTANYL CITRATESODIUMEXELDERM 59 CHLORIDE 6 fluocinonide 63 EXELON 97 FENTORA 6 fluocinonide emulsified base 63 exemestane 36 FERRIPROX 26 FLUORABON 86 EXFORGE 32 ferrous fumarate-folic acid 79 fluorescein sodium topical 94

Index 8

fluorescein w benoxinate fluorescein w proparacaine fluorometholone (ophth)

94 94 93

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS FREESTYLE LIBRE 14

67

GENVOYA GEODON GIAZO

44 42 74

FLUOROPLEX fluorouracil FLUOROURACIL fluorouracil (topical)

60 35 60 60

DAYREADERFLASHMONITORING SYSTEM 82 FREESTYLE LITE TEST STRIPS 67 FREESTYLE PRECISION NEO

GILENYA GILOTRIF glatiramer acetate GLEEVEC

98 38 98 38

FLUOXETINE 98 BLOOD GLUCOSE GLEOSTINE 35 FLUOXETINE DR fluoxetine hcl

21 21

MONITORING SYSTEM FREESTYLE TEST STRIPS

82

67

glimepiride glipizide

26 26

fluoxetine hcl (pmdd) FLUOXETINE HYDROCHLORIDE fluphenazine hcl flurandrenolide FLURAZEPAM HCL flurazepam hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate(nasal) fluvastatin sodium fluvoxamine maleate FML FML FORTE FML LIQUIFILM FOCALIN FOCALIN XR folic acid FOLOTYN fondaparinux sodium FORFIVO XL FORTAMET FORTEO FORTESTA FOSAMAX FOSAMAX PLUS D fosamprenavir calcium fosinopril sodium fosinopril sodium amphydrochlorothiazide FOSRENOL FRAGMIN FREAMINE HBC 69 FREESTYLE INSULINX BLOODGLUCOSE TEST

98

21 43 63 80 80 4

94 36 63

89 30 21 93 93 93 2 2

79 35 16 20 23 69 9

69 69 44 31

32 75 16 90

67

FROVA 84 frovatriptan succinate 84 FUL-GLO 94 FULPHILA 79 FURADANTIN 103 furosemide 68 FUROSEMIDE 68 furosemide 68 FUSILEV 40 FUZEON 44 FYCOMPA 17 gabapentin 18 GABITRIL 19 GALAFOLD 71 galantamine hydrobromide 97 GALANTAMINE HYDROBROMIDE 97 galantamine hydrobromide 97 GALZIN 87 GASTROCROM 74 gatifloxacin (ophth) 92 GATTEX 75 GAZYVA 36 GELNIQUE 103 GELNIQUE PUMP 104 gemcitabine hcl 35 gemfibrozil 29 GEMZAR 35 GENERESS FE 52 GENOTROPIN 70 GENOTROPIN MINIQUICK 70 GENTAK 92 gentamicin sulfate (ophth) 92 gentamicin sulfate (topical) 59 GENTAMICIN SULFATE09SODIUM CHLORIDE 2

glipizide-metformin hcl 23 GLUCAGEN HYPOKIT 23 GLUCAGON EMERGENCY KIT 23 GLUCOPHAGE 23 GLUCOPHAGE XR 23 GLUCOTROL 26 GLUCOTROL XL 26 GLUCOVANCE 23 GLUMETZA 23 glyburide 26 glyburide micronized 26 glyburide-metformin 23 GLYCATE 101 GLYCOLIC ACID 61 GLYCOLIC ACID 70 HIGH PURITY 61 GLYCOPYRROLATE 101 glycopyrrolate 101 GLYCOPYRROLATE 101 GLYNASE 26 GLYSET 22 GLYXAMBI 23 GOLYTELY 81 GRALISE 98 GRALISE STARTER 98 granisetron hcl 27 GRANIX 79 GRIS-PEG 28 griseofulvin microsize 28 griseofulvin ultramicrosize 28 guaifenesin 56 guaifenesin-codeine 55 guanfacine hcl 31 guanfacine hcl (adhd) 1 GUANIDINE HCL 34

Index 9

GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC 83 GYNAZOLE-1 104 HP ACTHAR 69 HALAVEN 40 HALCION 80 halobetasol propionate 63 HALOG 63 haloperidol 43 haloperidol lactate 43 HARVONI 46 HECTOROL 71 HELIXATE FS 77 HEMANGEOL 48 HEMOFIL M 77 heparin (porcine) in sodiumchloride 16 HEPARIN LOCK FLUSH 16 heparin sod (porcine) in d5w 16 HEPARIN SODIUM 17 heparin sodium (porcine) 17 heparin sodium (porcine) lockflush 16 heparin sodium (porcine) lockflush amp nacl lock flush 16 HEPARIN SODIUMD5W 17 HEPARIN SODIUMDEXTROSE 17 HEPARIN SODIUMNACL045 17 HEPARIN SODIUMSODIUMCHLORIDE 17 HEPARIN SODIUMSODIUMCHLORIDE 09 17 HEPSERA 46 HETLIOZ 80 HEXALEN 35 HIPREX 103 homatropine hbr 91 HORIZANT 98 HUMALOG 24 HUMALOG JUNIOR KWIKPEN 24 HUMALOG KWIKPEN 24 HUMALOG MIX 5050 24 HUMALOG MIX 5050KWIKPEN 24 HUMALOG MIX 7525 24 HUMALOG MIX 7525KWIKPEN 24

HUMAPEN LUXURA HD 83 HUMATE-P 77 HUMATROPE 70 HUMATROPE COMBO PACK 70 HUMIRA 3 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 3 HUMIRA PEN 3 HUMIRA PEN-CDUCHSSTARTER 3 HUMIRA PEN-PSUVSTARTER 3 HUMULIN 7030 25 HUMULIN 7030KWIKPEN 25 HUMULIN N 25 HUMULIN N KWIKPEN 25 HUMULIN R 25 HUMULIN R U-500 (CONCENTRATED) 25 HUMULIN R U-500 KWIKPEN 25 HW EMBRACE PRO BLOOD GLUCOSE METER 83 HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS 67 HW EMBRACE TALK BLOOD GLUCOSE MONITOR 83 HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM 83 HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS 67 HYCAMTIN 40 HYCOFENIX 55 hydralazine hcl 33 HYDREA 39 hydrochlorothiazide 69 HYDROCODONE BITARTRATEACETAMINOPHEN 8 HYDROCODONE BITARTRATECHLORPHENIRAMINE MALEATEPSE 55 HYDROCODONE BITARTRATEGUAIFENESIN

55 hydrocodone polistirex-chlorpheniramine polistirex 55 hydrocodone whomatropine 54 hydrocodone-acetaminophen 8 hydrocodone-ibuprofen 8

hydrocortisone 54 hydrocortisone (intrarectal) 10 hydrocortisone (rectal) 10 hydrocortisone (topical) 6364 hydrocortisone acetate(rectal) 10 hydrocortisone acetate wpramoxine 10 hydrocortisone butyrate 64 hydrocortisone butyratehydrophilic lipo base 64 hydrocortisone valerate 64 hydrocortisone wacetic acid 95 hydromorphone hcl 6 hydroxychloroquine sulfate 33 hydroxyurea 39 hydroxyzine hcl 12 hydroxyzine pamoate 12 HYOPHEN 103 hyoscyamine sulfate 101 HYPER-SAL 56 HYPERSAL 56 HYQVIA 95 HYSINGLA ER 6 HYZAAR 32 ibandronate sodium 69 IBRANCE 38 ibuprofen 4 ICLUSIG 38 IDAMYCIN PFS 37 idarubicin hcl 37 IDELVION 77 IDHIFA 38 IFEX 35 ifosfamide 35 ILARIS 3 ILEVRO 94 ILUMYA 61 imatinib mesylate 38 IMBRUVICA 38 imipramine hcl 22 imipramine pamoate 22 imiquimod 65 IMIQUIMOD PUMP 65 IMITREX 84 IMITREX STATDOSE REFILL 84

Index 10

IMITREX STATDOSE IPRIVASK 17 JEVTANA 40 SYSTEM 84 irbesartan 31 JUBLIA 59IMPAVIDO 10 irbesartan-hydrochlorothiazide JUXTAPID 30IMURAN 87 32 K-BICARB 86INCRELEX 71 IRESSA 38 K-PHOS 86INCRUSE ELLIPTA 13 IRINOTECAN 41 K-PHOS NEUTRAL 86indapamide 69 irinotecan hcl 40 K-PHOS NO 2 75INDERAL LA 48 ISENTRESS 44 K-TAB 86INDERAL XL 48 ISOLYTE-PDEXTROSE

KADCYLA 365 86INDOCIN 4 ISOLYTE-S 86 KADIAN 6

indomethacin 4 ISOLYTE-S PH 74 86 KALETRA 44

INGREZZA 97 ISOMETHEPTENE KALYDECO 99INLYTA 38 MUCATECAFFEINEACETAMI KAPSPARGO SPRINKLE 48INNOPRAN XL 48 NOPHEN 83 KAPVAY 1isometheptene-caffeine-INPEN 100BLUELILLY 83

acetaminophen 83 KARBINAL ER 28INPEN 100BLUENOVO 83 isometheptene- KAZANO 23INPEN 100GRAYLILLY 83 dichloralphenazone- KCL 03D5WNACL 09 86INPEN 100GREYNOVO 83 acetaminophen 83 KEFLEX 50ISOMETHEPTENEDICHLORAINPEN 100PINKLILLY 83 LPHENAZONEACETAMINOP KENALOG 64INPEN 100PINKNOVO 83 HEN 83 KEPPRA 18INSPRA 33 ISONIAZID 34 KEPPRA XR 18INSULIN SYRINGES AND PEN isoniazid 34 KERYDIN 59NEEDLES 83 ISOPTO ATROPINE 91 KETAMINEINTELENCE 44

ISOPTO CARPINE 91 HYDROCHLORIDE 75INTERMEZZO 80 ISORDIL TITRADOSE 1112 KETOCARE 67

INTRON A 39 isosorbide dinitrate 12 ketoconazole 28

INTRON A WDILUENT 39 ISOSORBIDE DINITRATE ketoconazole (topical) 59INTUNIV 1 ER 12 KETONE TEST STRIPS 67INVEGA 42 isosorbide mononitrate 12 KETOPROFEN 4INVEGA SUSTENNA 42 isotretinoin 57 ketoprofen 4INVEGA TRINZA 42 isoxsuprine hcl 49 KETOPROFEN 4INVELTYS 93 ISOXSUPRINE HCL 49 ketoprofen 4INVIRASE 44 isradipine 49 ketorolac tromethamine 4INVOKAMET 23 ISTALOL 90 ketorolac tromethamine INVOKAMET XR 23 ISTODAX (OVERFILL) 38 (ophth) 94 INVOKANA 26 itraconazole 28 KETOSTIX 67 IODINE STRONG 86 ivermectin 10 KEVEYIS 68 IODOFLEX 44 IXINITY 77 KEYTRUDA 36 iodoquinol-hc 59 JADENU 26 KHAPZORY 40 IONOSOL-BDEXTROSE KHEDEZLA 22JAKAFI 385 85 KITABIS PAK 2IONOSOL-MBDEXTROSE JALYN 76 5 86 JANUMET 23 KLARON 57 IONSYS 6 JANUMET XR 23 KLONOPIN 18 IOPIDINE 91 JANUVIA 24 KLOR-CON M15 86 ipratropium bromide 13 JARDIANCE 26 KLOR-CON25 86

KMART VALU PLUS INSULINipratropium bromide (nasal) 89 JENTADUETO 23 SYRINGE03ML30G 83ipratropium-albuterol 15 JENTADUETO XR 23

Index 11

KMART VALU PLUS INSULIN SYRINGE05ML29G 83 KMART VALU PLUS INSULIN SYRINGE05ML30G 83 KOATE 77 KOATE-DVI 77 KOGENATE FS 77 KOGENATE FS BIO-SET 77 KOMBIGLYZE XR 23 KORLYM 23 KOVALTRY 77 KRISTALOSE 81 KUVAN 71 KYNAMRO 29 KYPROLIS 38 L-TRYPTOPHAN 90 labetalol hcl 47 LABETALOL HYDROCHLORIDESODIUMCHLORIDE 47 lactic acid (ammoniumlactate) 65 lactulose 81 lactulose (encephalopathy) 75

LATANOPROST 95 latanoprost 95 LATUDA 42 LAZANDA 6 LEDIPASVIRSOFOSBUVIR

46 leflunomide 5 LENVIMA 10 MG DAILY DOSE 38 LENVIMA 12MG DAILY DOSE 38 LENVIMA 14 MG DAILY DOSE 38 LENVIMA 18 MG DAILY DOSE 38 LENVIMA 20 MG DAILY DOSE 38 LENVIMA 24 MG DAILY DOSE 38 LENVIMA 4 MG DAILY DOSE 38 LENVIMA 8 MG DAILY DOSE 38 LESCOL XL 30 LETAIRIS 50 letrozole 36

levonorgestrel-eth estradiol(triphasic) 52 levonorgestrel-ethinyl estradiol(91-day) 52 levonorgestrel-ethinyl estradiol(continuous) 52 levorphanol tartrate 6 levothyroxine sodium 100 LEVSIN 101 LEVSINSL 101 LEVULAN KERASTICK 60 LEXAPRO 21 LEXETTE 64 LEXIVA 45 LIALDA 74 LIBRAX 101 lidocaine 66 lidocaine hcl 66 LIDOCAINE HCL 88 lidocaine hcl (mouth-throat) 88 lidocaine-hydrocortisone acetate(rectal) 10 lidocaine-prilocaine 66 LIDODERM 66

LAMICTAL 18 LEUCOVORIN CALCIUM 40 LIDOPIN 66 LAMICTAL CHEWABLE DISPERSIBLE 18 LAMICTAL ODT 18 LAMICTAL STARTERNOTTAKING CARBAMAZEPINE 18

leucovorin calcium LEUCOVORIN CALCIUM leucovorin calcium LEUKERAN

40 40 40 35

LIDOVEX LILETTA LINDANE lindane

66 53 66 66

LAMICTAL STARTERTAKINGCARBAMAZEPINENOT TAKINGVALPROATE 18 LAMICTAL STARTERTAKINGVALPROATE 18 LAMICTAL XR 18

LEUKINE 79 leuprolide acetate 36 LEUPROLIDE ACETATEBUPIVACAINEHYDROCHLORIDE 36 levalbuterol hcl 15

linezolid LINZESS liothyronine sodium LIPITOR LIPOFEN

11 75

100 30 29

LAMISIL 28 lamivudine 44 lamivudine (hbv) 46 lamivudine-zidovudine 45 lamotrigine 1819 LANCETS AND LANCET DEVICES 83 LANOXIN 49 lansoprazole 102 lanthanum carbonate 75 LANTUS 25

levalbuterol tartrate 15 LEVAQUIN 73 LEVEMIR 25 LEVEMIR FLEXTOUCH 25 levetiracetam 19 levobunolol hcl 90 levocarnitine (metabolicmodifiers) 71 levofloxacin 7374 levofloxacin (ophth) 92 levoleucovorin calcium 40

lisinopril lisinopril amphydrochlorothiazide LITHIUM lithium carbonate LITHOBID LITHOSTAT LIVALO LO LOESTRIN FE LOCOID LOCOID LIPOCREAM

31

32 42 42 42 76 30 52 64 64

LANTUS SOLOSTAR LASIX LASTACAFT

25 68 94

levonorgestrel amp ethestradiol 52 levonorgestrel (emergencyoc) 53

LODINE LODOSYN LOESTRIN 1530-21

4 41 52

Index 12

LOESTRIN 120-21 52 LURIDE 86 melphalan 35 LOESTRIN FE 1530 52 LUXIQ 64 memantine hcl 97 LOESTRIN FE 120 52 LUZU 59 MENEST 73 LOFIBRA 30 LYNPARZA 38 MENOSTAR 73 LOHIST-DM LOKELMA

55 88

LYRICA LYRICA CR

19 98

meperidine hcl MEPERIDINE

6

HCLPROMETHAZINE HCL 8LOMOTIL 26 LYSODREN 37 MEPHYTON 105LONSURF 37 LYSTEDA 80 meprobamate 12LOPID 30 M-CLEAR WC 55 MEPRON 11lopinavir-ritonavir 45 MACROBID 103 mercaptopurine 35LOPRESSOR 48 MACRODANTIN 103 meropenem 11LOPRESSOR HCT 32 mafenide acetate 61 MERREM 11LOPROX 59 MAGNEBIND 400 86 mesalamine 74LOPROX SHAMPOO 59 MAKENA 96 mesna 40lorazepam 12 MALARONE 33 MESNEX 40LORBRENA 38 malathion 67 MESTINON 34LORTAB 8 maprotiline hcl 20 MESTINON TIMESPAN 34LORZONE 88 MAPROTILINE HCL 20 METADATE CD 2losartan potassium 31 MARINOL 27 metaproterenol sulfate 15losartan potassium amp MARPLAN 21

hydrochlorothiazide 32 METASTRON 39MARQIBO 40LOSEASONIQUE 52 METAXALONE 88MATULANE 39LOTEMAX 93 metaxalone 89MAVIK 31LOTENSIN 31 metformin hcl 23MAXALT 85LOTENSIN HCT 32 METFORMIN

MAXALT-MLT 85 HYDROCHLORIDE 23LOTREL 32 MAXIDEX 93 methadone hcl 6LOTRISONE 59 MAXITROL 93 METHADONE HCL 7LOTRONEX 75 MAXZIDE 68 methadone hcl 7lovastatin 30 MAXZIDE-25 68 methamphetamine hcl 1LOVAZA 29 MECLOFENAMATE methazolamide 68LOVENOX 17 SODIUM 4 methenamine hippurate 103loxapine succinate 43 MEDROL 54 methenamine mandelate 103LOZI-FLUR 86 MEDROL DOSEPAK 54 methenamine-hyosc-methylene

LUCENTIS 91 medroxyprogesterone blue-benzoic acid-phenylacetate 96LULICONAZOLE 59 sal 103medroxyprogesterone acetate methenamine-hyosc-methyleneLUMIGAN 95 (contraceptive) 53 blue-sod phos-phenyl sal 103LUNESTA 80 mefenamic acid 4 methimazole 100LUPANETA PACK 71 MEFLOQUINE HCL 34 METHITEST 9LUPRON DEPOT (1- mefloquine hcl 34 methocarbamol 89MONTH) 37 MEGACE ES 96LUPRON DEPOT (3- methotrexate sodium 35 MONTH) 37 MEGACE ORAL 37 METHOTREXATE SODIUM 35LUPRON DEPOT (4- megestrol acetate 37 methotrexate sodium 35MONTH) 37 megestrol acetateLUPRON DEPOT-PED (1- methoxsalen rapid 61(appetite) 96MONTH) 71 MEKINIST 38 methscopolamine bromide 101 LUPRON DEPOT-PED (3-

MEKTOVI 38 methyclothiazide 69MONTH) 71 meloxicam methyldopa 31LURADROX 67 4

Index 13

methyldopa amphydrochlorothiazide 32 methylergonovine maleate 95 METHYLIN 2 methylphenidate hcl 2 METHYLPHENIDATE HYDROCHLORIDE ER 2 METHYLPHENIDATE HYDROCHLORIDE ER (LA) 2 methylprednisolone 54 METHYLTESTOSTERONE 9

miglustat MIGRANAL MILLIPRED MILLIPRED DP MINASTRIN 24 FE MINIPRESS MINIVELLE MINOCIN minocycline hcl MINOCYCLINE

79 84 54 54 52 31 73

100 100

MORPHINE SULFATESODIUMCHLORIDE 7 MOTOFEN 26 MOVANTIK 75 MOVIPREP 81 MOXATAG 96 MOXEZA 92 moxifloxacin hcl 74 moxifloxacin hcl (ophth) 92 MOZOBIL 79

METIPRANOLOL 90 HYDROCHLORIDEER 100 MS CONTIN 7 metoclopramide hcl METOCLOPRAMIDE ODT

74 74

MINOLIRA minoxidil

100 33

MULPLETA MULTAQ

79 13

metolazone 69 MIRAPEX 41 mupirocin 59 metoprolol amphydrochlorothiazide 32 metoprolol succinate 48 METOPROLOL SUCCINATE ERHYDROCHLOROTHIAZIDE

32

MIRAPEX ER MIRCERA MIRCETTE MIRENA mirtazapine

41 79 52 53 20

mupirocin calcium (topical) MUSTARGEN MYALEPT MYAMBUTOL MYCOBUTIN

59 35 71 34 34

metoprolol tartrate 48 MIRVASO 66 mycophenolate mofetil 87 METOPROLOL TARTRATE 48 METOPROLOLHYDROCHLOROTHIAZIDE 32 METROCREAM 66 METROGEL 66 METROGEL-VAGINAL 104 METROLOTION 66 metronidazole 10 metronidazole (topical) 66 metronidazole in nacl 10 metronidazole vaginal 104 MEVACOR 30 mexiletine hcl 13 MIACALCIN 69 MICARDIS 31 MICARDIS HCT 33

misoprostol 103 MITIGARE 76 mitomycin 37 mitoxantrone hcl 37 MOBIC 4 modafinil 2 MODERIBA 1200 DOSE PACK 46 MODERIBA 800 DOSE PACK 46 moexipril hcl 31 moexipril-hydrochlorothiazide

33 MOEXIPRILHYDROCHLOROTHIAZIDE 33 MOLINDONE HYDROCHLORIDE 43 mometasone furoate 64

mycophenolate sodium 87 MYDRIACYL 91 MYFORTIC 87 MYLERAN 35 MYRBETRIQ 104 MYSOLINE 19 MYTESI 26 N-ACETYL-L-CARNOSINE 51 nabumetone 4 nadolol 48 nadolol amp bendroflumethiazide 33 NAFRINSE DAILYACIDULATED 88 NAFRINSE DAILYNEUTRAL 88 naftifine hcl 60

MICONAZOLE 3 104 mometasone furoate NAFTIN 60 MICONAZOLE NITRATEZINCOXIDEWHITEPETROLATUM 60 MICRO-K 86 MICROZIDE 69 midazolam hcl 80 MIDAZOLAMSODIUMCHLORIDE 80

(nasal) MONOCLATE-P MONODOX MONONINE montelukast sodium MONUROL morphine sulfate

89 77

100 77 13

103 7

NALFON 4 NALOCET 8 NALTREXONE 27 naltrexone hcl 27 NAMENDA 97 NAMENDA TITRATION PAK97 NAMENDA XR 97

midodrine hcl 105 MORPHINE SULFATE 7 NAMENDA XR TITRATION MIGERGOT miglitol

84 22

morphine sulfate MORPHINE SULFATE ER

7 7

PACK NAMZARIC

97 97

Index 14

NAPRELAN 4 NEVANAC 94 norethindrone amp ethinyl estradiol-fe 52NAPROSYN 4 nevirapine 45 norethindrone amp mestranol 52 naproxen 4 NEXAVAR 38 norethindrone

naproxen sodium 4 NEXIUM 102 (contraceptive) 53 naratriptan hcl 85 NEXIUM 24HR 102 norethindrone acet amp eth NARCAN 27 NEXIUM 24HR CLEAR estra 52

NARDIL 21 NASCOBAL 79 NASONEB NASAL NEBULIZER REPLACEMENT 83 NASONEB NASAL NEBULIZER STARTER KIT 83 NASONEX 89 NATACYN 92 NATAZIA 52 nateglinide 26 NATESTO 9 NATPARA 69 NATROBA 67 NATURE-THROID 100 NATURE-THROID NT-25 100 NAVELBINE 40 NEBUPENT 10 NEBUSAL 56 NECON 1011-28 52 nefazodone hcl 21 NEFAZODONE HYDROCHLORIDE 22 NEO-SYNALAR 59 neomycin sulfate 2 neomycin-bacitracin zn-polymyxin 92 neomycin-polymy-dexameth 93 neomycin-polymyxin-gramicidin

92 neomycin-polymyxin-hc(ophth) 93 neomycin-polymyxin-hc(otic) 95 NEORAL 87 NEOSPORIN 92 NEPHRAMINE 90 NEPTAZANE 68 NESINA 24

MINIS 102 niacin (antihyperlipidemic) 30 NIASPAN 30 nicardipine hcl 49 NICODERM CQ 98 nicotine 99 NICOTROL INHALER 99 NICOTROL NS 99 nifedipine 49 NILANDRON 37 nilutamide 37 nimodipine 49 NINLARO 38 NIPENT 39 nisoldipine 49 NISOLDIPINE ER 49 NITRO-BID 12 NITRO-DUR 12 nitrofurantoin 103 nitrofurantoin macrocrystal 103 nitrofurantoin monohyd macro 103 nitroglycerin 12 NITROGLYCERIN LINGUAL 12 NITROLINGUAL PUMPSPRAY 12 NITROMIST 12 NITROSTAT 12 NIVESTYM 79 nizatidine 101 NIZATIDINE 101 NIZORAL 60 NOCDURNA 72 NOR-QD 53 NORCO 8

norethindrone acetate 96 norethindrone acetate-ethinylestradiol 72 norethindrone acetate-ethinylestradiol-fe 52 norethindrone-eth estradiol (triphasic) 52 norgestimate-ethinylestradiol 52 norgestimate-ethinyl estradiol(triphasic) 52 norgestrel amp ethinyl estradiol 52 NORINYL 1+35 52 NORITATE 66 NORMOSOL -R 86 NORMOSOL-M IN D5W 86 NORMOSOL-R 86 NORMOSOL-R IN D5W 86 NORPACE 13 NORPACE CR 13 NORPRAMIN 22 NORTHERA 105 nortriptyline hcl 22 NORTUSS-EX 55 NORVASC 49 NORVIR 45 NOVOEIGHT 78 NOVOLIN 7030 25 NOVOLIN 7030 RELION 25 NOVOLIN N 25 NOVOLIN N RELION 25 NOVOLIN R 25 NOVOLIN R RELION 25 NOVOLOG 25 NOVOLOG FLEXPEN 25 NOVOLOG MIX 7030 25 NOVOLOG MIX 7030PREFILLED FLEXPEN 25

NEULASTA 79 NORDITROPIN FLEXPRO70 NOVOLOG PENFILL 25 NEULASTA ONPRO KIT NEUPOGEN NEUPRO

79 79 41

NOREPINEPHRINESODIUMCHLORIDE 105 norethin acet amp estrad-fe 52 norethindrone amp eth

NOVOPEN ECHO NOVOSEVEN RT NOXAFIL

83 78 28

NEURONTIN 19 estradiol 52 NUCALA 13

Index 15

NUCYNTA 7 OMEPRAZOLE + SYRSPEND OTIPRIO 95 SFALKA 102NUCYNTA ER 7 OTOVEL 95omeprazole-sodium

NUEDEXTA 98 OTREXUP 3bicarbonate 103 NULYTELYFLAVORPACKS 81 NUPLAZID 42 NUTROPIN AQ NUSPIN 10 70 NUTROPIN AQ NUSPIN 20 70 NUTROPIN AQ NUSPIN 5 70 NUVARING 53 NUVESSA 104 NUVIGIL 2 NUZYRA 99 NYMALIZE 49 nystatin 28 nystatin (mouth-throat) 88 nystatin (topical) 60 nystatin-triamcinolone 60 OBIZUR 78 OBREDON 55 OCALIVA 74 octreotide acetate 72 OCUFEN 94 OCUFLOX 92

OMNARIS 89 OMNIFLEX DIAPHRAGM 82 OMNIPRED 93 OMNITROPE 70 ONCASPAR 39 ondansetron 27 ondansetron hcl 27 ONETOUCH ULTRA BLUE 67 ONETOUCH VERIO TEST STRIPS 67 ONEXTON 57 ONFI 18 ONGLYZA 24 ONMEL 28 ONZETRA XSAIL 85 OPANA 7 OPANA ER (CRUSHRESISTANT) 7 OPDIVO 36 opium tincture 26 OPSUMIT 50

OVCON-35 53 OVIDE 67 oxaliplatin 35 OXANDRIN 9 oxandrolone 9 oxaprozin 4 OXAYDO 7 oxazepam 12 OXAZEPAM 12 oxcarbazepine 19 OXERVATE 92 oxiconazole nitrate 60 OXISTAT 60 OXSORALEN ULTRA 61 OXTELLAR XR 19 oxybutynin chloride 104 oxycodone hcl 7 OXYCODONE HCL ER 7 oxycodone w acetaminophen 8 OXYCODONEACETAMINOPHEN 8

ODOMZO 36 ORACEA 66 OXYCODONEIBUPROFEN 8 OFEV 99 ORACIT 75 OXYCONTIN 7 OFLOXACIN 74 ORAP 98 oxymorphone hcl 7 ofloxacin 74 ORAPRED ODT 54 OXYTROL 104 ofloxacin (ophth) 92 ORAVIG 88 OXYTROL FOR WOMEN 104 ofloxacin (otic) 95 ORENCIA 5 PACLITAXEL 40 olanzapine 43 ORENCIA CLICKJECT 5 paclitaxel 40 olanzapine-fluoxetine hcl 97 ORENITRAM 50 paliperidone 43 olmesartan medoxomil 31 olmesartan medoxomil-amlodipine-hydrochlorothiazide

33 olmesartan medoxomil-hydrochlorothiazide 33 olopatadine hcl 94 olopatadine hcl (nasal) 89

ORFADIN 71 ORILISSA 70 ORKAMBI 99 orphenadrine citrate 89 ORTHO MICRONOR 53 ORTHO TRI-CYCLEN 52 ORTHO TRI-CYCLEN LO 52

palonosetron hcl PALONOSETRON HYDROCHLORIDE PAMELOR PANCREAZE PANDEL PANOXYL-4 CREAMY WASH

27

27 22 68 64

57 OLUX 64 ORTHO-CYCLEN 53 PANRETIN 60 OLUX-E OLYSIO OMECLAMOX-PAK omega-3-acid ethyl esters

64 46

103 29

ORTHO-NOVUM 135 ORTHO-NOVUM 777 oseltamivir phosphate OSENI

53 53 47 23

pantoprazole sodium PARAFON FORTE DSC paregoric PAREMYD

102 89 26 94

OMEGAVEN omeprazole

90 102

OSPHENA OTEZLA

71 5

PARI SINUSTAR NASAL AEROSOL DELIVERY SYSTEM 83

Index 16

PARI SINUSTAR NASAL PEXEVA 21 POLYTRIM 92 NEBULIZER 83 paricalcitol 71 PARLODEL 41 PARNATE 21 paromomycin sulfate 2 paroxetine hcl 21 paroxetine mesylate(vasomotor) 99 PASER 34 PATADAY 94 PATANASE 89 PATANOL 94 PAXIL 21 PAXIL CR 21 PAZEO 94 PCE 82 PEDIAPRED 54 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 81 peg 3350-potassium chloride-sodbicarbonate-sod chloride 81 PEG-INTRON REDIPEN 46

phenazopyridine hcl 76 phenelzine sulfate 21 phenobarbital 80 phenobarbital-hyoscyamine-atropine-scopolamine 101 phenoxybenzamine hcl 31 phenylephrine hcl (ophth) 92 PHENYLEPHRINE HYDROCHLORIDE 105 PHENYLEPHRINE HYDROCHLORIDESODIUMCHLORIDE 105 phenylephrine w dm-gg 55 phenylephrine-brompheniramine-dm 55 PHENYLEPHRINEGUAIFENESIN 55 PHENYLHISTINE DH 55 PHENYTEK 20 phenytoin 20 phenytoin sodiumextended 20 PHOSLYRA 75

POMALYST 37 PONSTEL 4 pot amp sod citrates wcitric ac 75 pot phosphate monobasic w sodphosphate dibasic ampmonobasic 86 potassium bicarb amp chloride 86 potassium bicarbonate 86 potassium chloride 8687 POTASSIUM CHLORIDE 87 POTASSIUM CHLORIDE ER 87 potassium chloride in dextrose ampsodium chloride 86 potassium chloridemicroencapsulated crystals er 87 potassium citrate(alkalinizer) 75 potassium citrate-citricacid 7576 POTASSIUM CITRATESODIUMCITRATECITRIC ACID 76

PEGANONE 20 PHOSPHOLINE IODIDE 91 POTASSIUM HYDROXIDE 51 PEGASYS PEGASYS PROCLICK PEGINTRON penicillin v potassium

46 46 46 96

phytonadione PICATO PIFELTRO pilocarpine hcl

105 60 45 91

POTASSIUM PHOSPHATESDEXTROSE 86 POTASSIUM PHOSPHATESSODIUMCHLORIDE 86

PENICILLIN V POTASSIUM 96 pilocarpine hcl (oral) 88 POTELIGEO 36 penicillin v potassium 96 pimozide 98 POTIGA 19 PENLAC NAIL LACQUER 60 pindolol 48 PRADAXA 17 PENNSAID PENTASA pentazocine w naloxone pentoxifylline

59 74 9

78

pioglitazone hcl 24 pioglitazone hcl-glimepiride 23 pioglitazone hcl-metforminhcl 23

PRALUENT 30 pramipexole dihydrochloride 41 PRAMOSONE 64 PRAMOSONE E 64

PEPCID 102 PEPCID AC MAXIMUM STRENGTH 101 PERCOCET 8 PERFOROMIST 15 perindopril erbumine 31 PERJETA 36 permethrin 67 perphenazine 43 perphenazine-amitriptyline 97 PERPHENAZINEAMITRIPTYLINE 97 PERSERIS 43 PERTZYE 68

piroxicam PLAN B ONE-STEP PLAQUENIL PLASMA-LYTE A PLASMA-LYTE-148 PLASMA-LYTE-56D5W PLAVIX PLEGRIDY PLEGRIDY STARTER PACK PLENVU podofilox polymyxin b-trimethoprim

4 53 34 86 86 86 78 98

98 81 66 92

PRAMOTIC pramoxine hcl pramoxine-hc PRANDIN prasugrel hcl PRAVACHOL pravastatin sodium praziquantel prazosin hcl PRECISION XTRA BLOOD GLUCOSE TEST STRIPS PRECOSE PRED FORTE

95 66 64 26 78 30 30 10 32

67 23 93

Index 17

PRED MILD 93 PRED-G 93 PRED-G SOP 93 PREDNICARBATE 64 prednicarbate 64 PREDNISOLONE 54 prednisolone 54 prednisolone acetate (ophth) 93 PREDNISOLONE ACETATE P-F 93 prednisolone sodiumphosphate 54 PREDNISOLONE SODIUMPHOSPHATE 54 prednisolone sodiumphosphate 54 PREDNISOLONE SODIUMPHOSPHATE 93 PREDNISOLONE SODIUMPHOSPHATEBROMFENAC

93 PREDNISOLONE SODIUMPHOSPHATEGATIFLOXACIN

93 PREDNISOLONE SODIUMPHOSPHATEGATIFLOXACINBROMFENAC 93 PREDNISOLONEMOXIFLOXACIN 93 PREDNISOLONEMOXIFLOXACINBROMFENAC 93 PREDNISOLONEMOXIFLOXACINKETOROLAC 93 PREDNISONE 54 prednisone 54 PREDNISONE 54 prednisone 54 PREDNISONE INTENSOL 54 PREFERRED GLUCOMETERSUPPLIES AND STRIPS 67 PREFEST 72 PREMARIN 73104 PREMPHASE 73 PREMPRO 73 prenatal w calcium carbonate-vitb6-vit b12-folic acid 88 PREPOPIK 81 PRESTALIA 33 PREVACID 102 PREVACID SOLUTAB 102 PREVIDOLRX ANALGESICPAK 4 PREVPAC 103

PREZCOBIX 45 PREZISTA 45 PRIFTIN 34 PRIMAQUINEPHOSPHATE 34 primidone 19 PRIMLEV 8 PRIMSOL 10 PRINIVIL 31 PRISTIQ 22 PRO VOICE V8 BLOODGLUCOSE MONITORINGSYSTEM 83 PRO VOICE V8V9 BLOODGLUCOSE TEST STRIPS 67 PRO VOICE V9 BLOODGLUCOSE MONITORINGSYSTEM 83 PROAIR HFA 15 PROAIR RESPICLICK 15 probenecid 77 PROCALAMINE 90 PROCARDIA 49 PROCARDIA XL 49 PROCENTRA 1 prochlorperazine 43 prochlorperazine maleate 43 PROCORT 10 PROCRIT 79 PROCTOCORT 10 PROCTOFOAM HC 10 PROCYSBI 76 PRODRIN 84 PROFILNINE 78 PROFILNINE SD 78 progesterone micronized 96 PROGLYCEM 23 PROGRAF 87 PROLENSA 94 PROLIA 69 PROMACTA 79 promethazine ampphenylephrine 55 promethazine hcl 28 promethazine wcodeine 55 promethazine-dm 55 promethazine-phenylephrine-codeine 55 PROMETHAZINEPHENYLEPHRINE 55

PROMETHAZINEPHENYLEPHRINECODEINE 55 PROMETRIUM 96 propafenone hcl 13 PROPANTHELINEBROMIDE 101 proparacaine hcl 92 propranolol amphydrochlorothiazide 33 propranolol hcl 48 PROPRANOLOL HCL 48 propranolol hcl 48 propylthiouracil 100 PROSCAR 76 PROSOL 90 PROSTIN E2 95 PROTAMINE SULFATE 78 PROTONIX 102 PROTOPIC 65 protriptyline hcl 22 PROVENGE 36 PROVENTIL HFA 15 PROVERA 96 PROVIGIL 2 PROZAC 21 PROZAC WEEKLY 21 PRUDOXIN 60 pseudoephed-bromphen-dm 55 pseudoephed-cpm whydrocod 55 PSORCON 64 PULMICORT 14 PULMICORT FLEXHALER 14 PULMOZYME 99 PURIXAN 35 PYLERA 103 pyrazinamide 34 PYRIDIUM 76 pyridostigmine bromide 34 QBREXZA 66 QNASL 90 QNASL CHILDRENS 90 QUALAQUIN 34 QUARTETTE 53 QUAZEPAM 80 QUDEXY XR 19 QUESTRAN 29 QUESTRAN LIGHT 29

Index 18

quetiapine fumarate 43 QUILLICHEW ER 2 QUILLIVANT XR 2 quinapril hcl 31 quinapril-hydrochlorothiazide

33 quinidine gluconate 13 QUINIDINE SULFATE 13 quinine sulfate 34 QVAR 1415 rabeprazole sodium 102 RADIOGARDASE 26 raloxifene hcl 71 ramipril 31 RANEXA 11 ranitidine hcl 102 RAPAFLO 76 RAPAMUNE 8788 rasagiline mesylate 42 RASUVO 3 RAVICTI 71 RAYOS 54 RAZADYNE 97 RAZADYNE ER 97 REBETOL 46 REBIF 98 REBIF REBIDOSE 98 REBIF REBIDOSE

repaglinide 26 REPAGLINIDEMETFORMINHYDROCHLORIDE 23 REPATHA 30 REPATHA PUSHTRONEX SYSTEM 30 REPATHA SURECLICK 30 REPREXAIN 8 REQUIP 41 REQUIP XL 42 RESCRIPTOR 45 RESCULA 95 RESTASIS 92 RESTASIS MULTIDOSE 92 RESTORIL 80 RETIN-A 57 RETIN-A MICRO 5758 RETIN-A MICRO PUMP 58 RETROVIR 45 REVATIO 50 REVCOVI 71 REVLIMID 87 REXULTI 44 REYATAZ 45 REZIRA 55 RHINOCORT AQUA 90 RIAX 58 RIBASPHERE 46

RITALIN LA 2 ritonavir 45 RITUXAN 36 rivastigmine 97 rivastigmine tartrate 97 RIXUBIS 78 rizatriptan benzoate 85 ROBAXIN 89 ROBAXIN-750 89 ROBINUL 101 ROBINUL FORTE 101 ROCALTROL 71 ROMIDEPSIN 38 ropinirole hydrochloride 42 ROPIVACAINE HYDROCHLORIDESODIUMCHLORIDE 81 ROSULA 58 rosuvastatin calcium 30 ROXICODONE 7 ROXYBOND 7 ROZEREM 81 RUBRACA 38 RUCONEST 78 RYCLORA 28 RYTARY 42 RYTHMOL SR 13 SABRIL 19

TITRATIONPACK 98 RIBASPHERE RIBAPAK 46 SAFYRAL 53 REBIF TITRATION PACK 98 ribavirin 47 SAIZEN 70 RECLAST 69 ribavirin (hepatitis c) 46 SAIZEN CLICKEASY 70 RECOMBINATE 78 RIDAURA 3 SAIZENPREP RECTIV 10 rifabutin 34 RECONSTITUTIONKIT 70 REGLAN 74 RIFADIN 34 SALAGEN 88

REGRANEX 67 RIFAMATE 34 SALEX 66

RELAGARD RELENZA DISKHALER

104 47

rifampin RIFATER

34 34

salicylic acid salsalate

66 6

RELION KETONE 67 RILUTEK 90 SAMSCA 72 RELION KETONE TEST riluzole 90 SANCUSO 27 STRIPS RELISTOR RELPAX REMERON REMERON SOLTAB REMICADE RENAGEL RENVELA

67 75 85 20 20 74 75 75

rimantadine hydrochloride 47 RIOMET 23 risedronate sodium 69 RISPERDAL 43 RISPERDAL M-TAB 43 risperidone 43 RISPERIDONE ODT 43 RITALIN 2

SANDIMMUNE SANDOSTATIN SANTYL SAPHRIS SARAFEM SASH KIT FOR FLUSHING VASCULAR ACCESS DEVICES SAVAYSA

88 72 65 43 98

17 16

Index 19

SAVELLA 97 sodium citrate amp citric acid 76 STALEVO 50 42 SAVELLA TITRATION sodium fluoride 86 STALEVO 75 42 PACK 97 SODIUM FLUORIDE 86 STARLIX 26scopolamine 27 sodium fluoride 86 stavudine 45SEASONIQUE 53 SODIUM HYDROXIDE 51 STELARA 61SECONAL SODIUM 80 sodium phenylbutyrate 71 STIMATE 72SECTRAL 48 SODIUM STIOLTO RESPIMAT 15SEEBRI NEOHALER 13 PHOSPHATESODIUM STIVARGA 38selegiline hcl 42 CHLORIDE 86 STRATTERA 1sodium polystyreneselenium sulfide 61 sulfonate 88 STRENSIQ 72SELZENTRY 45 SODIUM SULFACETAMIDE STRIANT 9SEMPREX-D 55 WASH 61 STRIBILD 45SODIUMSENSIPAR 71

SULFACETAMIDESULFUR STRIVERDI RESPIMAT 15SEREVENT DISKUS 15 58 STROMECTOL 10SERNIVO 64 SOFOSBUVIRVELPATASVIR SUBOXONE 9SEROQUEL 43 46 SUBSYS 7SOLARAZE 60SEROQUEL XR 43 SUCRAID 68SOLODYN 100SEROSTIM 70 sucralfate 102SOLTAMOX 37sertraline hcl 21 SULAR 49SOMA 89sevelamer carbonate 75 sulfacetamide sod-SOMATULINE DEPOT 72SFROWASA 74 prednisolone 93 SHOHLS SOLUTION SOMAVERT 70 SULFACETAMIDE SODIUM 92 MODIFIED 76 SONATA 80 sulfacetamide sodium (acne)58SIGNIFOR 72 SOOLANTRA 66 sulfacetamide sodium SIKLOS 79 SORIATANE 61 (ophth) 92 sildenafil citrate (pulmonary sulfacetamide sodium wSORILUX 61hypertension) 50 sulfur 58

sotalol hcl 48SILENOR 80 SULFADIAZINE 99 silodosin 76 sotalol hcl (afibafl) 48 sulfamethoxazole-trimethoprim

SOTYLIZE 48 11SILVADENE 61 SOVALDI 46 SULFAMYLON 61SILVER NITRATE 61 SPACERAEROSOL-HOLDING sulfasalazine 75silver sulfadiazine 61 CHAMBER 83 SULFURATED LIME 67SIMBRINZA 91 SPECTRACEF 51 sulindac 5SIMPONI 3 SPINOSAD 67 sumatriptan 85simvastatin 30 SPIRIVA HANDIHALER 13 sumatriptan succinate 85SINEMET 42 SPIRIVA RESPIMAT 13 SUMATRIPTAN

SINEMET CR 42 spironolactone 68 SUCCINATE 85 SINGULAIR 1314 spironolactone amp sumatriptan succinate 85 sirolimus 88 hydrochlorothiazide 68 sumatriptan-naproxen

SPORANOX 28 sodium 84SIRTURO 34 SPORANOX PULSEPAK 28 SUMAVEL DOSEPRO 85SITAVIG 47 SPRITAM 19 SUMAXIN 58SIVEXTRO 11 SPRIX 4 SUMAXIN TS 58SKELAXIN 89 SPRYCEL 38 SUMAXIN WASH 58SKLICE 67 STALEVO 100 42 SUPRAX 51SKYLA 53 STALEVO 125 42 SUPREP BOWEL PREP KIT81sodium chloride (gu irrigant) 76

SURMONTIL 22sodium chloride (inhalant) 56 STALEVO 150 42 STALEVO 200 42 SUSTIVA 45

Index 20

SUSTOL SUTENT

27 39

TECFIDERA TECFIDERA STARTER

98 theophylline thioridazine hcl

16 43

SYLATRON SYMBICORT SYMBYAX SYMLINPEN 120 SYMLINPEN 60 SYMPAZAN SYMTUZA SYNALAR SYNALGOS-DC

39 15 97 23 23 18 45 64 8

PACK 98 TECHNIVIE 46 TEGRETOL 19 TEGRETOL-XR 19 TEKTURNA 33 TEKTURNA HCT 33 telmisartan 31 telmisartan-amlodipine 33 telmisartan-hydrochlorothiazide

33

thiotepa thiothixene thyroid THYROLAR-1 THYROLAR-12 THYROLAR-14 THYROLAR-2 THYROLAR-3 tiagabine hcl

35 44

100 100 100 100 100 100 20

SYNAREL SYNERA

71 66

temazepam TEMODAR

80 35

TIAZAC TIBSOVO

49 39

SYNERCID 11 TEMOVATE 64 TICASPRAY 89 SYNJARDY 23 TEMOVATE E 64 TIGAN 27 SYNRIBO 40 temozolomide 35 TIGECYCLINE 11 SYNTHROID 100 temsirolimus 39 tigecycline 11 SYPRINE 87 TENCON 5 TIGLUTIK 90 TABLOID 35 TENEX 32 TIKOSYN 13 TACLONEX tacrolimus tacrolimus (topical) tadalafil (pulmonaryhypertension) TAFINLAR TAGRISSO TALTZ TALZENNA TAMIFLU tamoxifen citrate tamsulosin hcl TANZEUM TAPAZOLE TAPERDEX 12-DAY TAPERDEX 6-DAY TARCEVA TARGADOX TARGRETIN TARKA TASIGNA TASMAR TAXOL TAXOTERE tazarotene TAZICEF TAZORAC

64 88 65

50 39 39 61 39 47 37 76 24

100 54 54 39

100 4060

33 39 41 40 40 61 51 61

tenofovir disoproxilfumarate 45 TENORETIC 100 33 TENORETIC 50 33 TENORMIN 48 TEPADINA 35 TERAZOL 7 104 terazosin hcl 32 terbinafine hcl 28 terbutaline sulfate 15 TERCONAZOLE 104 terconazole vaginal 104 TESSALON PERLES 55 TESTIM 9 TESTONE CIK 9 testosterone 9 TESTOSTERONE 9 testosterone 9 TESTOSTERONE PUMP 9 TESTRED 9 tetrabenazine 97 tetracaine hcl (ophth) 92 tetracycline hcl 100 TEXACORT 65 THALOMID 87 THE LIQUILIFT TRACE KIT 87 THEO-24 16

timolol maleate 48 timolol maleate (ophth) 91 TIMOLOL MALEATE OPHTHALMIC GEL FORMING 91 TIMOLOLBRIMONIDEDORZOLAMIDE 91 TIMOLOLBRIMONIDINEDORZOLAMIDELATANOPROST 91 TIMOLOLDORZOLAMIDELATANOPROST 91 TIMOLOLLATANOPROST 91 TIMOPTIC 91 TIMOPTIC OCUDOSE 91 TIMOPTIC-XE 91 TINDAMAX 10 tinidazole 11 TIROSINT 100 TIVICAY 45 TIVORBEX 5 tizanidine hcl 89 TOBI 2 TOBI PODHALER 2 TOBRADEX 93 TOBRADEX ST 93 TOBRAMYCIN 3 tobramycin 3 tobramycin (ophth) 92 TOBRAMYCIN SULFATE 3

Index 21

tobramycin sulfate 3 TRELSTAR MIXJECT 37 TRYPTOPHAN 90 tobramycin-dexamethasone 93 TRESIBA FLEXTOUCH2526 TUDORZA PRESSAIR 13 TOBREX 92 TRETIN-X 58 TUSNEL 55 TOFRANIL 22 tretinoin 58 TUSSICAPS 55 TOLAK TOLAZAMIDE tolazamide TOLBUTAMIDE tolcapone TOLMETIN SODIUM tolmetin sodium TOLMETIN SODIUM TOLSURA tolterodine tartrate TOPAMAX TOPAMAX SPRINKLE TOPICORT

60 26 26 26 41 5 5 5

28 104 19 19 65

tretinoin (chemotherapy) 40 tretinoin microsphere 58 TREXALL 35 TREXIMET 84 TRI-NORINYL 28 53 triamcinolone acetonide (mouth) 88 triamcinolone acetonide (topical) 65 triamterene amp hydrochlorothiazide 68 TRIAMTERENEHYDROCHLOROTHIAZIDE 68 TRIANEX 65 triazolam 80

TUSSIONEX PENNKINETIC EXTENDED RELEASE 55 TUZISTRA XR 55 TWYNSTA 33 TYBOST 45 TYGACIL 11 TYKERB 39 TYLENOLCODEINE 3 8 TYLENOLCODEINE 4 8 TYVASO 50 TYVASO REFILL 50 TYVASO STARTER 50 TYZINE PEDIATRIC NASAL DROPS 90

topiramate 19 TRIBENZOR 33 UCERIS 1054 TOPIRAMATE ER 19 TRICHLOROACETIC UDENYCA 79 TOPOTECAN HCL 41 topotecan hcl 41 TOPROL XL 48 TORISEL 39 torsemide 68 TOTECT 40 TOUJEO MAX SOLOSTAR 25 TOUJEO SOLOSTAR 25 TOVIAZ 104 TRACLEER 50 TRADJENTA 24 tramadol hcl 7 TRAMADOL HCL ER 7 tramadol-acetaminophen 8 trandolapril 31 trandolapril-verapamil hcl 33 TRANDOLAPRILVERAPAMILHCL ER 33 tranexamic acid 80 TRANSDERM-SCOP 27 TRANXENE T 12 tranylcypromine sulfate 21 TRAVATAN Z 95 trazodone hcl 22 TREANDA 35 TRECATOR 34 TRELSTAR 37

ACID 51 TRICITRATES 76 TRICOR 30 TRIDESILON 65 trientine hcl 87 trifluoperazine hcl 43 trifluridine 92 TRIGLIDE 30 trihexyphenidyl hcl 41 TRILEPTAL 19 TRILIPIX 30 trimethobenzamide hcl 27 trimethoprim 11 trimipramine maleate 22 TRIMPEX 11 TRINTELLIX 22 TRIUMEQ 45 TRIZIVIR 45 TROKENDI XR 19 tropicamide 91 TROPICAMIDEPROPARACAINEPHENYLEPHRINEKETOROLAC 91 trospium chloride 104 TRULANCE 74 TRULICITY 24 TRUSOPT 94 TRUVADA 45

ULESFIA ULORIC ULTRACET ULTRAM ULTRAVATE UPTRAVI urea URECHOLINE UROCIT-K 10 UROCIT-K 15 UROCIT-K 5 UROXATRAL URSO 250 URSO FORTE ursodiol UTIBRON NEOHALER UTOPIC VAGIFEM valacyclovir hcl VALCHLOR VALCYTE valganciclovir hcl VALIUM valproate sodium valproic acid valsartan

67 77 8 7

65 50 65

104 76 76 76 76 74 74 74 15 65

104 47 60 46 46 12 20 20 31

Index 22

valsartan-hydrochlorothiazide33

VALSTAR 37 VALTREX 47 VANATOL LQ 5 VANATOL S 5 VANCOMYCIN HYDROCHLORIDE 11 VANCOMYCIN

VIDAZA 36 WIDE-SEAL SILICONE VIDEX EC VIDEXPEDIATRIC

45 45

DIAPHRAGM KIT 60 WIDE-SEAL SILICONE DIAPHRAGM KIT 65

82

82 VIEKIRA PAK 47 WIDE-SEAL SILICONE VIEKIRA XR vigabatrin

47 20

DIAPHRAGM KIT 70 WIDE-SEAL SILICONE DIAPHRAGM KIT 75

82

82 VIGAMOX 92 WIDE-SEAL SILICONE VIIBRYD 22 DIAPHRAGM KIT 80 82

HYDROCHLORIDEDEXTROSE VIIBRYD STARTER PACK22 WIDE-SEAL SILICONE DIAPHRAGM KIT 85 8211 VIMOVO 5 WIDE-SEAL SILICONEVANOS 65

VIMPAT 19 DIAPHRAGM KIT 90 82VANTAS 37 WIDE-SEAL SILICONEvinorelbine tartrate 40VARUBI 27 DIAPHRAGM KIT 95 82VIOKACE 68VASCEPA 29 WILATE 78VIRACEPT 45VASERETIC 33 WP THYROID 100VIRAMUNE 45VASOPRESSINDEXTROSE XALATAN 95

72 VIRAMUNE XR 45 XALKORI 39VASOTEC 31 VIRAZOLE 47 XANAX 12VECAMYL 33 VIREAD 45 XANAX XR 12VECTIBIX 36 VIROPTIC 92 XARELTO 16VECTICAL 61 VISTARIL 12 XARELTO STARTER PACK 16VELCADE 39 VISTOGARD 26 XARTEMIS XR 8VELETRI 50 VITEKTA 45 XELJANZ 3VELPHORO 75 VITRAKVI 39 XELJANZ XR 3VELTASSA 88 VITUZ 55 XELODA 36VELTIN 58 VIVELLE-DOT 73 XELPROS 95VENCLEXTA 36 VIVITROL 27 XENAZINE 97VENCLEXTA STARTING VIVLODEX 5 XEPI 59PACK 36 VIZIMPRO 39venlafaxine hcl 22 XERESE 61

VOGELXO 10VENTAVIS 50 XGEVA 69

VOGELXO PUMP 10VENTOLIN HFA 15 XIAFLEX 87

VOLTAREN 59VERAMYST 90 XIFAXAN 11

VOPAC MDS 59verapamil hcl 49 XIGDUO XR 23

VORAXAZE 40VERAPAMIL HCL SR 49 XODOL 8

voriconazole 28VERDESO 65 XOFIGO 39

VOSPIRE ER 15VERDROCET 8 XOFLUZA 47

VOTRIENT 39VEREGEN 59 XOLAIR 13

VRAYLAR 42VERELAN 49 XOLEGEL 60

VUSION 60VERELAN PM 49 XOPENEX 15

VYTORIN 29VERIPRED 20 54 XOPENEX CONCENTRATE 15

VYVANSE 1VERSACLOZ 43 XOPENEX HFA 15

warfarin sodium 16VESICARE 104 XOSPATA 39

WELCHOL 29VFEND 28 XTAMPZA ER 7

WELLBUTRIN SR 21VIBERZI 75 XTANDI 37

WELLBUTRIN XL 21VIBRAMYCIN 100 XULANE 53

WESTCORT 65VICTOZA 24 XURIDEN 72

WESTHROID 100 XYNTHA 78

Index 23

XYNTHA SOLOFUSE 78 ZITHRANOL 61 ZYTIGA 37 XYOSTED 10 ZITHROMAX 81 ZYVOX 11 XYREM 97 ZITHROMAX TRI-PAK 81 YASMIN 28 53 ZITHROMAX Z-PAK 81 YAZ 53 ZMAX 82 YBUPHEN 5 ZOCOR 30 YERVOY 36 ZODEX 12-DAY 54 YUPELRI 13 ZODEX 6-DAY 54 YUTIQ 93 ZOFRAN 27 zafirlukast 14 ZOFRAN ODT 27 zaleplon 80 ZOHYDRO ER 7 ZALTRAP 36 ZOLADEX 37 ZAMICET 8 zoledronic acid 69 ZANAFLEX 89 ZOLINZA 39 ZANTAC ZANTAC 150 MAXIMUM

102 zolmitriptan ZOLOFT

85 21

STRENGTH 102 ZARONTIN 20 ZARXIO 79 ZAVESCA 79 ZEBETA 48 ZEGERID 103 ZELAPAR 42 ZELBORAF 39 ZEMBRACE SYMTOUCH 85 ZEMPLAR 72 ZENPEP 68 ZENZEDI 1 ZEPATIER 47 ZERIT 45 ZESTORETIC 33 ZESTRIL 31 ZETIA 30 ZETONNA 90 ZEVALIN Y-90 36 ZIAC 33 ZIAGEN 4546 ZIANA 58 zidovudine 46 zileuton 14 ZINBRYTA 98 ZINECARD 40 ZIOPTAN 95 ziprasidone hcl 42 ZIPSOR 5 ZIRGAN 92

zolpidem tartrate ZOLPIMIST ZOMACTON ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZORVOLEX ZOVIRAX ZTLIDO ZUBSOLV ZUPLENZ ZURAMPIC ZUTRIPRO ZYBAN ZYCLARA ZYCLARA PUMP ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYLET ZYLOPRIM ZYMAXID ZYPREXA ZYPREXA ZYDIS

80 80 71 85 85 60 19 19 78 71 88 5

4761 66 9

27 77 56 99 65 65 39 14 14 39 94 77 92 43 43

Index 24

• Classes
• • ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to Treat ADHD Sleep and Eating Disorders
  • 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
  • ANDROGENS-ANABOLIC - Drugs to Regulate Hormones
  • ANORECTAL AGENTS - Rectal Drugs to Treat Pain Swelling and Itching
  • ANTHELMINTICS - Drugs to Treat Worm Infections
  • ANTI-INFECTIVE AGENTS - MISC - Drugs to Treat Bacterial Infections
  • ANTIANGINAL AGENTS - Drugs to Treat Chest Pain
  • ANTIANXIETY AGENTS - Drugs to Treat Anxiety
  • ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms
  • ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions
  • ANTICOAGULANTS - Blood Thinners
  • ANTICONVULSANTS - Drugs to Treat Seizures
  • ANTIDEPRESSANTS - Drugs to Treat Depression
  • ANTIDIABETICS - Drugs to Regulate Blood Sugar
  • ANTIDIARRHEALPROBIOTIC AGENTS - Drugs to Treat Diarrhea
  • ANTIDOTES AND SPECIFIC ANTAGONISTS
  • ANTIEMETICS - Drugs to Treat Nausea and Vomiting
  • ANTIFUNGALS - Drugs to Treat Fungal Infections
  • ANTIHISTAMINES - Drugs to Treat Allergies
  • ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol
  • ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure
  • ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections)
  • ANTIMYASTHENICCHOLINERGIC AGENTS
  • ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections)
  • ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer
  • ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease
  • ANTIPSYCHOTICSANTIMANIC AGENTS - Drugs to Treat Mood Disorders
  • ANTISEPTICS amp DISINFECTANTS
  • ANTIVIRALS - Drugs to Treat Viral Infections
  • 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
  • CHEMICALS
  • 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
  • GENERAL ANESTHETICS
  • GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System
  • GOUT AGENTS - Drugs to Treat Gout
  • 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
  • LAXATIVES - Bowel Treatment Drugs
  • LOCAL ANESTHETICS-Parenteral - Drugs for Numbing
  • MACROLIDES - Drugs to Treat Bacterial Infections
  • MEDICAL DEVICES AND SUPPLIES
  • MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches
  • MINERALS amp ELECTROLYTES
  • MISCELLANEOUS THERAPEUTIC CLASSES
  • MOUTHTHROATDENTAL AGENTS
  • 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
  • OPHTHALMIC AGENTS - Drugs to Treat the Eye
  • OTIC AGENTS - Drugs to Treat the Ear
  • OXYTOCICS - Drugs to PreventControl Uterine Bleeding
  • PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune System
  • PENICILLINS - Drugs to Treat Bacterial Infections
  • 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
  • ULCER DRUGS - Drugs to Treat Bowel Intestine and Stomach Conditions
  • URINARY ANTI-INFECTIVES - Drugs to Treat BladderKidney Infections
  • URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms
  • VAGINAL PRODUCTS - Drugs to Treat Vaginal Infections and Low Hormones
  • VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions
  • VITAMINS

Navajo Saad Bee k1 Ersquoeyeed Trsquo11 J77krsquoe Atarsquo halnersquo7g77 h0l= Trsquo11 h0 hazaad krsquoehj7 naaltsoos hachrsquo8rsquo w0ltah d00 [arsquo da hachrsquo8rsquo 4lrsquo88hSh7k1 arsquodoowo[ n7n7zingo naaltsoos bee n47horsquod0lzin7g77 bik1arsquogi b44sh

bee hanersquo7 bik11rsquo 1aj8rsquo hod77lnih Trsquo11 h0 d00 harsquo1[ch7n7 bi[ hakrsquo4rsquo4stirsquo7g77 koj8rsquo hojilnih

1-888-926-5057 (TTY 711) Small business dei[n7n7j7 atah n7l98go 47 koj8rsquo h0lnersquo 1-888-926-5122 (TTY 711) Employer group-j7 atah n7l98go 47 koj8rsquo hod77lnih 1-800-289-2818 (TTY 711)

Persian (Farsi) با شمارهکسب اطلاعات با ما به شماره ای که در کارت شناسايی شما قيد شده تماس بگيريد اعضای برنامه انفرادی و خانواده لطفا

TTY 711( 1-888-926-5057تماس بگ )د اعضای واحد بازرگانی کوچک با شمارهيريTTY 711( 1-888-926-5122تماس بگ )با شماره د اعضای گروه کارفرما لطفايري TTY 711( 1-800-289-2818تماس )

د يريبگ

Russian Бесплатная помощь переводчиков Вы можете получить помощь устного переводчика Вам могут прочитать документы За помощью обращайтесь к нам по телефону приведенному на вашейидентификационной карточке участника плана Участники планов для семей и частных лиц звоните по телефону 1-888-926-5057 (TTY 711) Участники планов для малых предприятий звоните по телефону 1-888-926-5122 (TTY 711) Участники групповых планов предоставляемых работодателем звоните по телефону 1-800-289-2818 (TTY 711)

Serbo-Croatian Besplatne jezičke usluge Možemo vam obezbediti tumača Možemo vam pročitati vaše dokumente Ukolikovam je potrebna pomoć nazovite broj napisan na vašoj zdravstvenoj kartici Molimo članove individualnog iporodičnog plana da nazovu 1-888-926-5057 (TTY 711) molimo članove malog preduzeća da nazovu 1-888-926-5122 (TTY 711) Molimo članove grupe osigurane preko poslodavca da nazovu 1-800-289-2818 (TTY 711)

SpanishServicios de idiomas sin costo Puede solicitar un inteacuterprete Puede obtener el servicio de lectura dedocumentos Para obtener ayuda llaacutemenos al nuacutemero que aparece en su tarjeta de identificacioacuten Los afiliadosde planes individuales y familiares deben llamar al 1-888-926-5057 (TTY 711) los afiliados de pequentildeas empresas deben llamar al 1-888-926-5122 (TTY 711) Los afiliados del grupo del empleador deben llamar al 1-800-289-2818 (TTY 711)

ܢ ܠܐ ܬܚ ܫܡܠSyriac (Assyrian)

ܐܪܬܝܗܐܩ ܟܬܘ ܦܐ ܛܫܕܛܬ ܡܐܢܡܬܕܚܕܗܬ ܡܐ( ܢ ܓܝ ܪܓܟܘܐܠܘܨܘܦ ܕܐܬ ܒܠܬܨ ܪܥ)ܕܠܢ ܡܐ ܠܐܡܣܒܢ ܬܕܒܐ ܕܗܢܝܐ ܪܨܘܦ ܕܗܝܐ ܬܩܥܐܡܢܝܢܥܢܠ

ܩܐܪܝܩܝܫܝܪ ܢܝܢܥܢ ܪܝܩܢܘ ܐܡܠ ܘܡܘܟܐܐ ܬܘܝܡܦܟܬܘܘܝܦܠ ܝܪܫܐ ܡܠ ܪܝܩ

1-888-926-5057(TTY 711) 5122-926-888-1ܠ ܥܢܘܡܪܝܩܢܘܘܟܠܐܡܣܒܢܐܐܪܬܘܙܥܐ ܬܪܘܓܕܬܐ ܬܘܪܡ(TTY 711)

)TTY 711( ܐܢܝܢܡܠ ܥܢܘܡܪܝܩܢܘܘܟܠܐܡܣܒܢܐܐ ܚܠܕܦܐ ܢܚܠܦܕܡܐ ܬܣܕܕܐ ܡܕܗ 1-800-289-2818

TagalogWalang Bayad na Mga Serbisyo sa Wika Makakakuha kayo ng isang interpreter Makakakuha kayo ng mga dokumento na babasahin sa inyo Para sa tulong tawagan kami sa nakalistang numero sa inyong ID cardPara sa mga miyembro ng Plano para sa Indibiduwal at Pamilya mangyaring tawagan ang1-888-926-5057 (TTY 711) Para sa mga miyembro na Maliit na Negosyo mangyaring tawagan ang 1-888-926-5122 (TTY 711) Para sa mga miyembro ng grupo ng empleyado mangyaring tawagan ang 1-800-289-2818 (TTY 711)

Thai ไมมคาบรการดานภาษา คณสามารถใชลามได คณสามารถใหอานเอกสารใหฟงได สาหรบความชวยเหลอ โทรหาเราตาม

หมายเลขทใหไวบนบตรประจาตวของคณ สมาชกแผนบคคลและครอบครว กรณาโทร 1-888-926-5057 (TTY 711) สมาชก

ธรกจขนาดเลก กรณาโทร 1-888-926-5122 (TTY 711) สมาชกกลมนายจาง กรณาโทร 1-800-289-2818 (TTY 711)

Vietnamese Caacutec Dịch Vụ Ngocircn Ngữ Miễn Phiacute Quyacute vị coacute thể coacute một phiecircn dịch viecircn Quyacute vị coacute thể yecircu cầu được đọc cho nghe tagravei liệu Để nhận trợ giuacutep hatildey gọi cho chuacuteng tocirci theo số được liệt kecirc trecircn thẻ ID của quyacute vị Caacutec thagravenh viecircn của Chương Trigravenh Caacute Nhacircn amp Gia Đigravenh vui lograveng gọi số 1-888-926-5057 (TTY 711) Caacutec thagravenh viecircn thuộc Doanh Nghiệp Nhỏ vui lograveng gọi số 1-888-926-5122 (TTY 711) Caacutec thagravenh viecircn thuộc chương trigravenh theo nhoacutem của chủ sử dụng lao động vui lograveng gọi số 1-800-289-2818 (TTY 711)

Health Net of Arizona Inc underwrites benefits for HMO plans and Health Net Life Insurance Company underwrites benefits for PPO and indemnity plans and for life insurance coverage Health Net of Arizona Inc and Health Net Life Insurance Company are subsidiaries of Health Net Inc All rights reserved

AZ Commercial On and Off-Exchange Member Notice of Language Assistance

FLY007786EH00 (0616)

Drug Name DrugTier

RequirementsLimits

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to TreatADHD Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine-Dextroamphetamine)

4

ADDERALL XR CP24 (Use Amphetamine-Dextroamphetamine)

4

ADZENYS XR-ODT TBED 4 PA

amphetamine sulfate tabs 4 PA

amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg25mg-25mg-25mg-25mg 75mg-75mg-75mg-75mg 125mg-125mg-125mg-125mg375mg-375mg-375mg-375mg 625mg-625mg-625mg-625mg

1

amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg25mg-25mg-25mg-25mg 75mg-75mg-75mg-75mg 125mg-125mg-125mg-125mg375mg-375mg-375mg-375mg 1875mg-1875mg-1875mg-1875mg 3125mg-3125mg-3125mg-3125mg

2

DESOXYN TABS (Use Methamphetamine HCl) 4

DEXEDRINE CP24 (Use DextroamphetamineSulfate)

4

dextroamphetamine sulfatecp24 5 mg 10 mg 15 mg 2

dextroamphetamine sulfatesoln 5 mg5ml 4

dextroamphetamine sulfatetabs 5 mg 10 mg 2

Drug Name DrugTier

RequirementsLimits

DYANAVEL XR SUER 4 PA QL(8 mldaily)

EVEKEO TABS (Use Amphetamine Sulfate) 4 PA

methamphetamine hcl tabs 4

PROCENTRA SOLN (Use DextroamphetamineSulfate)

4

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

3

VYVANSE CHEW 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG

3 QL(1 ea daily)

ZENZEDI TABS 4 PA

Analeptics caffeine citrate soln 1

Attention-DeficitHyperactivity Disorder (ADHD) atomoxetine hcl caps 10mg 18 mg 25 mg 40 mg 3 QL(2 ea daily)

atomoxetine hcl caps 60mg 80 mg 100 mg 3 QL(1 ea daily)

clonidine hcl (adhd) tb12 2 QL(4 ea daily)

guanfacine hcl (adhd) tb24 2 QL(1 ea daily)

INTUNIV TB24 (Use Guanfacine HCl (ADHD)) 4 QL(1 ea daily)

KAPVAY TB12 (Use Clonidine HCl (ADHD)) 4 QL(4 ea daily)

STRATTERA CAPS 10 MG 18 MG 25 MG 40 MG (Use Atomoxetine HCl)

4 QL(2 ea daily)

STRATTERA CAPS 60 MG 80 MG 100 MG (Use Atomoxetine HCl)

4 QL(1 ea daily)

Stimulants - Misc

APTENSIO XR CP24 4 PA QL(1 eadaily)

armodafinil tabs 3 PA

CONCERTA TBCR (Use Methylphenidate HCl) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

1

Drug Name DrugTier

RequirementsLimits

DAYTRANA PTCH 4

dexmethylphenidate hclcp24 5 mg 10 mg 15 mg20 mg 25 mg 30 mg 35mg 40 mg

4

dexmethylphenidate hcltabs 5 mg 10 mg 25 mg 1

FOCALIN TABS (Use Dexmethylphenidate HCl) 4

FOCALIN XR CP24 (Use Dexmethylphenidate HCl) 4

METADATE CD CPCR 10 MG 20 MG 30 MG (Use Methylphenidate HCl)

4 QL(1 ea daily)

METADATE CD CPCR 40 MG 50 MG 60 MG (Use Methylphenidate HCl)

4

METHYLIN CHEW 25 MG (Use Methylphenidate HCl) 4

METHYLIN CHEW 5 MG 10 MG (Use Methylphenidate HCl)

3

METHYLIN SOLN 5 MG5ML 10 MG5ML (Use Methylphenidate HCl)

4

methylphenidate hcl chew25 mg 4

methylphenidate hcl chew5 mg 10 mg 3

methylphenidate hcl cp2410 mg 4 QL(1 ea daily)

methylphenidate hcl cp2420 mg 30 mg 40 mg 3 QL(1 ea daily)

methylphenidate hcl cpcr10 mg 20 mg 30 mg 4 QL(1 ea daily)

methylphenidate hcl cpcr40 mg 50 mg 60 mg 4

methylphenidate hcl soln 5mg5ml 10 mg5ml 2

methylphenidate hcl tabs 5mg 10 mg 20 mg 1

methylphenidate hcl tb2427 mg 36 mg 54 mg 2

methylphenidate hcl tbcr 10mg 20 mg 1

Drug Name DrugTier

RequirementsLimits

methylphenidate hcl tbcr 18mg 27 mg 36 mg 54 mg 2

METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24

4 QL(1 ea daily)

METHYLPHENIDATE HYDROCHLORIDE ER TB24

4

modafinil tabs 4 ST

NUVIGIL TABS (Use Armodafinil) 4 PA

PROVIGIL TABS (Use Modafinil) 4 ST

QUILLICHEW ER CHER 4 PA

QUILLIVANT XR SUSR 4 PA QL(12 mldaily)

RITALIN LA CP24 (Use Methylphenidate HCl) 4 QL(1 ea daily)

RITALIN TABS (Use Methylphenidate HCl) 4

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections Aminoglycosides ARIKAYCE SUSP 4 PA

BETHKIS NEBU 4 Specialty Tier 3May Apply

GENTAMICIN SULFATE09 SODIUMCHLORIDE SOLN

3

KITABIS PAK NEBU 4

Specialty MayApply BrandTier 3 Generic Tier 1

neomycin sulfate tabs 1

paromomycin sulfate caps 2

TOBI NEBU (Use Tobramycin) 4

Specialty MayApply BrandTier 3 Generic Tier 1

TOBI PODHALER CAPS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

2

Drug Name DrugTier

RequirementsLimits

TOBRAMYCIN NEBU 4

Specialty MayApply BrandTier 3 Generic Tier 1

tobramycin nebu 1

Specialty MayApply BrandTier 3 Generic Tier 1

TOBRAMYCIN SULFATE SOLN 40 MGML J PA

tobramycin sulfate soln 40mgml 80 mg2ml 12gm30ml

J PA

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain Swelling Muscle and JointConditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

J PA SpecialtyTier 2 MayApply

HUMIRA PEN PNKT J PA SpecialtyTier 2 MayApply

HUMIRA PEN-CDUCHSSTARTER PNKT J

PA SpecialtyTier 2 MayApply

HUMIRA PEN-PSUVSTARTER PNKT J

PA SpecialtyTier 2 MayApply

HUMIRA PSKT J PA SpecialtyTier 2 MayApply

SIMPONI SOAJ J PA SpecialtyTier 2 MayApply

SIMPONI SOSY J PA SpecialtyTier 2 MayApply

Antirheumatic - Enzyme Inhibitors

XELJANZ TABS 4 PA SpecialtyTier 2 MayApply

XELJANZ XR TB24 4 PA

Antirheumatic Antimetabolites

Drug Name DrugTier

RequirementsLimits

OTREXUP SOAJ 10 MG04ML 15 MG04ML20 MG04ML 25MG04ML 75 MG04ML125 MG04ML

J

PA SpecialtyTier 2 MayApply

OTREXUP SOAJ 175 MG04ML 225 MG04ML J PA

RASUVO SOAJ J PA SpecialtyTier 2 MayApply

Gold Compounds RIDAURA CAPS 3

Interleukin-1 Blockers

ARCALYST SOLR J PA SpecialtyTier 4 MayApply

Interleukin-1beta Blockers

ILARIS SOLN J PA SpecialtyTier 3 MayApply

Interleukin-6 Receptor Inhibitors

ACTEMRA SOSY J PA SpecialtyTier 2 MayApply

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Use Naproxen Sodium) 4

ARTHROTEC 50 TBEC (Use Diclofenac wMisoprostol)

4

ARTHROTEC 75 TBEC (Use Diclofenac wMisoprostol)

4

CELEBREX CAPS (Use Celecoxib) 4 AL(At least 60

yrs old)

celecoxib caps 3 AL(At least 60yrs old)

DAYPRO TABS (Use Oxaprozin) 4

diclofenac potassium tabs 2

diclofenac sodium tb24 100 mg 1

diclofenac sodium tbec 25 mg 50 mg 75 mg 2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

3

Drug Name DrugTier

RequirementsLimits

diclofenac w misoprostoltbec 4

DUEXIS TABS 4 PA

EC-NAPROSYN TBEC (Use Naproxen) 4

etodolac caps 2

etodolac tabs 2

etodolac tb24 2

FELDENE CAPS (Use Piroxicam) 4

FENOPROFEN CALCIUM CAPS 200 MG 400 MG 4

fenoprofen calcium tabs600 mg 1

FENORTHO CAPS 4

flurbiprofen tabs 100 mg 1

flurbiprofen tabs 50 mg 2

ibuprofen tabs 1

INDOCIN SUPP 4

INDOCIN SUSP 4

indomethacin caps 1

indomethacin cpcr 1

KETOPROFEN CAPS 25 MG 4 PA

ketoprofen caps 50 mg 75 mg 1

KETOPROFEN CAPS 50 MG 75 MG 4

ketoprofen cp24 200 mg 3

ketorolac tromethamine tabs 1

QL(20 ea per180 daysretail20 ea per180 days mail)

LODINE TABS (Use Etodolac) 4

Drug Name DrugTier

RequirementsLimits

MECLOFENAMATE SODIUM CAPS 4

mefenamic acid caps 4

meloxicam tabs 15 mg 1 QL(1 ea daily)

meloxicam tabs 75 mg 1 QL(2 ea daily)

MOBIC TABS 15 MG (Use Meloxicam) 4 QL(1 ea daily)

MOBIC TABS 75 MG (Use Meloxicam) 4 QL(2 ea daily)

nabumetone tabs 2

NALFON CAPS 400 MG 4

NALFON TABS 600 MG (Use Fenoprofen Calcium) 4 PA

NAPRELAN TB24 375 MG 500 MG (Use NaproxenSodium)

4

NAPRELAN TB24 750 MG 4

NAPROSYN SUSP (Use Naproxen) 4

NAPROSYN TABS (Use Naproxen) 4

naproxen sodium tabs 275mg 550 mg 1

naproxen sodium tb24 375mg 500 mg 4

naproxen susp 125 mg5ml 1

naproxen tabs 250 mg 375mg 500 mg 1

naproxen tbec 375 mg 500 mg 2

oxaprozin tabs 1

piroxicam caps 1

PONSTEL CAPS (Use Mefenamic Acid) 4

PREVIDOLRX ANALGESIC PAK THPK 4 PA

SPRIX SOLN 4 QL(1 ea daily5day(s) limit)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

4

Drug Name DrugTier

RequirementsLimits

sulindac tabs 1

TIVORBEX CAPS 4 ST QL(3 eadaily)

TOLMETIN SODIUM CAPS 400 MG 4

tolmetin sodium tabs 200 mg 2

TOLMETIN SODIUM TABS 600 MG 4

VIMOVO TBEC 4 PA

VIVLODEX CAPS 4 PA

YBUPHEN TBPK 4 PA

ZIPSOR CAPS 4 ST QL(4 eadaily7 day(s)limit)

ZORVOLEX CAPS 4 ST QL(3 eadaily)

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS 4 PA SpecialtyTier 2 MayApply

OTEZLA TBPK 4 PA SpecialtyTier 2 MayApply

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) 4

leflunomide tabs 1

Selective Costimulation Modulators

ORENCIA CLICKJECT SOAJ J

PA SpecialtyTier 2 MayApply

ORENCIA SOSY J PA SpecialtyTier 2 MayApply

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL SOLR J PA SpecialtyTier 2 MayApply

Drug Name DrugTier

RequirementsLimits

ENBREL SOSY J PA SpecialtyTier 2 MayApply

ENBREL SURECLICK SOAJ J

PA SpecialtyTier 2 MayApply

ANALGESICS - NonNarcotic - Drugs to TreatPain Muscle and Joint Conditions Analgesic Combinations ALLZITAL TABS 4 PA

butalbital-acetaminophentabs 300mg-50mg 4

butalbital-acetaminophentabs 325mg-50mg 2

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

4

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

1

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

1

butalbital-aspirin-caffeine caps 1

BUTALBITALACETAMINOPHEN CAPS 4 PA

BUTALBITALASPIRINCAFFEINE TABS 4

DURAXIN CAPS 4

ESGIC TABS (Use Butalbital-Acetaminophen-Caffeine)

4

FIORICET CAPS (Use Butalbital-Acetaminophen-Caffeine)

4

FIORINAL CAPS (Use Butalbital-Aspirin-Caffeine) 4

TENCON TABS 4

VANATOL LQ SOLN 4

VANATOL S SOLN 4

Salicylates You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

5

Drug Name DrugTier

RequirementsLimits

choline amp mag salicylateliqd 2

diflunisal tabs 2

DISALCID TABS (Use Salsalate) 4

salsalate tabs 1

ANALGESICS - OPIOID - Drugs to Treat PainMuscle and Joint Conditions Opioid Agonists ABSTRAL SUBL 4 PA

ACTIQ LPOP (Use Fentanyl Citrate) 4 PA QL(3 ea

daily) codeine sulfate tabs 15 mg30 mg 60 mg 1

CODEINE SULFATE TABS 30 MG 60 MG (Use Codeine Sulfate)

4

CONZIP CP24 4

DEMEROL TABS (Use Meperidine HCl) 4

DILAUDID LIQD (Use Hydromorphone HCl) 4

DILAUDID TABS (Use Hydromorphone HCl) 4

DOLOPHINE TABS (Use Methadone HCl) 4

DURAGESIC PT72 (Use Fentanyl) 4

Limit 10 permonthQL(034ea daily)

EMBEDA CPCR 4 PA

EXALGO T24A 32 MG (Use Hydromorphone HCl) 4 QL(2 ea daily)

EXALGO T24A 8 MG 12 MG 16 MG (Use Hydromorphone HCl)

4 QL(4 ea daily)

fentanyl citrate lpop bu 200mcg 400 mcg 600 mcg800 mcg 1200 mcg 1600 mcg

1

PA QL(3 eadaily)

FENTANYL CITRATE SOSY IJ 50 MCG5ML 4 PA

Drug Name DrugTier

RequirementsLimits

FENTANYL CITRATE SOSY IV 1500 MCG30ML2750 MCG55ML

4 PA

FENTANYL CITRATESODIUMCHLORIDE SOSY

4 PA

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

2 Limit 10 permonthQL(034ea daily)

fentanyl pt72 375 mcghr625 mcghr 875 mcghr 4

Limit 10 permonthQL(034ea daily)

FENTORA TABS 4 PA

hydromorphone hcl liqd 1mgml 4

hydromorphone hcl t24a 32 mg 4 QL(2 ea daily)

hydromorphone hcl t24a8mg 8 mg 12 mg 16 mg 2 QL(4 ea daily)

hydromorphone hcl tabs 2mg 4 mg 8 mg 1

HYSINGLA ER T24A 4 PA

IONSYS PTCH 4 PA

KADIAN CP24 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 80 MG 100 MG (Use Morphine Sulfate)

4

KADIAN CP24 200 MG 4

LAZANDA SOLN 4 PA

levorphanol tartrate tabs 4 PA

meperidine hcl soln 2

meperidine hcl tabs 2

methadone hcl conc 10 mgml 2

methadone hcl soln 10 mg5ml 1

methadone hcl soln 5 mg5ml 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

6

Drug Name DrugTier

RequirementsLimits

METHADONE HCL SOLN 5 MG5ML (Use Methadone HCl)

4

methadone hcl tabs 5 mg10 mg 1

methadone hcl tbso 40 mg 2

morphine sulfate cp24 or10 mg 20 mg 30 mg 50mg 60 mg 80 mg 100 mg

3

morphine sulfate cp24 or40 mg 4

MORPHINE SULFATE ER CP24 2 QL(1 ea daily)

morphine sulfate soln or 20mgml 10 mg5ml 20mg5ml 100 mg5ml

2

morphine sulfate supp re20 mg 1

MORPHINE SULFATE SUPP RE 5 MG 10 MG 30 MG

4

morphine sulfate tabs or 15mg 30 mg 2

morphine sulfate tbcr or 15mg 30 mg 60 mg 100 mg200 mg

3

MORPHINE SULFATESODIUMCHLORIDE SOSY

4 PA

MS CONTIN TBCR (Use Morphine Sulfate) 4

NUCYNTA ER TB12 2 QL(2 ea daily)

NUCYNTA TABS 2

OPANA ER (CRUSH RESISTANT) T12A 2 QL(2 ea daily)

OPANA TABS (Use Oxymorphone HCl) 4

OXAYDO TABA 4 QL(4 ea daily)

oxycodone hcl caps 5 mg 1

oxycodone hcl conc 100mg5ml 2

Drug Name DrugTier

RequirementsLimits

OXYCODONE HCL ER T12A 4 PA QL(3 ea

daily) oxycodone hcl soln 5mg5ml 2

oxycodone hcl tabs 5 mg10 mg 15 mg 20 mg 30 mg

1

OXYCONTIN T12A 4 PA QL(3 eadaily)

oxymorphone hcl tabs 5mg 10 mg 1

oxymorphone hcl tb12 5mg 10 mg 15 mg 20 mg30 mg 40 mg 75 mg

1 QL(2 ea daily)

ROXICODONE TABS (Use Oxycodone HCl) 4

ROXYBOND TABA 4 QL(4 ea daily)

SUBSYS LIQD 4 PA

TRAMADOL HCL ER CP24 4

tramadol hcl tabs 50 mg 1 QL(8 ea daily)

tramadol hcl tb24 100 mg200 mg 300 mg 4

tramadol hcl tb24 100 mg200 mg 300 mg 4 QL(1 ea daily)

ULTRAM TABS (Use Tramadol HCl) 4 QL(8 ea daily)

XTAMPZA ER C12A 4 PA

ZOHYDRO ER C12A 4 PA

Opioid Combinations acetaminophen w codeinesoln 1

acetaminophen w codeinetabs 1

ASPIRIN-CAFFEINE-DIHYDROCODEINE CAPS 4

butalbital-acetaminophen-caffeine w codeine caps300mg-50mg-40mg-30mg

4

butalbital-acetaminophen-caffeine w codeine caps325mg-50mg-40mg-30mg

2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

7

Drug Name DrugTier

RequirementsLimits

butalbital-aspirin-caffeinewcod caps 2

CAPITALCODEINE SUSP 4

FIORICETCODEINECAPS (Use Butalbital-Acetaminophen-Caffeinew Codeine)

4

FIORINALCODEINE 3CAPS (Use Butalbital-Aspirin-Caffeine wCod)

4

HYDROCODONE BITARTRATEACETAMINOPHEN SOLN

4

hydrocodone-acetaminophen soln10mg15ml-325mg15ml

4

hydrocodone-acetaminophen soln25mg5ml-108mg5ml5mg10ml-217mg10ml75mg15ml-325mg15ml

1

hydrocodone-acetaminophen tabs25mg-325mg

4

hydrocodone-acetaminophen tabs 5mg-300mg 10mg-300mg75mg-300mg

2

hydrocodone-acetaminophen tabs 5mg-325mg 10mg-325mg75mg-325mg

1

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

1

hydrocodone-ibuprofentabs 200mg-75mg 2

LORTAB ELIX 4

MEPERIDINE HCLPROMETHAZINEHCL CAPS

4

NALOCET TABS 3

NORCO TABS (Use Hydrocodone-Acetaminophen)

4

Drug Name DrugTier

RequirementsLimits

oxycodone wacetaminophen tabs 1

OXYCODONEACETAMINOPHEN SOLN 4

OXYCODONEIBUPROFEN TABS 4

PERCOCET TABS (Use Oxycodone wAcetaminophen)

4

PRIMLEV TABS 3

REPREXAIN TABS (Use Hydrocodone-Ibuprofen) 4

SYNALGOS-DC CAPS 4

tramadol-acetaminophentabs 2

TYLENOLCODEINE 3TABS (Use Acetaminophenw Codeine)

4

TYLENOLCODEINE 4TABS (Use Acetaminophenw Codeine)

4

ULTRACET TABS (Use Tramadol-Acetaminophen) 4

VERDROCET TABS 4

XARTEMIS XR TBCR 4 PA

XODOL TABS (Use Hydrocodone-Acetaminophen)

4

ZAMICET SOLN 4

Opioid Partial Agonists BELBUCA FILM 4 QL(2 ea daily)

BUNAVAIL FILM 4 PA

buprenorphine hcl subl 2 PA

buprenorphine hcl-naloxone hcl dihydrate film 4 PA

buprenorphine hcl-naloxone hcl dihydrate subl 4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

8

Drug Name DrugTier

RequirementsLimits

buprenorphine ptwk 5mcghr 10 mcghr 15mcghr 20 mcghr

4 Limit 4 permonthQL(015ea daily)

BUPRENORPHINE PTWK 5 MCGHR 10 MCGHR15 MCGHR 20 MCGHR75 MCGHR

4

Limit 4 permonthQL(015ea daily)

butorphanol tartrate soln 4 QL(6 ml per fillretail18 ml perfill mail)

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

4

Limit 4 permonthQL(015ea daily)

BUTRANS PTWK 75 MCGHR 4

Limit 4 permonthQL(015ea daily)

pentazocine w naloxonetabs 2

SUBOXONE FILM 4 PA

ZUBSOLV SUBL 4 PA

ANDROGENS-ANABOLIC - Drugs to RegulateHormones Anabolic Steroids ANADROL-50 TABS 4

OXANDRIN TABS (Use Oxandrolone) 4

oxandrolone tabs 4

Androgens

ANDRODERM PT24 4 ST QL(1 eadaily)

ANDROGEL GEL 25 MG25GM 405MG25GM 2025MG125GM (Use Testosterone)

3

QL(10 gmdaily)

ANDROGEL GEL 50 MG5GM 3 QL(10 gm

daily) ANDROGEL PUMP GEL (Use Testosterone) 3 QL(10 gm

daily) ANDROID CAPS (Use Methyltestosterone) 4

Drug Name DrugTier

RequirementsLimits

ANDROXY TABS 3

AXIRON SOLN (Use Testosterone) 4 ST QL(6 ml

daily)

danazol caps 3

FIRST-TESTOSTERONE OINT 4 PA

FORTESTA GEL (Use Testosterone) 4

PA Limit 1 permonthQL(35gm daily)

METHITEST TABS 4

METHYLTESTOSTERONE CAPS 4

NATESTO GEL 4

PA Limit 21 grams permonthQL(074gm daily)

STRIANT MISC 4 QL(2 ea daily)

TESTIM GEL (Use Testosterone) 4 PA QL(10 gm

daily)

TESTONE CIK KIT J PA SpecialtyTier 1 MayApply

testosterone gel 1 4 PA QL(10 gmdaily)

testosterone gel 1 4 PA

testosterone gel 1 50mg5gm 25 mg25gm 1 QL(10 gm

daily) TESTOSTERONE GEL 1 50 MG5GM 25MG25GM

4 PA QL(10 gmdaily)

testosterone gel 162 405 mg25gm 2025mg125gm

3 QL(10 gmdaily)

testosterone gel 10 mgact 4 PA Limit 1 permonthQL(35gm daily)

TESTOSTERONE PUMP GEL 4 PA QL(10 gm

daily)

testosterone soln 30 mgact 4 ST QL(6 mldaily)

TESTRED CAPS (Use Methyltestosterone) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

9

Drug Name DrugTier

RequirementsLimits

VOGELXO GEL 4 PA QL(10 gmdaily)

VOGELXO PUMP GEL 4 PA QL(10 gmdaily)

XYOSTED SOAJ 4 PA

ANORECTAL AGENTS - Rectal Drugs to TreatPain Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone(Intrarectal))

4

CORTIFOAM FOAM 3

hydrocortisone (intrarectal) enem 1

UCERIS FOAM RE 2 MGACT 4 PA

Rectal Combinations ANALPRAM HC CREA (Use HydrocortisoneAcetate w Pramoxine)

4

ANALPRAM HC SINGLES CREA (Use HydrocortisoneAcetate w Pramoxine)

4

ANALPRAM-HC CREA 1-1 (Use Hydrocortisone Acetate wPramoxine)

4

ANALPRAM-HC LOTN 1-25 3

hydrocortisone acetate wpramoxine crea 1-1 1

hydrocortisone acetate wpramoxine crea 1-25 2

lidocaine-hydrocortisoneacetate (rectal) kit 1

PROCORT CREA 4

PROCTOFOAM HC FOAM 3

Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) 4

hydrocortisone (rectal) crea 1

Drug Name DrugTier

RequirementsLimits

hydrocortisone acetate(rectal) supp 1

PROCTOCORT SUPP (Use HydrocortisoneAcetate (Rectal))

4

Vasodilating Agents RECTIV OINT 4

ANTHELMINTICS - Drugs to Treat WormInfections Anthelmintics albendazole tabs 1

ALBENZA TABS (Use Albendazole) 3

BILTRICIDE TABS (Use Praziquantel) 3

EMVERM CHEW 3

ivermectin tabs 1

praziquantel tabs 1

STROMECTOL TABS (Use Ivermectin) 4

ANTI-INFECTIVE AGENTS - MISC - Drugs toTreat Bacterial Infections Anti-infective Agents - Misc FLAGYL CAPS (Use Metronidazole) 4

FLAGYL TABS (Use Metronidazole) 4

IMPAVIDO CAPS 4

metronidazole caps 1

metronidazole in nacl soln 3

metronidazole tabs 1

NEBUPENT SOLR 2

PRIMSOL SOLN 3

TINDAMAX TABS (Use Tinidazole) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

10

Drug Name DrugTier

RequirementsLimits

tinidazole tabs 4

trimethoprim tabs 1

TRIMPEX SOLN 3

XIFAXAN TABS 4 PA

Anti-infective Misc - Combinations BACTRIM DS TABS (Use Sulfamethoxazole-Trimethoprim)

4

BACTRIM TABS (Use Sulfamethoxazole-Trimethoprim)

4

sulfamethoxazole-trimethoprim susp 1

sulfamethoxazole-trimethoprim tabs 1

Antiprotozoal Agents ALINIA SUSR 4

ALINIA TABS 4

atovaquone susp 1

MEPRON SUSP (Use Atovaquone) 4

Carbapenems DORIBAX SOLR 3

DORIPENEM SOLR 3

meropenem solr 3

MERREM SOLR (Use Meropenem) 3

Glycopeptides VANCOMYCIN HYDROCHLORIDE SOLR 4 PA

VANCOMYCIN HYDROCHLORIDEDEXTROSE SOLN

4 PA

Glycylcyclines TIGECYCLINE SOLR 3

Drug Name DrugTier

RequirementsLimits

tigecycline solr 3

TYGACIL SOLR (Use Tigecycline) 3

Leprostatics dapsone tabs 1

Lincosamides CLEOCIN CAPS OR 75 MG 150 MG 300 MG (Use Clindamycin HCl)

4

CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin PalmitateHydrochloride)

4

clindamycin hcl caps 1

clindamycin palmitatehydrochloride solr 1

Oxazolidinones linezolid susr 2

linezolid tabs 2

SIVEXTRO TABS 2 QL(6 ea per 90days retail)

ZYVOX SUSR (Use Linezolid) 4

ZYVOX TABS (Use Linezolid) 4

Streptogramins SYNERCID SOLR 3

ANTIANGINAL AGENTS - Drugs to Treat ChestPain Antianginals-Other RANEXA TB12 4

Nitrates DILATRATE SR CPCR 4

ISORDIL TITRADOSE TABS 40 MG 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

11

Drug Name DrugTier

RequirementsLimits

ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate)

4

ISOSORBIDE DINITRATE ER TBCR 4

isosorbide dinitrate tabs 1

isosorbide mononitrate tabs 10 mg 20 mg 2

isosorbide mononitrate tb24 30 mg 60 mg 120 mg 1

NITRO-BID OINT 3

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

4

NITRO-DUR PT24 03 MGHR 08 MGHR 2

nitroglycerin cpcr 1

NITROGLYCERIN LINGUAL AERS 4

nitroglycerin pt24 1

nitroglycerin soln 1

nitroglycerin subl 1

NITROLINGUAL PUMPSPRAY SOLN (Use Nitroglycerin)

4

NITROMIST AERS 4

NITROSTAT SUBL (Use Nitroglycerin) 3

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc buspirone hcl tabs 5 mg10 mg 15 mg 30 mg 2

buspirone hcl tabs 75 mg 3

hydroxyzine hcl syrp 1

hydroxyzine hcl tabs 1

Drug Name DrugTier

RequirementsLimits

hydroxyzine pamoate caps 1

meprobamate tabs 2

VISTARIL CAPS (Use Hydroxyzine Pamoate) 4

Benzodiazepines ALPRAZOLAM INTENSOL CONC 3

alprazolam tabs 025 mg05 mg 1 mg 2 mg 1

alprazolam tb24 05 mg 1mg 2 mg 3 mg 1

alprazolam tbdp 025 mg05 mg 1 mg 2 mg 4

ATIVAN TABS (Use Lorazepam) 4 PA

chlordiazepoxide hcl caps 1

clorazepate dipotassiumtabs 2

diazepam conc or 5 mgml 4

DIAZEPAM SOLN OR 5 MG5ML 4

diazepam tabs or 2 mg 5mg 10 mg 1

lorazepam conc 2 mgml 4

lorazepam tabs 05 mg 1mg 2 mg 1

oxazepam caps 10 mg 15mg 30 mg 1

OXAZEPAM CAPS 30 MG 4

TRANXENE T TABS (Use Clorazepate Dipotassium) 4

VALIUM TABS (Use Diazepam) 4

XANAX TABS (Use Alprazolam) 4

XANAX XR TB24 (Use Alprazolam) 4

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms Antiarrhythmics Type I-A

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

12

Drug Name DrugTier

RequirementsLimits

disopyramide phosphate caps 2

NORPACE CAPS (Use Disopyramide Phosphate) 4

NORPACE CR CP12 100 MG 3

NORPACE CR CP12 150 MG 4

quinidine gluconate tbcr 2

QUINIDINE SULFATE TABS 4

Antiarrhythmics Type I-B mexiletine hcl caps 150 mg 2

mexiletine hcl caps 200mg 250 mg 1

Antiarrhythmics Type I-C flecainide acetate tabs 2

propafenone hcl cp12 225mg 325 mg 2

propafenone hcl cp12 425 mg 3

propafenone hcl tabs 150mg 225 mg 300 mg 2

RYTHMOL SR CP12 (Use Propafenone HCl) 4

Antiarrhythmics Type III amiodarone hcl tabs 1

dofetilide caps 3

MULTAQ TABS 3

TIKOSYN CAPS (Use Dofetilide) 3

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu 1

Antiasthmatic - Monoclonal Antibodies NUCALA SOLR J PA

Drug Name DrugTier

RequirementsLimits

XOLAIR SOLR J PA SpecialtyTier 3 MayApply

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 2

Limit 2 inhalers permonthQL(086gm daily)

INCRUSE ELLIPTA AEPB 2 QL(1 ea daily)

ipratropium bromide soln 1

SEEBRI NEOHALER CAPS 4 QL(2 ea daily)

SPIRIVA HANDIHALER CAPS 2 QL(1 ea daily)

SPIRIVA RESPIMAT AERS 2

Limit 1 inhaler permonthQL(014gm daily)

TUDORZA PRESSAIR AEPB 4

ST Limit 1 inhaler permonthQL(004ea daily)

YUPELRI SOLN 4 PA

Leukotriene Modulators ACCOLATE TABS (Use Zafirlukast) 4

montelukast sodium chew 4 mg 1

QL(1 ea daily)AL(Up to 12 yrsold )

montelukast sodium chew 5 mg 1

QL(1 ea daily)AL(Up to 14 yrsold )

montelukast sodium pack 4 mg 1

QL(1 ea daily)AL(Up to 12 yrsold )

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

SINGULAIR CHEW 4 MG (Use Montelukast Sodium) 4

QL(1 ea daily)AL(Up to 12 yrsold )

SINGULAIR CHEW 5 MG (Use Montelukast Sodium) 4

QL(1 ea daily)AL(Up to 14 yrsold )

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

13

Drug Name DrugTier

RequirementsLimits

SINGULAIR PACK 4 MG (Use Montelukast Sodium) 4

QL(1 ea daily)AL(Up to 12 yrsold )

SINGULAIR TABS 10 MG (Use Montelukast Sodium) 4 QL(1 ea daily)

zafirlukast tabs 1

zileuton tb12 4 ST

ZYFLO CR TB12 (Use Zileuton) 4 ST

ZYFLO TABS 4 ST

Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TABS 4 QL(1 ea daily)

Steroid Inhalants

AEROSPAN AERS 2

Limit 2 inhalers permonthQL(06gm daily)

ALVESCO AERS 4

Limit 2 inhalers permonthQL(041gm daily)

ARNUITY ELLIPTA AEPB 2 QL(1 ea daily)

ASMANEX HFA AERO 2

Limit 1 inhaler permonthQL(044gm daily)

ASMANEX TWISTHALER 120 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

ASMANEX TWISTHALER 14 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

ASMANEX TWISTHALER 30 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

ASMANEX TWISTHALER 60 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

Drug Name DrugTier

RequirementsLimits

ASMANEX TWISTHALER 7 METERED DOSES AEPB

2

QL(1 ea per 30days retail3 eaper 90 daysmail)

budesonide (inhalation)susp 025 mg2ml 2 QL(8 ml daily)

budesonide (inhalation)susp 05 mg2ml 1 mg2ml 2 QL(4 ml daily)

FLOVENT DISKUS AEPB 100 MCGBLIST 2 QL(20 ea daily)

FLOVENT DISKUS AEPB 250 MCGBLIST 2 QL(8 ea daily)

FLOVENT DISKUS AEPB 50 MCGBLIST 2 QL(40 ea daily)

FLOVENT HFA AERO 110 MCGACT 220 MCGACT 2

Limit 2 inhalers permonthQL(08gm daily)

FLOVENT HFA AERO 44 MCGACT 2

Limit 1 inhaler permonthQL(036gm daily)

PULMICORT FLEXHALER AEPB 180 MCGACT 2

Limit 2 inhalers permonthQL(007ea daily)

PULMICORT FLEXHALER AEPB 90 MCGACT 2

Limit 4 inhalers permonthQL(027ea daily)

PULMICORT SUSP 025 MG2ML (Use Budesonide (Inhalation))

4 QL(8 ml daily)

PULMICORT SUSP 05 MG2ML 1 MG2ML (Use Budesonide (Inhalation))

4 QL(4 ml daily)

QVAR AERS 40 MCGACT 2

Limit 3 Inhalers per Month-73g pkg Limit2 Inhalers perMonth-87 pkgQL(058gm daily)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

14

Drug Name DrugTier

RequirementsLimits

QVAR AERS 80 MCGACT 2

Limit 2 Inhalers per Month-73g pkg 1Inhaler perMonth-87 pkgQL(029gm daily)

Sympathomimetics ADVAIR DISKUS AEPB 2 QL(2 ea daily)

ADVAIR HFA AERO 2

Limit 1 inhaler permonthQL(04gm daily)

AIRDUO RESPICLICK 5514 AEPB 4 QL(004 ea

daily) ALBUTEROL SULFATE ER TB12 4

albuterol sulfate nebu in 063 mg3ml 0083 05 125 mg3ml

1

albuterol sulfate syrp or 2mg5ml 1

albuterol sulfate tabs or 2 mg 4 mg 1

albuterol sulfate tb12 or 4 mg 8 mg 2

ANORO ELLIPTA AEPB 2 QL(2 ea daily)

ARCAPTA NEOHALER CAPS 4 QL(1 ea daily)

BEVESPI AEROSPHERE AERO 4 QL(036 gm

daily)

BREO ELLIPTA AEPB 2 QL(2 ea daily)

BROVANA NEBU 4

COMBIVENT RESPIMAT AERS 4

Limit 1 inhaler permonthQL(02gm daily)

DULERA AERO 2

Limit 1 inhaler permonthQL(045gm daily)

ipratropium-albuterol soln 1

Drug Name DrugTier

RequirementsLimits

levalbuterol hcl nebu 1

levalbuterol tartrate aero 2

metaproterenol sulfate syrp 1

metaproterenol sulfate tabs 1

PERFOROMIST NEBU 3 QL(4 ml daily)

PROAIR HFA AERS 4

PROAIR RESPICLICK AEPB 4

PROVENTIL HFA AERS 2

SEREVENT DISKUS AEPB 2 QL(2 ea daily)

STIOLTO RESPIMAT AERS 2

Limit 1 inhaler permonthQL(014gm daily)

STRIVERDI RESPIMAT AERS 2

Limit 1 inhaler permonthQL(014gm daily)

SYMBICORT AERO 2

Limit 1 inhaler permonthQL(034gm daily)

terbutaline sulfate tabs 2

UTIBRON NEOHALER CAPS 4 QL(2 ea daily)

VENTOLIN HFA AERS 4

VOSPIRE ER TB12 (Use Albuterol Sulfate) 4

XOPENEX CONCENTRATE NEBU (Use Levalbuterol HCl)

4

XOPENEX HFA AERO 2

XOPENEX NEBU (Use Levalbuterol HCl) 4

Xanthines aminophylline soln 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

15

Drug Name DrugTier

RequirementsLimits

ELIXOPHYLLIN ELIX 4

THEO-24 CP24 3

theophylline soln 80mg15ml 4

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) 4

warfarin sodium tabs 1

Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS 2

ELIQUIS TABS 2

SAVAYSA TABS 4

XARELTO STARTER PACK TBPK 2

XARELTO TABS 2

Heparins And Heparinoid-Like Agents

ARIXTRA SOLN 5 MG04ML 10 MG08ML25 MG05ML (Use Fondaparinux Sodium)

J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

ARIXTRA SOLN 75 MG06ML (Use Fondaparinux Sodium)

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

enoxaparin sodium soln ij300 mg3ml J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

Drug Name DrugTier

RequirementsLimits

enoxaparin sodium soln sc100 mgml 30 mg03ml40 mg04ml 60 mg06ml80 mg08ml 120 mg08ml

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

enoxaparin sodium soln sc150 mgml J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

fondaparinux sodium soln 5mg04ml 10 mg08ml 25mg05ml

J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

fondaparinux sodium soln75 mg06ml J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

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

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

FRAGMIN SOLN 95000 UNIT38ML J QL(20 ml per

10 days retail)

heparin (porcine) in sodiumchloride soln J

PA SpecialtyTier 1 MayApply

HEPARIN LOCK FLUSH SOLN J

PA SpecialtyTier 1 MayApply

heparin sod (porcine) ind5w soln J

PA SpecialtyTier 1 MayApply

heparin sodium (porcine)lock flush amp nacl lock flush kit

J PA SpecialtyTier 1 MayApply

heparin sodium (porcine)lock flush soln J

PA SpecialtyTier 1 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

16

Drug Name DrugTier

RequirementsLimits

heparin sodium (porcine)soln J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUM SOSY IV 4 PA

HEPARIN SODIUMD5WSOLN J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMDEXTROSESOLN

J PA SpecialtyTier 1 MayApply

HEPARIN SODIUMNACL045 SOLN J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMSODIUMCHLORIDE 09 SOLN (Use Heparin (Porcine) in Sodium Chloride)

J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMSODIUMCHLORIDE SOLN IJ 2UNITML-09

J

PA SpecialtyTier 1 MayApply

HEPARIN SODIUMSODIUMCHLORIDE SOSY IV 100UNIT50ML-09

4

PA SpecialtyTier 1 MayApply

LOVENOX SOLN IJ 300 MG3ML (Use EnoxaparinSodium)

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

LOVENOX SOLN SC 100 MGML 30 MG03ML 40MG04ML 60 MG06ML80 MG08ML 120MG08ML (Use Enoxaparin Sodium)

J

Specialty Tier 1MayApplyQL(20 mlper 10 daysretail)

LOVENOX SOLN SC 150 MGML (Use EnoxaparinSodium)

J

Specialty MayApply BrandTier 3 Generic Tier 1QL(20 mlper 10 daysretail)

SASH KIT FOR FLUSHING VASCULAR ACCESS DEVICES KIT

J PA SpecialtyTier 1 MayApply

Thrombin Inhibitors

Drug Name DrugTier

RequirementsLimits

IPRIVASK SOLR J

Specialty Tier 1MayApplyQL(24 eaper 12 daysretail)

PRADAXA CAPS 4

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists FYCOMPA SUSP 4

FYCOMPA TABS 4

Anticonvulsants - Benzodiazepines clobazam susp 4

clobazam tabs 4

clonazepam tabs 05 mg 1mg 2 mg 1

clonazepam tbdp 0125mg 025 mg 05 mg 1 mg2 mg

2

DIASTAT ACUDIAL GEL 10 MG 2

Limit 4 boxes (8 syringes) per30 days

DIASTAT ACUDIAL GEL 20 MG 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

DIASTAT PEDIATRIC GEL 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

diazepam (anticonvulsant)gel 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

DIAZEPAM GEL RE 20 MG 25 MG 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

17

Drug Name DrugTier

RequirementsLimits

DIAZEPAM RECTAL GEL GEL 2

Limit 4 boxes (8 syringes) per30 daysQL(4ea per 30 daysretail)

KLONOPIN TABS (Use Clonazepam) 4

ONFI SUSP (Use Clobazam) 4

ONFI TABS (Use Clobazam) 4

SYMPAZAN FILM 4 PA

Anticonvulsants - Misc APTIOM TABS 200 MG 400 MG 600 MG 4 QL(2 ea daily)

APTIOM TABS 800 MG 4 QL(1 ea daily)

BANZEL SUSP 3

BANZEL TABS 3

BRIVIACT SOLN 4 PA

BRIVIACT TABS 4 PA

carbamazepine chew 100 mg 1

carbamazepine cp12 100mg 200 mg 300 mg 1

carbamazepine susp 100mg5ml 1

carbamazepine tabs 200 mg 1

carbamazepine tb12 100 mg 1

carbamazepine tb12 200mg 400 mg 2

CARBATROL CP12 (Use Carbamazepine) 4

EPIDIOLEX SOLN 4 PA

gabapentin caps 2

gabapentin soln 2

Drug Name DrugTier

RequirementsLimits

gabapentin tabs 2

KEPPRA SOLN (Use Levetiracetam) 4

KEPPRA TABS (Use Levetiracetam) 4

KEPPRA XR TB24 (Use Levetiracetam) 4

LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine)

4

LAMICTAL ODT KIT 4 PA

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

4 PA

LAMICTAL STARTERNOTTAKING CARBAMAZEPINE KIT (Use Lamotrigine)

4

LAMICTAL STARTERTAKINGCARBAMAZEPINENOTTAKING VALPROATE KIT (Use Lamotrigine)

4

LAMICTAL STARTERTAKINGVALPROATE KIT (Use Lamotrigine)

4

LAMICTAL TABS (Use Lamotrigine) 4

LAMICTAL XR KIT 4 PA

LAMICTAL XR TB24 25 MG 50 MG 100 MG 200 MG 250 MG 300 MG (Use Lamotrigine)

4

PA

lamotrigine chew 5 mg 25 mg 3

lamotrigine kit 4 PA

lamotrigine kit 25 mg 4

lamotrigine tabs 25 mg100 mg 150 mg 200 mg 1

lamotrigine tb24 25 mg 50mg 100 mg 200 mg 250mg 300 mg

4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

18

Drug Name DrugTier

RequirementsLimits

lamotrigine tbdp 25 mg 50mg 100 mg 200 mg 4 PA

levetiracetam soln 100 mgml 500 mg5ml 2

levetiracetam tabs 250 mg500 mg 750 mg 1000 mg 3

levetiracetam tb24 500 mg750 mg 3

LYRICA CAPS 150 MG 225 MG 300 MG 4 PA QL(2 ea

daily) LYRICA CAPS 25 MG 50 MG 75 MG 100 MG 200 MG

4 PA QL(3 eadaily)

LYRICA SOLN 20 MGML 4 PA QL(30 mldaily)

MYSOLINE TABS (Use Primidone) 4

NEURONTIN CAPS (Use Gabapentin) 4

NEURONTIN SOLN (Use Gabapentin) 4

NEURONTIN TABS (Use Gabapentin) 4

oxcarbazepine susp 3

oxcarbazepine tabs 3

OXTELLAR XR TB24 4 ST

POTIGA TABS 4

primidone tabs 1

QUDEXY XR CS24 4 PA

SPRITAM TB3D 4 PA

TEGRETOL SUSP (Use Carbamazepine) 4

TEGRETOL TABS (Use Carbamazepine) 4

TEGRETOL-XR TB12 100 MG (Use Carbamazepine) 3

TEGRETOL-XR TB12 200 MG 400 MG (Use Carbamazepine)

4

Drug Name DrugTier

RequirementsLimits

TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate)

4

TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate)

3

TOPAMAX TABS (Use Topiramate) 4

topiramate cpsp 15 mg 25 mg 3

TOPIRAMATE ER CS24 4 PA

topiramate tabs 25 mg 50mg 100 mg 200 mg 2

TRILEPTAL SUSP (Use Oxcarbazepine) 4

TRILEPTAL TABS (Use Oxcarbazepine) 4

TROKENDI XR CP24 4 PA

VIMPAT SOLN 2

VIMPAT TABS 2

ZONEGRAN CAPS (Use Zonisamide) 4

zonisamide caps 3

Carbamates felbamate susp 3

felbamate tabs 3

FELBATOL SUSP (Use Felbamate) 4

FELBATOL TABS (Use Felbamate) 4

GABA Modulators GABITRIL TABS 12 MG 16 MG (Use TiagabineHCl)

3

GABITRIL TABS 2 MG 4 MG (Use Tiagabine HCl) 4

SABRIL PACK (Use Vigabatrin) 3

SABRIL TABS 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

19

Drug Name DrugTier

RequirementsLimits

tiagabine hcl tabs 12 mg16 mg 3

tiagabine hcl tabs 2 mg 4 mg 1

vigabatrin pack 3

Hydantoins DILANTIN CAPS 100 MG (Use Phenytoin SodiumExtended)

4

DILANTIN CAPS 30 MG 4

DILANTIN INFATABS CHEW (Use Phenytoin) 4

DILANTIN-125 SUSP (Use Phenytoin) 4

PEGANONE TABS 4

PHENYTEK CAPS (Use Phenytoin SodiumExtended)

4

phenytoin chew 1

phenytoin sodium extendedcaps 100 mg 1

phenytoin sodium extendedcaps 200 mg 300 mg 4

phenytoin susp 1

Succinimides CELONTIN CAPS 3

ethosuximide caps 2

ethosuximide soln 2

ZARONTIN CAPS (Use Ethosuximide) 4

ZARONTIN SOLN (Use Ethosuximide) 4

Valproic Acid DEPAKENE CAPS (Use Valproic Acid) 4

DEPAKENE SOLN (Use Valproate Sodium) 4

Drug Name DrugTier

RequirementsLimits

DEPAKOTE ER TB24 (Use Divalproex Sodium) 4

DEPAKOTE SPRINKLES CSDR (Use DivalproexSodium)

4

DEPAKOTE TBEC (Use Divalproex Sodium) 4

divalproex sodium csdr 125 mg 1

divalproex sodium tb24 250mg 500 mg 2

divalproex sodium tbec 125mg 250 mg 500 mg 1

valproate sodium soln 1

valproic acid caps 1

ANTIDEPRESSANTS - Drugs to TreatDepression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 2

mirtazapine tbdp 2

REMERON SOLTAB TBDP (Use Mirtazapine) 4

REMERON TABS (Use Mirtazapine) 4

Antidepressants - Misc

APLENZIN TB24 4 PA QL(1 eadaily)

bupropion hcl tabs 2

bupropion hcl tb12 2

bupropion hcl tb24 2

BUPROPION HYDROCHLORIDE ER TB24

4 ST QL(1 eadaily)

FORFIVO XL TB24 4 ST QL(1 eadaily)

maprotiline hcl tabs 25 mg 2

MAPROTILINE HCL TABS 50 MG 75 MG 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

20

Drug Name DrugTier

RequirementsLimits

WELLBUTRIN SR TB12 (Use Bupropion HCl) 4

WELLBUTRIN XL TB24 (Use Bupropion HCl) 4 PA

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 4

MARPLAN TABS 3

NARDIL TABS (Use Phenelzine Sulfate) 3

PARNATE TABS (Use Tranylcypromine Sulfate) 4

phenelzine sulfate tabs 3

tranylcypromine sulfatetabs 2

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

4 QL(4 ea daily)

CELEXA TABS 20 MG (Use CitalopramHydrobromide)

4 QL(2 ea daily)

CELEXA TABS 40 MG (Use CitalopramHydrobromide)

4 QL(1 ea daily)

citalopram hydrobromidesoln 10 mg5ml 1 QL(20 ml daily)

citalopram hydrobromidetabs 10 mg 1 QL(4 ea daily)

citalopram hydrobromidetabs 20 mg 1 QL(2 ea daily)

citalopram hydrobromidetabs 40 mg 1 QL(1 ea daily)

escitalopram oxalate soln 1

escitalopram oxalate tabs 1

FLUOXETINE DR CPDR 4

fluoxetine hcl caps 10 mg20 mg 40 mg 1

fluoxetine hcl soln 20 mg5ml 2

Drug Name DrugTier

RequirementsLimits

fluoxetine hcl tabs 10 mg20 mg 1

fluoxetine hcl tabs 60 mg 4 ST QL(1 eadaily)

FLUOXETINE HYDROCHLORIDE TABS 4 ST QL(1 ea

daily) FLUOXETINE HYDROCHLORIDE TABS (Use Fluoxetine HCl)

4 ST QL(1 eadaily)

fluvoxamine maleate cp24100 mg 150 mg 1

fluvoxamine maleate tabs 25 mg 50 mg 100 mg 2

LEXAPRO SOLN (Use Escitalopram Oxalate) 4

LEXAPRO TABS (Use Escitalopram Oxalate) 4

paroxetine hcl tabs 1

paroxetine hcl tb24 1

PAXIL CR TB24 (Use Paroxetine HCl) 4

PAXIL SUSP 10 MG5ML 4

PAXIL TABS 10 MG 20 MG 30 MG 40 MG (Use Paroxetine HCl)

4

PEXEVA TABS 10 MG 4

PEXEVA TABS 20 MG 30 MG 40 MG 4 QL(1 ea daily)

PROZAC CAPS (Use Fluoxetine HCl) 4

PROZAC WEEKLY CPDR (Use Fluoxetine HCl) 4

sertraline hcl conc 1

sertraline hcl tabs 1

ZOLOFT CONC (Use Sertraline HCl) 4

ZOLOFT TABS (Use Sertraline HCl) 4

Serotonin Modulators nefazodone hcl tabs 2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

21

Drug Name DrugTier

RequirementsLimits

NEFAZODONE HYDROCHLORIDE TABS 4

trazodone hcl tabs 1

TRINTELLIX TABS 4 ST QL(1 eadaily)

VIIBRYD STARTER PACK KIT 4 PA

VIIBRYD TABS 4 ST

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use Duloxetine HCl) 4

DESVENLAFAXINE ER TB24 50 MG 100 MG 4 ST QL(1 ea

daily) DESVENLAFAXINE ER TB24 50 MG 100 MG 4 ST

desvenlafaxine succinate tb24 2

duloxetine hcl cpep 20 mg30 mg 60 mg 2

duloxetine hcl cpep 40 mg 4 PA

EFFEXOR XR CP24 (Use Venlafaxine HCl) 4 QL(1 ea daily)

FETZIMA CP24 20 MG 4 ST QL(2 eadaily)

FETZIMA CP24 40 MG 80 MG 120 MG 4 ST QL(1 ea

daily) FETZIMA TITRATION PACK C4PK 4 ST

KHEDEZLA TB24 4 ST QL(1 eadaily)

PRISTIQ TB24 (Use Desvenlafaxine Succinate) 4

venlafaxine hcl cp24 75mg 150 mg 375 mg 1 QL(1 ea daily)

venlafaxine hcl tabs 25 mg50 mg 75 mg 100 mg375 mg

2

venlafaxine hcl tb24 75 mg150 mg 225 mg 375 mg 4

Tricyclic Agents amitriptyline hcl tabs 1

Drug Name DrugTier

RequirementsLimits

AMOXAPINE TABS 4

ANAFRANIL CAPS (Use Clomipramine HCl) 4

clomipramine hcl caps 1

desipramine hcl tabs 1

doxepin hcl caps 1

doxepin hcl conc 1

ELAVIL TABS (Use Amitriptyline HCl) 4

imipramine hcl tabs 1

imipramine pamoate caps100 mg 150 mg 4

imipramine pamoate caps125 mg 3

imipramine pamoate caps75 mg 1

NORPRAMIN TABS (Use Desipramine HCl) 4

nortriptyline hcl caps 1

nortriptyline hcl soln 1

PAMELOR CAPS (Use Nortriptyline HCl) 4

protriptyline hcl tabs 1

SURMONTIL CAPS (Use Trimipramine Maleate) 4

TOFRANIL TABS (Use Imipramine HCl) 4

trimipramine maleate caps 4

ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors acarbose tabs 2

GLYSET TABS (Use Miglitol) 3

miglitol tabs 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

22

Drug Name DrugTier

RequirementsLimits

PRECOSE TABS (Use Acarbose) 4

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN J PA SpecialtyTier 1 MayApply

SYMLINPEN 60 SOPN J PA SpecialtyTier 1 MayApply

Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl-Metformin HCl)

4

ACTOPLUS MET XR TB24 15MG-1000MG 4 QL(2 ea daily)

ACTOPLUS MET XR TB24 30MG-1000MG 4 QL(1 ea daily)

ALOGLIPTINMETFORMINHCL TABS 4

ALOGLIPTINPIOGLITAZONE TABS 4

DUETACT TABS (Use Pioglitazone HCl-Glimepiride)

4

glipizide-metformin hcl tabs 2

GLUCOVANCE TABS (Use Glyburide-Metformin) 4

glyburide-metformin tabs 2

GLYXAMBI TABS 3

INVOKAMET TABS 3

INVOKAMET XR TB24 3

JANUMET TABS 3

JANUMET XR TB24 3

JENTADUETO TABS 3

JENTADUETO XR TB24 3

KAZANO TABS 4

Drug Name DrugTier

RequirementsLimits

KOMBIGLYZE XR TB24 4

OSENI TABS 4

pioglitazone hcl-glimepiridetabs 1

pioglitazone hcl-metforminhcl tabs 2

REPAGLINIDEMETFORMIN HYDROCHLORIDE TABS

4

SYNJARDY TABS 3

XIGDUO XR TB24 4

Biguanides FORTAMET TB24 (Use Metformin HCl) 4

GLUCOPHAGE TABS (Use Metformin HCl) 4

GLUCOPHAGE XR TB24 (Use Metformin HCl) 4

GLUMETZA TB24 (Use Metformin HCl) 4 PA

metformin hcl tabs 500 mg850 mg 1000 mg 1

metformin hcl tb24 500 mg1000 mg 2

metformin hcl tb24 500 mg1000 mg 4 PA

metformin hcl tb24 500 mg750 mg 1

METFORMIN HYDROCHLORIDE SOLN 4

RIOMET SOLN 4

Diabetic Other GLUCAGEN HYPOKIT SOLR J Specialty Tier 1

May Apply GLUCAGON EMERGENCY KIT KIT J Specialty Tier 1

May Apply

KORLYM TABS 4 PA SpecialtyTier 3 MayApply

PROGLYCEM SUSP 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

23

Drug Name DrugTier

RequirementsLimits

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ALOGLIPTIN TABS 4

JANUVIA TABS 3

NESINA TABS 4

ONGLYZA TABS 4

TRADJENTA TABS 3

Dopamine Receptor Agonists - Antidiabetic CYCLOSET TABS 4

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON PEN PEN J PA SpecialtyTier 1 MayApply

BYDUREON SRER J PA SpecialtyTier 1 MayApply

BYETTA SOPN J PA SpecialtyTier 1 MayApply

TANZEUM PEN J PA SpecialtyTier 1 MayApply

TRULICITY SOPN J PA SpecialtyTier 1 MayApply

VICTOZA SOPN J PA SpecialtyTier 1 MayApply

Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) 4

AVANDIA TABS 3

pioglitazone hcl tabs 2

Insulin

ADMELOG SOLN 4

PA Limit 45mls permonthQL(15ml daily)

Drug Name DrugTier

RequirementsLimits

ADMELOG SOLOSTAR SOPN 4

PA Limit 45mls permonthQL(15ml daily)

AFREZZA POWD 4 PA

AFREZZA POWD 4 UNIT 8 UNIT 12 UNIT 4 PA QL(3 ea

daily)

APIDRA SOLN 4 PA

APIDRA SOLOSTAR SOPN 4 PA

BASAGLAR KWIKPEN SOPN 4 PA

FIASP FLEXTOUCH SOPN 4

PA Limit 45mls permonthQL(15ml daily)

FIASP SOLN 4

PA Limit 45mls permonthQL(15ml daily)

HUMALOG JUNIOR KWIKPEN SOPN 2

Limit 45mls permonthQL(15ml daily)

HUMALOG KWIKPEN SOPN 100 UNITML 2

Limit 45mls permonthQL(15ml daily)

HUMALOG KWIKPEN SOPN 200 UNITML 2

Limit 24mls permonthQL(08ml daily)

HUMALOG MIX 5050KWIKPEN SUPN 2

Limit 45mls permonthQL(15ml daily)

HUMALOG MIX 5050SUSP 2

Limit 45mls permonthQL(15ml daily)

HUMALOG MIX 7525KWIKPEN SUPN 2

Limit 45mls permonthQL(15ml daily)

HUMALOG MIX 7525SUSP 2

Limit 45mls permonthQL(15ml daily)

HUMALOG SOCT 2 Limit 45mls permonthQL(15ml daily)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

24

Drug Name DrugTier

RequirementsLimits

HUMALOG SOLN 2 Limit 45mls permonthQL(15ml daily)

HUMULIN 7030 KWIKPENSUPN 2

HUMULIN 7030 SUSP 2 Limit 45mls permonthQL(15ml daily)

HUMULIN 7030 SUSP 2 Limit 40mls permonthQL(134ml daily)

HUMULIN N KWIKPEN SUPN 2

Limit 45mls permonthQL(15ml daily)

HUMULIN N SUSP 2 Limit 40mls permonthQL(134ml daily)

HUMULIN N SUSP 2 Limit 45mls permonthQL(15ml daily)

HUMULIN R SOLN 2 Limit 45mls permonthQL(15ml daily)

HUMULIN R SOLN 2 Limit 40mls permonthQL(134ml daily)

HUMULIN R U-500 (CONCENTRATED) SOLN 2

Limit 40mls permonthQL(134ml daily)

HUMULIN R U-500 KWIKPEN SOPN 2

Limit 40mls permonthQL(134ml daily)

LANTUS SOLN 3 Limit 45mls permonthQL(15ml daily)

LANTUS SOLOSTAR SOPN 3

Limit 45mls permonthQL(15ml daily)

LEVEMIR FLEXTOUCH SOPN 3

Limit 45mls permonthQL(15ml daily)

LEVEMIR SOLN 3 Limit 45mls permonthQL(15ml daily)

NOVOLIN 7030 RELIONSUSP 4

PA Limit 40mls permonthQL(134ml daily)

Drug Name DrugTier

RequirementsLimits

NOVOLIN 7030 SUSP 3

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN N RELION SUSP 4

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN N SUSP 4

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN R RELION SOLN 4

PA Limit 40mls permonthQL(134ml daily)

NOVOLIN R SOLN 3

PA Limit 40mls permonthQL(134ml daily)

NOVOLOG FLEXPEN SOPN 4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG MIX 7030PREFILLED FLEXPEN SUPN

4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG MIX 7030SUSP 4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG PENFILL SOCT 4

PA Limit 45mls permonthQL(15ml daily)

NOVOLOG SOLN 4

PA Limit 45mls permonthQL(15ml daily)

TOUJEO MAX SOLOSTAR SOPN 3 QL(05 ml

daily) TOUJEO SOLOSTAR SOPN 3 QL(05 ml

daily)

TRESIBA FLEXTOUCH SOPN 100 UNITML 3

Limit 45mls permonthQL(15ml daily)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

25

Drug Name DrugTier

RequirementsLimits

TRESIBA FLEXTOUCH SOPN 200 UNITML 3

Limit 27mls permonthQL(09ml daily)

Meglitinide Analogues nateglinide tabs 2

PRANDIN TABS 05 MG (Use Repaglinide) 3

PRANDIN TABS 1 MG 2 MG (Use Repaglinide) 4

repaglinide tabs 05 mg 3

repaglinide tabs 1 mg 2 mg 2

STARLIX TABS (Use Nateglinide) 4

Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS 4

INVOKANA TABS 3

JARDIANCE TABS 3

Sulfonylureas AMARYL TABS (Use Glimepiride) 4

chlorpropamide tabs 1

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

GLUCOTROL TABS (Use Glipizide) 4

GLUCOTROL XL TB24 (Use Glipizide) 4

glyburide micronized tabs 1

glyburide tabs 1

GLYNASE TABS (Use Glyburide Micronized) 4

TOLAZAMIDE TABS 250 MG 4

Drug Name DrugTier

RequirementsLimits

tolazamide tabs 500 mg 1

TOLBUTAMIDE TABS 4

ANTIDIARRHEALPROBIOTIC AGENTS - Drugsto Treat Diarrhea Antidiarrheal - Chloride Channel Antagonists

MYTESI TBEC 4 PA QL(2 eadaily)

Antiperistaltic Agents diphenoxylate w atropineliqd 1

diphenoxylate w atropinetabs 1

LOMOTIL TABS (Use Diphenoxylate w Atropine) 4

MOTOFEN TABS 2

opium tincture tinc 4

paregoric tinc 2

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents CHEMET CAPS 2

EXJADE TBSO 2 PA SpecialtyTier 3 MayApply

FERRIPROX SOLN 4 Specialty Tier 3May Apply

FERRIPROX TABS 4 Specialty Tier 3May Apply

JADENU TABS 2

PA SpecialtyTier 3 MayApply - Directto Acaria Specialty

Antidotes and Specific Antagonists CETYLEV TBEF 4 PA

RADIOGARDASE CAPS 4 PA

VISTOGARD PACK 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

26

Drug Name DrugTier

RequirementsLimits

Opioid Antagonists

EVZIO SOAJ J PA SpecialtyTier 3 MayApply

naltrexone hcl tabs 2

NALTREXONE IMPL 4 PA

NARCAN LIQD 4 QL(4 ea per 30days retail)

VIVITROL SUSR J PA SpecialtyTier 3 MayApply

ANTIEMETICS - Drugs to Treat Nausea andVomiting 5-HT3 Receptor Antagonists ALOXI SOLN (Use Palonosetron HCl) 3

ANZEMET TABS 4 PA

granisetron hcl tabs 4 PA QL(2 eadaily)

ondansetron hcl soln 4 mg5ml 3 QL(5 ml daily)

ondansetron hcl tabs 24 mg 3

QL(31 ea per30 daysretail93 ea per90 days mail)

ondansetron hcl tabs 4 mg8 mg 3

Limit 30 permonthQL(1 eadaily)

ondansetron tbdp 3

QL(31 ea per30 daysretail93 ea per90 days mail)

palonosetron hcl soln 3

PALONOSETRON HYDROCHLORIDE SOLN 3

SANCUSO PTCH 4 QL(1 ea per 30days retail)

SUSTOL PRSY J PA SpecialtyTier 3 MayApply

Drug Name DrugTier

RequirementsLimits

ZOFRAN ODT TBDP (Use Ondansetron) 4

QL(31 ea per30 daysretail93 ea per90 days mail)

ZOFRAN SOLN 4 MG5ML(Use Ondansetron HCl) 4 QL(5 ml daily)

ZOFRAN TABS 4 MG 8 MG (Use Ondansetron HCl)

4 Limit 30 permonthQL(1 eadaily)

ZUPLENZ FILM 4 QL(10 ea per30 days retail)

Antiemetics - Anticholinergic scopolamine pt72 1

TIGAN CAPS (Use Trimethobenzamide HCl) 4

TRANSDERM-SCOP PT72 2

TRANSDERM-SCOP PT72 (Use Scopolamine) 3

trimethobenzamide hcl caps 1

Antiemetics - Miscellaneous

AKYNZEO CAPS 4 QL(2 ea per 28days retail)

CESAMET CAPS 4 PA

DICLEGIS TBEC 4 QL(4 ea daily)

dronabinol caps 3

MARINOL CAPS (Use Dronabinol) 4

Substance PNeurokinin 1 (NK1) Receptor aprepitant caps 4

EMEND CAPS 40 MG 80 MG 125 MG (Use Aprepitant)

4

EMEND SUSR 125 MG 4 PA

EMEND TRIPACK CAPS (Use Aprepitant) 4

VARUBI TABS 4 QL(4 ea per fillretail)

ANTIFUNGALS - Drugs to Treat Fungal Infections

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Arizona 4-Tier Drug List Updated January 1 2019

27

Drug Name DrugTier

RequirementsLimits

Antifungals ANCOBON CAPS (Use Flucytosine) 4

BIO-STATIN CAPS 4

flucytosine caps 4

GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) 4

griseofulvin microsize susp125 mg5ml 1

griseofulvin microsize tabs500 mg 3

griseofulvin ultramicrosizetabs 2

LAMISIL TABS (Use Terbinafine HCl) 4 QL(90 ea per

365 days retail)

nystatin tabs 1

terbinafine hcl tabs 1 QL(90 ea per365 days retail)

Imidazole-Related Antifungals CRESEMBA CAPS 4

DIFLUCAN SUSR (Use Fluconazole) 4

DIFLUCAN TABS (Use Fluconazole) 4

fluconazole susr 1

fluconazole tabs 1

itraconazole caps 100 mg 3 PA

itraconazole soln 10 mgml 3

ketoconazole tabs 1

NOXAFIL SUSP 4

NOXAFIL TBEC 4

ONMEL TABS 4 PA

SPORANOX CAPS 100 MG (Use Itraconazole) 4 PA

Drug Name DrugTier

RequirementsLimits

SPORANOX PULSEPAK CAPS (Use Itraconazole) 4 PA

SPORANOX SOLN 10 MGML (Use Itraconazole) 3

TOLSURA CAPS 4 PA

VFEND SUSR (Use Voriconazole) 4

VFEND TABS (Use Voriconazole) 4

voriconazole susr 1

voriconazole tabs 1

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines BROMPHENIRAMINE TANNATE CHEW 4

RYCLORA SYRP 4

Antihistamines - Ethanolamines carbinoxamine maleate soln 4 mg5ml 1

carbinoxamine maleate tabs 4 mg 4

diphenhydramine hcl caps 1 RXOTC

KARBINAL ER SUER 4

Antihistamines - Phenothiazines promethazine hcl soln or625 mg5ml 4

promethazine hcl supp re25 mg 50 mg 125 mg 2

promethazine hcl syrp or625 mg5ml 4

promethazine hcl tabs or25 mg 50 mg 125 mg 1

Antihistamines - Piperidines cyproheptadine hcl syrp 1

cyproheptadine hcl tabs 1

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

28

Drug Name DrugTier

RequirementsLimits

Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs 10mg-10mg 10mg-20mg40mg-10mg

1

ezetimibe-simvastatin tabs 80mg-10mg 1 PA

VYTORIN TABS 10MG-10MG 10MG-20MG 40MG-10MG (Use Ezetimibe-Simvastatin)

3

VYTORIN TABS 80MG-10MG (Use Ezetimibe-Simvastatin)

3 PA

Antihyperlipidemics - Misc

KYNAMRO SOSY J PA SpecialtyTier 2 MayApply

LOVAZA CAPS (Use Omega-3-acid EthylEsters)

4

omega-3-acid ethyl esters caps 1

VASCEPA CAPS 4 ST

Bile Acid Sequestrants cholestyramine light pack 2

cholestyramine light powd 2

cholestyramine pack 2

cholestyramine powd 2

colesevelam hcl pack 4

colesevelam hcl tabs 4

COLESTID FLAVORED GRAN (Use Colestipol HCl) 4

COLESTID FLAVORED PACK (Use Colestipol HCl) 4

COLESTID GRAN (Use Colestipol HCl) 4

COLESTID PACK (Use Colestipol HCl) 4

COLESTID TABS (Use Colestipol HCl) 4

Drug Name DrugTier

RequirementsLimits

colestipol hcl gran 1

colestipol hcl pack 1

colestipol hcl tabs 1

QUESTRAN LIGHT POWD (Use Cholestyramine Light) 4

QUESTRAN PACK (Use Cholestyramine) 4

QUESTRAN POWD (Use Cholestyramine) 4

WELCHOL PACK (Use Colesevelam HCl) 4

WELCHOL TABS (Use Colesevelam HCl) 4

Fibric Acid Derivatives ANTARA CAPS 4

choline fenofibrate cpdr 2

FENOFIBRATE CAPS 150 MG 4

FENOFIBRATE CAPS 50 MG 3

fenofibrate micronized caps 1

FENOFIBRATE TABS 160 MG 4

fenofibrate tabs 40 mg 120 mg 3 PA

fenofibrate tabs 48 mg 145 mg 2

fenofibrate tabs 54 mg 160 mg 1

FENOFIBRIC ACID TABS 4

FENOGLIDE TABS (Use Fenofibrate) 3 PA

FIBRICOR TABS 4

gemfibrozil tabs 1

LIPOFEN CAPS 150 MG 4

LIPOFEN CAPS 50 MG 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

29

Drug Name DrugTier

RequirementsLimits

LOFIBRA CAPS (Use Fenofibrate Micronized) 4

LOPID TABS (Use Gemfibrozil) 4

TRICOR TABS (Use Fenofibrate) 4

TRIGLIDE TABS 4

TRILIPIX CPDR (Use Choline Fenofibrate) 4

HMG CoA Reductase Inhibitors ALTOPREV TB24 4

atorvastatin calcium tabs 1 QL(1 ea daily)

CRESTOR TABS 40 MG (Use Rosuvastatin Calcium)

4

CRESTOR TABS 5 MG 10 MG 20 MG (Use Rosuvastatin Calcium)

4 QL(1 ea daily)

fluvastatin sodium caps 20mg 40 mg 1

fluvastatin sodium tb24 80 mg 2

LESCOL XL TB24 (Use Fluvastatin Sodium) 4

LIPITOR TABS (Use Atorvastatin Calcium) 4 QL(1 ea daily)

LIVALO TABS 4 QL(1 ea daily)

lovastatin tabs 1

$0 copay forGeneric onlyage 40 to75QL(1 eadaily) AL(Atleast 40 yrs old- Up to 75 yrsold) PV

MEVACOR TABS (Use Lovastatin) 4

$0 copay forGeneric onlyage 40 to75QL(1 eadaily) AL(Atleast 40 yrs old- Up to 75 yrsold) PV

Drug Name DrugTier

RequirementsLimits

PRAVACHOL TABS (Use Pravastatin Sodium) 4 QL(1 ea daily)

pravastatin sodium tabs 1 QL(1 ea daily)

rosuvastatin calcium tabs 40 mg 2

rosuvastatin calcium tabs 5 mg 10 mg 20 mg 2 QL(1 ea daily)

simvastatin tabs 1

ZOCOR TABS (Use Simvastatin) 4

Intestinal Cholesterol Absorption Inhibitors ezetimibe tabs 1

ZETIA TABS (Use Ezetimibe) 3

Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS 30 MG 40 MG 60 MG 4 PA

JUXTAPID CAPS 5 MG 10 MG 20 MG 4

PA SpecialtyTier 4 MayApply

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1

NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) 4

Proprotein Convertase SubtilisinKexin Type 9

PRALUENT SOPN J PA SpecialtyTier 3 MayApply

PRALUENT SOSY J PA SpecialtyTier 3 MayApply

REPATHA PUSHTRONEX SYSTEM SOCT J

PA SpecialtyTier 3 MayApply

REPATHA SOSY J PA SpecialtyTier 3 MayApply

REPATHA SURECLICK SOAJ J

PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

30

Drug Name DrugTier

RequirementsLimits

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) 4

ACEON TABS (Use Perindopril Erbumine) 4

ALTACE CAPS (Use Ramipril) 4

benazepril hcl tabs 1

captopril tabs 1

enalapril maleate tabs 1

EPANED SOLR 4 QL(5 ml daily)

fosinopril sodium tabs 1

lisinopril tabs 1

LOTENSIN TABS (Use Benazepril HCl) 4

MAVIK TABS (Use Trandolapril) 4

moexipril hcl tabs 1

perindopril erbumine tabs 1

PRINIVIL TABS (Use Lisinopril) 4

quinapril hcl tabs 1

ramipril caps 2

trandolapril tabs 2

VASOTEC TABS (Use Enalapril Maleate) 4

ZESTRIL TABS (Use Lisinopril) 4

Agents for Pheochromocytoma DEMSER CAPS 4

DIBENZYLINE CAPS (Use Phenoxybenzamine HCl) 3

Drug Name DrugTier

RequirementsLimits

phenoxybenzamine hcl caps 3

Angiotensin II Receptor Antagonists ATACAND TABS (Use Candesartan Cilexetil) 4

AVAPRO TABS (Use Irbesartan) 4

BENICAR TABS (Use Olmesartan Medoxomil) 3

candesartan cilexetil tabs 1

COZAAR TABS (Use Losartan Potassium) 4

DIOVAN TABS (Use Valsartan) 4

EDARBI TABS 4

EPROSARTAN MESYLATE TABS 4

irbesartan tabs 1

losartan potassium tabs 1

MICARDIS TABS (Use Telmisartan) 4

olmesartan medoxomil tabs 3

telmisartan tabs 1

valsartan tabs 2

Antiadrenergic Antihypertensives CARDURA TABS (Use Doxazosin Mesylate) 4

CATAPRES TABS (Use Clonidine HCl) 4

clonidine hcl tabs 1

doxazosin mesylate tabs 1

guanfacine hcl tabs 1

methyldopa tabs 1

MINIPRESS CAPS (Use Prazosin HCl) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

31

Drug Name DrugTier

RequirementsLimits

prazosin hcl caps 1

TENEX TABS (Use Guanfacine HCl) 4

terazosin hcl caps 1

Antihypertensive Combinations ACCURETIC TABS (Use Quinapril-Hydrochlorothiazide)

4

amlodipine besylate-benazepril hcl caps 1

amlodipine besylate-olmesartan medoxomil tabs 3 ST

amlodipine besylate-valsartan tabs 3

amlodipine-valsartan-hydrochlorothiazide tabs 3

ATACAND HCT TABS (Use Candesartan Cilexetil-Hydrochlorothiazide)

4

atenolol amp chlorthalidone tabs 1

AVALIDE TABS (Use Irbesartan-Hydrochlorothiazide)

4

AZOR TABS (Use Amlodipine Besylate-Olmesartan Medoxomil)

3 ST

benazepril amphydrochlorothiazide tabs 1

BENICAR HCT TABS (Use Olmesartan Medoxomil-Hydrochlorothiazide)

3

bisoprolol amphydrochlorothiazide tabs 1

BYVALSON TABS 4

candesartan cilexetil-hydrochlorothiazide tabs 1

captopril amphydrochlorothiazide tabs 1

CLORPRES TABS 3

CORZIDE TABS 40MG-5MG (Use Nadolol amp Bendroflumethiazide)

4

Drug Name DrugTier

RequirementsLimits

CORZIDE TABS 80MG-5MG 4

DIOVAN HCT TABS (Use Valsartan-Hydrochlorothiazide)

4

DUTOPROL TB24 4

EDARBYCLOR TABS 4

enalapril maleate amphydrochlorothiazide tabs 1

EXFORGE HCT TABS (Use Amlodipine-Valsartan-Hydrochlorothiazide)

3

EXFORGE TABS (Use Amlodipine Besylate-Valsartan)

3

fosinopril sodium amphydrochlorothiazide tabs 2

HYZAAR TABS (Use Losartan Potassium amp Hydrochlorothiazide)

4

irbesartan-hydrochlorothiazide tabs 1

lisinopril amphydrochlorothiazide tabs 1

LOPRESSOR HCT TABS (Use Metoprolol ampHydrochlorothiazide)

4

losartan potassium amphydrochlorothiazide tabs 1

LOTENSIN HCT TABS (Use Benazepril ampHydrochlorothiazide)

4

LOTREL CAPS (Use Amlodipine Besylate-Benazepril HCl)

4

methyldopa amphydrochlorothiazide tabs 1

metoprolol amphydrochlorothiazide tabs 2

METOPROLOL SUCCINATE ERHYDROCHLOROTHIAZIDE TB24

4

METOPROLOLHYDROCHLOROTHIAZIDE TABS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

32

Drug Name DrugTier

RequirementsLimits

MICARDIS HCT TABS (Use Telmisartan-Hydrochlorothiazide)

4

moexipril-hydrochlorothiazide tabs 2

MOEXIPRILHYDROCHLOROTHIAZIDE TABS 4

nadolol amp bendroflumethiazide tabs 4

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

3 ST

olmesartan medoxomil-hydrochlorothiazide tabs 3

PRESTALIA TABS 4 ST

propranolol amphydrochlorothiazide tabs 1

quinapril-hydrochlorothiazide tabs 2

TARKA TBCR (Use Trandolapril-VerapamilHCl)

4

TEKTURNA HCT TABS 4 ST

telmisartan-amlodipine tabs 1

telmisartan-hydrochlorothiazide tabs 1

TENORETIC 100 TABS (Use Atenolol amp Chlorthalidone)

4

TENORETIC 50 TABS (Use Atenolol amp Chlorthalidone)

4

trandolapril-verapamil hcltbcr 4

TRANDOLAPRILVERAPAMIL HCL ER TBCR 4

TRIBENZOR TABS (Use Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)

3

ST

TWYNSTA TABS (Use Telmisartan-Amlodipine) 4

valsartan-hydrochlorothiazide tabs 2

Drug Name DrugTier

RequirementsLimits

VASERETIC TABS (Use Enalapril Maleate ampHydrochlorothiazide)

4

ZESTORETIC TABS (Use Lisinopril ampHydrochlorothiazide)

4

ZIAC TABS (Use Bisoprololamp Hydrochlorothiazide) 4

Antihypertensives - Misc VECAMYL TABS 4

Direct Renin Inhibitors TEKTURNA TABS 4 ST

Selective Aldosterone Receptor Antagonists eplerenone tabs 4

INSPRA TABS (Use Eplerenone) 4

Vasodilators hydralazine hcl tabs 1

minoxidil tabs 2

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations atovaquone-proguanil hcltabs 3

COARTEM TABS 2

MALARONE TABS (Use Atovaquone-Proguanil HCl) 4

Antimalarials ARAKODA TABS 4 PA

CHLOROQUINE PHOSPHATE TABS 250 MG

4

chloroquine phosphate tabs500 mg 2

DARAPRIM TABS 2 PA

hydroxychloroquine sulfatetabs 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

33

Drug Name DrugTier

RequirementsLimits

MEFLOQUINE HCL TABS 4

mefloquine hcl tabs 3

PLAQUENIL TABS (Use HydroxychloroquineSulfate)

4

PRIMAQUINE PHOSPHATE TABS 2

QUALAQUIN CAPS (Use Quinine Sulfate) 4

QL(42 ea per365 daysretail42 ea per365 days mail)

quinine sulfate caps 4

QL(42 ea per365 daysretail42 ea per365 days mail)

ANTIMYASTHENICCHOLINERGIC AGENTS

AntimyasthenicCholinergic Agents GUANIDINE HCL TABS 3

MESTINON SYRP 60 MG5ML 4 PA

MESTINON TABS 60 MG (Use PyridostigmineBromide)

4

MESTINON TIMESPAN TBCR (Use PyridostigmineBromide)

4

pyridostigmine bromidetabs 60 mg 2

pyridostigmine bromidetbcr 180 mg 4

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Anti TB Combinations RIFAMATE CAPS 4

RIFATER TABS 3

Antimycobacterial Agents CYCLOSERINE CAPS 4

ethambutol hcl tabs 1

Drug Name DrugTier

RequirementsLimits

ISONIAZID SYRP 50 MG5ML 4

isoniazid tabs 100 mg 300 mg 1

MYAMBUTOL TABS (Use Ethambutol HCl) 4

MYCOBUTIN CAPS (Use Rifabutin) 3

PASER PACK 4

PRIFTIN TABS 4

pyrazinamide tabs 2

rifabutin caps 3

RIFADIN CAPS (Use Rifampin) 4

rifampin caps 2

SIRTURO TABS 4

TRECATOR TABS 4

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS (Use Melphalan) 3

carboplatin soln J PA

CISPLATIN SOLN 200 MG200ML J PA

cisplatin soln 50 mg50ml100 mg100ml J PA

cyclophosphamide caps or25 mg 4 PA

CYCLOPHOSPHAMIDE CAPS OR 25 MG (Use Cyclophosphamide)

4 PA

cyclophosphamide caps or50 mg 4

CYCLOPHOSPHAMIDE CAPS OR 50 MG (Use Cyclophosphamide)

4

cyclophosphamide solr ij 1gm 2 gm 500 mg J PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

34

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 10 MG 40 MG 100 MG (Use Lomustine)

4

GLEOSTINE CAPS 5 MG 4

HEXALEN CAPS 2

IFEX SOLR (Use Ifosfamide) J PA

ifosfamide soln J PA

ifosfamide solr J PA

LEUKERAN TABS 2

melphalan tabs 1

MUSTARGEN SOLR J PA

MYLERAN TABS 2

oxaliplatin soln J PA

TEMODAR CAPS OR 250 MG (Use Temozolomide) 4 Specialty Tier 2

May Apply TEMODAR CAPS OR 5 MG 20 MG 100 MG 140 MG 180 MG (Use Temozolomide)

4

Specialty MayApply BrandTier 4 Generic Tier 1

TEMODAR SOLR IV 100 MG J PA

temozolomide caps 250 mg 1 Specialty Tier 2May Apply

temozolomide caps 5 mg20 mg 100 mg 140 mg180 mg

1

Specialty MayApply BrandTier 4 Generic Tier 1

TEPADINA SOLR J PA

thiotepa solr J PA

TREANDA SOLR J PA

Antimetabolites azacitidine susr J PA

capecitabine tabs 2

Drug Name DrugTier

RequirementsLimits

cladribine soln J PA

cytarabine soln J PA

CYTARABINEAQUEOUS SOLN J PA

DACOGEN SOLR (Use Decitabine) J PA

decitabine solr J PA

DEPOCYT SUSP J PA

floxuridine solr J PA

fludarabine phosphate soln J PA

fludarabine phosphate solr J PA

fluorouracil soln iv 1 gm20ml 5 gm100ml 25gm50ml 500 mg10ml

J PA

FOLOTYN SOLN J PA

gemcitabine hcl soln J PA

gemcitabine hcl solr J PA

GEMZAR SOLR (Use Gemcitabine HCl) J PA

mercaptopurine tabs 2

methotrexate sodium soln ij1 gm40ml 50 mg2ml 200mg8ml 250 mg10ml

J PA SpecialtyTier 1 MayApply

METHOTREXATE SODIUM SOLN IJ 250 MG10ML

J PA SpecialtyTier 1 MayApply

methotrexate sodium solr ij1 gm J

PA SpecialtyTier 1 MayApply

methotrexate sodium tabs or 25 mg 1

PURIXAN SUSP 4 AL(Up to 13 yrsold )

TABLOID TABS 2

TREXALL TABS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

35

Drug Name DrugTier

RequirementsLimits

VIDAZA SUSR (Use Azacitidine) J PA

XELODA TABS (Use Capecitabine) 4

Antineoplastic - Angiogenesis Inhibitors AVASTIN SOLN J PA

CYRAMZA SOLN J PA

ZALTRAP SOLN J PA

Antineoplastic - Antibodies ADCETRIS SOLR J PA

ARZERRA CONC J PA

BLINCYTO SOLR J PA

ERBITUX SOLN J PA

GAZYVA SOLN J PA

KADCYLA SOLR J PA

KEYTRUDA SOLN J PA SpecialtyTier 3 MayApply

OPDIVO SOLN J PA

PERJETA SOLN J PA

POTELIGEO SOLN 4 PA

RITUXAN SOLN J PA

VECTIBIX SOLN J PA

YERVOY SOLN J PA

ZEVALIN Y-90 KIT J PA

Antineoplastic - BCL-2 Inhibitors

VENCLEXTA STARTING PACK TBPK 2

PA SpecialtyTier 3 MayApply

VENCLEXTA TABS 2 PA SpecialtyTier 3 MayApply

Drug Name DrugTier

RequirementsLimits

Antineoplastic - Cellular Immunotherapy PROVENGE SUSP J PA

Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO TABS 4 PA

ERIVEDGE CAPS 2 Specialty Tier 2May Apply

ODOMZO CAPS 2 Specialty Tier 2May Apply

Antineoplastic - Hormonal and Related Agents

abiraterone acetate tabs 1 PA SpecialtyTier 2 MayApply

anastrozole tabs 2 AL(At least 40yrs old)

ARIMIDEX TABS (Use Anastrozole) 4 AL(At least 40

yrs old) AROMASIN TABS (Use Exemestane) 4 AL(At least 40

yrs old)

bicalutamide tabs 1

CASODEX TABS (Use Bicalutamide) 4

DEPO-PROVERA SUSP J PA

EMCYT CAPS 2

exemestane tabs 2 AL(At least 40yrs old)

FARESTON TABS 2

FASLODEX SOLN J PA

FEMARA TABS (Use Letrozole) 4 AL(At least 40

yrs old)

FIRMAGON SOLR J PA

flutamide caps 3

letrozole tabs 2 AL(At least 40yrs old)

leuprolide acetate kit J PA

LEUPROLIDE ACETATEBUPIVACAINEHYDROCHLORIDE SOLN

4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

36

Drug Name DrugTier

RequirementsLimits

LUPRON DEPOT (1-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LUPRON DEPOT (3-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LUPRON DEPOT (4-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LYSODREN TABS 2

MEGACE ORAL SUSP (Use Megestrol Acetate) 4

megestrol acetate susp 40mgml 400 mg10ml 2

megestrol acetate tabs 20mg 40 mg 1

NILANDRON TABS (Use Nilutamide) 3

nilutamide tabs 1

SOLTAMOX SOLN 4

tamoxifen citrate tabs 1 PV

TRELSTAR MIXJECT SUSR J PA

TRELSTAR SUSR J PA

VANTAS KIT J PA

XTANDI CAPS 4 PA SpecialtyTier 2 MayApply

ZOLADEX IMPL J PA

ZYTIGA TABS (Use Abiraterone Acetate) 3

PA SpecialtyTier 2 MayApply

Antineoplastic - Immunomodulators

POMALYST CAPS 4 Specialty Tier 2May Apply

Antineoplastic Antibiotics bleomycin sulfate solr J PA

ELLENCE SOLN (Use Epirubicin HCl) J PA

Drug Name DrugTier

RequirementsLimits

epirubicin hcl soln J PA

IDAMYCIN PFS SOLN (Use Idarubicin HCl) J PA

idarubicin hcl soln J PA

mitomycin solr J PA

mitoxantrone hcl conc J PA

VALSTAR SOLN J PA

Antineoplastic Combinations

LONSURF TABS 2 PA SpecialtyTier 2 MayApply

Antineoplastic Enzyme Inhibitors AFINITOR DISPERZ TBSO 4 PA

AFINITOR TABS 4 PA SpecialtyTier 2 MayApply

ALECENSA CAPS 2 PA SpecialtyTier 2 MayApply

BELEODAQ SOLR J PA

BOSULIF TABS 4 PA SpecialtyTier 2 MayApply

BRAFTOVI CAPS 2 PA

CABOMETYX TABS 2 PA

CAPRELSA TABS 2 Specialty Tier 4May Apply

COMETRIQ KIT 4 Specialty Tier 2May Apply

COPIKTRA CAPS 4 PA

COTELLIC TABS 2 PA SpecialtyTier 2 MayApply

FARYDAK CAPS 2 PA SpecialtyTier 2 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

37

Drug Name DrugTier

RequirementsLimits

GILOTRIF TABS 20 MG 30 MG 2

PA SpecialtyTier 3 MayApply

GILOTRIF TABS 40 MG 2 PA

GLEEVEC TABS (Use Imatinib Mesylate) 4

PA SpecialtyTier 2 MayApply - Directto Acaria Specialty

IBRANCE CAPS 2

PA SpecialtyTier 2 MayApply - Directto Acaria Specialty

ICLUSIG TABS 4 PA SpecialtyTier 2 MayApply

IDHIFA TABS 4 PA

imatinib mesylate tabs 100mg 400 mg 1

imatinib mesylate tabs 400 mg 1 Specialty Tier 2

May Apply

IMBRUVICA CAPS 70 MG 140 MG 2

PA SpecialtyTier 2 MayApply

IMBRUVICA TABS 140 MG 280 MG 420 MG 560 MG

2

PA SpecialtyTier 2 MayApplyQL(1 eadaily)

INLYTA TABS 4 PA SpecialtyTier 2 MayApply

IRESSA TABS 2 Specialty Tier 2May Apply

ISTODAX (OVERFILL) SOLR J PA

JAKAFI TABS 2 Specialty Tier 3May Apply

KYPROLIS SOLR J PA

LENVIMA 10 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 12MG DAILY DOSE CPPK 4 PA

Drug Name DrugTier

RequirementsLimits

LENVIMA 14 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 18 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 20 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 24 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LENVIMA 4 MG DAILY DOSE CPPK 4 PA

LENVIMA 8 MG DAILY DOSE CPPK 2

PA SpecialtyTier 2 MayApply

LORBRENA TABS 4 PA

LYNPARZA CAPS 50 MG 2 PA SpecialtyTier 2 MayApply

LYNPARZA TABS 100 MG 150 MG 4 PA

MEKINIST TABS 2 PA SpecialtyTier 3 MayApply

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

PA SpecialtyTier 2 MayApply - Directto Acaria Specialty

NINLARO CAPS 2 PA

ROMIDEPSIN SOLR J PA

RUBRACA TABS 2 PA SpecialtyTier 3 MayApply

SPRYCEL TABS 3 PA SpecialtyTier 2 MayApply

STIVARGA TABS 4 PA SpecialtyTier 2 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

38

Drug Name DrugTier

RequirementsLimits

SUTENT CAPS 25 MG 50 MG 125 MG 2 Specialty Tier 2

May Apply

SUTENT CAPS 375 MG 2

TAFINLAR CAPS 2 PA SpecialtyTier 3 MayApply

TAGRISSO TABS 2 PA SpecialtyTier 3 MayApply

TALZENNA CAPS 4 PA

TARCEVA TABS 2 PA SpecialtyTier 2 MayApply

TASIGNA CAPS 2 PA SpecialtyTier 2 MayApply

temsirolimus soln J PA

TIBSOVO TABS 4 PA

TORISEL SOLN (Use Temsirolimus) J PA

TYKERB TABS 2 Specialty Tier 2May Apply

VELCADE SOLR J PA

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

VIZIMPRO TABS 4 PA

VOTRIENT TABS 2 Specialty Tier 2May Apply

XALKORI CAPS 2 PA SpecialtyTier 2 MayApply

XOSPATA TABS 4 PA

ZELBORAF TABS 2 PA SpecialtyTier 2 MayApply

ZOLINZA CAPS 4 PA SpecialtyTier 2 MayApply

Drug Name DrugTier

RequirementsLimits

ZYDELIG TABS 2 PA SpecialtyTier 2 MayApply

ZYKADIA CAPS 4 PA SpecialtyTier 2 MayApply

Antineoplastic Enzymes ERWINAZE SOLR J PA

ONCASPAR SOLN J PA

Antineoplastic Radiopharmaceuticals METASTRON SOLN J PA

XOFIGO SOLN J PA

Antineoplastics Misc

ACTIMMUNE SOLN J PA SpecialtyTier 3 MayApply

ALFERON N SOLN J PA SpecialtyTier 3 MayApply

bexarotene caps 1

dacarbazine solr J PA

HYDREA CAPS (Use Hydroxyurea) 4

hydroxyurea caps 1

INTRON A SOLN J PA SpecialtyTier 3 MayApply

INTRON A SOLR J PA SpecialtyTier 3 MayApply

INTRON A WDILUENTSOLR J

PA SpecialtyTier 3 MayApply

MATULANE CAPS 2 Specialty Tier 1May Apply

NIPENT SOLR J PA

SYLATRON KIT J PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

39

Drug Name DrugTier

RequirementsLimits

SYNRIBO SOLR J PA SpecialtyTier 2 MayApply

TARGRETIN CAPS OR 75 MG (Use Bexarotene) 4

tretinoin (chemotherapy) caps 2

Chemotherapy RescueAntidote Agents dexrazoxane solr J PA

FUSILEV SOLR (Use Levoleucovorin Calcium) J PA

KHAPZORY SOLR 4 PA

LEUCOVORIN CALCIUM SOLN IJ 500 MG50ML 4 PA

leucovorin calcium solr ij 50mg 100 mg 200 mg 350mg 500 mg

J PA

LEUCOVORIN CALCIUM TABS OR 10 MG 15 MG 4

leucovorin calcium tabs or 5 mg 25 mg 2

levoleucovorin calcium soln J PA

levoleucovorin calcium solr J PA

mesna soln J PA

MESNEX SOLN IV 100 MGML (Use Mesna) J PA

MESNEX TABS OR 400 MG 2

TOTECT SOLR J PA

VORAXAZE SOLR J PA

ZINECARD SOLR (Use Dexrazoxane) J PA

Mitotic Inhibitors DOCEFREZ SOLR J PA

DOCETAXEL CONC 20 MGML 80 MG2ML 80MG4ML 140 MG7ML160 MG8ML

J

PA

Drug Name DrugTier

RequirementsLimits

docetaxel conc 20 mgml80 mg4ml J PA

docetaxel soln 20 mg2ml80 mg8ml 160 mg16ml J PA

DOCETAXEL SOLN 20 MG2ML 80 MG8ML 160MG16ML

J PA

DOCETAXEL SOLN 20 MG2ML 80 MG8ML 160MG16ML (Use Docetaxel)

J PA

etoposide caps or 50 mg 2

etoposide soln iv 1gm50ml 100 mg5ml 500mg25ml

J PA

HALAVEN SOLN J PA

JEVTANA SOLN J PA

MARQIBO SUSP J PA

NAVELBINE SOLN (Use Vinorelbine Tartrate) J PA

PACLITAXEL CONC 150 MG25ML J PA

paclitaxel conc 30 mg5ml300 mg50ml 100mg167ml

J PA

TAXOL CONC (Use Paclitaxel) J PA

TAXOTERE CONC (Use Docetaxel) J PA

vinorelbine tartrate soln J PA

Topoisomerase I Inhibitors CAMPTOSAR SOLN 300 MG15ML J PA

CAMPTOSAR SOLN 40 MG2ML 100 MG5ML(Use Irinotecan HCl)

J PA

HYCAMTIN CAPS OR 025 MG 1 MG 4

HYCAMTIN SOLR IV 4 MG (Use Topotecan HCl) J PA

irinotecan hcl soln J PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

40

Drug Name DrugTier

RequirementsLimits

IRINOTECAN SOLN J PA

TOPOTECAN HCL SOLN 4 MG4ML J PA

topotecan hcl soln 4mg4ml J PA

TOPOTECAN HCL SOLN 4 MG4ML (Use TopotecanHCl)

J PA

topotecan hcl solr 4 mg J PA

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease Antiparkinson Adjuvants carbidopa tabs 4

LODOSYN TABS (Use Carbidopa) 4

Antiparkinson Anticholinergics benztropine mesylate tabs 1

trihexyphenidyl hcl elix 1

trihexyphenidyl hcl tabs 1

Antiparkinson COMT Inhibitors COMTAN TABS (Use Entacapone) 4

entacapone tabs 4

TASMAR TABS (Use Tolcapone) 4

tolcapone tabs 4

Antiparkinson Dopaminergics amantadine hcl caps 1

amantadine hcl syrp 1

amantadine hcl tabs 1

bromocriptine mesylate caps 3

bromocriptine mesylatetabs 3

Drug Name DrugTier

RequirementsLimits

carbidopa-levodopa tabs10mg-100mg 25mg-100mg 25mg-250mg

2

carbidopa-levodopa tbcr25mg-100mg 50mg-200mg

2

carbidopa-levodopa tbdp10mg-100mg 25mg-100mg 25mg-250mg

4

carbidopa-levodopa-entacapone tabs 1

CARBIDOPALEVODOPAENTACAPONE TABS 3

DUOPA SUSP 4 Specialty Tier 3May Apply

MIRAPEX ER TB24 0375 MG 075 MG 3 MG 15 MG 45 MG 225 MG (Use PramipexoleDihydrochloride)

4

MIRAPEX ER TB24 375 MG (Use PramipexoleDihydrochloride)

4 PA

MIRAPEX TABS (Use PramipexoleDihydrochloride)

4

NEUPRO PT24 4

PARLODEL CAPS (Use Bromocriptine Mesylate) 4

PARLODEL TABS (Use Bromocriptine Mesylate) 4

pramipexoledihydrochloride tabs 0125mg 025 mg 05 mg 1 mg15 mg

3

pramipexoledihydrochloride tabs 075 mg

2

pramipexoledihydrochloride tb24 0375mg 075 mg 3 mg 15 mg45 mg 225 mg

4

pramipexoledihydrochloride tb24 375 mg

4 PA

REQUIP TABS (Use Ropinirole Hydrochloride) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

41

Drug Name DrugTier

RequirementsLimits

REQUIP XL TB24 (Use Ropinirole Hydrochloride) 4

ropinirole hydrochloridetabs 2

ropinirole hydrochloridetb24 2

RYTARY CPCR 4 PA

SINEMET CR TBCR (Use Carbidopa-Levodopa) 4

SINEMET TABS (Use Carbidopa-Levodopa) 4

STALEVO 100 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 125 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 150 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 200 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 50 TABS (Use Carbidopa-Levodopa-Entacapone)

4

STALEVO 75 TABS (Use Carbidopa-Levodopa-Entacapone)

4

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Use Rasagiline Mesylate) 3

ELDEPRYL CAPS (Use Selegiline HCl) 4

rasagiline mesylate tabs 3

selegiline hcl caps 2

selegiline hcl tabs 2

ZELAPAR TBDP 4

ANTIPSYCHOTICSANTIMANIC AGENTS -Drugs to Treat Mood Disorders Antimanic Agents

Drug Name DrugTier

RequirementsLimits

lithium carbonate caps 1

lithium carbonate tabs 1

lithium carbonate tbcr 1

LITHIUM SOLN 4

LITHOBID TBCR (Use Lithium Carbonate) 4

Antipsychotics - Misc EQUETRO CP12 4

GEODON CAPS (Use Ziprasidone HCl) 4

LATUDA TABS 120 MG 4 PA QL(1 eadaily)

LATUDA TABS 20 MG 4 PA

LATUDA TABS 40 MG 60 MG 80 MG 4 PA QL(2 ea

daily)

NUPLAZID CAPS 34 MG 4 PA QL(1 eadaily)

NUPLAZID TABS 10 MG 4 PA QL(1 eadaily)

NUPLAZID TABS 17 MG 4 PA

VRAYLAR CAPS 4 PA

VRAYLAR CPPK 4 PA

ziprasidone hcl caps 1

Benzisoxazoles FANAPT TABS 4 PA

FANAPT TITRATION PACK TABS 4 PA

INVEGA SUSTENNA SUSP J

PA SpecialtyTier 2 MayApply

INVEGA TB24 (Use Paliperidone) 4

INVEGA TRINZA SUSP J PA SpecialtyTier 2 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

42

Drug Name DrugTier

RequirementsLimits

paliperidone tb24 4

PERSERIS PRSY 4 PA

RISPERDAL M-TAB TBDP (Use Risperidone) 4

RISPERDAL SOLN (Use Risperidone) 4

RISPERDAL TABS (Use Risperidone) 4

RISPERIDONE ODT TBDP 4

risperidone soln 1 mgml 1

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

1

risperidone tbdp 025 mg 4

risperidone tbdp 05 mg 1mg 2 mg 3 mg 4 mg 1

Butyrophenones haloperidol lactate conc 1

haloperidol tabs 1

Dibenzapines CLOZAPINE ODT TBDP 4

clozapine tabs 25 mg 50mg 100 mg 200 mg 2

clozapine tbdp 25 mg 100mg 125 mg 4

CLOZARIL TABS (Use Clozapine) 4

FAZACLO TBDP 150 MG 200 MG 4

FAZACLO TBDP 25 MG 100 MG 125 MG (Use Clozapine)

4

loxapine succinate caps 2

olanzapine tabs 5 mg 10mg 15 mg 20 mg 25 mg75 mg

1

olanzapine tbdp 5 mg 10mg 15 mg 20 mg 4

Drug Name DrugTier

RequirementsLimits

quetiapine fumarate tabs25 mg 50 mg 100 mg 200mg 300 mg 400 mg

1

quetiapine fumarate tb2450 mg 150 mg 200 mg300 mg 400 mg

4 PA

SAPHRIS SUBL 4 PA

SEROQUEL TABS (Use Quetiapine Fumarate) 4

SEROQUEL XR TB24 (Use Quetiapine Fumarate) 4 PA

VERSACLOZ SUSP 4 QL(18 ml daily)

ZYPREXA TABS (Use Olanzapine) 4

ZYPREXA ZYDIS TBDP (Use Olanzapine) 4

Dihydroindolones MOLINDONE HYDROCHLORIDE TABS 3

Phenothiazines chlorpromazine hcl tabs 1

fluphenazine hcl conc 1

fluphenazine hcl elix 1

fluphenazine hcl tabs 1

perphenazine tabs 1

prochlorperazine maleatetabs 1

prochlorperazine supp 1

thioridazine hcl tabs 1

trifluoperazine hcl tabs 1

Quinolinone Derivatives ABILIFY MYCITE TABS 4 PA

ABILIFY TABS (Use Aripiprazole) 4

aripiprazole soln 1 mgml 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

43

Drug Name DrugTier

RequirementsLimits

aripiprazole tabs 2 mg 5mg 10 mg 15 mg 20 mg30 mg

1

aripiprazole tbdp 10 mg 15 mg 4

REXULTI TABS 4 PA

Thioxanthenes thiothixene caps 1

ANTISEPTICS amp DISINFECTANTS

Chlorine Antiseptics CHLORHEXIDINE GLUCONATE SOLN 3

Iodine Antiseptics IODOFLEX PADS 3

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 1

abacavir sulfate tabs 1

abacavir sulfate-lamivudine tabs 1

abacavir sulfate-lamivudine-zidovudine tabs 1

APTIVUS CAPS 2

APTIVUS SOLN 2

atazanavir sulfate caps 1

ATRIPLA TABS 2 ST

COMBIVIR TABS (Use Lamivudine-Zidovudine) 4

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 4 PA

DESCOVY TABS 2

Drug Name DrugTier

RequirementsLimits

didanosine cpdr 2

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

EPIVIR SOLN (Use Lamivudine) 4

EPIVIR TABS (Use Lamivudine) 4

EPZICOM TABS (Use Abacavir Sulfate-Lamivudine)

3

EVOTAZ TABS 2

fosamprenavir calcium tabs 1

FUZEON SOLR J PA SpecialtyTier 2 MayApply

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS PACK 2

ISENTRESS TABS 2

KALETRA SOLN 400MG5ML-100MG5ML(Use Lopinavir-Ritonavir)

3

KALETRA TABS 100MG-25MG 200MG-50MG 2

lamivudine soln 1

lamivudine tabs 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

44

Drug Name DrugTier

RequirementsLimits

lamivudine-zidovudine tabs 1

LEXIVA SUSP 50 MGML 2

LEXIVA TABS 700 MG (Use FosamprenavirCalcium)

3

lopinavir-ritonavir soln 1

nevirapine tabs 200 mg 1

nevirapine tb24 100 mg400 mg 2

NORVIR CAPS 100 MG 2

NORVIR PACK 100 MG 4

NORVIR SOLN 80 MGML 2

NORVIR TABS 100 MG (Use Ritonavir) 3

PIFELTRO TABS 4 PA

PREZCOBIX TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

RETROVIR CAPS (Use Zidovudine) 4

RETROVIR SYRP (Use Zidovudine) 4

REYATAZ CAPS 150 MG 200 MG 300 MG (Use Atazanavir Sulfate)

3

REYATAZ PACK 50 MG 2

ritonavir tabs 1

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

Drug Name DrugTier

RequirementsLimits

SUSTIVA CAPS (Use Efavirenz) 3

SUSTIVA TABS (Use Efavirenz) 3

SYMTUZA TABS 4 ST

tenofovir disoproxilfumarate tabs 1

TIVICAY TABS 2

TRIUMEQ TABS 2

TRIZIVIR TABS (Use Abacavir Sulfate-Lamivudine-Zidovudine)

4

TRUVADA TABS 2

TYBOST TABS 2

VIDEX EC CPDR 125 MG 4

VIDEX EC CPDR 200 MG 250 MG 400 MG (Use Didanosine)

4

VIDEXPEDIATRIC SOLR 2

VIRACEPT TABS 2

VIRAMUNE TABS (Use Nevirapine) 4

VIRAMUNE XR TB24 (Use Nevirapine) 4

VIREAD POWD 40 MGGM 3

VIREAD TABS 150 MG 200 MG 250 MG 2

VIREAD TABS 300 MG (Use Tenofovir DisoproxilFumarate)

3

VITEKTA TABS 2

ZERIT CAPS 15 MG 20 MG 30 MG 40 MG (Use Stavudine)

4

ZERIT SOLR 1 MGML 4

ZIAGEN SOLN 20 MGML(Use Abacavir Sulfate) 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

45

Drug Name DrugTier

RequirementsLimits

ZIAGEN TABS 300 MG (Use Abacavir Sulfate) 4

zidovudine caps 100 mg 2

zidovudine syrp 50 mg5ml 2

zidovudine tabs 300 mg 1

CMV Agents VALCYTE SOLR 50 MGML (Use ValganciclovirHCl)

3 QL(21 ml daily)

VALCYTE TABS 450 MG (Use Valganciclovir HCl) 4

valganciclovir hcl solr 50mgml 1 QL(21 ml daily)

valganciclovir hcl tabs 450 mg 2

Hepatitis Agents adefovir dipivoxil tabs 1

BARACLUDE SOLN 005 MGML 2

BARACLUDE TABS 05 MG 1 MG (Use Entecavir) 4 PA

COPEGUS TABS (Use Ribavirin (Hepatitis C)) 4 PA

DAKLINZA TABS 4 PA SpecialtyTier 3 MayApply

entecavir tabs 1

EPCLUSA TABS 4 PA SpecialtyTier 3 MayApply

EPIVIR HBV SOLN 5 MGML 4

EPIVIR HBV TABS 100 MG (Use Lamivudine (HBV))

4

HARVONI TABS 4 PA SpecialtyTier 3 MayApply

HEPSERA TABS 2

lamivudine (hbv) tabs 1

Drug Name DrugTier

RequirementsLimits

LEDIPASVIRSOFOSBUVIR TABS 4

PA SpecialtyTier 3 MayApply

MODERIBA 1200 DOSE PACK TABS 4 PA

MODERIBA 800 DOSE PACK TABS 3 PA

OLYSIO CAPS 4 PA SpecialtyTier 3 MayApply

PEG-INTRON REDIPEN KIT J

PA SpecialtyTier 2 MayApply

PEGASYS PROCLICK SOLN J

PA SpecialtyTier 2 MayApply

PEGASYS SOLN J PA SpecialtyTier 2 MayApply

PEGINTRON KIT J PA SpecialtyTier 2 MayApply

REBETOL CAPS 200 MG (Use Ribavirin (HepatitisC))

4 PA

REBETOL SOLN 40 MGML 3 PA

RIBASPHERE RIBAPAK TABS 400 MG 3 PA

RIBASPHERE RIBAPAK TABS 600 MG 4 PA

RIBASPHERE TABS 3 PA

ribavirin (hepatitis c) caps 3 PA

ribavirin (hepatitis c) tabs 3 PA

SOFOSBUVIRVELPATASVIR TABS 4

PA SpecialtyTier 3 MayApply

SOVALDI TABS 4 PA SpecialtyTier 3 MayApply

TECHNIVIE TABS 4 PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

46

Drug Name DrugTier

RequirementsLimits

VIEKIRA PAK TBPK 4 PA SpecialtyTier 3 MayApply

VIEKIRA XR TB24 4 PA SpecialtyTier 3 MayApply

ZEPATIER TABS 4 PA SpecialtyTier 3 MayApply

Herpes Agents acyclovir caps 1

acyclovir sodium soln 3

acyclovir susp 1

acyclovir tabs 1

famciclovir tabs 3

FAMVIR TABS (Use Famciclovir) 4

SITAVIG TABS 4 PA

valacyclovir hcl tabs 2

VALTREX TABS (Use Valacyclovir HCl) 4

ZOVIRAX CAPS OR 200 MG (Use Acyclovir) 4

ZOVIRAX SUSP OR 200 MG5ML (Use Acyclovir) 4

ZOVIRAX TABS OR 400 MG 800 MG (Use Acyclovir)

4

Influenza Agents FLUMADINE TABS (Use Rimantadine Hydrochloride)

4

oseltamivir phosphate caps30 mg 45 mg 4

QL(10 ea perfill retail10 ea per fill mail)

oseltamivir phosphate caps75 mg 4

Drug Name DrugTier

RequirementsLimits

oseltamivir phosphate susr6 mgml 4

QL(120 ml per30 days retail)AL(At least 1yrs old - Up to12 yrs old)

RELENZA DISKHALER AEPB 4 QL(20 ea per

fill retail) rimantadine hydrochloridetabs 2

TAMIFLU CAPS 30 MG 45 MG (Use Oseltamivir Phosphate)

4 QL(10 ea perfill retail10 ea per fill mail)

TAMIFLU CAPS 75 MG (Use Oseltamivir Phosphate)

4

TAMIFLU SUSR 6 MGML(Use Oseltamivir Phosphate)

4

QL(120 ml per30 days retail)AL(At least 1yrs old - Up to12 yrs old)

XOFLUZA TBPK 4 PA QL(2 eaper fill retail)

Respiratory Syncytial Virus (RSV) Agents ribavirin solr 3

VIRAZOLE SOLR (Use Ribavirin) 3

BETA BLOCKERS - Drugs to Treat High BloodPressure Alpha-Beta Blockers carvedilol phosphate cp24 4

carvedilol tabs 1

COREG CR CP24 (Use Carvedilol Phosphate) 4

COREG TABS (Use Carvedilol) 4

labetalol hcl tabs 1

LABETALOL HYDROCHLORIDESODIUM CHLORIDE SOLN

4 PA

Beta Blockers Cardio-Selective acebutolol hcl caps 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

47

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

betaxolol hcl tabs 2

bisoprolol fumarate tabs 2

BYSTOLIC TABS 4

KAPSPARGO SPRINKLE CS24 4 PA

LOPRESSOR TABS (Use Metoprolol Tartrate) 4

metoprolol succinate tb24 2

metoprolol tartrate tabs 25 mg 1 QL(2 ea daily)

metoprolol tartrate tabs 50mg 100 mg 1

METOPROLOL TARTRATE TABS 75 MG 375 MG

4 PA

SECTRAL CAPS (Use Acebutolol HCl) 4

TENORMIN TABS (Use Atenolol) 4

TOPROL XL TB24 (Use Metoprolol Succinate) 4

ZEBETA TABS (Use Bisoprolol Fumarate) 4

Beta Blockers Non-Selective BETAPACE AF TABS (Use Sotalol HCl (AFIBAFL)) 4

BETAPACE TABS (Use Sotalol HCl) 4

CORGARD TABS (Use Nadolol) 4

HEMANGEOL SOLN 4 AL(Up to 1 yrsold )

INDERAL LA CP24 (Use Propranolol HCl) 4

INDERAL XL CP24 4

INNOPRAN XL CP24 4

nadolol tabs 1

Drug Name DrugTier

RequirementsLimits

pindolol tabs 1

propranolol hcl cp24 60 mg 2

propranolol hcl cp24 80mg 120 mg 160 mg 1

PROPRANOLOL HCL SOLN 20 MG5ML 40MG5ML

4

propranolol hcl tabs 10 mg20 mg 40 mg 60 mg 80 mg

1

sotalol hcl (afibafl) tabs 2

sotalol hcl tabs 2

SOTYLIZE SOLN 4

timolol maleate tabs 1

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure Calcium Channel Blockers ADALAT CC TB24 (Use Nifedipine) 4

amlodipine besylate tabs 1 QL(1 ea daily)

CALAN SR TBCR (Use Verapamil HCl) 4

CALAN TABS (Use Verapamil HCl) 4

CARDIZEM CD CP24 (Use Diltiazem HCl Coated Beads)

4

CARDIZEM LA TB24 120 MG 4

CARDIZEM LA TB24 180 MG 240 MG 300 MG 360 MG 420 MG (Use Diltiazem HCl Coated Beads)

4

CARDIZEM TABS (Use Diltiazem HCl) 4

diltiazem hcl coated beads cp24 120 mg 180 mg 240mg 300 mg 360 mg

2

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

48

Drug Name DrugTier

RequirementsLimits

diltiazem hcl coated beads tb24 180 mg 240 mg 300mg 360 mg 420 mg

1

diltiazem hcl cp12 1

diltiazem hcl cp24 1

diltiazem hcl extended release beads cp24 2

diltiazem hcl tabs 1

DILTIAZEM HYDROCHLORIDE SOSY 4 PA

felodipine tb24 2

isradipine caps 25 mg 1

isradipine caps 5 mg 3

nicardipine hcl caps 2

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 2 QL(12 eadaily21 day(s)limit)

NISOLDIPINE ER TB24 4

nisoldipine tb24 17 mg 34mg 85 mg 255 mg 2

nisoldipine tb24 20 mg 40 mg 1 QL(1 ea daily)

NORVASC TABS (Use Amlodipine Besylate) 4 QL(1 ea daily)

NYMALIZE SOLN 4

PROCARDIA CAPS (Use Nifedipine) 4

PROCARDIA XL TB24 (Use Nifedipine) 4

SULAR TB24 (Use Nisoldipine) 4

TIAZAC CP24 (Use Diltiazem HCl Extended Release Beads)

4

Drug Name DrugTier

RequirementsLimits

verapamil hcl cp24 1

VERAPAMIL HCL SR CP24 4

verapamil hcl tabs 1

verapamil hcl tbcr 1

VERELAN CP24 120 MG 180 MG 240 MG (Use Verapamil HCl)

4

VERELAN CP24 360 MG 4

VERELAN PM CP24 (Use Verapamil HCl) 4

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm Cardiac Glycosides digoxin soln 1

digoxin tabs 1

LANOXIN TABS 125 MCG 250 MCG (Use Digoxin) 4

LANOXIN TABS 625 MCG 1875 MCG 4

CARDIOVASCULAR AGENTS - MISC - Drugs toTreat Heart and Circulation Conditions Cardiovascular Agents Misc - Combinations amlodipine besylate-atorvastatin calcium tabs 3

BIDIL TABS 4

CADUET TABS (Use Amlodipine Besylate-Atorvastatin Calcium)

4

ENTRESTO TABS 4 PA

Peripheral Vasodilators isoxsuprine hcl tabs 10 mg 1

ISOXSUPRINE HCL TABS 20 MG 4

Prostaglandin Vasodilators

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

49

Drug Name DrugTier

RequirementsLimits

epoprostenol sodium solr J PA SpecialtyTier 4 MayApply

FLOLAN SOLR (Use Epoprostenol Sodium) J

PA SpecialtyTier 4 MayApply

ORENITRAM TBCR 4 PA

TYVASO REFILL SOLN 4 PA SpecialtyTier 4 MayApply

TYVASO SOLN 4 PA SpecialtyTier 4 MayApply

TYVASO STARTER SOLN 4 PA SpecialtyTier 4 MayApply

VELETRI SOLR J PA SpecialtyTier 4 MayApply

VENTAVIS SOLN 10 MCGML 4

PA SpecialtyTier 4 MayApply

VENTAVIS SOLN 20 MCGML 4 PA

Pulmonary Hypertension - Endothelin Receptor

LETAIRIS TABS 3 PA SpecialtyTier 2 MayApply

OPSUMIT TABS 4 PA SpecialtyTier 3 MayApply

TRACLEER TABS 3

PA PA Required todirect to Caremark Specialty -Specialty Tier 2May Apply

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (Use Tadalafil (PulmonaryHypertension))

3 PA SpecialtyTier 1 MayApply

REVATIO SUSR 10 MGML 4

PA SpecialtyTier 1 MayApply

Drug Name DrugTier

RequirementsLimits

REVATIO TABS 20 MG (Use Sildenafil Citrate (Pulmonary Hypertension))

4 PA SpecialtyTier 1 MayApply

sildenafil citrate (pulmonaryhypertension) tabs 4

PA SpecialtyTier 1 MayApply

tadalafil (pulmonaryhypertension) tabs 3

PA SpecialtyTier 1 MayApply

Pulmonary Hypertension - Prostacyclin Receptor

UPTRAVI TABS 4 PA SpecialtyTier 3 MayApply

UPTRAVI TBPK 4 PA SpecialtyTier 3 MayApply

Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 4 PA

Sinus Node Inhibitors CORLANOR TABS 4 ST

CEPHALOSPORINS - Drugs to Treat BacterialInfections Cephalosporins - 1st Generation cefadroxil caps 500 mg 1

cefadroxil susr 250 mg5ml 2

cefadroxil susr 500 mg5ml 1

cefadroxil tabs 1 gm 2

cephalexin caps 250 mg500 mg 1

cephalexin caps 750 mg 4

cephalexin susr 125mg5ml 250 mg5ml 1

CEPHALEXIN TABS 250 MG 500 MG 4

KEFLEX CAPS (Use Cephalexin) 4

Cephalosporins - 2nd Generation cefaclor caps 250 mg 500 mg 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

50

Drug Name DrugTier

RequirementsLimits

CEFACLOR ER TB12 4

cefaclor susr 125 mg5ml250 mg5ml 375 mg5ml 1

CEFACLOR SUSR 250 MG5ML 375 MG5ML 4

cefprozil susr 2

cefprozil tabs 2

CEFTIN SUSR 4

cefuroxime axetil tabs 1

Cephalosporins - 3rd Generation CEDAX CAPS 4

CEDAX SUSR 4

cefdinir caps 300 mg 2

cefdinir susr 125 mg5ml250 mg5ml 1

CEFDITOREN PIVOXIL TABS 200 MG 400 MG 4

cefixime susr 3

cefpodoxime proxetil susr 2

cefpodoxime proxetil tabs 2

CEFTIBUTEN CAPS 4

CEFTIBUTEN SUSR 4

SPECTRACEF TABS 4

SUPRAX CAPS 400 MG 3

SUPRAX CHEW 100 MG 200 MG 4

SUPRAX SUSR 100 MG5ML 200 MG5ML(Use Cefixime)

4

SUPRAX SUSR 500 MG5ML 4

TAZICEF SOLN 3

Drug Name DrugTier

RequirementsLimits

CHEMICALS

Acids Bases amp Buffers POTASSIUM HYDROXIDE SOLN 3

SODIUM HYDROXIDE SOLN 3

Bulk Chemicals - Cs CROSCARMELLOSE SODIUM POWD 4 PA

Bulk Chemicals - Hs

HEPARIN SODIUM POWD XX J

PA SpecialtyTier 1 MayApply

Bulk Chemicals - Ns N-ACETYL-L-CARNOSINE POWD 4 PA

Bulk Chemicals - Ts TRICHLOROACETIC ACID SOLN 3

CONTRACEPTIVES - Drugs to PreventPregnancy Combination Contraceptives - Oral BEYAZ TABS (Use Drospirenone-EthinylEstradiol-Levomefolate Calcium)

3

PV

BREVICON-28 TABS (Use Norethindrone amp Eth Estradiol)

4 PV

CYCLESSA TABS (Use Desogestrel-EthinylEstradiol (Triphasic))

4 PV

DESOGEN TABS (Use Desogestrel amp EthinylEstradiol)

4 PV

desogestrel amp ethinylestradiol tabs 1 PV

desogestrel-ethinylestradiol (biphasic) tabs 1 PV

desogestrel-ethinylestradiol (triphasic) tabs 1 PV

drospirenone-ethinylestradiol tabs 1 PV

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

51

Drug Name DrugTier

RequirementsLimits

drospirenone-ethinylestradiol-levomefolate calcium tabs

1 PV

ESTROSTEP FE TABS (Use Norethindrone Acetate-Ethinyl Estradiol-Fe)

4

PV

ethynodiol diacet amp ethestrad tabs 1 PV

FEMCON FE CHEW (Use Norethindrone amp EthinylEstradiol-Fe)

4 PV

GENERESS FE CHEW (Use Norethindrone amp Ethinyl Estradiol-Fe)

4 QL(1 ea daily)PV

levonorgestrel amp ethestradiol tabs 1 QL(1 ea daily)

PV levonorgestrel-eth estradiol(triphasic) tabs 1 QL(1 ea daily)

PV

levonorgestrel-ethinylestradiol (91-day) tabs 1

QL(90 ea perfill retail90 ea per fill mail) PV

levonorgestrel-ethinylestradiol (91-day) tabs 1

QL(91 ea perfill retail91 ea per fill mail) PV

levonorgestrel-ethinylestradiol (91-day) tabs 4

QL(90 ea perfill retail90 ea per fill mail) PV

levonorgestrel-ethinylestradiol (continuous) tabs 4 PV

LO LOESTRIN FE TABS 4 PV

LOESTRIN 1530-21TABS (Use Norethindrone Acet amp Eth Estra)

4 PV

LOESTRIN 120-21 TABS(Use Norethindrone Acet amp Eth Estra)

4 PV

LOESTRIN FE 1530TABS (Use Norethin Acet amp Estrad-Fe)

4 PV

LOESTRIN FE 120 TABS(Use Norethin Acet amp Estrad-Fe)

4 PV

LOSEASONIQUE TABS (Use Levonorgestrel-Ethinyl Estradiol (91-Day))

4 QL(90 ea perfill retail90 ea per fill mail) PV

Drug Name DrugTier

RequirementsLimits

MINASTRIN 24 FE CHEW (Use Norethin Acet amp Estrad-Fe)

3 PV

MIRCETTE TABS (Use Desogestrel-EthinylEstradiol (Biphasic))

4 PV

NATAZIA TABS 2 QL(1 ea daily)PV

NECON 1011-28 TABS 2 PV

norethin acet amp estrad-fe chew 1 PV

norethin acet amp estrad-fe tabs 1 PV

norethindrone amp eth estradiol tabs 1 PV

norethindrone amp ethinylestradiol-fe chew 04mg-35mcg

1 PV

norethindrone amp ethinylestradiol-fe chew 75mg-08mg-25mcg

1 QL(1 ea daily)PV

norethindrone amp mestranol tabs 1 PV

norethindrone acet amp eth estra tabs 1 PV

norethindrone acetate-ethinyl estradiol-fe tabs 4 PV

norethindrone-eth estradiol (triphasic) tabs 1 PV

norgestimate-ethinylestradiol (triphasic) tabs 1 PV

norgestimate-ethinylestradiol tabs 1 PV

norgestrel amp ethinylestradiol tabs 1 PV

NORINYL 1+35 TABS (Use Norethindrone amp Eth Estradiol)

4 PV

ORTHO TRI-CYCLEN LO TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

3

PV

ORTHO TRI-CYCLEN TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

4

PV

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

52

Drug Name DrugTier

RequirementsLimits

ORTHO-CYCLEN TABS (Use Norgestimate-EthinylEstradiol)

4 PV

ORTHO-NOVUM 135TABS (Use Norethindrone amp Eth Estradiol)

4 PV

ORTHO-NOVUM 777TABS (Use Norethindrone-Eth Estradiol (Triphasic))

4 PV

OVCON-35 TABS (Use Norethindrone amp Eth Estradiol)

4 PV

QUARTETTE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))

4 QL(90 ea perfill retail90 ea per fill mail) PV

SAFYRAL TABS (Use Drospirenone-EthinylEstradiol-Levomefolate Calcium)

3

PV

SEASONIQUE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))

4 QL(91 ea perfill retail91 ea per fill mail) PV

TRI-NORINYL 28 TABS (Use Norethindrone-Eth Estradiol (Triphasic))

4 PV

YASMIN 28 TABS (Use Drospirenone-EthinylEstradiol)

4 PV

YAZ TABS (Use Drospirenone-EthinylEstradiol)

4 PV

Combination Contraceptives - Transdermal XULANE PTWK 2 PV

Combination Contraceptives - Vaginal NUVARING RING 2 PV

Emergency Contraceptives ELLA TABS 4 PV

levonorgestrel (emergencyoc) tabs 1 PV

PLAN B ONE-STEP TABS (Use Levonorgestrel(Emergency OC))

4 PV

Progestin Contraceptives - IUD

Drug Name DrugTier

RequirementsLimits

LILETTA IUD 4 QL(1 ea per365 daysretail) PV

MIRENA IUD 4 PV

SKYLA IUD 4 PV

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSY (Use MedroxyprogesteroneAcetate (Contraceptive))

3

PV

DEPO-SUBQ PROVERA 104 SUSY 3 PV

medroxyprogesteroneacetate (contraceptive) susy

1 PV

Progestin Contraceptives - Oral NOR-QD TABS (Use Norethindrone (Contraceptive))

4 PV

norethindrone (contraceptive) tabs 1 PV

ORTHO MICRONOR TABS (Use Norethindrone (Contraceptive))

4 PV

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions Glucocorticosteroids budesonide cpep 3 mg 2

budesonide tb24 9 mg 4 PA

CORTEF TABS (Use Hydrocortisone) 4

cortisone acetate tabs 1

dexamethasone elix 05 mg5ml 1

DEXAMETHASONE INTENSOL CONC 4

DEXAMETHASONE SOLN 05 MG5ML 4

dexamethasone tabs 075 mg 05 mg 4 mg 6 mg15 mg

1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

53

Drug Name DrugTier

RequirementsLimits

DEXAMETHASONE TABS 1 MG 2 MG 4

dexamethasone tbpk 15 mg 4

DEXPAK 10 DAY TBPK (Use Dexamethasone) 4

DEXPAK 13 DAY TBPK (Use Dexamethasone) 4

DEXPAK 6 DAY TBPK (Use Dexamethasone) 4

ENTOCORT EC CPEP (Use Budesonide) 4

hydrocortisone tabs 1

MEDROL DOSEPAK TBPK (Use Methylprednisolone) 4

MEDROL TABS 2 MG 4

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

4

methylprednisolone tabs 1

methylprednisolone tbpk 1

MILLIPRED DP TBPK 4

MILLIPRED SOLN 10 MG5ML (Use Prednisolone Sodium Phosphate)

4

MILLIPRED TABS 5 MG 4

ORAPRED ODT TBDP (Use Prednisolone Sodium Phosphate)

4

PEDIAPRED SOLN (Use Prednisolone Sodium Phosphate)

4

prednisolone sodiumphosphate soln or 10mg5ml 20 mg5ml

4

PREDNISOLONE SODIUM PHOSPHATE SOLN OR 25 MG5ML

4

prednisolone sodiumphosphate soln or 5mg5ml 15 mg5ml

1

Drug Name DrugTier

RequirementsLimits

prednisolone sodiumphosphate tbdp or 10 mg15 mg 30 mg

4

PREDNISOLONE SOLN 4

prednisolone soln 1

prednisolone syrp 1

PREDNISONE INTENSOL CONC 2

PREDNISONE SOLN 5 MG5ML 4

prednisone tabs 1 mg 5mg 10 mg 20 mg 25 mg 1

PREDNISONE TABS 50 MG 4

prednisone tbpk 5 mg 10 mg 1

RAYOS TBEC 4 PA

TAPERDEX 12-DAY TBPK 4

TAPERDEX 6-DAY TBPK 4

UCERIS TB24 OR 9 MG (Use Budesonide) 4 PA

VERIPRED 20 SOLN (Use Prednisolone Sodium Phosphate)

4

ZODEX 12-DAY TBPK 4

ZODEX 6-DAY TBPK 4

Mineralocorticoids fludrocortisone acetate tabs 2

COUGHCOLDALLERGY - Drugs to TreatCough Cold and Allergy Symptoms Antitussives benzonatate caps 100 mg200 mg 1

benzonatate caps 150 mg 4

hydrocodone whomatropine syrp 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

54

Drug Name DrugTier

RequirementsLimits

hydrocodone whomatropine tabs 1

TESSALON PERLES CAPS (Use Benzonatate) 4

CoughColdAllergy Combinations ACTIDOM DMX LIQD 4

ALAHIST DM LIQD (Use Phenylephrine-Brompheniramine-DM)

4

AP-HIST DM LIQD 4

CLARINEX-D 12 HOUR TB12 3

CODITUSSIN AC LIQD 3

DALLERGY LIQD 4

DECON-G LIQD 3

DOMETUSS-DMX LIQD 4

FLOWTUSS SOLN 4

guaifenesin-codeine liqd 1

guaifenesin-codeine soln 1

guaifenesin-codeine syrp 1

HYCOFENIX SOLN 4 PA

HYDROCODONE BITARTRATECHLORPHENIRAMINE MALEATEPSESOLN

4

PA

HYDROCODONE BITARTRATEGUAIFENESIN SOLN

4

hydrocodone polistirex-chlorpheniramine polistirex suer

4

QL(300 ml per31 daysretail900 ml per 93 daysmail)

LOHIST-DM SYRP 4

M-CLEAR WC SOLN 4

Drug Name DrugTier

RequirementsLimits

NORTUSS-EX LIQD 4

OBREDON SOLN 4

phenylephrine w dm-ggliqd 1 RXOTC

phenylephrine-brompheniramine-dm liqd 1

PHENYLEPHRINEGUAIFENESIN LIQD 4

PHENYLHISTINE DH LIQD 4

promethazine ampphenylephrine soln 1

promethazine wcodeinesoln 1

promethazine wcodeine syrp 1

promethazine-dm syrp 1

promethazine-phenylephrine-codeine syrp 1

PROMETHAZINEPHENYLEPHRINE SYRP 4

PROMETHAZINEPHENYLEPHRINECODEINE SYRP 4

pseudoephed-bromphen-dm syrp 1

pseudoephed-cpm whydrocod soln 4 PA

REZIRA SOLN 4

SEMPREX-D CAPS 4

TUSNEL TABS 3

TUSSICAPS CP12 4

TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER (Use HydrocodonePolistirex-ChlorpheniraminePolistirex)

4

QL(300 ml per31 daysretail900 ml per 93 daysmail)

TUZISTRA XR SUER 4 PA

VITUZ SOLN 4 PA

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

55

Drug Name DrugTier

RequirementsLimits

ZUTRIPRO SOLN (Use Pseudoephed-CPM wHydrocod)

4 PA

Expectorants guaifenesin tabs 1

Misc Respiratory Inhalants HYPER-SAL NEBU (Use Sodium Chloride (Inhalant)) 4

HYPERSAL NEBU 35 4

HYPERSAL NEBU 7 (Use Sodium Chloride (Inhalant))

4

NEBUSAL NEBU 4

sodium chloride (inhalant)nebu 1

Mucolytics acetylcysteine soln 2

DERMATOLOGICALS - Drugs to Treat SkinConditions Acne Products ABSORICA CAPS 10 MG 20 MG 30 MG 40 MG 4 PA

ABSORICA CAPS 25 MG 35 MG 4

ACANYA GEL 4 PA

ACZONE GEL 5 (Use Dapsone (Topical)) 4 PA

ACZONE GEL 75 4 PA QL(2 gmdaily)

adapalene crea 01 3

adapalene gel 01 3 RXOTC

adapalene gel 03 3

ADAPALENE LOTN 01 4 Limit 59mls permonthQL(197ml daily)

Drug Name DrugTier

RequirementsLimits

adapalene-benzoylperoxide gel 4

Limit 45gms permonthQL(15gm daily)

ALTRENO LOTN 4 PA

ATRALIN GEL (Use Tretinoin) 4

Limit 45gms permonthQL(15gm daily)AL(Up to 46 yrsold )

AZELEX CREA 3

BENZACLIN GEL (Use Clindamycin Phosphate-Benzoyl Peroxide)

4

BENZACLIN WITH PUMP GEL (Use ClindamycinPhosphate-BenzoylPeroxide)

4

BENZAMYCIN GEL (Use Benzoyl Peroxide-Erythromycin)

4

benzoyl peroxide bar 10 3

BENZOYL PEROXIDE CLEANSER LOTN 4

benzoyl peroxide crea 10 4

benzoyl peroxide liqd 4 7 4

benzoyl peroxide lotn 6 4

benzoyl peroxide misc 6 4 RXOTC

benzoyl peroxide-erythromycin gel 2

CLEOCIN-T GEL (Use Clindamycin Phosphate(Topical))

4

CLEOCIN-T LOTN (Use Clindamycin Phosphate(Topical))

4

CLEOCIN-T SOLN (Use Clindamycin Phosphate(Topical))

4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

56

Drug Name DrugTier

RequirementsLimits

CLEOCIN-T SWAB (Use Clindamycin Phosphate(Topical))

4

CLINDAGEL GEL (Use Clindamycin Phosphate(Topical))

4 PA

clindamycin phosphate(topical) foam 4

clindamycin phosphate(topical) gel 1

clindamycin phosphate(topical) lotn 1

clindamycin phosphate(topical) soln 1

clindamycin phosphate(topical) swab 1

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

3

clindamycin phosphate-benzoyl peroxide gel 4

clindamycin phosphate-tretinoin gel 4 QL(1 gm daily)

CLINDAMYCIN PHOSPHATEBENZOYLPEROXIDE GEL

4 PA

dapsone (topical) gel 4 PA

DIFFERIN CREA 01 (Use Adapalene) 4

DIFFERIN GEL 01 (Use Adapalene) 4 RXOTC

DIFFERIN GEL 03 (Use Adapalene) 4

DIFFERIN LOTN 01 4 Limit 59mls permonthQL(197ml daily)

DUAC GEL (Use Clindamycin Phosphate-Benzoyl Peroxide(Refrigerate))

4

EPIDUO FORTE GEL 4

PA Limit 45gms permonthQL(15gm daily)

Drug Name DrugTier

RequirementsLimits

EPIDUO GEL (Use Adapalene-BenzoylPeroxide)

4

Limit 45gms permonthQL(15gm daily)

ERYGEL GEL (Use Erythromycin (Acne Aid)) 4

erythromycin (acne aid) gel 1

erythromycin (acne aid)pads 1

erythromycin (acne aid)soln 1

EVOCLIN FOAM (Use Clindamycin Phosphate(Topical))

4

FABIOR FOAM 4

Limit 50gms permonthQL(167gm daily)AL(Up to 46 yrsold )

isotretinoin caps 10 mg 20mg 30 mg 40 mg 1

isotretinoin caps 10 mg 20mg 30 mg 40 mg 3

isotretinoin caps 30 mg 4

isotretinoin caps 30 mg 40 mg 1

Limited to 5 months of treatment

KLARON LOTN (Use Sulfacetamide Sodium (Acne))

4

ONEXTON GEL 4 PA

PANOXYL-4 CREAMY WASH LIQD (Use BenzoylPeroxide)

4

RETIN-A CREA (Use Tretinoin) 4 AL(Up to 46 yrs

old ) RETIN-A GEL (Use Tretinoin) 4 AL(Up to 46 yrs

old ) RETIN-A MICRO GEL 004 (Use Tretinoin Microsphere)

3 QL(067 gmdaily) AL(Up to46 yrs old )

RETIN-A MICRO GEL 004 (Use Tretinoin Microsphere)

4 QL(067 gmdaily) AL(Up to46 yrs old )

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

57

Drug Name DrugTier

RequirementsLimits

RETIN-A MICRO GEL 01 (Use Tretinoin Microsphere)

4

Limit 20gms permonthQL(067gm daily)AL(Up to 46 yrsold )

RETIN-A MICRO PUMP GEL 004 (Use Tretinoin Microsphere)

4 QL(067 gmdaily) AL(Up to46 yrs old )

RETIN-A MICRO PUMP GEL 008 4

PA Limit 50gms permonthQL(17gm daily)

RETIN-A MICRO PUMP GEL 01 (Use Tretinoin Microsphere)

2

Limit 50gms permonthQL(17gm daily)AL(Up to 46 yrsold )

RIAX FOAM 4

ROSULA LIQD 45-10 4 PA

ROSULA PADS 5-10 4 QL(30 ea perfill retail)

SODIUM SULFACETAMIDESULFUR LOTN

4 QL(25 gm perfill retail)

SODIUM SULFACETAMIDESULFUR SUSP

4

sulfacetamide sodium (acne) lotn 1

sulfacetamide sodium wsulfur liqd 4-9 1

sulfacetamide sodium wsulfur pads 4-10 4-4-10-10

4

sulfacetamide sodium wsulfur susp 4-8 1

SUMAXIN PADS (Use Sulfacetamide Sodium wSulfur)

4

SUMAXIN TS SUSP (Use Sulfacetamide Sodium wSulfur)

4

Drug Name DrugTier

RequirementsLimits

SUMAXIN WASH LIQD (Use Sulfacetamide Sodium w Sulfur)

4

TRETIN-X CREA 4 PA

tretinoin crea 0025 005 01 2 AL(Up to 46 yrs

old ) tretinoin gel 0025 001 2 AL(Up to 46 yrs

old )

tretinoin gel 005 4

Limit 45gms permonthQL(15gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel004 2

QL(067 gmdaily) AL(Up to46 yrs old )

tretinoin microsphere gel01 1

Limit 50gms permonthQL(17gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel01 1

Limit 20gms permonthQL(06749 gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel01 1

Limit 45gms permonthQL(15gm daily)AL(Up to 46 yrsold )

tretinoin microsphere gel01 1

Limit 20gms permonthQL(067gm daily)AL(Up to 46 yrsold )

VELTIN GEL 4 QL(1 gm daily)

ZIANA GEL (Use Clindamycin Phosphate-Tretinoin)

4 QL(1 gm daily)

Agents for External Genital and Perianal Warts

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

58

Drug Name DrugTier

RequirementsLimits

VEREGEN OINT 4

Anti-inflammatory Agents - Topical DFSMSMENTHCAP PAKKIT 4 PA

diclofenac sodium (topical)gel 1 1

diclofenac sodium (topical)soln 15 2 QL(5 ml daily)

FLECTOR PTCH 4

PENNSAID SOLN 4 PA QL(4 gmdaily)

VOLTAREN GEL (Use Diclofenac Sodium (Topical))

3

VOPAC MDS KIT 4 PA

Antibiotics - Topical ALTABAX OINT 4

BACTROBAN CREA (Use Mupirocin Calcium(Topical))

4

CORTISPORIN CREA 3

CORTISPORIN OINT 3

gentamicin sulfate (topical) crea 1

gentamicin sulfate (topical)oint 1

mupirocin calcium (topical) crea 1

mupirocin oint 1

NEO-SYNALAR CREA 4 PA

XEPI CREA 4 PA

Antifungals - Topical ciclopirox gel 077 2

ciclopirox olamine crea 2

ciclopirox olamine susp 2

Drug Name DrugTier

RequirementsLimits

ciclopirox sham 1 2

ciclopirox soln 8 1

clotrimazole wbetamethasone crea 2

clotrimazole wbetamethasone lotn 2 QL(1 ml daily)

econazole nitrate crea 1

ECOZA FOAM 4

Limit 70gms permonthQL(25gm daily)

ERTACZO CREA 4 PA

EXELDERM CREA 4

EXELDERM SOLN 4

EXTINA FOAM (Use Ketoconazole (Topical)) 4

iodoquinol-hc crea 2

JUBLIA SOLN 4 PA

KERYDIN SOLN 4 PA

ketoconazole (topical) crea 2

ketoconazole (topical) foam 4

ketoconazole (topical)sham 1

LOPROX CREA (Use Ciclopirox Olamine) 4

LOPROX SHAMPOO SHAM (Use Ciclopirox) 4

LOPROX SUSP (Use Ciclopirox Olamine) 4

LOTRISONE CREA (Use Clotrimazole wBetamethasone)

4

LULICONAZOLE CREA 4

LUZU CREA 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

59

Drug Name DrugTier

RequirementsLimits

MICONAZOLE NITRATEZINCOXIDEWHITEPETROLATUM OINT

4

naftifine hcl crea 4

NAFTIN CREA 2 (Use Naftifine HCl) 4

NAFTIN GEL 1 2 4

NIZORAL SHAM (Use Ketoconazole (Topical)) 4

nystatin (topical) crea 1

nystatin (topical) oint 1

nystatin (topical) powd 2

nystatin-triamcinolone crea 1

nystatin-triamcinolone oint 1

oxiconazole nitrate crea 4

OXISTAT CREA (Use Oxiconazole Nitrate) 4

OXISTAT LOTN 4

PENLAC NAIL LACQUER SOLN (Use Ciclopirox) 4

VUSION OINT 4

XOLEGEL GEL 4

Antineoplastic or Premalignant Lesion Agents -CARAC CREA 4

diclofenac sodium (actinickeratoses) gel 4 PA

EFUDEX CREA (Use Fluorouracil (Topical)) 4

FLUOROPLEX CREA 4

fluorouracil (topical) crea 1

FLUOROURACIL CREA EX 05 4

Drug Name DrugTier

RequirementsLimits

FLUOROURACIL SOLN EX 2 5 4

LEVULAN KERASTICK SOLR 4 PA

PANRETIN GEL 4 PA

PICATO GEL 4

SOLARAZE GEL (Use Diclofenac Sodium (ActinicKeratoses))

4 PA

TARGRETIN GEL EX 1 4

TOLAK CREA 4 PA

VALCHLOR GEL 4 PA SpecialtyTier 2 MayApply

Antipruritics - Topical doxepin hcl (antipruritic) crea 4

PRUDOXIN CREA 4

ZONALON CREA 4

ZONALON CREA 4 PA

Antipsoriatics acitretin caps 2

calcipotriene crea 3

calcipotriene oint 3

calcipotriene soln 3

calcitriol (topical) oint 3

Limit 100gms permonthQL(34gm daily)

COSENTYX SENSOREADY PEN SOAJ J

PA SpecialtyTier 2 MayApply

COSENTYX SOSY J PA SpecialtyTier 2 MayApply

DOVONEX CREA (Use Calcipotriene) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

60

Drug Name DrugTier

RequirementsLimits

ILUMYA SOSY J PA SpecialtyTier 3 MayApply

methoxsalen rapid caps 3

OXSORALEN ULTRA CAPS (Use Methoxsalen Rapid)

3

SORIATANE CAPS (Use Acitretin) 4

SORILUX FOAM 4 QL(4 gm daily)

STELARA SOLN J PA SpecialtyTier 2 MayApply

STELARA SOSY J PA SpecialtyTier 2 MayApply

TALTZ SOAJ J PA SpecialtyTier 3 MayApply

TALTZ SOSY J PA SpecialtyTier 3 MayApply

tazarotene crea 3 QL(1 gm daily)AL(Up to 46 yrsold )

TAZORAC CREA 005 3 QL(1 gm daily)AL(Up to 46 yrsold )

TAZORAC CREA 01 (Use Tazarotene) 3

QL(1 gm daily)AL(Up to 46 yrsold )

TAZORAC GEL 005 01 3

QL(1 gm daily)AL(Up to 46 yrsold )

VECTICAL OINT (Use Calcitriol (Topical)) 3

Limit 100gms permonthQL(34gm daily)

ZITHRANOL SHAM 4 PA

Antiseborrheic Products GLYCOLIC ACID 70 HIGH PURITY SOLN 3 RXOTC

GLYCOLIC ACID SOLN 3 RXOTC

Drug Name DrugTier

RequirementsLimits

selenium sulfide lotn 25 1

selenium sulfide sham 225 4 MO

SODIUM SULFACETAMIDE WASH LIQD

4

Antivirals - Topical acyclovir topical oint 4

DENAVIR CREA 4

Limited to 5 gms permonthQL(017gm daily)

XERESE CREA 4

PA Limit 5gms permonthQL(017gm daily)

ZOVIRAX CREA EX 5 4 PA QL(5 gmper 30 daysretail)

ZOVIRAX OINT EX 5 (Use Acyclovir Topical) 4

Burn Products mafenide acetate pack 4

SILVADENE CREA (Use Silver Sulfadiazine) 4

silver sulfadiazine crea 1

SULFAMYLON CREA 85 MGGM 4

SULFAMYLON PACK 5 (Use Mafenide Acetate) 4

Cauterizing Agents SILVER NITRATE OINT 4

SILVER NITRATE SOLN 4

Corticosteroids - Topical ACLOVATE CREA (Use Alclometasone Dipropionate)

4

ALA SCALP LOTN 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

61

Drug Name DrugTier

RequirementsLimits

alclometasone dipropionate crea 2

alclometasone dipropionateoint 2

AMCINONIDE CREA 4

AMCINONIDE LOTN 3

AMCINONIDE OINT 3

APEXICON E CREA 3

AUGMENTED BETAMETHASONE DIPROPIONATE GEL

4

betamethasone dipropionate (topical) crea 1

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint 1

betamethasone dipropionate augmented crea

1

betamethasone dipropionate augmentedgel

1

betamethasone dipropionate augmentedlotn

1

betamethasone dipropionate augmentedoint

2

betamethasone valerate crea 01 1

betamethasone valerate foam 012 4

betamethasone valerate lotn 01 1

betamethasone valerate oint 01 1

BRYHALI LOTN 4 PA

calcipotriene-betamethasone dipropionate oint

3 ST QL(2 gmdaily)

Drug Name DrugTier

RequirementsLimits

CAPEX SHAM 4

clobetasol propionate crea 1

clobetasol propionateemollient base crea 1

clobetasol propionateemulsion foam 4

clobetasol propionate foam 4

clobetasol propionate gel 1

clobetasol propionate liqd 4

clobetasol propionate lotn 4

clobetasol propionate oint 1

clobetasol propionate sham 2

clobetasol propionate soln 1

CLOBEX LIQD (Use Clobetasol Propionate) 4

CLOBEX LOTN (Use Clobetasol Propionate) 4

CLOBEX SHAM (Use Clobetasol Propionate) 4

CLOCORTOLONE PIVALATE CREA 4

CLOCORTOLONE PIVALATE PUMP CREA 4

CLODERM CREA 4

CLODERM PUMP CREA 4

CORDRAN CREA 0025 4 PA

CORDRAN CREA 005 (Use Flurandrenolide) 4

CORDRAN LOTN 005 (Use Flurandrenolide) 4 PA

CORDRAN OINT 005 (Use Flurandrenolide) 4 PA

CORDRAN TAPE 4 MCGSQCM 4

CUTIVATE LOTN (Use Fluticasone Propionate) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

62

Drug Name DrugTier

RequirementsLimits

DERMA-SMOOTHEFSBODY OIL (Use Fluocinolone Acetonide)

4

DERMA-SMOOTHEFSSCALP OIL (Use Fluocinolone Acetonide)

4

DERMATOP CREA (Use Prednicarbate) 4

DERMATOP OINT (Use Prednicarbate) 4

DESONATE GEL 4

desonide crea 1

desonide lotn 1

desonide oint 1

DESOWEN CREA (Use Desonide) 4

DESOWEN LOTN (Use Desonide) 4

desoximetasone crea 005 025 1

desoximetasone gel 005 1

desoximetasone liqd 025 4 ST

desoximetasone oint 005 4

desoximetasone oint 025 1

diflorasone diacetate crea 3

diflorasone diacetate oint 3

DIPROLENE AF CREA (Use Betamethasone Dipropionate Augmented)

4

DIPROLENE LOTN (Use Betamethasone Dipropionate Augmented)

4

DIPROLENE OINT (Use Betamethasone Dipropionate Augmented)

4

ELOCON CREA (Use Mometasone Furoate) 4

Drug Name DrugTier

RequirementsLimits

ELOCON OINT (Use Mometasone Furoate) 4

ENSTILAR FOAM 4 PA

EPIFOAM FOAM 4

fluocinolone acetonide crea 0025 001 1

fluocinolone acetonide oil 001 2

fluocinolone acetonide oint 0025 1

fluocinolone acetonide soln 001 1

fluocinonide crea 005 1

fluocinonide crea 01 4

fluocinonide emulsified base crea 1

fluocinonide gel 005 1

fluocinonide oint 005 1

fluocinonide soln 005 1

flurandrenolide crea 4

flurandrenolide lotn 4 PA

flurandrenolide oint 4 PA

fluticasone propionate crea005 1 QL(30 gm per

fill retail) fluticasone propionate lotn005 4

fluticasone propionate oint0005 1 QL(30 gm per

fill retail) halobetasol propionate crea 1

halobetasol propionate oint 1

HALOG CREA 4

HALOG OINT 4

hydrocortisone (topical)crea 25 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

63

Drug Name DrugTier

RequirementsLimits

hydrocortisone (topical)lotn 25 1

hydrocortisone (topical)oint 25 1

hydrocortisone (topical)soln 1 3

hydrocortisone butyrate crea 1

hydrocortisone butyratehydrophilic lipo base crea 1

hydrocortisone butyratelotn 4 PA

hydrocortisone butyrateoint 1

hydrocortisone butyratesoln 1

hydrocortisone valerate crea 1

hydrocortisone valerateoint 1

KENALOG AERS (Use Triamcinolone Acetonide (Topical))

4

LEXETTE FOAM 4 PA

LOCOID CREA (Use Hydrocortisone Butyrate) 4

LOCOID LIPOCREAM CREA (Use HydrocortisoneButyrate Hydrophilic LipoBase)

4

LOCOID LOTN (Use Hydrocortisone Butyrate) 4 PA

LOCOID OINT (Use Hydrocortisone Butyrate) 4

LOCOID SOLN (Use Hydrocortisone Butyrate) 4

LUXIQ FOAM (Use Betamethasone Valerate) 4

mometasone furoate crea 1

mometasone furoate oint 1

mometasone furoate soln 1

OLUX FOAM (Use Clobetasol Propionate) 4

Drug Name DrugTier

RequirementsLimits

OLUX-E FOAM (Use Clobetasol PropionateEmulsion)

4

PANDEL CREA 4

PRAMOSONE CREA 1-1 4

PRAMOSONE CREA 1-25 (Use Pramoxine-HC) 4

PRAMOSONE E CREA 4

PRAMOSONE LOTN 1-1 1-25 2

PRAMOSONE OINT 1-1 2

PRAMOSONE OINT 1-25 4

pramoxine-hc crea 1

PREDNICARBATE CREA 4

prednicarbate crea 1

PREDNICARBATE OINT 4

PSORCON CREA 4

SERNIVO EMUL 4 PA

SYNALAR CREA (Use Fluocinolone Acetonide) 4

SYNALAR OINT (Use Fluocinolone Acetonide) 4

SYNALAR SOLN (Use Fluocinolone Acetonide) 4

TACLONEX OINT (Use Calcipotriene-Betamethasone Dipropionate)

3

ST QL(2 gmdaily)

TACLONEX SUSP 4 ST QL(2 gmdaily)

TEMOVATE CREA (Use Clobetasol Propionate) 4

TEMOVATE E CREA (Use Clobetasol PropionateEmollient Base)

4

TEMOVATE OINT (Use Clobetasol Propionate) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

64

Drug Name DrugTier

RequirementsLimits

TEXACORT SOLN 4

TOPICORT CREA 005 025 (Use Desoximetasone)

4

TOPICORT GEL 005 (Use Desoximetasone) 4

TOPICORT LIQD 025 (Use Desoximetasone) 4 ST

TOPICORT OINT 005 025 (Use Desoximetasone)

4

triamcinolone acetonide (topical) aers 0147 mggm 3

triamcinolone acetonide (topical) crea 0025 01 05

1

triamcinolone acetonide (topical) lotn 0025 01

1

triamcinolone acetonide (topical) oint 0025 01 05

1

TRIANEX OINT 3

TRIDESILON CREA (Use Desonide) 4

ULTRAVATE CREA (Use Halobetasol Propionate) 4

ULTRAVATE LOTN 4 PA

ULTRAVATE OINT (Use Halobetasol Propionate) 4

VANOS CREA (Use Fluocinonide) 4

VERDESO FOAM 3

WESTCORT OINT (Use Hydrocortisone Valerate) 4

EmollientKeratolytic Agents urea crea 40 1 RXOTC

urea crea 41 4

urea gel 40 2

Drug Name DrugTier

RequirementsLimits

urea lotn 40 1

UTOPIC CREA (Use Urea) 4

Emollients lactic acid (ammoniumlactate) lotn 4

Enzymes - Topical SANTYL OINT 4

Immunomodulating Agents - Topical ALDARA CREA (Use Imiquimod) 4

imiquimod crea 1

IMIQUIMOD PUMP CREA 4

PA Limit 2 bottles per 28daysQL(28 gmper 28 daysretail)

ZYCLARA CREA 4

PA Limit 2 bottles per 28daysQL(28 gmper 28 daysretail)

ZYCLARA PUMP CREA 25 4

PA Limit 2 bottles per 28daysQL(06gm daily)

ZYCLARA PUMP CREA 375 4

PA Limit 2 bottles per 28daysQL(28 gmper 28 daysretail)

Immunosuppressive Agents - Topical ELIDEL CREA 4 PA

PROTOPIC OINT (Use Tacrolimus (Topical)) 4

tacrolimus (topical) oint 3

KeratolyticAntimitotic Agents CONDYLOX GEL 3

CONDYLOX SOLN (Use Podofilox) 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

65

Drug Name DrugTier

RequirementsLimits

podofilox soln 3

SALEX SHAM (Use Salicylic Acid) 4

salicylic acid crea 6 1

salicylic acid liqd 26 4

salicylic acid lotn 6 1

salicylic acid sham 6 1

salicylic acid soln 26 4

Local Anesthetics - Topical AFTERTEST TOPICAL PAIN RELIEF STCK 3 QL(1 ml per

365 days retail)

CETACAINE AERO 4

lidocaine hcl crea ex 3 2 RXOTC

lidocaine hcl soln ex 4 1

lidocaine oint 2

lidocaine ptch 2 QL(3 ea daily)

lidocaine-prilocaine crea 2

lidocaine-prilocaine kit 4

LIDODERM PTCH (Use Lidocaine) 4 QL(3 ea daily)

LIDOPIN CREA 4 PA

LIDOVEX CREA 4 PA

pramoxine hcl gel 3 RXOTC

SYNERA PTCH 4

ZTLIDO PTCH 4 PA

Misc Topical DRYSOL SOLN 4

QBREXZA PADS 4 PA

Drug Name DrugTier

RequirementsLimits

Rosacea Agents

azelaic acid gel 3

QL(50 gm per30 daysretail150 gmper 90 daysmail)

DOXYCYCLINE CPDR 4 PA

FINACEA FOAM 4

FINACEA GEL (Use Azelaic Acid) 3

QL(50 gm per30 daysretail150 gmper 90 daysmail)

METROCREAM CREA (Use Metronidazole (Topical))

4

METROGEL GEL (Use Metronidazole (Topical)) 4

METROLOTION LOTN (Use Metronidazole (Topical))

4

metronidazole (topical)crea 075 2

metronidazole (topical) gel075 2

metronidazole (topical) gel1 1

metronidazole (topical) lotn075 2

MIRVASO GEL 4 PA

NORITATE CREA 4 PA

ORACEA CPDR 4 PA

SOOLANTRA CREA 4 PA QL(1 gmdaily)

Scabicides amp Pediculicides ELIMITE CREA (Use Permethrin) 4

LINDANE SHAM 4

lindane sham 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

66

Drug Name DrugTier

RequirementsLimits

malathion lotn 3 QL(59 ml perfill retail)

NATROBA SUSP 4

OVIDE LOTN (Use Malathion) 4 QL(59 ml per

fill retail)

permethrin crea 1

SKLICE LOTN 4

SPINOSAD SUSP 4

SULFURATED LIME SOLN 3

ULESFIA LOTN 4

Wound Care Products LURADROX GEL 4 PA

REGRANEX GEL 4

DIAGNOSTIC PRODUCTS

Diagnostic Radiopharmaceuticals AXUMIN SOLN 4 PA

Diagnostic Tests CHEK-STIX COMBO PAK URINALYSIS CONTROL STRP

2

CHEK-STIX CONTROL STRP 2

CHEMSTRIP-K STRP 2

CONTOUR NEXT BLOOD GLUCOSE TEST STRP 4 PA RXOTC

DIATHRIVE BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP

2

Limit 200 permonthQL(667ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

FREESTYLE INSULINX BLOODGLUCOSE TEST STRP

2

Limit 200 permonthQL(667ea daily)RXOTC

FREESTYLE LITE TEST STRIPS STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

FREESTYLE TEST STRIPS STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

KETOCARE STRP 2

KETONE TEST STRIPS STRP 2

KETOSTIX STRP 2

ONETOUCH ULTRA BLUE STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

ONETOUCH VERIO TEST STRIPS STRP 2

Limit 200 permonthQL(667ea daily)RXOTC

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP

2

Limit 200 permonthQL(667ea daily)RXOTC

PREFERRED GLUCOMETER SUPPLIES AND STRIPS

2 Limit 200 permonth

PRO VOICE V8V9BLOOD GLUCOSE TEST STRIPS STRP

4 PA RXOTC

RELION KETONE STRP 2

RELION KETONE TEST STRIPS STRP 2

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

67

Drug Name DrugTier

RequirementsLimits

Digestive Enzymes CREON CPEP 3

PANCREAZE CPEP 4

PERTZYE CPEP 4

SUCRAID SOLN 2 Specialty Tier 3May Apply

VIOKACE TABS 4

ZENPEP CPEP 3

DIURETICS - Drugs to Treat Heart CirculationConditions and Blood Pressure Carbonic Anhydrase Inhibitors acetazolamide cp12 1

acetazolamide tabs 1

DIAMOX CP12 (Use Acetazolamide) 4

KEVEYIS TABS 4 PA SpecialtyTier 3 MayApply

methazolamide tabs 2

NEPTAZANE TABS (Use Methazolamide) 4

Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Use Spironolactone ampHydrochlorothiazide)

4

ALDACTAZIDE TABS 50MG-50MG 4

amiloride amp hydrochlorothiazide tabs 1

DYAZIDE CAPS (Use Triamterene amp Hydrochlorothiazide)

4

MAXZIDE TABS (Use Triamterene amp Hydrochlorothiazide)

4

MAXZIDE-25 TABS (Use Triamterene amp Hydrochlorothiazide)

4

Drug Name DrugTier

RequirementsLimits

spironolactone amphydrochlorothiazide tabs 1

triamterene amp hydrochlorothiazide caps 1

triamterene amp hydrochlorothiazide tabs 1

TRIAMTERENEHYDROCHLOROTHIAZIDE CAPS 4

Loop Diuretics bumetanide tabs 1

BUMEX TABS (Use Bumetanide) 4

DEMADEX TABS (Use Torsemide) 4

EDECRIN TABS (Use Ethacrynic Acid) 3 ST

ethacrynic acid tabs 3 ST

furosemide soln 10 mgml 1

FUROSEMIDE SOLN 8 MGML 4

furosemide tabs 20 mg 40mg 80 mg 1

LASIX TABS (Use Furosemide) 4

torsemide tabs 1

Potassium Sparing Diuretics ALDACTONE TABS (Use Spironolactone) 4

amiloride hcl tabs 2

DYRENIUM CAPS 2

spironolactone tabs 2

Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG 4

chlorothiazide tabs 500 mg 1

chlorthalidone tabs 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

68

Drug Name DrugTier

RequirementsLimits

DIURIL SUSP 4

hydrochlorothiazide caps 1

hydrochlorothiazide tabs 1

indapamide tabs 1

methyclothiazide tabs 1

metolazone tabs 2

MICROZIDE CAPS (Use Hydrochlorothiazide) 4

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

ACTONEL TABS 150 MG (Use Risedronate Sodium) 4

QL(1 ea per 28days retail3 eaper 84 daysmail)

ACTONEL TABS 35 MG (Use Risedronate Sodium) 4 QL(4 ea per 30

days retail) ACTONEL TABS 5 MG 30 MG (Use Risedronate Sodium)

4

ALENDRONATE SODIUM SOLN 70 MG75ML 4

alendronate sodium tabs 5 mg 10 mg 35 mg 40 mg 1

alendronate sodium tabs 70 mg 1

QL(4 ea per fillretail12 ea perfill mail)

ATELVIA TBEC (Use Risedronate Sodium) 4

BINOSTO TBEF 4

BONIVA SOLN IV 3 MG3ML (Use Ibandronate Sodium)

J PA SpecialtyTier 3 MayApply

BONIVA TABS OR 150 MG (Use Ibandronate Sodium) 4 QL(1 ea per 30

days retail)

calcitonin (salmon) soln 2

etidronate disodium tabs 3

Drug Name DrugTier

RequirementsLimits

FORTEO SOLN J PA SpecialtyTier 2 MayApply

FOSAMAX PLUS D TABS 4

FOSAMAX TABS (Use Alendronate Sodium) 4

QL(4 ea per fillretail12 ea perfill mail)

ibandronate sodium soln iv 3 mg3ml J

PA SpecialtyTier 3 MayApply

ibandronate sodium tabs or 150 mg 1 QL(1 ea per 30

days retail) MIACALCIN SOLN IJ 200 UNITML J PA

MIACALCIN SOLN NA 200 UNITACT (Use Calcitonin (Salmon))

4

NATPARA CART J PA SpecialtyTier 3 MayApply

PROLIA SOLN J PA SpecialtyTier 3 MayApply

RECLAST SOLN (Use Zoledronic Acid) J

PA SpecialtyTier 3 MayApply

risedronate sodium tabs 150 mg 4

QL(1 ea per 28days retail3 eaper 84 daysmail)

risedronate sodium tabs 35 mg 4 QL(4 ea per 30

days retail) risedronate sodium tabs 5 mg 30 mg 4

risedronate sodium tbec 35 mg 1

XGEVA SOLN J PA SpecialtyTier 3 MayApply

zoledronic acid soln J PA SpecialtyTier 3 MayApply

Corticotropin

HP ACTHAR GEL J PA SpecialtyTier 4 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

69

Drug Name DrugTier

RequirementsLimits

GnRHLHRH Antagonists ORILISSA TABS 4 PA

Growth Hormone Receptor Antagonists

SOMAVERT SOLR 10 MG 15 MG 20 MG 25 MG J

PA SpecialtyTier 3 MayApply

SOMAVERT SOLR 30 MG J PA

Growth Hormones

GENOTROPIN MINIQUICK SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

GENOTROPIN SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

HUMATROPE COMBO PACK SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

HUMATROPE SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

NORDITROPIN FLEXPRO SOLN 10 MG15ML J

PA SpecialtyMay ApplyHumatrope Tier2 OmnitropeTier 2 NutropinTier 3 Genotropin Tier3

NORDITROPIN FLEXPRO SOLN 30 MG3ML 15MG15ML

J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

Drug Name DrugTier

RequirementsLimits

NORDITROPIN FLEXPRO SOLN 5 MG15ML J

PA SpecialtyTier 2 MayApply

NUTROPIN AQ NUSPIN 10 SOLN J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

NUTROPIN AQ NUSPIN 20 SOLN J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

NUTROPIN AQ NUSPIN 5 SOLN J

PA SpecialtyTier 3 MayApply

OMNITROPE SOLN 10 MG15ML J

PA SpecialtyMay ApplyHumatrope Tier2 OmnitropeTier 2 NutropinTier 3 Genotropin Tier3

OMNITROPE SOLN 5 MG15ML J

PA SpecialtyTier 2 MayApply

OMNITROPE SOLR 58 MG J

PA SpecialtyMay ApplyHumatrope Tier2 OmnitropeTier 2 NutropinTier 3 Genotropin Tier3

SAIZEN CLICKEASY SOLR J

PA SpecialtyTier 3 MayApply

SAIZEN SOLR J PA SpecialtyTier 3 MayApply

SAIZENPREP RECONSTITUTIONKIT SOLR

J PA SpecialtyTier 3 MayApply

SEROSTIM SOLR J PA SpecialtyTier 3 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

70

Drug Name DrugTier

RequirementsLimits

ZOMACTON SOLR J

PA SpecialtyMay ApplyHumaptrop Tier2 Nutropin Tier3 GenotropinTier 3

ZORBTIVE SOLR J PA SpecialtyTier 3 MayApply

Hormone Receptor Modulators EVISTA TABS (Use Raloxifene HCl) 4 PV

OSPHENA TABS 4

raloxifene hcl tabs 1 PV

Insulin-Like Growth Factors (Somatomedins)

INCRELEX SOLN J PA SpecialtyTier 3 MayApply

LHRHGnRH Agonist Analog Pituitary

LUPANETA PACK KIT J PA SpecialtyTier 2 MayApply

LUPRON DEPOT-PED (1-MONTH) KIT J

PA SpecialtyTier 3 MayApply

LUPRON DEPOT-PED (3-MONTH) KIT J

PA SpecialtyTier 3 MayApply

SYNAREL SOLN 3

Metabolic Modifiers BUPHENYL POWD 3 GMTSP (Use Sodium Phenylbutyrate)

4 Specialty Tier 4May Apply

BUPHENYL TABS 500 MG (Use Sodium Phenylbutyrate)

4

calcitriol caps 1

CARBAGLU TABS 3 Specialty Tier 2May Apply

CARNITOR SF SOLN (Use Levocarnitine (MetabolicModifiers))

4

Drug Name DrugTier

RequirementsLimits

CARNITOR SOLN 1 GM10ML (Use Levocarnitine (MetabolicModifiers))

4

CARNITOR TABS 330 MG (Use Levocarnitine (Metabolic Modifiers))

4 RXOTC

doxercalciferol caps 4

GALAFOLD CAPS 4 PA

HECTOROL CAPS (Use Doxercalciferol) 4

KUVAN PACK 2 Specialty Tier 2May Apply

KUVAN TBSO 2 Specialty Tier 2May Apply

levocarnitine (metabolicmodifiers) soln 1 gm10ml 1

levocarnitine (metabolicmodifiers) tabs 330 mg 1 RXOTC

MYALEPT SOLR J PA SpecialtyTier 3 MayApply

ORFADIN CAPS 2 MG 5 MG 10 MG 20 MG 4 Specialty Tier 4

May Apply

ORFADIN SUSP 4 MGML 4 PA SpecialtyTier 4 MayApply

paricalcitol caps 2

RAVICTI LIQD 4 PA SpecialtyTier 4 MayApply

REVCOVI SOLN J PA SpecialtyTier 3 MayApply

ROCALTROL CAPS (Use Calcitriol) 4

SENSIPAR TABS 4

sodium phenylbutyratepowd 3 gmtsp 4 Specialty Tier 4

May Apply sodium phenylbutyrate tabs500 mg 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

71

Drug Name DrugTier

RequirementsLimits

STRENSIQ SOLN J PA SpecialtyTier 3 MayApply

XURIDEN PACK 4

ZEMPLAR CAPS (Use Paricalcitol) 4

Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCGML (Use Desmopressin Acetate)

4

DDAVP SOLN NA 001 4

DDAVP SOLN NA 001 (Use DesmopressinAcetate Spray)

4

DDAVP TABS OR 01 MG 02 MG (Use Desmopressin Acetate)

4

desmopressin acetate solnij 4 mcgml 3

desmopressin acetatespray refrigerated soln 3

desmopressin acetatespray soln 3

desmopressin acetate tabsor 01 mg 02 mg 2

NOCDURNA SUBL 4 PA

STIMATE SOLN 4

VASOPRESSINDEXTROSE SOLN 4 PA

Prolactin Inhibitors cabergoline tabs 2

Somatostatic Agents

octreotide acetate soln J

PA SpecialtyMay ApplyBrand Tier 2 Generic Tier 1

SANDOSTATIN SOLN (Use Octreotide Acetate) J

PA SpecialtyMay ApplyBrand Tier 2 Generic Tier 1

Drug Name DrugTier

RequirementsLimits

SIGNIFOR SOLN J PA SpecialtyTier 4 MayApply

SOMATULINE DEPOT SOLN 120 MG05ML J

PA SpecialtyMay ApplyBrand Tier 4 Generic Tier 1

SOMATULINE DEPOT SOLN 60 MG02ML 90MG03ML

J PA SpecialtyTier 2 MayApply

Vasopressin Receptor Antagonists

SAMSCA TABS 3

Specialty Tier 2MayApplyQL(1 eadaily)

ESTROGENS - Hormone ReplacementModifyingDrugs Estrogen Combinations ACTIVELLA TABS (Use Estradiol amp Norethindrone Acetate)

4

ANGELIQ TABS 4

CLIMARA PRO PTWK 2

QL(4 ea per 30days retail12ea per 90 daysmail)

COMBIPATCH PTTW 4

DUAVEE TABS 4

esterified estrogens ampmethyltestosterone tabs0625mg-125mg

1

esterified estrogens ampmethyltestosterone tabs125mg-25mg

2

estradiol amp norethindrone acetate tabs 1

FEMHRT LOW DOSE TABS (Use Norethindrone Acetate-Ethinyl Estradiol)

4

norethindrone acetate-ethinyl estradiol tabs 1

PREFEST TABS 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

72

Drug Name DrugTier

RequirementsLimits

PREMPHASE TABS 2 QL(1 ea daily)

PREMPRO TABS 2 QL(1 ea daily)

Estrogens

ALORA PTTW 4

QL(8 ea per 28days retail24ea per 84 daysmail)

CLIMARA PTWK (Use Estradiol) 4

QL(8 ea per 28days retail24ea per 84 daysmail)

DIVIGEL GEL 4

ELESTRIN GEL 4

ESTRACE TABS OR 05 MG 1 MG 2 MG (Use Estradiol)

4

estradiol pttw td 00375mg24hr 0025 mg24hr0075 mg24hr 005mg24hr 01 mg24hr

1

QL(8 ea per 28days retail24ea per 84 daysmail)

estradiol ptwk td 0025mg24hr 0075 mg24hr005 mg24hr 006mg24hr 01 mg24hr 375mcg24hr

1

QL(8 ea per 28days retail24ea per 84 daysmail)

estradiol tabs or 05 mg 1mg 2 mg 1

ESTROGEL GEL 4

ESTROPIPATE TABS 075 MG 15 MG 4

estropipate tabs 3 mg 1

EVAMIST SOLN 4

MENEST TABS 4

MENOSTAR PTWK 4

QL(8 ea per 28days retail24ea per 84 daysmail)

Drug Name DrugTier

RequirementsLimits

MINIVELLE PTTW (Use Estradiol) 4

QL(8 ea per 28days retail24ea per 84 daysmail)

PREMARIN TABS OR 0625 MG 045 MG 03 MG 09 MG 125 MG

2

VIVELLE-DOT PTTW (Use Estradiol) 4

QL(8 ea per 28days retail24ea per 84 daysmail)

FLUOROQUINOLONES - Drugs to Treat BacterialInfections Fluoroquinolones AVELOX ABC PACK TABS (Use Moxifloxacin HCl) 4

AVELOX TABS (Use Moxifloxacin HCl) 4

CIPRO SUSR 5 GM100ML 4

CIPRO SUSR 500 MG5ML(Use Ciprofloxacin) 4

CIPRO TABS 250 MG 500 MG (Use CiprofloxacinHCl)

4

CIPRO XR TB24 (Use Ciprofloxacin-CiprofloxacinHCl)

4

QL(14 ea per30 daysretail42 ea per90 days mail)

CIPROFLOXACIN ER TB24 4

QL(14 ea per30 daysretail42 ea per90 days mail)

CIPROFLOXACIN HCL TABS 100 MG 4

ciprofloxacin hcl tabs 250mg 500 mg 750 mg 1

ciprofloxacin susr 4

FACTIVE TABS 4 PA QL(7 eaper 30 daysretail)

LEVAQUIN TABS (Use Levofloxacin) 4 QL(14 ea per

fill retail)

levofloxacin soln 25 mgml 1

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

73

Drug Name DrugTier

RequirementsLimits

levofloxacin tabs 250 mg500 mg 750 mg 1 QL(14 ea per

fill retail)

moxifloxacin hcl tabs 2

OFLOXACIN TABS 300 MG 2

ofloxacin tabs 400 mg 3

GASTROINTESTINAL AGENTS - MISC -Miscellaneous Gastrointestinal Drugs Agents for Chronic Idiopathic Constipation (CIC) TRULANCE TABS 4 PA

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS 4 PA SpecialtyTier 3 MayApply

Farnesoid X Receptor (FXR) Agonists OCALIVA TABS 4 PA

Gallstone Solubilizing Agents ACTIGALL CAPS (Use Ursodiol) 4

CHENODAL TABS 4 PA

URSO 250 TABS (Use Ursodiol) 4

URSO FORTE TABS (Use Ursodiol) 4

ursodiol caps 3

ursodiol tabs 3

Gastrointestinal Antiallergy Agents cromolyn sodium(mastocytosis) conc 1

GASTROCROM CONC (Use Cromolyn Sodium(Mastocytosis))

4

Gastrointestinal Chloride Channel Activators AMITIZA CAPS 3

Gastrointestinal Stimulants metoclopramide hcl soln 1

Drug Name DrugTier

RequirementsLimits

metoclopramide hcl tabs 1

METOCLOPRAMIDE ODT TBDP 4

REGLAN TABS (Use Metoclopramide HCl) 4

Inflammatory Bowel Agents APRISO CP24 4 PA

ASACOL HD TBEC 4 PA

ASACOL HD TBEC (Use Mesalamine) 4 PA

AZULFIDINE EN-TABS TBEC (Use Sulfasalazine) 4

AZULFIDINE TABS (Use Sulfasalazine) 4

balsalazide disodium caps 1

CANASA SUPP 3

CIMZIA KIT J PA SpecialtyTier 3 MayApply

CIMZIA STARTER KIT KIT J PA SpecialtyTier 3 MayApply

COLAZAL CAPS (Use Balsalazide Disodium) 4

DELZICOL CPDR 4 PA

DIPENTUM CAPS 4

GIAZO TABS 4 PA QL(6 eadaily)

LIALDA TBEC (Use Mesalamine) 3

mesalamine enem 3

mesalamine tbec 3

PENTASA CPCR 4 PA

REMICADE SOLR J PA SpecialtyTier 2 MayApply

SFROWASA ENEM 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

74

Drug Name DrugTier

RequirementsLimits

sulfasalazine tabs 1

sulfasalazine tbec 1

Intestinal Acidifiers lactulose (encephalopathy)soln 1

Irritable Bowel Syndrome (IBS) Agents alosetron hcl tabs 4

LINZESS CAPS 3

LOTRONEX TABS (Use Alosetron HCl) 4

VIBERZI TABS 4 PA SpecialtyTier 3 MayApply

Peripheral Opioid Receptor Antagonists ENTEREG CAPS 3

MOVANTIK TABS 4

RELISTOR SOLN SC 8 MG04ML 12 MG06ML J

PA SpecialtyTier 3 MayApply

RELISTOR TABS OR 150 MG 4

PA SpecialtyTier 3 MayApply

Phosphate Binder Agents AURYXIA TABS 4 PA

calcium acetate (phosphatebinder) caps 1

calcium acetate (phosphatebinder) tabs 1 RXOTC

ELIPHOS TABS (Use Calcium Acetate (Phosphate Binder))

4 RXOTC

FOSRENOL CHEW 500 MG 750 MG 1000 MG (Use Lanthanum Carbonate)

4

FOSRENOL PACK 750 MG 1000 MG 4

lanthanum carbonate chew 4

Drug Name DrugTier

RequirementsLimits

PHOSLYRA SOLN 4

RENAGEL TABS 4 PA

RENVELA PACK (Use Sevelamer Carbonate) 4

RENVELA TABS (Use Sevelamer Carbonate) 4

sevelamer carbonate pack 4

sevelamer carbonate tabs 4

VELPHORO CHEW 4 PA

Short Bowel Syndrome (SBS) Agents

GATTEX KIT J PA SpecialtyTier 4 MayApply

GENERAL ANESTHETICS

Anesthetics - Misc KETAMINE HYDROCHLORIDE SOSY 4 PA

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System Acidifiers K-PHOS NO 2 TABS 4

Alkalinizers ORACIT SOLN 2

pot amp sod citrates wcitricac soln 1

pot amp sod citrates wcitric ac syrp 1

potassium citrate(alkalinizer) tbcr 15 meq 4

potassium citrate(alkalinizer) tbcr 540 mg1080 mg

1

potassium citrate-citric acidpack 3300mg-1002mg 2

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Arizona 4-Tier Drug List Updated January 1 2019

75

Drug Name DrugTier

RequirementsLimits

potassium citrate-citric acidsoln 1100mg5ml-334mg5ml 1100mg5ml-1100mg5ml-334mg5ml-334mg5ml

1

RXOTC

POTASSIUM CITRATESODIUMCITRATECITRIC ACID SOLN

4

SHOHLS SOLUTION MODIFIED SOLN (Use Sodium Citrate amp Citric Acid)

4

RXOTC

sodium citrate amp citric acid soln 1 RXOTC

TRICITRATES SOLN 4

UROCIT-K 10 TBCR (Use Potassium Citrate (Alkalinizer))

4

UROCIT-K 15 TBCR (Use Potassium Citrate (Alkalinizer))

4

UROCIT-K 5 TBCR (Use Potassium Citrate (Alkalinizer))

4

Cystinosis Agents CYSTAGON CAPS 4

PROCYSBI CPDR 4

Genitourinary Irrigants sodium chloride (guirrigant) soln 1

Interstitial Cystitis Agents ELMIRON CAPS 4 QL(3 ea daily)

Prostatic Hypertrophy Agents alfuzosin hcl tb24 1

AVODART CAPS (Use Dutasteride) 4 AL(At least 40

yrs old)

CARDURA XL TB24 4

dutasteride caps 1 AL(At least 40yrs old)

Drug Name DrugTier

RequirementsLimits

dutasteride-tamsulosin hcl caps 2

finasteride tabs 2 AL(At least 40yrs old)

FLOMAX CAPS (Use Tamsulosin HCl) 4

JALYN CAPS (Use Dutasteride-Tamsulosin HCl)

4

PROSCAR TABS (Use Finasteride) 4 AL(At least 40

yrs old)

RAPAFLO CAPS 4 MG 4

RAPAFLO CAPS 4 MG 8 MG (Use Silodosin) 4

silodosin caps 4

tamsulosin hcl caps 1

UROXATRAL TB24 (Use Alfuzosin HCl) 4

Urinary Analgesics phenazopyridine hcl tabs 1

PYRIDIUM TABS (Use Phenazopyridine HCl) 4

Urinary Stone Agents LITHOSTAT TABS 4

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w probenecidtabs 2

Gout Agents allopurinol tabs 1

COLCHICINE CAPS 4

COLCHICINE TABS 4 PA

colchicine tabs 4

COLCRYS TABS 4

MITIGARE CAPS 4

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Arizona 4-Tier Drug List Updated January 1 2019

76

Drug Name DrugTier

RequirementsLimits

ULORIC TABS 3

ZURAMPIC TABS 4 PA

ZYLOPRIM TABS (Use Allopurinol) 4

Uricosurics probenecid tabs 1

HEMATOLOGICAL AGENTS - MISC - Drugs toTreat Blood Disorders Antihemophilic Products ADVATE SOLR 250 UNIT 500 UNIT 1000 UNIT 1500 UNIT 2000 UNIT 3000 UNIT

J

PA SpecialtyTier 4 MayApply

ADVATE SOLR 4000 UNIT J PA

ALPHANATEVONWILLEBRANDFACTOR COMPLEXHUMAN SOLR2000 UNIT

J

PA

ALPHANATEVONWILLEBRANDFACTOR COMPLEXHUMAN SOLR250 UNIT 500 UNIT 1000 UNIT 1500 UNIT

J

PA SpecialtyTier 4 MayApply

ALPHANINE SD SOLR J PA SpecialtyTier 4 MayApply

ALPROLIX SOLR J PA

BEBULIN SOLR J PA SpecialtyTier 4 MayApply

BENEFIX KIT J PA SpecialtyTier 4 MayApply

CORIFACT KIT J PA

ELOCTATE SOLR J PA SpecialtyTier 4 MayApply

FEIBA SOLR J PA SpecialtyTier 4 MayApply

Drug Name DrugTier

RequirementsLimits

HELIXATE FS KIT 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

HELIXATE FS KIT 3000 UNIT J PA

HEMOFIL M SOLR J PA SpecialtyTier 4 MayApply

HUMATE-P SOLR J PA SpecialtyTier 4 MayApply

IDELVION SOLR J PA

IXINITY SOLR 250 UNIT 500 UNIT 1000 UNIT 1500 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

IXINITY SOLR 3000 UNIT J PA

KOATE SOLR J PA SpecialtyTier 4 MayApply

KOATE-DVI SOLR J PA SpecialtyTier 4 MayApply

KOGENATE FS BIO-SET KIT 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

KOGENATE FS BIO-SET KIT 3000 UNIT J PA

KOGENATE FS KIT 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

KOGENATE FS KIT 3000 UNIT J PA

KOVALTRY SOLR 2000 UNIT 3000 UNIT J PA

KOVALTRY SOLR 250 UNIT 500 UNIT 1000 UNIT

J PA SpecialtyTier 4 MayApply

MONOCLATE-P KIT J PA SpecialtyTier 4 MayApply

MONONINE SOLR J PA SpecialtyTier 4 MayApply

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

77

Drug Name DrugTier

RequirementsLimits

NOVOEIGHT SOLR 1500 UNIT 2000 UNIT 3000 UNIT

J PA

NOVOEIGHT SOLR 250 UNIT 500 UNIT 1000 UNIT

J PA SpecialtyTier 4 MayApply

NOVOSEVEN RT SOLR J PA

OBIZUR SOLR J PA SpecialtyTier 4 MayApply

PROFILNINE SD SOLR 1000 UNIT J PA

PROFILNINE SD SOLR 500 UNIT 1500 UNIT J

PA SpecialtyTier 4 MayApply

PROFILNINE SOLR 1000 UNIT J PA

PROFILNINE SOLR 500 UNIT 1500 UNIT J

PA SpecialtyTier 4 MayApply

RECOMBINATE SOLR J PA SpecialtyTier 4 MayApply

RIXUBIS SOLR 250 UNIT 500 UNIT 1000 UNIT 2000 UNIT

J PA SpecialtyTier 4 MayApply

RIXUBIS SOLR 3000 UNIT J PA

WILATE KIT J PA SpecialtyTier 4 MayApply

XYNTHA KIT J PA

XYNTHA SOLOFUSE KIT J PA

Bradykinin B2 Receptor Antagonists

FIRAZYR SOLN J Specialty Tier 2May Apply

Complement Inhibitors

CINRYZE SOLR J PA SpecialtyTier 3 MayApply

RUCONEST SOLR J PA

Hematorheologic Agents

Drug Name DrugTier

RequirementsLimits

pentoxifylline tbcr 2

Plasma Proteins ALBUMINEX SOLN 4 PA

Platelet Aggregation Inhibitors AGGRENOX CP12 (Use Aspirin-Dipyridamole) 4

AGRYLIN CAPS (Use Anagrelide HCl) 4

anagrelide hcl caps 3

aspirin-dipyridamole cp12 4

BRILINTA TABS 3

cilostazol tabs 100 mg 2

cilostazol tabs 50 mg 1

clopidogrel bisulfate tabs300 mg 2

clopidogrel bisulfate tabs75 mg 2 QL(1 ea daily)

dipyridamole tabs 1

EFFIENT TABS (Use Prasugrel HCl) 4

PLAVIX TABS 300 MG (Use Clopidogrel Bisulfate) 4

PLAVIX TABS 75 MG (Use Clopidogrel Bisulfate) 4 QL(1 ea daily)

prasugrel hcl tabs 2

ZONTIVITY TABS 3

Protamine PROTAMINE SULFATE SOLN 3

Thrombolytic Enzymes ACTIVASE SOLR 3

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders Agents for Gaucher Disease

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Arizona 4-Tier Drug List Updated January 1 2019

78

Drug Name DrugTier

RequirementsLimits

CERDELGA CAPS 4 PA SpecialtyTier 3 MayApply

miglustat caps 3 PA SpecialtyTier 4 MayApply

ZAVESCA CAPS (Use Miglustat) 3

PA SpecialtyTier 4 MayApply

Agents for Sickle Cell Anemia DROXIA CAPS 2

SIKLOS TABS 4 PA

Cobalamins

cyanocobalamin soln J PA SpecialtyTier 1 MayApply

NASCOBAL SOLN 4

Folic AcidFolates folic acid tabs 1 RXOTC

Hematopoietic Growth Factors ARANESP ALBUMIN FREE SOLN 25 MCGML40 MCGML 60 MCGML100 MCGML 200MCGML 300 MCGML

J

PA SpecialtyTier 3 MayApply

ARANESP ALBUMIN FREE SOSY 10 MCG04ML

J PA

ARANESP ALBUMIN FREE SOSY 500 MCGML40 MCG04ML 60MCG03ML 100MCG05ML 150MCG03ML 200MCG04ML 25MCG042ML 300MCG06ML

J

PA SpecialtyTier 3 MayApply

EPOGEN SOLN J

PA SpecialtyMay ApplyProcrit Tier 2 Epogen Tier 3

FULPHILA SOSY 4 PA

Drug Name DrugTier

RequirementsLimits

GRANIX SOSY J PA SpecialtyTier 3 MayApply

LEUKINE SOLR J PA SpecialtyTier 3 List MayApply

MIRCERA SOSY J PA SpecialtyTier 3 MayApply

MULPLETA TABS 4 PA

NEULASTA ONPRO KIT PSKT J

PA SpecialtyTier 3 MayApply

NEULASTA SOSY J PA SpecialtyTier 3 MayApply

NEUPOGEN SOLN J PA SpecialtyTier 3 MayApply

NEUPOGEN SOSY J PA SpecialtyTier 3 MayApply

NIVESTYM SOSY 4 PA

PROCRIT SOLN 2000 UNITML 3000 UNITML4000 UNITML 10000UNITML 20000 UNITML40000 UNITML

J

PA SpecialtyMay ApplyProcrit Tier 2 Epogen Tier 3

PROMACTA TABS 25 MG 50 MG 125 MG 4 PA

PROMACTA TABS 75 MG 4 PA SpecialtyTier 2 MayApply

UDENYCA SOSY 4 PA

ZARXIO SOSY J PA SpecialtyTier 3 MayApply

Hematopoietic Mixtures ferrous fumarate-folic acid tabs 1

Stem Cell Mobilizers MOZOBIL SOLN J PA

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Arizona 4-Tier Drug List Updated January 1 2019

79

Drug Name DrugTier

RequirementsLimits

HEMOSTATICS - Drugs to Stop BleedingTreatBlood Disorders Hemostatics - Systemic AMICAR SOLN 025 GMML 4

AMICAR TABS 500 MG 1000 MG (Use Aminocaproic Acid)

4

aminocaproic acid tabs1000 mg 4 PA

aminocaproic acid tabs 500 mg 3

LYSTEDA TABS (Use Tranexamic Acid) 4

QL(30 ea per30 daysretail90 ea per90 days mail)

tranexamic acid tabs 1

QL(30 ea per30 daysretail90 ea per90 days mail)

HYPNOTICSSEDATIVESSLEEP DISORDERAGENTS Barbiturate Hypnotics BUTISOL SODIUM TABS 4

phenobarbital elix 1

phenobarbital soln 1

phenobarbital tabs 1

SECONAL SODIUM CAPS 4

Hypnotics - Tricyclic Agents

SILENOR TABS 4 ST QL(1 eadaily)

Non-Barbiturate Hypnotics AMBIEN CR TBCR (Use Zolpidem Tartrate) 4 QL(1 ea daily)

AMBIEN TABS (Use Zolpidem Tartrate) 4 QL(1 ea daily)

DORAL TABS 4

EDLUAR SUBL 4 PA

Drug Name DrugTier

RequirementsLimits

estazolam tabs 1

eszopiclone tabs 4 QL(1 ea daily)

FLURAZEPAM HCL CAPS 15 MG 4

flurazepam hcl caps 30 mg 1

HALCION TABS (Use Triazolam) 4

INTERMEZZO SUBL (Use Zolpidem Tartrate) 4 PA

LUNESTA TABS (Use Eszopiclone) 4 QL(1 ea daily)

midazolam hcl syrp 1

MIDAZOLAMSODIUMCHLORIDE SOLN 4 PA

QUAZEPAM TABS 4

RESTORIL CAPS (Use Temazepam) 4

SONATA CAPS (Use Zaleplon) 4 QL(1 ea daily)

temazepam caps 1

triazolam tabs 1

zaleplon caps 1 QL(1 ea daily)

zolpidem tartrate subl sl 35mg 175 mg 4 PA

zolpidem tartrate tabs or 5mg 10 mg 1 QL(1 ea daily)

zolpidem tartrate tbcr or125 mg 625 mg 4 QL(1 ea daily)

ZOLPIMIST SOLN 4

ST Limit 1 bottle permonthQL(026ml daily)

Orexin Receptor Antagonists

BELSOMRA TABS 3 ST QL(1 eadaily)

Selective Melatonin Receptor Agonists

HETLIOZ CAPS 4 PA SpecialtyTier 3 MayApply

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Arizona 4-Tier Drug List Updated January 1 2019

80

Drug Name DrugTier

RequirementsLimits

ROZEREM TABS 4 ST QL(1 eadaily)

LAXATIVES - Bowel Treatment Drugs

Laxative Combinations bisacodyl-peg 3350-potchloride-sod bicarb-sod chloride kit

4 AL(At least 50yrs old - Up to74 yrs old) PV

COLYTE-FLAVOR PACKS SOLR (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

4

AL(At least 50yrs old - Up to74 yrs old) PV

GOLYTELY SOLR 2271GM-215GM-553GM-282GM-636GM

4

PA AL(At least50 yrs old - Upto 74 yrs old)PV

GOLYTELY SOLR 236GM-2274GM-586GM-297GM-674GM (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

4

AL(At least 50yrs old - Up to74 yrs old) PV

MOVIPREP SOLR 4 AL(At least 50yrs old - Up to74 yrs old) PV

NULYTELYFLAVORPACKS SOLR (Use PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)

4

AL(At least 50yrs old - Up to74 yrs old) PV

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

2

AL(At least 50yrs old - Up to74 yrs old) PV

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr 240gm-2272gm-584gm-298gm-672gm

1

AL(At least 50yrs old - Up to74 yrs old) PV

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

1 AL(At least 50yrs old - Up to74 yrs old) PV

PLENVU SOLR 4 PA

PREPOPIK PACK 4

PA AL(At least50 yrs old - Upto 74 yrs old)PV

Drug Name DrugTier

RequirementsLimits

SUPREP BOWEL PREP KIT SOLN 4

AL(At least 50yrs old - Up to74 yrs old) PV

Laxatives - Miscellaneous KRISTALOSE PACK 10 GM (Use Lactulose) 3

KRISTALOSE PACK 20 GM 2

lactulose pack 1

lactulose soln 1

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing Local Anesthetics - Amides BUPIVACAINE HYDROCHLORIDE SOSY 4 PA

BUPIVACAINE HYDROCHLORIDEDEXTROSE SOSY

4 PA

EXPAREL SUSP 4 PA

ROPIVACAINE HYDROCHLORIDESODIUM CHLORIDE SOLN

4 PA

MACROLIDES - Drugs to Treat BacterialInfections Azithromycin azithromycin pack 1 gm 1

azithromycin susr 100mg5ml 200 mg5ml 2

azithromycin tabs 250 mg500 mg 600 mg 2

ZITHROMAX PACK (Use Azithromycin) 4

ZITHROMAX SUSR (Use Azithromycin) 4

ZITHROMAX TABS (Use Azithromycin) 4

ZITHROMAX TRI-PAK TABS (Use Azithromycin) 4

ZITHROMAX Z-PAK TABS (Use Azithromycin) 4

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Arizona 4-Tier Drug List Updated January 1 2019

81

Drug Name DrugTier

RequirementsLimits

ZMAX SUSR 4 PA QL(1 eadaily)

Clarithromycin BIAXIN TABS (Use Clarithromycin) 4

CLARITHROMYCIN SUSR 125 MG5ML 250 MG5ML 4

clarithromycin susr 125mg5ml 250 mg5ml 2

clarithromycin tabs 250 mg500 mg 1

clarithromycin tb24 500 mg 2

Erythromycins EES GRANULES SUSR (Use ErythromycinEthylsuccinate)

4

ERY-TAB TBEC 4

ERYPED 200 SUSR (Use ErythromycinEthylsuccinate)

4

ERYPED 400 SUSR 4

ERYTHROCIN STEARATE TABS 4

erythromycin base cpep 1

erythromycin base tabs 1

erythromycinethylsuccinate susr 200mg5ml

4

erythromycinethylsuccinate tabs 400 mg 1

PCE TBEC 3

Fidaxomicin DIFICID TABS 4

MEDICAL DEVICES AND SUPPLIES

Contraceptives CAYA DPRH 2 PV

Drug Name DrugTier

RequirementsLimits

FEMCAP DEVI 3 PV

FEMCAP DEVI 4 PV

OMNIFLEX DIAPHRAGM DPRH 2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 60 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 65 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 70 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 75 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 80 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 85 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 90 DPRH

2 PV

WIDE-SEAL SILICONE DIAPHRAGM KIT 95 DPRH

2 PV

Diabetic Supplies EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI

4 PA

EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT

4 PA RXOTC

FREESTYLE LIBRE 14 DAYREADERFLASHMONITORING SYSTEM DEVI

4

PA

FREESTYLE PRECISION NEO BLOOD GLUCOSE MONITORING SYSTEM KIT

2

RXOTC

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

82

Drug Name DrugTier

RequirementsLimits

GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC DEVI

3

QL(0002 eadaily) B NT

HW EMBRACE PRO BLOOD GLUCOSE METER DEVI

4 PA

HW EMBRACE TALK BLOOD GLUCOSE MONITOR DEVI

4 PA

HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM KIT

4

PA RXOTC

LANCETS AND LANCET DEVICES 2

PRO VOICE V8 BLOOD GLUCOSE MONITORING SYSTEM DEVI

4 PA

PRO VOICE V9 BLOOD GLUCOSE MONITORING SYSTEM DEVI

4 PA

Parenteral Therapy Supplies AUTOPEN DEVI 4 RXOTC

BD PEN MINI MISC 4 RXOTC

BD PEN MISC 4 RXOTC

HUMAPEN LUXURA HD DEVI 4 RXOTC

INPEN 100BLUELILLYDEVI 4 RXOTC

INPEN 100BLUENOVODEVI 4 RXOTC

INPEN 100GRAYLILLYDEVI 4 RXOTC

INPEN 100GREYNOVODEVI 4 RXOTC

INPEN 100PINKLILLYDEVI 4 RXOTC

INPEN 100PINKNOVODEVI 4 RXOTC

INSULIN SYRINGES AND PEN NEEDLES 2

Drug Name DrugTier

RequirementsLimits

KMART VALU PLUS INSULIN SYRINGE03ML30GMISC

2

KMART VALU PLUS INSULIN SYRINGE05ML29GMISC

2

KMART VALU PLUS INSULIN SYRINGE05ML30GMISC

2

NOVOPEN ECHO DEVI 4 RXOTC

Respiratory Therapy Supplies NASONEB NASAL NEBULIZER REPLACEMENT MISC

3 RXOTC

NASONEB NASAL NEBULIZER STARTER KIT MISC

3 RXOTC

PARI SINUSTAR NASAL AEROSOL DELIVERY SYSTEM MISC

3 RXOTC

PARI SINUSTAR NASAL NEBULIZER MISC 3 RXOTC

SPACERAEROSOL-HOLDING CHAMBER 2

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches Migraine Combinations CAFERGOT TABS (Use Ergotamine w Caffeine) 4

ergotamine w caffeine tabs 2

ISOMETHEPTENE MUCATECAFFEINEACETAMINOPHEN TABS

4

isometheptene-caffeine-acetaminophen tabs 2

isometheptene-dichloralphenazone-acetaminophen caps

1

ISOMETHEPTENEDICHLORALPHENAZONEACETAMINOPHEN CAPS

4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

83

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

QL(12 ea per30 daysretail36 ea per90 days mail)

PRODRIN TABS (Use Isometheptene-Caffeine-Acetaminophen)

4

sumatriptan-naproxensodium tabs 4

PA QL(9 eaper fill retail27ea per fill mail9ea per 30 daysretail27 ea per90 days mail)

TREXIMET TABS (Use Sumatriptan-NaproxenSodium)

4

PA QL(9 eaper fill retail27ea per fill mail9ea per 30 daysretail27 ea per90 days mail)

Migraine Products - NSAIDs

CAMBIA PACK 4 PA Limit 9 permonthQL(03ea daily)

Migraine Products DHE 45 SOLN (Use DihydroergotamineMesylate)

J PA SpecialtyTier 1 MayApply

dihydroergotaminemesylate soln ij 1 mgml J

PA SpecialtyTier 1 MayApply

dihydroergotaminemesylate soln na 4 mgml 4

ERGOMAR SUBL 4

MIGRANAL SOLN 4

Serotonin Agonists

almotriptan malate tabs 3

QL(6 ea per 30days retail18ea per 90 daysmail)

AMERGE TABS (Use Naratriptan HCl) 4

QL(9 ea per 30days retail27ea per 90 daysmail)

Drug Name DrugTier

RequirementsLimits

AXERT TABS (Use Almotriptan Malate) 4

QL(6 ea per 30days retail18ea per 90 daysmail)

eletriptan hydrobromidetabs 4

QL(6 ea per fillretail6 ea per30 daysretail18 ea per90 days mail)

FROVA TABS (Use Frovatriptan Succinate) 4

QL(9 ea per 30days retail18ea per 90 daysmail)

frovatriptan succinate tabs 4

QL(9 ea per 30days retail18ea per 90 daysmail)

IMITREX SOLN NA 5 MGACT 20 MGACT (Use Sumatriptan)

4

Limit 6 sprays permonthQL(023ea daily)

IMITREX SOLN SC 6 MG05ML (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

IMITREX STATDOSE REFILL SOCT (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

IMITREX STATDOSE SYSTEM SOAJ 4 MG05ML (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

IMITREX STATDOSE SYSTEM SOAJ 6 MG05ML (Use Sumatriptan Succinate)

J

PA SpecialtyTier 1 MayApplyQL(3 mlper 30 daysretail)

IMITREX TABS OR 25 MG 50 MG 100 MG (Use Sumatriptan Succinate)

4 QL(035 eadaily)

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

84

Drug Name DrugTier

RequirementsLimits

MAXALT TABS (Use Rizatriptan Benzoate) 4

QL(9 ea per 30days retail27ea per 90 daysmail)

MAXALT-MLT TBDP (Use Rizatriptan Benzoate) 4

QL(9 ea per 30days retail27ea per 90 daysmail)

naratriptan hcl tabs 3

QL(9 ea per 30days retail27ea per 90 daysmail)

ONZETRA XSAIL EXHP 4 PA

RELPAX TABS (Use Eletriptan Hydrobromide) 4

QL(6 ea per fillretail6 ea per30 daysretail18 ea per90 days mail)

rizatriptan benzoate tabs 2

QL(9 ea per 30days retail27ea per 90 daysmail)

rizatriptan benzoate tbdp 2

QL(9 ea per 30days retail27ea per 90 daysmail)

sumatriptan soln 2

Limit 6 sprays permonthQL(023ea daily)

sumatriptan succinate soajsc 4 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

sumatriptan succinate soajsc 6 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper 30 daysretail)

sumatriptan succinate soctsc 4 mg05ml 6 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

Drug Name DrugTier

RequirementsLimits

sumatriptan succinate solnsc 6 mg05ml J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

SUMATRIPTAN SUCCINATE SOSY SC 6 MG05ML

J

PA SpecialtyTier 1 MayApplyQL(3 mlper fill retail3ml per 30 daysretail)

sumatriptan succinate tabsor 25 mg 50 mg 100 mg 2 QL(035 ea

daily)

SUMAVEL DOSEPRO SOTJ J

PA SpecialtyTier 3 MayApply

ZEMBRACE SYMTOUCH SOAJ J PA

zolmitriptan tabs 4

QL(6 ea per 30days retail18ea per 90 daysmail)

zolmitriptan tbdp 4

QL(6 ea per 30days retail18ea per 90 daysmail)

ZOMIG SOLN NA 5 MG 25 MG 4

QL(6 ea per 30days retail18ea per 90 daysmail)

ZOMIG TABS OR 5 MG 25 MG (Use Zolmitriptan) 4

QL(6 ea per 30days retail18ea per 90 daysmail)

ZOMIG ZMT TBDP (Use Zolmitriptan) 4

QL(6 ea per 30days retail18ea per 90 daysmail)

MINERALS amp ELECTROLYTES

Calcium CALCIUM GLUCONATE SOSY 4 PA

Electrolyte Mixtures IONOSOL-BDEXTROSE5 SOLN 3

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

85

Drug Name DrugTier

RequirementsLimits

IONOSOL-MBDEXTROSE5 SOLN 3

ISOLYTE-PDEXTROSE5 SOLN 3

ISOLYTE-S PH 74 SOLN 3

ISOLYTE-S SOLN 3

KCL 03D5WNACL09 SOLN 3

NORMOSOL -R SOLN 3

NORMOSOL-M IN D5W SOLN 3

NORMOSOL-R IN D5W SOLN 3

NORMOSOL-R SOLN 3

PLASMA-LYTE A SOLN 3

PLASMA-LYTE-148 SOLN 3

PLASMA-LYTE-56D5WSOLN 3

potassium chloride indextrose amp sodium chloride soln

3

Fluoride FLUORABON SOLN 4 PV

LOZI-FLUR LOZG 2

LURIDE SOLN (Use Sodium Fluoride) 4 PV

sodium fluoride chew 025 mg 05 mg 1 mg 22 mg 1 PV

sodium fluoride soln 0125 mgdrop 3 PV

sodium fluoride soln 025 mgdrop 05 mgml 1 PV

SODIUM FLUORIDE TABS 05 MG 4 PV

sodium fluoride tabs 1 mg 1

Iodine Products IODINE STRONG SOLN 3

Drug Name DrugTier

RequirementsLimits

Magnesium MAGNEBIND 400 TABS 3

Phosphate K-PHOS NEUTRAL TABS (Use Pot PhosphateMonobasic w SodPhosphate Dibasic ampMonobasic)

4

K-PHOS TABS 3

pot phosphate monobasicw sod phosphate dibasic ampmonobasic tabs

2

POTASSIUM PHOSPHATESDEXTROSE SOLN

4 PA

POTASSIUM PHOSPHATESSODIUMCHLORIDE SOLN

4 PA

SODIUM PHOSPHATESODIUMCHLORIDE SOLN

4 PA

Potassium EFFER-K TBEF 3

K-BICARB CAPS 4

K-TAB TBCR 10 MEQ (Use Potassium Chloride) 4

K-TAB TBCR 20 MEQ 4

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 4

KLOR-CON25 PACK 4

MICRO-K CPCR (Use Potassium Chloride) 4

potassium bicarb amp chloridetbef 2

potassium bicarbonate tbef 1

potassium chloride cpcr or8 meq 10 meq 1

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Arizona 4-Tier Drug List Updated January 1 2019

86

Drug Name DrugTier

RequirementsLimits

POTASSIUM CHLORIDE ER TBCR 20 MEQ 4

POTASSIUM CHLORIDE ER TBCR 8 MEQ 2

potassium chloridemicroencapsulated crystalser tbcr

1

potassium chloride pack or20 meq 1

POTASSIUM CHLORIDE SOSY IV 10 MEQ5ML 4 PA

potassium chloride tbcr or8 meq 10 meq 1

Trace Minerals THE LIQUILIFT TRACE KIT KIT 4 PA

Zinc GALZIN CAPS 4

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS 3 PA

DEPEN TITRATABS TABS 4

SYPRINE CAPS (Use Trientine HCl) 4

PA SpecialtyTier 1 MayApply

trientine hcl caps 4 PA SpecialtyTier 1 MayApply

Enzymes

XIAFLEX SOLR J PA SpecialtyTier 3 MayApply

Immunomodulators REVLIMID CAPS 20 MG 25 MG 4 PA

REVLIMID CAPS 5 MG 10 MG 15 MG 25 MG 4

PA SpecialtyTier 2 MayApply

THALOMID CAPS 4 Specialty Tier 2May Apply

Immunosuppressive Agents

Drug Name DrugTier

RequirementsLimits

ASTAGRAF XL CP24 4 PA

AZASAN TABS 4

azathioprine tabs 2

CELLCEPT CAPS (Use Mycophenolate Mofetil) 4

CELLCEPT SUSR (Use Mycophenolate Mofetil) 4

CELLCEPT TABS (Use Mycophenolate Mofetil) 4

cyclosporine caps 2

cyclosporine modified (formicroemulsion) caps 25mg 100 mg

2

cyclosporine modified (formicroemulsion) caps 50 mg 1

cyclosporine modified (formicroemulsion) soln 100mgml

2

ENVARSUS XR TB24 4 ST

IMURAN TABS (Use Azathioprine) 4

mycophenolate mofetil caps 2

mycophenolate mofetil susr 2

mycophenolate mofetil tabs 2

mycophenolate sodiumtbec 1

MYFORTIC TBEC (Use Mycophenolate Sodium) 4

NEORAL CAPS (Use Cyclosporine Modified (ForMicroemulsion))

4

NEORAL SOLN (Use Cyclosporine Modified (ForMicroemulsion))

4

PROGRAF CAPS (Use Tacrolimus) 4

RAPAMUNE SOLN 1 MGML 2

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Arizona 4-Tier Drug List Updated January 1 2019

87

Drug Name DrugTier

RequirementsLimits

RAPAMUNE TABS 05 MG 1 MG 2 MG (Use Sirolimus)

4

SANDIMMUNE CAPS 25 MG 100 MG (Use Cyclosporine)

4

SANDIMMUNE SOLN 100 MGML 4

sirolimus tabs 1

tacrolimus caps 2

ZORTRESS TABS 2

Potassium Removing Agents LOKELMA PACK 4 PA

sodium polystyrenesulfonate susp or 15gm60ml

2

sodium polystyrenesulfonate susp re 30gm120ml 50 gm200ml

1

VELTASSA PACK 4 ST

MOUTHTHROATDENTAL AGENTS

Anesthetics Topical Oral FIRST-MOUTHWASH BLM SUSP 4

lidocaine hcl (mouth-throat)soln 1

LIDOCAINE HCL SOLN MT 4 3

Anti-infectives - Throat clotrimazole lozg 3

clotrimazole troc 3

nystatin (mouth-throat) susp 1

ORAVIG TABS 4

Dental Products NAFRINSE DAILYACIDULATEDSOLR

3

Drug Name DrugTier

RequirementsLimits

NAFRINSE DAILYNEUTRAL SOLR 3

Steroids - MouthThroat triamcinolone acetonide (mouth) pste 1

Throat Products - Misc cevimeline hcl caps 4

EVOXAC CAPS (Use Cevimeline HCl) 4

pilocarpine hcl (oral) tabs 2

SALAGEN TABS (Use Pilocarpine HCl (Oral)) 4

MULTIVITAMINS

Prenatal Vitamins prenatal w calciumcarbonate-vit b6-vit b12-folic acid tabs

1

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms Central Muscle Relaxants AMRIX CP24 4

baclofen tabs 10 mg 20 mg 1

BACLOFEN TABS 5 MG 4

carisoprodol tabs 250 mg 2

carisoprodol tabs 350 mg 1

CHLORZOXAZONE TABS 250 MG 2

CHLORZOXAZONE TABS 500 MG 4

cyclobenzaprine hcl tabs 1

FEXMID TABS (Use Cyclobenzaprine HCl) 3

LORZONE TABS 4

METAXALONE TABS 400 MG 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

88

Drug Name DrugTier

RequirementsLimits

metaxalone tabs 800 mg 4

methocarbamol tabs 1

orphenadrine citrate tb12 2

PARAFON FORTE DSC TABS (Use Chlorzoxazone)

4

ROBAXIN TABS (Use Methocarbamol) 4

ROBAXIN-750 TABS (Use Methocarbamol) 4

SKELAXIN TABS (Use Metaxalone) 4

SOMA TABS (Use Carisoprodol) 4

tizanidine hcl tabs 1

ZANAFLEX TABS (Use Tizanidine HCl) 4

Direct Muscle Relaxants DANTRIUM CAPS (Use Dantrolene Sodium) 4

dantrolene sodium caps 3

Muscle Relaxant Combinations carisoprodol w aspirin ampcodeine tabs 2

carisoprodol w aspirin tabs 2

CYCLOGABA10300PACK THPK 4 PA

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus Nasal Agent Combinations

DYMISTA SUSP 4

Limit 1 bottle permonthQL(077gm daily)

Nasal Agents - Misc TICASPRAY THPK 4 PA

Nasal Anti-infectives

Drug Name DrugTier

RequirementsLimits

BACTROBAN NASAL OINT 2

Nasal Antiallergy ASTEPRO SOLN (Use Azelastine HCl) 4

azelastine hcl soln 1

olopatadine hcl (nasal) soln 4

PATANASE SOLN (Use Olopatadine HCl (Nasal)) 4

Nasal Anticholinergics ipratropium bromide (nasal)soln 1

Nasal Steroids BECONASE AQ SUSP 4

budesonide (nasal) susp 2

QL(9 ml per 30days retail26ml per 90 daysmail) RXOTC

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use Fluticasone Propionate (Nasal))

4

RXOTC

FLONASE ALLERGY RELIEF SUSP (Use Fluticasone Propionate(Nasal))

4

RXOTC

FLONASE SENSIMIST SUSP 4 RXOTC

FLUNISOLIDE SOLN 4

fluticasone propionate(nasal) susp 1 RXOTC

mometasone furoate (nasal) susp 1

QL(34 gm perfill retail34 gmper 30 daysretail)

NASONEX SUSP (Use Mometasone Furoate (Nasal))

3

QL(34 gm perfill retail34 gmper 30 daysretail)

OMNARIS SUSP 4 Limit 1 permonthQL(042gm daily)

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Arizona 4-Tier Drug List Updated January 1 2019

89

Drug Name DrugTier

RequirementsLimits

QNASL AERS 4

Limit 1 inhaler permonthQL(03gm daily)

QNASL CHILDRENS AERS 4

Limit 1 inhaler permonthQL(017gm daily)

RHINOCORT AQUA SUSP (Use Budesonide (Nasal)) 4

QL(9 ml per 30days retail26ml per 90 daysmail) RXOTC

VERAMYST SUSP 4 RXOTC

ZETONNA AERS 4

Limit 1 inhaler permonthQL(03gm daily)

Sympathomimetic Decongestants ADRENALIN SOLN 4

TYZINE PEDIATRIC NASAL DROPS SOLN 3

NEUROMUSCULAR AGENTS - Drugs toRelaxParalyze Muscles ALS Agents RILUTEK TABS (Use Riluzole) 4

riluzole tabs 3

TIGLUTIK SUSP 4 PA

NUTRIENTS

Carbohydrates alcohol soln 3

Lipids OMEGAVEN EMUL 4 PA

Proteins FREAMINE HBC 69 SOLN 3

L-TRYPTOPHAN CAPS 3 RXOTC

Drug Name DrugTier

RequirementsLimits

NEPHRAMINE SOLN 3

PROCALAMINE SOLN 3

PROSOL SOLN 3

TRYPTOPHAN CAPS 3 RXOTC

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Beta-blockers - Ophthalmic BETAGAN SOLN (Use Levobunolol HCl) 4

betaxolol hcl (ophth) soln 2

BETIMOL SOLN 2

BETOPTIC-S SUSP 3

carteolol hcl (ophth) soln 2

CARTEOLOL HCL SOLN 4

COMBIGAN SOLN 4

COSOPT PF SOLN (Use Dorzolamide HCl-Timolol Maleate)

4

COSOPT SOLN (Use Dorzolamide HCl-Timolol Maleate)

4

dorzolamide hcl-timolol maleate soln 2-05223mgml-68mgml

2

dorzolamide hcl-timolol maleate soln 20mgml-5mgml

4

DORZOLAMIDE HCLTIMOLOL MALEATESOLN

4

ISTALOL SOLN 4

ISTALOL SOLN (Use Timolol Maleate (Ophth)) 4

levobunolol hcl soln 1

METIPRANOLOL SOLN 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

90

Drug Name DrugTier

RequirementsLimits

timolol maleate (ophth)solg 025 05 2

timolol maleate (ophth)soln 025 05 1

timolol maleate (ophth)soln 05 4

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG

4

TIMOLOLBRIMONIDEDORZOLAMIDE SOLN 4 PA

TIMOLOLBRIMONIDINEDORZOLAMIDELATANOPROST SOLN

4 PA

TIMOLOLDORZOLAMIDELATANOPROST SOLN 4 PA

TIMOLOLLATANOPROSTSOLN 4 PA

TIMOPTIC OCUDOSE SOLN 4

TIMOPTIC SOLN (Use Timolol Maleate (Ophth)) 4

TIMOPTIC-XE SOLG 025 (Use Timolol Maleate (Ophth))

4

TIMOPTIC-XE SOLG 025 05 4

Cycloplegic Mydriatics ATROPINE SULFATE OINT OP 1 2

ATROPINE SULFATE SOLN OP 1 4

ATROPINE SULFATESODIUMCHLORIDE SOLN

2

CYCLOGYL SOLN (Use Cyclopentolate HCl) 4

CYCLOMYDRIL SOLN 4

cyclopentolate hcl soln 05 2 4

cyclopentolate hcl soln 1 1

homatropine hbr soln 1

ISOPTO ATROPINE SOLN 4

Drug Name DrugTier

RequirementsLimits

MYDRIACYL SOLN (Use Tropicamide) 4

tropicamide soln 2

TROPICAMIDEPROPARACAINEPHENYLEPHRINEKETOROLAC SOLN

4 PA

Miotics ISOPTO CARPINE SOLN (Use Pilocarpine HCl) 4

PHOSPHOLINE IODIDE SOLR 3

pilocarpine hcl soln 1

Ophthalmic - Angiogenesis Inhibitors

LUCENTIS SOSY J PA SpecialtyTier 4 MayApply

Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 01 3

ALPHAGAN P SOLN 015 (Use Brimonidine Tartrate)

4

apraclonidine hcl soln 3

BRIMONIDEDORZOLAMIDE P-F SOLN 4 PA

brimonidine tartrate soln 2

IOPIDINE SOLN 05 (Use Apraclonidine HCl) 4

IOPIDINE SOLN 1 4

SIMBRINZA SUSP 4

Ophthalmic Anti-infectives

AZASITE SOLN 4

Limit 25mls permonthQL(018ml daily14day(s) limit)

BACITRACIN OINT 4

bacitracin-polymyxin b(ophth) oint 1

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Arizona 4-Tier Drug List Updated January 1 2019

91

Drug Name DrugTier

RequirementsLimits

BESIVANCE SUSP 4

BETADINE OPHTHALMIC PREP SOLN 4

BLEPH-10 SOLN (Use Sulfacetamide Sodium (Ophth))

4

CILOXAN OINT 4

CILOXAN SOLN (Use Ciprofloxacin HCl (Ophth)) 4

ciprofloxacin hcl (ophth)soln 2

erythromycin (ophth) oint 1

gatifloxacin (ophth) soln 1

GENTAK OINT 4

gentamicin sulfate (ophth)oint 1

gentamicin sulfate (ophth)soln 1

levofloxacin (ophth) soln 4

MOXEZA SOLN 2

moxifloxacin hcl (ophth)soln 1

NATACYN SUSP 4

neomycin-bacitracin zn-polymyxin oint 1

neomycin-polymyxin-gramicidin soln 2

NEOSPORIN SOLN (Use Neomycin-Polymyxin-Gramicidin)

4

OCUFLOX SOLN (Use Ofloxacin (Ophth)) 4 QL(5 ml per fill

retail)

ofloxacin (ophth) soln 2 QL(5 ml per fillretail)

polymyxin b-trimethoprimsoln 1

POLYTRIM SOLN (Use Polymyxin B-Trimethoprim) 4

Drug Name DrugTier

RequirementsLimits

sulfacetamide sodium (ophth) soln 1

SULFACETAMIDE SODIUM OINT 3

tobramycin (ophth) soln 1

TOBREX OINT 4

TOBREX SOLN (Use Tobramycin (Ophth)) 4

trifluridine soln 3

VIGAMOX SOLN (Use Moxifloxacin HCl (Ophth)) 3

VIROPTIC SOLN (Use Trifluridine) 4

ZIRGAN GEL 4

ZYMAXID SOLN (Use Gatifloxacin (Ophth)) 4

Ophthalmic Decongestants phenylephrine hcl (ophth)soln 1

Ophthalmic Immunomodulators CEQUA SOLN 4 PA

RESTASIS EMUL 4

RESTASIS MULTIDOSE EMUL 4

Ophthalmic Local Anesthetics AKTEN GEL 4

ALCAINE SOLN (Use Proparacaine HCl) 4

proparacaine hcl soln 2

tetracaine hcl (ophth) soln 4

Ophthalmic Nerve Growth Factors OXERVATE SOLN 4 PA

Ophthalmic Steroids ALREX SUSP 4

You can find information on what the symbols and abbreviations on this table mean by going topage ii-iii

Arizona 4-Tier Drug List Updated January 1 2019

92

Drug Name DrugTier

RequirementsLimits

bacitracin-poly-neomycin-hc oint 1

BLEPHAMIDE SOP OINT 4

BLEPHAMIDE SUSP 4

DEXAMETHASONE SODIUM PHOSPHATE SOLN

4

DUREZOL EMUL 4

FLAREX SUSP 2

fluorometholone (ophth) susp 1

FML FORTE SUSP 4 Limit 5mls permonthQL(017ml daily)

FML LIQUIFILM SUSP (Use Fluorometholone (Ophth))

4

FML OINT 4

INVELTYS SUSP 4 PA

LOTEMAX GEL 4

LOTEMAX OINT 4

LOTEMAX SUSP 4

MAXIDEX SUSP 4

MAXITROL OINT (Use Neomycin-Polymy-Dexameth)

4

MAXITROL SUSP (Use Neomycin-Polymy-Dexameth)

4

neomycin-polymy-dexameth oint 1

neomycin-polymy-dexameth susp 1

neomycin-polymyxin-hc(ophth) susp 1

OMNIPRED SUSP (Use Prednisolone Acetate (Ophth))

4

Drug Name DrugTier

RequirementsLimits

PRED FORTE SUSP (Use Prednisolone Acetate (Ophth))

4

PRED MILD SUSP 4

PRED-G SOP OINT 4

PRED-G SUSP 3

prednisolone acetate(ophth) susp 1

PREDNISOLONE ACETATE P-F SUSP 4

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1

4

PREDNISOLONE SODIUM PHOSPHATEBROMFENAC SOLN

4 PA

PREDNISOLONE SODIUM PHOSPHATEGATIFLOXACIN SOLN

4 PA

PREDNISOLONE SODIUM PHOSPHATEGATIFLOXACINBROMFENAC SOLN

4 PA

PREDNISOLONEMOXIFLOXACIN SOLN 4 PA

PREDNISOLONEMOXIFLOXACINBROMFENACSOLN

4 PA

PREDNISOLONEMOXIFLOXACINKETOROLACSOLN

4 PA

sulfacetamide sod-prednisolone soln 1

TOBRADEX OINT 4

TOBRADEX ST SUSP 4

TOBRADEX SUSP (Use Tobramycin-Dexamethasone)

4 QL(5 ml per fillretail5 ml per30 days retail)

tobramycin-dexamethasone susp 1

QL(5 ml per fillretail5 ml per30 days retail)

YUTIQ IMPL 4 PA

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Arizona 4-Tier Drug List Updated January 1 2019

93

Drug Name DrugTier

RequirementsLimits

ZYLET SUSP 4 Limit 5mls permonthQL(017ml daily)

Ophthalmics - Misc ACULAR LS SOLN (Use Ketorolac Tromethamine (Ophth))

4

ACULAR SOLN (Use Ketorolac Tromethamine (Ophth))

4

ACUVAIL SOLN 4

ALOCRIL SOLN 4

ALOMIDE SOLN 3

azelastine hcl (ophth) soln 2

AZOPT SUSP 2

BEPREVE SOLN 4

ST Limit 10 permonthQL(034ml daily)

bromfenac sodium (ophth)soln 1

BROMFENAC SOLN 4

CHONDROITIN SULFATE SOLN 4 PA

cromolyn sodium (ophth)soln 2

CYSTARAN SOLN 4 Limit 30mls permonthQL(133ml daily)

diclofenac sodium (ophth)soln 2

DORZOLAMIDE HCL SOLN 4

dorzolamide hcl soln 1

ELESTAT SOLN (Use Epinastine HCl (Ophth)) 4

EMADINE SOLN 4

epinastine hcl (ophth) soln 2

Drug Name DrugTier

RequirementsLimits

fluorescein sodium topical strp 3

fluorescein w benoxinatesoln 3

fluorescein w proparacainesoln 3

flurbiprofen sodium soln 2

FUL-GLO STRP 3

ILEVRO SUSP 4

ketorolac tromethamine (ophth) soln 3

LASTACAFT SOLN 4 ST

NEVANAC SUSP 4

OCUFEN SOLN (Use Flurbiprofen Sodium) 4

olopatadine hcl soln 01 2

olopatadine hcl soln 02 2

Limit 25mls permonthQL(009ml daily)

PAREMYD SOLN 3

PATADAY SOLN (Use Olopatadine HCl) 4

Limit 25mls permonthQL(009ml daily)

PATANOL SOLN (Use Olopatadine HCl) 4

PAZEO SOLN 4

ST Limit 1 bottle permonthQL(0084 ml daily)

PROLENSA SOLN 4

TRUSOPT SOLN (Use Dorzolamide HCl) 4

Prostaglandins - Ophthalmic

bimatoprost soln 3

QL(5 ml per 30days retail15ml per 90 daysmail)

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Arizona 4-Tier Drug List Updated January 1 2019

94

Drug Name DrugTier

RequirementsLimits

LATANOPROST SOLN 4

Limit 25mls permonthQL(009ml daily)

latanoprost soln 2

Limit 25mls permonthQL(009ml daily)

LUMIGAN SOLN 3

Limit 25mls permonthQL(009ml daily)

RESCULA SOLN 4

Limit 1 bottle permonthQL(017ml daily)

TRAVATAN Z SOLN 3

QL(3 ml per 30days retail8 mlper 90 daysmail)

XALATAN SOLN (Use Latanoprost) 4

Limit 25mls permonthQL(009ml daily)

XELPROS EMUL 4 PA

ZIOPTAN SOLN 4 QL(1 ea daily)

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous acetic acid (otic) soln 1

acetic acid-aluminum acetate soln 1

Otic Anti-infectives CETRAXAL SOLN (Use Ciprofloxacin HCl (Otic)) 4

ciprofloxacin hcl (otic) soln 1

FLOXIN OTIC SOLN (Use Ofloxacin (Otic)) 4

ofloxacin (otic) soln 2

OTIPRIO SUSP 4 PA

Otic Combinations

Drug Name DrugTier

RequirementsLimits

CIPRO HC SUSP 3

CIPRODEX SUSP 3

COLY-MYCIN S SUSP 4

neomycin-polymyxin-hc(otic) soln 1

neomycin-polymyxin-hc(otic) susp 1

OTOVEL SOLN 4 Limit 14mls permonthQL(05ea daily)

PRAMOTIC LIQD 4

Otic Steroids DERMOTIC OIL (Use Fluocinolone Acetonide (Otic))

4

fluocinolone acetonide (otic) oil 1

hydrocortisone waceticacid soln 4

OXYTOCICS - Drugs to PreventControl UterineBleeding AbortifacientsAgents for Cervical Ripening PROSTIN E2 SUPP 3

Oxytocics methylergonovine maleatesoln ij 02 mgml 3

methylergonovine maleatetabs or 02 mg 2

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem Antitoxins-Antivenins ANAVIP SOLR 4 PA

Passive Immunizing Agents - Combinations HYQVIA KIT J PA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

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Arizona 4-Tier Drug List Updated January 1 2019

95

Drug Name DrugTier

RequirementsLimits

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 250 mg500 mg 1

AMPICILLIN CAPS 500 MG 2

ampicillin susr 125 mg5ml250 mg5ml 1

MOXATAG TB24 4

Natural Penicillins penicillin v potassium solr125 mg5ml 250 mg5ml 1

PENICILLIN V POTASSIUM SOLR 125 MG5ML 250 MG5ML

2

penicillin v potassium tabs250 mg 4

penicillin v potassium tabs500 mg 1

Penicillin Combinations amoxicillin amp potclavulanate susr 1

amoxicillin amp potclavulanate tabs 1

amoxicillin amp potclavulanate tb12 1

AMOXICILLINCLAVULANATE POTASSIUM CHEW 4

AMPICILLIN-SULBACTAM SOLR 3

AUGMENTIN ES-600 SUSR (Use Amoxicillin amp Pot Clavulanate)

4

AUGMENTIN SUSR 125MG5ML-3125MG5ML 2

AUGMENTIN SUSR 250MG5ML-625MG5ML(Use Amoxicillin amp Pot Clavulanate)

4

Drug Name DrugTier

RequirementsLimits

AUGMENTIN TABS 500MG-125MG 875MG-125MG (Use Amoxicillin amp Pot Clavulanate)

4

AUGMENTIN XR TB12 (Use Amoxicillin amp Pot Clavulanate)

4

Penicillinase-Resistant Penicillins dicloxacillin sodium caps 1

PROGESTINS - Hormone ReplacementModifyingDrugs Progestins AYGESTIN TABS (Use Norethindrone Acetate) 4

MAKENA SOAJ J PA SpecialtyTier 2 MayApply

medroxyprogesteroneacetate tabs 1

MEGACE ES SUSP (Use Megestrol Acetate(Appetite))

4

megestrol acetate(appetite) susp 4

norethindrone acetate tabs 2

progesterone micronized caps 4 QL(2 ea daily)

PROMETRIUM CAPS (Use Progesterone Micronized) 4 QL(2 ea daily)

PROVERA TABS (Use MedroxyprogesteroneAcetate)

4

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental andEmotional Conditions Agents for Chemical Dependency acamprosate calcium tbec 2

ANTABUSE TABS (Use Disulfiram) 4

disulfiram tabs 1

Anti-Cataplectic Agents

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Arizona 4-Tier Drug List Updated January 1 2019

96

Drug Name DrugTier

RequirementsLimits

XYREM SOLN 4 PA SpecialtyTier 3 MayApply

Antidementia Agents ARICEPT TABS (Use Donepezil Hydrochloride) 4 QL(1 ea daily)

donepezil hydrochloridetabs 23 mg 1 QL(1 ea daily)

donepezil hydrochloridetabs 5 mg 10 mg 2 QL(1 ea daily)

donepezil hydrochloridetbdp 5 mg 10 mg 2 QL(1 ea daily)

EXELON PT24 (Use Rivastigmine) 4

galantamine hydrobromidecp24 8 mg 16 mg 24 mg 1

GALANTAMINE HYDROBROMIDE SOLN 4 MGML

4

galantamine hydrobromidetabs 4 mg 8 mg 12 mg 1

memantine hcl cp24 7 mg14 mg 21 mg 28 mg 4 PA

memantine hcl soln 2 mgml 1

memantine hcl tabs 5 mg10 mg 1

NAMENDA SOLN (Use Memantine HCl) 4

NAMENDA TABS (Use Memantine HCl) 4

NAMENDA TITRATION PAK TABS (Use Memantine HCl)

4

NAMENDA XR CP24 (Use Memantine HCl) 4 PA

NAMENDA XR TITRATION PACK CP24 4 PA

NAMZARIC CP24 4 PA

RAZADYNE ER CP24 (Use Galantamine Hydrobromide)

4

RAZADYNE TABS (Use Galantamine Hydrobromide)

4

Drug Name DrugTier

RequirementsLimits

rivastigmine pt24 3

rivastigmine tartrate caps 3

Combination Psychotherapeutics CHLORDIAZEPOXIDEAMITRIPTYLINE TABS 4

olanzapine-fluoxetine hcl caps 4

perphenazine-amitriptylinetabs 1

PERPHENAZINEAMITRIPTYLINE TABS 4

SYMBYAX CAPS (Use Olanzapine-Fluoxetine HCl) 4

Fibromyalgia Agents

SAVELLA TABS 4 PA QL(2 eadaily)

SAVELLA TITRATION PACK MISC 4 PA

Movement Disorder Drug Therapy

INGREZZA CAPS 4 PA SpecialtyTier 3 MayApply

tetrabenazine tabs 4 Specialty Tier 2May Apply

XENAZINE TABS (Use Tetrabenazine) 4 Specialty Tier 2

May Apply Multiple Sclerosis Agents

AMPYRA TB12 (Use Dalfampridine) 3

PA SpecialtyTier 1 MayApply

AUBAGIO TABS 4 PA SpecialtyTier 2 MayApply

AVONEX KIT J PA SpecialtyTier 2 MayApply

AVONEX PEN AJKT J PA SpecialtyTier 2 MayApply

AVONEX PSKT J PA SpecialtyTier 2 MayApply

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Arizona 4-Tier Drug List Updated January 1 2019

97

Drug Name DrugTier

RequirementsLimits

BETASERON KIT J PA SpecialtyTier 2 MayApply

COPAXONE SOSY (Use Glatiramer Acetate) J

PA SpecialtyTier 2 MayApply

dalfampridine tb12 1 PA SpecialtyTier 1 MayApply

EXTAVIA KIT J PA SpecialtyTier 2 MayApply

GILENYA CAPS 4 PA SpecialtyTier 2 MayApply

glatiramer acetate sosy J PA SpecialtyTier 2 MayApply

PLEGRIDY SOPN J PA SpecialtyTier 2 MayApply

PLEGRIDY SOSY J PA SpecialtyTier 2 MayApply

PLEGRIDY STARTER PACK SOPN J

PA SpecialtyTier 2 MayApply

PLEGRIDY STARTER PACK SOSY J

PA SpecialtyTier 2 MayApply

REBIF REBIDOSE SOAJ J PA SpecialtyTier 2 MayApply

REBIF REBIDOSE TITRATIONPACK SOAJ J

PA SpecialtyTier 2 MayApply

REBIF SOSY J PA SpecialtyTier 2 MayApply

REBIF TITRATION PACK SOSY J

PA SpecialtyTier 2 MayApply

TECFIDERA CPDR 4 PA SpecialtyTier 2 MayApply

TECFIDERA STARTER PACK MISC 4

PA SpecialtyTier 2 MayApply

Drug Name DrugTier

RequirementsLimits

ZINBRYTA SOSY J PA SpecialtyTier 3 MayApply

Postherpetic Neuralgia (PHN)Neuropathic Pain GRALISE STARTER MISC 4 PA

GRALISE TABS 4 PA

LYRICA CR TB24 165 MG 825 MG 4 PA QL(1 ea

daily)

LYRICA CR TB24 330 MG 4 PA QL(2 eadaily)

Premenstrual Dysphoric Disorder (PMDD) Agents FLUOXETINE CAPS 10 MG 4 QL(1 ea daily)

FLUOXETINE CAPS 20 MG 3

fluoxetine hcl (pmdd) tabs 4

SARAFEM TABS (Use Fluoxetine HCl (PMDD)) 4

Pseudobulbar Affect (PBA) Agents NUEDEXTA CAPS 4 PA

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS 4

ORAP TABS (Use Pimozide) 3

pimozide tabs 3

Restless Leg Syndrome (RLS) Agents HORIZANT TBCR 4 QL(1 ea daily)

Smoking Deterrents bupropion hcl (smokingdeterrent) tb12 1 PV

CHANTIX CONTINUING MONTHPAK TABS 2 PV

CHANTIX STARTING MONTH PAK TABS 2 PV

CHANTIX TABS 2 PV

NICODERM CQ PT24 (Use Nicotine) 4 PV

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Arizona 4-Tier Drug List Updated January 1 2019

98

Drug Name DrugTier

RequirementsLimits

nicotine pt24 1 PV

NICOTROL INHALER INHA 4 PV

NICOTROL NS SOLN 4 PV

ZYBAN TB12 (Use Bupropion HCl (SmokingDeterrent))

4 PV

Vasomotor Symptom Agents BRISDELLE CAPS (Use Paroxetine Mesylate(Vasomotor))

4

paroxetine mesylate(vasomotor) caps 4

RESPIRATORY AGENTS - MISC - Drugs toTreat Lung Conditions Cystic Fibrosis Agents KALYDECO PACK 50 MG 75 MG 2 PA

KALYDECO TABS 150 MG 2 PA SpecialtyTier 3 MayApply

ORKAMBI PACK 100MG-125MG 150MG-188MG 4 PA

ORKAMBI TABS 100MG-125MG 200MG-125MG 2

PA SpecialtyTier 3 MayApply

PULMOZYME SOLN 4 Specialty Tier 3May Apply

Pulmonary Fibrosis Agents

ESBRIET CAPS 4 PA SpecialtyTier 3 MayApply

ESBRIET TABS 4 PA SpecialtyTier 3 MayApply

OFEV CAPS 4 PA SpecialtyTier 3 MayApply

SULFONAMIDES - Drugs to Treat BacterialInfections Sulfonamides SULFADIAZINE TABS 4

Drug Name DrugTier

RequirementsLimits

TETRACYCLINES - Drugs to Treat BacterialInfections Aminomethylcyclines NUZYRA SOLR 4 PA

NUZYRA TABS 4 PA

Tetracyclines ACTICLATE TABS (Use Doxycycline Hyclate) 4 PA

ADOXA PAK 1100 TABS(Use Doxycycline(Monohydrate))

4

ADOXA PAK 1150 TABS(Use Doxycycline(Monohydrate))

4

ADOXA PAK 2100 TABS(Use Doxycycline(Monohydrate))

4

ADOXA TABS (Use Doxycycline(Monohydrate))

4

demeclocycline hcl tabs 4

DORYX MPC TBEC 4 PA

DORYX TBEC (Use Doxycycline Hyclate) 4 PA

doxycycline (monohydrate)caps 50 mg 100 mg 1

doxycycline (monohydrate)caps 75 mg 150 mg 3

doxycycline (monohydrate)susr 25 mg5ml 1

doxycycline (monohydrate)tabs 50 mg 75 mg 100mg 150 mg

3

doxycycline hyclate caps50 mg 100 mg 1

doxycycline hyclate tabs 20mg 100 mg 1

DOXYCYCLINE HYCLATE TABS 50 MG 4 PA

doxycycline hyclate tabs 75mg 150 mg 4 PA

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Arizona 4-Tier Drug List Updated January 1 2019

99

Drug Name DrugTier

RequirementsLimits

doxycycline hyclate tbec 50mg 200 mg 4 PA

doxycycline hyclate tbec 75mg 100 mg 150 mg 4 ST

MINOCIN CAPS (Use Minocycline HCl) 4 PA

minocycline hcl caps 50mg 75 mg 100 mg 1

minocycline hcl tb24 45mg 65 mg 90 mg 115 mg135 mg

4 PA

MINOCYCLINE HYDROCHLORIDEER TB24

4 PA

MINOLIRA TB24 4 PA

MONODOX CAPS 100 MG (Use Doxycycline(Monohydrate))

3

MONODOX CAPS 75 MG (Use Doxycycline(Monohydrate))

4

SOLODYN TB24 55 MG 80 MG 105 MG 4 PA

SOLODYN TB24 65 MG 115 MG (Use MinocyclineHCl)

4 PA

TARGADOX TABS 4 PA

tetracycline hcl caps 1

VIBRAMYCIN CAPS 100 MG (Use DoxycyclineHyclate)

4

VIBRAMYCIN SUSR 25 MG5ML (Use Doxycycline(Monohydrate))

4

VIBRAMYCIN SYRP 50 MG5ML 4

THYROID AGENTS - Drugs to Regulate ThyroidHormones Antithyroid Agents methimazole tabs 1

propylthiouracil tabs 1

Drug Name DrugTier

RequirementsLimits

TAPAZOLE TABS (Use Methimazole) 4

Thyroid Hormones ARMOUR THYROID TABS 15 MG 30 MG 60 MG 90 MG 120 MG (Use Thyroid)

4

ARMOUR THYROID TABS 180 MG 240 MG 300 MG 4

CYTOMEL TABS (Use Liothyronine Sodium) 4

levothyroxine sodium tabs 1

liothyronine sodium tabs 1

NATURE-THROID NT-25 TABS 4

NATURE-THROID TABS 1625 MG 3

NATURE-THROID TABS 65 MG 130 MG 195 MG 260 MG 325 MG 325 MG 975 MG 4875 MG 8125 MG 11375 MG 14625 MG

4

SYNTHROID TABS (Use Levothyroxine Sodium) 4

thyroid tabs 1

THYROLAR-1 TABS 2

THYROLAR-12 TABS 2

THYROLAR-14 TABS 2

THYROLAR-2 TABS 2

THYROLAR-3 TABS 2

TIROSINT CAPS 4

WESTHROID TABS 4

WP THYROID TABS 1625 MG 3

WP THYROID TABS 65 MG 130 MG 325 MG 975 MG 4875 MG 8125 MG 11375 MG

4

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Arizona 4-Tier Drug List Updated January 1 2019

100

Drug Name DrugTier

RequirementsLimits

ULCER DRUGS - Drugs to Treat Bowel Intestineand Stomach Conditions Antispasmodics ANASPAZ TBDP (Use Hyoscyamine Sulfate) 4

ATROPINE SULFATE SOSY IV 12 MG3ML 4 PA

BELLADONNA ALKALOIDS amp OPIUM SUPP

4

BENTYL CAPS (Use Dicyclomine HCl) 4

chlordiazepoxide hcl-clidinium bromide caps 1

CUVPOSA SOLN 3

dicyclomine hcl caps 1

dicyclomine hcl soln 1

dicyclomine hcl tabs 1

DONNATAL ELIX (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)

4

DONNATAL TABS (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)

4

GLYCATE TABS 4 PA

GLYCOPYRROLATE SOSY IJ 06 MG3ML 1MG5ML

4 PA

glycopyrrolate tabs or 1mg 2 mg 1

GLYCOPYRROLATE TABS OR 15 MG 4 PA

hyoscyamine sulfate elix 1

hyoscyamine sulfate soln 1

hyoscyamine sulfate subl 1

hyoscyamine sulfate tabs 1

Drug Name DrugTier

RequirementsLimits

hyoscyamine sulfate tbdp 1

LEVSIN TABS (Use Hyoscyamine Sulfate) 4

LEVSINSL SUBL (Use Hyoscyamine Sulfate) 4

LIBRAX CAPS (Use Chlordiazepoxide HCl-Clidinium Bromide)

4 PA

methscopolamine bromidetabs 2

phenobarbital-hyoscyamine-atropine-scopolamine elix01037mg5ml-00065mg5ml-00194mg5ml-162mg5ml

1

phenobarbital-hyoscyamine-atropine-scopolamine tabs01037mg-00065mg-00194mg-162mg

4

PROPANTHELINE BROMIDE TABS 4

ROBINUL FORTE TABS (Use Glycopyrrolate) 4

ROBINUL TABS (Use Glycopyrrolate) 4

H-2 Antagonists CIMETIDINE HCL SOLN 4

cimetidine tabs 1

famotidine susr 40 mg5ml 1

famotidine tabs 20 mg 1 RXOTC

famotidine tabs 40 mg 1

nizatidine caps 150 mg300 mg 1

NIZATIDINE SOLN 15 MGML 4

PEPCID AC MAXIMUM STRENGTH TABS (Use Famotidine)

4 RXOTC

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Arizona 4-Tier Drug List Updated January 1 2019

101

Drug Name DrugTier

RequirementsLimits

PEPCID SUSR 40 MG5ML(Use Famotidine) 4

PEPCID TABS 20 MG (Use Famotidine) 4 RXOTC

PEPCID TABS 40 MG (Use Famotidine) 4

ranitidine hcl caps 150 mg300 mg 1

ranitidine hcl syrp 15mgml 75 mg5ml 150mg10ml

1

ranitidine hcl tabs 150 mg 1 RXOTC

ranitidine hcl tabs 300 mg 1

ZANTAC 150 MAXIMUM STRENGTH TABS (Use Ranitidine HCl)

4 RXOTC

ZANTAC TABS 150 MG (Use Ranitidine HCl) 4 RXOTC

ZANTAC TABS 300 MG (Use Ranitidine HCl) 4

Misc Anti-Ulcer CARAFATE SUSP 1 GM10ML 4

CARAFATE TABS 1 GM (Use Sucralfate) 4

sucralfate tabs 1

Proton Pump Inhibitors ACIPHEX SPRINKLE CPSP 4 PA

ACIPHEX TBEC (Use Rabeprazole Sodium) 4 PA

DEXILANT CPDR 4 PA

esomeprazole magnesiumcpdr 20 mg 4 PA RXOTC

esomeprazole magnesiumcpdr 40 mg 4 PA

ESOMEPRAZOLE STRONTIUM CPDR 493 MG 2465 MG

4 PA QL(1 eadaily)

FIRST-LANSOPRAZOLE SUSP 4

Drug Name DrugTier

RequirementsLimits

FIRST-OMEPRAZOLE SUSP 4

lansoprazole cpdr 15 mg 1 QL(1 ea daily)RXOTC

lansoprazole cpdr 15 mg 1 RXOTC

lansoprazole cpdr 30 mg 1

lansoprazole tbdp 15 mg30 mg 4

QL(1 ea daily)AL(Up to 12 yrsold )

NEXIUM 24HR CLEAR MINIS CPDR (Use Esomeprazole Magnesium)

4 PA RXOTC

NEXIUM 24HR CPDR (Use Esomeprazole Magnesium) 4 PA RXOTC

NEXIUM CPDR 20 MG (Use EsomeprazoleMagnesium)

4 PA RXOTC

NEXIUM CPDR 40 MG (Use EsomeprazoleMagnesium)

4 PA

NEXIUM PACK 5 MG 10 MG 20 MG 40 MG 25 MG

4 PA

OMEPRAZOLE + SYRSPEND SFALKA SUSP

4

omeprazole cpdr 10 mg 40 mg 1

omeprazole cpdr 20 mg 1 RXOTC

pantoprazole sodium tbec 1

PREVACID CPDR 15 MG (Use Lansoprazole) 4 RXOTC

PREVACID CPDR 30 MG (Use Lansoprazole) 4

PREVACID SOLUTAB TBDP (Use Lansoprazole) 4

QL(1 ea daily)AL(Up to 12 yrsold )

PROTONIX PACK 40 MG 4 QL(1 ea daily)

PROTONIX TBEC 20 MG 40 MG (Use PantoprazoleSodium)

4

rabeprazole sodium tbec 4 PA

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Arizona 4-Tier Drug List Updated January 1 2019

102

Drug Name DrugTier

RequirementsLimits

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use Misoprostol) 4

misoprostol tabs 2

Ulcer Therapy Combinations

amoxicillin-clarithromycinw lansoprazole misc 1

QL(112 ea per365 daysretail112 ea per 365 daysmail)

OMECLAMOX-PAK MISC 4

omeprazole-sodiumbicarbonate caps 20mg-1100mg

4 PA RXOTC

omeprazole-sodiumbicarbonate caps 40mg-1100mg

4 PA

omeprazole-sodiumbicarbonate pack 20mg-1680mg 40mg-1680mg

4 PA

PREVPAC MISC (Use Amoxicillin-Clarithromycinw Lansoprazole)

4

QL(112 ea per365 daysretail112 ea per 365 daysmail)

PYLERA CAPS 4 QL(120 ea per10 days retail)

ZEGERID CAPS 20MG-1100MG (Use Omeprazole-SodiumBicarbonate)

4

PA RXOTC

ZEGERID CAPS 40MG-1100MG (Use Omeprazole-SodiumBicarbonate)

4

PA

ZEGERID PACK 20MG-1680MG 40MG-1680MG (Use Omeprazole-SodiumBicarbonate)

4

PA

URINARY ANTI-INFECTIVES - Drugs to TreatBladderKidney Infections Urinary Anti-infective Combinations HYOPHEN TABS 4

Drug Name DrugTier

RequirementsLimits

methenamine-hyosc-methylene blue-benzoicacid-phenyl sal tabs

4

methenamine-hyosc-methylene blue-sod phos-phenyl sal caps

3

Urinary Anti-infectives FURADANTIN SUSP (Use Nitrofurantoin) 4

HIPREX TABS (Use Methenamine Hippurate) 4

MACROBID CAPS (Use Nitrofurantoin MonohydMacro)

4

MACRODANTIN CAPS (Use Nitrofurantoin Macrocrystal)

4

methenamine hippuratetabs 2

methenamine mandelate tabs 05 gm 1 gm 2

methenamine mandelate tabs 500 mg 4 PA

MONUROL PACK 4

nitrofurantoin macrocrystal caps 1

nitrofurantoin monohyd macro caps 2

nitrofurantoin susp 2

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms Urinary Antispasmodic - Antimuscarinics darifenacin hydrobromidetb24 4

DETROL LA CP24 (Use Tolterodine Tartrate) 4 QL(1 ea daily)

DETROL TABS (Use Tolterodine Tartrate) 4

DITROPAN XL TB24 (Use Oxybutynin Chloride) 4

ENABLEX TB24 (Use Darifenacin Hydrobromide) 4

GELNIQUE GEL 4

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Arizona 4-Tier Drug List Updated January 1 2019

103

Drug Name DrugTier

RequirementsLimits

GELNIQUE PUMP GEL 4

oxybutynin chloride syrp 5mg5ml 1

oxybutynin chloride tabs 5 mg 1

oxybutynin chloride tb24 5mg 10 mg 15 mg 2

OXYTROL FOR WOMEN PTTW 4 RXOTC

OXYTROL PTTW 4 RXOTC

tolterodine tartrate cp24 2mg 4 mg 1 QL(1 ea daily)

tolterodine tartrate tabs 1 mg 2 mg 1

TOVIAZ TB24 3

trospium chloride cp24 60 mg 2

trospium chloride tabs 20 mg 1

VESICARE TABS 4

Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 4 QL(1 ea daily)

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs 5 mg 10 mg 25 mg 4

bethanechol chloride tabs 50 mg 1

URECHOLINE TABS (Use Bethanechol Chloride) 4

Urinary Antispasmodics - Direct Muscle Relaxants flavoxate hcl tabs 2

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones Miscellaneous Vaginal Products FEM PH GEL 4

RELAGARD GEL 4

Vaginal Anti-infectives

Drug Name DrugTier

RequirementsLimits

AVC CREA 4

CLEOCIN CREA VA 2 (Use ClindamycinPhosphate Vaginal)

4

CLEOCIN SUPP VA 100 MG 4

clindamycin phosphatevaginal crea 2

CLINDESSE CREA 3

GYNAZOLE-1 CREA 4

METROGEL-VAGINAL GEL (Use Metronidazole Vaginal)

4

metronidazole vaginal gel 1

MICONAZOLE 3 SUPP 3

NUVESSA GEL 4 PA

TERAZOL 7 CREA (Use Terconazole Vaginal) 4

TERCONAZOLE CREA 4

terconazole vaginal crea 1

terconazole vaginal supp 1

Vaginal Estrogens ESTRACE CREA VA 01 MGGM (Use Estradiol Vaginal)

3

estradiol vaginal crea 01mggm 3

estradiol vaginal tabs 10 mcg 3 QL(90 ea per

fill retail)

ESTRING RING 4 QL(1 ea per 83days retail)

FEMRING RING 4 QL(90 ea perfill retail)

PREMARIN CREA VA 0625 MGGM 2 GL

VAGIFEM TABS (Use Estradiol Vaginal) 3 QL(90 ea per

fill retail) Vaginal Progestins

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Arizona 4-Tier Drug List Updated January 1 2019

104

Drug Name DrugTier

RequirementsLimits

CRINONE GEL 4

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions Anaphylaxis Therapy Agents

ADRENACLICK SOAJ 5

Specialty Tier 1MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

AUVI-Q SOAJ J

PA SpecialtyTier 1 MayApplyQL(4 eaper 30 daysretail)2 rtl packlmt per fill

epinephrine (anaphylaxis)soaj 015 mg015ml 015mg03ml 03 mg03ml

5

Specialty Tier 1MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

epinephrine (anaphylaxis)soaj 03 mg03ml 4 PA

EPIPEN 2-PAK SOAJ (Use Epinephrine (Anaphylaxis)) 5

PA SpecialtyTier 1 MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

EPIPEN-JR 2-PAK SOAJ 5

PA SpecialtyTier 1 MayApplyQL(2 eaper fill retail4ea per 30 daysretail)

Neurogenic Orthostatic Hypotension (NOH) -NORTHERA CAPS 4 PA

Vasopressors dobutamine hcl soln 3

dobutamine in d5w soln 3

dopamine hcl soln 40mgml 3

Drug Name DrugTier

RequirementsLimits

DOPAMINE HCL SOLN 80 MGML 160 MGML 3

dopamine in d5w soln 3

EPHEDRINE SULFATE SOSY 4 PA

EPINEPHRINE SOSY 4 PA

midodrine hcl tabs 3

NOREPINEPHRINESODIUM CHLORIDE SOLN 4 PA

PHENYLEPHRINE HYDROCHLORIDE SOSY 4 PA

PHENYLEPHRINE HYDROCHLORIDESODIUM CHLORIDE SOLN

4 PA

VITAMINS

Oil Soluble Vitamins DRISDOL CAPS (Use Ergocalciferol) 4

ergocalciferol caps 1

MEPHYTON TABS (Use Phytonadione) 3

phytonadione tabs 1

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Arizona 4-Tier Drug List Updated January 1 2019

105

Indexabacavir sulfate 44 abacavir sulfate-lamivudine 44 abacavir sulfate-lamivudine-zidovudine 44 ABILIFY 43 ABILIFY MYCITE 43 abiraterone acetate 36 ABSORICA 56 ABSTRAL 6 acamprosate calcium 96 ACANYA 56 acarbose 22 ACCOLATE 13 ACCUPRIL 31 ACCURETIC 32 acebutolol hcl 47 ACEON 31 acetaminophen w codeine 7 acetazolamide 68 acetic acid (otic) 95 acetic acid-aluminumacetate 95 acetylcysteine 56 ACIPHEX 102 ACIPHEX SPRINKLE 102 acitretin 60 ACLOVATE 61 ACTEMRA 3 ACTICLATE 99 ACTIDOM DMX 55 ACTIGALL 74 ACTIMMUNE 39 ACTIQ 6 ACTIVASE 78 ACTIVELLA 72 ACTONEL 69 ACTOPLUS MET 23 ACTOPLUS MET XR 23 ACTOS 24 ACULAR 94 ACULAR LS 94 ACUVAIL 94 acyclovir 47 acyclovir sodium 47 acyclovir topical 61 ACZONE 56 ADALAT CC 48

adapalene 56 ADAPALENE 56 adapalene-benzoylperoxide 56 ADCETRIS 36 ADCIRCA 50 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 46 ADEMPAS 50 ADMELOG 24 ADMELOG SOLOSTAR 24 ADOXA 99 ADOXA PAK 1100 99 ADOXA PAK 1150 99 ADOXA PAK 2100 99 ADRENACLICK 105 ADRENALIN 90 ADVAIR DISKUS 15 ADVAIR HFA 15 ADVATE 77 ADZENYS XR-ODT 1 AEROSPAN 14 AFINITOR 37 AFINITOR DISPERZ 37 AFREZZA 24 AFTERTEST TOPICAL PAINRELIEF 66 AGGRENOX 78 AGRYLIN 78 AIRDUO RESPICLICK5514 15 AKTEN 92 AKYNZEO 27 ALA SCALP 61 ALAHIST DM 55 albendazole 10 ALBENZA 10 ALBUMINEX 78 albuterol sulfate 15 ALBUTEROL SULFATEER 15 ALCAINE 92 alclometasonedipropionate 62 alcohol 90 ALDACTAZIDE 68 ALDACTONE 68

ALDARA 65 ALECENSA 37 ALENDRONATE SODIUM 69 alendronate sodium 69 ALFERON N 39 alfuzosin hcl 76 ALINIA 11 ALKERAN 34 allopurinol 76 ALLZITAL 5 almotriptan malate 84 ALOCRIL 94 ALOGLIPTIN 24 ALOGLIPTINMETFORMINHCL 23 ALOGLIPTINPIOGLITAZONE

23 ALOMIDE 94 ALORA 73 alosetron hcl 75 ALOXI 27 ALPHAGAN P 91 ALPHANATEVONWILLEBRANDFACTORCOMPLEXHUMAN 77 ALPHANINE SD 77 alprazolam 12 ALPRAZOLAM INTENSOL 12 ALPROLIX 77 ALREX 92 ALTABAX 59 ALTACE 31 ALTOPREV 30 ALTRENO 56 ALVESCO 14 amantadine hcl 41 AMARYL 26 AMBIEN 80 AMBIEN CR 80 AMCINONIDE 62 AMERGE 84 AMICAR 80 amiloride amphydrochlorothiazide 68 amiloride hcl 68 aminocaproic acid 80 aminophylline 15 amiodarone hcl 13

Index 1

AMITIZA 74 ANZEMET 27 atazanavir sulfate 44 amitriptyline hcl 22 AP-HIST DM 55 ATELVIA 69 amlodipine besylate 48 amlodipine besylate-atorvastatincalcium 49 amlodipine besylate-benazeprilhcl 32

APEXICON E APIDRA APIDRA SOLOSTAR APLENZIN

62 24 24 20

atenolol atenolol amp chlorthalidone ATIVAN atomoxetine hcl

48 32 12 1

amlodipine besylate-olmesartanmedoxomil 32 amlodipine besylate-valsartan 32

apraclonidine hcl aprepitant APRISO

91 27 74

atorvastatin calcium atovaquone atovaquone-proguanil hcl

30 11 33

amlodipine-valsartan-hydrochlorothiazide 32 AMOXAPINE 22 amoxicillin 96 amoxicillin amp pot clavulanate 96 amoxicillin-clarithromycin wlansoprazole 103 AMOXICILLINCLAVULANATEPOTASSIUM 96 amphetamine sulfate 1 amphetamine-dextroamphetamine 1 ampicillin 96 AMPICILLIN 96 ampicillin 96 AMPICILLIN-SULBACTAM 96 AMPYRA 97 AMRIX 88 ANADROL-50 9 ANAFRANIL 22 anagrelide hcl 78 ANALPRAM HC 10 ANALPRAM HC SINGLES 10 ANALPRAM-HC 10 ANAPROX DS 3 ANASPAZ 101 anastrozole 36 ANAVIP 95 ANCOBON 28 ANDRODERM 9 ANDROGEL 9 ANDROGEL PUMP 9 ANDROID 9 ANDROXY 9 ANGELIQ 72 ANORO ELLIPTA 15 ANTABUSE 96 ANTARA 29 ANUSOL-HC 10

APTENSIO XR 1 APTIOM 18 APTIVUS 44 ARAKODA 33 ARANESP ALBUMIN FREE 79 ARAVA 5 ARCALYST 3 ARCAPTA NEOHALER 15 ARICEPT 97 ARIKAYCE 2 ARIMIDEX 36 aripiprazole 4344 ARIXTRA 16 armodafinil 1 ARMOUR THYROID 100 ARNUITY ELLIPTA 14 AROMASIN 36 ARTHROTEC 50 3 ARTHROTEC 75 3 ARZERRA 36 ASACOL HD 74 ASMANEX HFA 14 ASMANEX TWISTHALER 120 METERED DOSES 14 ASMANEX TWISTHALER 14 METERED DOSES 14 ASMANEX TWISTHALER 30 METERED DOSES 14 ASMANEX TWISTHALER 60 METERED DOSES 14 ASMANEX TWISTHALER 7 METERED DOSES 14 ASPIRIN-CAFFEINE-DIHYDROCODEINE 7 aspirin-dipyridamole 78 ASTAGRAF XL 87 ASTEPRO 89 ATACAND 31 ATACAND HCT 32

ATRALIN 56 ATRIPLA 44 ATROPINE SULFATE 91101 ATROPINE SULFATESODIUMCHLORIDE 91 ATROVENT HFA 13 AUBAGIO 97 AUGMENTED BETAMETHASONE DIPROPIONATE 62 AUGMENTIN 96 AUGMENTIN ES-600 96 AUGMENTIN XR 96 AURYXIA 75 AUTOPEN 83 AUVI-Q 105 AVALIDE 32 AVANDIA 24 AVAPRO 31 AVASTIN 36 AVC 104 AVELOX 73 AVELOX ABC PACK 73 AVODART 76 AVONEX 97 AVONEX PEN 97 AXERT 84 AXIRON 9 AXUMIN 67 AYGESTIN 96 azacitidine 35 AZASAN 87 AZASITE 91 azathioprine 87 azelaic acid 66 azelastine hcl 89 azelastine hcl (ophth) 94 AZELEX 56

Index 2

AZILECT 42 BETADINE OPHTHALMIC BROMFENAC 94 azithromycin 81 AZOPT 94 AZOR 32 AZULFIDINE 74 AZULFIDINE EN-TABS 74 BACITRACIN 91 bacitracin-poly-neomycin-hc 93 bacitracin-polymyxin b(ophth) 91 baclofen 88

PREP 92 BETAGAN 90 betamethasone dipropionate(topical) 62 betamethasone dipropionateaugmented 62 betamethasone valerate 62 BETAPACE 48 BETAPACE AF 48 BETASERON 98 betaxolol hcl 48

bromfenac sodium (ophth) bromocriptine mesylate BROMPHENIRAMINE TANNATE BROVANA BRYHALI budesonide budesonide (inhalation) budesonide (nasal) bumetanide

94 41

28 15 62 53 14 89 68

BACLOFEN BACTRIM

88 11

betaxolol hcl (ophth) bethanechol chloride

90 104

BUMEX BUNAVAIL

68 8

BACTRIM DS 11 BETHKIS 2 BUPHENYL 71 BACTROBAN BACTROBAN NASAL balsalazide disodium BANZEL

59 89 74 18

BETIMOL 90 BETOPTIC-S 90 BEVESPI AEROSPHERE 15 bexarotene 39

BUPIVACAINE HYDROCHLORIDE 81 BUPIVACAINE HYDROCHLORIDEDEXTROSE

81 BARACLUDE 46 BEYAZ 51 buprenorphine 9 BASAGLAR KWIKPEN 24 BIAXIN 82 BUPRENORPHINE 9 BD PEN 83 BD PEN MINI 83 BEBULIN 77 BECONASE AQ 89 BELBUCA 8 BELEODAQ 37 BELLADONNA ALKALOIDS amp OPIUM 101

bicalutamide BIDIL BILTRICIDE bimatoprost BINOSTO BIO-STATIN bisacodyl-peg 3350-potchloride-sod bicarb-sod

36 49 10 94 69 28

buprenorphine hcl 8 buprenorphine hcl-naloxone hcldihydrate 8 bupropion hcl 20 bupropion hcl (smokingdeterrent) 98 BUPROPION HYDROCHLORIDE ER 20 buspirone hcl 12

BELSOMRA benazepril amphydrochlorothiazide benazepril hcl BENEFIX BENICAR BENICAR HCT BENTYL BENZACLIN BENZACLIN WITH PUMP BENZAMYCIN

80

32 31 77 31 32

101 56 56 56

chloride bisoprolol amphydrochlorothiazide bisoprolol fumarate bleomycin sulfate BLEPH-10 BLEPHAMIDE BLEPHAMIDE SOP BLINCYTO BONIVA BOSULIF

81

32 48 37 92 93 93 36 69 37

butalbital-acetaminophen 5 butalbital-acetaminophen-caffeine 5 butalbital-acetaminophen-caffeine w codeine 7 butalbital-aspirin-caffeine 5 butalbital-aspirin-caffeinewcod 8 BUTALBITALACETAMINOPHEN

5 BUTALBITALASPIRINCAFFEINE 5 BUTISOL SODIUM 80

benzonatate benzoyl peroxide BENZOYL PEROXIDE CLEANSER benzoyl peroxide-erythromycin benztropine mesylate

54 56

56

56 41

BRAFTOVI 37 BREO ELLIPTA 15 BREVICON-28 51 BRILINTA 78 BRIMONIDEDORZOLAMIDEP-F 91 brimonidine tartrate 91

butorphanol tartrate BUTRANS BYDUREON BYDUREON PEN BYETTA BYSTOLIC

9 9

24 24 24 48

BEPREVE 94 BYVALSON 32BRISDELLE 99 BESIVANCE 92 cabergoline 72BRIVIACT 18

Index 3

CABOMETYX 37 CADUET 49 CAFERGOT 83 caffeine citrate 1 CALAN 48 CALAN SR 48 calcipotriene 60 calcipotriene-betamethasonedipropionate 62 calcitonin (salmon) 69 calcitriol 71 calcitriol (topical) 60 calcium acetate (phosphatebinder) 75 CALCIUM GLUCONATE 85 CAMBIA 84 CAMPTOSAR 40 CANASA 74 candesartan cilexetil 31 candesartan cilexetil-hydrochlorothiazide 32 capecitabine 35 CAPEX 62 CAPITALCODEINE 8 CAPRELSA 37 captopril 31 captopril amphydrochlorothiazide 32 CARAC 60 CARAFATE 102 CARBAGLU 71 carbamazepine 18 CARBATROL 18 carbidopa 41 carbidopa-levodopa 41 carbidopa-levodopa-entacapone

41 CARBIDOPALEVODOPAENTACAPONE 41 carbinoxamine maleate 28 carboplatin 34 CARDIZEM 48 CARDIZEM CD 48 CARDIZEM LA 48 CARDURA 31 CARDURA XL 76 carisoprodol 88 carisoprodol w aspirin 89

carisoprodol w aspirin ampcodeine 89 CARNITOR 71 CARNITOR SF 71 CARTEOLOL HCL 90 carteolol hcl (ophth) 90 carvedilol 47 carvedilol phosphate 47 CASODEX 36 CATAPRES 31 CAYA 82 CEDAX 51 cefaclor 5051 CEFACLOR 51 CEFACLOR ER 51 cefadroxil 50 cefdinir 51 CEFDITOREN PIVOXIL 51 cefixime 51 cefpodoxime proxetil 51 cefprozil 51 CEFTIBUTEN 51 CEFTIN 51 cefuroxime axetil 51 CELEBREX 3 celecoxib 3 CELEXA 21 CELLCEPT 87 CELONTIN 20 cephalexin 50 CEPHALEXIN 50 CEQUA 92 CERDELGA 79 CESAMET 27 CETACAINE 66 CETRAXAL 95 CETYLEV 26 cevimeline hcl 88 CHANTIX 98 CHANTIX CONTINUINGMONTHPAK 98 CHANTIX STARTING MONTHPAK 98 CHEK-STIX COMBO PAKURINALYSIS CONTROL 67 CHEK-STIX CONTROL 67 CHEMET 26 CHEMSTRIP-K 67

CHENODAL 74 chlordiazepoxide hcl 12 chlordiazepoxide hcl-clidiniumbromide 101 CHLORDIAZEPOXIDEAMITRIPTYLINE 97 CHLORHEXIDINEGLUCONATE 44 CHLOROQUINEPHOSPHATE 33 chloroquine phosphate 33 CHLOROTHIAZIDE 68 chlorothiazide 68 chlorpromazine hcl 43 chlorpropamide 26 chlorthalidone 68 CHLORZOXAZONE 88 CHOLBAM 74 cholestyramine 29 cholestyramine light 29 choline amp mag salicylate 6 choline fenofibrate 29 CHONDROITIN SULFATE 94 ciclopirox 59 ciclopirox olamine 59 cilostazol 78 CILOXAN 92 cimetidine 101 CIMETIDINE HCL 101 CIMZIA 74 CIMZIA STARTER KIT 74 CINRYZE 78 CIPRO 73 CIPRO HC 95 CIPRO XR 73 CIPRODEX 95 ciprofloxacin 73 CIPROFLOXACIN ER 73 CIPROFLOXACIN HCL 73 ciprofloxacin hcl 73 ciprofloxacin hcl (ophth) 92 ciprofloxacin hcl (otic) 95 CISPLATIN 34 cisplatin 34 citalopram hydrobromide 21 cladribine 35 CLARINEX-D 12 HOUR 55 CLARITHROMYCIN 82

Index 4

clarithromycin 82 codeine sulfate 6 COUMADIN 16 CLEOCIN 11104 CODEINE SULFATE 6 COZAAR 31 CLEOCIN PEDIATRIC CODITUSSIN AC 55 CREON 68 GRANULES 11 COLAZAL 74 CRESEMBA 28CLEOCIN-T 56 COLCHICINE 76 CRESTOR 30CLIMARA 73 colchicine 76 CRINONE 105CLIMARA PRO 72 colchicine w probenecid 76 CRIXIVAN 44CLINDAGEL 57 COLCRYS 76 cromolyn sodium 13clindamycin hcl 11 colesevelam hcl 29 cromolyn sodiumclindamycin palmitate (mastocytosis) 74COLESTID 29hydrochloride 11 cromolyn sodium (ophth) 94clindamycin phosphate COLESTID FLAVORED 29 CROSCARMELLOSE(topical) 57 colestipol hcl 29 SODIUM 51clindamycin phosphate COLY-MYCIN S 95 CUPRIMINE 87vaginal 104 clindamycin phosphate-benzoyl COLYTE-FLAVOR PACKS81 CUTIVATE 62 peroxide 57 COMBIGAN 90 CUVPOSA 101clindamycin phosphate-benzoyl COMBIPATCH 72 cyanocobalamin 79peroxide (refrigerate) 57 clindamycin phosphate- COMBIVENT RESPIMAT 15 CYCLESSA 51 tretinoin 57 COMBIVIR 44 CYCLOGABA10300 PACK 89 CLINDAMYCIN COMETRIQ 37 cyclobenzaprine hcl 88PHOSPHATEBENZOYL COMPLERA 44 CYCLOGYL 91PEROXIDE 57 CLINDESSE 104 COMTAN 41 CYCLOMYDRIL 91 clobazam 17 CONCERTA 1 cyclopentolate hcl 91 clobetasol propionate 62 CONDYLOX 65 cyclophosphamide 34 clobetasol propionate emollient CONTOUR NEXT BLOOD CYCLOPHOSPHAMIDE 34

GLUCOSE TEST 67base 62 cyclophosphamide 34clobetasol propionate CONZIP 6 CYCLOPHOSPHAMIDE 34emulsion 62 COPAXONE 98

CLOBEX 62 cyclophosphamide 34COPEGUS 46 CLOCORTOLONE CYCLOSERINE 34COPIKTRA 37PIVALATE 62 CYCLOSET 24CORDRAN 62CLOCORTOLONE PIVALATE cyclosporine 87PUMP 62 COREG 47 cyclosporine modified (forCLODERM 62 COREG CR 47 microemulsion) 87 CLODERM PUMP 62 CORGARD 48 CYMBALTA 22 clomipramine hcl 22 CORIFACT 77 cyproheptadine hcl 28 clonazepam 17 CORLANOR 50 CYRAMZA 36 clonidine hcl 31 53 76CORTEF CYSTAGON clonidine hcl (adhd) 1 CORTENEMA 10 CYSTARAN 94 clopidogrel bisulfate 78 CORTIFOAM 10 cytarabine 35 clorazepate dipotassium 12 cortisone acetate 53 CYTARABINEAQUEOUS 35 CLORPRES 32 CORTISPORIN 59 CYTOMEL 100 clotrimazole 88 32 103CORZIDE CYTOTEC clotrimazole w COSENTYX 60 DHE 45 84betamethasone 59 COSENTYX SENSOREADY dacarbazine 39clozapine 43 PEN 60 DACOGEN 35CLOZAPINE ODT 43 COSOPT 90

DAKLINZA 46CLOZARIL 43 COSOPT PF 90 dalfampridine 98COARTEM 33 COTELLIC 37

Index 5

DALIRESP 14 desogestrel-ethinyl estradiol diclofenac sodium (ophth) 94 (biphasic) 51DALLERGY 55 diclofenac sodium (topical) 59desogestrel-ethinyl estradiol

danazol 9 diclofenac w misoprostol 4(triphasic) 51 DANTRIUM 89 DESONATE 63 dicloxacillin sodium 96 dantrolene sodium 89 desonide 63 dicyclomine hcl 101 dapsone 11 DESOWEN 63 didanosine 44 dapsone (topical) 57 desoximetasone 63 DIFFERIN 57 DARAPRIM 33 DESOXYN 1 DIFICID 82 darifenacin hydrobromide 103 DESVENLAFAXINE ER 22 diflorasone diacetate 63 DAURISMO 36 desvenlafaxine succinate 22 DIFLUCAN 28 DAYPRO 3 DETROL 103 diflunisal 6 DAYTRANA 2 DETROL LA 103 digoxin 49 DDAVP 72 dexamethasone 53 dihydroergotamine mesylate 84 decitabine 35 DEXAMETHASONE 53 DILANTIN 20 DECON-G 55 dexamethasone 53 DILANTIN INFATABS 20 DELSTRIGO 44 DEXAMETHASONE 54 DILANTIN-125 20 DELZICOL 74 dexamethasone 54 DILATRATE SR 11 DEMADEX 68 DEXAMETHASONE DILAUDID 6 demeclocycline hcl DEMEROL DEMSER DENAVIR

99 6

31 61

INTENSOL 53 DEXAMETHASONE SODIUM PHOSPHATE 93 DEXEDRINE 1 DEXILANT 102

diltiazem hcl 49 diltiazem hcl coated beads 4849 diltiazem hcl extended release beads 49

DEPAKENE 20 DEPAKOTE 20 DEPAKOTE ER 20 DEPAKOTE SPRINKLES 20 DEPEN TITRATABS 87 DEPO-PROVERA 36 DEPO-PROVERA CONTRACEPTIVE 53 DEPO-SUBQ PROVERA 104 53 DEPOCYT 35 DERMA-SMOOTHEFSBODY 63 DERMA-SMOOTHEFSSCALP 63 DERMATOP 63 DERMOTIC 95 DESCOVY 44 desipramine hcl 22 desmopressin acetate 72 desmopressin acetate spray 72 desmopressin acetate sprayrefrigerated 72 DESOGEN 51 desogestrel amp ethinylestradiol 51

dexmethylphenidate hcl 2 DEXPAK 10 DAY 54 DEXPAK 13 DAY 54 DEXPAK 6 DAY 54 dexrazoxane 40 dextroamphetamine sulfate 1 DFSMSMENTHCAPPAK 59 DIAMOX 68 DIASTAT ACUDIAL 17 DIASTAT PEDIATRIC 17 DIATHRIVE BLOOD GLUCOSE TEST STRIPS 67 diazepam 12 DIAZEPAM 12 diazepam 12 DIAZEPAM 17 diazepam (anticonvulsant) 17 DIAZEPAM RECTAL GEL 18 DIBENZYLINE 31 DICLEGIS 27 diclofenac potassium 3 diclofenac sodium 3 diclofenac sodium (actinickeratoses) 60

DILTIAZEM HYDROCHLORIDE DIOVAN DIOVAN HCT DIPENTUM diphenhydramine hcl diphenoxylate w atropine DIPROLENE DIPROLENE AF dipyridamole DISALCID disopyramide phosphate disulfiram DITROPAN XL DIURIL divalproex sodium DIVIGEL dobutamine hcl dobutamine in d5w DOCEFREZ DOCETAXEL docetaxel DOCETAXEL dofetilide

49 31 32 74 28 26 63 63 78 6

13 96

103 69 20 73

105 105 40 40 40 40 13

Index 6

DOLOPHINE 6 DUTOPROL 32 EMTRIVA 44 DOMETUSS-DMX 55 DYANAVEL XR 1 EMVERM 10 donepezil hydrochloride 97 DONNATAL 101 dopamine hcl 105 DOPAMINE HCL 105 dopamine in d5w 105 DORAL 80 DORIBAX 11 DORIPENEM 11 DORYX 99 DORYX MPC 99 DORZOLAMIDE HCL 94 dorzolamide hcl 94 dorzolamide hcl-timolol maleate 90 DORZOLAMIDE HCLTIMOLOLMALEATE 90 DOVONEX 60 doxazosin mesylate 31 doxepin hcl 22 doxepin hcl (antipruritic) 60 doxercalciferol 71 DOXYCYCLINE 66 doxycycline (monohydrate) 99 doxycycline hyclate 99 DOXYCYCLINE HYCLATE 99 doxycycline hyclate 99100 DRISDOL 105 dronabinol 27 drospirenone-ethinylestradiol 51 drospirenone-ethinyl estradiol-levomefolate calcium 52 DROXIA 79 DRYSOL 66 DUAC 57 DUAVEE 72 DUETACT 23 DUEXIS 4 DULERA 15 duloxetine hcl 22 DUOPA 41 DURAGESIC 6 DURAXIN 5 DUREZOL 93 dutasteride 76 dutasteride-tamsulosin hcl 76

DYAZIDE 68 DYMISTA 89 DYRENIUM 68 EES GRANULES 82 EC-NAPROSYN 4 econazole nitrate 59 ECOZA 59 EDARBI 31 EDARBYCLOR 32 EDECRIN 68 EDLUAR 80 EDURANT 44 efavirenz 44 EFFER-K 86 EFFEXOR XR 22 EFFIENT 78 EFUDEX 60 ELAVIL 22 ELDEPRYL 42 ELESTAT 94 ELESTRIN 73 eletriptan hydrobromide 84 ELIDEL 65 ELIMITE 66 ELIPHOS 75 ELIQUIS 16 ELIQUIS STARTER PACK 16 ELIXOPHYLLIN 16 ELLA 53 ELLENCE 37 ELMIRON 76 ELOCON 63 ELOCTATE 77 EMADINE 94 EMBEDA 6 EMBRACE TALK BLOOD GLUCOSE MONITOR 82 EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM 82 EMBRACE TALK BLOOD GLUCOSE TEST STRIPS 67 EMCYT 36 EMEND 27 EMEND TRIPACK 27 EMSAM 21

ENABLEX 103 enalapril maleate 31 enalapril maleate amphydrochlorothiazide 32 ENBREL 5 ENBREL SURECLICK 5 enoxaparin sodium 16 ENSTILAR 63 entacapone 41 entecavir 46 ENTEREG 75 ENTOCORT EC 54 ENTRESTO 49 ENVARSUS XR 87 EPANED 31 EPCLUSA 46 EPHEDRINE SULFATE 105 EPIDIOLEX 18 EPIDUO 57 EPIDUO FORTE 57 EPIFOAM 63 epinastine hcl (ophth) 94 EPINEPHRINE 105 epinephrine (anaphylaxis) 105 EPIPEN 2-PAK 105 EPIPEN-JR 2-PAK 105 epirubicin hcl 37 EPIVIR 44 EPIVIR HBV 46 eplerenone 33 EPOGEN 79 epoprostenol sodium 50 EPROSARTAN MESYLATE 31 EPZICOM 44 EQUETRO 42 ERBITUX 36 ergocalciferol 105 ERGOLOID MESYLATES 98 ERGOMAR 84 ergotamine w caffeine 83 ERIVEDGE 36 ERTACZO 59 ERWINAZE 39 ERY-TAB 82

Index 7

ERYGEL 57 EXFORGE HCT 32 FETZIMA 22 ERYPED 200 82 EXJADE 26 FETZIMA TITRATION PACK22 ERYPED 400 82 EXPAREL 81 FEXMID 88 ERYTHROCIN STEARATE 82 EXTAVIA 98 FIASP 24 erythromycin (acne aid) 57 EXTINA 59 FIASP FLEXTOUCH 24 erythromycin (ophth) 92 ezetimibe 30 FIBRICOR 29 erythromycin base 82 ezetimibe-simvastatin 29 FINACEA 66 erythromycin ethylsuccinate 82 FABIOR 57 finasteride 76 ESBRIET 99 FACTIVE 73 FIORICET 5 escitalopram oxalate 21 famciclovir 47 FIORICETCODEINE 8 ESGIC 5 famotidine 101 FIORINAL 5 esomeprazole magnesium 102 FAMVIR 47 FIORINALCODEINE 3 8 ESOMEPRAZOLE FANAPT 42 FIRAZYR 78 STRONTIUM 102 FANAPT TITRATION FIRMAGON 36estazolam 80 PACK 42 FIRST-LANSOPRAZOLE 102esterified estrogens amp FARESTON 36 FIRST-MOUTHWASH BLM 88methyltestosterone 72 FARXIGA 26ESTRACE 73104 FIRST-OMEPRAZOLE 102

FARYDAK 37estradiol 73 FIRST-TESTOSTERONE 9

FASLODEX 36estradiol amp norethindrone FLAGYL 10FAZACLO 43acetate 72 FLAREX 93

estradiol vaginal 104 FEIBA 77 flavoxate hcl 104 ESTRING 104 felbamate 19 flecainide acetate 13 ESTROGEL 73 FELBATOL 19 FLECTOR 59 ESTROPIPATE 73 FELDENE 4 FLOLAN 50 estropipate 73 felodipine 49 FLOMAX 76 ESTROSTEP FE 52 FEM PH 104 FLONASE ALLERGY eszopiclone 80 FEMARA 36 RELIEF 89 ethacrynic acid 68 FEMCAP 82 FLONASE ALLERGY RELIEF

CHILDRENS 89ethambutol hcl 34 FEMCON FE 52 FLONASE SENSIMIST 89

ethosuximide 20 FEMHRT LOW DOSE 72 FLOVENT DISKUS 14ethynodiol diacet amp eth FEMRING 104 FLOVENT HFA 14estrad 52 FENOFIBRATE 29

etidronate disodium 69 FLOWTUSS 55fenofibrate 29 etodolac 4 FLOXIN OTIC 95fenofibrate micronized 29 etoposide 40 floxuridine 35FENOFIBRIC ACID 29 EVAMIST 73 fluconazole 28FENOGLIDE 29 EVEKEO 1 flucytosine 28FENOPROFEN CALCIUM 4 EVISTA 71 fludarabine phosphate 35fenoprofen calcium 4 EVOCLIN 57 fludrocortisone acetate 54FENORTHO 4 EVOTAZ 44 FLUMADINE 47fentanyl 6 EVOXAC 88 FLUNISOLIDE 89fentanyl citrate 6 EVZIO 27 fluocinolone acetonide 63FENTANYL CITRATE 6 EXALGO 6 fluocinolone acetonide (otic) 95FENTANYL CITRATESODIUMEXELDERM 59 CHLORIDE 6 fluocinonide 63 EXELON 97 FENTORA 6 fluocinonide emulsified base 63 exemestane 36 FERRIPROX 26 FLUORABON 86 EXFORGE 32 ferrous fumarate-folic acid 79 fluorescein sodium topical 94

Index 8

fluorescein w benoxinate fluorescein w proparacaine fluorometholone (ophth)

94 94 93

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS FREESTYLE LIBRE 14

67

GENVOYA GEODON GIAZO

44 42 74

FLUOROPLEX fluorouracil FLUOROURACIL fluorouracil (topical)

60 35 60 60

DAYREADERFLASHMONITORING SYSTEM 82 FREESTYLE LITE TEST STRIPS 67 FREESTYLE PRECISION NEO

GILENYA GILOTRIF glatiramer acetate GLEEVEC

98 38 98 38

FLUOXETINE 98 BLOOD GLUCOSE GLEOSTINE 35 FLUOXETINE DR fluoxetine hcl

21 21

MONITORING SYSTEM FREESTYLE TEST STRIPS

82

67

glimepiride glipizide

26 26

fluoxetine hcl (pmdd) FLUOXETINE HYDROCHLORIDE fluphenazine hcl flurandrenolide FLURAZEPAM HCL flurazepam hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate(nasal) fluvastatin sodium fluvoxamine maleate FML FML FORTE FML LIQUIFILM FOCALIN FOCALIN XR folic acid FOLOTYN fondaparinux sodium FORFIVO XL FORTAMET FORTEO FORTESTA FOSAMAX FOSAMAX PLUS D fosamprenavir calcium fosinopril sodium fosinopril sodium amphydrochlorothiazide FOSRENOL FRAGMIN FREAMINE HBC 69 FREESTYLE INSULINX BLOODGLUCOSE TEST

98

21 43 63 80 80 4

94 36 63

89 30 21 93 93 93 2 2

79 35 16 20 23 69 9

69 69 44 31

32 75 16 90

67

FROVA 84 frovatriptan succinate 84 FUL-GLO 94 FULPHILA 79 FURADANTIN 103 furosemide 68 FUROSEMIDE 68 furosemide 68 FUSILEV 40 FUZEON 44 FYCOMPA 17 gabapentin 18 GABITRIL 19 GALAFOLD 71 galantamine hydrobromide 97 GALANTAMINE HYDROBROMIDE 97 galantamine hydrobromide 97 GALZIN 87 GASTROCROM 74 gatifloxacin (ophth) 92 GATTEX 75 GAZYVA 36 GELNIQUE 103 GELNIQUE PUMP 104 gemcitabine hcl 35 gemfibrozil 29 GEMZAR 35 GENERESS FE 52 GENOTROPIN 70 GENOTROPIN MINIQUICK 70 GENTAK 92 gentamicin sulfate (ophth) 92 gentamicin sulfate (topical) 59 GENTAMICIN SULFATE09SODIUM CHLORIDE 2

glipizide-metformin hcl 23 GLUCAGEN HYPOKIT 23 GLUCAGON EMERGENCY KIT 23 GLUCOPHAGE 23 GLUCOPHAGE XR 23 GLUCOTROL 26 GLUCOTROL XL 26 GLUCOVANCE 23 GLUMETZA 23 glyburide 26 glyburide micronized 26 glyburide-metformin 23 GLYCATE 101 GLYCOLIC ACID 61 GLYCOLIC ACID 70 HIGH PURITY 61 GLYCOPYRROLATE 101 glycopyrrolate 101 GLYCOPYRROLATE 101 GLYNASE 26 GLYSET 22 GLYXAMBI 23 GOLYTELY 81 GRALISE 98 GRALISE STARTER 98 granisetron hcl 27 GRANIX 79 GRIS-PEG 28 griseofulvin microsize 28 griseofulvin ultramicrosize 28 guaifenesin 56 guaifenesin-codeine 55 guanfacine hcl 31 guanfacine hcl (adhd) 1 GUANIDINE HCL 34

Index 9

GUARDIAN REAL-TIME REPLACEMENT MONITOR PEDIATRIC 83 GYNAZOLE-1 104 HP ACTHAR 69 HALAVEN 40 HALCION 80 halobetasol propionate 63 HALOG 63 haloperidol 43 haloperidol lactate 43 HARVONI 46 HECTOROL 71 HELIXATE FS 77 HEMANGEOL 48 HEMOFIL M 77 heparin (porcine) in sodiumchloride 16 HEPARIN LOCK FLUSH 16 heparin sod (porcine) in d5w 16 HEPARIN SODIUM 17 heparin sodium (porcine) 17 heparin sodium (porcine) lockflush 16 heparin sodium (porcine) lockflush amp nacl lock flush 16 HEPARIN SODIUMD5W 17 HEPARIN SODIUMDEXTROSE 17 HEPARIN SODIUMNACL045 17 HEPARIN SODIUMSODIUMCHLORIDE 17 HEPARIN SODIUMSODIUMCHLORIDE 09 17 HEPSERA 46 HETLIOZ 80 HEXALEN 35 HIPREX 103 homatropine hbr 91 HORIZANT 98 HUMALOG 24 HUMALOG JUNIOR KWIKPEN 24 HUMALOG KWIKPEN 24 HUMALOG MIX 5050 24 HUMALOG MIX 5050KWIKPEN 24 HUMALOG MIX 7525 24 HUMALOG MIX 7525KWIKPEN 24

HUMAPEN LUXURA HD 83 HUMATE-P 77 HUMATROPE 70 HUMATROPE COMBO PACK 70 HUMIRA 3 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 3 HUMIRA PEN 3 HUMIRA PEN-CDUCHSSTARTER 3 HUMIRA PEN-PSUVSTARTER 3 HUMULIN 7030 25 HUMULIN 7030KWIKPEN 25 HUMULIN N 25 HUMULIN N KWIKPEN 25 HUMULIN R 25 HUMULIN R U-500 (CONCENTRATED) 25 HUMULIN R U-500 KWIKPEN 25 HW EMBRACE PRO BLOOD GLUCOSE METER 83 HW EMBRACE PRO BLOOD GLUCOSE TEST STRIPS 67 HW EMBRACE TALK BLOOD GLUCOSE MONITOR 83 HW EMBRACE TALK BLOOD GLUCOSE MONITORING SYSTEM 83 HW EMBRACE TALK BLOOD GLUCOSE TEST STRIPS 67 HYCAMTIN 40 HYCOFENIX 55 hydralazine hcl 33 HYDREA 39 hydrochlorothiazide 69 HYDROCODONE BITARTRATEACETAMINOPHEN 8 HYDROCODONE BITARTRATECHLORPHENIRAMINE MALEATEPSE 55 HYDROCODONE BITARTRATEGUAIFENESIN

55 hydrocodone polistirex-chlorpheniramine polistirex 55 hydrocodone whomatropine 54 hydrocodone-acetaminophen 8 hydrocodone-ibuprofen 8

hydrocortisone 54 hydrocortisone (intrarectal) 10 hydrocortisone (rectal) 10 hydrocortisone (topical) 6364 hydrocortisone acetate(rectal) 10 hydrocortisone acetate wpramoxine 10 hydrocortisone butyrate 64 hydrocortisone butyratehydrophilic lipo base 64 hydrocortisone valerate 64 hydrocortisone wacetic acid 95 hydromorphone hcl 6 hydroxychloroquine sulfate 33 hydroxyurea 39 hydroxyzine hcl 12 hydroxyzine pamoate 12 HYOPHEN 103 hyoscyamine sulfate 101 HYPER-SAL 56 HYPERSAL 56 HYQVIA 95 HYSINGLA ER 6 HYZAAR 32 ibandronate sodium 69 IBRANCE 38 ibuprofen 4 ICLUSIG 38 IDAMYCIN PFS 37 idarubicin hcl 37 IDELVION 77 IDHIFA 38 IFEX 35 ifosfamide 35 ILARIS 3 ILEVRO 94 ILUMYA 61 imatinib mesylate 38 IMBRUVICA 38 imipramine hcl 22 imipramine pamoate 22 imiquimod 65 IMIQUIMOD PUMP 65 IMITREX 84 IMITREX STATDOSE REFILL 84

Index 10

IMITREX STATDOSE IPRIVASK 17 JEVTANA 40 SYSTEM 84 irbesartan 31 JUBLIA 59IMPAVIDO 10 irbesartan-hydrochlorothiazide JUXTAPID 30IMURAN 87 32 K-BICARB 86INCRELEX 71 IRESSA 38 K-PHOS 86INCRUSE ELLIPTA 13 IRINOTECAN 41 K-PHOS NEUTRAL 86indapamide 69 irinotecan hcl 40 K-PHOS NO 2 75INDERAL LA 48 ISENTRESS 44 K-TAB 86INDERAL XL 48 ISOLYTE-PDEXTROSE

KADCYLA 365 86INDOCIN 4 ISOLYTE-S 86 KADIAN 6

indomethacin 4 ISOLYTE-S PH 74 86 KALETRA 44

INGREZZA 97 ISOMETHEPTENE KALYDECO 99INLYTA 38 MUCATECAFFEINEACETAMI KAPSPARGO SPRINKLE 48INNOPRAN XL 48 NOPHEN 83 KAPVAY 1isometheptene-caffeine-INPEN 100BLUELILLY 83

acetaminophen 83 KARBINAL ER 28INPEN 100BLUENOVO 83 isometheptene- KAZANO 23INPEN 100GRAYLILLY 83 dichloralphenazone- KCL 03D5WNACL 09 86INPEN 100GREYNOVO 83 acetaminophen 83 KEFLEX 50ISOMETHEPTENEDICHLORAINPEN 100PINKLILLY 83 LPHENAZONEACETAMINOP KENALOG 64INPEN 100PINKNOVO 83 HEN 83 KEPPRA 18INSPRA 33 ISONIAZID 34 KEPPRA XR 18INSULIN SYRINGES AND PEN isoniazid 34 KERYDIN 59NEEDLES 83 ISOPTO ATROPINE 91 KETAMINEINTELENCE 44

ISOPTO CARPINE 91 HYDROCHLORIDE 75INTERMEZZO 80 ISORDIL TITRADOSE 1112 KETOCARE 67

INTRON A 39 isosorbide dinitrate 12 ketoconazole 28

INTRON A WDILUENT 39 ISOSORBIDE DINITRATE ketoconazole (topical) 59INTUNIV 1 ER 12 KETONE TEST STRIPS 67INVEGA 42 isosorbide mononitrate 12 KETOPROFEN 4INVEGA SUSTENNA 42 isotretinoin 57 ketoprofen 4INVEGA TRINZA 42 isoxsuprine hcl 49 KETOPROFEN 4INVELTYS 93 ISOXSUPRINE HCL 49 ketoprofen 4INVIRASE 44 isradipine 49 ketorolac tromethamine 4INVOKAMET 23 ISTALOL 90 ketorolac tromethamine INVOKAMET XR 23 ISTODAX (OVERFILL) 38 (ophth) 94 INVOKANA 26 itraconazole 28 KETOSTIX 67 IODINE STRONG 86 ivermectin 10 KEVEYIS 68 IODOFLEX 44 IXINITY 77 KEYTRUDA 36 iodoquinol-hc 59 JADENU 26 KHAPZORY 40 IONOSOL-BDEXTROSE KHEDEZLA 22JAKAFI 385 85 KITABIS PAK 2IONOSOL-MBDEXTROSE JALYN 76 5 86 JANUMET 23 KLARON 57 IONSYS 6 JANUMET XR 23 KLONOPIN 18 IOPIDINE 91 JANUVIA 24 KLOR-CON M15 86 ipratropium bromide 13 JARDIANCE 26 KLOR-CON25 86

KMART VALU PLUS INSULINipratropium bromide (nasal) 89 JENTADUETO 23 SYRINGE03ML30G 83ipratropium-albuterol 15 JENTADUETO XR 23

Index 11

KMART VALU PLUS INSULIN SYRINGE05ML29G 83 KMART VALU PLUS INSULIN SYRINGE05ML30G 83 KOATE 77 KOATE-DVI 77 KOGENATE FS 77 KOGENATE FS BIO-SET 77 KOMBIGLYZE XR 23 KORLYM 23 KOVALTRY 77 KRISTALOSE 81 KUVAN 71 KYNAMRO 29 KYPROLIS 38 L-TRYPTOPHAN 90 labetalol hcl 47 LABETALOL HYDROCHLORIDESODIUMCHLORIDE 47 lactic acid (ammoniumlactate) 65 lactulose 81 lactulose (encephalopathy) 75

LATANOPROST 95 latanoprost 95 LATUDA 42 LAZANDA 6 LEDIPASVIRSOFOSBUVIR

46 leflunomide 5 LENVIMA 10 MG DAILY DOSE 38 LENVIMA 12MG DAILY DOSE 38 LENVIMA 14 MG DAILY DOSE 38 LENVIMA 18 MG DAILY DOSE 38 LENVIMA 20 MG DAILY DOSE 38 LENVIMA 24 MG DAILY DOSE 38 LENVIMA 4 MG DAILY DOSE 38 LENVIMA 8 MG DAILY DOSE 38 LESCOL XL 30 LETAIRIS 50 letrozole 36

levonorgestrel-eth estradiol(triphasic) 52 levonorgestrel-ethinyl estradiol(91-day) 52 levonorgestrel-ethinyl estradiol(continuous) 52 levorphanol tartrate 6 levothyroxine sodium 100 LEVSIN 101 LEVSINSL 101 LEVULAN KERASTICK 60 LEXAPRO 21 LEXETTE 64 LEXIVA 45 LIALDA 74 LIBRAX 101 lidocaine 66 lidocaine hcl 66 LIDOCAINE HCL 88 lidocaine hcl (mouth-throat) 88 lidocaine-hydrocortisone acetate(rectal) 10 lidocaine-prilocaine 66 LIDODERM 66

LAMICTAL 18 LEUCOVORIN CALCIUM 40 LIDOPIN 66 LAMICTAL CHEWABLE DISPERSIBLE 18 LAMICTAL ODT 18 LAMICTAL STARTERNOTTAKING CARBAMAZEPINE 18

leucovorin calcium LEUCOVORIN CALCIUM leucovorin calcium LEUKERAN

40 40 40 35

LIDOVEX LILETTA LINDANE lindane

66 53 66 66

LAMICTAL STARTERTAKINGCARBAMAZEPINENOT TAKINGVALPROATE 18 LAMICTAL STARTERTAKINGVALPROATE 18 LAMICTAL XR 18

LEUKINE 79 leuprolide acetate 36 LEUPROLIDE ACETATEBUPIVACAINEHYDROCHLORIDE 36 levalbuterol hcl 15

linezolid LINZESS liothyronine sodium LIPITOR LIPOFEN

11 75

100 30 29

LAMISIL 28 lamivudine 44 lamivudine (hbv) 46 lamivudine-zidovudine 45 lamotrigine 1819 LANCETS AND LANCET DEVICES 83 LANOXIN 49 lansoprazole 102 lanthanum carbonate 75 LANTUS 25

levalbuterol tartrate 15 LEVAQUIN 73 LEVEMIR 25 LEVEMIR FLEXTOUCH 25 levetiracetam 19 levobunolol hcl 90 levocarnitine (metabolicmodifiers) 71 levofloxacin 7374 levofloxacin (ophth) 92 levoleucovorin calcium 40

lisinopril lisinopril amphydrochlorothiazide LITHIUM lithium carbonate LITHOBID LITHOSTAT LIVALO LO LOESTRIN FE LOCOID LOCOID LIPOCREAM

31

32 42 42 42 76 30 52 64 64

LANTUS SOLOSTAR LASIX LASTACAFT

25 68 94

levonorgestrel amp ethestradiol 52 levonorgestrel (emergencyoc) 53

LODINE LODOSYN LOESTRIN 1530-21

4 41 52

Index 12

LOESTRIN 120-21 52 LURIDE 86 melphalan 35 LOESTRIN FE 1530 52 LUXIQ 64 memantine hcl 97 LOESTRIN FE 120 52 LUZU 59 MENEST 73 LOFIBRA 30 LYNPARZA 38 MENOSTAR 73 LOHIST-DM LOKELMA

55 88

LYRICA LYRICA CR

19 98

meperidine hcl MEPERIDINE

6

HCLPROMETHAZINE HCL 8LOMOTIL 26 LYSODREN 37 MEPHYTON 105LONSURF 37 LYSTEDA 80 meprobamate 12LOPID 30 M-CLEAR WC 55 MEPRON 11lopinavir-ritonavir 45 MACROBID 103 mercaptopurine 35LOPRESSOR 48 MACRODANTIN 103 meropenem 11LOPRESSOR HCT 32 mafenide acetate 61 MERREM 11LOPROX 59 MAGNEBIND 400 86 mesalamine 74LOPROX SHAMPOO 59 MAKENA 96 mesna 40lorazepam 12 MALARONE 33 MESNEX 40LORBRENA 38 malathion 67 MESTINON 34LORTAB 8 maprotiline hcl 20 MESTINON TIMESPAN 34LORZONE 88 MAPROTILINE HCL 20 METADATE CD 2losartan potassium 31 MARINOL 27 metaproterenol sulfate 15losartan potassium amp MARPLAN 21

hydrochlorothiazide 32 METASTRON 39MARQIBO 40LOSEASONIQUE 52 METAXALONE 88MATULANE 39LOTEMAX 93 metaxalone 89MAVIK 31LOTENSIN 31 metformin hcl 23MAXALT 85LOTENSIN HCT 32 METFORMIN

MAXALT-MLT 85 HYDROCHLORIDE 23LOTREL 32 MAXIDEX 93 methadone hcl 6LOTRISONE 59 MAXITROL 93 METHADONE HCL 7LOTRONEX 75 MAXZIDE 68 methadone hcl 7lovastatin 30 MAXZIDE-25 68 methamphetamine hcl 1LOVAZA 29 MECLOFENAMATE methazolamide 68LOVENOX 17 SODIUM 4 methenamine hippurate 103loxapine succinate 43 MEDROL 54 methenamine mandelate 103LOZI-FLUR 86 MEDROL DOSEPAK 54 methenamine-hyosc-methylene

LUCENTIS 91 medroxyprogesterone blue-benzoic acid-phenylacetate 96LULICONAZOLE 59 sal 103medroxyprogesterone acetate methenamine-hyosc-methyleneLUMIGAN 95 (contraceptive) 53 blue-sod phos-phenyl sal 103LUNESTA 80 mefenamic acid 4 methimazole 100LUPANETA PACK 71 MEFLOQUINE HCL 34 METHITEST 9LUPRON DEPOT (1- mefloquine hcl 34 methocarbamol 89MONTH) 37 MEGACE ES 96LUPRON DEPOT (3- methotrexate sodium 35 MONTH) 37 MEGACE ORAL 37 METHOTREXATE SODIUM 35LUPRON DEPOT (4- megestrol acetate 37 methotrexate sodium 35MONTH) 37 megestrol acetateLUPRON DEPOT-PED (1- methoxsalen rapid 61(appetite) 96MONTH) 71 MEKINIST 38 methscopolamine bromide 101 LUPRON DEPOT-PED (3-

MEKTOVI 38 methyclothiazide 69MONTH) 71 meloxicam methyldopa 31LURADROX 67 4

Index 13

methyldopa amphydrochlorothiazide 32 methylergonovine maleate 95 METHYLIN 2 methylphenidate hcl 2 METHYLPHENIDATE HYDROCHLORIDE ER 2 METHYLPHENIDATE HYDROCHLORIDE ER (LA) 2 methylprednisolone 54 METHYLTESTOSTERONE 9

miglustat MIGRANAL MILLIPRED MILLIPRED DP MINASTRIN 24 FE MINIPRESS MINIVELLE MINOCIN minocycline hcl MINOCYCLINE

79 84 54 54 52 31 73

100 100

MORPHINE SULFATESODIUMCHLORIDE 7 MOTOFEN 26 MOVANTIK 75 MOVIPREP 81 MOXATAG 96 MOXEZA 92 moxifloxacin hcl 74 moxifloxacin hcl (ophth) 92 MOZOBIL 79

METIPRANOLOL 90 HYDROCHLORIDEER 100 MS CONTIN 7 metoclopramide hcl METOCLOPRAMIDE ODT

74 74

MINOLIRA minoxidil

100 33

MULPLETA MULTAQ

79 13

metolazone 69 MIRAPEX 41 mupirocin 59 metoprolol amphydrochlorothiazide 32 metoprolol succinate 48 METOPROLOL SUCCINATE ERHYDROCHLOROTHIAZIDE

32

MIRAPEX ER MIRCERA MIRCETTE MIRENA mirtazapine

41 79 52 53 20

mupirocin calcium (topical) MUSTARGEN MYALEPT MYAMBUTOL MYCOBUTIN

59 35 71 34 34

metoprolol tartrate 48 MIRVASO 66 mycophenolate mofetil 87 METOPROLOL TARTRATE 48 METOPROLOLHYDROCHLOROTHIAZIDE 32 METROCREAM 66 METROGEL 66 METROGEL-VAGINAL 104 METROLOTION 66 metronidazole 10 metronidazole (topical) 66 metronidazole in nacl 10 metronidazole vaginal 104 MEVACOR 30 mexiletine hcl 13 MIACALCIN 69 MICARDIS 31 MICARDIS HCT 33

misoprostol 103 MITIGARE 76 mitomycin 37 mitoxantrone hcl 37 MOBIC 4 modafinil 2 MODERIBA 1200 DOSE PACK 46 MODERIBA 800 DOSE PACK 46 moexipril hcl 31 moexipril-hydrochlorothiazide

33 MOEXIPRILHYDROCHLOROTHIAZIDE 33 MOLINDONE HYDROCHLORIDE 43 mometasone furoate 64

mycophenolate sodium 87 MYDRIACYL 91 MYFORTIC 87 MYLERAN 35 MYRBETRIQ 104 MYSOLINE 19 MYTESI 26 N-ACETYL-L-CARNOSINE 51 nabumetone 4 nadolol 48 nadolol amp bendroflumethiazide 33 NAFRINSE DAILYACIDULATED 88 NAFRINSE DAILYNEUTRAL 88 naftifine hcl 60

MICONAZOLE 3 104 mometasone furoate NAFTIN 60 MICONAZOLE NITRATEZINCOXIDEWHITEPETROLATUM 60 MICRO-K 86 MICROZIDE 69 midazolam hcl 80 MIDAZOLAMSODIUMCHLORIDE 80

(nasal) MONOCLATE-P MONODOX MONONINE montelukast sodium MONUROL morphine sulfate

89 77

100 77 13

103 7

NALFON 4 NALOCET 8 NALTREXONE 27 naltrexone hcl 27 NAMENDA 97 NAMENDA TITRATION PAK97 NAMENDA XR 97

midodrine hcl 105 MORPHINE SULFATE 7 NAMENDA XR TITRATION MIGERGOT miglitol

84 22

morphine sulfate MORPHINE SULFATE ER

7 7

PACK NAMZARIC

97 97

Index 14

NAPRELAN 4 NEVANAC 94 norethindrone amp ethinyl estradiol-fe 52NAPROSYN 4 nevirapine 45 norethindrone amp mestranol 52 naproxen 4 NEXAVAR 38 norethindrone

naproxen sodium 4 NEXIUM 102 (contraceptive) 53 naratriptan hcl 85 NEXIUM 24HR 102 norethindrone acet amp eth NARCAN 27 NEXIUM 24HR CLEAR estra 52

NARDIL 21 NASCOBAL 79 NASONEB NASAL NEBULIZER REPLACEMENT 83 NASONEB NASAL NEBULIZER STARTER KIT 83 NASONEX 89 NATACYN 92 NATAZIA 52 nateglinide 26 NATESTO 9 NATPARA 69 NATROBA 67 NATURE-THROID 100 NATURE-THROID NT-25 100 NAVELBINE 40 NEBUPENT 10 NEBUSAL 56 NECON 1011-28 52 nefazodone hcl 21 NEFAZODONE HYDROCHLORIDE 22 NEO-SYNALAR 59 neomycin sulfate 2 neomycin-bacitracin zn-polymyxin 92 neomycin-polymy-dexameth 93 neomycin-polymyxin-gramicidin

92 neomycin-polymyxin-hc(ophth) 93 neomycin-polymyxin-hc(otic) 95 NEORAL 87 NEOSPORIN 92 NEPHRAMINE 90 NEPTAZANE 68 NESINA 24

MINIS 102 niacin (antihyperlipidemic) 30 NIASPAN 30 nicardipine hcl 49 NICODERM CQ 98 nicotine 99 NICOTROL INHALER 99 NICOTROL NS 99 nifedipine 49 NILANDRON 37 nilutamide 37 nimodipine 49 NINLARO 38 NIPENT 39 nisoldipine 49 NISOLDIPINE ER 49 NITRO-BID 12 NITRO-DUR 12 nitrofurantoin 103 nitrofurantoin macrocrystal 103 nitrofurantoin monohyd macro 103 nitroglycerin 12 NITROGLYCERIN LINGUAL 12 NITROLINGUAL PUMPSPRAY 12 NITROMIST 12 NITROSTAT 12 NIVESTYM 79 nizatidine 101 NIZATIDINE 101 NIZORAL 60 NOCDURNA 72 NOR-QD 53 NORCO 8

norethindrone acetate 96 norethindrone acetate-ethinylestradiol 72 norethindrone acetate-ethinylestradiol-fe 52 norethindrone-eth estradiol (triphasic) 52 norgestimate-ethinylestradiol 52 norgestimate-ethinyl estradiol(triphasic) 52 norgestrel amp ethinyl estradiol 52 NORINYL 1+35 52 NORITATE 66 NORMOSOL -R 86 NORMOSOL-M IN D5W 86 NORMOSOL-R 86 NORMOSOL-R IN D5W 86 NORPACE 13 NORPACE CR 13 NORPRAMIN 22 NORTHERA 105 nortriptyline hcl 22 NORTUSS-EX 55 NORVASC 49 NORVIR 45 NOVOEIGHT 78 NOVOLIN 7030 25 NOVOLIN 7030 RELION 25 NOVOLIN N 25 NOVOLIN N RELION 25 NOVOLIN R 25 NOVOLIN R RELION 25 NOVOLOG 25 NOVOLOG FLEXPEN 25 NOVOLOG MIX 7030 25 NOVOLOG MIX 7030PREFILLED FLEXPEN 25

NEULASTA 79 NORDITROPIN FLEXPRO70 NOVOLOG PENFILL 25 NEULASTA ONPRO KIT NEUPOGEN NEUPRO

79 79 41

NOREPINEPHRINESODIUMCHLORIDE 105 norethin acet amp estrad-fe 52 norethindrone amp eth

NOVOPEN ECHO NOVOSEVEN RT NOXAFIL

83 78 28

NEURONTIN 19 estradiol 52 NUCALA 13

Index 15

NUCYNTA 7 OMEPRAZOLE + SYRSPEND OTIPRIO 95 SFALKA 102NUCYNTA ER 7 OTOVEL 95omeprazole-sodium

NUEDEXTA 98 OTREXUP 3bicarbonate 103 NULYTELYFLAVORPACKS 81 NUPLAZID 42 NUTROPIN AQ NUSPIN 10 70 NUTROPIN AQ NUSPIN 20 70 NUTROPIN AQ NUSPIN 5 70 NUVARING 53 NUVESSA 104 NUVIGIL 2 NUZYRA 99 NYMALIZE 49 nystatin 28 nystatin (mouth-throat) 88 nystatin (topical) 60 nystatin-triamcinolone 60 OBIZUR 78 OBREDON 55 OCALIVA 74 octreotide acetate 72 OCUFEN 94 OCUFLOX 92

OMNARIS 89 OMNIFLEX DIAPHRAGM 82 OMNIPRED 93 OMNITROPE 70 ONCASPAR 39 ondansetron 27 ondansetron hcl 27 ONETOUCH ULTRA BLUE 67 ONETOUCH VERIO TEST STRIPS 67 ONEXTON 57 ONFI 18 ONGLYZA 24 ONMEL 28 ONZETRA XSAIL 85 OPANA 7 OPANA ER (CRUSHRESISTANT) 7 OPDIVO 36 opium tincture 26 OPSUMIT 50

OVCON-35 53 OVIDE 67 oxaliplatin 35 OXANDRIN 9 oxandrolone 9 oxaprozin 4 OXAYDO 7 oxazepam 12 OXAZEPAM 12 oxcarbazepine 19 OXERVATE 92 oxiconazole nitrate 60 OXISTAT 60 OXSORALEN ULTRA 61 OXTELLAR XR 19 oxybutynin chloride 104 oxycodone hcl 7 OXYCODONE HCL ER 7 oxycodone w acetaminophen 8 OXYCODONEACETAMINOPHEN 8

ODOMZO 36 ORACEA 66 OXYCODONEIBUPROFEN 8 OFEV 99 ORACIT 75 OXYCONTIN 7 OFLOXACIN 74 ORAP 98 oxymorphone hcl 7 ofloxacin 74 ORAPRED ODT 54 OXYTROL 104 ofloxacin (ophth) 92 ORAVIG 88 OXYTROL FOR WOMEN 104 ofloxacin (otic) 95 ORENCIA 5 PACLITAXEL 40 olanzapine 43 ORENCIA CLICKJECT 5 paclitaxel 40 olanzapine-fluoxetine hcl 97 ORENITRAM 50 paliperidone 43 olmesartan medoxomil 31 olmesartan medoxomil-amlodipine-hydrochlorothiazide

33 olmesartan medoxomil-hydrochlorothiazide 33 olopatadine hcl 94 olopatadine hcl (nasal) 89

ORFADIN 71 ORILISSA 70 ORKAMBI 99 orphenadrine citrate 89 ORTHO MICRONOR 53 ORTHO TRI-CYCLEN 52 ORTHO TRI-CYCLEN LO 52

palonosetron hcl PALONOSETRON HYDROCHLORIDE PAMELOR PANCREAZE PANDEL PANOXYL-4 CREAMY WASH

27

27 22 68 64

57 OLUX 64 ORTHO-CYCLEN 53 PANRETIN 60 OLUX-E OLYSIO OMECLAMOX-PAK omega-3-acid ethyl esters

64 46

103 29

ORTHO-NOVUM 135 ORTHO-NOVUM 777 oseltamivir phosphate OSENI

53 53 47 23

pantoprazole sodium PARAFON FORTE DSC paregoric PAREMYD

102 89 26 94

OMEGAVEN omeprazole

90 102

OSPHENA OTEZLA

71 5

PARI SINUSTAR NASAL AEROSOL DELIVERY SYSTEM 83

Index 16

PARI SINUSTAR NASAL PEXEVA 21 POLYTRIM 92 NEBULIZER 83 paricalcitol 71 PARLODEL 41 PARNATE 21 paromomycin sulfate 2 paroxetine hcl 21 paroxetine mesylate(vasomotor) 99 PASER 34 PATADAY 94 PATANASE 89 PATANOL 94 PAXIL 21 PAXIL CR 21 PAZEO 94 PCE 82 PEDIAPRED 54 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 81 peg 3350-potassium chloride-sodbicarbonate-sod chloride 81 PEG-INTRON REDIPEN 46

phenazopyridine hcl 76 phenelzine sulfate 21 phenobarbital 80 phenobarbital-hyoscyamine-atropine-scopolamine 101 phenoxybenzamine hcl 31 phenylephrine hcl (ophth) 92 PHENYLEPHRINE HYDROCHLORIDE 105 PHENYLEPHRINE HYDROCHLORIDESODIUMCHLORIDE 105 phenylephrine w dm-gg 55 phenylephrine-brompheniramine-dm 55 PHENYLEPHRINEGUAIFENESIN 55 PHENYLHISTINE DH 55 PHENYTEK 20 phenytoin 20 phenytoin sodiumextended 20 PHOSLYRA 75

POMALYST 37 PONSTEL 4 pot amp sod citrates wcitric ac 75 pot phosphate monobasic w sodphosphate dibasic ampmonobasic 86 potassium bicarb amp chloride 86 potassium bicarbonate 86 potassium chloride 8687 POTASSIUM CHLORIDE 87 POTASSIUM CHLORIDE ER 87 potassium chloride in dextrose ampsodium chloride 86 potassium chloridemicroencapsulated crystals er 87 potassium citrate(alkalinizer) 75 potassium citrate-citricacid 7576 POTASSIUM CITRATESODIUMCITRATECITRIC ACID 76

PEGANONE 20 PHOSPHOLINE IODIDE 91 POTASSIUM HYDROXIDE 51 PEGASYS PEGASYS PROCLICK PEGINTRON penicillin v potassium

46 46 46 96

phytonadione PICATO PIFELTRO pilocarpine hcl

105 60 45 91

POTASSIUM PHOSPHATESDEXTROSE 86 POTASSIUM PHOSPHATESSODIUMCHLORIDE 86

PENICILLIN V POTASSIUM 96 pilocarpine hcl (oral) 88 POTELIGEO 36 penicillin v potassium 96 pimozide 98 POTIGA 19 PENLAC NAIL LACQUER 60 pindolol 48 PRADAXA 17 PENNSAID PENTASA pentazocine w naloxone pentoxifylline

59 74 9

78

pioglitazone hcl 24 pioglitazone hcl-glimepiride 23 pioglitazone hcl-metforminhcl 23

PRALUENT 30 pramipexole dihydrochloride 41 PRAMOSONE 64 PRAMOSONE E 64

PEPCID 102 PEPCID AC MAXIMUM STRENGTH 101 PERCOCET 8 PERFOROMIST 15 perindopril erbumine 31 PERJETA 36 permethrin 67 perphenazine 43 perphenazine-amitriptyline 97 PERPHENAZINEAMITRIPTYLINE 97 PERSERIS 43 PERTZYE 68

piroxicam PLAN B ONE-STEP PLAQUENIL PLASMA-LYTE A PLASMA-LYTE-148 PLASMA-LYTE-56D5W PLAVIX PLEGRIDY PLEGRIDY STARTER PACK PLENVU podofilox polymyxin b-trimethoprim

4 53 34 86 86 86 78 98

98 81 66 92

PRAMOTIC pramoxine hcl pramoxine-hc PRANDIN prasugrel hcl PRAVACHOL pravastatin sodium praziquantel prazosin hcl PRECISION XTRA BLOOD GLUCOSE TEST STRIPS PRECOSE PRED FORTE

95 66 64 26 78 30 30 10 32

67 23 93

Index 17

PRED MILD 93 PRED-G 93 PRED-G SOP 93 PREDNICARBATE 64 prednicarbate 64 PREDNISOLONE 54 prednisolone 54 prednisolone acetate (ophth) 93 PREDNISOLONE ACETATE P-F 93 prednisolone sodiumphosphate 54 PREDNISOLONE SODIUMPHOSPHATE 54 prednisolone sodiumphosphate 54 PREDNISOLONE SODIUMPHOSPHATE 93 PREDNISOLONE SODIUMPHOSPHATEBROMFENAC

93 PREDNISOLONE SODIUMPHOSPHATEGATIFLOXACIN

93 PREDNISOLONE SODIUMPHOSPHATEGATIFLOXACINBROMFENAC 93 PREDNISOLONEMOXIFLOXACIN 93 PREDNISOLONEMOXIFLOXACINBROMFENAC 93 PREDNISOLONEMOXIFLOXACINKETOROLAC 93 PREDNISONE 54 prednisone 54 PREDNISONE 54 prednisone 54 PREDNISONE INTENSOL 54 PREFERRED GLUCOMETERSUPPLIES AND STRIPS 67 PREFEST 72 PREMARIN 73104 PREMPHASE 73 PREMPRO 73 prenatal w calcium carbonate-vitb6-vit b12-folic acid 88 PREPOPIK 81 PRESTALIA 33 PREVACID 102 PREVACID SOLUTAB 102 PREVIDOLRX ANALGESICPAK 4 PREVPAC 103

PREZCOBIX 45 PREZISTA 45 PRIFTIN 34 PRIMAQUINEPHOSPHATE 34 primidone 19 PRIMLEV 8 PRIMSOL 10 PRINIVIL 31 PRISTIQ 22 PRO VOICE V8 BLOODGLUCOSE MONITORINGSYSTEM 83 PRO VOICE V8V9 BLOODGLUCOSE TEST STRIPS 67 PRO VOICE V9 BLOODGLUCOSE MONITORINGSYSTEM 83 PROAIR HFA 15 PROAIR RESPICLICK 15 probenecid 77 PROCALAMINE 90 PROCARDIA 49 PROCARDIA XL 49 PROCENTRA 1 prochlorperazine 43 prochlorperazine maleate 43 PROCORT 10 PROCRIT 79 PROCTOCORT 10 PROCTOFOAM HC 10 PROCYSBI 76 PRODRIN 84 PROFILNINE 78 PROFILNINE SD 78 progesterone micronized 96 PROGLYCEM 23 PROGRAF 87 PROLENSA 94 PROLIA 69 PROMACTA 79 promethazine ampphenylephrine 55 promethazine hcl 28 promethazine wcodeine 55 promethazine-dm 55 promethazine-phenylephrine-codeine 55 PROMETHAZINEPHENYLEPHRINE 55

PROMETHAZINEPHENYLEPHRINECODEINE 55 PROMETRIUM 96 propafenone hcl 13 PROPANTHELINEBROMIDE 101 proparacaine hcl 92 propranolol amphydrochlorothiazide 33 propranolol hcl 48 PROPRANOLOL HCL 48 propranolol hcl 48 propylthiouracil 100 PROSCAR 76 PROSOL 90 PROSTIN E2 95 PROTAMINE SULFATE 78 PROTONIX 102 PROTOPIC 65 protriptyline hcl 22 PROVENGE 36 PROVENTIL HFA 15 PROVERA 96 PROVIGIL 2 PROZAC 21 PROZAC WEEKLY 21 PRUDOXIN 60 pseudoephed-bromphen-dm 55 pseudoephed-cpm whydrocod 55 PSORCON 64 PULMICORT 14 PULMICORT FLEXHALER 14 PULMOZYME 99 PURIXAN 35 PYLERA 103 pyrazinamide 34 PYRIDIUM 76 pyridostigmine bromide 34 QBREXZA 66 QNASL 90 QNASL CHILDRENS 90 QUALAQUIN 34 QUARTETTE 53 QUAZEPAM 80 QUDEXY XR 19 QUESTRAN 29 QUESTRAN LIGHT 29

Index 18

quetiapine fumarate 43 QUILLICHEW ER 2 QUILLIVANT XR 2 quinapril hcl 31 quinapril-hydrochlorothiazide

33 quinidine gluconate 13 QUINIDINE SULFATE 13 quinine sulfate 34 QVAR 1415 rabeprazole sodium 102 RADIOGARDASE 26 raloxifene hcl 71 ramipril 31 RANEXA 11 ranitidine hcl 102 RAPAFLO 76 RAPAMUNE 8788 rasagiline mesylate 42 RASUVO 3 RAVICTI 71 RAYOS 54 RAZADYNE 97 RAZADYNE ER 97 REBETOL 46 REBIF 98 REBIF REBIDOSE 98 REBIF REBIDOSE

repaglinide 26 REPAGLINIDEMETFORMINHYDROCHLORIDE 23 REPATHA 30 REPATHA PUSHTRONEX SYSTEM 30 REPATHA SURECLICK 30 REPREXAIN 8 REQUIP 41 REQUIP XL 42 RESCRIPTOR 45 RESCULA 95 RESTASIS 92 RESTASIS MULTIDOSE 92 RESTORIL 80 RETIN-A 57 RETIN-A MICRO 5758 RETIN-A MICRO PUMP 58 RETROVIR 45 REVATIO 50 REVCOVI 71 REVLIMID 87 REXULTI 44 REYATAZ 45 REZIRA 55 RHINOCORT AQUA 90 RIAX 58 RIBASPHERE 46

RITALIN LA 2 ritonavir 45 RITUXAN 36 rivastigmine 97 rivastigmine tartrate 97 RIXUBIS 78 rizatriptan benzoate 85 ROBAXIN 89 ROBAXIN-750 89 ROBINUL 101 ROBINUL FORTE 101 ROCALTROL 71 ROMIDEPSIN 38 ropinirole hydrochloride 42 ROPIVACAINE HYDROCHLORIDESODIUMCHLORIDE 81 ROSULA 58 rosuvastatin calcium 30 ROXICODONE 7 ROXYBOND 7 ROZEREM 81 RUBRACA 38 RUCONEST 78 RYCLORA 28 RYTARY 42 RYTHMOL SR 13 SABRIL 19

TITRATIONPACK 98 RIBASPHERE RIBAPAK 46 SAFYRAL 53 REBIF TITRATION PACK 98 ribavirin 47 SAIZEN 70 RECLAST 69 ribavirin (hepatitis c) 46 SAIZEN CLICKEASY 70 RECOMBINATE 78 RIDAURA 3 SAIZENPREP RECTIV 10 rifabutin 34 RECONSTITUTIONKIT 70 REGLAN 74 RIFADIN 34 SALAGEN 88

REGRANEX 67 RIFAMATE 34 SALEX 66

RELAGARD RELENZA DISKHALER

104 47

rifampin RIFATER

34 34

salicylic acid salsalate

66 6

RELION KETONE 67 RILUTEK 90 SAMSCA 72 RELION KETONE TEST riluzole 90 SANCUSO 27 STRIPS RELISTOR RELPAX REMERON REMERON SOLTAB REMICADE RENAGEL RENVELA

67 75 85 20 20 74 75 75

rimantadine hydrochloride 47 RIOMET 23 risedronate sodium 69 RISPERDAL 43 RISPERDAL M-TAB 43 risperidone 43 RISPERIDONE ODT 43 RITALIN 2

SANDIMMUNE SANDOSTATIN SANTYL SAPHRIS SARAFEM SASH KIT FOR FLUSHING VASCULAR ACCESS DEVICES SAVAYSA

88 72 65 43 98

17 16

Index 19

SAVELLA 97 sodium citrate amp citric acid 76 STALEVO 50 42 SAVELLA TITRATION sodium fluoride 86 STALEVO 75 42 PACK 97 SODIUM FLUORIDE 86 STARLIX 26scopolamine 27 sodium fluoride 86 stavudine 45SEASONIQUE 53 SODIUM HYDROXIDE 51 STELARA 61SECONAL SODIUM 80 sodium phenylbutyrate 71 STIMATE 72SECTRAL 48 SODIUM STIOLTO RESPIMAT 15SEEBRI NEOHALER 13 PHOSPHATESODIUM STIVARGA 38selegiline hcl 42 CHLORIDE 86 STRATTERA 1sodium polystyreneselenium sulfide 61 sulfonate 88 STRENSIQ 72SELZENTRY 45 SODIUM SULFACETAMIDE STRIANT 9SEMPREX-D 55 WASH 61 STRIBILD 45SODIUMSENSIPAR 71

SULFACETAMIDESULFUR STRIVERDI RESPIMAT 15SEREVENT DISKUS 15 58 STROMECTOL 10SERNIVO 64 SOFOSBUVIRVELPATASVIR SUBOXONE 9SEROQUEL 43 46 SUBSYS 7SOLARAZE 60SEROQUEL XR 43 SUCRAID 68SOLODYN 100SEROSTIM 70 sucralfate 102SOLTAMOX 37sertraline hcl 21 SULAR 49SOMA 89sevelamer carbonate 75 sulfacetamide sod-SOMATULINE DEPOT 72SFROWASA 74 prednisolone 93 SHOHLS SOLUTION SOMAVERT 70 SULFACETAMIDE SODIUM 92 MODIFIED 76 SONATA 80 sulfacetamide sodium (acne)58SIGNIFOR 72 SOOLANTRA 66 sulfacetamide sodium SIKLOS 79 SORIATANE 61 (ophth) 92 sildenafil citrate (pulmonary sulfacetamide sodium wSORILUX 61hypertension) 50 sulfur 58

sotalol hcl 48SILENOR 80 SULFADIAZINE 99 silodosin 76 sotalol hcl (afibafl) 48 sulfamethoxazole-trimethoprim

SOTYLIZE 48 11SILVADENE 61 SOVALDI 46 SULFAMYLON 61SILVER NITRATE 61 SPACERAEROSOL-HOLDING sulfasalazine 75silver sulfadiazine 61 CHAMBER 83 SULFURATED LIME 67SIMBRINZA 91 SPECTRACEF 51 sulindac 5SIMPONI 3 SPINOSAD 67 sumatriptan 85simvastatin 30 SPIRIVA HANDIHALER 13 sumatriptan succinate 85SINEMET 42 SPIRIVA RESPIMAT 13 SUMATRIPTAN

SINEMET CR 42 spironolactone 68 SUCCINATE 85 SINGULAIR 1314 spironolactone amp sumatriptan succinate 85 sirolimus 88 hydrochlorothiazide 68 sumatriptan-naproxen

SPORANOX 28 sodium 84SIRTURO 34 SPORANOX PULSEPAK 28 SUMAVEL DOSEPRO 85SITAVIG 47 SPRITAM 19 SUMAXIN 58SIVEXTRO 11 SPRIX 4 SUMAXIN TS 58SKELAXIN 89 SPRYCEL 38 SUMAXIN WASH 58SKLICE 67 STALEVO 100 42 SUPRAX 51SKYLA 53 STALEVO 125 42 SUPREP BOWEL PREP KIT81sodium chloride (gu irrigant) 76

SURMONTIL 22sodium chloride (inhalant) 56 STALEVO 150 42 STALEVO 200 42 SUSTIVA 45

Index 20

SUSTOL SUTENT

27 39

TECFIDERA TECFIDERA STARTER

98 theophylline thioridazine hcl

16 43

SYLATRON SYMBICORT SYMBYAX SYMLINPEN 120 SYMLINPEN 60 SYMPAZAN SYMTUZA SYNALAR SYNALGOS-DC

39 15 97 23 23 18 45 64 8

PACK 98 TECHNIVIE 46 TEGRETOL 19 TEGRETOL-XR 19 TEKTURNA 33 TEKTURNA HCT 33 telmisartan 31 telmisartan-amlodipine 33 telmisartan-hydrochlorothiazide

33

thiotepa thiothixene thyroid THYROLAR-1 THYROLAR-12 THYROLAR-14 THYROLAR-2 THYROLAR-3 tiagabine hcl

35 44

100 100 100 100 100 100 20

SYNAREL SYNERA

71 66

temazepam TEMODAR

80 35

TIAZAC TIBSOVO

49 39

SYNERCID 11 TEMOVATE 64 TICASPRAY 89 SYNJARDY 23 TEMOVATE E 64 TIGAN 27 SYNRIBO 40 temozolomide 35 TIGECYCLINE 11 SYNTHROID 100 temsirolimus 39 tigecycline 11 SYPRINE 87 TENCON 5 TIGLUTIK 90 TABLOID 35 TENEX 32 TIKOSYN 13 TACLONEX tacrolimus tacrolimus (topical) tadalafil (pulmonaryhypertension) TAFINLAR TAGRISSO TALTZ TALZENNA TAMIFLU tamoxifen citrate tamsulosin hcl TANZEUM TAPAZOLE TAPERDEX 12-DAY TAPERDEX 6-DAY TARCEVA TARGADOX TARGRETIN TARKA TASIGNA TASMAR TAXOL TAXOTERE tazarotene TAZICEF TAZORAC

64 88 65

50 39 39 61 39 47 37 76 24

100 54 54 39

100 4060

33 39 41 40 40 61 51 61

tenofovir disoproxilfumarate 45 TENORETIC 100 33 TENORETIC 50 33 TENORMIN 48 TEPADINA 35 TERAZOL 7 104 terazosin hcl 32 terbinafine hcl 28 terbutaline sulfate 15 TERCONAZOLE 104 terconazole vaginal 104 TESSALON PERLES 55 TESTIM 9 TESTONE CIK 9 testosterone 9 TESTOSTERONE 9 testosterone 9 TESTOSTERONE PUMP 9 TESTRED 9 tetrabenazine 97 tetracaine hcl (ophth) 92 tetracycline hcl 100 TEXACORT 65 THALOMID 87 THE LIQUILIFT TRACE KIT 87 THEO-24 16

timolol maleate 48 timolol maleate (ophth) 91 TIMOLOL MALEATE OPHTHALMIC GEL FORMING 91 TIMOLOLBRIMONIDEDORZOLAMIDE 91 TIMOLOLBRIMONIDINEDORZOLAMIDELATANOPROST 91 TIMOLOLDORZOLAMIDELATANOPROST 91 TIMOLOLLATANOPROST 91 TIMOPTIC 91 TIMOPTIC OCUDOSE 91 TIMOPTIC-XE 91 TINDAMAX 10 tinidazole 11 TIROSINT 100 TIVICAY 45 TIVORBEX 5 tizanidine hcl 89 TOBI 2 TOBI PODHALER 2 TOBRADEX 93 TOBRADEX ST 93 TOBRAMYCIN 3 tobramycin 3 tobramycin (ophth) 92 TOBRAMYCIN SULFATE 3

Index 21

tobramycin sulfate 3 TRELSTAR MIXJECT 37 TRYPTOPHAN 90 tobramycin-dexamethasone 93 TRESIBA FLEXTOUCH2526 TUDORZA PRESSAIR 13 TOBREX 92 TRETIN-X 58 TUSNEL 55 TOFRANIL 22 tretinoin 58 TUSSICAPS 55 TOLAK TOLAZAMIDE tolazamide TOLBUTAMIDE tolcapone TOLMETIN SODIUM tolmetin sodium TOLMETIN SODIUM TOLSURA tolterodine tartrate TOPAMAX TOPAMAX SPRINKLE TOPICORT

60 26 26 26 41 5 5 5

28 104 19 19 65

tretinoin (chemotherapy) 40 tretinoin microsphere 58 TREXALL 35 TREXIMET 84 TRI-NORINYL 28 53 triamcinolone acetonide (mouth) 88 triamcinolone acetonide (topical) 65 triamterene amp hydrochlorothiazide 68 TRIAMTERENEHYDROCHLOROTHIAZIDE 68 TRIANEX 65 triazolam 80

TUSSIONEX PENNKINETIC EXTENDED RELEASE 55 TUZISTRA XR 55 TWYNSTA 33 TYBOST 45 TYGACIL 11 TYKERB 39 TYLENOLCODEINE 3 8 TYLENOLCODEINE 4 8 TYVASO 50 TYVASO REFILL 50 TYVASO STARTER 50 TYZINE PEDIATRIC NASAL DROPS 90

topiramate 19 TRIBENZOR 33 UCERIS 1054 TOPIRAMATE ER 19 TRICHLOROACETIC UDENYCA 79 TOPOTECAN HCL 41 topotecan hcl 41 TOPROL XL 48 TORISEL 39 torsemide 68 TOTECT 40 TOUJEO MAX SOLOSTAR 25 TOUJEO SOLOSTAR 25 TOVIAZ 104 TRACLEER 50 TRADJENTA 24 tramadol hcl 7 TRAMADOL HCL ER 7 tramadol-acetaminophen 8 trandolapril 31 trandolapril-verapamil hcl 33 TRANDOLAPRILVERAPAMILHCL ER 33 tranexamic acid 80 TRANSDERM-SCOP 27 TRANXENE T 12 tranylcypromine sulfate 21 TRAVATAN Z 95 trazodone hcl 22 TREANDA 35 TRECATOR 34 TRELSTAR 37

ACID 51 TRICITRATES 76 TRICOR 30 TRIDESILON 65 trientine hcl 87 trifluoperazine hcl 43 trifluridine 92 TRIGLIDE 30 trihexyphenidyl hcl 41 TRILEPTAL 19 TRILIPIX 30 trimethobenzamide hcl 27 trimethoprim 11 trimipramine maleate 22 TRIMPEX 11 TRINTELLIX 22 TRIUMEQ 45 TRIZIVIR 45 TROKENDI XR 19 tropicamide 91 TROPICAMIDEPROPARACAINEPHENYLEPHRINEKETOROLAC 91 trospium chloride 104 TRULANCE 74 TRULICITY 24 TRUSOPT 94 TRUVADA 45

ULESFIA ULORIC ULTRACET ULTRAM ULTRAVATE UPTRAVI urea URECHOLINE UROCIT-K 10 UROCIT-K 15 UROCIT-K 5 UROXATRAL URSO 250 URSO FORTE ursodiol UTIBRON NEOHALER UTOPIC VAGIFEM valacyclovir hcl VALCHLOR VALCYTE valganciclovir hcl VALIUM valproate sodium valproic acid valsartan

67 77 8 7

65 50 65

104 76 76 76 76 74 74 74 15 65

104 47 60 46 46 12 20 20 31

Index 22

valsartan-hydrochlorothiazide33

VALSTAR 37 VALTREX 47 VANATOL LQ 5 VANATOL S 5 VANCOMYCIN HYDROCHLORIDE 11 VANCOMYCIN

VIDAZA 36 WIDE-SEAL SILICONE VIDEX EC VIDEXPEDIATRIC

45 45

DIAPHRAGM KIT 60 WIDE-SEAL SILICONE DIAPHRAGM KIT 65

82

82 VIEKIRA PAK 47 WIDE-SEAL SILICONE VIEKIRA XR vigabatrin

47 20

DIAPHRAGM KIT 70 WIDE-SEAL SILICONE DIAPHRAGM KIT 75

82

82 VIGAMOX 92 WIDE-SEAL SILICONE VIIBRYD 22 DIAPHRAGM KIT 80 82

HYDROCHLORIDEDEXTROSE VIIBRYD STARTER PACK22 WIDE-SEAL SILICONE DIAPHRAGM KIT 85 8211 VIMOVO 5 WIDE-SEAL SILICONEVANOS 65

VIMPAT 19 DIAPHRAGM KIT 90 82VANTAS 37 WIDE-SEAL SILICONEvinorelbine tartrate 40VARUBI 27 DIAPHRAGM KIT 95 82VIOKACE 68VASCEPA 29 WILATE 78VIRACEPT 45VASERETIC 33 WP THYROID 100VIRAMUNE 45VASOPRESSINDEXTROSE XALATAN 95

72 VIRAMUNE XR 45 XALKORI 39VASOTEC 31 VIRAZOLE 47 XANAX 12VECAMYL 33 VIREAD 45 XANAX XR 12VECTIBIX 36 VIROPTIC 92 XARELTO 16VECTICAL 61 VISTARIL 12 XARELTO STARTER PACK 16VELCADE 39 VISTOGARD 26 XARTEMIS XR 8VELETRI 50 VITEKTA 45 XELJANZ 3VELPHORO 75 VITRAKVI 39 XELJANZ XR 3VELTASSA 88 VITUZ 55 XELODA 36VELTIN 58 VIVELLE-DOT 73 XELPROS 95VENCLEXTA 36 VIVITROL 27 XENAZINE 97VENCLEXTA STARTING VIVLODEX 5 XEPI 59PACK 36 VIZIMPRO 39venlafaxine hcl 22 XERESE 61

VOGELXO 10VENTAVIS 50 XGEVA 69

VOGELXO PUMP 10VENTOLIN HFA 15 XIAFLEX 87

VOLTAREN 59VERAMYST 90 XIFAXAN 11

VOPAC MDS 59verapamil hcl 49 XIGDUO XR 23

VORAXAZE 40VERAPAMIL HCL SR 49 XODOL 8

voriconazole 28VERDESO 65 XOFIGO 39

VOSPIRE ER 15VERDROCET 8 XOFLUZA 47

VOTRIENT 39VEREGEN 59 XOLAIR 13

VRAYLAR 42VERELAN 49 XOLEGEL 60

VUSION 60VERELAN PM 49 XOPENEX 15

VYTORIN 29VERIPRED 20 54 XOPENEX CONCENTRATE 15

VYVANSE 1VERSACLOZ 43 XOPENEX HFA 15

warfarin sodium 16VESICARE 104 XOSPATA 39

WELCHOL 29VFEND 28 XTAMPZA ER 7

WELLBUTRIN SR 21VIBERZI 75 XTANDI 37

WELLBUTRIN XL 21VIBRAMYCIN 100 XULANE 53

WESTCORT 65VICTOZA 24 XURIDEN 72

WESTHROID 100 XYNTHA 78

Index 23

XYNTHA SOLOFUSE 78 ZITHRANOL 61 ZYTIGA 37 XYOSTED 10 ZITHROMAX 81 ZYVOX 11 XYREM 97 ZITHROMAX TRI-PAK 81 YASMIN 28 53 ZITHROMAX Z-PAK 81 YAZ 53 ZMAX 82 YBUPHEN 5 ZOCOR 30 YERVOY 36 ZODEX 12-DAY 54 YUPELRI 13 ZODEX 6-DAY 54 YUTIQ 93 ZOFRAN 27 zafirlukast 14 ZOFRAN ODT 27 zaleplon 80 ZOHYDRO ER 7 ZALTRAP 36 ZOLADEX 37 ZAMICET 8 zoledronic acid 69 ZANAFLEX 89 ZOLINZA 39 ZANTAC ZANTAC 150 MAXIMUM

102 zolmitriptan ZOLOFT

85 21

STRENGTH 102 ZARONTIN 20 ZARXIO 79 ZAVESCA 79 ZEBETA 48 ZEGERID 103 ZELAPAR 42 ZELBORAF 39 ZEMBRACE SYMTOUCH 85 ZEMPLAR 72 ZENPEP 68 ZENZEDI 1 ZEPATIER 47 ZERIT 45 ZESTORETIC 33 ZESTRIL 31 ZETIA 30 ZETONNA 90 ZEVALIN Y-90 36 ZIAC 33 ZIAGEN 4546 ZIANA 58 zidovudine 46 zileuton 14 ZINBRYTA 98 ZINECARD 40 ZIOPTAN 95 ziprasidone hcl 42 ZIPSOR 5 ZIRGAN 92

zolpidem tartrate ZOLPIMIST ZOMACTON ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZORVOLEX ZOVIRAX ZTLIDO ZUBSOLV ZUPLENZ ZURAMPIC ZUTRIPRO ZYBAN ZYCLARA ZYCLARA PUMP ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYLET ZYLOPRIM ZYMAXID ZYPREXA ZYPREXA ZYDIS

80 80 71 85 85 60 19 19 78 71 88 5

4761 66 9

27 77 56 99 65 65 39 14 14 39 94 77 92 43 43

Index 24

• Classes
• • ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to Treat ADHD Sleep and Eating Disorders
  • 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
  • ANDROGENS-ANABOLIC - Drugs to Regulate Hormones
  • ANORECTAL AGENTS - Rectal Drugs to Treat Pain Swelling and Itching
  • ANTHELMINTICS - Drugs to Treat Worm Infections
  • ANTI-INFECTIVE AGENTS - MISC - Drugs to Treat Bacterial Infections
  • ANTIANGINAL AGENTS - Drugs to Treat Chest Pain
  • ANTIANXIETY AGENTS - Drugs to Treat Anxiety
  • ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms
  • ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions
  • ANTICOAGULANTS - Blood Thinners
  • ANTICONVULSANTS - Drugs to Treat Seizures
  • ANTIDEPRESSANTS - Drugs to Treat Depression
  • ANTIDIABETICS - Drugs to Regulate Blood Sugar
  • ANTIDIARRHEALPROBIOTIC AGENTS - Drugs to Treat Diarrhea
  • ANTIDOTES AND SPECIFIC ANTAGONISTS
  • ANTIEMETICS - Drugs to Treat Nausea and Vomiting
  • ANTIFUNGALS - Drugs to Treat Fungal Infections
  • ANTIHISTAMINES - Drugs to Treat Allergies
  • ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol
  • ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure
  • ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections)
  • ANTIMYASTHENICCHOLINERGIC AGENTS
  • ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections)
  • ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer
  • ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease
  • ANTIPSYCHOTICSANTIMANIC AGENTS - Drugs to Treat Mood Disorders
  • ANTISEPTICS amp DISINFECTANTS
  • ANTIVIRALS - Drugs to Treat Viral Infections
  • 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
  • CHEMICALS
  • 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
  • GENERAL ANESTHETICS
  • GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System
  • GOUT AGENTS - Drugs to Treat Gout
  • 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
  • LAXATIVES - Bowel Treatment Drugs
  • LOCAL ANESTHETICS-Parenteral - Drugs for Numbing
  • MACROLIDES - Drugs to Treat Bacterial Infections
  • MEDICAL DEVICES AND SUPPLIES
  • MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches
  • MINERALS amp ELECTROLYTES
  • MISCELLANEOUS THERAPEUTIC CLASSES
  • MOUTHTHROATDENTAL AGENTS
  • 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
  • OPHTHALMIC AGENTS - Drugs to Treat the Eye
  • OTIC AGENTS - Drugs to Treat the Ear
  • OXYTOCICS - Drugs to PreventControl Uterine Bleeding
  • PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune System
  • PENICILLINS - Drugs to Treat Bacterial Infections
  • 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
  • ULCER DRUGS - Drugs to Treat Bowel Intestine and Stomach Conditions
  • URINARY ANTI-INFECTIVES - Drugs to Treat BladderKidney Infections
  • URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms
  • VAGINAL PRODUCTS - Drugs to Treat Vaginal Infections and Low Hormones
  • VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions
  • VITAMINS