san francisco health plan medi-cal formulary · san francisco health plan medi-cal formulary as of...

San Francisco Health Plan Medi-Cal Formulary AS OF August 2020

SAN FRANCISCO HEALTH PLAN

Medi-Cal Formulary As of August 2020


San Francisco Health Plan Medi-Cal Formulary The San Francisco Health Plan (SFHP), with the direction from the Pharmacy and Therapeutics Committee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. The P&T Committee is composed of the SFHP Chief Medical Officer, the SFHP Pharmacy Director, physicians from various medical specialties and clinics, and community clinical pharmacists. The P&T meets quarterly to review formulary changes based on quality of care considerations and sound pharmacoeconomic principles. The formulary is a list of drug products designed to reflect the most appropriate, high quality and cost-effective drug therapies. The formulary is updated regularly and is subject to change without notice. The formulary requires the continuous support of all our providers and pharmacists. Please contact us at (415) 547-7818 x 7085 option 3 or [email protected] if you have any questions regarding the formulary. The SFHP formulary can be easily accessed online at http://www.sfhp.org/providers/formulary/sfhp-formulary/.

Request for Addition or Deletion of a Drug to the Formulary SFHP providers may request evaluation of drugs for addition to or deletion from the formulary by submitting the Formulary Modification Request Form available on our website at http://www.sfhp.org/providers/formulary/prior-authorization-requests/.

Request for Non-Preferred Medications Non-preferred or non-formulary medications may be authorized when there is clinical justification for doing so. Providers can submit a prior authorization (PA) request in one of three different ways:

1. Online: Submit using the Online Pharmacy Prior Authorization Request Form. 2. Fax: Download a Prior Authorization Request Form and fax to 1(855) 811-9331 for both standard

and urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the prior authorization request form.

3. Phone: Pharmacy Benefits Manager (PBM) PerformRx at (888) 989-0091 to submit a verbal request.

The Prior Authorization Request Form and the Online Pharmacy Prior Authorization Request Form can be accessed from our website at http://www.sfhp.org/providers/formulary/prior-authorization-requests/.

mailto:[email protected]

http://www.sfhp.org/providers/formulary/sfhp-formulary/

http://www.sfhp.org/files/providers/formulary/formulary_modification_form.pdf

http://www.sfhp.org/providers/formulary/prior-authorization-requests/

https://ppa.performrx.com/PublicUser/CaliforniaForm/OnlineForm.aspx?cucu_id=8WNE9dA4crj04kitEF%2bZ1A%3d%3d

http://www.sfhp.org/files/providers/forms/UniversalPAForm.pdf

http://www.sfhp.org/files/providers/forms/UniversalPAForm.pdf

https://ppa.performrx.com/PublicUser/CaliforniaForm/OnlineForm.aspx?cucu_id=8WNE9dA4crj04kitEF%2bZ1A%3d%3d




Brand Medication Policy SFHP has a mandatory generic policy and requires generic substitution when an equivalent AB-rated generic product is available. Dispensing of brand name medications when generic equivalent is available is allowed only in certain cases:

• Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product). • Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available). • Pharmacy is dispensing one (1) of the following narrow therapeutic index drugs/classes: Dilantin

(phenytoin), thyroid hormones, coumarin type anticoagulants. • For all other brand name medication requests, prior authorization with documentation that two

(2) generic medications from different manufacturers were tried and did not meet the medical needs of the member.

All brand name medication prior authorization requests are reviewed by an SFHP pharmacist or Medical Director. In all other cases, a prior authorization (PA) request should be submitted using the instructions above. Detailed PA criteria for brand name medication requests can be found at http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf under “Brand Medication Requests” section.

Medi-Cal Formulary Exclusions The following drugs classes are excluded from the SFHP Medi-Cal formulary and are covered by fee-for-service (FFS) Medi-Cal. TAR may need to be submitted to FFS Medi-Cal for certain medications. For more information, refer to the “Capitiated/Noncapitated Drugs” section in the “MCP: Two-Plan Model” document available at Medi-Cal’s website (www.medi-cal.ca.gov).

• Anti-psychotics • AIDs/HIV drugs (except didanosine, zidovudine covered on SFHP Medi-Cal formulary)

o Note: If a medication is carved out, it is carved out regardless of indications. For example, Viread® (tenofovir) and Epivir® (lamivudine) are carved out whether they are used for treatment of HIV or Hepatitis B.

• Alcohol, heroin detoxification and dependency treatment drugs

Medications in the following categories are excluded from the SFHP Medi-Cal formulary: • Erectile dysfunction drugs • Fertility medications • Medications for cosmetic uses (e.g. hydroquinone for hyperpigmentation of the skin)

Day Supply Policy SFHP standard day supply policy is 30 day supply for most brand medications and 90 day supply for generic medications with some exceptions. Refills are allowed when 75% of the medication has been used, except for opiate pain medications where refills are allowed when 90% of the medication has been used.

http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CB4QFjAA&url=https%3A%2F%2Ffiles.medi-cal.ca.gov%2Fpubsdoco%2Fpublications%2Fmasters-mtp%2Fpart1%2Fmcptwoplan_z01.doc&ei=p4PmVNbUIYergwSRlYLABw&usg=AFQjCNHILugbMjFEK8LSMoK2yyiJl08HiA&sig2=o45TgWKrXQP3OIfrRNvNnw&bvm=bv.86475890,d.eXY

http://www.medi-cal.ca.gov/


Exceptions to the 30 day supply policy for brand medications are as follows:

• Up to 100 day supply is allowed for test strips, lancets, insulin syringes and urine ketone testing strips

• Up to 90 day supply is allowed for select medications used for treatment of chronic conditions. Examples include but are not limited to antidiabetic medications including insulin, anticonvulsants, anticoagulants, antidepressants, antihyperlipidemics, antihypertensives, inhaled steroids and contraceptives.

Exceptions to the 90 day supply policy for generic medications are as follows: • 30 day supply only is allowed for all opiate medications except tramadol

Formulary Restrictions Standard formulary restrictions applicable to SFHP formulary are medication quantity and age limitations. All formulary restrictions are based on FDA approved indications, standards of practice and safety and abuse potential considerations.

Step Therapy (ST) Step Therapy (ST) medications will process at point of sale at the pharmacy if there are paid prescription claims for preferred medications. If there are no paid prescription claims, a prior authorization (PA) request must be submitted for consideration of coverage. Visit our website at http://www.sfhp.org/providers/formulary/sfhp-formulary/ for detailed information on all active step therapy rules.

Therapeutic Interchange Policy Per American College of Clinical Pharmacy (AACP), therapeutic interchange is defined as the dispensing of a drug that is therapeutically equivalent to but chemically different from the drug originally prescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeutic interchange and will only employ therapeutic interchange with prescriber’s approval. Criteria for consideration in therapeutic interchange include availability of agents within a therapeutic class, therapeutic equivalence, safety data, and costs.

Diabetic Supplies The following diabetic supplies are covered on SFHP formulary as a pharmacy benefit:

• Glucometers: ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days

• Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits:

o 400 per 100 days for all members o 800 per 100 days for members with gestational diabetes

• Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100 day supply


http://www.sfhp.org/files/providers/pharmacy/SFHP_Step_Therapy_List.pdf

http://www.sfhp.org/files/providers/pharmacy/SFHP_Step_Therapy_List.pdf


Respiratory Supplies The following respiratory supplies are covered as a pharmacy benefit for a quantity of 2 per 365 days:

• Inhalers and inhaler assist devices • Nebulizers • Peak flow meters

Home Blood Pressure Monitors Omron Series 3, 5, and 10 home blood pressure monitors are covered as a pharmacy benefit for a quantity of 1 monitor per member every 5 years.

Vaccines Certain vaccines are covered as a pharmacy benefit for Medi-Cal members over the age of 18. Please visit SFHP website at http://www.sfhp.org/providers/formulary/sfhp-formulary/ for a detailed list of covered vaccines. Children 18 years of age or younger are eligible for vaccinations through the California Vaccines for Children (VFC) Program. Please contact VFC at 1-877-243-8832 for more information.

Formulary Document Details The SFHP formulary document is listed by drug class and includes the following information: drug name, dosage form, drug tier, quantity and age limit and prior authorization or step therapy requirements. Brand products are listed in all uppercase letters and generic products are listed in all lowercase letters. Tier 1 drugs are formulary preferred and will pay at point of sale if quantity and age limits are met (see “Formulary Restrictions” above). Tier 2 drugs require a Prior Authorization (see “Request for Non-Preferred Medications” above) or Step Therapy (see “Step Therapy (ST)” above). **Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formulary and another strength of the same medication requiring a prior authorization. If you are hearing impaired, please call the TDD/TYY line at 1(415) 547-7830, toll-free at 1(888) 883-7347 or through the California Relay Service at 711. You may request this document in alternative formats like Braille, large size print, and audio. To request other formats, or for help with reading this document and other SFHP materials, please call Customer Service at 1(415) 547-7800 or toll-free at 1(800) 288-5555.


http://www.sfhp.org/files/providers/formulary/SFHPVaccineDrugList.pdf

http://www.sfhp.org/files/providers/formulary/SFHPVaccineDrugList.pdf

1

Drug Generic drugs = lowercase italics Brand name drugs = UPPERCASE

Tier T1= Formulary, Generic T2= Formulary, Brand T3= Formulary, Prior Authorization or Step Therapy T4= Specialty Pharmacy, Prior Authorization T5= Non-Formulary, Carve Out, or Obtain through the Medical Benefit

Notes AL= Age Limit CO= Carve-Out. Bill to Fee-for-Service (FFS) Medi-Cal PA= Prior Authorization QL= Quantity Limit ST= Step Therapy

Drug Tier Notes

Antihistamine Drugs

Ethanolamine Derivatives

ALLERGY (DIPHENHYDRAMINE) ORAL LIQUID

T1

CHILDREN'S BENADRYL ALLERGY ORAL TABLET,CHEWABLE

T1

dimenhydrinate oral T1

diphenhydramine hcl injection solution 50 mg/ml T5

diphenhydramine hcl injection syringe T5

diphenhydramine hcl oral capsule T1

diphenhydramine hcl oral tablet 25 mg T1

SLEEP AID (DOXYLAMINE) T1

Ethylenediamine Derivatives

pyrilamine-phenylephrine oral tablet T5

First Gen. Antihist. Derivatives, Misc.

cyproheptadine T1

First Generation Antihistamines


T1


T1

chlorpheniramine maleate oral tablet T1

chlorpheniramine maleate oral tablet extended release

T1

2

Drug Tier Notes

cyproheptadine T1







Phenothiazine Derivatives

PHENADOZ RECTAL SUPPOSITORY 12.5 MG T1 AL (Min 2 Years)

promethazine injection solution T5

promethazine oral T1 AL (Min 2 Years)

promethazine rectal suppository 25 mg T1 AL (Min 2 Years)

PROMETHAZINE VC T1 AL (Min 2 Years)

promethazine-dm T1 AL (Min 2 Years)

Piperazine Derivatives

hydroxyzine hcl oral solution 10 mg/5 ml T1

hydroxyzine hcl oral tablet T1

hydroxyzine pamoate T1

meclizine oral tablet 12.5 mg, 25 mg T1

meclizine oral tablet,chewable T1

Propylamine Derivatives

APRODINE T1 AL (Min 6 Years)



T1

PEDIA RELIEF COUGH-COLD T1 AL (Min 6 Years)

Second Generation Antihistamines

ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING

T1

cetirizine oral solution 1 mg/ml T1

cetirizine oral tablet T1

cetirizine oral tablet,chewable T1

CHILDREN'S ALLEGRA ALLERGY ORAL TABLET,DISINTEGRATING

T1

3

Drug Tier Notes

desloratadine oral tablet T1

fexofenadine oral suspension T1

fexofenadine oral tablet 180 mg, 60 mg T1

levocetirizine oral tablet T1

loratadine oral solution T1

loratadine oral tablet T1

LORATADINE-D T1 AL (Min 12 Years)

Anti-Infective Agents

1St Generation Cephalosporin Antibiotics

cefadroxil oral capsule T1

cephalexin oral capsule 250 mg, 500 mg T1

cephalexin oral suspension for reconstitution T1 AL (Max 12 Years)

2Nd Generation Cephalosporin Antibiotics

cefaclor oral capsule T1

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

T1 AL (Max 12 Years)

cefprozil oral suspension for reconstitution T1 AL (Max 12 Years)

cefprozil oral tablet T1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML


cefuroxime axetil oral suspension for reconstitution 125 mg/5 ml


cefuroxime axetil oral tablet T1

3Rd Generation Cephalosporin Antibiotics

cefdinir oral capsule T1

cefdinir oral suspension for reconstitution T1 AL (Max 12 Years)

cefixime oral capsule T1

cefixime oral suspension for reconstitution T1 AL (Max 12 Years)

cefpodoxime oral suspension for reconstitution T1 AL (Max 12 Years)

cefpodoxime oral tablet T1

4Th Generation Cephalosporin Antibiotics

cefepime injection recon soln 1 gram T5

5Th Generation Cephalosporin Antibiotics

4

Drug Tier Notes

TEFLARO INTRAVENOUS RECON SOLN 400 MG

T5

Adamantane Antivirals

amantadine hcl T5 CO

GOCOVRI T5 CO

OSMOLEX ER T5 CO

Allylamine Antifungals

terbinafine hcl oral T1 QL (180 EA per 365 days)

Amebicides

metronidazole oral tablet T1

Aminoglycoside Antibiotics

BETHKIS T5

neomycin T1

paromomycin T1

TOBI PODHALER T5

tobramycin in 0.225 % nacl T4 PA

tobramycin with nebulizer T5

Aminomethylcyclines

NUZYRA ORAL T5

Aminopenicillin Antibiotics

amoxicillin oral capsule T1

amoxicillin oral suspension for reconstitution T1 AL (Max 12 Years)

amoxicillin oral tablet T1

amoxicillin oral tablet,chewable 125 mg, 250 mg T1 AL (Max 12 Years)

amoxicillin-pot clavulanate oral suspension for reconstitution


amoxicillin-pot clavulanate oral tablet T1

amoxicillin-pot clavulanate oral tablet extended release 12 hr


amoxicillin-pot clavulanate oral tablet,chewable T1 AL (Max 12 Years)

ampicillin oral capsule T1

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML


Anthelmintics

5

Drug Tier Notes

albendazole T1 QL (6 EA per 365 days)

ivermectin oral T1 QL (30 EA per 365 days)

PIN-X ORAL SUSPENSION T1

praziquantel T1 QL (15 EA per 365 days)

Antifungals, Miscellaneous

griseofulvin microsize T1

griseofulvin ultramicrosize T1

Antimalarials

atovaquone-proguanil T1 QL (180 EA per 365 days)

chloroquine phosphate T1

DARAPRIM T4 PA

hydroxychloroquine T1

mefloquine T1

primaquine T1

quinidine gluconate injection T5

quinidine gluconate oral T1

Antimycobacterials, Miscellaneous

dapsone oral T1

Antiprotozoals, Miscellaneous

ALINIA T2 QL (30 ML per 365 days)

atovaquone T1

dapsone oral T1

metronidazole oral tablet T1

NEBUPENT T3 PA

PENTAM T5

tinidazole T1 QL (30 EA per 365 days)

Antituberculosis Agents

ciprofloxacin T1 AL (Max 12 Years)

ciprofloxacin (mixture) T5

ciprofloxacin hcl oral T1

clarithromycin oral suspension for reconstitution T1

clarithromycin oral tablet T1

cycloserine T1

6

Drug Tier Notes

ethambutol T1

isoniazid oral solution T1 AL (Max 12 Years)

isoniazid oral tablet T1

levofloxacin oral solution T1 AL (Max 12 Years)

levofloxacin oral tablet T1

moxifloxacin oral T3 PA

PASER T2

pretomanid T3 PA

PRIFTIN T2

pyrazinamide T1

rifabutin T1

rifampin oral T1

RIFATER T2

SIRTURO T3 PA

TRECATOR T2

Antivirals, Miscellaneous

FOSCAVIR T5

XOFLUZA T2 QL (2 tabs per 180 days)

Azole Antifungals

CRESEMBA T5

fluconazole T1

fluconazole in dextrose(iso-o) T5

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

T5

itraconazole oral capsule T3 PA

itraconazole oral solution T5

ketoconazole oral T1

NOXAFIL ORAL SUSPENSION T5

ONMEL T3 PA

posaconazole oral tablet,delayed release (dr/ec) T5

SPORANOX ORAL SOLUTION T5

voriconazole oral T3 PA

Bacitracin Antibiotics

bacitracin intramuscular T5

7

Drug Tier Notes

Carbapenem Antibiotics

meropenem intravenous recon soln 500 mg T5

Chloramphenicol Antibiotics

chloramphenicol sod succinate T5

Cyclic Lipopeptide Antibiotics

daptomycin intravenous recon soln 500 mg T5

Echinocandin Antifungals

caspofungin intravenous recon soln 50 mg T5

Erythromycin Antibiotics

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

T1

erythromycin ethylsuccinate oral suspension for reconstitution


erythromycin ethylsuccinate oral tablet T1

erythromycin oral T1

PCE T2

Fluorocyclines

XERAVA T5

Glycopeptide Antibiotics

FIRVANQ ORAL RECON SOLN 25 MG/ML T2 QL (400 ML per 10 days); AL (Max 12 Years)

vancomycin oral capsule T1

vancomycin oral recon soln T1 AL (Max 12 Years)

Glycylcycline Antibiotics

tigecycline T5

Hcv Polymerase Inhibitor Antivirals

HARVONI ORAL PELLETS IN PACKET T4 PA

HARVONI ORAL TABLET 45-200 MG T4 PA

ledipasvir-sofosbuvir T4 PA

sofosbuvir-velpatasvir T4 PA

SOVALDI ORAL PELLETS IN PACKET T4 PA

SOVALDI ORAL TABLET 200 MG T4 PA

SOVALDI ORAL TABLET 400 MG T5

VIEKIRA PAK T5

8

Drug Tier Notes

VOSEVI T4 PA

Hcv Protease Inhibitor Antivirals

MAVYRET T4 PA

TECHNIVIE T5

VIEKIRA PAK T5

ZEPATIER T5

Hcv Replication Complex Inhibitors

DAKLINZA ORAL TABLET 30 MG, 60 MG T5

HARVONI ORAL PELLETS IN PACKET T4 PA

HARVONI ORAL TABLET 45-200 MG T4 PA

ledipasvir-sofosbuvir T4 PA

MAVYRET T4 PA

sofosbuvir-velpatasvir T4 PA

TECHNIVIE T5

VIEKIRA PAK T5

VOSEVI T4 PA

ZEPATIER T5

Hiv Entry And Fusion Inhibitors

FUZEON SUBCUTANEOUS RECON SOLN T5 CO

RUKOBIA T5 CO

SELZENTRY ORAL TABLET T5 CO

TROGARZO T5 CO

Hiv Integrase Inhibitor Antiretrovirals

DOVATO T5 CO

GENVOYA T5 CO

ISENTRESS T5 CO

STRIBILD T5 CO

TIVICAY T5 CO

TIVICAY PD T5 CO

TRIUMEQ T5 CO

Hiv Nonnucleoside Rev.Transcrip. Inhib.

ATRIPLA T5 CO

COMPLERA T5 CO

9

Drug Tier Notes

DELSTRIGO T5 CO

EDURANT T5 CO

efavirenz oral capsule T5 CO

efavirenz oral tablet T5

INTELENCE T5 CO

nevirapine T5 CO

ODEFSEY T5 CO

RESCRIPTOR T5 CO

SYMFI T5 CO

SYMFI LO T5 CO

Hiv Nucleoside, Nucleotide Rt Inhibitors

abacavir T5 CO

abacavir-lamivudine-zidovudine T5 CO

ATRIPLA T5 CO

COMPLERA T5 CO

DELSTRIGO T5 CO

DESCOVY T5 CO

didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg

T1

DOVATO T5 CO

EMTRIVA T5 CO

EPIVIR HBV ORAL SOLUTION T5 CO

EPIVIR ORAL SOLUTION T5 CO

EPZICOM T5 CO

GENVOYA T5 CO

lamivudine oral tablet T5 CO

lamivudine-zidovudine T5 CO

ODEFSEY T5 CO

RETROVIR INTRAVENOUS T5 CO

stavudine oral capsule T5 CO

STRIBILD T5 CO

SYMFI T5 CO

SYMFI LO T5 CO

SYMTUZA T5 CO

10

Drug Tier Notes

tenofovir disoproxil fumarate T5 CO

TRIUMEQ T5 CO

TRUVADA T5 CO

VIDEX 2 GRAM PEDIATRIC T2

VIDEX 4 GRAM PEDIATRIC T1

VIREAD ORAL POWDER T5 CO

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

T5 CO

zidovudine T1

Hiv Protease Inhibitor Antiretrovirals

APTIVUS T5 CO

APTIVUS (WITH VITAMIN E) T5 CO

atazanavir T5 CO

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T5 CO

EVOTAZ T5 CO

fosamprenavir T5 CO

INVIRASE ORAL TABLET T5 CO

KALETRA T5 CO

LEXIVA ORAL SUSPENSION T5 CO

NORVIR ORAL POWDER IN PACKET T5 CO

NORVIR ORAL SOLUTION T5 CO

PREZCOBIX T5 CO

PREZISTA ORAL SUSPENSION T5 CO

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

T5 CO

REYATAZ ORAL POWDER IN PACKET T5 CO

ritonavir T5 CO

SYMTUZA T5 CO

TECHNIVIE T5

VIEKIRA PAK T5

VIRACEPT ORAL TABLET T5 CO

Interferon Antivirals

PEGASYS SUBCUTANEOUS SYRINGE T5

Lincomycin Antibiotics

11

Drug Tier Notes

CLEOCIN INTRAVENOUS SOLUTION 300 MG/2 ML

T5

clindamycin hcl oral capsule 150 mg, 300 mg T1

clindamycin palmitate hcl T1 AL (Max 12 Years)

clindamycin phosphate intravenous solution 300 mg/2 ml

T5

Macrolide Antibiotics

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

T1

erythromycin ethylsuccinate oral suspension for reconstitution


erythromycin ethylsuccinate oral tablet T1

erythromycin oral T1

PCE T2

Monobactam Antibiotics

CAYSTON T4 PA

Monoclonal Antibody Antivirals

SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML

T5

Natural Penicillin Antibiotics

penicillin g sodium T5

penicillin v potassium oral recon soln T1 AL (Max 12 Years)

penicillin v potassium oral tablet T1

Neuraminidase Inhibitor Antivirals

oseltamivir oral capsule 30 mg, 75 mg T1

oseltamivir oral capsule 45 mg T1 AL (Max 12 Years)

oseltamivir oral suspension for reconstitution T1 AL (Max 12 Years)

RELENZA DISKHALER T2 QL (20 QY per 30 DYs)

Nucleoside And Nucleotide Antivirals

acyclovir oral capsule T1 QL (150 QY per 30 DYs)

acyclovir oral suspension 200 mg/5 ml T1 AL (Max 12 Years)

acyclovir oral tablet T1 QL (150 QY per 30 DYs)

adefovir T5

BARACLUDE ORAL SOLUTION T2 AL (Max 12 Years)

cidofovir T5

12

Drug Tier Notes

entecavir T1 QL (30 EA per 30 days)

famciclovir oral tablet 125 mg T1 QL (60 EA per 30 days)



ganciclovir sodium intravenous recon soln T5

ribavirin oral capsule T1

ribavirin oral tablet 200 mg T1

SYMTUZA T5 CO

valacyclovir oral tablet 1 gram T1 QL (120 EA per 30 days)

valacyclovir oral tablet 500 mg T1 QL (90 QY per 30 DYs)

valganciclovir T3 PA

VEMLIDY T5 CO

Other Macrolide Antibiotics

azithromycin oral packet T1

azithromycin oral suspension for reconstitution T1 AL (Max 12 Years)

azithromycin oral tablet T1

clarithromycin oral suspension for reconstitution T1

clarithromycin oral tablet T1

DIFICID T4 PA

Oxazolidinone Antibiotics

linezolid oral suspension for reconstitution T1 AL (Max 12 Years)

linezolid oral tablet T1

Penicillinase-Resistant Penicillins

dicloxacillin T1

Pleuromutilins

XENLETA ORAL T5

Polyene Antifungals

amphotericin b T5

nystatin oral suspension T1

nystatin oral tablet T1

Polymyxin Antibiotics

polymyxin b sulfate T5

Quinolone Antibiotics

13

Drug Tier Notes

BAXDELA ORAL T5

ciprofloxacin T1 AL (Max 12 Years)

ciprofloxacin (mixture) T5

ciprofloxacin hcl oral T1

FACTIVE T5

levofloxacin oral solution T1 AL (Max 12 Years)

levofloxacin oral tablet T1

moxifloxacin oral T3 PA

ofloxacin oral tablet 300 mg, 400 mg T5

Rifamycin Antibiotics

PRIFTIN T2

rifabutin T1

RIFAMATE T2

rifampin oral T1

RIFATER T2

XIFAXAN ORAL TABLET 200 MG T3 ST; QL (90 QY per 30 DYs)

XIFAXAN ORAL TABLET 550 MG T3 ST; QL (60 QY per 30 DYs)

Streptogramin Antibiotics

SYNERCID T5

Sulfonamide Antibiotics (Systemic)

sulfadiazine T1

sulfamethoxazole-trimethoprim intravenous T5

sulfamethoxazole-trimethoprim oral suspension T1 AL (Max 12 Years)

sulfamethoxazole-trimethoprim oral tablet T1

sulfasalazine T1

Tetracycline Antibiotics

doxycycline hyclate oral capsule T1 QL (60 EA per 30 days)

doxycycline hyclate oral tablet 100 mg T1 QL (60 EA per 30 days)

doxycycline monohydrate oral capsule 100 mg, 50 mg

T1 QL (60 EA per 30 days)

doxycycline monohydrate oral tablet 100 mg T1 QL (60 EA per 30 days)

minocycline oral capsule T1 QL (60 EA per 30 days)

tetracycline T1 QL (120 QY per 30 DYs)

Urinary Anti-Infectives

14

Drug Tier Notes

methenamine hippurate T1

nitrofurantoin T1 AL (Max 12 Years)

nitrofurantoin macrocrystal T1

nitrofurantoin monohyd/m-cryst T1

trimethoprim T1

Antineoplastic Agents

Antineoplastic Agents

abiraterone T4 PA

ADRIAMYCIN INTRAVENOUS SOLUTION 10 MG/5 ML, 2 MG/ML, 50 MG/25 ML

T5

AFINITOR DISPERZ T4 PA

AFINITOR ORAL TABLET 10 MG T4 PA

ALECENSA T3 PA

ALIMTA T5

ALKERAN T4 PA

ALUNBRIG T3 PA

anastrozole T1 QL (30 QY per 30 DYs)

ARRANON T5

ARZERRA T5

AVASTIN T5

AYVAKIT T4 PA

BALVERSA T4 PA

BENDEKA T5

bexarotene T4 PA

bicalutamide T1

BICNU T5

BOSULIF T4 PA

BRAFTOVI T4 PA

BRUKINSA T4 PA

BUSULFEX T5

CABOMETYX T4 PA

CALQUENCE T4 PA

CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15 ML

T5

15

Drug Tier Notes

capecitabine T4 PA

CAPRELSA T3 PA

carboplatin T5

cisplatin intravenous solution T5

cladribine T5

COMETRIQ T4 PA

COPIKTRA T4 PA

COTELLIC T3 PA

cyclophosphamide intravenous T5

cyclophosphamide oral capsule T3 PA

CYRAMZA T5 PA

dacarbazine T5

DARZALEX T5

daunorubicin T5

DAURISMO T4 PA

decitabine T5

diclofenac sodium topical gel 3 % T5

docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/8 ml (10 mg/ml)

T5

doxorubicin T5

DROXIA T5

ELIGARD T4 PA

ELIGARD (3 MONTH) T4 PA



EMCYT T4 PA

EMPLICITI T5

epirubicin intravenous solution T5

ERBITUX T5

ERIVEDGE T4 PA

ERLEADA T4 PA

erlotinib T4 PA

ETOPOPHOS T5

etoposide intravenous T5

16

Drug Tier Notes

etoposide oral T4 PA

everolimus (antineoplastic) T4 PA

exemestane T3 PA

FARESTON T4 PA

FARYDAK T4 PA

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

T4 PA

floxuridine T5

fludarabine intravenous recon soln T5

fluorouracil intravenous T5

fluorouracil topical cream 5 % T1 QL (1 FL per 365 DYs)

fluorouracil topical solution T5

flutamide T1

fulvestrant T5

GAZYVA T5

gemcitabine intravenous recon soln 1 gram, 200 mg

T5

GILOTRIF T4 PA

GLEOSTINE T3 PA

HALAVEN T5

HERCEPTIN INTRAVENOUS RECON SOLN 440 MG

T5

HEXALEN T4 PA

HYCAMTIN ORAL T3 PA

hydroxyurea T1

IBRANCE T4 PA

ICLUSIG T3 PA

IDHIFA T4 PA

ifosfamide intravenous recon soln T5

ifosfamide-mesna T5

imatinib T4 PA

IMBRUVICA T4 PA

INLYTA T4 PA

INREBIC T4 PA

IRESSA T4 PA

17

Drug Tier Notes

irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml

T5

IXEMPRA T5

JAKAFI T4 PA

JEVTANA T5

KADCYLA T5

KEYTRUDA INTRAVENOUS SOLUTION T3 PA

KISQALI T3 PA

KOSELUGO T4 PA

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)

T4 PA

letrozole T1

LEUKERAN T3 PA

leuprolide T3 PA

LONSURF T4 PA

LORBRENA T4 PA

LUPANETA PACK (1 MONTH) T5


LUPRON DEPOT T4 PA

LUPRON DEPOT (3 MONTH) T4 PA


LUPRON DEPOT-PED T4 PA

LUPRON DEPOT-PED (3 MONTH) T4 PA

LYNPARZA T4 PA

LYSODREN T4 PA

MATULANE T4 PA

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

T1

megestrol oral tablet T1

MEKINIST T3 PA

MEKTOVI T4 PA

mercaptopurine T1

methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days)

18

Drug Tier Notes

methotrexate sodium injection T1 QL (16 ML per 28 days)

methotrexate sodium oral T1

mitomycin intravenous T5

mitoxantrone T5

MYLERAN T3 PA

NERLYNX T3 PA

NEXAVAR T4 PA

NINLARO T3 PA

NIPENT T5

NUBEQA T4 PA

ODOMZO T3 PA

ONCASPAR T5

OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML

T5

oxaliplatin intravenous solution T5

paclitaxel T5

PANRETIN T5

PEMAZYRE T4 PA

PERJETA T5

PHOTOFRIN T5

PIQRAY T4 PA

POMALYST T4 PA

PORTRAZZA T5

PROLEUKIN T5

PURIXAN T3 PA

QINLOCK T4 PA

RETEVMO T4 PA

REVLIMID T4 PA

RITUXAN T5

ROZLYTREK T4 PA

RUBRACA T4 PA

RYDAPT T3 PA

SOLTAMOX T3 PA

SPRYCEL T4 PA

19

Drug Tier Notes

STIVARGA T4 PA

SUTENT T4 PA

SYNRIBO T4 PA

TABLOID T3 PA

TABRECTA T4 PA

TAFINLAR T3 PA

TAGRISSO T4 PA

TALZENNA T4 PA

tamoxifen T1

TASIGNA T4 PA

TAZVERIK T4 PA

TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML)

T5

TEMODAR INTRAVENOUS T5

temozolomide T3 PA

teniposide T5

thiotepa injection recon soln 15 mg T5

TIBSOVO T4 PA

topotecan intravenous recon soln T5

TREANDA INTRAVENOUS RECON SOLN T5

TRELSTAR INTRAMUSCULAR SYRINGE T5

tretinoin (antineoplastic) T3 PA

TREXALL T3 PA

TUKYSA T4 PA

TURALIO T4 PA

TYKERB T4 PA

VALCHLOR T5

VECTIBIX T5

VELCADE T5

VENCLEXTA T4 PA

VENCLEXTA STARTING PACK T4 PA

VERZENIO T4 PA

vinblastine intravenous solution T5

20

Drug Tier Notes

VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML

T5

vincristine T5

vinorelbine T5

VITRAKVI T4 PA

VIZIMPRO T3 PA

VOTRIENT T4 PA

XALKORI T4 PA

XOSPATA T4 PA

XPOVIO T4 PA

XTANDI T4 PA

YERVOY T5

YONDELIS T5

YONSA T4 PA

ZALTRAP T5

ZANOSAR T5

ZEJULA T3 PA

ZELBORAF T4 PA

ZOLADEX T5

ZOLINZA T4 PA

ZYDELIG T4 PA

ZYKADIA T4 PA

Antitoxins,Immune Glob,Toxoids,Vaccines

Allergenic Extracts (Therapeutic)

GRASTEK T5

ODACTRA T5

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

T5

RAGWITEK T5

Antitoxins And Immune Globulins

HEPAGAM B T2 AL (Min 19 Years)

HYPERHEP B S/D T2 AL (Min 19 Years)

HYPERHEP B S-D NEONATAL T2 AL (Min 19 Years)

NABI-HB T2 AL (Min 19 Years)

21

Drug Tier Notes

VARIZIG INTRAMUSCULAR SOLUTION T5

Toxoids

ADACEL(TDAP ADOLESN/ADULT)(PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)

BOOSTRIX TDAP T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)

TENIVAC (PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)

tetanus-diphtheria toxoids-td T5

Vaccines

ACTHIB (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)

AFLURIA QD 2020-21(3YR UP)(PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

AFLURIA QD 2020-21(6-35MO)(PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

AFLURIA QUAD 2020-2021(6MO UP) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

BEXSERO T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)

ENGERIX-B (PF) T2 AL (Min 19 Years)

ENGERIX-B PEDIATRIC (PF) T2 AL (Min 19 Years)

FLUAD QUAD 2020-21(65Y UP)(PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

FLUARIX QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

FLUBLOK QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

FLUCELVAX QUAD 2020-2021 T2 QL (1 Rx per 270 days); AL (Min 19 Years)

FLUCELVAX QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

FLULAVAL QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Max 19 Years)

FLUMIST QUAD 2020-2021 T2 QL (1 Rx per 270 days); AL (Max 19 Years)

FLUZONE HIGHDOSE QUAD 20-21 PF T2 QL (1 Rx per 270 days); AL (Min 19 Years)

22

Drug Tier Notes

FLUZONE QUAD 2020-2021 T2 QL (1 Rx per 270 days); AL (Min 19 Years)

FLUZONE QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)

GARDASIL (PF) T2 AL (Min 19 Years)

GARDASIL 9 (PF) T2 AL (Min 19 Years)

HAVRIX (PF) T2 AL (Min 19 Years)

HEPLISAV-B (PF) T2 AL (Min 19 Years)

IMOVAX RABIES VACCINE (PF) T2 AL (Min 19 Years)

MENACTRA (PF) INTRAMUSCULAR SOLUTION

T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)

MENOMUNE - A/C/Y/W-135 T2 QL (1 EA per 1 fill); AL (Min 19 Years)

MENOMUNE - A/C/Y/W-135 (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)

MENVEO A-C-Y-W-135-DIP (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)

M-M-R II (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)

PENTACEL (PF) INTRAMUSCULAR KIT 15LF-48MCG-62DU -10 MCG/0.5ML

T2 AL (Min 19 Years)

PENTACEL ACTHIB COMPONENT (PF) T2 AL (Min 19 Years)

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 62 DU/0.5 ML


PNEUMOVAX-23 T2 QL (1 ML per 1 fill); AL (Min 19 Years)

PREVNAR 13 (PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)

RABAVERT (PF) T2 AL (Min 19 Years)

RECOMBIVAX HB (PF) T2 AL (Min 19 Years)

SHINGRIX (PF) T2 QL (1 EA per 1 Fill)

TRUMENBA T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)

TWINRIX (PF) T2 AL (Min 19 Years)

VAQTA (PF) T2 AL (Min 19 Years)

VARIVAX (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)

23

Drug Tier Notes

VIVOTIF BERNA VACCINE T2 QL (4 EA per 1 fill)

ZOSTAVAX (PF) T2 QL (1 EA per 1 fill); AL (Min 50 Years)

Autonomic Drugs

Alpha- And Beta-Adrenergic Agonists

ADRENACLICK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML

T5

ADRENALIN INJECTION SOLUTION 1 MG/ML (1 ML)

T5


AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML

T5

CHILDREN'S SILFEDRINE T1 AL (Min 4 Years)

epinephrine injection auto-injector T1 QL (6 EA per 365 days)

EPIPEN 2-PAK T5

EPIPEN JR 2-PAK T5



pseudoephedrine hcl oral liquid T1 AL (Min 4 Years)

pseudoephedrine hcl oral tablet 30 mg T1 AL (Min 4 Years)

pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg

T1 AL (Min 6 Years)

SUDAFED 24 HOUR T1

SUDOGEST 12-HOUR T1 AL (Min 4 Years)

SUDOGEST ORAL TABLET 60 MG T1 AL (Min 4 Years)

Alpha-Adrenergic Agonists

clonidine hcl T1

clonidine transdermal patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days)

clonidine transdermal patch weekly 0.2 mg/24 hr, 0.3 mg/24 hr


methyldopa T1

midodrine T1



Antimuscarinics/Antispasmodics

24

Drug Tier Notes

ANORO ELLIPTA T3 ST

ATROVENT HFA T2 QL (25.8 QY per 30 DYs)

BEVESPI AEROSPHERE T3 ST

COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs)

dicyclomine oral capsule T1

dicyclomine oral tablet T1

diphenoxylate-atropine oral tablet T1

glycopyrrolate oral tablet 1 mg, 2 mg T1

hyoscyamine sulfate oral tablet T1

hyoscyamine sulfate oral tablet extended release 12 hr

T1

hyoscyamine sulfate sublingual T1

INCRUSE ELLIPTA T2 QL (30 EA per 30 days)

ipratropium bromide inhalation T1 QL (312.5 QY per 30 DYs)

ipratropium-albuterol T1 QL (570 QY per 30 DYs)

phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 -0.0194 mg/5 ml

T5

phenobarb-hyoscy-atropine-scop oral tablet T5

PHENOHYTRO T5

SPIRIVA RESPIMAT T2 QL (4 GM per 30 days)

STIOLTO RESPIMAT T2 QL (4 GM per 30 days)

TRELEGY ELLIPTA T3 ST

Antiparkinsonian Agents

benztropine T5 CO

trihexyphenidyl T5 CO

Autonomic Drugs, Miscellaneous

CHANTIX T2 QL (60 EA per 30 days)

CHANTIX STARTING MONTH BOX T2 QL (159 EA per 365 days)

nicotine (polacrilex) buccal gum T1 QL (360 QY per 30 DYs)

nicotine (polacrilex) buccal lozenge T1 QL (600 EA per 30 days)

nicotine (polacrilex) buccal mini lozenge T1 QL (600 EA per 30 days)

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr

T1 QL (30 QY per 30 DYs)

NICOTROL T3 PA

NICOTROL NS T3 PA

25

Drug Tier Notes

Centrally Acting Skeletal Muscle Relaxnt

cyclobenzaprine oral tablet 10 mg, 5 mg T1 QL (90 QY per 30 DYs)

methocarbamol oral T1 QL (120 EA per 30 days)

tizanidine oral tablet T1 QL (90 QY per 30 DYs)

Direct-Acting Skeletal Muscle Relaxants

dantrolene oral capsule 100 mg T5

Gaba-Derivative Skeletal Muscle Relaxant

baclofen oral T1

Neuromuscular Blocking Agents

vecuronium bromide intravenous recon soln 10 mg T5

Non-Sel. Beta-Adrenergic Blocking Agents

carvedilol T1

carvedilol phosphate T5

labetalol oral T1

nadolol T1

propranolol intravenous T5

propranolol oral T1

sotalol oral T1

Non-Sel.Alpha-1-Adrenergic Blocking Agts

doxazosin T1

prazosin T1

terazosin T1

Non-Sel.Alpha-Adrenergic Blocking Agents

CAFERGOT T5

phenoxybenzamine T3 PA

Non-Selective Beta-Adrenergic Agonists

ISUPREL T5

Parasympathomimetic (Cholinergic Agents)

bethanechol chloride T1

donepezil T1

galantamine T1

NAMZARIC T2

pilocarpine hcl oral tablet 5 mg T1 QL (180 QY per 30 DYs)

26

Drug Tier Notes

pilocarpine hcl oral tablet 7.5 mg T1 QL (120 EA per 30 days)

pyridostigmine bromide oral syrup T1

pyridostigmine bromide oral tablet 60 mg T1

pyridostigmine bromide oral tablet extended release

T1

rivastigmine T1

rivastigmine tartrate T1

Selective Alpha-1-Adrenergic Block.Agent

alfuzosin T1

carvedilol T1


labetalol oral T1

tamsulosin T1

Selective Beta-1-Adrenergic Agonists

dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml)

T5


ADVAIR HFA T3 PA

albuterol sulfate inhalation hfa aerosol inhaler T1 QL (2 INH per 30 days)

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/0.5 ml

T1

albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %)


albuterol sulfate inhalation solution for nebulization 5 mg/ml


albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years)

albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs)

ANORO ELLIPTA T3 ST

ARCAPTA NEOHALER T2 QL (30 EA per 30 days)


BREO ELLIPTA T3 PA

BROVANA T3 PA

budesonide-formoterol T1 QL (20.4 QY per 30 days)


27

Drug Tier Notes

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION


DULERA INHALATION HFA AEROSOL INHALER 50-5 MCG/ACTUATION

T2 QL (13 GM per 30 days)

fluticasone propion-salmeterol inhalation aerosol powdr breath activated


fluticasone propion-salmeterol inhalation blister with device



levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml

T3 ST; QL (240 QY per 30 DYs)

levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml


levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml


levalbuterol tartrate T3 ST; QL (30 GM per 30 days)

PERFOROMIST T5

PROAIR RESPICLICK T2 QL (2 EA per 30 days)

SEREVENT DISKUS T3 PA

STIOLTO RESPIMAT T2 QL (4 GM per 30 days)

STRIVERDI RESPIMAT T2 QL (4 GM per 30 days)

terbutaline oral T1

terbutaline subcutaneous T5


WIXELA INHUB T1 QL (60 EA per 30 days)

Selective Beta-Adrenergic Blocking Agent

atenolol T1

atenolol-chlorthalidone T1

bisoprolol fumarate T1

bisoprolol-hydrochlorothiazide T1

metoprolol succinate T1

metoprolol tartrate intravenous T5

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

T1

Blood Derivatives

28

Drug Tier Notes

Blood Derivatives

albumin, human 25 % T5

Blood Formation, Coagulation, Thrombosis

Anticoagulants, Miscellaneous

CEPROTIN (BLUE BAR) T5

Antihemorrhagic Agents, Miscellaneous

PRAXBIND T5

Antiheparin Agents

protamine T5

Antithrombotic Agents, Miscellaneous

DEFITELIO T5

Blood Form.,Coag,Thrombosis Agents Misc.

OXBRYTA T3 PA

TAVALISSE T5

Coumarin Derivatives

warfarin T1

Direct Factor Xa Inhibitors

ELIQUIS T2 QL (60 EA per 30 days)

ELIQUIS DVT-PE TREAT 30D START T2 QL (74 EA per 30 days)

SAVAYSA T2 QL (30 EA per 30 days)

XARELTO ORAL TABLET 10 MG, 20 MG T2 QL (30 EA per 30 days)

XARELTO ORAL TABLET 15 MG, 2.5 MG T2 QL (60 EA per 30 days)

XARELTO ORAL TABLETS,DOSE PACK T2 QL (51 EA per 30 days)

Direct Thrombin Inhibitors

PRADAXA T3 PA

Hematopoietic Agents

ARANESP (IN POLYSORBATE) T3 PA

DOPTELET (10 TAB PACK) T5

DOPTELET (15 TAB PACK) T5

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML

T3 PA

FULPHILA T5

29

Drug Tier Notes

GRANIX T5

MIRCERA T5

MOZOBIL T4 PA

MULPLETA T5

NEULASTA T5

NEUPOGEN T5

NIVESTYM T3 PA

NPLATE T5

PROCRIT INJECTION SOLUTION 4,000 UNIT/ML, 40,000 UNIT/ML

T3 PA

PROMACTA ORAL POWDER IN PACKET T5

PROMACTA ORAL TABLET T3 PA

RETACRIT T3 PA

UDENYCA T5

ZARXIO T5

ZIEXTENZO T3 PA

Hemorrheologic Agents

pentoxifylline T1

Hemostatics

ADVATE T5 CO

ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

T5 CO

ALPHANATE T5 CO

ALPHANINE SD T5 CO

ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 3,000 UNIT, 500 UNIT

T5 CO

BEBULIN T5 CO

BENEFIX T5 CO

COAGADEX T5 CO

CORIFACT T5 CO

DDAVP NASAL SOLUTION T5

desmopressin nasal spray,non-aerosol T1

desmopressin oral T1

30

Drug Tier Notes

ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT, 750 UNIT

T5 CO

ESPEROCT T5 CO

FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT

T5 CO

HELIXATE FS T5 CO

HEMLIBRA T5 CO

HEMOFIL M HIGH T5 CO

HEMOFIL M LOW T5 CO

HEMOFIL M MID T5 CO

HEMOFIL M SUPER HIGH T5 CO

HUMATE-P T5 CO

IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

T5 CO

IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 500 UNIT

T5 CO

JIVI INTRAVENOUS RECON SOLN 3,000 (+/-) UNIT

T5 CO

KOATE INTRAVENOUS RECON SOLN 250 (+/-) UNIT, 500 (+/-) UNIT

T5 CO

KOGENATE FS T5 CO

MONOCLATE-P INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT

T5 CO

NOVOEIGHT T5 CO

NOVOSEVEN RT T5 CO

OBIZUR T5 CO

PROFILNINE T5 CO

REBINYN T5 CO

RECOMBINATE T5 CO

RIXUBIS T5 CO

STIMATE T3 PA

tranexamic acid oral T1

TRETTEN T5 CO

31

Drug Tier Notes

WILATE INTRAVENOUS RECON SOLN 450-450 UNIT, 900-900 UNIT

T5 CO

XYNTHA T5 CO

XYNTHA SOLOFUSE T5 CO

Heparins

enoxaparin subcutaneous solution T1 QL (18 ML per 30 days)

enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml

T1 QL (60 ML per 30 days)

enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml


enoxaparin subcutaneous syringe 30 mg/0.3 ml T1 QL (18 ML per 30 days)



heparin (porcine) injection solution 10,000 unit/ml, 20,000 unit/ml

T1

Iron Preparations

ATABEX EC T2 QL (30 QY per 30 DYs)

BIOTECT PLUS T1

CENTRUM COMPLETE T1

CLASSIC PRENATAL T2

ELITE-OB 400 T1 QL (30 QY per 30 DYs)

ferrous gluconate oral tablet 324 mg (38 mg iron) T1

ferrous sulfate oral drops T1

ferrous sulfate oral elixir T1

ferrous sulfate oral solution T1

ferrous sulfate oral tablet 325 mg (65 mg iron) T1

ferrous sulfate oral tablet extended release T1

ferrous sulfate oral tablet,delayed release (dr/ec) T1

FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE 18 MG IRON


FOLIVANE-OB T1 QL (30 QY per 30 DYs)

INFED T5

KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs)

NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs)

NEWGEN T1 QL (30 EA per 30 days)

32

Drug Tier Notes

OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs)

O-CAL FA T2 QL (30 QY per 30 DYs)

ONE DAILY MULTI-VIT W-MINERAL ORAL TABLET

T1

POLYVITAMIN WITH IRON T1 AL (Max 12 Years)

PRENATA T2 QL (30 QY per 30 DYs)

PRENATAL PLUS T1 QL (30 QY per 30 DYs)

PRENATAL PLUS (CALCIUM CARB) T1

PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG

T1

PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs)

prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs)

PRETAB T1 QL (30 EA per 30 days)

PUREFE OB PLUS T2 QL (30 QY per 30 DYs)

SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs)

STROVITE FORTE T2

THERA-M ORAL TABLET , 9 MG IRON-400 MCG

T1

THEREMS-M T2

TRIADVANCE T1

TRINATAL GT T1 QL (30 QY per 30 DYs)

TRIVEEN-ONE T1 QL (30 QY per 30 DYs)

TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs)

TRI-VI-SOL WITH IRON T2 AL (Max 12 Years)

ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs)

VINACAL B T1

VINATE M T1 QL (30 QY per 30 DYs)

VINATE ONE T1 QL (30 QY per 30 DYs)

VINATE ULTRA T1 QL (30 EA per 30 days)

VIRT-SELECT T1 QL (30 QY per 30 DYs)

VITAFOL GUMMIES T2

VITAMED MD ONE RX T2 QL (30 EA per 30 days)

VOL-NATE T1 QL (30 EA per 30 days)

VP-CH PLUS T1 QL (30 EA per 30 days)

ZATEAN-CH T1

33

Drug Tier Notes

Platelet-Aggregation Inhibitors

aspirin oral tablet T1

aspirin oral tablet,chewable T1

aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg

T1

aspirin-dipyridamole T1 QL (60 EA per 30 days)

BRILINTA T2 QL (60 EA per 30 days)

BUFFERED ASPIRIN T5

BUFFERIN T5

butalbital-aspirin-caffeine oral tablet T3 PA

cilostazol T1 QL (60 QY per 30 DYs)

clopidogrel oral tablet 75 mg T1

dipyridamole oral T1

MIGRAINE FORMULA T1

prasugrel T1 ST; QL (30 EA per 30 days)

TRI-BUFFERED ASPIRIN T5

Platelet-Reducing Agents

anagrelide T1

Thrombolytic Agents




T1

BUFFERED ASPIRIN T5

BUFFERIN T5


MIGRAINE FORMULA T1


Cardiovascular Drugs

Alpha-Adrenergic Blocking Agents

carvedilol T1


doxazosin T1

labetalol oral T1

34

Drug Tier Notes

prazosin T1

terazosin T1

Alpha-Adrenergic Blocking Agt.(Hypoten)

doxazosin T1

labetalol oral T1

prazosin T1

terazosin T1

Angiotensin Ii Receptor Antagon.(Hypotn)

amlodipine-valsartan T1

irbesartan T1

irbesartan-hydrochlorothiazide T1

losartan T1

losartan-hydrochlorothiazide T1

olmesartan T1

telmisartan T1

valsartan T1

valsartan-hydrochlorothiazide T1

Angiotensin Ii Receptor Antagonists


ENTRESTO T3 ST

irbesartan T1


losartan T1


olmesartan T1

telmisartan T1

valsartan T1


Angiotensin-Convert.Enzyme Inhib(Hypotn)

amlodipine-benazepril T1

benazepril T1

benazepril-hydrochlorothiazide T1

captopril T1

35

Drug Tier Notes

enalapril maleate T1

enalapril-hydrochlorothiazide T1

fosinopril T1

lisinopril T1

lisinopril-hydrochlorothiazide T1

quinapril T1

ramipril T1

Angiotensin-Converting Enzyme Inhibitors


benazepril T1


captopril T1

enalapril maleate T1


fosinopril T1

lisinopril T1


quinapril T1

ramipril T1

Antiarrhythmics, Miscellaneous

digoxin injection solution T5

digoxin oral solution 50 mcg/ml (0.05 mg/ml) T1

digoxin oral tablet T1

Antilipemic Agents, Miscellaneous

FISH OIL ORAL CAPSULE 340-1,000 MG T1

niacin oral capsule, extended release 250 mg, 500 mg

T1

niacin oral tablet 100 mg, 500 mg T1

niacin oral tablet extended release 24 hr 1,000 mg, 750 mg

T5

niacin oral tablet extended release 500 mg T1

NIACOR T1

omega-3 acid ethyl esters T5

36

Drug Tier Notes

omega-3 fatty acids-fish oil oral capsule 300-1,000 mg

T1

VASCEPA T5

Beta-Adrenergic Blocking Agents

atenolol T1




carvedilol T1


labetalol oral T1

LEVATOL T5




T1

nadolol T1


propranolol oral T1

sotalol oral T1

Beta-Adrenergic Blocking Agt.(Hypoten)

atenolol T1




labetalol oral T1




T1

nadolol T1


propranolol oral T1

sotalol oral T1

37

Drug Tier Notes

Bile Acid Sequestrants

cholestyramine (with sugar) T1

CHOLESTYRAMINE LIGHT T1

colesevelam oral tablet T3 PA

colestipol oral granules T3 PA

colestipol oral packet T3 PA

colestipol oral tablet T1

WELCHOL ORAL POWDER IN PACKET T3 PA

Calcium-Channel Block.Agt,Misc(Hypoten)

diltiazem hcl oral capsule,ext.rel 24h degradable T1

diltiazem hcl oral capsule,extended release 12 hr T1

diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 360 mg, 420 mg

T1

diltiazem hcl oral capsule,extended release 24hr T1

diltiazem hcl oral tablet T1

TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 240 MG

T1

verapamil intravenous T5

verapamil oral capsule,ext rel. pellets 24 hr T1

verapamil oral tablet T1

verapamil oral tablet extended release T1

Calcium-Channel Blocking Agents

amlodipine T1






T1



felodipine T1

nifedipine oral tablet extended release T1

nifedipine oral tablet extended release 24hr T1

38

Drug Tier Notes


T1





Calcium-Channel Blocking Agents(Hypoten)




T1




T1





Calcium-Channel Blocking Agents, Misc.




T1




T1





Carbonic Anhydrase Inhibitors(Hypoten)

acetazolamide T1

Cardiac Drugs, Miscellaneous

39

Drug Tier Notes

ranolazine T3 ST

Cardiotonic Agents

digoxin injection solution T5

digoxin oral solution 50 mcg/ml (0.05 mg/ml) T1

digoxin oral tablet T1

dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml)

T5

Central Alpha-Agonists

clonidine hcl T1

clonidine transdermal patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days)

clonidine transdermal patch weekly 0.2 mg/24 hr, 0.3 mg/24 hr


guanfacine T1

methyldopa T1

Cholesterol Absorption Inhibitors

ezetimibe T1

Class Ia Antiarrhythmics

disopyramide phosphate oral capsule T1

NORPACE CR T2

procainamide injection solution 100 mg/ml T5

quinidine gluconate injection T5

quinidine gluconate oral T1

Class Ib Antiarrhythmics

DILANTIN T2

mexiletine T1

phenytoin oral suspension 125 mg/5 ml T1 AL (Max 16 Years)

phenytoin oral tablet,chewable T1 AL (Max 16 Years)

phenytoin sodium extended T1

Class Ic Antiarrhythmics

flecainide T1

propafenone oral tablet T1

Class Ii Antiarrhythmics

atenolol T1


40

Drug Tier Notes



carvedilol T1


labetalol oral T1




T1

nadolol T1


propranolol oral T1

sotalol oral T1

Class Iii Antiarrhythmics

amiodarone oral T1

dofetilide T1

sotalol oral T1

Class Iv Antiarrhythmics




T1




T1





Dihydropyridines

amlodipine T1



41

Drug Tier Notes

felodipine T1



Dihydropyridines (Antihypertensive)

amlodipine T1



felodipine T1



Direct Vasodilators

BIDIL T5

hydralazine injection T5

hydralazine oral T1

minoxidil oral T1

Diuretics, Miscellaneous (Hypotensive)

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg

T1

theophylline oral tablet extended release 24 hr T1

Fibric Acid Derivatives

ANTARA ORAL CAPSULE 30 MG, 90 MG T5

fenofibrate micronized T1

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

T1

fenofibrate oral tablet 160 mg, 54 mg T1

fenofibric acid (choline) T1

gemfibrozil T1

Hmg-Coa Reductase Inhibitors

atorvastatin T1

fluvastatin oral tablet extended release 24 hr T5

lovastatin T1

pravastatin T1

rosuvastatin T1

simvastatin oral tablet T1

42

Drug Tier Notes

Hypotensive Agents, Miscellaneous

amlodipine T1



carvedilol T1


doxazosin T1

felodipine T1



phenoxybenzamine T3 PA


propranolol oral T1

sotalol oral T1

terazosin T1

Loop Diuretics (Hypotensive Agents)

bumetanide oral T1

furosemide injection syringe T5

furosemide oral T1

torsemide oral T1

Mineralocorticoid (Aldosterone) Antagnts

eplerenone T3 ST

spironolactone T1

spironolacton-hydrochlorothiaz T1

Mineralocorticoid(Aldoster.)Antag(Hypot)

eplerenone T3 ST

spironolactone T1


Nitrates And Nitrites

BIDIL T5

DILATRATE-SR T2

isosorbide dinitrate oral T1

isosorbide mononitrate T1

43

Drug Tier Notes

NITRO-BID T2

nitroglycerin sublingual T1

Osmotic Diuretics (Hypotensive Agents)

mannitol 20 % T5

Pcsk9 Inhibitors

PRALUENT PEN T3 PA

REPATHA PUSHTRONEX T4 PA

REPATHA SURECLICK T4 PA

REPATHA SYRINGE T4 PA

Phosphodiesterase Type 5 Inhibitors

cilostazol T1 QL (60 QY per 30 DYs)

sildenafil (pulm.hypertension) intravenous T5

sildenafil (pulm.hypertension) oral suspension for reconstitution

T5

sildenafil (pulm.hypertension) oral tablet T3 PA

tadalafil (pulm. hypertension) T3 PA

Potassium-Sparing Diuretics (Hypoten)

amiloride T1

eplerenone T3 ST

spironolactone T1


triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

T1

triamterene-hydrochlorothiazid oral capsule 50-25 mg

T5

triamterene-hydrochlorothiazid oral tablet T1

Renin Inhibitors

aliskiren T5

TEKTURNA HCT T5

Renin-Angioten.-Aldost. Sys. Inhib, Misc

ENTRESTO T3 ST

Sclerosing Agents

VARITHENA T5

Thiazide Diuretics(Hypotensive Agents)

44

Drug Tier Notes



chlorothiazide T1

DIURIL T2 AL (Max 12 Years)


hydrochlorothiazide T1





TEKTURNA HCT T5


T1


T5



Thiazide-Like Diuretics(Hypotensive Agt)


chlorthalidone oral tablet 25 mg, 50 mg T1

indapamide T1

metolazone T1

Vasodilating Agents, Miscellaneous

ADEMPAS T4 PA

ambrisentan T4 PA

amlodipine T1




bosentan T5




T1


45

Drug Tier Notes


dipyridamole oral T1

felodipine T1



OPSUMIT T5

ORENITRAM T5


T1

treprostinil sodium T4 PA

TYVASO T4 PA

TYVASO INSTITUTIONAL START KIT T4 PA

TYVASO REFILL KIT T4 PA

TYVASO STARTER KIT T4 PA

UPTRAVI T4 PA

VENTAVIS T4 PA





Cellular And Gene Therapy

Cellular And Gene Therapy

PROVENGE T5

Cellular Therapy

PROVENGE T5

Central Nervous System Agents

Adamantanes (Cns)

amantadine hcl T5 CO

GOCOVRI T5 CO

OSMOLEX ER T5 CO

Amphetamine Derivatives

diethylpropion oral tablet T5

LOMAIRA T5

46

Drug Tier Notes

phendimetrazine tartrate oral tablet T5

phentermine T3 PA

QSYMIA T5

Amphetamines

ADZENYS XR-ODT T5

amphetamine T5

amphetamine sulfate T5

benzphetamine T5

dextroamphetamine oral capsule, extended release T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)

dextroamphetamine oral solution T5

dextroamphetamine oral tablet 10 mg T1 QL (120 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)

dextroamphetamine oral tablet 5 mg T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)

dextroamphetamine-amphetamine T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)

DYANAVEL XR T5

EVEKEO ODT T5

methamphetamine T5

MYDAYIS T5

PROCENTRA T5

VYVANSE T5

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

T5

Analgesics And Antipyretics, Misc.

acetaminophen oral elixir T1

acetaminophen oral tablet T1

acetaminophen oral tablet extended release T1

acetaminophen rectal suppository 120 mg T1

acetaminophen-codeine oral solution 120-12 mg/5 ml


acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)

butalbital-acetaminophen-caff oral capsule T5

47

Drug Tier Notes

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

T3 PA

CHILDREN'S PAIN RELIEF ORAL SUSPENSION

T1

FEVERALL RECTAL SUPPOSITORY 325 MG, 80 MG

T1

FIORICET ORAL CAPSULE T5

gabapentin oral capsule T1

gabapentin oral solution 250 mg/5 ml T1 AL (Max 16 Years)

gabapentin oral tablet 600 mg, 800 mg T1

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

T5

hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg

T5



hydrocodone-acetaminophen oral tablet 2.5-325 mg


INFANT'S NON-ASPIRIN ORAL DROPS T1

INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION 80 MG/0.8 ML

T1

MAPAP (ACETAMINOPHEN) ORAL LIQUID 160 MG/5 ML

T1

MIGRAINE FORMULA T1

NORTEMP ORAL DROPS T1

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg


oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs)

PHRENILIN FORTE(WITH CAFFEINE) T5

pregabalin oral capsule T1 QL (2 EA per 1 day)

PRIMLEV T5

TENSION HEADACHE T1

tramadol-acetaminophen T1 QL (120 EA per 30 DYs); AL (Min 18 Years)

VICODIN ES T5

VICODIN HP T5

Anorexigenic Agents, Miscellaneous

48

Drug Tier Notes

CONTRAVE T3 PA

Anticholinergic Agents (Cns)

benztropine T5 CO

trihexyphenidyl T5 CO

Anticonvulsants, Miscellaneous

APTIOM T2

BANZEL ORAL TABLET T2

carbamazepine oral capsule, er multiphase 12 hr T1

carbamazepine oral suspension 100 mg/5 ml T1 AL (Max 16 Years)

carbamazepine oral tablet T1

carbamazepine oral tablet extended release 12 hr T1

carbamazepine oral tablet,chewable T1 AL (Max 16 Years)

divalproex T1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG, 300 MG

T5

gabapentin oral capsule T1

gabapentin oral solution 250 mg/5 ml T1 AL (Max 16 Years)

gabapentin oral tablet 600 mg, 800 mg T1

lamotrigine oral tablet T1

lamotrigine oral tablet, chewable dispersible T1 AL (Max 16 Years)

levetiracetam oral solution 100 mg/ml T1 AL (Max 16 Years)

levetiracetam oral tablet T1

oxcarbazepine oral suspension T1 AL (Max 16 Years)

oxcarbazepine oral tablet T1

POTIGA T2


QSYMIA T5

topiramate oral capsule, sprinkle T1

topiramate oral tablet T1

valproic acid T1

valproic acid (as sodium salt) oral solution 250 mg/5 ml


VIMPAT ORAL SOLUTION T2 AL (Max 16 Years)

VIMPAT ORAL TABLET T2

49

Drug Tier Notes

zonisamide T1

Antidepressants, Miscellaneous

bupropion hcl (smoking deter) T1

bupropion hcl oral tablet T1

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

T1

bupropion hcl oral tablet sustained-release 12 hr T1

mirtazapine T1

Antimanic Agents

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

T5 CO

aripiprazole T5 CO

ARISTADA INITIO T5 CO

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML

T5 CO

carbamazepine oral capsule, er multiphase 12 hr T1

carbamazepine oral suspension 100 mg/5 ml T1 AL (Max 16 Years)

carbamazepine oral tablet T1

carbamazepine oral tablet extended release 12 hr T1

carbamazepine oral tablet,chewable T1 AL (Max 16 Years)

divalproex T1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG, 300 MG

T5

GEODON INTRAMUSCULAR T5 CO

lamotrigine oral tablet T1

lamotrigine oral tablet, chewable dispersible T1 AL (Max 16 Years)

lithium carbonate T5 CO

lithium citrate oral solution 8 meq/5 ml T5 CO

olanzapine T5 CO

quetiapine oral tablet T5 CO

RISPERDAL CONSTA T5 CO

risperidone oral solution T5 CO

risperidone oral tablet T5 CO

risperidone oral tablet,disintegrating T5 CO

50

Drug Tier Notes

SAPHRIS (BLACK CHERRY) T5 CO

SECUADO T5 CO

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

T5 CO

valproic acid T1



ziprasidone hcl T5 CO

ZYPREXA RELPREVV T5 CO

Antimigraine Agents, Miscellaneous

AIMOVIG AUTOINJECTOR T5

AIMOVIG AUTOINJECTOR (2 PACK) T5

AJOVY SYRINGE T5




T1

BUFFERED ASPIRIN T5

BUFFERIN T5



T3 PA


CAFERGOT T5

divalproex T1

EMGALITY PEN T3 PA

EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML

T3 PA


MIGRAINE FORMULA T1



propranolol oral T1



51

Drug Tier Notes

valproic acid T1



Antipsychotics, Miscellaneous

loxapine succinate T5 CO

pimozide T5 CO

Anxiolytics,Sedatives,And Hypnotics,Misc

BELSOMRA T5

buspirone T1

EDLUAR T5

eszopiclone oral tablet 1 mg T1 QL (30 EA per 30 days); AL (Min 16 Years)

eszopiclone oral tablet 2 mg, 3 mg T3 ST; QL (30 EA per 30 days); AL (Min 16 Years)

HETLIOZ T5

hydroxyzine hcl oral solution 10 mg/5 ml T1

hydroxyzine hcl oral tablet T1

hydroxyzine pamoate T1

PHENADOZ RECTAL SUPPOSITORY 12.5 MG T1 AL (Min 2 Years)



promethazine rectal suppository 25 mg T1 AL (Min 2 Years)

propofol intravenous emulsion T5

ramelteon T3 PA


zaleplon T1 QL (30 EA per 30 days); AL (Min 16 Years)

zolpidem oral tablet T1 QL (30 QY per 30 DYs); AL (Min 16 Years)

zolpidem oral tablet,ext release multiphase T3 PA

zolpidem sublingual T5

ZOLPIMIST T5

Atypical Antipsychotics

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

T5 CO

52

Drug Tier Notes

aripiprazole T5 CO

ARISTADA INITIO T5 CO

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML

T5 CO

CAPLYTA T5 CO

clozapine T5 CO

FANAPT T5 CO

GEODON INTRAMUSCULAR T5 CO

INVEGA T5 CO

INVEGA SUSTENNA T5 CO

INVEGA TRINZA T5 CO

LATUDA T5 CO

NUPLAZID ORAL TABLET 17 MG T5 CO

olanzapine T5 CO

olanzapine-fluoxetine T5 CO

quetiapine oral tablet T5 CO

REXULTI T5 CO

RISPERDAL CONSTA T5 CO

risperidone oral solution T5 CO

risperidone oral tablet T5 CO

risperidone oral tablet,disintegrating T5 CO

SAPHRIS (BLACK CHERRY) T5 CO

SECUADO T5 CO

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

T5 CO

VRAYLAR T5 CO

ziprasidone hcl T5 CO

ZYPREXA RELPREVV T5 CO

Barbiturates (Anticonvulsants)

BREVITAL INJECTION RECON SOLN 500 MG T5


T5


phenobarbital oral elixir T1 AL (Max 16 Years)

53

Drug Tier Notes

phenobarbital oral tablet T1

PHENOHYTRO T5

primidone T1

Barbiturates (Anxiolytic, Sedative/Hyp)



T3 PA




T5


phenobarbital oral elixir T1 AL (Max 16 Years)

phenobarbital oral tablet T1

PHENOHYTRO T5


Barbiturates (General Anesthetics)

BREVITAL INJECTION RECON SOLN 500 MG T5

Benzodiazepines (Anticonvulsants)

clobazam oral suspension T1 AL (Max 16 Years)

clobazam oral tablet T1

clonazepam oral tablet T1 QL (60 QY per 30 DYs)

clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 2 mg

T1 QL (90 EA per 30 days); AL (Max 12 Years)

diazepam oral tablet T1 QL (120 QY per 30 DYs)

diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg


diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs)

lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs)

lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs)

NAYZILAM T2 QL (3 fills per 365 days)

VALTOCO T2 QL (3 fills per 365 days)

Benzodiazepines (Anxiolytic,Sedativ/Hyp)

chlordiazepoxide hcl T1 QL (120 QY per 30 DYs)

clobazam oral suspension T1 AL (Max 16 Years)

54

Drug Tier Notes

clobazam oral tablet T1

clonazepam oral tablet T1 QL (60 QY per 30 DYs)

clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg

T1 QL (90 EA per 30 days); AL (Max 12 Years)

diazepam oral tablet T1 QL (120 QY per 30 DYs)

diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg


diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs)

estazolam T5

flurazepam T5

lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs)

lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs)

midazolam injection solution 5 mg/ml T1 QL (5 ML per 1 fill)

NAYZILAM T2 QL (3 fills per 365 days)

ONFI ORAL SUSPENSION T2 AL (Max 16 Years)

quazepam T5

temazepam T1 QL (30 QY per 30 DYs); AL (Min 16 Years)

triazolam T5

VALTOCO T2 QL (3 fills per 365 days)

Butyrophenones

haloperidol T5 CO

haloperidol decanoate T5 CO

haloperidol lactate injection T5 CO

haloperidol lactate oral T5 CO

Calcitonin Gene-Related Peptide Antag.

AIMOVIG AUTOINJECTOR T5

AIMOVIG AUTOINJECTOR (2 PACK) T5

AJOVY AUTOINJECTOR T5

AJOVY SYRINGE T5

EMGALITY PEN T3 PA

EMGALITY SYRINGE T3 PA

NURTEC ODT T5

UBRELVY T5

55

Drug Tier Notes

Catechol-O-Methyltransferase(Comt)Inhib.

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

T5

carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

T1

entacapone T1

tolcapone T3 PA

Central Nervous System Agents, Misc.

acamprosate T5 CO

atomoxetine T1 QL (60 EA per 30 days)

AUSTEDO T4 PA

carbidopa T1

guanfacine T1

INGREZZA T4 PA

memantine T1

NAMZARIC T2

NUEDEXTA T3 PA

riluzole T1

tetrabenazine T4 PA

XYREM T5

Cyclooxygenase-2 (Cox-2) Inhibitors

celecoxib T1

Dopamine Precursors

carbidopa-levodopa oral tablet T1

carbidopa-levodopa oral tablet extended release T1

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

T5

carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

T1

Ergot-Deriv. Dopamine Receptor Agonists

bromocriptine T1

cabergoline T1

Fibromyalgia Agents

56

Drug Tier Notes

duloxetine T1


SAVELLA T5

General Anesthetics, Miscellaneous

propofol intravenous emulsion T5

Hydantoins

DILANTIN T2

phenytoin oral suspension 125 mg/5 ml T1 AL (Max 16 Years)

phenytoin oral tablet,chewable T1 AL (Max 16 Years)

phenytoin sodium extended T1

Inhalation Anesthetics

sevoflurane T5

Monoamine Oxidase B Inhibitors

EMSAM T5 CO

selegiline hcl T1

Monoamine Oxidase Inhibitors

EMSAM T5 CO

phenelzine T5 CO

selegiline hcl T1

tranylcypromine T5 CO

Nonergot-Deriv.Dopamine Receptor Agonist

pramipexole oral tablet T1

pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 3 mg, 4.5 mg

T5

ropinirole oral tablet T1

Opiate Agonists

acetaminophen-codeine oral solution 120-12 mg/5 ml


acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)

ARYMO ER T5

codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)

codeine-guaifenesin T1 AL (Min 18 Years)

57

Drug Tier Notes

DEMEROL (PF) INJECTION SOLUTION 100 MG/2 ML, 100 MG/ML, 25 MG/0.5 ML, 75 MG/1.5 ML

T5

DEMEROL INJECTION T5

fentanyl T3 PA

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

T5


T5



hydrocodone-acetaminophen oral tablet 2.5-325 mg


hydromorphone oral tablet T1 QL (120 QY per 30 DYs)

hydromorphone oral tablet extended release 24 hr 12 mg, 32 mg, 8 mg

T5

hydromorphone rectal T5

levorphanol tartrate T5

meperidine (pf) injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml

T5

meperidine oral solution T5

methadone oral concentrate T5

methadone oral solution T5

methadone oral tablet T5

methadone oral tablet,soluble T5

MORPHABOND ER T5

morphine concentrate oral solution T1 QL (360 ML per 30 days)

morphine oral capsule, er multiphase 24 hr T5

morphine oral capsule,extend.release pellets T3 PA

morphine oral solution T1 QL (360 ML per 30 days)

morphine oral tablet T1 QL (120 QY per 30 DYs)

morphine oral tablet extended release T1 QL (90 EA per 30 days)

NUCYNTA ER T5

oxycodone oral concentrate T1 QL (360 ML per 30 days)

oxycodone oral solution T1 QL (360 ML per 30 days)

oxycodone oral tablet T1 QL (120 QY per 30 DYs)

58

Drug Tier Notes

oxycodone oral tablet,oral only,ext.rel.12 hr T3 PA

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg


oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG

T3 PA

oxymorphone oral tablet extended release 12 hr T5

PRIMLEV T5

tramadol oral tablet 100 mg T5

tramadol oral tablet 50 mg T1 QL (240 QY per 30 DYs); AL (Min 18 Years)


VICODIN ES T5

VICODIN HP T5

XTAMPZA ER T5

Opiate Antagonists

EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML

T5 CO

naloxone injection solution T5 CO

naloxone injection syringe T5 CO

naltrexone T5 CO

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

T5 CO

VIVITROL T5 CO

Opiate Partial Agonists

BUNAVAIL T5 CO

buprenorphine hcl injection solution T5 CO

buprenorphine hcl sublingual T5 CO

buprenorphine-naloxone sublingual tablet T5 CO

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR

T5 CO

SUBOXONE T5 CO

ZUBSOLV T5 CO

Other Nonsteroidal Anti-Inflam. Agents

59

Drug Tier Notes

DICLO GEL T5

diclofenac potassium T1

diclofenac sodium oral T1

diclofenac sodium topical drops T5

diclofenac sodium topical gel 1 % T1 QL (300 GM per 30 days)

diclofenac-misoprostol T1

etodolac T1

FLECTOR T5

flurbiprofen T1

IBUPROFEN JR STRENGTH T1

ibuprofen oral suspension T1

ibuprofen oral tablet 200 mg, 400 mg, 600 mg, 800 mg

T1

INDOCIN ORAL T2 AL (Max 12 Years)

INDOCIN RECTAL T2

indomethacin oral T1

INFANT'S IBUPROFEN T1

ketorolac oral T1 QL (20 EA per 30 days)

meloxicam oral tablet T1

nabumetone T1

naproxen oral suspension T1 AL (Max 12 Years)

naproxen oral tablet T1

naproxen oral tablet,delayed release (dr/ec) T1

naproxen sodium oral tablet T1

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP

T5

piroxicam T1

sulindac T1

sumatriptan-naproxen T5

Phenothiazines

chlorpromazine T5 CO

fluphenazine decanoate T5 CO

fluphenazine hcl T5 CO

perphenazine T5 CO

60

Drug Tier Notes

prochlorperazine T1

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)

T5

prochlorperazine maleate T1

thioridazine T5 CO

trifluoperazine T5 CO

Respiratory And Cns Stimulants

ADHANSIA XR T5

APTENSIO XR T5



T3 PA


COTEMPLA XR-ODT T5

DAYTRANA T5

dexmethylphenidate oral capsule,er biphasic 50-50

T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)

dexmethylphenidate oral tablet 10 mg T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)

dexmethylphenidate oral tablet 2.5 mg, 5 mg T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)


JORNAY PM T5

methylphenidate hcl oral capsule, er biphasic 30-70


methylphenidate hcl oral capsule,er biphasic 50-50


methylphenidate hcl oral solution 10 mg/5 ml T1 QL (900 QY per 30 DYs); AL (Min 5 Years and Max 12 Years)

methylphenidate hcl oral solution 5 mg/5 ml T1 QL (300 QY per 30 DYs); AL (Min 5 Years and Max 12 Years)

methylphenidate hcl oral tablet T1 QL (90 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)

methylphenidate hcl oral tablet extended release 10 mg

T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)

methylphenidate hcl oral tablet extended release 20 mg

T1 QL (90 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)

61

Drug Tier Notes

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg


methylphenidate hcl oral tablet extended release 24hr 72 mg

T5

methylphenidate hcl oral tablet,chewable T5

MIGRAINE FORMULA T1


QUILLICHEW ER T5

QUILLIVANT XR T5

TENSION HEADACHE T1

Salicylates




T1


BUFFERED ASPIRIN T5

BUFFERIN T5


choline,magnesium salicylate T1

MIGRAINE FORMULA T1

MUSCLE RUB (WITH CAMPHOR) T1

PAIN RELIEVING(CAM-M.SAL-MENT) TOPICAL ADHESIVE PATCH,MEDICATED

T1 QL (40 EA per 30 days); AL (Min 18 Years)

salsalate T1


Sel.Serotonin,Norepi Reuptake Inhibitor

desvenlafaxine T5

desvenlafaxine fumarate T5

desvenlafaxine succinate T5

duloxetine T1

SAVELLA T5

venlafaxine oral capsule,extended release 24hr T1

venlafaxine oral tablet T1

venlafaxine oral tablet extended release 24hr T5

62

Drug Tier Notes

Selective Serotonin Agonists

almotriptan malate T5

eletriptan T5

frovatriptan T5

naratriptan T3 ST; QL (36 EA per 30 days)

ONZETRA XSAIL T5

REYVOW T5

rizatriptan T1 QL (36 EA per 30 days); AL (Min 6 Years)

sumatriptan T3 PA

sumatriptan succinate oral T1 QL (36 EA per 30 days); AL (Min 12 Years)

sumatriptan succinate subcutaneous cartridge T5

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml

T5

sumatriptan succinate subcutaneous solution T5

sumatriptan-naproxen T5

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML

T5

TOSYMRA T5

ZEMBRACE SYMTOUCH T5

zolmitriptan T5

ZOMIG NASAL T5

Selective Serotonin Receptor Agonists

BELVIQ XR T3 PA

Selective-Serotonin Reuptake Inhibitors

citalopram oral solution T1 AL (Max 12 Years)

citalopram oral tablet T1

escitalopram oxalate oral solution T1 AL (Max 12 Years)

escitalopram oxalate oral tablet T1

fluoxetine oral capsule T1

fluoxetine oral capsule,delayed release(dr/ec) T5

fluoxetine oral solution T1 AL (Max 12 Years)

fluoxetine oral tablet T5

fluvoxamine oral tablet T1

63

Drug Tier Notes

olanzapine-fluoxetine T5 CO

paroxetine hcl oral tablet T1

sertraline oral concentrate T1 AL (Max 12 Years)

sertraline oral tablet T1

Serotonin Modulators

trazodone T1

TRINTELLIX T5

VIIBRYD ORAL TABLET T5

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

T5

Succinimides

ethosuximide oral capsule T1

ethosuximide oral solution T1 AL (Max 16 Years)

Thioxanthenes

thiothixene T5 CO

Tricyclics, Other Norepi-Ru Inhibitors

amitriptyline T1

desipramine T1

doxepin oral capsule T1

doxepin oral concentrate T1

doxepin oral tablet T5

imipramine hcl T1

nortriptyline oral capsule T1

Vesicular Monoamine Transport2 Inhibitor

AUSTEDO T4 PA

INGREZZA T4 PA

INGREZZA INITIATION PACK T4 PA

tetrabenazine T4 PA

Wakefulness-Promoting Agents

armodafinil T3 PA

modafinil T3 PA

SUNOSI T5

WAKIX T5

64

Drug Tier Notes

Devices

Devices

ACCU-CHEK AVIVA CONTROL SOLN T1

ACCU-CHEK FASTCLIX LANCET DRUM T1

ACCU-CHEK FASTCLIX LANCING DEV T1

ACCU-CHEK GUIDE GLUCOSE METER T1 QL (1 EA per 365 days)

ACCU-CHEK GUIDE L1-L2 CTRL SOL T1

ACCU-CHEK GUIDE ME GLUCOSE MTR T1 QL (1 EA per 365 days)

ACCU-CHEK SMARTVIEW CONTRL SOL T1

ACCU-CHEK SOFT DEV LANCETS T1

ACCU-CHEK SOFTCLIX LANCET DEV T1

ACCU-CHEK SOFTCLIX LANCETS T1

AEROCHAMBER PLUS FLOW-VU,S MSK T1 QL (2 FL per 365 DYs)

AEROECLIPSE II NEBULIZER T1 QL (2 FL per 365 days)

BIONECT TOPICAL CREAM T5

BIOTENE DRY MOUTH ORAL RINSE T2

BLOOD PRESSURE KIT T1 QL (1 EA per 5 yrs)

blood pressure kit med and lrg T1 QL (1 EA per 5 yrs)

blood pressure monitor T1 QL (1 EA per 5 yrs)

COMPACT COMPRESSOR NEBULIZER T1 QL (2 FL per 365 days)

FREESTYLE LIBRE 10 DAY READER T3 PA

FREESTYLE LIBRE 10 DAY SENSOR T3 PA

FREESTYLE LIBRE 14 DAY READER T3 PA

FREESTYLE LIBRE 14 DAY SENSOR T3 PA

SILICONE MASK - INFANT T1 QL (2 FL per 365 days)

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

T1

SOFT TOUCH LANCETS T1

TRUZONE PEAK FLOW METER T1 QL (2 FL per 365 days)

Diagnostic Agents

Adrenocortical Insufficiency

ACTHAR H.P. T4 PA

ACTHREL T5

Cardiac Function

65

Drug Tier Notes

thallous chloride tl-201 intravenous solution 74 mbq/ml (2 mci/ml)

T5

Diabetes Mellitus

ACCU-CHEK AVIVA PLUS TEST STRP T1 QL (120 EA per 30 days)

ACCU-CHEK GUIDE TEST STRIPS T1 QL (120 EA per 30 days)

ACCU-CHEK SMARTVIEW TEST STRIP T1 QL (120 EA per 30 days)

Diagnostic Agents

GLUCAGEN DIAGNOSTIC KIT T5

Drug Hypersensitivity

PRE-PEN T2

Ketones

KETOSTIX T2 QL (100 QY per 100 DYs)

Kidney Function

mannitol 20 % T5

Ocular Disorders

ALTAFLUOR T1

Pituitary Function

ACTHREL T5

Thyroid Function

THYROGEN T5

Urine And Feces Contents

KETO-DIASTIX T5

Electrolytic, Caloric, And Water Balance

Alkalinizing Agents

CYTRA K CRYSTALS T1 QL (120 EA per 30 days)

potassium citrate T1 QL (120 QY per 30 DYs)

sodium bicarbonate intravenous syringe 8.4 % (1 meq/ml)

T1

sodium citrate-citric acid T1 QL (120 ML per 1 day)

Ammonia Detoxicants

ENULOSE T1

lactulose oral solution 10 gram/15 ml T1

Caloric Agents

66

Drug Tier Notes

AMINOSYN 10 % T5

AMINOSYN 8.5 % T5

AMINOSYN 8.5 %-ELECTROLYTES T5

AMINOSYN II 10 % T5

AMINOSYN II 15 % T5

AMINOSYN II 8.5 % T5

AMINOSYN II 8.5 %-ELECTROLYTES T5

AMINOSYN M 3.5 % T5

AMINOSYN-HBC 7% T5

AMINOSYN-PF 10 % T5

AMINOSYN-PF 7 % (SULFITE-FREE) T5

AMINOSYN-RF 5.2 % T5

BOOST CALORIE SMART ORAL LIQUID T3 PA

CLINIMIX 5%/D15W SULFITE FREE T5

CLINIMIX 5%/D25W SULFITE-FREE T5

CLINIMIX 2.75%/D5W SULFIT FREE T5

CLINIMIX 4.25%/D5W SULFIT FREE T5

CLINIMIX 4.25%-D20W SULF-FREE T5

CLINIMIX 4.25%-D25W SULF-FREE T5

CLINIMIX 5%-D20W(SULFITE-FREE) T5

CLINIMIX E 2.75%/D5W SULF FREE T5

CLINIMIX E 4.25%/D10W SUL FREE T5

CLINIMIX E 4.25%/D25W SUL FREE T5

CLINIMIX E 4.25%/D5W SULF FREE T5

CLINIMIX E 5%/D15W SULFIT FREE T5



CLINISOL SF 15 % T5

d10 %-0.45 % sodium chloride T5

d2.5 %-0.45 % sodium chloride T5

dextrose 10 % and 0.2 % nacl T5

dextrose 10 % in water (d10w) T5



67

Drug Tier Notes


dextrose 5 % in water (d5w) intravenous piggyback

T5

dextrose 5%-0.2 % sod chloride T5

dextrose 5%-0.3 % sod.chloride T5

dextrose 50 % in water (d50w) intravenous parenteral solution

T5


ENSURE ORIGINAL ORAL LIQUID 0.04-1.05 GRAM-KCAL/ML

T3 PA

ENSURE PLUS T3 PA

FREAMINE HBC 6.9 % T5

FREAMINE III 10 % T5

glucose oral tablet,chewable 4 gram T1

HEPATAMINE 8% T5

INTRALIPID INTRAVENOUS EMULSION 20 %, 30 %

T5

KABIVEN T5

NEPHRAMINE 5.4 % T5

NEPRO CARB STEADY T3 PA

NUTRAMIGEN WITH ENFLORA LGG T3 PA

NUTRILIPID T5

PEDIASURE ORAL LIQUID 0.03-1 GRAM-KCAL/ML

T3 PA

PERIKABIVEN T5

PKU 2 T3 PA

PKU TRIO T3 PA

PREMASOL 10 % T5

PREMASOL 6 % T5

PROCALAMINE 3% T5

SIMILAC ALIMENTUM T3 PA

SIMILAC EXPERT CARE NEOSURE T3 PA

SIMILAC NEOSURE T3 PA

TROPHAMINE 10 % T5

TROPHAMINE 6% T5

68

Drug Tier Notes

Carbonic Anhydrase Inhibitors

acetazolamide T1

Diuretics, Miscellaneous


T1


Electrolytic,Caloric,Water Balance Misc,

CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML

T5

Irrigating Solutions

acetic acid irrigation T5

lactated ringers irrigation T5

sodium chloride irrigation T1

Loop Diuretics

bumetanide oral T1

furosemide injection syringe T5

furosemide oral T1

torsemide oral T1

Osmotic Diuretics

mannitol 20 % T5

Other Ion-Removing Agents

RADIOGARDASE T5

Phosphate-Removing Agents

AURYXIA T3 PA

calcium acetate(phosphat bind) T1

lanthanum T3 PA

PHOSLYRA T2 AL (Max 12 Years)

sevelamer carbonate oral powder in packet T3 PA

sevelamer carbonate oral tablet T1

sevelamer hcl T5

VELPHORO T3 PA

Potassium-Removing Agents

KIONEX (WITH SORBITOL) T1

69

Drug Tier Notes

LOKELMA T2 QL (35 EA per 30 DYs)

SODIUM POLYSTYRENE (SORB FREE) T1

sodium polystyrene sulfonate oral powder T1

SPS (WITH SORBITOL) ORAL T2

VELTASSA T3 ST

Potassium-Sparing Diuretics

amiloride T1

spironolactone T1



T1


T5


Replacement Preparations

ANTACID (CALCIUM CARBONATE) ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)

T1


CALCIUM 500 WITH D T1

CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -400 UNIT

T1

CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)

T1

calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg calcium (1,500 mg)

T1

calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit

T1

calcium citrate-vitamin d3 oral tablet 200-125 mg-unit

T1

calcium gluconate oral tablet 45 mg (500 mg) T1

dextrose 5 %-lactated ringers T5

electrolyte-48 in d5w T5

IONOSOL-B IN D5W T5

IONOSOL-MB IN D5W T5

ISOLYTE S PH 7.4 T5

70

Drug Tier Notes

ISOLYTE-P IN 5 % DEXTROSE T5

ISOLYTE-S T5

KLOR-CON M15 T2

lactated ringers intravenous T5

magnesium gluconate oral tablet 27 mg magnesium (500 mg)

T1

magnesium oral tablet 200 mg T1


NORMOSOL-M IN 5 % DEXTROSE T5

NORMOSOL-R T5

NORMOSOL-R PH 7.4 T5



ORALYTE T1

OS-CAL 500 + D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT

T1

OYSTER SHELL + D3 T1

PEDIATRIC ELECTROLYTE ORAL SOLUTION

T1

PHOS-NAK T2

PLASMA-LYTE 148 T5

PLASMA-LYTE A T5

potassium chlorid-d5-0.45%nacl T5

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

T5

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

T5

potassium chloride in lr-d5 T5

potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml

T5

potassium chloride intravenous T5

potassium chloride oral capsule, extended release T1

potassium chloride oral liquid T1 AL (Max 12 Years)

potassium chloride oral tablet extended release T1

potassium chloride oral tablet,er particles/crystals T1

71

Drug Tier Notes

potassium chloride-0.45 % nacl T5

potassium chloride-d5-0.2%nacl T5

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

T5

potassium chloride-d5-0.9%nacl T5


T1


ringer's intravenous T5

RISACAL-D T1

sodium chloride 0.45 % intravenous T5

sodium chloride 0.9 % intravenous piggyback T5

sodium chloride 3 % T5

sodium chloride 5 % T5

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

T1

sodium chloride oral T1

THERA-M ORAL TABLET 9 MG IRON-400 MCG

T1

TRIADVANCE T1







VITAFOL GUMMIES T2


ZATEAN-CH T1

zinc sulfate oral capsule T1

ZINGIBER T1 QL (60 QY per 30 DYs)

Thiazide Diuretics



chlorothiazide T1

72

Drug Tier Notes

DIURIL T2 AL (Max 12 Years)


hydrochlorothiazide T1





TEKTURNA HCT T5


T1


T5



Thiazide-Like Diuretics


chlorthalidone oral tablet 25 mg, 50 mg T1

indapamide T1

metolazone T1

Uricosuric Agents

probenecid T1

Vasopressin Antagonists

tolvaptan T5

Enzymes

Enzymes

PULMOZYME T4 PA

Eye, Ear, Nose And Throat (Eent) Preps.

Alpha-Adrenergic Agonists (Eent)

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

T2

brimonidine T1

COMBIGAN T2

Antiallergic Agents

azelastine nasal aerosol,spray T1 QL (30 QY per 30 DYs)

73

Drug Tier Notes

azelastine nasal spray,non-aerosol T5

azelastine ophthalmic (eye) T1

BEPREVE T5

cromolyn nasal T1 AL (Min 2 Years)

cromolyn ophthalmic (eye) T1

epinastine T3 ST

ketotifen fumarate T1

LASTACAFT T5

olopatadine ophthalmic (eye) T3 ST

PAZEO T5

Antibacterials (Eent)

bacitracin ophthalmic (eye) T1

bacitracin-polymyxin b ophthalmic (eye) T1

BLEPHAMIDE T3 ST

BLEPHAMIDE S.O.P. T3 ST

CIPRO HC T5

CIPRODEX T2 QL (7.5 QY per 30 DYs)

ciprofloxacin hcl ophthalmic (eye) T1

doxycycline hyclate oral tablet 20 mg T1 QL (60 EA per 30 days)

erythromycin ophthalmic (eye) T1

gentamicin ophthalmic (eye) T1

neomycin-bacitracin-poly-hc T1

neomycin-polymyxin b-dexameth T1

neomycin-polymyxin-gramicidin T1

neomycin-polymyxin-hc T1

NEO-POLYCIN T1

ofloxacin ophthalmic (eye) T1

ofloxacin otic (ear) T1

polymyxin b sulf-trimethoprim T1

sulfacetamide sodium ophthalmic (eye) T1

sulfacetamide-prednisolone T1

TOBRADEX OPHTHALMIC (EYE) OINTMENT

T2

tobramycin T1

74

Drug Tier Notes

tobramycin-dexamethasone T1

Antifungals (Eent)

NATACYN T2

Antiglaucoma Agents, Miscellaneous

RHOPRESSA T5

Antivirals (Eent)

trifluridine T1

ZIRGAN T2

Beta-Adrenergic Blocking Agents (Eent)

betaxolol ophthalmic (eye) T1

COMBIGAN T2

dorzolamide-timolol T1

levobunolol ophthalmic (eye) drops 0.5 % T1

timolol maleate ophthalmic (eye) drops T1

Carbonic Anhydrase Inhibitors (Eent)

acetazolamide T1

dorzolamide T1

dorzolamide-timolol T1

Corticosteroids (Eent)

budesonide nasal T1 QL (8.6 GM per 30 days)

CIPRO HC T5

CIPRODEX T2 QL (7.5 QY per 30 DYs)

dexamethasone sodium phosphate ophthalmic (eye)

T1

DUREZOL T3 ST; QL (5 QY per 30 DYs)

fluocinolone acetonide oil T1

fluorometholone T1

fluticasone propionate nasal T1 QL (16 QY per 30 DYs)

hydrocortisone-acetic acid T1

NASAL ALLERGY T1 QL (16.9 ML per 30 days)

neomycin-bacitracin-poly-hc T1

neomycin-polymyxin b-dexameth T1

neomycin-polymyxin-hc ophthalmic (eye) T1

75

Drug Tier Notes

PRED MILD T3 ST

prednisolone acetate T1

prednisolone sodium phosphate ophthalmic (eye) T1

RHINOCORT ALLERGY T2 QL (8.43 ML per 30 days)

TOBRADEX OPHTHALMIC (EYE) OINTMENT

T2

tobramycin-dexamethasone T1

triamcinolone acetonide nasal T1

Eent Anti-Infectives, Miscellaneous

acetic acid otic (ear) T1

chlorhexidine gluconate mucous membrane T1

EAR DROPS (CARBAMIDE PEROXIDE) T1

hydrocortisone-acetic acid T1

Eent Anti-Inflammatory Agents, Misc.

CEQUA T5

RESTASIS T3 PA

RESTASIS MULTIDOSE T3 PA

XIIDRA T3 PA

Eent Drugs, Miscellaneous

ARTIFICIAL TEARS (PETRO/MIN) T1

ARTIFICIAL TEARS (PF) OPHTHALMIC (EYE) DROPPERETTE 0.1-0.3 %

T1

ARTIFICIAL TEARS (POLYVIN ALC) T1

ARTIFICIAL TEARS(DEXT70-HYPRO) T1

BABY AYR SALINE T2

DEEP SEA NASAL T1 QL (90 QY per 30 DYs)

ENUCLENE T2

HYPOTEARS T1

ipratropium bromide nasal spray,non-aerosol 0.03 %


ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %)


MURO 128 OPHTHALMIC (EYE) DROPS 2 % T1

sodium chloride ophthalmic (eye) T1

76

Drug Tier Notes

THERATEARS OPHTHALMIC (EYE) DROPPERETTE,GEL

T1

ULTRA FRESH T1

Eent Nonsteroidal Anti-Inflam. Agents

ACUVAIL (PF) T5

bromfenac T5

BROMSITE T5

diclofenac sodium ophthalmic (eye) T1

flurbiprofen sodium T1

ILEVRO T5

ketorolac ophthalmic (eye) T1

NEVANAC T5

PROLENSA T5

Local Anesthetics (Eent)

ALTAFLUOR T1

lidocaine hcl mucous membrane jelly T1

LIDOCAINE VISCOUS T1

proparacaine T1

Miotics

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

T1

Mydriatics

atropine ophthalmic (eye) drops T1

atropine ophthalmic (eye) ointment T1

cyclopentolate T1

tropicamide ophthalmic (eye) drops 1 % T1

Prostaglandin Analogs

bimatoprost ophthalmic (eye) T1

latanoprost T1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

T5

travoprost T5

VYZULTA T5

XELPROS T5

77

Drug Tier Notes

ZIOPTAN (PF) T5

Rho Kinase Inhibitors

RHOPRESSA T5

Vasoconstrictors

EYE ALLERGY RELIEF T1

phenylephrine hcl ophthalmic (eye) T5

Gastrointestinal Drugs

5-Ht3 Receptor Antagonists

AKYNZEO (NETUPITANT) T3 PA

ALOXI T5

granisetron hcl intravenous solution 1 mg/ml (1 ml)

T5

granisetron hcl oral T3 PA

ondansetron hcl (pf) T5

ondansetron hcl intravenous T5

ondansetron hcl oral solution T3 PA

ondansetron hcl oral tablet 4 mg T1 QL (180 EA per 30 days)

ondansetron hcl oral tablet 8 mg T1 QL (90 EA per 30 days)

ondansetron oral tablet,disintegrating 4 mg T1 QL (180 EA per 30 days)

ondansetron oral tablet,disintegrating 8 mg T1 QL (90 EA per 30 days)

Antacids And Adsorbents

alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 ml

T1

ANTACID (CALCIUM CARBONATE) ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)

T1

CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)

T1

calcium carbonate oral tablet 260 mg calcium (648 mg)

T1

MAALOX MAXIMUM STRENGTH T1

magnesium oxide oral tablet 250 mg magnesium, 400 mg (241.3 mg magnesium)

T1

PEPTIC RELIEF ORAL TABLET,CHEWABLE T1

PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML

T1

78

Drug Tier Notes

PINK BISMUTH ORAL TABLET T1

sodium bicarbonate oral T1

Antidiarrhea Agents

ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET



loperamide oral capsule T1 QL (30 EA per 30 days)

loperamide oral liquid 1 mg/5 ml T1 QL (150 ML per 30 days)

PEPTIC RELIEF ORAL TABLET,CHEWABLE T1

PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML

T1

PINK BISMUTH ORAL TABLET T1

Antiemetics, Miscellaneous

BONJESTA T5

DICLEGIS T5

dronabinol T3 PA

scopolamine base T3 PA

Antiflatulents

alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 ml

T1

GAS RELIEF (SIMETHICONE) ORAL TABLET,CHEWABLE 80 MG

T1

MAALOX MAXIMUM STRENGTH T1

simethicone oral capsule 180 mg T1

simethicone oral drops,suspension T1

simethicone oral tablet,chewable 125 mg T1

Antihistamines (Gi Drugs)

BONJESTA T5

DICLEGIS T5


meclizine oral tablet 12.5 mg, 25 mg T1

meclizine oral tablet,chewable T1

prochlorperazine T1

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)

T5

79

Drug Tier Notes

prochlorperazine maleate T1

Anti-Inflammatory Agents (Gi Drugs)

alosetron T3 PA

balsalazide T1

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

T1

mesalamine oral tablet,delayed release (dr/ec) 800 mg

T3 ST

mesalamine rectal T1

sulfasalazine T1

Cathartics And Laxatives

AMITIZA T3 PA


bisacodyl T1

CVS DAILY FIBER 0.52 GRAM CAP T1

DAILY FIBER (PSYLLIUM-SUCROSE) ORAL POWDER 3.4 GRAM/12 GRAM

T1

docusate calcium T1

docusate sodium oral capsule T1

docusate sodium oral liquid T1

ENEMA DISPOSABLE T1

glycerin (adult) T1

magnesium citrate oral solution T1

METAMUCIL (SUGAR) T1

MILK OF MAGNESIA T1

MINERAL OIL LAXATIVE T1

MOVIPREP T2

NATURAL FIBER LAXATIVE (SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM

T1

peg 3350-electrolytes T1

PEG-3350 WITH FLAVOR PACKS T1

polyethylene glycol 3350 T1

PREPOPIK T2

SENNA ORAL SYRUP 176 MG/5 ML T2

SENNA ORAL SYRUP 8.8 MG/5 ML T1

80

Drug Tier Notes

SENNA ORAL TABLET T1

SENNA WITH DOCUSATE SODIUM T1

SILACE ORAL SYRUP T1

STOOL SOFTENER ORAL CAPSULE 50 MG T1

SUPREP BOWEL PREP KIT T2





ZATEAN-CH T1

Cholelitholytic Agents

ursodiol T1

Digestants

CREON T2

lactase T1

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,000-47,000 -63,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000 -14,000-UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT

T2

Gi Drugs, Miscellaneous

ALLI T2

CIMZIA T4 PA

CIMZIA POWDER FOR RECONST T4 PA

CULTURELLE KIDS PROBIOTICS ORAL POWDER IN PACKET

T2

CULTURELLE ORAL CAPSULE, SPRINKLE T2

ENDARI T4 PA

HUMIRA PEN T4 PA

HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA

HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML

T4 PA

81

Drug Tier Notes

HUMIRA(CF) T4 PA

HUMIRA(CF) PEDI CROHNS STARTER T4 PA

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML

T4 PA

LINZESS T2

MOVANTIK T3 PA

OCALIVA T4 PA

PROBIOTIC (S.BOULARDII) T1

RELISTOR ORAL T5

RELISTOR SUBCUTANEOUS SOLUTION T5

RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML

T5

SIMPONI T4 PA

SYMPROIC T3 PA

VSL#3 ORAL CAPSULE T3 PA

XENICAL T5

Histamine H2-Antagonists

cimetidine T1

famotidine oral suspension T1 AL (Max 12 Years)

famotidine oral tablet T1

ranitidine hcl oral syrup T1 AL (Max 12 Years)

ranitidine hcl oral tablet T1

Lipotropic Agents

FISH OIL ORAL CAPSULE 120-180 MG T5

Neurokinin-1 Receptor Antagonists

AKYNZEO (NETUPITANT) T3 PA

aprepitant oral capsule T3 PA

EMEND ORAL CAPSULE,DOSE PACK T3 PA

EMEND ORAL SUSPENSION FOR RECONSTITUTION

T3 PA

Prokinetic Agents

metoclopramide hcl injection T5

metoclopramide hcl oral solution T1

metoclopramide hcl oral tablet T1

82

Drug Tier Notes

Prostaglandins

diclofenac-misoprostol T1

misoprostol T1

Protectants

sucralfate oral suspension T1 AL (Max 12 Years)

sucralfate oral tablet T1

Proton-Pump Inhibitors

ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 5 MG

T5

DEXILANT T5

esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg

T1

esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

T5

lansoprazole oral capsule,delayed release(dr/ec) T1

lansoprazole oral tablet,disintegrat, delay rel T1 AL (Max 12 Years)

NEXIUM PACKET T5

OMEPPI T5

omeprazole magnesium oral capsule,delayed release(dr/ec)

T5

omeprazole oral capsule,delayed release(dr/ec) T1

omeprazole oral tablet,delayed release (dr/ec) T5

omeprazole oral tablet,disintegrat, delay rel T5

omeprazole-sodium bicarbonate T5

pantoprazole oral T1

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

T5

PRILOSEC OTC T5

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

T5

rabeprazole oral capsule, delayed rel sprinkle T5

rabeprazole oral tablet,delayed release (dr/ec) T1

Gold Compounds

Gold Compounds

RIDAURA T2

83

Drug Tier Notes

Heavy Metal Antagonists

Heavy Metal Antagonists

CHEMET T3 PA

deferasirox oral tablet 180 mg, 360 mg T4 PA

deferasirox oral tablet, dispersible T4 PA

JADENU ORAL TABLET 90 MG T4 PA

JADENU SPRINKLE T4 PA

Hormones And Synthetic Substitutes

Adrenals

ADVAIR HFA T3 PA

ARNUITY ELLIPTA T2 QL (60 EA per 30 days)

ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION


ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs)

BREO ELLIPTA T3 PA

budesonide inhalation suspension for nebulization 0.25 mg/2 ml




budesonide oral capsule,delayed,extend.release T1


DEXAMETHASONE INTENSOL T1

dexamethasone oral elixir T1

dexamethasone oral solution T1

dexamethasone oral tablet T1

dexamethasone sodium phosphate injection solution 4 mg/ml

T5





EMFLAZA T3 PA

FLOVENT DISKUS T2 QL (120 QY per 30 DYs)

84

Drug Tier Notes

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION

T2 QL (21.2 QY per 30 DYs)

fludrocortisone T1





hydrocortisone oral T1

MEDROL ORAL TABLET 2 MG T2

methylprednisolone T1

prednisolone oral solution 15 mg/5 ml T1

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

T1

prednisolone sodium phosphate oral tablet,disintegrating

T5

prednisone T1

PREDNISONE INTENSOL T1

PULMICORT FLEXHALER T2 QL (2 EA per 30 days)

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML


QVAR REDIHALER T2 QL (21.2 GM per 30 days)


triamcinolone acetonide injection T5


Alpha-Glucosidase Inhibitors

acarbose T1

Amylinomimetics

SYMLINPEN 120 T5

SYMLINPEN 60 T5

Androgens

ANDRODERM T5 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)

T3 PA

85

Drug Tier Notes

danazol T1

JATENZO T5

NATESTO T5

oxandrolone T3 PA

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml


testosterone enanthate T1 QL (5 ML per 30 days)

testosterone transdermal gel T3 PA

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation

T5 PA

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %), 20.25 mg/1.25 gram (1.62 %)

T3 PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)

T3 PA

testosterone transdermal solution in metered pump w/app

T5

Antidiabetic Agents, Miscellaneous

colesevelam oral tablet T3 PA

KORLYM T5

WELCHOL ORAL POWDER IN PACKET T3 PA

Antiestrogens

anastrozole T1 QL (30 QY per 30 DYs)

exemestane T3 PA

letrozole T1

Antigonadtropins


T4 PA

ORILISSA T3 PA

Antihypoglycemic Agents, Miscellaneous

GLUCOSE POWDER T5

Antiparathyroid Agents

calcitonin (salmon) T1

cinacalcet T3 PA

MIACALCIN INJECTION T5

86

Drug Tier Notes

Antithyroid Agents

methimazole oral tablet 10 mg, 5 mg T1

propylthiouracil T1

Biguanides

alogliptin-metformin T3 ST

glipizide-metformin T1

glyburide-metformin T1

INVOKAMET T3 ST

INVOKAMET XR T3 ST

JANUMET T5

JANUMET XR T5

JENTADUETO T5

JENTADUETO XR T5

KOMBIGLYZE XR T5

metformin oral tablet T1

metformin oral tablet extended release 24 hr T1

metformin oral tablet extended release 24hr 1,000 mg

T5

SEGLUROMET T5

SYNJARDY T3 ST

SYNJARDY XR T3 ST

TRIJARDY XR T5

XIGDUO XR T5

Contraceptives

AMETHIA T1

ANNOVERA T2

BALCOLTRA T2

CAMRESE LO T1

CHATEAL (28) T1

CRYSELLE (28) T1

CYCLAFEM 1/35 (28) T1

drospirenone-e.estradiol-lm.fa T1

ELLA T2

etonogestrel-ethinyl estradiol T1

87

Drug Tier Notes

FALMINA (28) T1

GIANVI (28) T1

JOLESSA T1

JUNEL FE 1.5/30 (28) T1

JUNEL FE 1/20 (28) T1

JUNEL FE 24 T1

KELNOR 1/35 (28) T1

LEENA 28 T1

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (28)

T1

LO LOESTRIN FE T2

MIBELAS 24 FE T1

MICROGESTIN 1.5/30 (21) T1

MICROGESTIN 1/20 (21) T1

MONONESSA (28) T1

MY WAY T1

MYZILRA T1

NATAZIA T2

NORA-BE T1

noreth-ethinyl estradiol-iron T1

norethindrone-e.estradiol-iron oral tablet,chewable

T1

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg

T1

NORTREL 0.5/35 (28) T1

NORTREL 7/7/7 (28) T1

OGESTREL (28) T1

PHILITH T1

QUARTETTE T2

RAJANI T1

RECLIPSEN (28) T1

SLYND T2

SYEDA T1

TAYTULLA T2

TRI-LEGEST FE T1

88

Drug Tier Notes

TRI-SPRINTEC (28) T1

TWIRLA T2

VELIVET TRIPHASIC REGIMEN (28) T1

VIORELE (28) T1

XULANE T1

ZOVIA 1/50E (28) T1

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors

alogliptin T3 ST

alogliptin-metformin T3 ST

alogliptin-pioglitazone T3 ST

GLYXAMBI T5

JANUMET T5

JANUMET XR T5

JANUVIA T5

JENTADUETO T5

JENTADUETO XR T5

KOMBIGLYZE XR T5

ONGLYZA T5

QTERN T5

STEGLUJAN T5

TRADJENTA T5

TRIJARDY XR T5

Estrogen Agonist-Antagonists

FARESTON T4 PA

raloxifene T1

SOLTAMOX T3 PA

tamoxifen T1

Estrogens

CLIMARA PRO T2 QL (4 QY per 28 DYs)

COMBIPATCH T2 QL (8 QY per 28 DYs)

DEPO-ESTRADIOL T1 QL (10 QY per 90 DYs)

ESTRACE VAGINAL T2

estradiol oral T1

estradiol transdermal patch semiweekly T1 QL (24 EA per 84 days)

89

Drug Tier Notes

estradiol transdermal patch weekly T1 QL (4 QY per 28 DYs)

estradiol vaginal tablet T1

estradiol valerate T1 QL (10 QY per 90 DYs)

ESTRING T2 QL (1 EA per 30 days)

ESTROGEL T2 QL (50 GM per 30 days)

MENOSTAR T2 QL (4 QY per 28 DYs)

norethindrone ac-eth estradiol oral tablet 1-5 mg-mcg

T1

PREMARIN ORAL T2

PREMARIN VAGINAL T2

PREMPHASE T2

PREMPRO T2

Glycogenolytic Agents

BAQSIMI T2

GLUCAGEN DIAGNOSTIC KIT T5

GLUCAGEN HYPOKIT T5

GLUCAGON EMERGENCY KIT (HUMAN) T2

GVOKE PFS 1-PACK SYRINGE T2


Gonadotropins

ELIGARD T4 PA




leuprolide T3 PA



LUPRON DEPOT T4 PA





SYNAREL T5

TRELSTAR INTRAMUSCULAR SYRINGE T5

90

Drug Tier Notes

ZOLADEX T5

Gonadotropins And Antigonadotropins

ELIGARD T4 PA




leuprolide T3 PA



LUPRON DEPOT T4 PA





SYNAREL T5

ZOLADEX T5

Incretin Mimetics

BYDUREON T5

BYDUREON BCISE T5

BYETTA T5

OZEMPIC T3 ST; QL (9 ML per 84 days)

RYBELSUS ORAL TABLET 14 MG, 7 MG T3 ST

RYBELSUS ORAL TABLET 3 MG T3

SAXENDA T5

TRULICITY T5

VICTOZA 2-PAK T3 ST; QL (27 ML per 90 days)

VICTOZA 3-PAK T3 ST; QL (27 ML per 90 days)

Insulins

ADMELOG SOLOSTAR U-100 INSULIN T2

ADMELOG U-100 INSULIN LISPRO T2

BASAGLAR KWIKPEN U-100 INSULIN T2

HUMALOG MIX 50-50 INSULN U-100 T2

HUMALOG MIX 50-50 KWIKPEN T2

HUMALOG MIX 75-25(U-100)INSULN T2

91

Drug Tier Notes

HUMULIN 70/30 U-100 INSULIN T2

HUMULIN 70/30 U-100 KWIKPEN T2

HUMULIN N NPH INSULIN KWIKPEN T2

HUMULIN N NPH U-100 INSULIN T2

HUMULIN R REGULAR U-100 INSULN T2

HUMULIN R U-500 (CONC) INSULIN T2

HUMULIN R U-500 (CONC) KWIKPEN T2

insulin aspart protamine-insulin aspart 70-30 flexpen outer,suv,latex-free

T1

insulin aspart protamine-insulin aspart 70-30 vial T1

insulin lispro jr 100 unit/ml kwikpen suv, outer T1

insulin lispro mix 75-25 kwkpn suv, outer T1

insulin lispro subcutaneous insulin pen T1

insulin lispro subcutaneous solution T1

LANTUS SOLOSTAR U-100 INSULIN T5

LANTUS U-100 INSULIN T5

LEVEMIR FLEXTOUCH U-100 INSULN T3 ST

LEVEMIR U-100 INSULIN T3 ST

NOVOLIN N NPH U-100 INSULIN T2

NOVOLIN R REGULAR U-100 INSULN T2

TOUJEO MAX U-300 SOLOSTAR T5

TOUJEO SOLOSTAR U-300 INSULIN T5

TRESIBA FLEXTOUCH U-100 T3 ST


TRESIBA U-100 INSULIN T3 ST

Intermediate-Acting Insulins






HUMULIN N NPH INSULIN KWIKPEN T2

HUMULIN N NPH U-100 INSULIN T2

92

Drug Tier Notes


T1



NOVOLIN N NPH U-100 INSULIN T2

Leptins

MYALEPT T5

Long-Acting Insulins

BASAGLAR KWIKPEN U-100 INSULIN T2

LANTUS SOLOSTAR U-100 INSULIN T5

LANTUS U-100 INSULIN T5

LEVEMIR FLEXTOUCH U-100 INSULN T3 ST

LEVEMIR U-100 INSULIN T3 ST

TOUJEO MAX U-300 SOLOSTAR T5

TOUJEO SOLOSTAR U-300 INSULIN T5



TRESIBA U-100 INSULIN T3 ST

Meglitinides

nateglinide T1

repaglinide T1

Parathyroid Agents

FORTEO T3 PA

teriparatide T3 PA

TYMLOS T3 PA

Parathyroid And Antiparathyroid Agents


FORTEO T3 PA


TYMLOS T3 PA

Pituitary

ACTHAR H.P. T4 PA

DDAVP NASAL SOLUTION T5

93

Drug Tier Notes

desmopressin nasal spray,non-aerosol T1

desmopressin oral T1

GENOTROPIN T5

GENOTROPIN MINIQUICK T5

HUMATROPE T5

NORDITROPIN FLEXPRO T4 PA

NUTROPIN AQ NUSPIN T4 PA

OMNITROPE T5

SAIZEN SUBCUTANEOUS RECON SOLN 8.8 MG

T5

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 6 MG

T5

STIMATE T3 PA

ZOMACTON T4 PA

Progestins

COMBIPATCH T2 QL (8 QY per 28 DYs)

CRINONE T2

DEPO-SUBQ PROVERA 104 T2

ENDOMETRIN T3 PA

hydroxyprogest(pf)(preg presv) T4 PA

hydroxyprogesterone cap(ppres) T4 PA



MAKENA (PF) T4 PA

medroxyprogesterone T1

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)

T1

megestrol oral tablet T1

norethindrone acetate T1

norethindrone ac-eth estradiol oral tablet 1-5 mg-mcg

T1

progesterone micronized T1 QL (30 QY per 30 DYs)

SLYND T2

Rapid-Acting Insulins

ADMELOG SOLOSTAR U-100 INSULIN T2

94

Drug Tier Notes

ADMELOG U-100 INSULIN LISPRO T2





T1


insulin lispro jr 100 unit/ml kwikpen suv, outer T1


insulin lispro subcutaneous insulin pen T1

insulin lispro subcutaneous solution T1

Short-Acting Insulins



HUMULIN R REGULAR U-100 INSULN T2

HUMULIN R U-500 (CONC) INSULIN T2

HUMULIN R U-500 (CONC) KWIKPEN T2

NOVOLIN R REGULAR U-100 INSULN T2

Sodium-Gluc Cotransport 2 (Sglt2) Inhib

FARXIGA T5

GLYXAMBI T5

INVOKAMET T3 ST

INVOKANA T3 ST

JARDIANCE T3 ST

QTERN T5

SEGLUROMET T5

STEGLATRO T5

STEGLUJAN T5

SYNJARDY T3 ST

SYNJARDY XR T3 ST

TRIJARDY XR T5

XIGDUO XR T5

Somatostatin Agonists

95

Drug Tier Notes

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml

T4 PA

octreotide acetate injection syringe T3 PA

SANDOSTATIN INJECTION SOLUTION 50 MCG/ML, 500 MCG/ML

T4 PA

Somatotropin Agonists

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

T5

EGRIFTA SV 2 MG VIAL T5

Somatotropin Antagonists

SOMAVERT T4 PA

Sulfonylureas

chlorpropamide T5

glimepiride T1

glipizide T1

glipizide-metformin T1

glyburide T1

glyburide-metformin T1

tolazamide T5

Thiazolidinediones

alogliptin-pioglitazone T3 ST

pioglitazone T1

Thyroid Agents

ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG

T2

levothyroxine oral T1

liothyronine oral T1

NATURE-THROID T2

NP THYROID ORAL TABLET 15 MG, 30 MG, 60 MG, 90 MG

T1

thyroid (pork) oral tablet 120 mg T1

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

T5

Local Anesthetics (Parenteral)

96

Drug Tier Notes

Local Anesthetics (Parenteral)

lidocaine (pf) injection solution 10 mg/ml (1 %) T5

lidocaine hcl injection solution 10 mg/ml (1 %) T5

Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors

dutasteride T1

finasteride oral tablet 5 mg T1

Alcohol Deterrents

disulfiram T1

naltrexone T5 CO

VIVITROL T5 CO

Antidotes

acetylcysteine intravenous T5

BAQSIMI T2

CHEMET T3 PA

EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML

T5 CO

GLUCAGEN HYPOKIT T5

GLUCAGON EMERGENCY KIT (HUMAN) T2



KIONEX (WITH SORBITOL) T1

lanthanum T3 PA

leucovorin calcium injection recon soln 100 mg, 50 mg

T5

leucovorin calcium oral T1

naloxone injection solution T5 CO

naloxone injection syringe T5 CO

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

T5 CO

phytonadione (vitamin k1) oral tablet 5 mg T1

protamine T5

RADIOGARDASE T5

sevelamer carbonate oral powder in packet T3 PA

97

Drug Tier Notes

sevelamer carbonate oral tablet T1

sevelamer hcl T5

SODIUM POLYSTYRENE (SORB FREE) T1

sodium polystyrene sulfonate oral powder T1

SPS (WITH SORBITOL) ORAL T2

VITAMIN K1 INJECTION T5

Antigout Agents

allopurinol T1

colchicine T1 QL (60 EA per 30 days)

febuxostat T3 PA

INDOCIN ORAL T2 AL (Max 12 Years)

INDOCIN RECTAL T2

indomethacin oral T1

naproxen oral suspension T1 AL (Max 12 Years)

naproxen oral tablet T1

naproxen oral tablet,delayed release (dr/ec) T1

naproxen sodium oral tablet T1

probenecid T1

Antisense Oligonucleotides

TEGSEDI T5

Bone Anabolic Agents

EVENITY SUBCUTANEOUS SYRINGE 105 MG/1.17 ML

T5

FORTEO T3 PA

teriparatide T3 PA

TYMLOS T3 PA

Bone Resorption Inhibitors

alendronate oral solution T5

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg T1

alendronate oral tablet 40 mg T5

BINOSTO T5


etidronate disodium T5

FOSAMAX PLUS D T5

98

Drug Tier Notes

ibandronate oral T1


pamidronate intravenous recon soln T5

raloxifene T1

risedronate T5

Carbonic Anhydrase Inhibitors (Misc.)

KEVEYIS T5

Cariostatic Agents

DENTA 5000 PLUS T1

FLUOR-A-DAY T1

fluoride (sodium) dental paste T1

fluoride (sodium) oral drops T1

fluoride (sodium) oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride)

T1

FLUORIDEX DAILY DEFENSE DENTAL PASTE

T1

FLURA-DROPS T1

LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID)

T1

MULTIVITAMIN WITH FLUORIDE T1

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 1 MG


PREVIDENT DENTAL GEL T1

PREVIDENT DENTAL SOLUTION T2

TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC 0.25 MG/ML FLUORIDE

T5

TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML


Complement Inhibitors

HAEGARDA T5

icatibant T4 PA

KALBITOR T5

TAKHZYRO T3 PA

Disease-Modifying Antirheumatic Agents

99

Drug Tier Notes

ACTEMRA ACTPEN T4 PA

ACTEMRA SUBCUTANEOUS T4 PA

azathioprine T1

CIMZIA T4 PA


cyclosporine modified oral capsule T1

cyclosporine modified oral solution T1 AL (Max 12 Years)

ENBREL T4 PA

ENBREL MINI T4 PA

ENBREL SURECLICK T4 PA

HUMIRA PEN T4 PA



T4 PA

HUMIRA(CF) T4 PA

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

T4 PA


T4 PA


KEVZARA T5

KINERET T4 PA

leflunomide T1




OLUMIANT T4 PA

ORENCIA T4 PA

ORENCIA CLICKJECT T4 PA

OTEZLA T4 PA

OTEZLA STARTER T4 PA

RIDAURA T2

RINVOQ T5

SANDIMMUNE ORAL SOLUTION T5

100

Drug Tier Notes

SIMPONI T4 PA

STELARA SUBCUTANEOUS T4 PA

sulfasalazine T1

TREXALL T3 PA

XELJANZ T4 PA

XELJANZ XR T4 PA

Gonadotropin-Releasing Hormone Antagnts


T4 PA

Immunomodulatory Agents

ACTEMRA ACTPEN T4 PA

ACTEMRA SUBCUTANEOUS T4 PA

AUBAGIO T5

AVONEX (WITH ALBUMIN) T4 PA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

T4 PA

AVONEX INTRAMUSCULAR SYRINGE KIT T4 PA

azathioprine T1

BETASERON SUBCUTANEOUS KIT T4 PA

CIMZIA T4 PA




ENBREL T4 PA

ENBREL MINI T4 PA


EXTAVIA T4 PA

GILENYA ORAL CAPSULE 0.5 MG T4 PA

glatiramer T4 PA

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML

T4 PA

HUMIRA PEN T4 PA



T4 PA

101

Drug Tier Notes

HUMIRA(CF) T4 PA

HUMIRA(CF) PEDI CROHNS STARTER T4 PA


T4 PA


KEVZARA T5

KINERET T4 PA

leflunomide T1

MAYZENT T5




OLUMIANT T4 PA

ORENCIA T4 PA

ORENCIA CLICKJECT T4 PA

OTEZLA T4 PA


PLEGRIDY T5

POMALYST T4 PA

PROLEUKIN T5

REBIF (WITH ALBUMIN) T4 PA

REBIF REBIDOSE T4 PA

REBIF TITRATION PACK T4 PA

REVLIMID T4 PA

RIDAURA T2

RINVOQ T5


SIMPONI T4 PA


sulfasalazine T1

TECFIDERA T4 PA

TREXALL T3 PA

XELJANZ T4 PA

XELJANZ XR T4 PA

102

Drug Tier Notes

Immunosuppressive Agents

azathioprine T1

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION


cyclophosphamide intravenous T5

cyclophosphamide oral capsule T3 PA



everolimus (immunosuppressive) T1

MAVENCLAD (10 TABLET PACK) T4 PA

mercaptopurine T1




mycophenolate mofetil oral capsule T1

mycophenolate mofetil oral tablet T1

mycophenolate sodium T1

pimecrolimus T5

PURIXAN T3 PA


sirolimus oral solution T1 AL (Max 12 Years)

sirolimus oral tablet 0.5 mg, 1 mg T1

sirolimus oral tablet 2 mg T1 AL (Min 2 Years)

tacrolimus oral T1

TREXALL T3 PA

ZORTRESS ORAL TABLET 1 MG T2

Other Miscellaneous Therapeutic Agents

acetylcysteine solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days)

acetylcysteine solution 200 mg/ml (20 %) T1

CERDELGA T4 PA

cinacalcet T3 PA

dalfampridine T4 PA

ENDARI T4 PA

GRASTEK T5

103

Drug Tier Notes

levocarnitine (with sugar) T1

levocarnitine oral solution 100 mg/ml T1

levocarnitine oral tablet T5

melatonin oral liquid 5 mg/15 ml T1

melatonin oral tablet 1 mg, 3 mg, 5 mg T1

melatonin oral tablet,disintegrating 3 mg, 5 mg T1

miglustat T4 PA

nitisinone T5

NITYR T4 PA

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml

T4 PA

octreotide acetate injection syringe T3 PA

OCUVITE LUTEIN AND ZEAXANTHIN T2

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

T5

ORFADIN ORAL CAPSULE 20 MG T5

ORFADIN ORAL SUSPENSION T5

RAGWITEK T5

SANDOSTATIN INJECTION SOLUTION 50 MCG/ML

T4 PA

SYMTUZA T5 CO

TYBOST T5 CO

Protective Agents

ELMIRON T2

Nonhormonal Contraceptives

Nonhormonal Contraceptives

CONCEPTROL T1

GYNOL II T1

PHEXXI T2

TODAY CONTRACEPTIVE SPONGE T2

VAGINAL CONTRACEPTIVE FILM T2

VAGINAL CONTRACEPTIVE FOAM T1

VCF CONTRACEPTIVE GEL T1

WIDE-SEAL DIAPHRAGM 60 T1

104

Drug Tier Notes

Oxytocics

Oxytocics

methylergonovine oral T1 QL (30 EA per 30 days)

Pharmaceutical Aids

Pharmaceutical Aids

water for inject, bacteriostat T5

water for injection, sterile intravenous T5

Radioactive Agents

Radioactive Agents

AMYVID T5

Respiratory Tract Agents

Alpha And Beta Adrenergic Agonist(Respr)

ADRENACLICK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML

T5

ADRENALIN INJECTION SOLUTION 1 MG/ML (1 ML)

T5


AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML

T5

CHILDREN'S SILFEDRINE T1 AL (Min 4 Years)

epinephrine injection auto-injector T1 QL (6 EA per 365 days)

EPIPEN 2-PAK T5

EPIPEN JR 2-PAK T5



pseudoephedrine hcl oral liquid T1 AL (Min 4 Years)

pseudoephedrine hcl oral tablet 30 mg T1 AL (Min 4 Years)


T1 AL (Min 6 Years)

SUDAFED 24 HOUR T1

SUDOGEST 12-HOUR T1 AL (Min 4 Years)

SUDOGEST ORAL TABLET 60 MG T1 AL (Min 4 Years)

Anticholinergic Agents (Respir.Tract)

ANORO ELLIPTA T3 ST

105

Drug Tier Notes

ATROVENT HFA T2 QL (25.8 QY per 30 DYs)



INCRUSE ELLIPTA T2 QL (30 EA per 30 days)

ipratropium bromide inhalation T1 QL (312.5 QY per 30 DYs)


SPIRIVA RESPIMAT T2 QL (4 GM per 30 days)


Antifibrotic Agents

ESBRIET T4 PA

OFEV T5

Anti-Inflammatory Agents (Respiratory)

NUCALA SUBCUTANEOUS RECON SOLN T5

Antitussives

ADULT TUSSIN COUGH CONGEST DM T1 AL (Min 2 Years)

benzonatate oral capsule 100 mg, 200 mg T1

codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)


dextromethorphan polistirex T1 AL (Min 4 Years)

dextromethorphan-guaifenesin oral syrup T1 AL (Min 2 Years)

DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML

T1 AL (Min 2 Years)

NUEDEXTA T3 PA



Cystic Fibrosis (Cftr) Correctors

ORKAMBI T4 PA

SYMDEKO T4 PA

TRIKAFTA T4 PA

Cystic Fibrosis (Cftr) Potentiators

KALYDECO T4 PA

ORKAMBI T4 PA

SYMDEKO T4 PA

106

Drug Tier Notes

TRIKAFTA T4 PA

Expectorants

ADULT TUSSIN COUGH CONGEST DM T1 AL (Min 2 Years)


dextromethorphan-guaifenesin oral syrup T1 AL (Min 2 Years)

DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML

T1 AL (Min 2 Years)

guaifenesin oral tablet 200 mg T1 AL (Min 2 Years)

guaifenesin oral tablet extended release 12hr T1 AL (Min 2 Years)


T1 AL (Min 6 Years)

TUSSIN ORAL LIQUID T1 AL (Min 2 Years)

First Generation Antihist.(Respir Tract)


T1


BONJESTA T5


T1



T1

cyproheptadine T1

DICLEGIS T5












107

Drug Tier Notes


Interleukin Antagonists

CINQAIR T5

DUPIXENT PEN T4 PA

DUPIXENT SYRINGE T4 PA

FASENRA T5

FASENRA PEN T5

NUCALA T5

Leukotriene Modifiers

montelukast oral granules in packet T1 AL (Max 2 Years)

montelukast oral tablet T1

montelukast oral tablet,chewable T1

Mast-Cell Stabilizers

cromolyn inhalation T1

cromolyn nasal T1 AL (Min 2 Years)

cromolyn ophthalmic (eye) T1

cromolyn oral T1

Mucolytic Agents

acetylcysteine solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days)

acetylcysteine solution 200 mg/ml (20 %) T1

PULMOZYME T4 PA

Nasal Preparations (Steroids)

budesonide nasal T1 QL (8.6 GM per 30 days)

fluticasone propionate nasal T1 QL (16 QY per 30 DYs)

NASAL ALLERGY T1 QL (16.9 ML per 30 days)

RHINOCORT ALLERGY T2 QL (8.43 ML per 30 days)

triamcinolone acetonide nasal T1

Non-Select.Beta-Adrenergic Agont(Respir)

ISUPREL T5

Orally Inhaled Preparations (Steroids)

ADVAIR HFA T3 PA

ARNUITY ELLIPTA T2 QL (60 EA per 30 days)

108

Drug Tier Notes

ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION


ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs)

BREO ELLIPTA T3 PA










FLOVENT DISKUS T2 QL (120 QY per 30 DYs)

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION

T2 QL (21.2 QY per 30 DYs)





PULMICORT FLEXHALER T2 QL (2 EA per 30 days)

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML


QVAR REDIHALER T2 QL (21.2 GM per 30 days)



Phosphodiesterase Type 4 Inhibitors

DALIRESP T3 PA

Pulmonary Surfactants

SURVANTA T5

Respiratory Tract Agents, Miscellaneous

XOLAIR SUBCUTANEOUS RECON SOLN T5

109

Drug Tier Notes

Second Generation Antihist(Respir Tract)

ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING

T1

cetirizine oral solution 1 mg/ml T1

cetirizine oral tablet T1

cetirizine oral tablet,chewable T1

CHILDREN'S ALLEGRA ALLERGY ORAL TABLET,DISINTEGRATING

T1

desloratadine oral tablet T1

fexofenadine oral suspension T1

fexofenadine oral tablet 180 mg, 60 mg T1

loratadine oral solution T1

loratadine oral tablet T1


Select.Beta-2-Adrenergic Agonist(Respir)

ADVAIR HFA T3 PA

albuterol sulfate inhalation hfa aerosol inhaler T1 QL (2 INH per 30 days)

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/0.5 ml

T1

albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %)


albuterol sulfate inhalation solution for nebulization 5 mg/ml


albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years)

albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs)

ANORO ELLIPTA T3 ST

ARCAPTA NEOHALER T2 QL (30 EA per 30 days)


BREO ELLIPTA T3 PA

BROVANA T3 PA



110

Drug Tier Notes










levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml


levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml


levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml


levalbuterol tartrate T3 ST; QL (30 GM per 30 days)

PERFOROMIST T5

PROAIR RESPICLICK T2 QL (2 EA per 30 days)

SEREVENT DISKUS T3 PA

STRIVERDI RESPIMAT T2 QL (4 GM per 30 days)

terbutaline oral T1

terbutaline subcutaneous T5



Vasodilating Agents (Respiratory Tract)

ADEMPAS T4 PA

ambrisentan T4 PA

bosentan T5

OPSUMIT T5

ORENITRAM T5

sildenafil (pulm.hypertension) intravenous T5

sildenafil (pulm.hypertension) oral suspension for reconstitution

T5

sildenafil (pulm.hypertension) oral tablet T3 PA

tadalafil (pulm. hypertension) T3 PA

treprostinil sodium T4 PA

111

Drug Tier Notes

TYVASO T4 PA

TYVASO INSTITUTIONAL START KIT T4 PA

TYVASO REFILL KIT T4 PA

TYVASO STARTER KIT T4 PA

UPTRAVI T4 PA

VENTAVIS T4 PA

Xanthine Derivatives


T1


Skin And Mucous Membrane Agents

Allylamines (Skin And Mucous Membrane)

terbinafine hcl topical T1 QL (120 QY per 30 DYs)

Antibacterials (Skin, Mucous Membrane)

AKTIPAK T5

bacitracin topical ointment T1

bacitracin zinc topical ointment T1

bacitracin-polymyxin b topical ointment T1

clindamycin phosphate topical gel T1

clindamycin phosphate topical lotion T1

clindamycin phosphate topical solution T1

clindamycin phosphate topical swab T1

clindamycin phosphate vaginal T1

clindamycin-benzoyl peroxide T5

clindamycin-tretinoin T5

erythromycin with ethanol topical gel T1

erythromycin with ethanol topical solution T1

erythromycin-benzoyl peroxide T5

metronidazole topical cream T1 QL (45 QY per 30 DYs)

metronidazole topical gel 0.75 % T1 QL (45 QY per 30 DYs)

metronidazole topical gel 1 % T3 ST; QL (60 QY per 30 DYs)

metronidazole topical gel with pump T3 ST; QL (60 QY per 30 DYs)

metronidazole topical lotion T1 QL (59 QY per 30 DYs)

metronidazole vaginal T1

112

Drug Tier Notes

mupirocin T1

mupirocin calcium T5

neomycin-polymyxin b gu T5

NEUAC T5

NEUAC KIT T5

ONEXTON TOPICAL GEL WITH PUMP T5

TRIPLE ANTIBIOTIC TOPICAL OINTMENT T1

Anti-Inflammatory Agents (Skin, Mucous)

alclometasone T5

amcinonide T5

ANTI-ITCH (HC) TOPICAL LOTION T5

ANUSOL-HC RECTAL CREAM WITH APPLICATOR

T1

APEXICON E T5

betamethasone dipropionate topical cream T1 QL (240 GM per 30 DYs)

betamethasone dipropionate topical lotion T1 QL (240 QY per 30 DYs)

betamethasone dipropionate topical ointment T1 QL (120 QY per 30 DYs)

betamethasone valerate topical cream T1 QL (240 QY per 30 DYs)

betamethasone valerate topical foam T5

betamethasone valerate topical lotion T1 QL (240 QY per 30 DYs)

betamethasone valerate topical ointment T1 QL (240 GM per 30 DYs)

betamethasone, augmented T1 QL (120 QY per 30 DYs)

CAPEX T5

clobetasol scalp T1 QL (100 ML per 30 days)

clobetasol topical cream T1 QL (120 GM per 30 days)

clobetasol topical foam T5

clobetasol topical gel T1 QL (120 GM per 30 days)

clobetasol topical lotion T5

clobetasol topical ointment T1 QL (120 GM per 30 days)

clobetasol topical shampoo T1 QL (118 ML per 30 days)

clobetasol topical spray,non-aerosol T5

clobetasol-emollient T5

clocortolone pivalate T5

clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs)

113

Drug Tier Notes

CORDRAN TAPE LARGE ROLL T5

CORDRAN TOPICAL CREAM 0.025 % T5

CORTISONE COOLING T5

desonide T5

desoximetasone topical cream 0.05 % T5

desoximetasone topical cream 0.25 % T1 QL (120 QY per 30 DYs)

desoximetasone topical gel T5

desoximetasone topical ointment T5

desoximetasone topical spray,non-aerosol T5

diflorasone T5

EUCRISA T5

fluocinolone and shower cap T1 QL (119 ML per 30 DYs)

fluocinolone topical cream 0.01 % T5

fluocinolone topical cream 0.025 % T1 QL (240 QY per 30 DYs)

fluocinolone topical oil T1 QL (119 ML per 30 DYs)

fluocinolone topical ointment T5

fluocinolone topical solution T1 QL (180 ML per 30 DYs)

fluocinonide topical cream 0.05 % T1 QL (240 GM per 30 DYs)

fluocinonide topical cream 0.1 % T5

fluocinonide topical gel T1 QL (240 QY per 30 DYs)

fluocinonide topical ointment T1 QL (240 QY per 30 DYs)

fluocinonide topical solution T1 QL (240 QY per 30 DYs)

FLUOCINONIDE-E T5

fluocinonide-emollient T5

flurandrenolide T5

fluticasone propionate topical cream T1 QL (240 QY per 30 DYs)

fluticasone propionate topical lotion T5

fluticasone propionate topical ointment T5

halobetasol propionate topical cream T1 QL (120 GM per 30 days)

halobetasol propionate topical ointment T1 QL (120 QY per 30 DYs)

HALOG TOPICAL CREAM T5

HALOG TOPICAL OINTMENT T5

hydrocortisone acetate rectal suppository 25 mg T1

hydrocortisone acetate topical cream 1 % T1 QL (240 GM per 30 DYs)

114

Drug Tier Notes

hydrocortisone butyrate T5

hydrocortisone butyr-emollient T5

hydrocortisone rectal T1

hydrocortisone topical cream T1 QL (240 QY per 30 DYs)

hydrocortisone topical cream in packet T5

hydrocortisone topical cream with perineal applicator 1 %

T5

hydrocortisone topical lotion 1 % T1 QL (240 GM per 30 DYs)

hydrocortisone topical lotion 2.5 % T1 QL (240 QY per 30 DYs)

hydrocortisone topical ointment T1 QL (240 QY per 30 DYs)

hydrocortisone valerate T5

hydrocortisone-aloe vera topical cream 1 % T1 QL (240 QY per 30 DYs)

IMPOYZ T5

MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

T5

mometasone topical cream T1 QL (60 QY per 30 DYs)

mometasone topical ointment T1 QL (240 QY per 30 DYs)

mometasone topical solution T1 QL (240 QY per 30 DYs)

NOLIX TOPICAL LOTION T5

NUCORT T5

PANDEL T5

prednicarbate T5

PROCTOFOAM HC T2

PROCTO-PAK T5

PROCTOZONE-HC T1 QL (60 GM per 30 DYs)

PSORCON T5

SCALACORT T5

SCALP RELIEF TOPICAL SOLUTION T5

SERNIVO T5

TEXACORT T5

TOPICORT TOPICAL GEL T5

triamcinolone acetonide dental T1

triamcinolone acetonide topical aerosol T5

triamcinolone acetonide topical cream 0.025 %, 0.5 %


115

Drug Tier Notes

triamcinolone acetonide topical cream 0.1 % T1 QL (454 QY per 30 DYs)

triamcinolone acetonide topical lotion T1 QL (240 QY per 30 DYs)

triamcinolone acetonide topical ointment 0.025 %, 0.5 %


triamcinolone acetonide topical ointment 0.1 % T1 QL (454 GM per 30 days)

TRIANEX T5

ULTRAVATE TOPICAL LOTION T5

VERDESO T5

Anti-Inflammatory Agents, Misc (Skin)

EUCRISA T5

Antipruritics And Local Anesthetics

ANTI-ITCH (BENZ-RESOR) T1

ANTI-ITCH (DIPHENHYDRAMINE) TOPICAL GEL

T1

ANTI-ITCH (PRAMOXINE) T1

LIDOCAINE PAIN RELIEF TOPICAL ADHESIVE PATCH,MEDICATED

T1

lidocaine topical adhesive patch,medicated 5 % T1

lidocaine topical cream 4 % T1 QL (60 GM per 30 days)

lidocaine topical cream 5 % T1

lidocaine topical ointment T1 QL (60 QY per 30 DYs)

lidocaine-prilocaine topical cream T1

phenazopyridine oral tablet 100 mg, 200 mg T1

PROCTOFOAM HC T2

VAGICAINE (WITH VIT A,D) T1

Antivirals (Skin And Mucous Membrane)

ABREVA T2 QL (2 QY per 30 DYs)

acyclovir topical T3 PA

DENAVIR T3 PA

Astringents

aluminum chloride T1 QL (75 ML per 30 days)

HEMORRHOIDAL (WITCH HAZEL) T1

Azoles (Skin And Mucous Membrane)

AZOLEN TINCTURE T1

116

Drug Tier Notes

clotrimazole mucous membrane T1

clotrimazole topical cream T1 QL (180 QY per 30 DYs)

clotrimazole topical solution T1

clotrimazole vaginal cream T1


econazole T1 QL (340 QY per 30 DYs)

GYNE-LOTRIMIN T1

JUBLIA T5

ketoconazole topical cream T1

ketoconazole topical shampoo T1

LOTRIMIN AF POWDER T1

LOTRIMIN AF TOPICAL POWDER T1

MICONAZOLE 7 T1

miconazole nitrate topical cream T1

MICONAZOLE-3 VAGINAL SUPPOSITORY T1

terconazole vaginal cream T1

Basic Lotions And Liniments

ammonium lactate topical lotion T1

calamine T5

calamine-zinc oxide topical lotion 8-8 % T1

LAC-HYDRIN FIVE T2

Basic Ointments And Protectants

ammonium lactate topical cream T1

Benzylamines (Skin And Mucous Membrane)

LOTRIMIN ULTRA T5

Cell Stimulants And Proliferants

ALTRENO T5

clindamycin-tretinoin T5

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.06 %, 0.08 %

T5

tretinoin microspheres T5

tretinoin topical cream T1 QL (20 QY per 30 DYs); AL (Max 30 Years)

117

Drug Tier Notes

tretinoin topical gel 0.01 %, 0.025 % T1 QL (15 QY per 30 DYs); AL (Max 30 Years)

Corticosteroids (Skin, Mucous Membrane)

alclometasone T5

amcinonide T5

ANTI-ITCH (HC) TOPICAL LOTION T5

ANUSOL-HC RECTAL CREAM WITH APPLICATOR

T1

APEXICON E T5

betamethasone dipropionate topical cream T1 QL (240 GM per 30 DYs)

betamethasone dipropionate topical lotion T1 QL (240 QY per 30 DYs)

betamethasone dipropionate topical ointment T1 QL (120 QY per 30 DYs)

betamethasone valerate topical cream T1 QL (240 QY per 30 DYs)

betamethasone valerate topical foam T5

betamethasone valerate topical lotion T1 QL (240 QY per 30 DYs)

betamethasone valerate topical ointment T1 QL (240 GM per 30 DYs)

betamethasone, augmented T1 QL (120 QY per 30 DYs)

BRYHALI T5

CAPEX T5

clobetasol scalp T1 QL (100 ML per 30 days)

clobetasol topical cream T1 QL (120 GM per 30 days)

clobetasol topical foam T5

clobetasol topical gel T1 QL (120 GM per 30 days)

clobetasol topical lotion T5

clobetasol topical ointment T1 QL (120 GM per 30 days)

clobetasol topical shampoo T1 QL (118 ML per 30 days)

clobetasol topical spray,non-aerosol T5

clobetasol-emollient T5

clocortolone pivalate T5


CORDRAN TAPE LARGE ROLL T5

CORDRAN TOPICAL CREAM 0.025 % T5

CORTISONE COOLING T5

DESONATE T5

118

Drug Tier Notes

desonide T5

desoximetasone topical cream 0.05 % T5

desoximetasone topical cream 0.25 % T1 QL (120 QY per 30 DYs)

desoximetasone topical gel T5

desoximetasone topical ointment T5

desoximetasone topical spray,non-aerosol T5

diflorasone T5

fluocinolone and shower cap T1 QL (119 ML per 30 DYs)

fluocinolone topical cream 0.01 % T5

fluocinolone topical cream 0.025 % T1 QL (240 QY per 30 DYs)

fluocinolone topical oil T1 QL (119 ML per 30 DYs)

fluocinolone topical ointment T5

fluocinolone topical solution T1 QL (180 ML per 30 DYs)

fluocinonide topical cream 0.05 % T1 QL (240 GM per 30 DYs)

fluocinonide topical cream 0.1 % T5

fluocinonide topical gel T1 QL (240 QY per 30 DYs)

fluocinonide topical ointment T1 QL (240 QY per 30 DYs)

fluocinonide topical solution T1 QL (240 QY per 30 DYs)

FLUOCINONIDE-E T5

fluocinonide-emollient T5

flurandrenolide T5

fluticasone propionate topical cream T1 QL (240 QY per 30 DYs)

fluticasone propionate topical lotion T5

fluticasone propionate topical ointment T5

halobetasol propionate topical cream T1 QL (120 GM per 30 days)

halobetasol propionate topical foam T5

halobetasol propionate topical ointment T1 QL (120 QY per 30 DYs)

HALOG TOPICAL CREAM T5

HALOG TOPICAL OINTMENT T5

hydrocortisone acetate rectal suppository 25 mg T1

hydrocortisone acetate topical cream 1 % T1 QL (240 GM per 30 DYs)

hydrocortisone butyrate T5

hydrocortisone butyr-emollient T5

hydrocortisone rectal T1

119

Drug Tier Notes

hydrocortisone topical cream T1 QL (240 QY per 30 DYs)

hydrocortisone topical cream in packet T5

hydrocortisone topical cream with perineal applicator 1 %

T5

hydrocortisone topical lotion 1 % T1 QL (240 GM per 30 DYs)

hydrocortisone topical lotion 2.5 % T1 QL (240 QY per 30 DYs)

hydrocortisone topical ointment T1 QL (240 QY per 30 DYs)

hydrocortisone valerate T5

hydrocortisone-aloe vera topical cream 1 % T1 QL (240 QY per 30 DYs)

IMPOYZ T5

LEXETTE T5

MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

T5

mometasone topical cream T1 QL (60 QY per 30 DYs)

mometasone topical ointment T1 QL (240 QY per 30 DYs)

mometasone topical solution T1 QL (240 QY per 30 DYs)

NOLIX TOPICAL LOTION T5

NUCORT T5

PANDEL T5

prednicarbate T5

PROCTOFOAM HC T2

PROCTO-PAK T5

PROCTOZONE-HC T1 QL (60 GM per 30 DYs)

PSORCON T5

SCALACORT T5

SCALP RELIEF TOPICAL SOLUTION T5

SERNIVO T5

TEXACORT T5

TOPICORT TOPICAL GEL T5

triamcinolone acetonide dental T1

triamcinolone acetonide topical aerosol T5

triamcinolone acetonide topical cream 0.025 %, 0.5 %


triamcinolone acetonide topical cream 0.1 % T1 QL (454 QY per 30 DYs)

triamcinolone acetonide topical lotion T1 QL (240 QY per 30 DYs)

120

Drug Tier Notes

triamcinolone acetonide topical ointment 0.025 %, 0.5 %


triamcinolone acetonide topical ointment 0.1 % T1 QL (454 GM per 30 days)

TRIANEX T5

ULTRAVATE TOPICAL LOTION T5

VERDESO T5

Detergents

PERIFRESH T2

Hydroxypyridones (Skin, Mucous Membrane)

ciclopirox topical cream T1 QL (90 QY per 30 DYs)

ciclopirox topical solution T1 QL (6.6 ML per 30 days)

Keratolytic Agents

ACNE MEDICATION TOPICAL LOTION 10 % T1

ACNE MEDICATION TOPICAL LOTION 5 % T2

benzoyl peroxide topical cleanser 10 %, 4 %, 6 % T1

benzoyl peroxide topical gel 10 %, 2.5 % T1 QL (60 QY per 30 DYs)

benzoyl peroxide topical gel 5 % T1

BP WASH TOPICAL CLEANSER 5 % T1

clindamycin-benzoyl peroxide T5

LIQUID CORN AND CALLUS REMOVER TOPICAL LIQUID 17 %


NEUAC T5

NEUAC KIT T5

ONEXTON TOPICAL GEL WITH PUMP T5

SELSUN BLUE (SALICYLIC ACID) T1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)


urea topical cream 20 % T1 QL (85 QY per 30 DYs)

urea topical cream 40 % T1 QL (198.4 GM per 30 days)

Keratoplastic Agents

coal tar (bulk) T1

Local Anti-Infectives, Miscellaneous

ALCOHOL PREP PADS T2

ANTI-DANDRUFF T1

121

Drug Tier Notes

ANTI-DANDRUFF WITH MENTHOL T1

ANTISEPTIC WOUND-SKIN T1

DANDRUFF SHAMPOO (SELEN-ALOE) T1

selenium sulfide topical lotion T1

silver sulfadiazine T1

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)


ULESFIA T5

Nonsteroidal Anti-Inflammat.Agents(Skin)

DICLO GEL T5




FLECTOR T5


T5

Oxaboroles

KERYDIN T5

Pigmenting Agents

methoxsalen T1 QL (12 EA per 28 days)

Polyenes (Skin And Mucous Membrane)

nystatin topical cream T1 QL (120 QY per 30 DYs)

nystatin topical ointment T1 QL (120 QY per 30 DYs)

nystatin topical powder T1 QL (1280 QY per 30 DYs)

nystatin-triamcinolone T1 QL (480 QY per 30 DYs)

Scabicides And Pediculicides

CROTAN T5

EURAX T5

LICE KILLING T1

LICE KILLING (PERMETHRIN) T1

malathion T3 PA

permethrin topical cream T1

SKLICE T5

spinosad T3 PA

122

Drug Tier Notes

ULESFIA T5

Skin And Mucous Membrane Agents, Misc.

ABSORICA T5

ABSORICA LD T5

acitretin T3 PA

adapalene topical cream T3 ST; QL (45 GM per 30 days); AL (Max 30 Years)

adapalene topical gel 0.3 % T3 ST; QL (45 GM per 30 days); AL (Max 30 Years)

adapalene topical gel with pump T3 ST; QL (45 GM per 30 days); AL (Max 30 Years)

adapalene topical lotion T5

adapalene topical solution T5

adapalene topical swab T5

adapalene-benzoyl peroxide T5

ARTHRITIS PAIN RELIEF(CAPSAIC) TOPICAL CREAM 0.075 %

T1

AVAGE T5

azelaic acid T3 PA

AZELEX T3 PA

calcipotriene scalp T1 QL (60 ML per 30 days)

calcipotriene topical cream T1 QL (60 QY per 30 DYs)

calcipotriene topical ointment T1 QL (60 QY per 30 DYs)

capsaicin topical cream 0.025 % T1

COSENTYX T4 PA

COSENTYX (2 SYRINGES) T4 PA

COSENTYX PEN T4 PA

COSENTYX PEN (2 PENS) T4 PA

DICLO GEL T5




DIFFERIN TOPICAL GEL 0.1 % T2 QL (45 GM per 30 days); AL (Max 30 Years)

DUPIXENT PEN T4 PA

123

Drug Tier Notes

DUPIXENT SYRINGE T4 PA

ENBREL T4 PA

ENBREL MINI T4 PA


EPIDUO FORTE T5

FABIOR T5

FINACEA TOPICAL FOAM T3 PA

FLECTOR T5

fluorouracil topical cream 5 % T1 QL (1 FL per 365 DYs)

fluorouracil topical solution T5

HIGH POTENCY CAPSAICIN T1 QL (42.5 QY per 30 DYs)

HUMIRA PEN T4 PA



T4 PA

HUMIRA(CF) T4 PA

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

T4 PA


T4 PA

ILUMYA T5

imiquimod topical cream in packet T1 AL (Min 12 Years)

isotretinoin T3 PA

K-Y LUBRICATING T1

ORAL RELIEF DRY MOUTH T2

OTEZLA T4 PA


PANRETIN T5


T5

pimecrolimus T5

podofilox T1

PROSHIELD FOAM/SPRAY CLEANSER T2

RECTIV T3 PA

124

Drug Tier Notes

SANTYL T2 QL (30 GM per 30 days)

SILIQ T5

SKYRIZI SUBCUTANEOUS SYRINGE KIT T5


tacrolimus topical ointment 0.03 % T3 ST; QL (30 GM per 30 days)

tacrolimus topical ointment 0.1 % T3 ST; QL (30 GM per 30 days); AL (Min 2 Years)

TALTZ AUTOINJECTOR T4 PA

TALTZ AUTOINJECTOR (2 PACK) T4 PA

TALTZ AUTOINJECTOR (3 PACK) T4 PA

TALTZ SYRINGE T4 PA

tazarotene T5

TAZORAC TOPICAL CREAM 0.05 % T5

TAZORAC TOPICAL GEL T5

TREMFYA T5

VALCHLOR T5

XYLIMELTS T5

Thiocarbamates(Skin And Mucous Membrane)

LAMISIL AF TOPICAL POWDER T1

tolnaftate topical cream T1 QL (120 QY per 30 DYs)

Smooth Muscle Relaxants

Antimuscarinics

darifenacin T5

flavoxate T5

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)

T5

GELNIQUE TRANSDERMAL GEL IN PACKET T5

oxybutynin chloride T1

OXYTROL T5

OXYTROL FOR WOMEN T3 ST; QL (8 EA per 28 days)

solifenacin T3 ST; QL (90 EA per 90 days)

tolterodine oral capsule,extended release 24hr T3 ST; QL (30 EA per 30 days)

tolterodine oral tablet T3 ST; QL (60 EA per 30 days)

125

Drug Tier Notes

TOVIAZ T5

trospium oral capsule,extended release 24hr T3 ST; QL (30 EA per 30 days)

trospium oral tablet T3 ST; QL (60 EA per 30 days)

Respiratory Smooth Muscle Relaxants


T1



MYRBETRIQ T5

Vitamins

Multivitamin Preparations


BIOTECT PLUS T1

CENTRAL-VITE SELECT T1

CENTRUM COMPLETE T1

CENTRUM SILVER ORAL TABLET T1

CHEWABLE-VITE T2

CHILDREN'S CHEWABLE VITAMIN T1 AL (Max 12 Years)

CHILD'S CHEWABLE VITAMINS/IRON ORAL TABLET,CHEWABLE


CLASSIC PRENATAL T2

COMPLETENATE T1 QL (30 QY per 30 DYs)

DAILY MULTI-VITAMIN T1


FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE 18 MG IRON




MULTI-DELYN T1

MULTIVITAMIN WITH FLUORIDE T1 AL (Max 12 Years)

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 1 MG


mv-min-folic acid-lutein T1



126

Drug Tier Notes



OCUVITE WITH LUTEIN T1

ONE DAILY FOR MEN 50+ ADVANCED T1

ONE DAILY MULTI-VIT W-MINERAL ORAL TABLET

T1

POLYVITAMIN WITH IRON T1 AL (Max 12 Years)



T1




STROVITE FORTE T2

THERA ORAL TABLET T1

THERA-M ORAL TABLET , 9 MG IRON-400 MCG

T1

THERATRUM COMPLETE 50 PLUS/LUT T1

THEREMS-M T2

TRIADVANCE T1



TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC 0.25 MG/ML FLUORIDE

T5





VIC-FORTE T1

VINACAL B T1

VINATE II T1



VINATE PN CARE T1 QL (30 QY per 30 DYs)


127

Drug Tier Notes


VITAFOL GUMMIES T2




ZATEAN-CH T1


Vitamin A




vitamin a oral capsule 10,000 unit T1

Vitamin B Complex


b-complex with vitamin c oral tablet T1

biotin oral capsule 5 mg T1

BONJESTA T5

CENTRUM COMPLETE T1

CENTRUM SILVER ORAL TABLET T1

CLASSIC PRENATAL T2

cyanocobalamin (vitamin b-12) injection T1 QL (1 QY per 30 DYs)

cyanocobalamin (vitamin b-12) oral tablet 500 mcg

T1

cyanocobalamin (vitamin b-12) oral tablet extended release 1,000 mcg

T1

DIALYVITE 800 ORAL TABLET T1

DIALYVITE 800-ULTRA D T2

DIALYVITE ORAL TABLET 100-1 MG T2

DICLEGIS T5


folic acid oral tablet T1



levomefolate calcium T1 QL (30 EA per 30 days)

mv-min-folic acid-lutein T1

128

Drug Tier Notes

MYNEPHROCAPS T1





ONE DAILY FOR MEN 50+ ADVANCED T1



T1



pyridoxine (vitamin b6) injection T5

pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg

T1

RENA-VITE RX T1


STROVITE FORTE T2

THERA-M ORAL TABLET 9 MG IRON-400 MCG

T1

thiamine hcl (vitamin b1) oral tablet 50 mg T1

thiamine mononitrate (vit b1) T1

TRIADVANCE T1




VIC-FORTE T1

VINACAL B T1





VITAFOL GUMMIES T2


VITAMIN B-1 ORAL TABLET 100 MG T1

VITAMIN B-12 ORAL TABLET 1,000 MCG T1

129

Drug Tier Notes

VITAMIN B-12 ORAL TABLET 100 MCG T1 QL (100 QY per 30 DYs)



ZATEAN-CH T1


Vitamin C

ascorbic acid (vitamin c) oral tablet 250 mg, 500 mg

T1

b-complex with vitamin c oral tablet T1

DIALYVITE 800 ORAL TABLET T1


DIALYVITE ORAL TABLET 100-1 MG T2

MYNEPHROCAPS T1




VITAMIN C ORAL TABLET 1,000 MG T1

VITAMIN C ORAL TABLET,CHEWABLE 500 MG

T1

Vitamin D

calcitriol oral capsule T1

calcitriol oral solution T1 AL (Max 12 Years)

CALCIUM 500 WITH D T1

CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -400 UNIT

T1

calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit

T1

calcium citrate-vitamin d3 oral tablet 200-125 mg-unit

T1

cholecalciferol (vitamin d3) oral capsule 1,250 mcg (50,000 unit), 125 mcg (5,000 unit)

T1

cholecalciferol (vitamin d3) oral drops 10 mcg/ml (400 unit/ml)

T1

cholecalciferol (vitamin d3) oral tablet 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit)

T1


130

Drug Tier Notes

ergocalciferol (vitamin d2) oral drops T1 AL (Max 12 Years)

FOSAMAX PLUS D T5

OS-CAL 500 + D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT

T1

OYSTER SHELL + D3 T1

RISACAL-D T1




VITAMIN D2 T1

VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT), 25 MCG (1,000 UNIT), 50 MCG (2,000 UNIT)

T1

VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT), 25 MCG (1,000 UNIT)

T1

VITAMIN D3 ORAL TABLET,CHEWABLE 10 MCG (400 UNIT)

T1

Vitamin E

vitamin e (dl, acetate) oral capsule 100 unit, 400 unit

T1

vitamin e (dl, acetate) oral drops 100 unit/0.25 ml T1

Vitamin K Activity

phytonadione (vitamin k1) oral tablet 5 mg T1

VITAMIN K1 INJECTION T5

131

Index

A abacavir .................................. 9 abacavir-lamivudine-

zidovudine .......................... 9 ABILIFY MAINTENA .. 48, 51 abiraterone ............................ 13 ABREVA ........................... 115 ABSORICA ........................ 121 ABSORICA LD ................. 121 acamprosate .......................... 54 acarbose ................................ 84 ACCU-CHEK AVIVA

CONTROL SOLN............ 63 ACCU-CHEK AVIVA PLUS

TEST STRP ...................... 64 ACCU-CHEK FASTCLIX

LANCET DRUM ............. 63 ACCU-CHEK FASTCLIX

LANCING DEV ............... 63 ACCU-CHEK GUIDE

GLUCOSE METER ......... 63 ACCU-CHEK GUIDE L1-L2

CTRL SOL ....................... 63 ACCU-CHEK GUIDE ME

GLUCOSE MTR .............. 63 ACCU-CHEK GUIDE TEST

STRIPS ............................. 64 ACCU-CHEK SMARTVIEW

CONTRL SOL ................. 63 ACCU-CHEK SMARTVIEW

TEST STRIP .................... 64 ACCU-CHEK SOFT DEV

LANCETS ........................ 63 ACCU-CHEK SOFTCLIX

LANCET DEV ................. 63 ACCU-CHEK SOFTCLIX

LANCETS ........................ 63 acetaminophen ...................... 46 acetaminophen-codeine .. 46, 56 acetazolamide ........... 38, 67, 74 acetic acid ....................... 67, 74 acetylcysteine ....... 95, 102, 107 ACIPHEX SPRINKLE ........ 81 acitretin ............................... 121 ACNE MEDICATION ....... 119 ACTEMRA .................... 98, 99 ACTEMRA ACTPEN .... 98, 99 ACTHAR H.P. ............... 64, 92 ACTHIB (PF) ....................... 21

ACTHREL...................... 64, 65 ACUVAIL (PF) .................... 75 acyclovir ....................... 11, 115 ADACEL(TDAP

ADOLESN/ADULT)(PF) 20 adapalene ............................ 121 adapalene-benzoyl peroxide

........................................ 121 adefovir ................................. 11 ADEMPAS ................... 44, 110 ADHANSIA XR................... 59 ADMELOG SOLOSTAR U-

100 INSULIN ............. 90, 93 ADMELOG U-100 INSULIN

LISPRO ...................... 90, 93 ADRENACLICK ......... 22, 104 ADRENALIN ............... 22, 104 ADRIAMYCIN .................... 13 ADULT TUSSIN COUGH

CONGEST DM .............. 105 ADVAIR HFA 26, 82, 107, 109 ADVATE.............................. 29 ADYNOVATE ..................... 29 ADZENYS XR-ODT ........... 45 AEROCHAMBER PLUS

FLOW-VU,S MSK ........... 63 AEROECLIPSE II

NEBULIZER .................... 63 AFINITOR ........................... 14 AFINITOR DISPERZ .......... 14 AFLURIA QD 2020-21(3YR

UP)(PF) ............................ 21 AFLURIA QD 2020-21(6-

35MO)(PF) ....................... 21 AFLURIA QUAD 2020-

2021(6MO UP) ................. 21 AIMOVIG AUTOINJECTOR

.................................... 49, 54 AIMOVIG AUTOINJECTOR

(2 PACK) .................... 49, 54 AJOVY AUTOINJECTOR .. 54 AJOVY SYRINGE......... 49, 54 AKTIPAK .......................... 110 AKYNZEO (NETUPITANT)

.................................... 76, 81 albendazole ............................. 4 albumin, human 25 % ........... 27 albuterol sulfate ............ 26, 109 alclometasone ............. 111, 116

ALCOHOL PREP PADS ... 120 ALECENSA ......................... 14 alendronate ........................... 97 alfuzosin ............................... 26 ALIMTA ............................... 14 ALINIA .................................. 5 aliskiren ................................ 43 ALKERAN ........................... 14 ALLERGY

(DIPHENHYDRAMINE) . 1, 106

ALLERGY RELIEF (LORATADINE) ........ 2, 108

ALLI ..................................... 80 allopurinol ............................. 96 almotriptan malate ................ 61 alogliptin ............................... 87 alogliptin-metformin ....... 85, 87 alogliptin-pioglitazone .... 87, 95 alosetron ............................... 78 ALOXI .................................. 76 ALPHAGAN P ..................... 72 ALPHANATE ...................... 29 ALPHANINE SD ................. 29 ALPROLIX .......................... 29 ALTAFLUOR ................ 65, 75 ALTRENO ......................... 116 aluminum chloride .............. 115 alum-mag hydroxide-simeth 77,

78 ALUNBRIG ......................... 14 amantadine hcl .................. 3, 45 ambrisentan ................... 44, 110 amcinonide ................. 111, 116 AMETHIA ............................ 86 amiloride ......................... 43, 68 AMINOSYN 10 % ............... 65 AMINOSYN 8.5 % .............. 65 AMINOSYN 8.5 %-

ELECTROLYTES ............ 65 AMINOSYN II 10 % ............ 65 AMINOSYN II 15 % ............ 65 AMINOSYN II 8.5 % ........... 65 AMINOSYN II 8.5 %-

ELECTROLYTES ............ 65 AMINOSYN M 3.5 % .......... 65 AMINOSYN-HBC 7% ......... 65 AMINOSYN-PF 10 % ......... 65

132

AMINOSYN-PF 7 % (SULFITE-FREE) ............ 65

AMINOSYN-RF 5.2 % ........ 65 amiodarone ........................... 40 AMITIZA ............................. 78 amitriptyline ......................... 63 amlodipine .......... 37, 40, 41, 44 amlodipine-benazepril ... 34, 37,

40, 41, 44 amlodipine-valsartan33, 34, 37,

40, 41, 44 ammonium lactate .............. 116 amoxicillin .............................. 4 amoxicillin-pot clavulanate .... 4 amphetamine ........................ 45 amphetamine sulfate ............. 45 amphotericin b ...................... 12 ampicillin ................................ 4 AMYVID ........................... 103 anagrelide ............................. 33 anastrozole ...................... 14, 85 ANDRODERM .................... 84 ANDROGEL ........................ 84 ANNOVERA ....................... 86 ANORO ELLIPTA 23, 26, 104,

109 ANTACID (CALCIUM

CARBONATE) .......... 69, 77 ANTARA ............................. 41 ANTI-DANDRUFF ........... 120 ANTI-DANDRUFF WITH

MENTHOL .................... 120 ANTI-DIARRHEAL

(LOPERAMIDE) ............. 77 ANTI-ITCH (BENZ-RESOR)

........................................ 114 ANTI-ITCH

(DIPHENHYDRAMINE) ........................................ 114

ANTI-ITCH (HC) ...... 111, 116 ANTI-ITCH (PRAMOXINE)

........................................ 114 ANTISEPTIC WOUND-SKIN

........................................ 120 ANUSOL-HC ............. 111, 116 APEXICON E ............ 111, 116 aprepitant .............................. 81 APRODINE ...... 2, 22, 104, 106 APTENSIO XR .................... 59 APTIOM............................... 47 APTIVUS ............................. 10

APTIVUS (WITH VITAMIN E) ...................................... 10

ARANESP (IN POLYSORBATE) ............ 28

ARCAPTA NEOHALER .... 26, 109

aripiprazole ..................... 48, 51 ARISTADA .................... 49, 51 ARISTADA INITIO....... 48, 51 armodafinil ........................... 63 ARMOUR THYROID ......... 95 ARNUITY ELLIPTA ... 82, 107 ARRANON .......................... 14 ARTHRITIS PAIN

RELIEF(CAPSAIC) ....... 121 ARTIFICIAL TEARS

(PETRO/MIN) .................. 75 ARTIFICIAL TEARS (PF) .. 75 ARTIFICIAL TEARS

(POLYVIN ALC) ............. 75 ARTIFICIAL

TEARS(DEXT70-HYPRO) .......................................... 75

ARYMO ER ......................... 56 ARZERRA ........................... 14 ascorbic acid (vitamin c) .... 128 ASMANEX HFA ......... 82, 107 ASMANEX TWISTHALER

.................................. 82, 107 aspirin ................. 32, 33, 50, 60 aspirin-dipyridamole 32, 44, 60 ATABEX EC ... 31, 69, 78, 124,

126 atazanavir.............................. 10 atenolol ............... 27, 35, 36, 39 atenolol-chlorthalidone .. 27, 35,

36, 39, 44, 72 atomoxetine .......................... 54 atorvastatin ........................... 41 atovaquone.............................. 5 atovaquone-proguanil ............. 4 ATRIPLA ........................... 8, 9 atropine ................................. 76 ATROVENT HFA ....... 23, 104 AUBAGIO............................ 99 AUGMENTIN ........................ 4 AURYXIA............................ 68 AUSTEDO ..................... 54, 63 AUVI-Q ........................ 23, 104 AVAGE .............................. 121 AVASTIN ............................ 14

AVONEX ........................... 100 AVONEX (WITH ALBUMIN)

.......................................... 99 AYVAKIT ............................ 14 azathioprine .......... 98, 100, 101 azelaic acid ......................... 122 azelastine .............................. 72 AZELEX ............................. 122 azithromycin ......................... 12 AZOLEN TINCTURE ....... 115 B BABY AYR SALINE .......... 75 bacitracin .................. 6, 72, 111 bacitracin zinc ..................... 111 bacitracin-polymyxin b . 72, 111 baclofen ................................ 24 BALCOLTRA ...................... 86 balsalazide ............................ 78 BALVERSA ......................... 14 BANZEL .............................. 47 BAQSIMI ....................... 88, 95 BARACLUDE ...................... 11 BASAGLAR KWIKPEN U-

100 INSULIN ............. 90, 91 BAXDELA ........................... 12 b-complex with vitamin c .. 126,

128 BEBULIN ............................. 29 BELSOMRA ........................ 50 BELVIQ XR ......................... 62 benazepril ............................. 34 benazepril-hydrochlorothiazide

........................ 34, 35, 43, 71 BENDEKA ........................... 14 BENEFIX ............................. 29 benzonatate ......................... 105 benzoyl peroxide ........ 119, 120 benzphetamine ...................... 45 benztropine ..................... 24, 47 BEPREVE ............................ 72 betamethasone dipropionate

........................ 111, 112, 116 betamethasone valerate ...... 112,

116 betamethasone, augmented 112,

116 BETASERON ..................... 100 betaxolol ............................... 73 bethanechol chloride ............. 25 BETHKIS ............................... 4

133

BEVESPI AEROSPHERE .. 23, 26, 109

bexarotene ............................ 14 BEXSERO ............................ 21 bicalutamide ......................... 14 BICNU ................................. 14 BIDIL ............................. 40, 42 bimatoprost ........................... 76 BINOSTO............................. 97 BIONECT............................. 63 BIOTECT PLUS .......... 31, 124 BIOTENE DRY MOUTH

ORAL RINSE .................. 64 biotin................................... 126 bisacodyl............................... 78 bisoprolol fumarate . 27, 35, 36,

39 bisoprolol-hydrochlorothiazide

............ 27, 35, 36, 39, 43, 71 BLEPHAMIDE .................... 73 BLEPHAMIDE S.O.P. ......... 73 BLOOD PRESSURE KIT .... 64 blood pressure kit med and lrg

.......................................... 64 blood pressure monitor ......... 64 BONJESTA .... 77, 78, 106, 126 BOOST CALORIE SMART 65 BOOSTRIX TDAP .............. 20 bosentan ........................ 44, 110 BOSULIF ............................. 14 BP WASH .......................... 120 BRAFTOVI .......................... 14 BREO ELLIPTA ... 26, 83, 107,

109 BREVITAL .................... 52, 53 BRILINTA ........................... 32 brimonidine .......................... 72 bromfenac ............................. 75 bromocriptine ....................... 55 BROMSITE .......................... 75 BROVANA .................. 26, 109 BRUKINSA ......................... 14 BRYHALI .......................... 117 budesonide .............. 74, 83, 107 budesonide-formoterol .. 26, 83,

107, 109 BUFFERED ASPIRIN .. 32, 33,

50, 61 BUFFERIN......... 32, 33, 50, 61 bumetanide ..................... 42, 67 BUNAVAIL ......................... 58

buprenorphine hcl ................. 58 buprenorphine-naloxone ....... 58 bupropion hcl ........................ 48 bupropion hcl (smoking deter)

.......................................... 48 buspirone .............................. 50 BUSULFEX ......................... 14 butalbital-acetaminophen-caff

........................ 46, 50, 52, 59 butalbital-aspirin-caffeine ... 32,

33, 50, 52, 59, 61 BUTRANS ........................... 58 BYDUREON ........................ 90 BYDUREON BCISE ........... 90 BYETTA .............................. 90 C cabergoline ........................... 55 CABOMETYX ..................... 14 CAFERGOT ................... 25, 50 calamine.............................. 116 calamine-zinc oxide ............ 116 calcipotriene ....................... 122 calcitonin (salmon) ... 85, 92, 97 calcitriol .............................. 129 CALCIUM 500 WITH D .... 69,

129 CALCIUM 600 + D(3) . 69, 129 calcium acetate(phosphat bind)

.......................................... 68 CALCIUM ANTACID... 69, 77 calcium carbonate ........... 69, 77 calcium carbonate-vitamin d3

.................................. 69, 129 calcium citrate-vitamin d3 ... 69,

129 calcium gluconate ................. 69 CALQUENCE ...................... 14 CAMPTOSAR...................... 14 CAMRESE LO ..................... 86 capecitabine .......................... 14 CAPEX ....................... 112, 117 CAPLYTA............................ 51 CAPRELSA.......................... 14 capsaicin ............................. 122 captopril .......................... 34, 35 carbamazepine ................ 47, 49 carbidopa .............................. 54 carbidopa-levodopa .............. 55 carbidopa-levodopa-

entacapone .................. 54, 55 carboplatin ............................ 14

carvedilol 25, 26, 33, 35, 39, 41 carvedilol phosphate 25, 26, 33,

35, 39, 41 caspofungin ............................. 6 CAYSTON ........................... 11 cefaclor ................................... 3 cefadroxil ................................ 3 cefdinir .................................... 3 cefepime ................................. 3 cefixime .................................. 3 cefpodoxime ........................... 3 cefprozil .................................. 3 CEFTIN .................................. 3 cefuroxime axetil .................... 3 celecoxib ............................... 55 CELLCEPT ........................ 101 CENTRAL-VITE SELECT 124 CENTRUM COMPLETE ... 31,

124, 127 CENTRUM SILVER .. 124, 127 cephalexin ............................... 3 CEPROTIN (BLUE BAR) ... 27 CEQUA ................................ 75 CERDELGA ....................... 102 cetirizine ......................... 2, 108 CHANTIX ............................ 24 CHANTIX STARTING

MONTH BOX .................. 24 CHATEAL (28) .................... 86 CHEMET ........................ 82, 95 CHEWABLE-VITE ........... 125 CHILDREN'S ALLEGRA

ALLERGY ................. 2, 108 CHILDREN'S BENADRYL

ALLERGY ................. 1, 106 CHILDREN'S CHEWABLE

VITAMIN ....................... 125 CHILDREN'S PAIN RELIEF

.......................................... 46 CHILDREN'S SILFEDRINE

.................................. 23, 104 CHILD'S CHEWABLE

VITAMINS/IRON .......... 125 chloramphenicol sod succinate

............................................ 6 chlordiazepoxide hcl ............. 53 chlorhexidine gluconate ........ 74 chloroquine phosphate ............ 5 chlorothiazide ................. 43, 71 chlorpheniramine maleate . 1, 2,

106

134

chlorpromazine ..................... 59 chlorpropamide..................... 94 chlorthalidone ................. 44, 72 cholecalciferol (vitamin d3) 129 cholestyramine (with sugar) . 36 CHOLESTYRAMINE LIGHT

.......................................... 36 choline,magnesium salicylate

.......................................... 61 ciclopirox ............................ 119 cidofovir ............................... 11 cilostazol......................... 33, 42 cimetidine ............................. 81 CIMZIA .................. 80, 98, 100 CIMZIA POWDER FOR

RECONST .......... 80, 98, 100 cinacalcet ...................... 85, 102 CINQAIR ........................... 106 CIPRO HC...................... 73, 74 CIPRODEX .................... 73, 74 ciprofloxacin..................... 5, 12 ciprofloxacin (mixture) .... 5, 12 ciprofloxacin hcl ......... 5, 12, 73 cisplatin ................................ 14 citalopram ............................. 62 cladribine .............................. 14 clarithromycin .................. 5, 12 CLASSIC PRENATAL ...... 31,

125, 127 CLEOCIN............................. 10 CLIMARA PRO ................... 88 clindamycin hcl .................... 10 clindamycin palmitate hcl .... 10 clindamycin phosphate . 10, 111 clindamycin-benzoyl peroxide

................................ 111, 120 clindamycin-tretinoin . 111, 116 CLINIMIX 5%/D15W

SULFITE FREE ............... 65 CLINIMIX 5%/D25W

SULFITE-FREE ............... 66 CLINIMIX 2.75%/D5W

SULFIT FREE.................. 66 CLINIMIX 4.25%/D5W

SULFIT FREE.................. 66 CLINIMIX 4.25%-D20W

SULF-FREE ..................... 66 CLINIMIX 4.25%-D25W

SULF-FREE ..................... 66 CLINIMIX 5%-

D20W(SULFITE-FREE) . 66

CLINIMIX E 2.75%/D5W SULF FREE ..................... 66

CLINIMIX E 4.25%/D10W SUL FREE ........................ 66

CLINIMIX E 4.25%/D25W SUL FREE ........................ 66

CLINIMIX E 4.25%/D5W SULF FREE ..................... 66

CLINIMIX E 5%/D15W SULFIT FREE .................. 66



CLINISOL SF 15 % ............. 66 clobazam ............................... 53 clobetasol .................... 112, 117 clobetasol-emollient ... 112, 117 clocortolone pivalate .. 112, 117 clonazepam ........................... 53 clonidine ......................... 23, 38 clonidine hcl ................... 23, 38 clopidogrel ............................ 33 clotrimazole ........................ 115 clotrimazole-betamethasone

........................ 112, 115, 117 clozapine ............................... 51 COAGADEX........................ 29 coal tar (bulk) ..................... 120 codeine sulfate .............. 56, 105 codeine-guaifenesin ...... 56, 105 colchicine.............................. 96 colesevelam .................... 36, 85 colestipol .............................. 36 COMBIGAN .................. 72, 73 COMBIPATCH .............. 88, 92 COMBIVENT RESPIMAT 23,

26, 104, 109 COMETRIQ ......................... 14 COMPACT COMPRESSOR

NEBULIZER .................... 64 COMPLERA ...................... 8, 9 COMPLETENATE ............ 125 CONCEPTROL .................. 103 CONTRAVE ........................ 47 COPIKTRA .......................... 14 CORDRAN ................ 112, 117 CORDRAN TAPE LARGE

ROLL...................... 112, 117 CORIFACT .......................... 29

CORTISONE COOLING .. 112, 117

COSENTYX ....................... 122 COSENTYX (2 SYRINGES)

........................................ 122 COSENTYX PEN .............. 122 COSENTYX PEN (2 PENS)

........................................ 122 COTELLIC ........................... 14 COTEMPLA XR-ODT ........ 59 CREON ................................. 79 CRESEMBA ........................... 6 CRINONE ............................ 93 CRIXIVAN ........................... 10 cromolyn ....................... 72, 107 CROTAN ............................ 121 CRYSELLE (28) .................. 86 CRYSVITA .......................... 67 CULTURELLE .................... 80 CULTURELLE KIDS

PROBIOTICS ................... 80 cyanocobalamin (vitamin b-12)

........................................ 127 CYCLAFEM 1/35 (28) ......... 86 cyclobenzaprine .................... 24 cyclopentolate ....................... 76 cyclophosphamide ........ 14, 101 cycloserine .............................. 5 cyclosporine modified . 98, 100,

101 cyproheptadine ............... 1, 106 CYRAMZA .......................... 15 CYTRA K CRYSTALS ....... 65 D d10 %-0.45 % sodium chloride

.......................................... 66 d2.5 %-0.45 % sodium

chloride ............................. 66 dacarbazine ........................... 15 DAILY FIBER ..................... 78 DAILY FIBER (PSYLLIUM-

SUCROSE) ....................... 79 DAILY MULTI-VITAMIN125 DAKLINZA ........................... 7 dalfampridine ...................... 102 DALIRESP ......................... 108 danazol .................................. 84 DANDRUFF SHAMPOO

(SELEN-ALOE) ............. 120 dantrolene ............................. 24 dapsone ................................... 5

135

daptomycin ............................. 6 DARAPRIM ........................... 5 darifenacin .......................... 124 DARZALEX ........................ 15 daunorubicin ......................... 15 DAURISMO......................... 15 DAYTRANA ....................... 59 DDAVP .......................... 29, 92 decitabine ............................. 15 DEEP SEA NASAL ............. 75 deferasirox ............................ 82 DEFITELIO ......................... 28 DELSTRIGO ...................... 8, 9 DEMEROL........................... 56 DEMEROL (PF) .................. 56 DENAVIR .......................... 115 DENTA 5000 PLUS............. 97 DEPO-ESTRADIOL ............ 88 DEPO-SUBQ PROVERA 104

.......................................... 93 DESCOVY ............................. 9 desipramine .......................... 63 desloratadine................... 2, 108 desmopressin .................. 29, 92 DESONATE ....................... 117 desonide ...................... 112, 117 desoximetasone .......... 112, 117 desvenlafaxine ...................... 61 desvenlafaxine fumarate ....... 61 desvenlafaxine succinate ...... 61 dexamethasone ..................... 83 DEXAMETHASONE

INTENSOL ...................... 83 dexamethasone sodium

phosphate .................... 74, 83 DEXILANT .......................... 81 dexmethylphenidate ............. 60 dextroamphetamine ........ 45, 46 dextroamphetamine-

amphetamine .................... 46 dextromethorphan polistirex

........................................ 105 dextromethorphan-guaifenesin

........................................ 105 dextrose 10 % and 0.2 % nacl

.......................................... 66 dextrose 10 % in water (d10w)


.......................................... 66

dextrose 30 % in water (d30w) .......................................... 66

dextrose 40 % in water (d40w) .......................................... 66

dextrose 5 % in water (d5w). 66 dextrose 5 %-lactated ringers69 dextrose 5%-0.2 % sod

chloride ............................. 66 dextrose 5%-0.3 %

sod.chloride ...................... 66 dextrose 50 % in water (d50w)


.......................................... 66 DIABETIC TUSSIN DM ... 105 DIALYVITE .............. 127, 128 DIALYVITE 800 ....... 127, 128 DIALYVITE 800-ULTRA D

........................ 127, 128, 129 diazepam ............................... 53 DICLEGIS ...... 77, 78, 106, 127 DICLO GEL ......... 58, 120, 122 diclofenac potassium ............ 58 diclofenac sodium.... 15, 58, 75,

120, 122 diclofenac-misoprostol ... 58, 81 dicloxacillin .......................... 12 dicyclomine .......................... 23 didanosine ............................... 9 diethylpropion ...................... 45 DIFFERIN .......................... 122 DIFICID ............................... 12 diflorasone .................. 112, 117 digoxin ............................ 35, 38 DILANTIN ..................... 39, 55 DILATRATE-SR ................. 42 diltiazem hcl . 36, 37, 38, 40, 44 dimenhydrinate ......... 1, 78, 106 diphenhydramine hcl ...... 1, 106 diphenoxylate-atropine .. 23, 77,

104 dipyridamole ................... 33, 44 disopyramide phosphate ....... 39 disulfiram.............................. 95 DIURIL .......................... 43, 71 divalproex ................. 48, 49, 50 dobutamine ..................... 26, 38 docetaxel ............................... 15 docusate calcium .................. 79 docusate sodium ................... 79 dofetilide ............................... 40

donepezil ............................... 25 DOPTELET (10 TAB PACK)

.......................................... 28 DOPTELET (15 TAB PACK)

.......................................... 28 dorzolamide .......................... 74 dorzolamide-timolol ....... 73, 74 DOVATO ........................... 8, 9 doxazosin .................. 25, 33, 41 doxepin ................................. 63 doxorubicin ........................... 15 doxycycline hyclate ........ 13, 73 doxycycline monohydrate .... 13 dronabinol ............................. 78 drospirenone-e.estradiol-lm.fa

.......................................... 86 DROXIA ............................... 15 DULERA ........ 26, 83, 107, 109 duloxetine ....................... 55, 61 DUPIXENT PEN ........ 106, 122 DUPIXENT SYRINGE ..... 106,

122 DUREZOL ........................... 74 dutasteride ............................. 95 DYANAVEL XR ................. 46 E EAR DROPS (CARBAMIDE

PEROXIDE) ..................... 74 econazole ............................ 115 EDLUAR .............................. 50 EDURANT ............................. 8 efavirenz ................................. 8 EGRIFTA ............................. 94 EGRIFTA SV ....................... 94 electrolyte-48 in d5w ............ 69 eletriptan ............................... 61 ELIGARD ....................... 15, 89 ELIGARD (3 MONTH) . 15, 89 ELIGARD (4 MONTH) . 15, 89 ELIGARD (6 MONTH) . 15, 89 ELIQUIS ............................... 28 ELIQUIS DVT-PE TREAT

30D START ...................... 28 ELITE-OB 400 ..... 31, 125, 127 ELLA .................................... 86 ELMIRON .......................... 103 ELOCTATE ......................... 29 EMCYT ................................ 15 EMEND ................................ 81 EMFLAZA ........................... 83 EMGALITY PEN ........... 50, 54

136

EMGALITY SYRINGE . 50, 54 EMPLICITI .......................... 15 EMSAM ............................... 56 EMTRIVA .............................. 9 enalapril maleate ............ 34, 35 enalapril-hydrochlorothiazide

........................ 34, 35, 43, 71 ENBREL .............. 98, 100, 122 ENBREL MINI .... 98, 100, 122 ENBREL SURECLICK ...... 98,

100, 122 ENDARI ....................... 80, 102 ENDOMETRIN ................... 93 ENEMA DISPOSABLE ...... 79 ENGERIX-B (PF) ................ 21 ENGERIX-B PEDIATRIC

(PF) ................................... 21 enoxaparin ...................... 30, 31 ENSURE ORIGINAL .......... 66 ENSURE PLUS.................... 66 entacapone ............................ 54 entecavir ............................... 11 ENTRESTO ................... 34, 43 ENUCLENE ......................... 75 ENULOSE ............................ 65 EPIDUO FORTE................ 122 epinastine .............................. 72 epinephrine ................... 23, 104 EPIPEN 2-PAK ............ 23, 104 EPIPEN JR 2-PAK ....... 23, 104 epirubicin .............................. 15 EPIVIR ................................... 9 EPIVIR HBV.......................... 9 eplerenone ...................... 42, 43 EPOGEN .............................. 28 EPZICOM .............................. 9 EQUETRO ..................... 48, 49 ERBITUX............................. 15 ergocalciferol (vitamin d2) . 129 ERIVEDGE .......................... 15 ERLEADA ........................... 15 erlotinib ................................ 15 ERYTHROCIN (AS

STEARATE) ................ 7, 10 erythromycin .............. 7, 11, 73 erythromycin ethylsuccinate . 7,

10, 11 erythromycin with ethanol . 111 erythromycin-benzoyl peroxide

........................................ 111 ESBRIET ............................ 104

escitalopram oxalate ............. 62 esomeprazole magnesium..... 81 ESPEROCT .......................... 29 estazolam .............................. 53 ESTRACE ............................ 88 estradiol ................................ 88 estradiol valerate................... 88 ESTRING ............................. 88 ESTROGEL.......................... 88 eszopiclone ..................... 50, 51 ethambutol .............................. 5 ethosuximide ........................ 62 etidronate disodium .............. 97 etodolac ................................ 58 etonogestrel-ethinyl estradiol86 ETOPOPHOS ....................... 15 etoposide ............................... 15 EUCRISA ................... 112, 114 EURAX .............................. 121 EVEKEO ODT ..................... 46 EVENITY ............................. 97 everolimus (antineoplastic) .. 15 everolimus

(immunosuppressive) ..... 101 EVOTAZ .............................. 10 EVZIO ............................ 58, 95 exemestane ..................... 15, 85 EXTAVIA .......................... 100 EYE ALLERGY RELIEF .... 76 ezetimibe .............................. 39 F FABIOR ............................. 122 FACTIVE ............................. 12 FALMINA (28) .................... 86 famciclovir............................ 11 famotidine ............................. 81 FANAPT .............................. 51 FARESTON ................... 15, 88 FARXIGA ............................ 94 FARYDAK ........................... 15 FASENRA .......................... 106 FASENRA PEN ................. 106 febuxostat ............................. 96 FEIBA NF ............................ 29 felodipine ............ 37, 40, 41, 44 fenofibrate ............................ 41 fenofibrate micronized ......... 41 fenofibrate nanocrystallized . 41 fenofibric acid (choline) ....... 41 fentanyl ................................. 56 ferrous gluconate .................. 31

ferrous sulfate ....................... 31 FEVERALL .......................... 46 fexofenadine ................... 2, 108 FINACEA ........................... 122 finasteride ............................. 95 FIORICET .......... 46, 50, 52, 60 FIRMAGON KIT W

DILUENT SYRINGE 15, 85, 99

FIRVANQ .............................. 7 FISH OIL ........................ 35, 81 flavoxate ............................. 124 flecainide .............................. 39 FLECTOR ............ 58, 120, 122 FLINTSTONES COMPLETE

(IRON) ...................... 31, 125 FLOVENT DISKUS .... 83, 108 FLOVENT HFA ........... 83, 108 floxuridine ............................ 15 FLUAD QUAD 2020-21(65Y

UP)(PF) ............................. 21 FLUARIX QUAD 2020-2021

(PF) ................................... 21 FLUBLOK QUAD 2020-2021

(PF) ................................... 21 FLUCELVAX QUAD 2020-

2021 .................................. 21 FLUCELVAX QUAD 2020-

2021 (PF) .......................... 21 fluconazole ............................. 6 fluconazole in dextrose(iso-o) 6 fluconazole in nacl (iso-osm) . 6 fludarabine ............................ 15 fludrocortisone ...................... 83 FLULAVAL QUAD 2020-

2021 (PF) .......................... 21 FLUMIST QUAD 2020-2021

.......................................... 21 fluocinolone ........ 112, 113, 117 fluocinolone acetonide oil .... 74 fluocinolone and shower cap

................................ 112, 117 fluocinonide ........ 113, 117, 118 FLUOCINONIDE-E ... 113, 118 fluocinonide-emollient 113, 118 FLUOR-A-DAY ................... 97 fluoride (sodium) .................. 97 FLUORIDEX DAILY

DEFENSE ......................... 97 fluorometholone ................... 74 fluorouracil ............. 15, 16, 122

137

fluoxetine .............................. 62 fluphenazine decanoate ........ 59 fluphenazine hcl ................... 59 FLURA-DROPS .................. 97 flurandrenolide ........... 113, 118 flurazepam ............................ 53 flurbiprofen........................... 58 flurbiprofen sodium .............. 75 flutamide............................... 16 fluticasone propionate . 74, 107,

113, 118 fluticasone propion-salmeterol

.................... 26, 83, 108, 109 fluvastatin ............................. 41 fluvoxamine .......................... 62 FLUZONE HIGHDOSE

QUAD 20-21 PF............... 21 FLUZONE QUAD 2020-2021

.......................................... 21 FLUZONE QUAD 2020-2021

(PF) ................................... 21 folic acid ............................. 127 FOLIVANE-OB ... 31, 125, 127 FORTEO ........................ 92, 97 FOSAMAX PLUS D .... 97, 129 fosamprenavir ....................... 10 FOSCAVIR ............................ 6 fosinopril ........................ 34, 35 FREAMINE HBC 6.9 % ...... 66 FREAMINE III 10 % ........... 66 FREESTYLE LIBRE 10 DAY

READER .......................... 64 FREESTYLE LIBRE 10 DAY

SENSOR........................... 64 FREESTYLE LIBRE 14 DAY

READER .......................... 64 FREESTYLE LIBRE 14 DAY

SENSOR........................... 64 frovatriptan ........................... 61 FULPHILA........................... 28 fulvestrant ............................. 16 furosemide ...................... 42, 68 FUZEON ................................ 8 G gabapentin ...................... 46, 48 galantamine .......................... 25 ganciclovir sodium ............... 11 GARDASIL (PF).................. 21 GARDASIL 9 (PF)............... 21 GAS RELIEF

(SIMETHICONE) ............ 78

GAZYVA ............................. 16 GELNIQUE ........................ 124 gemcitabine .......................... 16 gemfibrozil ........................... 41 GENOTROPIN .................... 92 GENOTROPIN MINIQUICK

.......................................... 92 gentamicin ............................ 73 GENVOYA ........................ 8, 9 GEODON ....................... 49, 51 GIANVI (28) ........................ 86 GILENYA .......................... 100 GILOTRIF ............................ 16 glatiramer............................ 100 GLATOPA ......................... 100 GLEOSTINE ........................ 16 glimepiride............................ 94 glipizide ................................ 94 glipizide-metformin ........ 85, 94 GLUCAGEN DIAGNOSTIC

KIT ............................. 64, 89 GLUCAGEN HYPOKIT 89, 96 GLUCAGON EMERGENCY

KIT (HUMAN)........... 89, 96 glucose .................................. 66 GLUCOSE POWDER .......... 85 glyburide ............................... 94 glyburide-metformin ...... 85, 95 glycerin (adult) ..................... 79 glycopyrrolate ....................... 23 GLYXAMBI .................. 87, 94 GOCOVRI ........................ 3, 45 granisetron hcl ...................... 76 GRANIX .............................. 28 GRASTEK.................... 20, 102 griseofulvin microsize ............ 4 griseofulvin ultramicrosize ..... 4 guaifenesin.......................... 105 guanfacine ...................... 39, 54 GVOKE PFS 1-PACK

SYRINGE ................... 89, 96 GVOKE PFS 2-PACK

SYRINGE ................... 89, 96 GYNE-LOTRIMIN ............ 115 GYNOL II .......................... 103 H HAEGARDA........................ 98 HALAVEN ........................... 16 halobetasol propionate 113, 118 HALOG ...................... 113, 118 haloperidol ............................ 54

haloperidol decanoate ........... 54 haloperidol lactate ................ 54 HARVONI .......................... 7, 8 HAVRIX (PF) ...................... 21 HELIXATE FS ..................... 29 HEMLIBRA ......................... 29 HEMOFIL M HIGH ............. 29 HEMOFIL M LOW .............. 30 HEMOFIL M MID ............... 30 HEMOFIL M SUPER HIGH30 HEMORRHOIDAL (WITCH

HAZEL) .......................... 115 HEPAGAM B ....................... 20 heparin (porcine) .................. 31 HEPATAMINE 8% .............. 66 HEPLISAV-B (PF) ............... 21 HERCEPTIN ........................ 16 HETLIOZ ............................. 51 HEXALEN ........................... 16 HIGH POTENCY

CAPSAICIN ................... 122 HUMALOG MIX 50-50

INSULN U-100 .... 90, 91, 93 HUMALOG MIX 50-50

KWIKPEN ............ 90, 91, 93 HUMALOG MIX 75-25(U-

100)INSULN ........ 90, 91, 93 HUMATE-P ......................... 30 HUMATROPE ..................... 92 HUMIRA ........ 80, 98, 100, 122 HUMIRA PEN80, 98, 100, 122 HUMIRA PEN PSOR-

UVEITS-ADOL HS .. 80, 98, 100, 122

HUMIRA(CF) 80, 98, 100, 122 HUMIRA(CF) PEDI

CROHNS STARTER 80, 99, 100, 123

HUMIRA(CF) PEN ....... 80, 99, 100, 123

HUMULIN 70/30 U-100 INSULIN .............. 90, 91, 93

HUMULIN 70/30 U-100 KWIKPEN ............ 90, 91, 93

HUMULIN N NPH INSULIN KWIKPEN .................. 90, 91

HUMULIN N NPH U-100 INSULIN .................... 90, 91

HUMULIN R REGULAR U-100 INSULN .............. 90, 93

138

HUMULIN R U-500 (CONC) INSULIN .................... 90, 93

HUMULIN R U-500 (CONC) KWIKPEN ................. 90, 94

HYCAMTIN ........................ 16 hydralazine ........................... 41 hydrochlorothiazide ........ 43, 71 hydrocodone-acetaminophen

.............................. 46, 47, 56 hydrocortisone ...... 83, 113, 118 hydrocortisone acetate 113, 118 hydrocortisone butyrate ..... 113,

118 hydrocortisone butyr-emollient

................................ 113, 118 hydrocortisone valerate ..... 113,

118 hydrocortisone-acetic acid.... 74 hydrocortisone-aloe vera ... 113,

118 hydromorphone .............. 56, 57 hydroxychloroquine . 5, 99, 100 hydroxyprogest(pf)(preg presv)

.......................................... 93 hydroxyprogesterone

cap(ppres) ......................... 93 hydroxyurea .......................... 16 hydroxyzine hcl ................ 2, 51 hydroxyzine pamoate ....... 2, 51 hyoscyamine sulfate ....... 23, 24 HYPERHEP B S/D .............. 20 HYPERHEP B S-D

NEONATAL .................... 20 HYPOTEARS ...................... 75 I ibandronate ........................... 97 IBRANCE ............................ 16 ibuprofen .............................. 58 IBUPROFEN JR STRENGTH

.......................................... 58 icatibant ................................ 98 ICLUSIG .............................. 16 IDELVION ........................... 30 IDHIFA ................................ 16 ifosfamide ............................. 16 ifosfamide-mesna ................. 16 ILEVRO ............................... 75 ILUMYA ............................ 123 imatinib................................. 16 IMBRUVICA ....................... 16 imipramine hcl...................... 63

imiquimod .......................... 123 IMOVAX RABIES VACCINE

(PF) ................................... 21 IMPOYZ ..................... 113, 118 INCRUSE ELLIPTA .... 24, 104 indapamide ..................... 44, 72 INDOCIN ....................... 58, 96 indomethacin .................. 59, 96 INFANT'S IBUPROFEN ..... 59 INFANT'S NON-ASPIRIN .. 47 INFANT'S PAIN RELIEF ... 47 INFED .................................. 31 INGREZZA .................... 55, 63 INGREZZA INITIATION

PACK ............................... 63 INLYTA ............................... 16 INREBIC .............................. 16 insulin asp prt-insulin aspart 90,

91, 93 insulin lispro ................... 90, 93 insulin lispro protamin-lispro

.............................. 90, 91, 93 INTELENCE .......................... 8 INTRALIPID........................ 67 INVEGA ............................... 51 INVEGA SUSTENNA ......... 51 INVEGA TRINZA ............... 51 INVIRASE ........................... 10 INVOKAMET ................ 85, 94 INVOKAMET XR ............... 85 INVOKANA ........................ 94 IONOSOL-B IN D5W.......... 69 IONOSOL-MB IN D5W ...... 69 ipratropium bromide ...... 24, 75,

104 ipratropium-albuterol..... 24, 27,

104, 109 irbesartan .............................. 34 irbesartan-hydrochlorothiazide

.............................. 34, 43, 71 IRESSA ................................ 16 irinotecan .............................. 16 ISENTRESS ........................... 8 ISOLYTE S PH 7.4 .............. 69 ISOLYTE-P IN 5 %

DEXTROSE ..................... 69 ISOLYTE-S .......................... 69 isoniazid.................................. 5 isosorbide dinitrate ............... 42 isosorbide mononitrate ......... 42 isotretinoin .......................... 123

ISUPREL ...................... 25, 107 itraconazole ............................. 6 ivermectin ............................... 4 IXEMPRA ............................ 16 IXINITY ............................... 30 J JADENU ............................... 82 JADENU SPRINKLE .......... 82 JAKAFI ................................ 16 JANUMET ..................... 85, 87 JANUMET XR ............... 85, 87 JANUVIA ............................. 87 JARDIANCE ........................ 94 JATENZO ............................. 84 JENTADUETO .............. 85, 88 JENTADUETO XR ........ 85, 88 JEVTANA ............................ 16 JIVI ....................................... 30 JOLESSA ............................. 86 JORNAY PM ........................ 60 JUBLIA .............................. 115 JUNEL FE 1.5/30 (28) ......... 86 JUNEL FE 1/20 (28) ............ 86 JUNEL FE 24 ....................... 86 K KABIVEN ............................ 67 KADCYLA ........................... 16 KALBITOR .......................... 98 KALETRA ........................... 10 KALYDECO ...................... 105 KELNOR 1/35 (28) .............. 86 KERYDIN .......................... 121 ketoconazole ................... 6, 115 KETO-DIASTIX .................. 65 ketorolac ......................... 59, 75 KETOSTIX ........................... 64 ketotifen fumarate ................. 72 KEVEYIS ............................. 97 KEVZARA ................... 99, 100 KEYTRUDA ........................ 16 KINERET ..................... 99, 100 KIONEX (WITH SORBITOL)

.................................... 68, 96 KISQALI .............................. 16 KLOR-CON M15 ................. 69 KOATE ................................. 30 KOGENATE FS ................... 30 KOMBIGLYZE XR ....... 85, 88 KORLYM ............................. 85 KOSELUGO ......................... 16 KPN ...................... 31, 125, 127

139

K-Y LUBRICATING ......... 123 L labetalol .. 25, 26, 33, 35, 36, 39 LAC-HYDRIN FIVE ......... 116 lactase ................................... 80 lactated ringers ............... 67, 69 lactulose ................................ 65 LAMISIL AF...................... 124 lamivudine .............................. 9 lamivudine-zidovudine ........... 9 lamotrigine ..................... 48, 49 lansoprazole .................... 81, 82 lanthanum ....................... 68, 96 LANTUS SOLOSTAR U-100

INSULIN .......................... 91 LANTUS U-100 INSULIN .. 91 LASTACAFT ....................... 72 latanoprost ............................ 76 LATUDA ............................. 51 ledipasvir-sofosbuvir .......... 7, 8 LEENA 28 ............................ 86 leflunomide................... 99, 100 LENVIMA ........................... 17 letrozole .......................... 17, 85 leucovorin calcium ............... 96 LEUKERAN ........................ 17 leuprolide ........................ 17, 89 levalbuterol hcl ............. 27, 109 levalbuterol tartrate ...... 27, 109 LEVATOL ........................... 36 LEVEMIR FLEXTOUCH U-

100 INSULN .................... 91 LEVEMIR U-100 INSULIN 91 levetiracetam ........................ 48 levobunolol ........................... 73 levocarnitine ....................... 102 levocarnitine (with sugar)... 102 levocetirizine .......................... 2 levofloxacin ...................... 5, 12 levomefolate calcium ......... 127 levonorgestrel-ethinyl estrad 86 levorphanol tartrate .............. 57 levothyroxine ........................ 95 LEXETTE .......................... 118 LEXIVA ............................... 10 LICE KILLING .................. 121 LICE KILLING

(PERMETHRIN) ............ 121 lidocaine ............................. 115 lidocaine (pf) ........................ 95 lidocaine hcl ................... 76, 95

LIDOCAINE PAIN RELIEF ........................................ 115

LIDOCAINE VISCOUS ...... 76 lidocaine-prilocaine ............ 115 linezolid ................................ 12 LINZESS .............................. 80 liothyronine .......................... 95 LIQUID CORN AND

CALLUS REMOVER .... 120 lisinopril.......................... 34, 35 lisinopril-hydrochlorothiazide

........................ 34, 35, 43, 71 lithium carbonate .................. 49 lithium citrate ....................... 49 LO LOESTRIN FE ............... 86 LOKELMA .......................... 68 LOMAIRA ........................... 45 LONSURF ............................ 17 loperamide ............................ 77 loratadine ........................ 2, 108 LORATADINE-D ... 2, 23, 104,

108 lorazepam ............................. 53 LORBRENA ........................ 17 losartan ................................. 34 losartan-hydrochlorothiazide

.............................. 34, 43, 71 LOTRIMIN AF .................. 115 LOTRIMIN AF POWDER 115 LOTRIMIN ULTRA .......... 116 lovastatin .............................. 41 loxapine succinate ................ 50 LUDENT FLUORIDE ......... 98 LUMIGAN ........................... 76 LUPANETA PACK (1

MONTH) .............. 17, 89, 93 LUPANETA PACK (3

MONTH) .............. 17, 89, 93 LUPRON DEPOT .......... 17, 89 LUPRON DEPOT (3

MONTH) .................... 17, 89 LUPRON DEPOT (4

MONTH) .................... 17, 89 LUPRON DEPOT-PED . 17, 89 LUPRON DEPOT-PED (3

MONTH) .................... 17, 89 LYNPARZA ......................... 17 LYSODREN ......................... 17 M MAALOX MAXIMUM

STRENGTH ............... 77, 78

magnesium ............................ 69 magnesium citrate ................. 79 magnesium gluconate ........... 69 magnesium oxide .................. 77 MAKENA (PF) .................... 93 malathion ............................ 121 mannitol 20 % ........... 42, 64, 68 MAPAP

(ACETAMINOPHEN) ..... 47 MATULANE ........................ 17 MAVENCLAD (10 TABLET

PACK) ............................ 101 MAVYRET ........................ 7, 8 MAYZENT ......................... 100 meclizine ........................... 2, 78 MEDROL ............................. 83 medroxyprogesterone ........... 93 mefloquine .............................. 5 megestrol ........................ 17, 93 MEKINIST ........................... 17 MEKTOVI ............................ 17 melatonin ............................ 102 meloxicam ............................ 59 memantine ............................ 55 MENACTRA (PF) ................ 21 MENOMUNE - A/C/Y/W-135

.......................................... 22 MENOMUNE - A/C/Y/W-135

(PF) ................................... 22 MENOSTAR ........................ 88 MENVEO A-C-Y-W-135-DIP

(PF) ................................... 22 meperidine ............................ 57 meperidine (pf) ..................... 57 mercaptopurine ............. 17, 101 meropenem ............................. 6 mesalamine ........................... 78 METAMUCIL (SUGAR) ..... 79 metformin ....................... 85, 86 methadone ............................. 57 methamphetamine ................. 46 methenamine hippurate ........ 13 methimazole ......................... 85 methocarbamol ..................... 24 methotrexate sodium ..... 17, 99,

100, 101 methotrexate sodium (pf) .... 17,

99, 100, 101 methoxsalen ........................ 121 methyldopa ..................... 23, 39 methylergonovine ............... 103

140

methylphenidate hcl ............. 60 methylprednisolone .............. 83 metoclopramide hcl .............. 81 metolazone ..................... 44, 72 metoprolol succinate 27, 36, 39 metoprolol tartrate .... 27, 36, 39 metronidazole ............. 4, 5, 111 mexiletine ............................. 39 MIACALCIN ........... 85, 92, 97 MIBELAS 24 FE .................. 86 MICONAZOLE 7 .............. 115 miconazole nitrate .............. 115 MICONAZOLE-3 .............. 115 MICORT-HC ............. 113, 118 MICROGESTIN 1.5/30 (21) 86 MICROGESTIN 1/20 (21) ... 86 midazolam ............................ 53 midodrine ............................. 23 miglustat ............................. 102 MIGRAINE FORMULA .... 33,

47, 50, 60, 61 MILK OF MAGNESIA ....... 79 MINERAL OIL LAXATIVE

.......................................... 79 minocycline .......................... 13 minoxidil .............................. 41 MIRCERA ............................ 28 mirtazapine ........................... 48 misoprostol ........................... 81 mitomycin............................. 17 mitoxantrone......................... 17 M-M-R II (PF) ...................... 22 modafinil .............................. 63 mometasone ................ 114, 118 MONOCLATE-P ................. 30 MONONESSA (28) ............. 86 montelukast ........................ 106 MORPHABOND ER ........... 57 morphine............................... 57 morphine concentrate ........... 57 MOVANTIK ........................ 80 MOVIPREP .......................... 79 moxifloxacin..................... 5, 12 MOZOBIL ............................ 28 MULPLETA......................... 28 MULTI-DELYN ................ 125 MULTIVITAMIN WITH

FLUORIDE .............. 98, 125 MULTI-VITAMIN WITH

FLUORIDE ...................... 98

MULTI-VITAMIN WITH FLUORIDE .................... 125

mupirocin............................ 111 mupirocin calcium .............. 111 MURO 128 ........................... 75 MUSCLE RUB (WITH

CAMPHOR) ..................... 61 mv-min-folic acid-lutein.... 125,

127 MY WAY ............................. 87 MYALEPT ........................... 91 mycophenolate mofetil ....... 102 mycophenolate sodium ....... 102 MYDAYIS ........................... 46 MYLERAN .......................... 17 MYNEPHROCAPS.... 127, 128 MYRBETRIQ .................... 124 MYZILRA ............................ 87 N NABI-HB ............................. 20 nabumetone .......................... 59 nadolol ...................... 25, 36, 39 naloxone ......................... 58, 96 naltrexone ....................... 58, 95 NAMZARIC ................... 25, 55 naproxen ......................... 59, 96 naproxen sodium ............ 59, 96 naratriptan ............................. 61 NARCAN ....................... 58, 96 NASAL ALLERGY ..... 74, 107 NATACHEW (FE BIS-

GLYCINATE) .. 31, 125, 127 NATACYN .......................... 73 NATAZIA ............................ 87 nateglinide ............................ 92 NATESTO ............................ 84 NATURAL FIBER

LAXATIVE (SUGAR)..... 79 NATURE-THROID ............. 95 NAYZILAM ................... 53, 54 NEBUPENT ........................... 5 neomycin ................................ 4 neomycin-bacitracin-poly-hc

.................................... 73, 74 neomycin-polymyxin b gu.. 111 neomycin-polymyxin b-

dexameth .................... 73, 74 neomycin-polymyxin-

gramicidin ......................... 73 neomycin-polymyxin-hc 73, 74 NEO-POLYCIN ................... 73

NEPHRAMINE 5.4 % .......... 67 NEPRO CARB STEADY .... 67 NERLYNX ........................... 17 NEUAC ...................... 111, 120 NEUAC KIT ............... 111, 120 NEULASTA ......................... 28 NEUPOGEN ......................... 28 NEVANAC ........................... 75 nevirapine ............................... 8 NEWGEN ....... 31, 69, 125, 127 NEXAVAR ........................... 17 NEXIUM PACKET .............. 82 niacin .................................... 35 NIACOR ............................... 35 nicotine ................................. 24 nicotine (polacrilex) .............. 24 NICOTROL .......................... 24 NICOTROL NS .................... 24 nifedipine ............ 37, 40, 41, 44 NINLARO ............................ 17 NIPENT ................................ 18 nitisinone ............................ 102 NITRO-BID .......................... 42 nitrofurantoin ........................ 13 nitrofurantoin macrocrystal .. 13 nitrofurantoin monohyd/m-

cryst .................................. 13 nitroglycerin ......................... 42 NITYR ................................ 102 NIVESTYM ......................... 28 NOLIX ........................ 114, 118 NORA-BE ............................ 87 NORDITROPIN FLEXPRO 92 noreth-ethinyl estradiol-iron . 87 norethindrone acetate ............ 93 norethindrone ac-eth estradiol

.................................... 88, 93 norethindrone-e.estradiol-iron

.......................................... 87 norgestimate-ethinyl estradiol

.......................................... 87 NORMOSOL-M IN 5 %

DEXTROSE ..................... 69 NORMOSOL-R .................... 69 NORMOSOL-R PH 7.4 ........ 69 NORPACE CR ..................... 39 NORTEMP ........................... 47 NORTREL 0.5/35 (28) ......... 87 NORTREL 7/7/7 (28) ........... 87 nortriptyline .......................... 63 NORVIR ............................... 10

141

NOVOEIGHT ...................... 30 NOVOLIN N NPH U-100

INSULIN .......................... 91 NOVOLIN R REGULAR U-

100 INSULN .............. 91, 94 NOVOSEVEN RT ............... 30 NOXAFIL .............................. 6 NP THYROID ...................... 95 NPLATE............................... 28 NUBEQA ............................. 18 NUCALA ................... 104, 106 NUCORT ................... 114, 119 NUCYNTA ER .................... 57 NUEDEXTA ................ 55, 105 NUPLAZID .......................... 52 NURTEC ODT ..................... 54 NUTRAMIGEN WITH

ENFLORA LGG .............. 67 NUTRILIPID ....................... 67 NUTROPIN AQ NUSPIN ... 92 NUZYRA ............................... 4 nystatin ......................... 12, 121 nystatin-triamcinolone ........ 121 O OB COMPLETE PREMIER

.................... 31, 69, 125, 127 OBIZUR ............................... 30 O-CAL FA...... 31, 69, 125, 127 OCALIVA ............................ 80 octreotide acetate .......... 94, 102 OCUVITE LUTEIN AND

ZEAXANTHIN .............. 102 OCUVITE WITH LUTEIN 125 ODACTRA........................... 20 ODEFSEY .......................... 8, 9 ODOMZO ............................ 18 OFEV ................................. 104 ofloxacin ......................... 12, 73 OGESTREL (28) .................. 87 olanzapine....................... 49, 52 olanzapine-fluoxetine ..... 52, 62 olmesartan ............................ 34 olopatadine ........................... 72 OLUMIANT................. 99, 100 omega-3 acid ethyl esters ..... 35 omega-3 fatty acids-fish oil .. 35 OMEPPI ............................... 82 omeprazole ........................... 82 omeprazole magnesium ........ 82 omeprazole-sodium

bicarbonate ....................... 82

OMNITROPE ....................... 92 ONCASPAR ......................... 18 ondansetron .......................... 77 ondansetron hcl............... 76, 77 ondansetron hcl (pf).............. 76 ONE DAILY FOR MEN 50+

ADVANCED.......... 125, 127 ONE DAILY MULTI-VIT W-

MINERAL ................ 31, 125 ONEXTON ................. 111, 120 ONFI ..................................... 54 ONGLYZA ........................... 88 ONMEL .................................. 6 ONZETRA XSAIL............... 61 OPDIVO ............................... 18 OPSUMIT .................... 44, 110 ORAL RELIEF DRY MOUTH

........................................ 123 ORALAIR .................... 20, 103 ORALYTE ........................... 69 ORENCIA .................... 99, 100 ORENCIA CLICKJECT ..... 99,

101 ORENITRAM .............. 44, 110 ORFADIN .......................... 103 ORILISSA ............................ 85 ORKAMBI ......................... 105 OS-CAL 500 + D3 ....... 70, 129 oseltamivir ............................ 11 OSMOLEX ER................. 3, 45 OTEZLA .............. 99, 101, 123 OTEZLA STARTER ... 99, 101,

123 oxaliplatin ............................. 18 oxandrolone .......................... 84 OXBRYTA ........................... 28 oxcarbazepine ....................... 48 oxybutynin chloride ............ 124 oxycodone ............................ 57 oxycodone-acetaminophen .. 47,

57 OXYCONTIN ...................... 57 oxymorphone ........................ 57 OXYTROL ......................... 124 OXYTROL FOR WOMEN 124 OYSTER SHELL + D3 70, 129 OZEMPIC ............................ 90 P paclitaxel .............................. 18 PAIN RELIEVING(CAM-

M.SAL-MENT) ................ 61

pamidronate .......................... 97 PANDEL .................... 114, 119 PANRETIN .................. 18, 123 pantoprazole ......................... 82 paromomycin .......................... 4 paroxetine hcl ....................... 62 PASER .................................... 5 PAZEO ................................. 72 PCE ................................... 7, 11 PEDIA RELIEF COUGH-

COLD ... 2, 23, 104, 105, 106 PEDIASURE ........................ 67 PEDIATRIC ELECTROLYTE

.......................................... 70 peg 3350-electrolytes ............ 79 PEG-3350 WITH FLAVOR

PACKS ............................. 79 PEGASYS ............................ 10 PEMAZYRE ......................... 18 penicillin g sodium ............... 11 penicillin v potassium ........... 11 PENNSAID .......... 59, 120, 123 PENTACEL (PF) .................. 22 PENTACEL ACTHIB

COMPONENT (PF) ......... 22 PENTACEL DTAP-IPV

COMPNT (PF) ................. 22 PENTAM ................................ 5 pentoxifylline ........................ 29 PEPTIC RELIEF .................. 77 PERFOROMIST ........... 27, 109 PERIFRESH ....................... 119 PERIKABIVEN ................... 67 PERJETA ............................. 18 permethrin ........................... 121 perphenazine ......................... 59 PHENADOZ ..................... 2, 51 phenazopyridine ................. 115 phendimetrazine tartrate ....... 45 phenelzine ............................. 56 phenobarb-hyoscy-atropine-

scop ............................. 24, 52 phenobarbital .................. 52, 53 PHENOHYTRO ....... 24, 52, 53 phenoxybenzamine ......... 25, 41 phentermine .......................... 45 phenylephrine hcl ................. 76 phenytoin ........................ 39, 55 phenytoin sodium extended . 39,

55 PHEXXI ............................. 103

142

PHILITH .............................. 87 PHOSLYRA ......................... 68 PHOS-NAK .......................... 70 PHOTOFRIN ....................... 18 PHRENILIN FORTE(WITH

CAFFEINE) ... 47, 50, 53, 60 phytonadione (vitamin k1) .. 96,

130 pilocarpine hcl ................ 25, 76 pimecrolimus .............. 102, 123 pimozide ............................... 50 PINK BISMUTH.................. 77 PIN-X ..................................... 4 pioglitazone .......................... 95 PIQRAY ............................... 18 piroxicam .............................. 59 PKU 2 ................................... 67 PKU TRIO............................ 67 PLASMA-LYTE 148 ........... 70 PLASMA-LYTE A .............. 70 PLEGRIDY ........................ 101 PNEUMOVAX-23 ............... 22 podofilox ............................ 123 polyethylene glycol 3350 ..... 79 polymyxin b sulfate .............. 12 polymyxin b sulf-trimethoprim

.......................................... 73 POLYVITAMIN WITH IRON

.................................. 31, 125 POMALYST ................ 18, 101 PORTRAZZA ...................... 18 posaconazole .......................... 6 potassium chlorid-d5-

0.45%nacl ......................... 70 potassium chloride................ 70 potassium chloride in 0.9%nacl

.......................................... 70 potassium chloride in 5 % dex

.......................................... 70 potassium chloride in lr-d5 ... 70 potassium chloride in water.. 70 potassium chloride-0.45 % nacl

.......................................... 70 potassium chloride-d5-

0.2%nacl ........................... 70 potassium chloride-d5-

0.3%nacl ........................... 70 potassium chloride-d5-

0.9%nacl ........................... 70 potassium citrate ................... 65 POTIGA ............................... 48

PRADAXA ........................... 28 PRALUENT PEN................. 42 pramipexole .......................... 56 prasugrel ............................... 33 pravastatin ............................ 41 PRAXBIND.......................... 27 praziquantel ............................ 4 prazosin .......................... 25, 33 PRED MILD......................... 74 prednicarbate .............. 114, 119 prednisolone ......................... 83 prednisolone acetate ............. 74 prednisolone sodium phosphate

.................................... 74, 83 prednisone ............................ 84 PREDNISONE INTENSOL. 84 pregabalin ................. 47, 48, 55 PREMARIN ......................... 88 PREMASOL 10 % ............... 67 PREMASOL 6 % ................. 67 PREMPHASE ...................... 88 PREMPRO ........................... 88 PRENATA............ 31, 125, 127 PRENATAL PLUS .............. 31 PRENATAL PLUS

(CALCIUM CARB) ......... 31 PRENATAL VITAMIN 31, 70,

125, 127 PRENATAL VITAMIN WITH

MINERALS...................... 31 prenatal vits96-iron fum-folic

.......................................... 32 PRE-PEN .............................. 64 PREPOPIK ........................... 79 PRETAB ......... 32, 70, 125, 127 pretomanid .............................. 5 PREVIDENT ........................ 98 PREVNAR 13 (PF) .............. 22 PREZCOBIX ........................ 10 PREZISTA ........................... 10 PRIFTIN ........................... 5, 13 PRILOSEC ........................... 82 PRILOSEC OTC .................. 82 primaquine .............................. 5 primidone.............................. 52 PRIMLEV ...................... 47, 57 PROAIR RESPICLICK 27, 110 probenecid ...................... 72, 97 PROBIOTIC (S.BOULARDII)

.......................................... 80 procainamide ........................ 39

PROCALAMINE 3% ........... 67 PROCENTRA ...................... 46 prochlorperazine ............. 59, 78 prochlorperazine edisylate ... 59,

78 prochlorperazine maleate 59, 78 PROCRIT ............................. 29 PROCTOFOAM HC . 114, 115,

119 PROCTO-PAK ........... 114, 119 PROCTOZONE-HC ... 114, 119 PROFILNINE ....................... 30 progesterone micronized ...... 93 PROLENSA ......................... 75 PROLEUKIN ............... 18, 101 PROMACTA ........................ 29 promethazine ............ 2, 51, 106 PROMETHAZINE VC ... 2, 23,

106 promethazine-dm .... 2, 105, 106 propafenone .......................... 39 proparacaine ......................... 76 propofol .......................... 51, 55 propranolol .. 25, 36, 39, 41, 42,

50 propylthiouracil .................... 85 PROSHIELD FOAM/SPRAY

CLEANSER ................... 123 protamine ........................ 28, 96 PROTONIX .......................... 82 PROVENGE ......................... 45 pseudoephedrine hcl ..... 23, 104 pseudoephedrine-guaifenesin

.......................... 23, 104, 105 PSORCON .................. 114, 119 PULMICORT ............... 84, 108 PULMICORT FLEXHALER

.................................. 84, 108 PULMOZYME ............. 72, 107 PUREFE OB PLUS ..... 32, 125,

127 PURIXAN .................... 18, 102 pyrazinamide .......................... 5 pyridostigmine bromide ........ 25 pyridoxine (vitamin b6) ...... 127 pyrilamine-phenylephrine 1, 23,

106 Q QINLOCK ............................ 18 QSYMIA ........................ 45, 48 QTERN ........................... 88, 94

143

QUARTETTE ...................... 87 quazepam .............................. 54 quetiapine ....................... 49, 52 QUILLICHEW ER ............... 60 QUILLIVANT XR ............... 60 quinapril ......................... 34, 35 quinidine gluconate .......... 5, 39 QVAR REDIHALER ... 84, 108 R RABAVERT (PF) ................ 22 rabeprazole ........................... 82 RADIOGARDASE ........ 68, 96 RAGWITEK................. 20, 103 RAJANI ................................ 87 raloxifene ........................ 88, 97 ramelteon .............................. 51 ramipril ........................... 34, 35 ranitidine hcl ......................... 81 ranolazine ............................. 38 REBIF (WITH ALBUMIN)

........................................ 101 REBIF REBIDOSE ............ 101 REBIF TITRATION PACK

........................................ 101 REBINYN ............................ 30 RECLIPSEN (28) ................. 87 RECOMBINATE ................. 30 RECOMBIVAX HB (PF) .... 22 RECTIV ............................. 123 RELENZA DISKHALER .... 11 RELISTOR ........................... 80 RENA-VITE RX ................ 127 repaglinide ............................ 92 REPATHA PUSHTRONEX 42 REPATHA SURECLICK .... 42 REPATHA SYRINGE ......... 42 RESCRIPTOR ........................ 8 RESTASIS ........................... 75 RESTASIS MULTIDOSE ... 75 RETACRIT .......................... 29 RETEVMO........................... 18 RETIN-A MICRO PUMP .. 116 RETROVIR ............................ 9 REVLIMID .................. 18, 101 REXULTI ............................. 52 REYATAZ ........................... 10 REYVOW ............................ 61 RHINOCORT ALLERGY .. 74,

107 RHOPRESSA ................. 73, 76 ribavirin ................................ 11

RIDAURA .............. 82, 99, 101 rifabutin ............................ 6, 13 RIFAMATE.......................... 13 rifampin ............................ 6, 13 RIFATER ......................... 6, 13 riluzole .................................. 55 ringer's .................................. 70 RINVOQ ...................... 99, 101 RISACAL-D ................. 70, 129 risedronate ............................ 97 RISPERDAL CONSTA . 49, 52 risperidone ...................... 49, 52 ritonavir ................................ 10 RITUXAN ............................ 18 rivastigmine .......................... 25 rivastigmine tartrate .............. 25 RIXUBIS .............................. 30 rizatriptan.............................. 61 ropinirole .............................. 56 rosuvastatin ........................... 41 ROZLYTREK ...................... 18 RUBRACA ........................... 18 RUKOBIA .............................. 8 RYBELSUS.......................... 90 RYDAPT .............................. 18 S SAIZEN ................................ 92 salsalate ................................ 61 SANDIMMUNE .. 99, 101, 102 SANDOSTATIN .......... 94, 103 SANTYL ............................ 123 SAPHRIS (BLACK

CHERRY) .................. 49, 52 SAVAYSA ........................... 28 SAVELLA ...................... 55, 61 SAXENDA ........................... 90 SCALACORT ............ 114, 119 SCALP RELIEF ......... 114, 119 scopolamine base .................. 78 SECUADO ..................... 49, 52 SEGLUROMET ............. 86, 94 SELECT-OB (FOLIC ACID)

.......................... 32, 125, 127 selegiline hcl ......................... 56 selenium sulfide .................. 120 SELSUN BLUE (SALICYLIC

ACID) ............................. 120 SELZENTRY ......................... 8 SENNA ................................. 79 SENNA WITH DOCUSATE

SODIUM .......................... 79

SEREVENT DISKUS .. 27, 110 SERNIVO ................... 114, 119 SEROQUEL XR ............. 49, 52 SEROSTIM .......................... 92 sertraline ............................... 62 sevelamer carbonate ....... 68, 96 sevelamer hcl .................. 68, 96 sevoflurane ........................... 55 SHINGRIX (PF) ................... 22 SILACE ................................ 79 sildenafil (pulm.hypertension)

............................ 42, 43, 110 SILICONE MASK - INFANT

.......................................... 64 SILIQ .................................. 123 silver sulfadiazine ............... 120 simethicone ........................... 78 SIMILAC ALIMENTUM .... 67 SIMILAC EXPERT CARE

NEOSURE ........................ 67 SIMILAC NEOSURE .......... 67 SIMPONI ................ 80, 99, 101 simvastatin ............................ 41 sirolimus ............................. 102 SIRTURO ............................... 6 SKLICE .............................. 121 SKYRIZI ............................ 123 SLEEP AID (DOXYLAMINE)

.............................. 1, 51, 106 SLYND ........................... 87, 93 sodium bicarbonate ......... 65, 77 sodium chloride .. 64, 67, 71, 75 sodium chloride 0.45 % ........ 70 sodium chloride 0.9 % .......... 70 sodium chloride 3 % ............. 70 sodium chloride 5 % ............. 70 sodium citrate-citric acid ...... 65 SODIUM POLYSTYRENE

(SORB FREE) ............ 68, 96 sodium polystyrene sulfonate

.................................... 68, 96 sofosbuvir-velpatasvir ........ 7, 8 SOFT TOUCH LANCETS ... 64 solifenacin ........................... 124 SOLTAMOX .................. 18, 88 SOMAVERT ........................ 94 sotalol ................. 25, 36, 40, 42 SOVALDI ............................... 7 spinosad .............................. 121 SPIRIVA RESPIMAT .. 24, 104 spironolactone ........... 42, 43, 68

144

spironolacton-hydrochlorothiaz ........................ 42, 43, 68, 71

SPORANOX .......................... 6 SPRYCEL ............................ 18 SPS (WITH SORBITOL).... 68,

96 stavudine................................. 9 STEGLATRO....................... 94 STEGLUJAN ................. 88, 94 STELARA ............ 99, 101, 123 STIMATE....................... 30, 92 STIOLTO RESPIMAT .. 24, 27 STIVARGA .......................... 18 STOOL SOFTENER ............ 79 STRIBILD .......................... 8, 9 STRIVERDI RESPIMAT ... 27,

110 STROVITE FORTE .... 32, 125,

127 SUBOXONE ........................ 58 sucralfate .............................. 81 SUDAFED 24 HOUR .. 23, 104 SUDOGEST ................. 23, 104 SUDOGEST 12-HOUR 23, 104 sulfacetamide sodium ........... 73 sulfacetamide sodium-sulfur

........................................ 120 sulfacetamide-prednisolone .. 73 sulfadiazine........................... 13 sulfamethoxazole-trimethoprim

.......................................... 13 sulfasalazine ..... 13, 78, 99, 101 sulindac................................. 59 sumatriptan ........................... 61 sumatriptan succinate ........... 61 sumatriptan-naproxen ..... 59, 62 SUMAVEL DOSEPRO ....... 62 SUNOSI ............................... 63 SUPREP BOWEL PREP KIT

.......................................... 79 SURVANTA ...................... 108 SUTENT............................... 18 SYEDA................................. 87 SYMDEKO ........................ 105 SYMFI ................................ 8, 9 SYMFI LO ......................... 8, 9 SYMLINPEN 120 ................ 84 SYMLINPEN 60 .................. 84 SYMPROIC ......................... 80 SYMTUZA......... 9, 10, 11, 103 SYNAGIS............................. 11

SYNAREL...................... 89, 90 SYNERCID .......................... 13 SYNJARDY ................... 86, 94 SYNJARDY XR............. 86, 94 SYNRIBO ............................ 18 T TABLOID ............................ 18 TABRECTA ......................... 18 tacrolimus ................... 102, 123 tadalafil (pulm. hypertension)

.................................. 43, 110 TAFINLAR .......................... 18 TAGRISSO .......................... 18 TAKHZYRO ........................ 98 TALTZ AUTOINJECTOR 123 TALTZ AUTOINJECTOR (2

PACK) ............................ 123 TALTZ AUTOINJECTOR (3

PACK) ............................ 123 TALTZ SYRINGE ............. 123 TALZENNA ......................... 18 tamoxifen ........................ 19, 88 tamsulosin ............................. 26 TASIGNA ............................ 19 TAVALISSE ........................ 28 TAYTULLA ......................... 87 tazarotene............................ 123 TAZORAC ......................... 123 TAZTIA XT ....... 37, 38, 40, 44 TAZVERIK .......................... 19 TECENTRIQ ........................ 19 TECFIDERA ...................... 101 TECHNIVIE ................. 7, 8, 10 TEFLARO .............................. 3 TEGSEDI ............................. 97 TEKTURNA HCT ......... 43, 71 telmisartan ............................ 34 temazepam ............................ 54 TEMODAR .......................... 19 temozolomide ....................... 19 teniposide.............................. 19 TENIVAC (PF) .................... 20 tenofovir disoproxil fumarate . 9 TENSION HEADACHE 47, 60 terazosin.................... 25, 33, 42 terbinafine hcl ................. 3, 110 terbutaline ..................... 27, 110 terconazole.......................... 116 teriparatide ...................... 92, 97 testosterone ........................... 84 testosterone cypionate .......... 84

testosterone enanthate ........... 84 tetanus-diphtheria toxoids-td 20 tetrabenazine ................... 55, 63 tetracycline ........................... 13 TEXACORT ............... 114, 119 thallous chloride tl-201 ......... 64 theophylline .... 41, 67, 110, 124 THERA ............................... 125 THERA-M ...... 32, 71, 125, 128 THERATEARS .................... 75 THERATRUM COMPLETE

50 PLUS/LUT ................ 126 THEREMS-M ............... 32, 126 thiamine hcl (vitamin b1) ... 128 thiamine mononitrate (vit b1)

........................................ 128 thioridazine ........................... 59 thiotepa ................................. 19 thiothixene ............................ 62 THYROGEN ........................ 65 thyroid (pork) ........................ 95 TIBSOVO ............................. 19 tigecycline ............................... 7 timolol maleate ..................... 74 tinidazole ................................ 5 TIROSINT ............................ 95 TIVICAY ................................ 8 TIVICAY PD .......................... 8 tizanidine .............................. 24 TOBI PODHALER ................ 4 TOBRADEX .................. 73, 74 tobramycin ............................ 73 tobramycin in 0.225 % nacl .... 4 tobramycin with nebulizer ...... 4 tobramycin-dexamethasone . 73,

74 TODAY CONTRACEPTIVE

SPONGE ......................... 103 tolazamide ............................. 95 tolcapone ............................... 54 tolnaftate ............................. 124 tolterodine ........................... 124 tolvaptan ............................... 72 TOPICORT ................. 114, 119 topiramate ............................. 48 topotecan ............................... 19 torsemide ........................ 42, 68 TOSYMRA ........................... 62 TOUJEO MAX U-300

SOLOSTAR ..................... 91

145

TOUJEO SOLOSTAR U-300 INSULIN .......................... 91

TOVIAZ ............................. 124 TRADJENTA ....................... 88 tramadol ................................ 57 tramadol-acetaminophen47, 50,

57 tranexamic acid .................... 30 tranylcypromine ................... 56 travoprost .............................. 76 trazodone .............................. 62 TREANDA ........................... 19 TRECATOR ........................... 6 TRELEGY ELLIPTA ... 24, 27,

84, 104, 108, 110 TRELSTAR .................... 19, 89 TREMFYA ......................... 123 treprostinil sodium........ 44, 110 TRESIBA FLEXTOUCH U-

100 .............................. 91, 92 TRESIBA FLEXTOUCH U-

200 .............................. 91, 92 TRESIBA U-100 INSULIN 91,

92 tretinoin .............................. 116 tretinoin (antineoplastic) ...... 19 tretinoin microspheres ........ 116 TRETTEN ............................ 30 TREXALL ...... 19, 99, 101, 102 TRIADVANCE ..... 32, 71, 126,

128 triamcinolone acetonide 74, 84,

107, 114, 119 triamterene-hydrochlorothiazid

........................ 43, 44, 68, 71 TRIANEX .................. 114, 119 triazolam ............................... 54 TRI-BUFFERED ASPIRIN 33,

50, 61 trifluoperazine ...................... 59 trifluridine............................. 73 trihexyphenidyl............... 24, 47 TRIJARDY XR ........ 86, 88, 94 TRIKAFTA ........................ 105 TRI-LEGEST FE.................. 87 trimethoprim ......................... 13 TRINATAL GT.................... 32 TRINTELLIX....................... 62 TRIPLE ANTIBIOTIC ...... 111 TRI-SPRINTEC (28)............ 87 TRIUMEQ .......................... 8, 9

TRIVEEN-ONE .... 32, 71, 126, 128

TRIVEEN-PRX RNF .... 32, 71, 79, 126, 128

TRI-VI-FLOR .............. 98, 126 TRI-VI-SOL WITH IRON .. 32,

126, 128, 129 TRI-VITAMIN WITH

FLUORIDE ..... 98, 126, 128, 129

TROGARZO .......................... 8 TROPHAMINE 10 % .......... 67 TROPHAMINE 6% ............. 67 tropicamide ........................... 76 trospium .............................. 124 TRULICITY ......................... 90 TRUMENBA........................ 22 TRUVADA ............................ 9 TRUZONE PEAK FLOW

METER ............................ 64 TUKYSA .............................. 19 TURALIO ............................ 19 TUSSIN .............................. 105 TWINRIX (PF)..................... 22 TWIRLA .............................. 87 TYBOST ............................ 103 TYKERB .............................. 19 TYMLOS........................ 92, 97 TYVASO ...................... 44, 110 TYVASO INSTITUTIONAL

START KIT .............. 44, 110 TYVASO REFILL KIT 44, 110 TYVASO STARTER KIT .. 45,

110 U UBRELVY ........................... 54 UDENYCA .......................... 29 ULESFIA.................... 120, 121 ULTIMATECARE ONE NF

.................... 32, 71, 126, 128 ULTRA FRESH ................... 75 ULTRAVATE ............ 114, 119 UPTRAVI ..................... 45, 110 urea ..................................... 120 ursodiol ................................. 79 V VAGICAINE (WITH VIT

A,D) ................................ 115 VAGINAL

CONTRACEPTIVE FILM ........................................ 103

VAGINAL CONTRACEPTIVE FOAM ........................................ 103

valacyclovir .......................... 11 VALCHLOR ................ 19, 123 valganciclovir ....................... 12 valproic acid ............. 48, 49, 50 valproic acid (as sodium salt)

.............................. 48, 49, 50 valsartan ................................ 34 valsartan-hydrochlorothiazide

.............................. 34, 44, 71 VALTOCO ..................... 53, 54 vancomycin ............................. 7 VAQTA (PF) ........................ 22 VARITHENA ....................... 43 VARIVAX (PF) .................... 22 VARIZIG .............................. 20 VASCEPA ............................ 35 VCF CONTRACEPTIVE GEL

........................................ 103 VECTIBIX ........................... 19 vecuronium bromide ............. 25 VELCADE ........................... 19 VELIVET TRIPHASIC

REGIMEN (28) ................ 87 VELPHORO ......................... 68 VELTASSA .......................... 68 VEMLIDY ............................ 12 VENCLEXTA ...................... 19 VENCLEXTA STARTING

PACK ............................... 19 venlafaxine ........................... 61 VENTAVIS .................. 45, 110 verapamil ............ 37, 38, 40, 45 VERDESO .................. 114, 119 VERZENIO .......................... 19 VIC-FORTE ............... 126, 128 VICODIN ES .................. 47, 57 VICODIN HP ................. 47, 57 VICTOZA 2-PAK ................ 90 VICTOZA 3-PAK ................ 90 VIDEX 2 GRAM PEDIATRIC

............................................ 9 VIDEX 4 GRAM PEDIATRIC

............................................ 9 VIEKIRA PAK ............. 7, 8, 10 VIIBRYD ............................. 62 VIMPAT ............................... 48 VINACAL B ........ 32, 126, 128 VINATE II .......................... 126

146

VINATE M .......... 32, 126, 128 VINATE ONE 32, 71, 126, 128 VINATE PN CARE ........... 126 VINATE ULTRA .... 32, 71, 79,

126, 128 vinblastine ............................ 19 VINCASAR PFS .................. 19 vincristine ............................. 19 vinorelbine ............................ 19 VIORELE (28) ..................... 87 VIRACEPT .......................... 10 VIREAD ................................. 9 VIRT-SELECT 32, 71, 79, 126,

128 VITAFOL GUMMIES .. 32, 71,

126, 128 VITAMED MD ONE RX ... 32,

126, 128 vitamin a ............................. 126 VITAMIN B-1.................... 128 VITAMIN B-12.................. 128 VITAMIN C ............... 128, 129 VITAMIN D2 ..................... 129 VITAMIN D3 ..................... 129 vitamin e (dl, acetate) ......... 130 VITAMIN K1 ............... 96, 130 VITRAKVI........................... 19 VIVITROL ..................... 58, 95 VIVOTIF BERNA VACCINE

.......................................... 22 VIZIMPRO........................... 19 VOL-NATE .... 32, 71, 126, 128 voriconazole ........................... 6 VOSEVI ............................. 7, 8 VOTRIENT .......................... 19 VP-CH PLUS . 32, 79, 126, 128 VRAYLAR........................... 52 VSL#3 .................................. 80 VYVANSE ........................... 46

VYZULTA ........................... 76 W WAKIX ................................ 63 warfarin ................................ 28 water for inject, bacteriostat

........................................ 103 water for injection, sterile ... 103 WELCHOL .................... 36, 85 WIDE-SEAL DIAPHRAGM

60 .................................... 103 WILATE ............................... 30 WIXELA INHUB.. 27, 84, 108,

110 X XALKORI ............................ 19 XARELTO ........................... 28 XELJANZ .................... 99, 101 XELJANZ XR .............. 99, 101 XELPROS ............................ 76 XENICAL ............................ 81 XENLETA............................ 12 XERAVA ............................... 7 XIFAXAN ............................ 13 XIGDUO XR .................. 86, 94 XIIDRA ................................ 75 XOFLUZA ............................. 6 XOLAIR ............................. 108 XOSPATA............................ 19 XPOVIO ............................... 20 XTAMPZA ER..................... 58 XTANDI ............................... 20 XULANE.............................. 87 XYLIMELTS ..................... 124 XYNTHA ............................. 30 XYNTHA SOLOFUSE ........ 30 XYREM................................ 55 Y YERVOY ............................. 20 YONDELIS .......................... 20

YONSA ................................ 20 Z zaleplon ................................. 51 ZALTRAP ............................ 20 ZANOSAR ........................... 20 ZARXIO ............................... 29 ZATEAN-CH .. 32, 71, 79, 126,

128 ZEJULA ............................... 20 ZELBORAF ......................... 20 ZEMBRACE SYMTOUCH . 62 ZENPEP ............................... 80 ZENZEDI ............................. 46 ZEPATIER ......................... 7, 8 zidovudine .............................. 9 ZIEXTENZO ........................ 29 zinc sulfate ............................ 71 ZINGIBER ........... 71, 126, 128 ZIOPTAN (PF) ..................... 76 ziprasidone hcl ................ 49, 52 ZIRGAN ............................... 73 ZOLADEX ............... 20, 89, 90 ZOLINZA ............................. 20 zolmitriptan ........................... 62 zolpidem ............................... 51 ZOLPIMIST ......................... 51 ZOMACTON ....................... 92 ZOMIG ................................. 62 zonisamide ............................ 48 ZORTRESS ........................ 102 ZOSTAVAX (PF) ................ 22 ZOVIA 1/50E (28) ............... 87 ZUBSOLV ............................ 58 ZYDELIG ............................. 20 ZYKADIA ............................ 20 ZYPREXA RELPREVV 49, 52

san francisco health plan medi-cal formulary · san francisco health plan medi-cal formulary as of...

Documents