table of contents analgesics - drugs for pain3 4 5...notes analgesics - drugs for pain...
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Navicent Health
Table of Contents
Analgesics - Drugs for Pain............................................................................................................................................ 3Analgesics - Drugs for Pain and Inflammation................................................................................................................5Anesthetics..................................................................................................................................................................... 5Anti-Addiction / Substance Abuse Treatment Agents..................................................................................................... 6Antibacterials.................................................................................................................................................................. 7Anticoagulants.............................................................................................................................................................. 11Anticonvulsants - Drugs for Seizures............................................................................................................................11Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.......................................................................... 12Antidepressants............................................................................................................................................................ 13Antiemetics - Drugs for Nausea and Vomiting.............................................................................................................. 14Antifungals.................................................................................................................................................................... 14Antigout Agents.............................................................................................................................................................15Anti-inflammatory Agents..............................................................................................................................................15Antimigraine Agents......................................................................................................................................................15Antimyasthenic Agents................................................................................................................................................. 16Antimycobacterials........................................................................................................................................................16Antineoplastics - Drugs for Cancer............................................................................................................................... 16Antiparasitics.................................................................................................................................................................20Antiparkinson Agents.................................................................................................................................................... 21Antiplatelets.................................................................................................................................................................. 21Antipsychotics - Drugs for Mood Disorders...................................................................................................................22Antivirals....................................................................................................................................................................... 22Anxiolytics - Drugs for Anxiety...................................................................................................................................... 24Bipolar Agents - Drugs for Mood Disorders.................................................................................................................. 24Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......................................................... 25Cardiovascular Agents - Drugs for Heart and Circulation Conditions........................................................................... 26Central Nervous System Agents - Drugs for Attention Deficit Disorder....................................................................... 31Central Nervous System Agents - Drugs for Multiple Sclerosis....................................................................................31Central Nervous System Agents - Miscellaneous.........................................................................................................32Dental and Oral Agents - Drugs for Mouth and Throat Conditions............................................................................... 32Dermatological Agents - Drugs for Skin Conditions......................................................................................................33Diabetes - Antidiabetic Agents......................................................................................................................................36Diabetes - Glucose Monitoring......................................................................................................................................37Diabetes - Glycemic Agents..........................................................................................................................................38Diabetes - Insulins........................................................................................................................................................ 38Electrolytes / Minerals / Metals / Vitamins.................................................................................................................... 39Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer........................................................................................... 43Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions............................................................ 44Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment......................................................... 45Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.................................................................. 45Genitourinary Agents - Drugs for Prostate Conditions..................................................................................................46Hormonal Agents - Adrenal...........................................................................................................................................46Hormonal Agents - Men's Health.................................................................................................................................. 47Hormonal Agents - Osteoporosis..................................................................................................................................48Hormonal Agents - Pituitary.......................................................................................................................................... 48Hormonal Agents - Prostaglandins............................................................................................................................... 48Hormonal Agents - Sex Hormones and Birth Control ................................................................................................... 49Hormonal Agents - Thyroid........................................................................................................................................... 52Immunological Agents - Drugs for Immune System Stimulation or Suppression..........................................................52Immunological Agents - Drugs for Vaccination............................................................................................................. 54Inflammatory Bowel Disease Agents............................................................................................................................ 55Metabolic Bone Disease Agents - Drugs for Osteoporosis...........................................................................................55Metabolic Bone Disease Agents - Other.......................................................................................................................55Miscellaneous Therapeutic Agents............................................................................................................................... 56
1
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...................................................................... 59Ophthalmic Agents - Drugs for Glaucoma.................................................................................................................... 60Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions.....................................................................................61Otic Agents - Drugs for Ear Conditions.........................................................................................................................61Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold................................................................... 62Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...............................................63Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis................................................................................64Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension................................................................64Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm.................................................................................. 65Sleep Disorder Agents.................................................................................................................................................. 65
2
Drug Name Drug Tier Notes
Analgesics - Drugs for Pain
acetaminophen-codeine TIER 01 QL
acetaminophen-codeine #2
TIER 01 QL
acetaminophen-codeine #3
TIER 01 QL
acetaminophen-codeine #4
TIER 01 QL
ACTIQ TIER 03 PA; QL
alfentanil hcl TIER 01
apap-caff-dihydrocodeine oral capsule
TIER 01 QL
ascomp-codeine TIER 01
BELBUCA TIER 02 PA; QL
BUPRENEX TIER 03
buprenorphine hcl injection
TIER 01
buprenorphine transdermal
TIER 01 PA; QL
butalbital-acetaminophen oral capsule
TIER 01
butalbital-acetaminophen oral tablet 50-325 mg
TIER 01
butalbital-apap-caff-cod TIER 01
butalbital-apap-caffeine TIER 01
butalbital-asa-caff-codeine
TIER 01
butalbital-aspirin-caffeine TIER 01
butorphanol tartrate injection
TIER 01
butorphanol tartrate nasal
TIER 01 QL
BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
TIER 03 PA; QL
carisoprodol-aspirin-codeine
TIER 01
codeine sulfate TIER 01 QL
DEMEROL TIER 03
DILAUDID INJECTION TIER 03
DOLOPHINE TIER 03 PA
duramorph TIER 01
Drug Name Drug Tier Notes
duraxin TIER 01
endocet TIER 01 QL
ESGIC TIER 03
fentanyl TIER 01 PA; QL
fentanyl citrate buccal lozenge on a handle
TIER 01 PA; QL
FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION
TIER 03
FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 5-0.9 MCG/ML-%, 500-0.9 MCG/50ML-%, 550-0.9 MCG/55ML-%
TIER 03
FIORINAL TIER 03
FIORINAL/CODEINE #3 TIER 03
hydrocodone bitartrate er oral capsule er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg
TIER 01 PA
hydrocodone-acetaminophen
TIER 01 QL
hydrocodone-ibuprofen TIER 01 QL
hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg
TIER 01 PA; QL
HYDROMORPHONE HCL INJECTION SOLUTION 0.2 MG/ML
TIER 03
hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml
TIER 01
HYDROMORPHONE HCL INTRAVENOUS
TIER 03
hydromorphone hcl oral TIER 01 QL
hydromorphone hcl pf TIER 01
HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION
TIER 03
hydromorphone hcl solution 1 mg/ml injection
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
3
Drug Name Drug Tier Notes
HYDROMORPHONE HCL-NACL
TIER 03
HYSINGLA ER TIER 02 PA; QL
INFUMORPH 200 TIER 03
INFUMORPH 500 TIER 03
LORTAB TIER 03 QL
MEDROX-RX TIER 03
meperidine hcl injection TIER 01
meperidine hcl oral TIER 01 QL
methadone hcl injection TIER 01
methadone hcl intensol TIER 01
methadone hcl oral concentrate
TIER 01
methadone hcl oral solution
TIER 01
methadone hcl oral tablet TIER 01 PA
methadone hcl oral tablet soluble
TIER 01
METHADONE HCL-NACL
TIER 03
METHADOSE ORAL CONCENTRATE 10 MG/ML
TIER 03
methadose oral tablet soluble
TIER 01
METHADOSE SUGAR-FREE
TIER 03
mitigo TIER 01
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
TIER 01 QL
morphine sulfate (pf) TIER 01
morphine sulfate er TIER 01 PA; QL
morphine sulfate er beads
TIER 01 PA; QL
MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML
TIER 03
morphine sulfate injection solution 2 mg/ml, 4 mg/ml, 5 mg/ml
TIER 01
MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML
TIER 03
Drug Name Drug Tier Notes
MORPHINE SULFATE INTRAVENOUS SOLUTION 1 MG/ML
TIER 03
morphine sulfate oral TIER 01 QL
MORPHINE SULFATE-NACL
TIER 03
nalbuphine hcl injection TIER 01
oxycodone hcl oral capsule
TIER 01 QL
oxycodone hcl oral concentrate 100 mg/5ml
TIER 01 QL
oxycodone hcl oral solution
TIER 01 QL
oxycodone hcl oral tablet TIER 01 QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
TIER 01 QL
oxycodone-aspirin TIER 01 QL
OXYCONTIN TIER 02 PA; QL
oxymorphone hcl TIER 01 QL
oxymorphone hcl er TIER 01
pentazocine-naloxone hcl
TIER 01 QL
PROBUPHINE IMPLANT KIT
TIER 03
remifentanil hcl TIER 01
tencon TIER 01
tramadol hcl er (biphasic) TIER 01 QL
tramadol hcl er oral capsule extended release 24 hour 150 mg
TIER 01 PA; QL
tramadol hcl er oral tablet extended release 24 hour
TIER 01 QL
tramadol hcl ir TIER 01 QL
tramadol-acetaminophen TIER 01 QL
TREZIX TIER 03 QL
ULTIVA TIER 03
XTAMPZA ER TIER 02 PA; QL
ZEBUTAL TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
4
Drug Name Drug Tier Notes
Analgesics - Drugs for Pain and Inflammation
CALDOLOR TIER 03
celecoxib oral TIER 01 QL
DAYPRO TIER 03
DICLOFENAC EPOLAMINE
TIER 03 QL
diclofenac potassium TIER 01
diclofenac sodium er TIER 01
diclofenac sodium oral TIER 01
diclofenac sodium transdermal gel 1 %
TIER 01 QL
diclofenac sodium transdermal solution
TIER 01 PA
diclofenac-misoprostol TIER 01
DICLOFONO TIER 03
diflunisal oral TIER 01
EC-NAPROSYN TIER 03
ec-naproxen TIER 01
etodolac TIER 01
etodolac er TIER 01
FELDENE TIER 03
flurbiprofen oral TIER 01
ibu TIER 01
ibuprofen lysine TIER 01
ibuprofen oral suspension
TIER 01
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
TIER 01
INDOCIN ORAL TIER 03 ST
indomethacin er TIER 01
indomethacin oral capsule 25 mg, 50 mg
TIER 01
indomethacin sodium TIER 01
ketoprofen er TIER 01
ketoprofen oral capsule 50 mg, 75 mg
TIER 01
ketorolac tromethamine injection solution 15 mg/ml
TIER 01
ketorolac tromethamine intramuscular
TIER 01
Drug Name Drug Tier Notes
ketorolac tromethamine oral
TIER 01 QL
KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML INJECTION
TIER 03
ketorolac tromethamine solution 30 mg/ml injection
TIER 01
LODINE TIER 03
meclofenamate sodium oral
TIER 01
meloxicam oral TIER 01
nabumetone oral TIER 01
naproxen dr TIER 01
naproxen oral tablet TIER 01
naproxen sodium oral tablet 275 mg, 550 mg
TIER 01
NEOPROFEN TIER 03
oxaprozin TIER 01
piroxicam oral TIER 01
sulindac oral TIER 01
tolmetin sodium TIER 01
Anesthetics
ARTICADENT DENTAL TIER 03
bupivacaine fisiopharma TIER 01
bupivacaine hcl (pf) TIER 01
bupivacaine hcl injection solution 0.25 %, 0.5 %
TIER 01
bupivacaine-epinephrine TIER 01
bupivacaine-epinephrine (pf)
TIER 01
CARBOCAINE TIER 03
CARBOCAINE PRESERVATIVE-FREE
TIER 03
chloroprocaine hcl (pf) TIER 01
CITANEST FORTE DENTAL
TIER 03
CITANEST PLAIN DENTAL
TIER 03
D-CARE 100X TIER 03
ethyl chloride TIER 01
EXPAREL TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
5
Drug Name Drug Tier Notes
GEBAUERS PAIN EASE TIER 03
GEBAUERS SPRAY AND STRETCH
TIER 03
glydo TIER 01
L.E.T. TIER 03
lidocaine external ointment
TIER 01
lidocaine external patch 5 %
TIER 01
lidocaine hcl (cardiac) TIER 01
lidocaine hcl (cardiac) pf TIER 01
lidocaine hcl (pf) TIER 01
lidocaine hcl external solution
TIER 01
lidocaine hcl injection solution 0.5 %
TIER 01
LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE
TIER 03
LIDOCAINE HCL SOLUTION 1 % INJECTION
TIER 03
lidocaine hcl solution 1 % injection
TIER 01
LIDOCAINE HCL SOLUTION 2 % INJECTION
TIER 03
lidocaine hcl solution 2 % injection
TIER 01
lidocaine hcl urethral/mucosal
TIER 01
LIDOCAINE IN D5W INTRAVENOUS SOLUTION 2-5 MG/ML-%
TIER 03
lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-%
TIER 01
LIDOCAINE IN DEXTROSE
TIER 03
lidocaine-epinephrine injection
TIER 01
lidocaine-prilocaine external cream
TIER 01
LIDOCAINE-SODIUM BICARBONATE
TIER 03
Drug Name Drug Tier Notes
LIDO-EPINEPHRINE-TETRACAINE
TIER 03
MARCAINE TIER 03
MARCAINE PRESERVATIVE FREE
TIER 03
MARCAINE/EPINEPHRINE
TIER 03
MARCAINE/EPINEPHRINE PF
TIER 03
NAROPIN TIER 03
NESACAINE TIER 03
NESACAINE-MPF TIER 03
ORABLOC TIER 03
polocaine TIER 01
polocaine-mpf TIER 01
PREPIV SUPPLY TIER 03
ropivacaine hcl injection solution 10 mg/ml, 2 mg/ml, 5 mg/ml, 7.5 mg/ml
TIER 01
sensorcaine TIER 01
sensorcaine/epinephrine TIER 01
sensorcaine-mpf TIER 01
sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000
TIER 01
SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75-1:200000 %
TIER 03
VENIPUNCTURE PX1 PHLEBOTOMY
TIER 03
XYLOCAINE TIER 03
xylocaine dental TIER 01
XYLOCAINE/EPINEPHRINE
TIER 03
XYLOCAINE-MPF TIER 03
XYLOCAINE-MPF/EPINEPHRINE
TIER 03
Anti-Addiction / Substance Abuse Treatment Agents
acamprosate calcium TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
6
Drug Name Drug Tier Notes
ANTABUSE TIER 03
BUNAVAIL TIER 03 QL
buprenorphine hcl sublingual
TIER 01 QL
buprenorphine hcl-naloxone hcl
TIER 01 QL
bupropion hcl er (smoking det)
TIER 01 QL
CHANTIX TIER 03 QL
CHANTIX CONTINUING MONTH PAK
TIER 03 QL
CHANTIX STARTING MONTH PAK
TIER 03 QL
disulfiram oral TIER 01
LUCEMYRA TIER 03
naloxone hcl injection solution
TIER 01
naloxone hcl injection solution cartridge
TIER 01
naloxone hcl injection solution prefilled syringe
TIER 01
naltrexone hcl oral TIER 01
NARCAN TIER 02
NICOTROL TIER 03 QL
NICOTROL NS TIER 03 QL
SUBLOCADE SPECIALTY
VIVITROL SPECIALTY
ZUBSOLV TIER 02 QL
Antibacterials
AEMCOLO TIER 03 PA
ALTABAX TIER 03
amikacin sulfate injection TIER 01
amoxicillin TIER 01
amoxicillin-potassium clavulanate er
TIER 01
amoxicillin-potassium clavulanate oral
TIER 01
ampicillin TIER 01
ampicillin sodium TIER 01
ampicillin-sulbactam sodium
TIER 01
ARIKAYCE SPECIALTY
AUGMENTIN TIER 03
Drug Name Drug Tier Notes
AUGMENTIN ES-600 TIER 03
avidoxy TIER 01
AVYCAZ TIER 03
AZACTAM TIER 03
azithromycin intravenous TIER 01
azithromycin oral TIER 01
aztreonam TIER 01
baciim TIER 01
bacitracin intramuscular TIER 01
BACTRIM TIER 03
BACTRIM DS TIER 03
BAXDELA TIER 03
benzalkonium chloride external solution
TIER 01
BICILLIN C-R TIER 03
BICILLIN C-R 900/300 TIER 03
BICILLIN L-A TIER 03
cefaclor TIER 01
cefaclor er TIER 01
cefadroxil TIER 01
CEFAZOLIN IN SODIUM CHLORIDE
TIER 03
cefazolin sodium injection
TIER 01
CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
cefazolin sodium intravenous solution reconstituted
TIER 01
cefazolin sodium-dextrose
TIER 01
cefdinir TIER 01
cefditoren pivoxil TIER 01
cefepime hcl injection TIER 01
cefepime hcl intravenous solution
TIER 01
cefepime-dextrose TIER 01
cefixime TIER 01
CEFOTAN TIER 03
cefotaxime sodium TIER 01
cefotetan disodium TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
7
Drug Name Drug Tier Notes
cefotetan disodium-dextrose
TIER 01
cefoxitin sodium TIER 01
CEFOXITIN SODIUM-DEXTROSE
TIER 03
cefpodoxime proxetil TIER 01
cefprozil TIER 01
ceftazidime and dextrose TIER 01
ceftazidime injection TIER 01
ceftriaxone sodium in dextrose
TIER 01
ceftriaxone sodium injection
TIER 01
ceftriaxone sodium intravenous
TIER 01
ceftriaxone sodium-dextrose
TIER 01
cefuroxime axetil TIER 01
cefuroxime sodium TIER 01
CENTANY TIER 03
cephalexin TIER 01
chloramphenicol sod succinate
TIER 01
CIPRO TIER 03
ciprofloxacin hcl oral TIER 01
ciprofloxacin in d5w TIER 01
clarithromycin er TIER 01
clarithromycin oral TIER 01
CLEOCIN ORAL TIER 03
CLEOCIN PHOSPHATE TIER 03
CLEOCIN VAGINAL CREAM
TIER 03
CLEOCIN VAGINAL SUPPOSITORY
TIER 02
clindamycin hcl oral TIER 01
clindamycin palmitate hcl TIER 01
clindamycin phosphate in d5w
TIER 01
CLINDAMYCIN PHOSPHATE IN NACL
TIER 03
clindamycin phosphate injection
TIER 01
Drug Name Drug Tier Notes
clindamycin phosphate vaginal
TIER 01
CLINDESSE TIER 03
colistimethate sodium (cba)
TIER 01
COLY-MYCIN M TIER 03
DALVANCE TIER 03
daptomycin TIER 01
demeclocycline hcl TIER 01
dicloxacillin sodium TIER 01
DIFICID TIER 03
doxy 100 TIER 01
doxycycline hyclate intravenous
TIER 01
doxycycline hyclate oral capsule
TIER 01
doxycycline hyclate oral tablet 100 mg, 20 mg
TIER 01
doxycycline monohydrate oral capsule 100 mg, 50 mg
TIER 01
doxycycline monohydrate oral suspension reconstituted
TIER 01
doxycycline monohydrate oral tablet
TIER 01
E.E.S. GRANULES TIER 03
ertapenem sodium TIER 01
ERYPED 200 TIER 03
ERYPED 400 TIER 03
ERY-TAB TIER 03
ERYTHROCIN LACTOBIONATE
TIER 03
ERYTHROCIN STEARATE
TIER 03
erythromycin base TIER 01
erythromycin ethylsuccinate oral
TIER 01
erythromycin oral TIER 01
FETROJA TIER 03
FIRVANQ TIER 03
FLAGYL TIER 03
FORTAZ TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
8
Drug Name Drug Tier Notes
gentamicin in saline TIER 01
gentamicin sulfate external
TIER 01
gentamicin sulfate injection
TIER 01
HIPREX TIER 03
hydrogen peroxide TIER 01
imipenem-cilastatin TIER 01
INVANZ TIER 03
KEFLEX TIER 03
levofloxacin in d5w TIER 01
levofloxacin intravenous TIER 01
levofloxacin oral TIER 01
LINCOCIN TIER 03
lincomycin hcl injection TIER 01
linezolid in sodium chloride
TIER 01
linezolid intravenous TIER 01
linezolid oral TIER 01 QL
MACROBID TIER 03
MACRODANTIN TIER 03
mafenide acetate external
TIER 01
meropenem TIER 01
MEROPENEM-SODIUM CHLORIDE
TIER 03
MERREM TIER 03
methenamine hippurate TIER 01
metronidazole in nacl TIER 01
metronidazole oral TIER 01
metronidazole vaginal TIER 01
MINOCIN INTRAVENOUS
TIER 03
minocycline hcl oral TIER 01
mondoxyne nl oral capsule 100 mg
TIER 01
MONUROL TIER 03
morgidox oral TIER 01
moxifloxacin hcl in nacl TIER 01
MOXIFLOXACIN HCL INTRAVENOUS
TIER 03
moxifloxacin hcl oral TIER 01
Drug Name Drug Tier Notes
mupirocin external TIER 01
NAFCILLIN SODIUM IN DEXTROSE
TIER 03
nafcillin sodium injection solution reconstituted 1 gm, 2 gm
TIER 01
nafcillin sodium intravenous
TIER 01
neomycin sulfate oral TIER 01
neomycin-polymyxin b gu
TIER 01
nitrofurantoin TIER 01
nitrofurantoin macrocrystal oral
TIER 01
nitrofurantoin monohydrate macrocrystals
TIER 01
NUZYRA TIER 03
ofloxacin oral TIER 01
ORBACTIV TIER 03
oxacillin sodium TIER 01
OXACILLIN SODIUM IN DEXTROSE
TIER 03
paromomycin sulfate oral TIER 01
PENICILLIN G POT IN DEXTROSE
TIER 03
penicillin g potassium TIER 01
penicillin g procaine TIER 01
penicillin g sodium TIER 01
penicillin v potassium TIER 01
PFIZERPEN TIER 03
piperacillin sod-tazobactam so
TIER 01
polymyxin b sulfate injection
TIER 01
PRIMAXIN IV TIER 03
PRIMSOL TIER 03
RECARBRIO TIER 03
SEYSARA TIER 03 ST
silver sulfadiazine external
TIER 01
SIVEXTRO INTRAVENOUS
TIER 03 QL
SOLOSEC TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
9
Drug Name Drug Tier Notes
ssd TIER 01
streptomycin sulfate intramuscular
TIER 01
sulfadiazine oral TIER 01
sulfamethoxazole-trimethoprim
TIER 01
SULFAMYLON EXTERNAL PACKET
TIER 03
sulfatrim pediatric TIER 01
SUPRAX TIER 03
SYNERCID TIER 03
tazicef injection TIER 01
TAZICEF INTRAVENOUS SOLUTION
TIER 03
tazicef intravenous solution reconstituted
TIER 01
TEFLARO TIER 03
tetracycline hcl oral TIER 01
tigecycline TIER 01
tinidazole oral TIER 01
tobramycin sulfate injection
TIER 01
trimethoprim oral TIER 01
TYGACIL TIER 03
UNASYN TIER 03
VABOMERE TIER 03
VANCOCIN TIER 03
VANCOCIN HCL TIER 03
VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-%
TIER 03
vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%
TIER 01
vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%
TIER 01
Drug Name Drug Tier Notes
VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/250ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/250ML-%, 1.75-0.9 GM/250ML-%, 2-0.9 GM/500ML-%
TIER 03
VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS
TIER 03
vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous
TIER 01
VANCOMYCIN HCL INTRAVENOUS SOLUTION 1000 MG/10ML, 1250 MG/12.5ML, 1500 MG/15ML, 1750 MG/17.5ML, 2000 MG/20ML, 750 MG/7.5ML
TIER 03
vancomycin hcl intravenous solution 1000 mg/200ml, 1250 mg/250ml, 1500 mg/300ml, 1750 mg/350ml, 2000 mg/400ml, 500 mg/100ml, 750 mg/150ml
TIER 01
vancomycin hcl intravenous solution reconstituted
TIER 01
vancomycin hcl oral TIER 01
vandazole TIER 01
VIBATIV TIER 03
VIBRAMYCIN TIER 03 ST
XENLETA TIER 03
XEPI TIER 03
XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG
TIER 03
XIFAXAN TIER 03 PA
XIMINO TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
10
Drug Name Drug Tier Notes
ZEMDRI TIER 03
ZERBAXA TIER 03
ZITHROMAX TIER 03
ZITHROMAX TRI-PAK TIER 03
ZITHROMAX Z-PAK TIER 03
ZOSYN TIER 03
ZYVOX INTRAVENOUS TIER 03
ZYVOX ORAL SUSPENSION RECONSTITUTED
TIER 03 QL
Anticoagulants
ACD FORMULA A TIER 03
ACD-A NOCLOT-50 TIER 03
ANGIOMAX TIER 03
anticoagulant cit dext soln a
TIER 01
anticoagulant sodium citrate
TIER 01
argatroban TIER 01
ARIXTRA SPECIALTY QL
bivalirudin trifluoroacetate
TIER 01
ELIQUIS TIER 02 QL
ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG
TIER 02 QL
enoxaparin sodium SPECIALTY QL
fondaparinux sodium SPECIALTY QL
FRAGMIN SPECIALTY QL
heparin (porcine) in nacl intravenous solution
TIER 01
HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 500-0.9 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-%
TIER 03
heparin sod (porcine) in d5w
TIER 01
heparin sodium (porcine) TIER 01
heparin sodium (porcine) pf
TIER 01
Drug Name Drug Tier Notes
jantoven TIER 01
LOVENOX SPECIALTY QL
PRADAXA TIER 02 QL
RETAVASE TIER 03
RETAVASE HALF-KIT TIER 03
SAVAYSA TIER 03 QL
SODIUM CITRATE IN VITRO
TIER 03
SODIUM CITRATE LOCK FLUSH
TIER 03
THROMBATE III SPECIALTY
TNKASE TIER 03
TRICITRASOL TIER 03
warfarin sodium oral TIER 01
XARELTO TIER 02 QL
XARELTO STARTER PACK
TIER 02 QL
Anticonvulsants - Drugs for Seizures
BANZEL TIER 03 PA
BRIVIACT TIER 03
carbamazepine er TIER 01
carbamazepine oral TIER 01
CELONTIN TIER 03
CEREBYX TIER 03
clobazam TIER 01 PA
DIACOMIT SPECIALTY PA
DIASTAT ACUDIAL TIER 03 QL
DIASTAT PEDIATRIC TIER 03 QL
diazepam rectal TIER 01 QL
DILANTIN ORAL CAPSULE 30 MG
TIER 03
divalproex sodium er TIER 01
divalproex sodium oral TIER 01
EPIDIOLEX SPECIALTY PA
epitol TIER 01
ethosuximide oral TIER 01
felbamate TIER 01
fosphenytoin sodium TIER 01
FYCOMPA TIER 03
gabapentin oral TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
11
Drug Name Drug Tier Notes
GABITRIL TIER 03
KEPPRA INTRAVENOUS
TIER 03
LAMICTAL XR ORAL KIT
TIER 03
lamotrigine er TIER 01
lamotrigine oral TIER 01
lamotrigine starter kit-blue
TIER 01
lamotrigine starter kit-green
TIER 01
lamotrigine starter kit-orange
TIER 01
levetiracetam er TIER 01
levetiracetam in nacl TIER 01
levetiracetam intravenous
TIER 01
levetiracetam oral TIER 01
NAYZILAM TIER 03 QL
NEMBUTAL TIER 03
oxcarbazepine TIER 01
PEGANONE TIER 03
pentobarbital sodium injection
TIER 01
phenobarbital oral TIER 01
phenobarbital sodium injection
TIER 01
PHENYTEK TIER 03
phenytoin infatabs TIER 01
phenytoin oral TIER 01
phenytoin sodium extended
TIER 01
phenytoin sodium injection
TIER 01
primidone oral TIER 01
roweepra TIER 01
roweepra xr TIER 01
subvenite TIER 01
subvenite starter kit-blue TIER 01
subvenite starter kit-green
TIER 01
subvenite starter kit-orange
TIER 01
Drug Name Drug Tier Notes
SYMPAZAN TIER 03 PA
tiagabine hcl TIER 01
topiramate er TIER 01
topiramate oral TIER 01
TROKENDI XR TIER 03
valproate sodium intravenous
TIER 01
valproic acid oral TIER 01
VALTOCO 10 MG DOSE TIER 03 QL
VALTOCO 15 MG DOSE TIER 03 QL
VALTOCO 20 MG DOSE TIER 03 QL
VALTOCO 5 MG DOSE TIER 03 QL
vigabatrin SPECIALTY PA
vigadrone SPECIALTY PA
VIMPAT TIER 03
XCOPRI TIER 03
XCOPRI (250 MG DAILY DOSE)
TIER 03
XCOPRI (350 MG DAILY DOSE)
TIER 03
ZARONTIN TIER 03
zonisamide oral TIER 01
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia
ARICEPT TIER 03
donepezil hcl TIER 01
EXELON TIER 03
galantamine hydrobromide
TIER 01
galantamine hydrobromide er
TIER 01
memantine hcl er TIER 01 QL
memantine hcl oral TIER 01
NAMENDA TIER 03
NAMENDA TITRATION PAK
TIER 03
NAMENDA XR TIER 03 QL
NAMENDA XR TITRATION PACK
TIER 03 QL
NAMZARIC TIER 02 QL
RAZADYNE ER TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
12
Drug Name Drug Tier Notes
rivastigmine TIER 01
rivastigmine tartrate TIER 01
Antidepressants
amitriptyline hcl oral TIER 01
amoxapine TIER 01
APLENZIN TIER 03 ST; QL
bupropion hcl er (sr) TIER 01 QL
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
TIER 01 QL
BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG
TIER 02 QL
bupropion hcl oral TIER 01
chlordiazepoxide-amitriptyline
TIER 01
citalopram hydrobromide TIER 01
clomipramine hcl oral TIER 01
desipramine hcl oral TIER 01
DESVENLAFAXINE ER TIER 03 ST; QL
desvenlafaxine succinate er
TIER 01 QL
doxepin hcl oral capsule TIER 01
doxepin hcl oral concentrate
TIER 01
DRIZALMA SPRINKLE TIER 03 QL
duloxetine hcl oral TIER 01 QL
EMSAM TIER 03 QL
escitalopram oxalate TIER 01
FETZIMA TIER 03 ST; QL
FETZIMA TITRATION TIER 03 ST; QL
fluoxetine hcl (pmdd) TIER 01
fluoxetine hcl oral capsule
TIER 01
fluoxetine hcl oral capsule delayed release
TIER 01 QL
fluoxetine hcl oral solution
TIER 01
fluoxetine hcl oral tablet TIER 01
fluvoxamine maleate TIER 01
fluvoxamine maleate er TIER 01 QL
FORFIVO XL TIER 03 QL
Drug Name Drug Tier Notes
imipramine hcl oral TIER 01
imipramine pamoate TIER 01
maprotiline hcl TIER 01
MARPLAN TIER 03
mirtazapine oral TIER 01
NARDIL TIER 03
nefazodone hcl TIER 01
NORPRAMIN TIER 03
nortriptyline hcl oral TIER 01
olanzapine-fluoxetine hcl TIER 01 QL
PARNATE TIER 03
paroxetine hcl TIER 01
paroxetine hcl er TIER 01
paroxetine mesylate TIER 01 QL
PAXIL ORAL SUSPENSION
TIER 02 ST
perphenazine-amitriptyline
TIER 01
PEXEVA TIER 03 QL
phenelzine sulfate oral TIER 01
protriptyline hcl TIER 01
REMERON TIER 03
REMERON SOLTAB TIER 03
SARAFEM TIER 03
sertraline hcl oral TIER 01
SPRAVATO (56 MG DOSE)
SPECIALTY
SPRAVATO (84 MG DOSE)
SPECIALTY
SYMBYAX TIER 03 QL
tranylcypromine sulfate TIER 01
trazodone hcl oral TIER 01
trimipramine maleate oral
TIER 01
TRINTELLIX TIER 03 ST; QL
venlafaxine hcl TIER 01
venlafaxine hcl er oral capsule extended release 24 hour
TIER 01
venlafaxine hcl er oral tablet extended release 24 hour 225 mg
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
13
Drug Name Drug Tier Notes
VIIBRYD TIER 03 QL
VIIBRYD STARTER PACK
TIER 03 QL
ZULRESSO SPECIALTY
Antiemetics - Drugs for Nausea and Vomiting
AKYNZEO INTRAVENOUS
TIER 03
AKYNZEO ORAL TIER 03 QL
ALOXI TIER 03
ANZEMET TIER 03 QL
aprepitant TIER 01 QL
BONJESTA TIER 03 PA; QL
CINVANTI TIER 03
compro TIER 01
DICLEGIS TIER 03 PA; QL
dimenhydrinate injection TIER 01
doxylamine-pyridoxine TIER 01 PA; QL
dronabinol TIER 01 PA; QL
droperidol injection TIER 01
EMEND INTRAVENOUS TIER 03
EMEND ORAL TIER 03 QL
EMEND TRI-PACK TIER 03 QL
fosaprepitant dimeglumine
TIER 01
granisetron hcl intravenous
TIER 01
granisetron hcl oral TIER 01 QL
MARINOL TIER 03 PA; QL
meclizine hcl oral tablet TIER 01
metoclopramide hcl injection
TIER 01
metoclopramide hcl oral TIER 01
ondansetron hcl injection TIER 01
ondansetron hcl oral solution
TIER 01 QL
ondansetron hcl oral tablet 24 mg
TIER 01 QL
ondansetron hcl oral tablet 4 mg, 8 mg
TIER 01
ondansetron odt TIER 01
palonosetron hcl TIER 01
Drug Name Drug Tier Notes
perphenazine oral TIER 01
prochlorperazine TIER 01
prochlorperazine edisylate injection
TIER 01
prochlorperazine maleate oral
TIER 01
REGLAN TIER 03
scopolamine TIER 01
SUSTOL TIER 03 QL
SYNDROS TIER 03 PA; QL
TIGAN TIER 03
TRANSDERM SCOP (1.5 MG)
TIER 03
TRANSDERM-SCOP (1.5 MG)
TIER 03
trimethobenzamide hcl oral
TIER 01
VARUBI (180 MG DOSE)
TIER 03 QL
Antifungals
ABELCET TIER 03
AMBISOME TIER 03
amphotericin b intravenous
TIER 01
ANCOBON TIER 03
BIO-STATIN ORAL CAPSULE
TIER 03
CANCIDAS TIER 03
caspofungin acetate TIER 01
ciclodan TIER 01
ciclopirox external TIER 01
ciclopirox olamine external
TIER 01
clotrimazole external TIER 01
clotrimazole mouth/throat TIER 01
clotrimazole-betamethasone
TIER 01
CRESEMBA SPECIALTY
DIFLUCAN TIER 03
econazole nitrate external
TIER 01
ERAXIS TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
14
Drug Name Drug Tier Notes
EXODERM EXTERNAL LOTION
TIER 02
fluconazole in sodium chloride
TIER 01
fluconazole oral TIER 01
flucytosine oral TIER 01
griseofulvin microsize oral
TIER 01
griseofulvin ultramicrosize
TIER 01
GYNAZOLE-1 TIER 03
itraconazole oral TIER 01 PA
KERYDIN TIER 03 PA
ketoconazole external cream
TIER 01
ketoconazole external shampoo
TIER 01
ketoconazole oral TIER 01
LOPROX EXTERNAL CREAM
TIER 03
LOPROX EXTERNAL SHAMPOO
TIER 03
LOPROX EXTERNAL SUSPENSION
TIER 03
micafungin sodium TIER 01
miconazole 3 vaginal suppository
TIER 01
MYCAMINE TIER 03
naftifine hcl TIER 01
NAFTIN TIER 03
NOXAFIL SPECIALTY
nyamyc TIER 01
nystatin external TIER 01
nystatin mouth/throat TIER 01
nystatin oral TIER 01
nystatin-triamcinolone TIER 01
nystop TIER 01
posaconazole SPECIALTY
SPORANOX TIER 03 PA
SPORANOX PULSEPAK TIER 03 PA
terbinafine hcl oral TIER 01 QL
terconazole TIER 01
VFEND IV SPECIALTY
Drug Name Drug Tier Notes
VFEND ORAL SUSPENSION RECONSTITUTED
SPECIALTY
voriconazole intravenous SPECIALTY
voriconazole oral SPECIALTY
Antigout Agents
allopurinol oral TIER 01
allopurinol sodium TIER 01
ALOPRIM TIER 03
colchicine oral tablet TIER 01
colchicine-probenecid TIER 01
COLCRYS TIER 02
febuxostat TIER 01 ST
KRYSTEXXA SPECIALTY PA
probenecid TIER 01
ULORIC TIER 03 ST
ZYLOPRIM TIER 03
Anti-inflammatory Agents
EMFLAZA SPECIALTY PA
Antimigraine Agents
AIMOVIG SPECIALTY
almotriptan malate TIER 01 QL
AMERGE TIER 03 QL
CAFERGOT TIER 03
D.H.E. 45 TIER 03
dihydroergotamine mesylate injection
TIER 01
dihydroergotamine mesylate nasal
TIER 01 QL
eletriptan hydrobromide TIER 01 QL
EMGALITY SPECIALTY
EMGALITY (300 MG DOSE)
SPECIALTY
ERGOMAR TIER 03
ergotamine-caffeine TIER 01
MIGERGOT TIER 03
MIGRANAL TIER 03 QL
naratriptan hcl TIER 01 QL
NURTEC TIER 02
rizatriptan benzoate TIER 01 QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
15
Drug Name Drug Tier Notes
sumatriptan nasal TIER 01 QL
sumatriptan succinate oral
TIER 01 QL
sumatriptan succinate refill
TIER 01 QL
sumatriptan succinate subcutaneous
TIER 01 QL
UBRELVY TIER 02
VYEPTI TIER 03
zolmitriptan oral TIER 01 QL
ZOMIG NASAL TIER 03 ST; QL
Antimyasthenic Agents
BLOXIVERZ TIER 03
GUANIDINE HCL TIER 03
MESTINON ORAL SOLUTION
TIER 03
MESTINON ORAL TABLET EXTENDED RELEASE
TIER 03
neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml
TIER 01
NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 MG/3ML, 5 MG/5ML
TIER 03
NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
pyridostigmine bromide er
TIER 01
pyridostigmine bromide oral
TIER 01
REGONOL TIER 03
Antimycobacterials
CAPASTAT SULFATE TIER 03
cycloserine oral TIER 01
dapsone oral TIER 01
ethambutol hcl oral TIER 01
isoniazid injection TIER 01
Drug Name Drug Tier Notes
isoniazid oral TIER 01
MYAMBUTOL TIER 03
MYCOBUTIN TIER 03
PASER TIER 03
PRETOMANID TIER 03
PRIFTIN TIER 03
pyrazinamide oral TIER 01
rifabutin TIER 01
RIFADIN TIER 03
rifampin intravenous TIER 01
rifampin oral TIER 01
SIRTURO TIER 03
TRECATOR TIER 03
Antineoplastics - Drugs for Cancer
abiraterone acetate SPECIALTY PA
ABRAXANE SPECIALTY
ADCETRIS SPECIALTY PA
adriamycin SPECIALTY
AFINITOR DISPERZ SPECIALTY PA
AFINITOR ORAL TABLET 10 MG
SPECIALTY PA; QL
ALECENSA SPECIALTY PA
ALIMTA SPECIALTY
ALIQOPA SPECIALTY PA
ALKERAN SPECIALTY
ALUNBRIG SPECIALTY PA; QL
anastrozole oral TIER 01
AROMASIN SPECIALTY
ARRANON SPECIALTY
arsenic trioxide intravenous
SPECIALTY
ARZERRA SPECIALTY PA
ASPARLAS SPECIALTY
AVASTIN SPECIALTY PA
AYVAKIT SPECIALTY PA; QL
azacitidine SPECIALTY
BALVERSA SPECIALTY PA
BAVENCIO SPECIALTY PA
BELEODAQ SPECIALTY PA
BENDEKA SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
16
Drug Name Drug Tier Notes
BESPONSA SPECIALTY PA
bexarotene SPECIALTY PA
bicalutamide TIER 01
BICNU SPECIALTY
bleomycin sulfate SPECIALTY
BLINCYTO SPECIALTY PA
BORTEZOMIB SPECIALTY PA
BOSULIF SPECIALTY PA
BRAFTOVI SPECIALTY PA
BRUKINSA SPECIALTY PA
busulfan SPECIALTY
BUSULFEX SPECIALTY
CABOMETYX SPECIALTY PA
CALQUENCE SPECIALTY PA
CAMPATH SPECIALTY
CAMPTOSAR SPECIALTY
capecitabine SPECIALTY PA
CAPRELSA ORAL TABLET 100 MG
SPECIALTY PA; QL
CAPRELSA ORAL TABLET 300 MG
SPECIALTY PA
carboplatin SPECIALTY
carmustine SPECIALTY
CASODEX TIER 03
cisplatin intravenous solution
SPECIALTY
CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED
SPECIALTY
cladribine SPECIALTY
clofarabine SPECIALTY
CLOLAR SPECIALTY
COMETRIQ (100 MG DAILY DOSE)
SPECIALTY PA
COMETRIQ (140 MG DAILY DOSE)
SPECIALTY PA
COMETRIQ (60 MG DAILY DOSE)
SPECIALTY PA
COPIKTRA SPECIALTY PA
COSMEGEN SPECIALTY
COTELLIC SPECIALTY PA
Drug Name Drug Tier Notes
cyclophosphamide injection
SPECIALTY
cyclophosphamide oral SPECIALTY
CYRAMZA SPECIALTY PA
cytarabine SPECIALTY
cytarabine (pf) SPECIALTY
dacarbazine SPECIALTY
DACOGEN SPECIALTY PA
dactinomycin SPECIALTY
DARZALEX SPECIALTY PA
daunorubicin hcl SPECIALTY
DAURISMO SPECIALTY PA
decitabine SPECIALTY PA
dexrazoxane hcl SPECIALTY
docetaxel SPECIALTY
DOXIL SPECIALTY
doxorubicin hcl SPECIALTY
doxorubicin hcl liposomal SPECIALTY
DROXIA TIER 03
ELITEK SPECIALTY
ELLENCE SPECIALTY
EMCYT SPECIALTY
EMPLICITI SPECIALTY PA
ENHERTU SPECIALTY PA
epirubicin hcl SPECIALTY
ERBITUX SPECIALTY PA
ERIVEDGE SPECIALTY PA
erlotinib hcl oral tablet 100 mg, 150 mg
SPECIALTY PA
erlotinib hcl oral tablet 25 mg
SPECIALTY PA; QL
ERWINAZE SPECIALTY
ETHYOL TIER 03
ETOPOPHOS SPECIALTY
etoposide intravenous SPECIALTY
etoposide oral SPECIALTY
everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg
SPECIALTY PA; QL
EVOMELA SPECIALTY
exemestane SPECIALTY
FARESTON SPECIALTY
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
17
Drug Name Drug Tier Notes
FARYDAK SPECIALTY PA
FASLODEX SPECIALTY
FEMARA TIER 03
floxuridine injection SPECIALTY
fludarabine phosphate SPECIALTY
fluorouracil intravenous SPECIALTY
flutamide TIER 01
FOLOTYN SPECIALTY PA
fulvestrant SPECIALTY
GAZYVA SPECIALTY PA
gemcitabine hcl SPECIALTY
GILOTRIF SPECIALTY PA; QL
GLEOSTINE SPECIALTY
HALAVEN SPECIALTY PA
HERCEPTIN SPECIALTY PA
HERCEPTIN HYLECTA SPECIALTY PA
HYCAMTIN SPECIALTY
HYDREA TIER 03
hydroxyurea oral TIER 01
IBRANCE SPECIALTY PA
ICLUSIG ORAL TABLET 15 MG
SPECIALTY PA; QL
ICLUSIG ORAL TABLET 45 MG
SPECIALTY PA
IDAMYCIN PFS SPECIALTY
idarubicin hcl SPECIALTY
IDHIFA SPECIALTY PA; QL
IFEX SPECIALTY
ifosfamide SPECIALTY
imatinib mesylate SPECIALTY PA
IMBRUVICA SPECIALTY PA
IMFINZI SPECIALTY PA
INFUGEM SPECIALTY
INLYTA SPECIALTY PA
INREBIC SPECIALTY PA
IRESSA SPECIALTY PA
irinotecan hcl SPECIALTY
ISTODAX (OVERFILL) SPECIALTY PA
IXEMPRA KIT SPECIALTY
JAKAFI ORAL TABLET 10 MG
SPECIALTY PA; QL
Drug Name Drug Tier Notes
JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG
SPECIALTY PA
JEVTANA SPECIALTY PA
KADCYLA SPECIALTY PA
KANJINTI SPECIALTY PA
KEYTRUDA SPECIALTY PA
KHAPZORY SPECIALTY
KISQALI (200 MG DOSE)
SPECIALTY PA
KISQALI (400 MG DOSE)
SPECIALTY PA
KISQALI (600 MG DOSE)
SPECIALTY PA
KISQALI FEMARA (400 MG DOSE)
SPECIALTY PA
KISQALI FEMARA (600 MG DOSE)
SPECIALTY PA
KISQALI FEMARA(200 MG DOSE)
SPECIALTY PA
KOSELUGO SPECIALTY PA
KYPROLIS SPECIALTY PA
LARTRUVO SPECIALTY PA
LENVIMA (10 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (12 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (14 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (18 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (20 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (24 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (4 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (8 MG DAILY DOSE)
SPECIALTY PA
letrozole oral TIER 01
leucovorin calcium injection
TIER 01
leucovorin calcium oral TIER 01
LEUKERAN SPECIALTY
levoleucovorin calcium SPECIALTY
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
18
Drug Name Drug Tier Notes
levoleucovorin calcium pf SPECIALTY
LIBTAYO SPECIALTY PA
LONSURF SPECIALTY PA
LORBRENA SPECIALTY PA
LUMOXITI SPECIALTY PA
LYNPARZA SPECIALTY PA
LYSODREN SPECIALTY
MARQIBO SPECIALTY
MATULANE SPECIALTY
MEKINIST SPECIALTY PA
MEKTOVI SPECIALTY PA
melphalan SPECIALTY
melphalan hcl SPECIALTY
mercaptopurine oral TIER 01
mesna SPECIALTY
MESNEX SPECIALTY
mitomycin intravenous SPECIALTY
mitoxantrone hcl SPECIALTY PA
mutamycin SPECIALTY
MVASI SPECIALTY PA
MYLERAN SPECIALTY
MYLOTARG SPECIALTY PA
NAVELBINE SPECIALTY
NERLYNX SPECIALTY PA; QL
NEXAVAR SPECIALTY PA
NILANDRON SPECIALTY
nilutamide SPECIALTY
NINLARO SPECIALTY PA
NIPENT SPECIALTY
NUBEQA SPECIALTY PA
ODOMZO SPECIALTY PA
ONCASPAR SPECIALTY
ONIVYDE SPECIALTY
OPDIVO SPECIALTY PA
oxaliplatin SPECIALTY
paclitaxel SPECIALTY
PADCEV SPECIALTY PA
PANRETIN SPECIALTY
paraplatin SPECIALTY
PERJETA SPECIALTY PA
Drug Name Drug Tier Notes
PHOTOFRIN SPECIALTY
PIQRAY (200 MG DAILY DOSE)
SPECIALTY PA
PIQRAY (250 MG DAILY DOSE)
SPECIALTY PA
PIQRAY (300 MG DAILY DOSE)
SPECIALTY PA
POLIVY SPECIALTY PA
POMALYST SPECIALTY PA
PORTRAZZA SPECIALTY PA
POTELIGEO SPECIALTY PA
PROLEUKIN SPECIALTY
PURIXAN SPECIALTY
QINLOCK SPECIALTY PA
QUADRAMET TIER 03
REVLIMID SPECIALTY PA
RITUXAN SPECIALTY PA
RITUXAN HYCELA SPECIALTY PA
ROZLYTREK SPECIALTY PA
RUBRACA SPECIALTY PA
RUXIENCE SPECIALTY PA
RYDAPT SPECIALTY PA
SIKLOS TIER 03
SOLTAMOX TIER 03
SPRYCEL SPECIALTY PA
STIVARGA SPECIALTY PA
SUTENT SPECIALTY PA
SYLVANT SPECIALTY PA
SYNRIBO SPECIALTY PA
TABLOID SPECIALTY
TAFINLAR SPECIALTY PA
TAGRISSO ORAL TABLET 40 MG
SPECIALTY PA; QL
TAGRISSO ORAL TABLET 80 MG
SPECIALTY PA
TALZENNA SPECIALTY PA
tamoxifen citrate oral TIER 01
TARCEVA ORAL TABLET 100 MG, 150 MG
SPECIALTY PA
TARCEVA ORAL TABLET 25 MG
SPECIALTY PA; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
19
Drug Name Drug Tier Notes
TARGRETIN EXTERNAL
SPECIALTY PA
TASIGNA SPECIALTY PA
TAXOTERE SPECIALTY
TECENTRIQ SPECIALTY PA
TEMODAR INTRAVENOUS
SPECIALTY
TEMODAR ORAL SPECIALTY PA
temozolomide SPECIALTY PA
teniposide SPECIALTY
TEPADINA SPECIALTY
THALOMID SPECIALTY PA
thiotepa injection SPECIALTY
TIBSOVO SPECIALTY PA
toposar SPECIALTY
topotecan hcl SPECIALTY
toremifene citrate SPECIALTY
TOTECT SPECIALTY
TRAZIMERA SPECIALTY PA
tretinoin oral SPECIALTY
TRISENOX SPECIALTY
TUKYSA SPECIALTY PA
TURALIO SPECIALTY PA
TYKERB SPECIALTY PA
UNITUXIN SPECIALTY PA
VALCHLOR SPECIALTY PA
valrubicin SPECIALTY
VALSTAR SPECIALTY
VECTIBIX SPECIALTY
VELCADE SPECIALTY PA
VENCLEXTA SPECIALTY PA
VENCLEXTA STARTING PACK
SPECIALTY PA
VERZENIO SPECIALTY PA
VIDAZA SPECIALTY
vinblastine sulfate SPECIALTY
vincristine sulfate SPECIALTY
vinorelbine tartrate SPECIALTY
VITRAKVI SPECIALTY PA
VIZIMPRO SPECIALTY PA
VORAXAZE TIER 03
Drug Name Drug Tier Notes
VOTRIENT SPECIALTY PA
VYXEOS SPECIALTY PA
XALKORI SPECIALTY PA
XELODA SPECIALTY PA
XOFIGO TIER 02
XOSPATA SPECIALTY PA
XPOVIO (100 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (40 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (40 MG TWICE WEEKLY)
SPECIALTY PA
XPOVIO (60 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (60 MG TWICE WEEKLY)
SPECIALTY PA
XPOVIO (80 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (80 MG TWICE WEEKLY)
SPECIALTY PA
XTANDI SPECIALTY PA
YERVOY SPECIALTY PA
YONDELIS SPECIALTY
ZALTRAP SPECIALTY PA
ZANOSAR SPECIALTY
ZEJULA SPECIALTY PA
ZELBORAF SPECIALTY PA
ZEVALIN Y-90 SPECIALTY
ZIRABEV SPECIALTY PA
ZOLINZA SPECIALTY PA
ZYDELIG SPECIALTY PA
ZYKADIA SPECIALTY PA
Antiparasitics
albendazole oral TIER 01
ALINIA TIER 02
ARAKODA TIER 03
atovaquone oral TIER 01
atovaquone-proguanil hcl TIER 01
BENZNIDAZOLE TIER 03
BILTRICIDE TIER 03
chloroquine phosphate oral
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
20
Drug Name Drug Tier Notes
COARTEM TIER 03
crotan TIER 01
DARAPRIM SPECIALTY
EGATEN TIER 03
ELIMITE TIER 03
EMVERM TIER 02
hydroxychloroquine sulfate oral
TIER 01
IMPAVIDO TIER 03
ivermectin oral TIER 01
KRINTAFEL TIER 03
lindane TIER 01
MALARONE TIER 03
malathion TIER 01
mefloquine hcl TIER 01
MEPRON TIER 03
NEBUPENT TIER 03
OVIDE TIER 03
PENTAM TIER 03
pentamidine isethionate TIER 01
permethrin external TIER 01
PLAQUENIL TIER 02
praziquantel oral TIER 01
primaquine phosphate TIER 01
pyrimethamine oral SPECIALTY
PYRIMETHAMINE-LEUCOVORIN
TIER 03
QUALAQUIN TIER 03 PA
quinine sulfate oral TIER 01 PA
SKLICE TIER 03
spinosad TIER 01
STROMECTOL TIER 03
sulfurated lime TIER 01
Antiparkinson Agents
amantadine hcl oral TIER 01
APOKYN SPECIALTY PA; QL
AZILECT TIER 03
benztropine mesylate TIER 01
bromocriptine mesylate oral
TIER 01
carbidopa oral TIER 01
Drug Name Drug Tier Notes
carbidopa-levodopa TIER 01
carbidopa-levodopa er TIER 01
carbidopa-levodopa-entacapone
TIER 01
COGENTIN TIER 03
COMTAN TIER 03
DUOPA TIER 03 PA
entacapone TIER 01
INBRIJA SPECIALTY
MIRAPEX TIER 03
MIRAPEX ER TIER 03
NEUPRO TIER 03 ST
NOURIANZ TIER 03 PA
PARLODEL TIER 03
pramipexole dihydrochloride
TIER 01
pramipexole dihydrochloride er
TIER 01
rasagiline mesylate oral TIER 01
REQUIP XL TIER 03
ropinirole hcl TIER 01
ropinirole hcl er TIER 01
RYTARY TIER 03 ST
selegiline hcl oral TIER 01
SINEMET TIER 03
STALEVO 100 TIER 03
STALEVO 125 TIER 03
STALEVO 150 TIER 03
STALEVO 200 TIER 03
STALEVO 50 TIER 03
STALEVO 75 TIER 03
TASMAR TIER 03
tolcapone TIER 01
trihexyphenidyl hcl TIER 01
XADAGO SPECIALTY ST
ZELAPAR TIER 03
Antiplatelets
AGGRASTAT TIER 03
AGGRENOX TIER 03
aspirin-dipyridamole er TIER 01
BRILINTA TIER 02
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
21
Drug Name Drug Tier Notes
CABLIVI SPECIALTY
cilostazol TIER 01
clopidogrel bisulfate oral TIER 01
dipyridamole oral TIER 01
EFFIENT TIER 03
eptifibatide TIER 01
INTEGRILIN TIER 03
KENGREAL TIER 03
prasugrel hcl TIER 01
ZONTIVITY TIER 03
Antipsychotics - Drugs for Mood Disorders
ABILIFY MAINTENA TIER 03
ADASUVE TIER 03 PA
aripiprazole TIER 01 QL
ARISTADA TIER 03
ARISTADA INITIO TIER 03
CAPLYTA TIER 03 ST; QL
chlorpromazine hcl injection
TIER 01
chlorpromazine hcl oral TIER 01
clozapine TIER 01 QL
CLOZARIL TIER 03 QL
FANAPT TIER 03 ST; QL
FANAPT TITRATION PACK
TIER 03 ST; QL
fluphenazine decanoate injection
TIER 01
fluphenazine hcl TIER 01
GEODON INTRAMUSCULAR
TIER 03
HALDOL TIER 03
HALDOL DECANOATE TIER 03
haloperidol decanoate intramuscular
TIER 01
haloperidol lactate TIER 01
haloperidol oral TIER 01
INVEGA TIER 03 QL
INVEGA SUSTENNA TIER 03
INVEGA TRINZA TIER 03
LATUDA TIER 03 QL
Drug Name Drug Tier Notes
loxapine succinate TIER 01
molindone hcl TIER 01
NUPLAZID TIER 03 PA
olanzapine intramuscular TIER 01
olanzapine oral TIER 01 QL
paliperidone er TIER 01 QL
PERSERIS TIER 03
pimozide TIER 01
quetiapine fumarate TIER 01 QL
quetiapine fumarate er TIER 01 QL
REXULTI TIER 03 QL
RISPERDAL CONSTA TIER 03
risperidone TIER 01 QL
SAPHRIS TIER 02 QL
thioridazine hcl oral TIER 01
thiothixene TIER 01
trifluoperazine hcl TIER 01
VERSACLOZ TIER 03 QL
VRAYLAR TIER 03 ST; QL
ziprasidone hcl TIER 01 QL
ziprasidone mesylate TIER 01
ZYPREXA RELPREVV TIER 03
ZYPREXA ZYDIS TIER 03 QL
Antivirals
abacavir sulfate TIER 01
abacavir sulfate-lamivudine
TIER 01
abacavir-lamivudine-zidovudine
TIER 01
acyclovir external TIER 01
acyclovir oral TIER 01
acyclovir sodium TIER 01
adefovir dipivoxil SPECIALTY
APTIVUS TIER 02
atazanavir sulfate TIER 01
BARACLUDE ORAL SOLUTION
SPECIALTY QL
BIKTARVY TIER 03
cidofovir intravenous TIER 01
CIMDUO TIER 02
COMBIVIR TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
22
Drug Name Drug Tier Notes
COMPLERA TIER 02
CRIXIVAN TIER 02
CYTOVENE TIER 03
DELSTRIGO TIER 03
DESCOVY TIER 03 PA
didanosine TIER 01
DOVATO TIER 02
EDURANT TIER 02
efavirenz TIER 01
efavirenz-lamivudine-tenofovir
TIER 01
emtricitabine TIER 01
EMTRIVA ORAL CAPSULE
TIER 03
EMTRIVA ORAL SOLUTION
TIER 02
entecavir SPECIALTY QL
EPCLUSA SPECIALTY PA; QL
EPIVIR TIER 03
EPIVIR HBV SPECIALTY
EPZICOM TIER 03
EVOTAZ TIER 02
famciclovir oral TIER 01
FAVIPIRAVIR TIER 03
fosamprenavir calcium TIER 01
FOSCAVIR TIER 03
FUZEON SPECIALTY
GANCICLOVIR TIER 03
ganciclovir sodium TIER 01
GENVOYA TIER 03
HARVONI SPECIALTY PA; QL
HEPSERA SPECIALTY
INTELENCE TIER 02
INTRON A SPECIALTY PA
INVIRASE TIER 02
ISENTRESS TIER 02
ISENTRESS HD TIER 02
JULUCA TIER 02
KALETRA ORAL SOLUTION
TIER 03
Drug Name Drug Tier Notes
KALETRA ORAL TABLET
TIER 02
lamivudine oral solution TIER 01
lamivudine oral tablet 100 mg
SPECIALTY
lamivudine oral tablet 150 mg, 300 mg
TIER 01
lamivudine-zidovudine TIER 01
LEXIVA ORAL SUSPENSION
TIER 02
LEXIVA ORAL TABLET TIER 03
lopinavir-ritonavir TIER 01
MAVYRET SPECIALTY PA; QL
nevirapine TIER 01
nevirapine er TIER 01
NORVIR ORAL PACKET TIER 02
NORVIR ORAL SOLUTION
TIER 02
NORVIR ORAL TABLET TIER 03
ODEFSEY TIER 03
oseltamivir phosphate oral
TIER 01 QL
PEGASYS SPECIALTY PA
PEGASYS PROCLICK SPECIALTY PA
PEGINTRON SPECIALTY PA
PIFELTRO TIER 03
PREVYMIS SPECIALTY
PREZCOBIX TIER 02
PREZISTA TIER 02
RAPIVAB TIER 03
RELENZA DISKHALER TIER 03 QL
RETROVIR INTRAVENOUS
TIER 02
RETROVIR ORAL TIER 03
REYATAZ ORAL CAPSULE
TIER 03
REYATAZ ORAL PACKET
TIER 02
ribavirin inhalation TIER 01
ribavirin oral SPECIALTY
rimantadine hcl TIER 01
ritonavir TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
23
Drug Name Drug Tier Notes
SELZENTRY TIER 02 PA
SITAVIG TIER 03 QL
SOVALDI SPECIALTY PA; QL
stavudine TIER 01
STRIBILD TIER 03
SUSTIVA TIER 03
SYMFI TIER 02
SYMFI LO TIER 02
SYMTUZA TIER 03
tenofovir disoproxil fumarate
TIER 01
TIVICAY TIER 02
TIVICAY PD TIER 02
TRIUMEQ TIER 02
TRIZIVIR TIER 03
TROGARZO TIER 03 PA
TRUVADA TIER 02
TYBOST TIER 02
valacyclovir hcl oral TIER 01 QL
valganciclovir hcl TIER 01
VEMLIDY SPECIALTY
VIEKIRA PAK SPECIALTY PA; QL
VIRACEPT TIER 02
VIRAMUNE TIER 03
VIRAMUNE XR TIER 03
VIRAZOLE TIER 03
VIREAD ORAL POWDER
TIER 02
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
TIER 02
VIREAD ORAL TABLET 300 MG
TIER 03
VOSEVI SPECIALTY PA; QL
XOFLUZA (40 MG DOSE)
TIER 03 QL
XOFLUZA (80 MG DOSE)
TIER 03 QL
ZEPATIER SPECIALTY PA; QL
ZIAGEN TIER 03
zidovudine TIER 01
Drug Name Drug Tier Notes
Anxiolytics - Drugs for Anxiety
alprazolam er TIER 01 QL
alprazolam intensol TIER 01 QL
alprazolam oral tablet TIER 01 QL
alprazolam xr TIER 01 QL
ATIVAN INJECTION TIER 03
buspirone hcl oral TIER 01
chlordiazepoxide hcl TIER 01 QL
clonazepam oral TIER 01 QL
clorazepate dipotassium TIER 01 QL
diazepam intensol TIER 01
diazepam intramuscular TIER 01
diazepam oral TIER 01
diazepam solution 5 mg/ml injection
TIER 01
DIAZEPAM SOLUTION 5 MG/ML INJECTION
TIER 03
DORAL TIER 03 QL
estazolam TIER 01 QL
HALCION TIER 03 QL
hydroxyzine hcl intramuscular
TIER 01
hydroxyzine hcl oral TIER 01
hydroxyzine pamoate oral
TIER 01
lorazepam injection TIER 01
lorazepam intensol TIER 01 QL
lorazepam oral concentrate 2 mg/ml
TIER 01 QL
lorazepam oral tablet TIER 01 QL
meprobamate TIER 01
oxazepam TIER 01 QL
quazepam TIER 01 QL
TRANXENE-T TIER 03 QL
triazolam TIER 01 QL
VISTARIL TIER 03
Bipolar Agents - Drugs for Mood Disorders
EQUETRO TIER 03
lithium TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
24
Drug Name Drug Tier Notes
lithium carbonate er TIER 01
lithium carbonate oral TIER 01
LITHOBID TIER 03
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders
ADVATE SPECIALTY
ADYNOVATE SPECIALTY
AFSTYLA SPECIALTY
AGRYLIN TIER 03
ALPHANATE/VWF COMPLEX/HUMAN
SPECIALTY
ALPHANINE SD SPECIALTY
ALPROLIX SPECIALTY
AMICAR SPECIALTY
aminocaproic acid intravenous
SPECIALTY
aminocaproic acid oral SPECIALTY
anagrelide hcl TIER 01
ARANESP (ALBUMIN FREE)
SPECIALTY PA
ASTRINGYN TIER 03
BENEFIX SPECIALTY
CEPROTIN SPECIALTY
COAGADEX SPECIALTY
CORIFACT SPECIALTY
CYKLOKAPRON TIER 03
DOPTELET SPECIALTY PA
ELOCTATE SPECIALTY
FEIBA SPECIALTY
FIBRYGA SPECIALTY
HEMLIBRA SPECIALTY
HEMOFIL M SPECIALTY
HESPAN TIER 03
hetastarch-nacl TIER 01
HEXTEND TIER 03
HUMATE-P SPECIALTY
IDELVION SPECIALTY
IXINITY SPECIALTY
JIVI SPECIALTY
Drug Name Drug Tier Notes
KCENTRA TIER 03
KOATE SPECIALTY
KOATE-DVI SPECIALTY
KOGENATE FS SPECIALTY
KOVALTRY SPECIALTY
LEUKINE SPECIALTY PA
LMD IN D5W TIER 03
LMD IN NACL TIER 03
LYSTEDA TIER 03
MIRCERA SPECIALTY PA
MONONINE SPECIALTY
MOZOBIL SPECIALTY PA; QL
MULPLETA SPECIALTY PA
NEULASTA SPECIALTY PA
NEULASTA ONPRO SPECIALTY PA
NIVESTYM SPECIALTY PA
NOVOEIGHT SPECIALTY
NOVOSEVEN RT SPECIALTY
NPLATE SPECIALTY PA
NUWIQ SPECIALTY
OBIZUR SPECIALTY
PANHEMATIN SPECIALTY
PROFILNINE SPECIALTY
PROMACTA SPECIALTY PA
protamine sulfate intravenous
TIER 01
REBINYN SPECIALTY
REBLOZYL SPECIALTY
RECOMBINATE SPECIALTY
RECOTHROM TIER 03
RECOTHROM SPRAY KIT
TIER 03
RETACRIT SPECIALTY PA
RIASTAP SPECIALTY
RIXUBIS SPECIALTY
SOLIRIS SPECIALTY PA
TAVALISSE SPECIALTY
THROMBIN-JMI TIER 03
THROMBIN-JMI EPISTAXIS
TIER 03
THROMBOGEN TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
25
Drug Name Drug Tier Notes
tranexamic acid intravenous
TIER 01
tranexamic acid oral TIER 01
TRANEXAMIC ACID-NACL
TIER 03
TRETTEN SPECIALTY
UDENYCA SPECIALTY PA
ULTOMIRIS SPECIALTY PA
VONVENDI SPECIALTY
WILATE SPECIALTY
XYNTHA SPECIALTY
XYNTHA SOLOFUSE SPECIALTY
ZARXIO SPECIALTY PA
ZIEXTENZO SPECIALTY PA
Cardiovascular Agents - Drugs for Heart and Circulation Conditions
ACCUPRIL TIER 03
ACCURETIC TIER 03
acebutolol hcl oral TIER 01
acetazolamide sodium TIER 01
ADENOCARD TIER 03
adenosine intravenous solution 12 mg/4ml, 6 mg/2ml
TIER 01
AKOVAZ TIER 03
ALDACTAZIDE TIER 03
ALDACTONE TIER 03
aliskiren fumarate TIER 01
alprostadil injection TIER 01
amiloride hcl oral TIER 01
amiloride-hydrochlorothiazide
TIER 01
amiodarone hcl TIER 01
amlodipine besylate oral TIER 01
amlodipine besylate-benazepril hcl
TIER 01
amlodipine besylate-valsartan
TIER 01
amlodipine-atorvastatin TIER 01
amlodipine-olmesartan TIER 01
Drug Name Drug Tier Notes
amlodipine-valsartan-hctz
TIER 01
ASCLERA TIER 03
ATACAND HCT TIER 03
atenolol oral TIER 01
atenolol-chlorthalidone TIER 01
atorvastatin calcium oral TIER 01
AVALIDE TIER 03
benazepril hcl oral TIER 01
benazepril-hydrochlorothiazide
TIER 01
BETAPACE AF TIER 03
betaxolol hcl oral TIER 01
BIDIL TIER 03
BIORPHEN TIER 03
bisoprolol fumarate TIER 01
bisoprolol-hydrochlorothiazide
TIER 01
BREVIBLOC TIER 03
BREVIBLOC IN NACL TIER 03
BREVIBLOC PREMIXED TIER 03
BREVIBLOC PREMIXED DS
TIER 03
bumetanide TIER 01
BUMEX TIER 03
BYSTOLIC TIER 02
CADUET TIER 03
CALAN SR TIER 03
candesartan cilexetil TIER 01
candesartan cilexetil-hctz TIER 01
captopril oral TIER 01
captopril-hydrochlorothiazide
TIER 01
CARDENE IV TIER 03
CARDIZEM TIER 03
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG
TIER 03
CARDURA TIER 03
CAROSPIR TIER 03
cartia xt TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
26
Drug Name Drug Tier Notes
carvedilol TIER 01
carvedilol phosphate er TIER 01
CATAPRES TIER 03
chlorothiazide sodium TIER 01
chlorthalidone TIER 01
cholestyramine light TIER 01
cholestyramine oral TIER 01
CLEVIPREX TIER 03
clonidine TIER 01
clonidine hcl oral TIER 01
colesevelam hcl TIER 01
colestipol hcl TIER 01
CONJUPRI TIER 03
CORLANOR TIER 03 PA; QL
CORLOPAM TIER 03
CORVERT TIER 03
DEMSER TIER 03
DIBENZYLINE TIER 03
digitek TIER 01
digox TIER 01
digoxin injection TIER 01
digoxin oral TIER 01
DILATRATE-SR TIER 03
diltiazem hcl er TIER 01
diltiazem hcl er beads TIER 01
diltiazem hcl er coated beads
TIER 01
diltiazem hcl intravenous TIER 01
diltiazem hcl oral TIER 01
DILTIAZEM HCL-DEXTROSE
TIER 03
DILTIAZEM HCL-SODIUM CHLORIDE
TIER 03
dilt-xr TIER 01
disopyramide phosphate TIER 01
DIURIL TIER 03
dobutamine hcl TIER 01
dobutamine in d5w TIER 01
dofetilide TIER 01
dopamine hcl intravenous
TIER 01
Drug Name Drug Tier Notes
dopamine in d5w TIER 01
doxazosin mesylate oral TIER 01
DYRENIUM TIER 03
EDARBI TIER 03 ST
EDARBYCLOR TIER 03 ST
EDECRIN TIER 03
enalapril maleate oral TIER 01
enalaprilat TIER 01
enalapril-hydrochlorothiazide
TIER 01
ENTRESTO TIER 02 QL
EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION PREFILLED SYRINGE 25 MG/5ML, 50 MG/5ML
TIER 03
ephedrine sulfate intravenous solution
TIER 01
EPHEDRINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
EPHEDRINE SULFATE-NACL
TIER 03
EPINEPHRINE HCL-DEXTROSE
TIER 03
EPINEPHRINE HCL-NACL
TIER 03
EPINEPHRINE INTRAVENOUS
TIER 03
epinephrine pf TIER 01
epinephrine solution prefilled syringe 1 mg/10ml injection
TIER 01
EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML INJECTION
TIER 03
EPINEPHRINE-DEXTROSE
TIER 03
EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 MG/250ML-%
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
27
Drug Name Drug Tier Notes
EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
eplerenone TIER 01
esmolol hcl intravenous solution 100 mg/10ml
TIER 01
ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML
TIER 03
esmolol hcl-sodium chloride
TIER 01
ethacrynate sodium TIER 01
ethacrynic acid TIER 01
ETHAMOLIN TIER 03
EZALLOR SPRINKLE TIER 03 ST
ezetimibe TIER 01
ezetimibe-simvastatin TIER 01
felodipine er TIER 01
fenofibrate micronized TIER 01
fenofibrate oral capsule TIER 01
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
TIER 01
fenofibric acid oral capsule delayed release
TIER 01
FIBRICOR ORAL TABLET 105 MG
TIER 03 ST
FIBRICOR ORAL TABLET 35 MG
TIER 03
flecainide acetate TIER 01
FLOLIPID TIER 03 ST
fosinopril sodium TIER 01
fosinopril sodium-hctz TIER 01
FUROSEMIDE IN SODIUM CHLORIDE
TIER 03
furosemide injection TIER 01
furosemide oral TIER 01
gemfibrozil oral TIER 01
GONITRO TIER 03
guanfacine hcl TIER 01
HEMANGEOL TIER 03
Drug Name Drug Tier Notes
hydralazine hcl injection TIER 01
hydralazine hcl oral TIER 01
hydrochlorothiazide oral TIER 01
ibutilide fumarate TIER 01
indapamide TIER 01
INSPRA TIER 03
irbesartan TIER 01
irbesartan-hydrochlorothiazide
TIER 01
isoproterenol hcl injection
TIER 01
ISORDIL TITRADOSE TIER 03
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg
TIER 01
isosorbide mononitrate TIER 01
isosorbide mononitrate er
TIER 01
isradipine TIER 01
ISUPREL TIER 03
JUXTAPID SPECIALTY PA; QL
LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
labetalol hcl oral TIER 01
labetalol hcl solution 5 mg/ml intravenous
TIER 01
LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS
TIER 03
LANOXIN INJECTION TIER 03
LANOXIN ORAL TIER 02
LANOXIN PEDIATRIC TIER 03
LEVOPHED TIER 03
LIPOFEN TIER 03
lisinopril oral TIER 01
lisinopril-hydrochlorothiazide
TIER 01
LIVALO TIER 03 ST
LOPID TIER 03
LOPRESSOR TIER 03
LOPRESSOR HCT TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
28
Drug Name Drug Tier Notes
losartan potassium oral TIER 01
losartan potassium-hctz TIER 01
LOTENSIN TIER 03
LOTENSIN HCT TIER 03
lovastatin TIER 01
mannitol intravenous TIER 01
matzim la TIER 01
MAXZIDE TIER 03
MAXZIDE-25 TIER 03
methyldopa TIER 01
methyldopa-hydrochlorothiazide
TIER 01
metolazone TIER 01
metoprolol succinate er TIER 01
metoprolol tartrate intravenous
TIER 01
metoprolol tartrate oral TIER 01
metoprolol-hydrochlorothiazide
TIER 01
metyrosine TIER 01
mexiletine hcl oral TIER 01
midodrine hcl TIER 01
milrinone lactate TIER 01
milrinone lactate in dextrose
TIER 01
MINIPRESS TIER 03
minoxidil oral TIER 01
moexipril hcl TIER 01
MULTAQ TIER 03
NEXLETOL TIER 02
NEXLIZET TIER 02
NEXTERONE TIER 03
niacin er (antihyperlipidemic)
TIER 01
nicardipine hcl TIER 01
NICARDIPINE HCL IN NACL
TIER 03
nifedipine er TIER 01
nifedipine er osmotic release
TIER 01
nifedipine oral TIER 01
nimodipine oral TIER 01
Drug Name Drug Tier Notes
nisoldipine er TIER 01
NITRO-BID TIER 03
NITRO-DUR TIER 03
nitroglycerin TIER 01
nitroglycerin in d5w TIER 01
NITROLINGUAL TIER 03
NITROMIST TIER 03
NITROPRESS TIER 03
nitroprusside sodium TIER 01
nitro-time oral capsule extended release 2.5 mg
TIER 01
norepinephrine bitartrate intravenous
TIER 01
NOREPINEPHRINE-DEXTROSE
TIER 03
NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 8-0.9 MG/250ML-%
TIER 03
NORPACE TIER 03
NORPACE CR TIER 02
NORTHERA SPECIALTY PA
NYMALIZE TIER 03
olmesartan medoxomil oral
TIER 01
olmesartan medoxomil-hctz
TIER 01
olmesartan-amlodipine-hctz
TIER 01
omega-3-acid ethyl esters
TIER 01
OSMITROL INTRAVENOUS SOLUTION 10 %
TIER 03
osmitrol intravenous solution 15 %, 20 %
TIER 01
PACERONE ORAL TABLET 100 MG, 400 MG
TIER 03
pacerone oral tablet 200 mg
TIER 01
pentoxifylline er TIER 01
perindopril erbumine TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
29
Drug Name Drug Tier Notes
phenoxybenzamine hcl oral
TIER 01
phentolamine mesylate injection
TIER 01
PHENYLEPHRINE HCL (PRESSORS)
TIER 03
phenylephrine hcl intravenous solution
TIER 01
PHENYLEPHRINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 20-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 50-0.9 MG/250ML-%, 80-0.9 MG/250ML-%
TIER 03
PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
pindolol TIER 01
PRALUENT TIER 02
pravastatin sodium TIER 01
prazosin hcl oral TIER 01
PRESTALIA TIER 03
prevalite TIER 01
procainamide hcl injection
TIER 01
PROCARDIA TIER 03
PROCARDIA XL TIER 03
propafenone hcl TIER 01
propafenone hcl er TIER 01
propranolol hcl er TIER 01
propranolol hcl intravenous
TIER 01
propranolol hcl oral TIER 01
propranolol-hctz TIER 01
PROSTIN VR TIER 03
quinapril hcl TIER 01
quinapril-hydrochlorothiazide
TIER 01
quinidine gluconate er TIER 01
Drug Name Drug Tier Notes
quinidine sulfate TIER 01
ramipril TIER 01
ranolazine er TIER 01
RECTIV TIER 03
REPATHA TIER 02
REPATHA PUSHTRONEX SYSTEM
TIER 02
REPATHA SURECLICK TIER 02
rosuvastatin calcium TIER 01
RYTHMOL SR TIER 03
simvastatin oral TIER 01
SODIUM DIURIL TIER 03
SODIUM EDECRIN TIER 03
sorine TIER 01
sotalol hcl (af) TIER 01
SOTALOL HCL INTRAVENOUS
TIER 03
sotalol hcl oral TIER 01
SOTYLIZE TIER 03
spironolactone oral TIER 01
spironolactone-hctz TIER 01
SULAR TIER 03
TARKA TIER 03
taztia xt TIER 01
TEKTURNA TIER 02
TEKTURNA HCT TIER 02 ST
telmisartan TIER 01
telmisartan-amlodipine TIER 01
telmisartan-hctz TIER 01
TENORETIC 100 TIER 03
TENORETIC 50 TIER 03
tiadylt er TIER 01
TIAZAC TIER 03
timolol maleate oral TIER 01
torsemide TIER 01
trandolapril TIER 01
trandolapril-verapamil hcl er
TIER 01
triamterene oral TIER 01
triamterene-hctz TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
30
Drug Name Drug Tier Notes
TRILIPIX TIER 03
TWYNSTA TIER 03
valsartan TIER 01
valsartan-hydrochlorothiazide
TIER 01
VARITHENA TIER 03
VASCEPA TIER 02
VASERETIC TIER 03
VAZCULEP TIER 03
VECAMYL TIER 03
verapamil hcl er TIER 01
verapamil hcl intravenous
TIER 01
verapamil hcl oral TIER 01
VERELAN TIER 03
VERELAN PM TIER 03
VYNDAMAX SPECIALTY
VYNDAQEL SPECIALTY
ZIAC TIER 03
Central Nervous System Agents - Drugs for Attention Deficit Disorder
ADZENYS ER TIER 03 PA; QL
ADZENYS XR-ODT TIER 03 ST; QL
AMPHETAMINE ER TIER 03 PA; QL
amphetamine sulfate TIER 01 PA; QL
amphetamine-dextroamphetamine
TIER 01 PA; QL
amphetamine-dextroamphetamine er
TIER 01 PA; QL
APTENSIO XR TIER 03 ST; QL
atomoxetine hcl TIER 01 QL
clonidine hcl er TIER 01
COTEMPLA XR-ODT TIER 03 ST; QL
DAYTRANA TIER 03 ST; QL
dexmethylphenidate hcl TIER 01 PA; QL
dexmethylphenidate hcl er
TIER 01 PA; QL
dextroamphetamine sulfate
TIER 01 PA; QL
dextroamphetamine sulfate er
TIER 01 PA; QL
Drug Name Drug Tier Notes
DYANAVEL XR TIER 03 ST; QL
EVEKEO ODT TIER 03 PA; QL
guanfacine hcl er TIER 01
JORNAY PM TIER 03 ST; QL
KAPVAY TIER 03 ST
metadate er TIER 01 PA; QL
METHYLIN TIER 03 ST; QL
methylphenidate hcl er TIER 01 PA; QL
methylphenidate hcl er (cd)
TIER 01 PA; QL
methylphenidate hcl er (la)
TIER 01 PA; QL
methylphenidate hcl oral TIER 01 PA; QL
MYDAYIS TIER 03 ST; QL
PROCENTRA TIER 03 ST; QL
QUILLICHEW ER TIER 03 ST; QL
QUILLIVANT XR TIER 03 ST; QL
relexxii TIER 01 PA; QL
VYVANSE TIER 02 PA; QL
ZENZEDI ORAL TABLET 10 MG, 5 MG
TIER 03 PA; QL
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
TIER 03 ST; QL
Central Nervous System Agents - Drugs for Multiple Sclerosis
AMPYRA SPECIALTY PA; QL
AUBAGIO SPECIALTY PA; QL
AVONEX PEN SPECIALTY PA; QL
AVONEX PREFILLED SPECIALTY PA; QL
BAFIERTAM SPECIALTY PA; QL
BETASERON SPECIALTY PA; QL
COPAXONE SPECIALTY PA; QL
dalfampridine er SPECIALTY PA; QL
dimethyl fumarate oral SPECIALTY PA; QL
GILENYA SPECIALTY PA; QL
glatiramer acetate SPECIALTY PA; QL
glatopa SPECIALTY PA; QL
LEMTRADA SPECIALTY PA
MAVENCLAD (10 TABS) SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
31
Drug Name Drug Tier Notes
MAVENCLAD (4 TABS) SPECIALTY PA
MAVENCLAD (5 TABS) SPECIALTY PA
MAVENCLAD (6 TABS) SPECIALTY PA
MAVENCLAD (7 TABS) SPECIALTY PA
MAVENCLAD (8 TABS) SPECIALTY PA
MAVENCLAD (9 TABS) SPECIALTY PA
MAYZENT SPECIALTY PA; QL
MAYZENT STARTER PACK
SPECIALTY PA; QL
OCREVUS SPECIALTY PA; QL
REBIF SPECIALTY PA; QL
REBIF REBIDOSE SPECIALTY PA; QL
REBIF REBIDOSE TITRATION PACK
SPECIALTY PA; QL
REBIF TITRATION PACK
SPECIALTY PA; QL
TECFIDERA SPECIALTY PA; QL
TYSABRI SPECIALTY PA; QL
VUMERITY SPECIALTY PA; QL
VUMERITY (STARTER) SPECIALTY PA; QL
Central Nervous System Agents - Miscellaneous
ADDYI TIER 03 PA; QL
ANECTINE TIER 03
atracurium besylate TIER 01
AUSTEDO SPECIALTY PA
CAFCIT TIER 03
caffeine citrate TIER 01
CAFFEINE-SODIUM BENZOATE
TIER 03
cisatracurium besylate TIER 01
cisatracurium besylate (pf)
TIER 01
DOPRAM TIER 03
GRALISE TIER 03 ST; QL
HORIZANT TIER 03 PA; QL
INGREZZA SPECIALTY PA
LYRICA CR TIER 03 ST; QL
NIMBEX TIER 03
NUEDEXTA TIER 03 PA
ONPATTRO SPECIALTY
Drug Name Drug Tier Notes
pancuronium bromide TIER 01
pregabalin oral TIER 01 QL
QUELICIN TIER 03
RADICAVA SPECIALTY PA
RILUTEK SPECIALTY PA; QL
riluzole SPECIALTY PA; QL
rocuronium bromide intravenous solution
TIER 01
ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
SAVELLA TIER 03 ST; QL
SAVELLA TITRATION PACK
TIER 03 ST; QL
SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE
TIER 03
SUCCINYLCHOLINE CHLORIDE INTRAVENOUS
TIER 03
succinylcholine chloride solution 20 mg/ml injection
TIER 01
SUCCINYLCHOLINE CHLORIDE SOLUTION 20 MG/ML INJECTION
TIER 03
TEGSEDI SPECIALTY
tetrabenazine SPECIALTY PA
TIGLUTIK SPECIALTY PA; QL
VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE
TIER 03
vecuronium bromide intravenous solution reconstituted
TIER 01
VYLEESI TIER 03 PA; QL
Dental and Oral Agents - Drugs for Mouth and Throat Conditions
cevimeline hcl TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
32
Drug Name Drug Tier Notes
chlorhexidine gluconate mouth/throat
TIER 01
DEBACTEROL TIER 03
EVOXAC TIER 03
fluoridex sensitivity relief TIER 01
KEPIVANCE SPECIALTY
lidocaine hcl mouth/throat
TIER 01
lidocaine viscous hcl TIER 01
MI PASTE TIER 03
MI PASTE PLUS TIER 03
NAFRINSE DAILY ACIDULATED
TIER 03
oralone TIER 01
paroex TIER 01
PERIDEX TIER 03
periogard TIER 01
pilocarpine hcl oral TIER 01
PREVIDENT 5000 ENAMEL PROTECT
TIER 03
PREVIDENT 5000 SENSITIVE
TIER 03
REMESENSE TIER 03
SALAGEN TIER 03
sodium fluoride 5000 sensitive
TIER 01
TOPEX TOPICAL ANESTHETIC
TIER 03
triamcinolone acetonide mouth/throat
TIER 01
Dermatological Agents - Drugs for Skin Conditions
ABSORICA LD TIER 03
acitretin TIER 01
ACZONE EXTERNAL GEL 7.5 %
TIER 02
adapalene external cream
TIER 01 PA
adapalene external gel TIER 01 PA
ADAPALENE EXTERNAL SOLUTION
TIER 03 PA
adapalene-benzoyl peroxide
TIER 01
Drug Name Drug Tier Notes
ala-cort TIER 01
alclometasone dipropionate
TIER 01
ALCOHOL PREP PADS EXTERNAL 70 %
TIER 03
ALTRENO TIER 03 PA
amcinonide external lotion
TIER 01
ammonium lactate external
TIER 01
amnesteem TIER 01
AMZEEQ TIER 03
ATRALIN TIER 03 PA
avita TIER 01 PA
azelaic acid external TIER 01
AZELEX TIER 03
balsam peru-castor oil TIER 01
benzoyl peroxide-erythromycin
TIER 01
beser external lotion TIER 01
betamethasone dipropionate aug
TIER 01
betamethasone dipropionate external
TIER 01
betamethasone valerate external
TIER 01
BPCO TIER 03
calcipotriene external cream
TIER 01
calcipotriene external ointment
TIER 01
calcipotriene external solution
TIER 01
calcipotriene-betameth diprop external suspension
TIER 01 QL
CALCITRENE TIER 03
calcitriol external TIER 01
CARAC TIER 03
claravis TIER 01
CLEOCIN-T EXTERNAL LOTION
TIER 03
clindacin etz external swab
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
33
Drug Name Drug Tier Notes
clindacin-p TIER 01
clindamycin phosphate-benzoyl peroxide
TIER 01
clindamycin phosphate external
TIER 01
clindamycin-tretinoin TIER 01
clobetasol prop emollient base
TIER 01
clobetasol propionate e TIER 01
clobetasol propionate emulsion
TIER 01
clobetasol propionate external
TIER 01
clocortolone pivalate TIER 01
clodan external shampoo TIER 01
coal tar external TIER 01
CONDYLOX TIER 03
CORTISPORIN TIER 03
CUTIVATE TIER 03
dapsone external gel 5 %
TIER 01
DERMA-SMOOTHE/FS BODY
TIER 03
DERMA-SMOOTHE/FS SCALP
TIER 03
DERMULCERA TIER 03
desonide external TIER 01
DESOWEN TIER 03
desoximetasone external cream 0.25 %
TIER 01
desoximetasone external gel
TIER 01
desoximetasone external liquid
TIER 01
desoximetasone external ointment 0.25 %
TIER 01
diclofenac sodium transdermal gel 3 %
TIER 01 ST; QL
DIPROLENE TIER 03
DIPROLENE AF TIER 03
DOVONEX TIER 03
DRYSOL TIER 03
DUPIXENT SPECIALTY PA; QL
Drug Name Drug Tier Notes
EFUDEX TIER 03
EPIDUO FORTE TIER 03
EPIFOAM TIER 03
ery TIER 01
ERYGEL TIER 03
erythromycin external TIER 01
EUCRISA TIER 02 ST
EVOCLIN TIER 03
FINACEA EXTERNAL FOAM
TIER 03 ST
fluocinolone acetonide body
TIER 01
fluocinolone acetonide external
TIER 01
fluocinolone acetonide scalp
TIER 01
fluocinonide emulsified base
TIER 01
fluocinonide external cream 0.05 %
TIER 01
fluocinonide external gel TIER 01
fluocinonide external ointment
TIER 01
fluocinonide external solution
TIER 01
FLUOROPLEX TIER 03
FLUOROURACIL EXTERNAL CREAM 0.5 %
TIER 02
fluorouracil external cream 5 %
TIER 01
fluorouracil external solution
TIER 01
fluticasone propionate external
TIER 01
GORDOFILM TIER 03
halobetasol propionate external cream
TIER 01
halobetasol propionate external ointment
TIER 01
HALOG EXTERNAL SOLUTION
TIER 03
hydrocortisone butyrate external cream
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
34
Drug Name Drug Tier Notes
hydrocortisone butyrate external ointment
TIER 01
hydrocortisone butyrate external solution
TIER 01
hydrocortisone external cream 1 %, 2.5 %
TIER 01
hydrocortisone external lotion 2.5 %
TIER 01
hydrocortisone external ointment 1 %, 2.5 %
TIER 01
hydrocortisone valerate TIER 01
imiquimod external TIER 01
isotretinoin oral TIER 01
KERAMATRIX REPLICINE 5CMX5CM
TIER 03
KLARON TIER 03
lactic acid e TIER 01
lactic acid external TIER 01
LEVULAN KERASTICK TIER 03
LUXIQ TIER 03
methoxsalen rapid TIER 01
METROCREAM TIER 03
METROLOTION TIER 03
metronidazole external TIER 01
MICROCYN EXTERNAL LIQUID 0.023 %
TIER 03
MIRVASO TIER 02
mometasone furoate external
TIER 01
myorisan TIER 01
NEO-SYNALAR EXTERNAL CREAM
TIER 03
neuac external gel TIER 01
OLUX TIER 03
OLUX-E TIER 03
ONEXTON TIER 03
OXSORALEN ULTRA TIER 03
PICATO TIER 03 ST
pimecrolimus TIER 01
podofilox external TIER 01
prednicarbate TIER 01
PROTOPIC TIER 03
Drug Name Drug Tier Notes
PYROGALLIC ACID TIER 03
QBREXZA TIER 03 QL
RADIAPLEXRX TIER 03
REGENECARE TIER 03
REGRANEX TIER 03 PA
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %
TIER 02 PA
RHOFADE TIER 03
rosadan external cream TIER 01
rosadan external gel TIER 01
SANTYL TIER 03
SCENESSE SPECIALTY
selenium sulfide external lotion
TIER 01
SERNIVO TIER 03
SOOLANTRA TIER 02
SORIATANE TIER 03
sulfacetamide sodium (acne)
TIER 01
SYNALAR TIER 03
TACLONEX EXTERNAL SUSPENSION
TIER 03 QL
tacrolimus external ointment
TIER 01
tazarotene external TIER 01
TAZORAC EXTERNAL CREAM 0.05 %
TIER 03
TAZORAC EXTERNAL GEL
TIER 03
TEMOVATE TIER 03
TEXACORT TIER 03
THERAHONEY EXTERNAL SHEET
TIER 03
TOLAK TIER 03
TOPICORT EXTERNAL CREAM 0.25 %
TIER 03
TOPICORT EXTERNAL GEL
TIER 03
TOPICORT EXTERNAL OINTMENT
TIER 03
tovet external foam TIER 01
tretinoin external TIER 01 PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
35
Drug Name Drug Tier Notes
tretinoin microsphere TIER 01 PA
tretinoin microsphere pump
TIER 01 PA
triamcinolone acetonide external cream
TIER 01
triamcinolone acetonide external lotion
TIER 01
triamcinolone acetonide external ointment
TIER 01
trianex TIER 01
TRI-CHLOR TIER 03
triderm TIER 01
TRIDESILON TIER 03
vashe cleansing TIER 01
VENELEX TIER 03
XERAC AC TIER 03
XEROFORM OIL EMULSION 2"X2"
TIER 03
XEROFORM OIL EMULSION GAUZE
TIER 03
XEROFORM OIL EMULSION STRIP
TIER 03
XEROFORM OIL ROLL 4"X9'
TIER 03
XEROFORM PETROLAT GAUZE 1"X8"
TIER 03
XEROFORM PETROLAT GAUZE 5"X9"
TIER 03
XEROFORM PETROLAT PATCH 2"X2"
TIER 03
XEROFORM PETROLAT PATCH 4"X4"
TIER 03
XEROFORM PETROLATUM ROLL 4"X9'
TIER 03
zenatane TIER 01
Diabetes - Antidiabetic Agents
acarbose oral TIER 01
ACTOPLUS MET TIER 03
ACTOS TIER 03
Drug Name Drug Tier Notes
AMARYL TIER 03
AVANDIA TIER 03 ST
BYDUREON TIER 02 ST; QL
BYDUREON BCISE AUTOINJECTOR
TIER 02 ST; QL
BYETTA 10 MCG PEN TIER 02 ST; QL
BYETTA 5 MCG PEN TIER 02 ST; QL
CYCLOSET TIER 03 ST
DUETACT TIER 03
FARXIGA TIER 02 ST
glimepiride TIER 01
glipizide er TIER 01
glipizide ir TIER 01
glipizide xl TIER 01
glipizide-metformin hcl TIER 01
GLUCOTROL TIER 03
GLUCOTROL XL TIER 03
glyburide micronized TIER 01
glyburide oral TIER 01
glyburide-metformin TIER 01
GLYNASE TIER 03
GLYSET TIER 03
GLYXAMBI TIER 02 ST
JANUMET TIER 02 ST
JANUMET XR TIER 02 ST
JANUVIA TIER 02 ST
JARDIANCE TIER 02 ST
JENTADUETO TIER 02 ST
JENTADUETO XR TIER 02 ST
metformin hcl er TIER 01
metformin hcl ir TIER 01
miglitol TIER 01
nateglinide TIER 01
OZEMPIC TIER 02 ST; QL
pioglitazone hcl TIER 01
pioglitazone hcl-glimepiride
TIER 01
pioglitazone hcl-metformin hcl
TIER 01
PRECOSE TIER 03
repaglinide TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
36
Drug Name Drug Tier Notes
RIOMET TIER 03 ST
RIOMET ER TIER 03 ST
RYBELSUS TIER 02 ST; QL
SOLIQUA TIER 02 ST; QL
STARLIX TIER 03
SYMLINPEN 120 TIER 03 PA
SYMLINPEN 60 TIER 03 PA
SYNJARDY TIER 02 ST
SYNJARDY XR TIER 02 ST
tolbutamide TIER 01
TRADJENTA TIER 02 ST
TRIJARDY XR TIER 02 ST
TRULICITY TIER 02 ST; QL
VICTOZA TIER 02 ST; QL
XIGDUO XR TIER 02 ST
XULTOPHY TIER 03 ST; QL
Diabetes - Glucose Monitoring
ACCU-CHEK FASTCLIX LANCET KIT
TIER 02
ACCU-CHEK MULTICLIX LANCET DEVICE KIT
TIER 02
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT
TIER 02
AUTOLET II CLINISAFE TIER 03
AUTOLET LANCING DEVICE
TIER 03
CARETOUCH LANCING/EJECTOR
TIER 03
CEQUR SIMPLICITY 2U TIER 03
CEQUR SIMPLICITY STARTER
TIER 03
CHEMSTRIP UGK TIER 03
DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)
TIER 02
Drug Name Drug Tier Notes
DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE
TIER 02
DIATHRIVE LANCING DEVICE
TIER 03
ENLITE GLUCOSE SENSOR
TIER 03
EVERSENSE SENSOR/HOLDER
TIER 03
EVERSENSE SMART TRANSMITTER
TIER 03
FREESTYLE LIBRE 14 DAY READER
TIER 02
FREESTYLE LIBRE 14 DAY SENSOR
TIER 02
GENTEEL LANCING KIT (BLUE)
TIER 03
GOJJI LANCING DEVICE/CLEAR CAP
TIER 03
GUARDIAN CONNECT TRANSMITTER
TIER 03
GUARDIAN LINK 3 TRANSMITTER
TIER 03
GUARDIAN SENSOR (3) TIER 03
INPEN 100-BLUE-LILLY TIER 03
INPEN 100-BLUE-NOVO TIER 03
INPEN 100-GRAY-LILLY TIER 03
INPEN 100-GREY-NOVO
TIER 03
INPEN 100-PINK-LILLY TIER 03
INPEN 100-PINK-NOVO TIER 03
KETONE TEST TIER 03
KETOSTIX TIER 03
LANCETS TIER 02
LANCETS TIER 03
LANCETS KIT TIER 03
MICROLET NEXT LANCING DEVICE
TIER 03
MINIMED GUARDIAN SENSOR 3
TIER 03
NOVOPEN ECHO TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
37
Drug Name Drug Tier Notes
OMNIPOD DASH SYSTEM
TIER 03
OMNIPOD STARTER TIER 03
ONETOUCH DELICA LANCING DEV
TIER 03
ONETOUCH DELICA PLUS LANCING
TIER 03
ONETOUCH ULTRA TIER 02 QL
ONETOUCH ULTRA 2 KIT W/DEVICE
TIER 02
ONETOUCH ULTRA MINI KIT W/DEVICE
TIER 02
ONETOUCH VERIO KIT W/DEVICE
TIER 02
ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE
TIER 02
ONETOUCH VERIO IN VITRO SOLUTION HIGH
TIER 03
ONETOUCH VERIO TEST STRIPS
TIER 02 QL
ONETOUCH VERIO IQ SYSTEM
TIER 02
ONETOUCH VERIO REFLECT KIT W/DEVICE
TIER 02
ONETOUCH VERIO REFLECT KIT W/DEVICE
TIER 03
ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE
TIER 02
SURESTEP PRO HIGH GLUCOSE
TIER 03
SURESTEP PRO LOW GLUCOSE
TIER 03
SURESTEP PRO NORMAL GLUCOSE
TIER 03
V-GO 20 TIER 02
V-GO 30 TIER 02
V-GO 40 TIER 02
VIVAGUARD LANCING DEVICE
TIER 03
Diabetes - Glycemic Agents
BAQSIMI ONE PACK TIER 02
Drug Name Drug Tier Notes
BAQSIMI TWO PACK TIER 02
diazoxide oral TIER 01
GLUCAGEN HYPOKIT TIER 03
GLUCAGON EMERGENCY KIT
TIER 02
GVOKE HYPOPEN 1-PACK
TIER 02
GVOKE HYPOPEN 2-PACK
TIER 02
GVOKE PFS TIER 02
PROGLYCEM TIER 03
Diabetes - Insulins
AFREZZA TIER 03 PA
BD AUTOSHIELD DUO PEN NEEDLES
TIER 02
BD ULTRA-FINE INSULIN SYRINGES
TIER 02
BD ULTRA-FINE PEN NEEDLES
TIER 02
BD VEO INSULIN SYR U/F 1/2UNIT
TIER 02
DIATHRIVE PEN NEEDLE
TIER 02
DROPLET MICRON TIER 02
HUMALOG KWIKPEN TIER 02
HUMALOG MIX 50/50 KWIKPEN
TIER 02
HUMALOG MIX 50/50 VIAL
TIER 02
HUMALOG MIX 75/25 KWIKPEN
TIER 02
HUMALOG MIX 75/25 VIAL
TIER 02
HUMALOG U-100 JUNIOR KWIKPEN
TIER 02
HUMALOG VIAL TIER 02
HUMULIN 70/30 KWIKPEN
TIER 02
HUMULIN 70/30 VIAL TIER 02
HUMULIN N KWIKPEN TIER 02
HUMULIN N VIAL TIER 02
HUMULIN R U-500 KWIKPEN
TIER 02
HUMULIN R U-500 VIAL TIER 02
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
38
Drug Name Drug Tier Notes
HUMULIN R VIAL TIER 02
INSULIN PEN NEEDLES TIER 02
INSULIN SYRINGES TIER 02
LANTUS SOLOSTAR TIER 02
LANTUS U-100 VIAL TIER 02
MAXICOMFORT SYR 27G X 1/2"
TIER 02
MYXREDLIN TIER 03
NOVOFINE AUTOCOVER PEN NEEDLE
TIER 02
NOVOFINE PEN NEEDLE
TIER 02
NOVOFINE PLUS PEN NEEDLE
TIER 02
NOVOTWIST PEN NEEDLE
TIER 02
TOUJEO MAX SOLOSTAR
TIER 02
TOUJEO SOLOSTAR TIER 02
Electrolytes / Minerals / Metals / Vitamins
ACTIVE FE TIER 03
AMINO ACID TIER 03
AMINOPROTECT TIER 03
AMINOSYN II TIER 03
AMINOSYN-PF TIER 03
AQUASOL A TIER 03
ARGININE HCL INJECTION
TIER 03
argyle sterile saline TIER 01
argyle sterile water TIER 01
ATABEX OB TIER 02
CALCIFOL TIER 03
CALCIUM CHLORIDE SOLUTION 10 % INTRAVENOUS
TIER 03
calcium chloride solution 10 % intravenous
TIER 01
calcium gluconate intravenous
TIER 01
Drug Name Drug Tier Notes
CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.675 GM/50ML-%
TIER 03
CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.9 GM/100ML-%, 2-0.9 GM/100ML-%
TIER 03
CARBAGLU SPECIALTY
CARNITOR INTRAVENOUS
TIER 03
CENTRATEX TIER 03
CHEMET TIER 03
chromagen TIER 01
chromic chloride intravenous
TIER 01
CLINIMIX E/DEXTROSE (2.75/5)
TIER 03
CLINIMIX E/DEXTROSE (4.25/10)
TIER 03
CLINIMIX E/DEXTROSE (4.25/5)
TIER 03
CLINIMIX E/DEXTROSE (5/15)
TIER 03
CLINIMIX E/DEXTROSE (5/20)
TIER 03
CLINIMIX/DEXTROSE (4.25/10)
TIER 03
CLINIMIX/DEXTROSE (4.25/5)
TIER 03
CLINIMIX/DEXTROSE (5/15)
TIER 03
CLINIMIX/DEXTROSE (5/20)
TIER 03
CLINISOL SF TIER 03
CLINOLIPID TIER 03
clovique SPECIALTY PA
corvita 150 TIER 01
CORVITE 150 ORAL TABLET
TIER 03
CORVITE 150 ORAL TABLET 150-1.25 MG
TIER 02
CORVITE FE TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
39
Drug Name Drug Tier Notes
CUPRIC CHLORIDE TIER 03
curity sterile saline TIER 01
cyanocobalamin injection solution 1000 mcg/ml
TIER 01
CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML
TIER 03
deferasirox SPECIALTY PA
deferasirox granules SPECIALTY PA
deferiprone SPECIALTY PA
dehydrated alcohol TIER 01
DEXPANTHENOL INJECTION
TIER 03
dextrose intravenous solution 10 %, 20 %, 30 %, 40 %, 5 %, 70 %
TIER 01
DEXTROSE SOLUTION 250 MG/ML INTRAVENOUS
TIER 03
dextrose solution 250 mg/ml intravenous
TIER 01
DEXTROSE SOLUTION 50 % INTRAVENOUS
TIER 03
dextrose solution 50 % intravenous
TIER 01
DILUENT FOR LEFAMULIN
TIER 03
DRISDOL TIER 03
EDETATE DISODIUM INTRAVENOUS
TIER 03
EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ
TIER 03
effer-k oral tablet effervescent 25 meq
TIER 01
ELITE-OB TIER 02
ergocalciferol oral capsule
TIER 01
EXJADE SPECIALTY PA
FERAHEME TIER 03
ferocon TIER 01
ferotrinsic TIER 01
FERRALET 90 TIER 03
FERRAPLUS 90 TIER 02
Drug Name Drug Tier Notes
FERRIPROX SPECIALTY PA
FERRIPROX TWICE-A-DAY
SPECIALTY PA
FERRLECIT TIER 03
ferrocite plus TIER 01
FERRO-PLEX HEMATINIC
TIER 03
FERROTRIN TIER 03
folic acid injection TIER 01
folic acid oral tablet 1 mg TIER 01
FOLIVANE-F TIER 03
FOLIVANE-PLUS TIER 03
foltrin TIER 01
FREAMINE HBC TIER 03
FREAMINE III TIER 03
FUSION PLUS TIER 03
GALZIN TIER 03
GLUTATHIONE INJECTION SOLUTION 200 MG/ML
TIER 03
GLUTATHIONE INTRAVENOUS
TIER 03
GLYCINE INJECTION TIER 03
GLYCOPHOS TIER 03
hematinic plus vit/minerals
TIER 01
hematinic/folic acid TIER 01
hematogen TIER 01
hematogen forte TIER 01
HEMATRON-AF TIER 03
HEMOCYTE PLUS TIER 03
hemocyte-f TIER 01
hemocyte-plus TIER 01
HEPATAMINE TIER 03
hydroxocobalamin acetate
TIER 01
ICAR-C PLUS TIER 02
iferex 150 forte TIER 01
INFED TIER 03
INJECTAFER TIER 03
INTEGRA F TIER 03
INTEGRA PLUS TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
40
Drug Name Drug Tier Notes
intralipid intravenous emulsion 20 %
TIER 01
INTRALIPID INTRAVENOUS EMULSION 30 %
TIER 03
iodine strong oral TIER 01
IS 24/6 TIER 03
JADENU SPECIALTY PA
JADENU SPRINKLE SPECIALTY PA
JYNARQUE SPECIALTY QL
KABIVEN TIER 03
kionex TIER 01
klor-con TIER 01
klor-con 10 TIER 01
klor-con m10 TIER 01
KLOR-CON M15 TIER 03
klor-con m20 TIER 01
klor-con sprinkle TIER 01
klor-con/ef TIER 01
K-PHOS TIER 03
K-PHOS-NEUTRAL TIER 03
k-prime TIER 01
k-tan plus TIER 01
lactated ringers irrigation TIER 01
LEVOCARNITINE INJECTION
TIER 03
levocarnitine oral solution
TIER 01
levocarnitine oral tablet TIER 01
levocarnitine sf TIER 01
LIPO TIER 03
LIPO-C TIER 03
LOKELMA TIER 03
LYSINE HCL INJECTION
TIER 03
MAGNEBIND 400 TIER 03
magnesium chloride injection
TIER 01
magnesium sulfate in d5w
TIER 01
Drug Name Drug Tier Notes
MAGNESIUM SULFATE INTRAVENOUS SOLUTION 1000 MG/1.6ML, 2000 MG/3.2ML, 3000 MG/4.8ML, 4000 MG/6.4ML
TIER 03
magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml
TIER 01
MAGNESIUM SULFATE SOLUTION 50 % INJECTION
TIER 03
magnesium sulfate solution 50 % injection
TIER 01
MAGNESIUM SULFATE-NACL
TIER 03
MANGANESE CHLORIDE
TIER 03
MEPHYTON TIER 03
METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED
TIER 03
M-NATAL PLUS TIER 02
monoject flush syringe TIER 01
monoject sodium chloride flush
TIER 01
MULTIGEN TIER 03
MULTIGEN FOLIC TIER 03
MULTIGEN PLUS TIER 03
myferon 150 forte TIER 01
na ferric gluc cplx in sucrose
TIER 01
n-acetyl-l-cysteine oral TIER 01
NASCOBAL TIER 03
NEOKE ALCAR TIER 03
NEONATAL PLUS TIER 02
NEPHRAMINE TIER 03
NEPHRON FA TIER 03
NESTABS TIER 02
NIFEREX TIER 03
normal saline flush TIER 01
NUFERA TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
41
Drug Name Drug Tier Notes
nutrilipid TIER 01
NUTRIVIT TIER 03
ONE VITE WOMENS PLUS
TIER 02
ORACIT TIER 03
PERIKABIVEN TIER 03
phospha 250 neutral TIER 01
phosphorous TIER 01
phospho-trin 250 neutral TIER 01
PHYSIOLYTE TIER 03
PHYSIOSOL IRRIGATION
TIER 03
phytonadione injection TIER 01
phytonadione oral TIER 01
PLENAMINE TIER 03
poly-iron 150 forte TIER 01
polysaccharide iron forte TIER 01
pot bicarb-pot chloride TIER 01
potassium acetate intravenous
TIER 01
potassium bicarbonate oral
TIER 01
potassium chloride crys er
TIER 01
potassium chloride er TIER 01
potassium chloride intravenous
TIER 01
potassium chloride oral TIER 01
potassium citrate er TIER 01
potassium phosphates(71 meq k)
TIER 01
PREMASOL TIER 03
prenatal oral tablet 27-1 mg
TIER 01
prenatal plus iron TIER 01
PRENATVITE PLUS TIER 02
PRENATVITE RX TIER 02
PRISMASOL B22GK 4/0 TIER 03
PRISMASOL BGK 0/2.5 TIER 03
PRISMASOL BGK 2/0 TIER 03
PRISMASOL BGK 2/3.5 TIER 03
PRISMASOL BGK 4/2.5 TIER 03
Drug Name Drug Tier Notes
PRISMASOL BK 0/0/1.2 TIER 03
PROCALAMINE TIER 03
PROSOL TIER 03
purevit dualfe plus TIER 01
PYRIDOXINE HCL SOLUTION 100 MG/ML INJECTION
TIER 03
pyridoxine hcl solution 100 mg/ml injection
TIER 01
RELNATE DHA TIER 02
RENATABS WITH IRON TIER 03
ringers irrigation TIER 01
saline bacteriostatic TIER 01
saline flush TIER 01
saline flush zr TIER 01
SALINE-PHENOL TIER 03
SAMSCA SPECIALTY QL
se-tan plus TIER 01
SMOFLIPID TIER 03
sod citrate-citric acid TIER 01
sodium acetate intravenous
TIER 01
sodium bicarbonate intravenous solution 4.2 %, 7.5 %
TIER 01
SODIUM BICARBONATE SOLUTION 8.4 % INTRAVENOUS
TIER 03
sodium bicarbonate solution 8.4 % intravenous
TIER 01
sodium chloride (pf) TIER 01
sodium chloride bacteriostatic
TIER 01
sodium chloride flush TIER 01
sodium chloride injection TIER 01
sodium chloride intravenous
TIER 01
sodium chloride irrigation TIER 01
sodium phosphates TIER 01
sodium polystyrene sulfonate
TIER 01
sps TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
42
Drug Name Drug Tier Notes
sterile water for irrigation TIER 01
swabflush saline flush TIER 01
TARON FORTE TIER 03
TAURINE INJECTION TIER 03
THAM TIER 03
THE LIQUILIFT TRACE TIER 03
thiamine hcl injection TIER 01
tis-u-sol TIER 01
tl-hem 150 TIER 01
tolvaptan SPECIALTY QL
TRALEMENT TIER 03
TRAVASOL TIER 03
TRI-AMINO TIER 03
TRICARE PRENATAL DHA ONE
TIER 02
tricon TIER 01
trientine hcl SPECIALTY PA
TRIFERIC HEMODIALYSIS PACKET
TIER 03
trigels-f forte TIER 01
trinate TIER 01
TRISODIUM CITRATE/CRRT
TIER 03
TROPHAMINE TIER 03
UROCIT-K 10 TIER 03
UROCIT-K 15 TIER 03
UROCIT-K 5 TIER 03
VELTASSA TIER 03
VENOFER TIER 03
VIRT-FEFA PLUS TIER 03
virt-phos 250 neutral TIER 01
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)
TIER 01
vitamin k1 injection TIER 01
vp-pnv-dha TIER 01
water for irrigation, sterile TIER 01
ZINC CHLORIDE INTRAVENOUS
TIER 03
Drug Name Drug Tier Notes
ZINC SULFATE INTRAVENOUS SOLUTION 5 MG/ML
TIER 03
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
CARAFATE ORAL SUSPENSION
TIER 03
cimetidine hcl TIER 01
cimetidine oral TIER 01
CYTOTEC TIER 03
DEXILANT TIER 02 QL
esomeprazole magnesium
TIER 01 QL
esomeprazole sodium TIER 01
famotidine intravenous TIER 01
famotidine oral suspension reconstituted
TIER 01
famotidine oral tablet 20 mg, 40 mg
TIER 01
famotidine premixed TIER 01
FIRST-LANSOPRAZOLE
TIER 03 ST
FIRST-OMEPRAZOLE TIER 03 ST
lansoprazole oral capsule delayed release
TIER 01 QL
lansoprazole oral tablet delayed release dispersible 15 mg
TIER 01 QL
misoprostol oral TIER 01
NEXIUM I.V. TIER 03
NEXIUM ORAL PACKET TIER 03 QL
nizatidine TIER 01
omeprazole oral capsule delayed release
TIER 01 QL
OMEPRAZOLE+SYRSPEND SF ALKA
TIER 03 ST
pantoprazole sodium intravenous
TIER 01 QL
pantoprazole sodium oral TIER 01 QL
PRILOSEC TIER 03 ST; QL
PROTONIX INTRAVENOUS
TIER 03 QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
43
Drug Name Drug Tier Notes
PROTONIX ORAL PACKET
TIER 03 ST; QL
rabeprazole sodium oral tablet delayed release
TIER 01 QL
sucralfate oral TIER 01
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions
ACTIGALL TIER 03
alosetron hcl TIER 01 PA
amoxicill-clarithro-lansopraz
TIER 01
ANASPAZ TIER 03
ATROPEN TIER 03
atropine sulfate injection solution 8 mg/20ml
TIER 01
atropine sulfate injection solution prefilled syringe
TIER 01
ATROPINE SULFATE INTRAVENOUS
TIER 03
BENTYL TIER 03
cascara sagrada oral fluid extract
TIER 01
CHENODAL SPECIALTY
chlordiazepoxide-clidinium
TIER 01
CLENPIQ TIER 03
constulose TIER 01
cromolyn sodium oral TIER 01
CUVPOSA TIER 03
dicyclomine hcl intramuscular
TIER 01
dicyclomine hcl oral TIER 01
diphenoxylate-atropine TIER 01
ed-spaz TIER 01
ENTEREG TIER 03
enulose TIER 01
GASTROCROM TIER 03
GATTEX SPECIALTY PA
gavilyte-c TIER 01
gavilyte-g TIER 01
gavilyte-h TIER 01
Drug Name Drug Tier Notes
gavilyte-n with flavor pack
TIER 01
generlac TIER 01
glycopyrrolate injection solution
TIER 01
GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE
TIER 03
GLYCOPYRROLATE INTRAVENOUS
TIER 03
glycopyrrolate oral tablet 1 mg, 2 mg
TIER 01
glycopyrrolate pf TIER 01
GLYRX-PF TIER 03
HELIDAC THERAPY TIER 03
hyoscyamine sulfate oral TIER 01
hyoscyamine sulfate sl TIER 01
hyoscyamine sulfate sublingual
TIER 01
lactulose encephalopathy
TIER 01
lactulose oral solution TIER 01
LINZESS TIER 02 ST; QL
LOMOTIL TIER 03
loperamide hcl oral capsule
TIER 01
methscopolamine bromide oral
TIER 01
mineral oil heavy oral TIER 01
MOTEGRITY TIER 03 ST; QL
MYTESI TIER 03 QL
nulev TIER 01
OMECLAMOX-PAK TIER 02
oscimin TIER 01
OSMOPREP TIER 03
peg 3350-kcl-na bicarb-nacl
TIER 01
peg-3350/electrolytes TIER 01
peg-3350/electrolytes/ascorbat
TIER 01
peg-kcl-nacl-nasulf-na asc-c
TIER 01
peg-prep TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
44
Drug Name Drug Tier Notes
PLENVU TIER 03
propantheline bromide oral
TIER 01
PYLERA TIER 02
RESTORA RX TIER 03
SEROSTIM SPECIALTY PA
sodium bicarbonate oral powder
TIER 01
SUPREP BOWEL PREP KIT
TIER 03
SYMPROIC SPECIALTY QL
TALICIA TIER 03
trilyte TIER 01
URSO 250 TIER 03
URSO FORTE TIER 03
ursodiol oral TIER 01
VIBERZI TIER 03 PA
XERMELO SPECIALTY
ZELNORM TIER 03 QL
ZORBTIVE SPECIALTY PA
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment
ALDURAZYME SPECIALTY PA
AMMONUL TIER 03
BUPHENYL SPECIALTY
CERDELGA SPECIALTY PA
CEREZYME SPECIALTY PA
CHOLBAM SPECIALTY PA
CREON TIER 02
CRYSVITA SPECIALTY
CYSTADANE SPECIALTY
CYSTAGON SPECIALTY
ELAPRASE SPECIALTY PA
ELELYSO SPECIALTY PA
FABRAZYME SPECIALTY PA
GALAFOLD SPECIALTY PA; QL
KANUMA SPECIALTY PA
KUVAN SPECIALTY PA
LUMIZYME SPECIALTY PA
Drug Name Drug Tier Notes
MEPSEVII SPECIALTY PA
miglustat SPECIALTY PA
MYALEPT SPECIALTY PA
NAGLAZYME SPECIALTY PA
nitisinone SPECIALTY
NITYR SPECIALTY
OCALIVA SPECIALTY PA; QL
ORFADIN SPECIALTY
PALYNZIQ SPECIALTY PA
PROCYSBI SPECIALTY PA
RAVICTI SPECIALTY PA
REVCOVI SPECIALTY PA
sapropterin dihydrochloride
SPECIALTY PA
sod benz-sod phenylacet TIER 01
sodium phenylbutyrate oral
SPECIALTY
STRENSIQ SPECIALTY PA
SUCRAID SPECIALTY
VIMIZIM SPECIALTY PA
VPRIV SPECIALTY PA
XURIDEN SPECIALTY PA; QL
ZAVESCA SPECIALTY PA
ZENPEP TIER 02
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions
acetic acid irrigation TIER 01
aminoacetic acid TIER 01
AURYXIA TIER 03
bethanechol chloride oral TIER 01
calcium acetate (phos binder)
TIER 01
calcium acetate oral tablet 667 mg
TIER 01
CUPRIMINE SPECIALTY PA
darifenacin hydrobromide er
TIER 01
DEPEN TITRATABS SPECIALTY
DETROL TIER 03
DETROL LA TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
45
Drug Name Drug Tier Notes
DITROPAN XL TIER 03
ELMIRON TIER 02
ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG
TIER 03
flavoxate hcl TIER 01
FOSRENOL TIER 03
GELNIQUE TIER 03
glycine irrigation TIER 01
glycine urologic TIER 01
INTRAROSA TIER 03
lanthanum carbonate TIER 01
LITHOSTAT TIER 03
MUSE TIER 03 QL
MYRBETRIQ TIER 02
oxybutynin chloride er TIER 01
oxybutynin chloride oral TIER 01
OXYTROL TIER 03 QL
penicillamine oral capsule
SPECIALTY PA
penicillamine oral tablet SPECIALTY
phenazo oral tablet 200 mg
TIER 01
phenazopyridine hcl oral tablet 100 mg, 200 mg
TIER 01
PHOSLYRA TIER 03
RENACIDIN TIER 03
RIMSO-50 TIER 03
sevelamer carbonate TIER 01
sevelamer hcl TIER 01
sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg
TIER 01 QL
solifenacin succinate TIER 01
tadalafil oral TIER 01 QL
THIOLA SPECIALTY
THIOLA EC SPECIALTY
tolterodine tartrate TIER 01
tolterodine tartrate er TIER 01
TOVIAZ TIER 03
trospium chloride TIER 01
Drug Name Drug Tier Notes
trospium chloride er TIER 01
uretron d/s oral tablet TIER 01
urin ds oral tablet TIER 01
utrona-c TIER 01
vardenafil hcl oral TIER 01 QL
VELPHORO TIER 03
Genitourinary Agents - Drugs for Prostate Conditions
alfuzosin hcl er TIER 01
CARDURA XL TIER 03 ST
dutasteride oral TIER 01
dutasteride-tamsulosin hcl
TIER 01
finasteride oral tablet 5 mg
TIER 01
JALYN TIER 03
PROSCAR TIER 03
RAPAFLO TIER 03
silodosin TIER 01
tamsulosin hcl TIER 01
terazosin hcl TIER 01
Hormonal Agents - Adrenal
betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml
TIER 01
CELESTONE SOLUSPAN
TIER 03
cortisone acetate oral TIER 01
DEPO-MEDROL TIER 03
DEXAMETHASONE (LA) TIER 03
dexamethasone intensol TIER 01
dexamethasone oral TIER 01
dexamethasone sod phosphate pf
TIER 01
dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
46
Drug Name Drug Tier Notes
DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MG/ML INJECTION
TIER 03
dexamethasone sodium phosphate solution 10 mg/ml injection
TIER 01
DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 MG/ML INJECTION
TIER 03
dexamethasone sodium phosphate solution 4 mg/ml injection
TIER 01
DEXONTO 0.4% TIER 03
fludrocortisone acetate oral
TIER 01
hydrocortisone oral TIER 01
KENALOG INJECTION SUSPENSION 10 MG/ML
TIER 03
KENALOG-80 TIER 03
MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG
TIER 03
MEDROL ORAL TABLET 2 MG
TIER 02
MEDROL ORAL TABLET THERAPY PACK
TIER 03
METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MG/ML
TIER 03
METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML INJECTION
TIER 03
methylprednisolone acetate suspension 40 mg/ml injection
TIER 01
METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML INJECTION
TIER 03
Drug Name Drug Tier Notes
methylprednisolone acetate suspension 80 mg/ml injection
TIER 01
methylprednisolone oral TIER 01
methylprednisolone sodium succ
TIER 01
METHYLPREDNISOLONE-BUPIVACAINE
TIER 03
MILLIPRED TIER 02
MILLIPRED DP 12-DAY TIER 03
ORAPRED ODT TIER 03
PEDIAPRED TIER 03
prednisolone oral solution
TIER 01
prednisolone sodium phosphate oral
TIER 01
prednisone intensol TIER 01
prednisone oral TIER 01
SOLU-CORTEF TIER 03
SOLU-MEDROL TIER 03
triamcinolone acetonide suspension 40 mg/ml injection
TIER 01
TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION
TIER 03
TRIAMCINOLONE DIACETATE INJECTION SUSPENSION 80 MG/ML
TIER 03
TRIAMCINOLONE-BUPIVACAINE
TIER 03
ZILRETTA TIER 03
Hormonal Agents - Men's Health
ANDRODERM TIER 02 PA
NATESTO TIER 03 PA
testosterone cypionate intramuscular
TIER 01 PA
testosterone enanthate intramuscular
TIER 01 PA
testosterone transdermal TIER 01 PA
XYOSTED TIER 03 PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
47
Drug Name Drug Tier Notes
Hormonal Agents - Osteoporosis
EVISTA TIER 03
OSPHENA TIER 03
raloxifene hcl TIER 01
Hormonal Agents - Pituitary
ACTHAR SPECIALTY PA
cabergoline TIER 01
DDAVP TIER 03
DDAVP RHINAL TUBE TIER 02
desmopressin ace spray refrig
TIER 01
desmopressin acetate injection
TIER 01
desmopressin acetate oral
TIER 01
desmopressin acetate spray
TIER 01
EGRIFTA SV SPECIALTY PA; QL
ELIGARD SPECIALTY PA; QL
FIRMAGON SPECIALTY PA; QL
FIRMAGON (240 MG DOSE)
SPECIALTY PA; QL
INCRELEX SPECIALTY PA
leuprolide acetate injection
SPECIALTY PA
LEUPROLIDE ACETATE-BUPIVACAINE
TIER 03
LUPANETA PACK SPECIALTY PA; QL
LUPRON DEPOT (1-MONTH)
SPECIALTY PA
LUPRON DEPOT (3-MONTH)
SPECIALTY PA
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG
SPECIALTY PA
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG
SPECIALTY PA
LUPRON DEPOT-PED (1-MONTH)
SPECIALTY PA
Drug Name Drug Tier Notes
LUPRON DEPOT-PED (3-MONTH)
SPECIALTY PA
NOCDURNA TIER 03
NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML
SPECIALTY PA
NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML
SPECIALTY PA
NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION 20 MG/2ML
SPECIALTY PA
NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION 5 MG/2ML
SPECIALTY PA
octreotide acetate SPECIALTY PA
ORILISSA TIER 02
oxytocin injection TIER 01
OXYTOCIN-LACTATED RINGERS
TIER 03
OXYTOCIN-SODIUM CHLORIDE
TIER 03
PITOCIN TIER 03
SIGNIFOR SPECIALTY PA
SIGNIFOR LAR SPECIALTY PA
SOMATULINE DEPOT SPECIALTY PA
SOMAVERT SPECIALTY PA
STIMATE SPECIALTY
SUPPRELIN LA SPECIALTY PA; QL
SYNAREL SPECIALTY
TEPEZZA SPECIALTY
TRELSTAR MIXJECT SPECIALTY PA; QL
TRIPTODUR SPECIALTY PA; QL
VANTAS SPECIALTY PA; QL
VAPRISOL TIER 03
VASOSTRICT TIER 03
ZOLADEX SPECIALTY QL
Hormonal Agents - Prostaglandins
KORLYM SPECIALTY PA; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
48
Drug Name Drug Tier Notes
Hormonal Agents - Sex Hormones and Birth Control
ACTIVELLA TIER 03
afirmelle TIER 01
ALORA TIER 03
altavera TIER 01
alyacen 1/35 TIER 01
alyacen 7/7/7 TIER 01
amabelz TIER 01
amethia TIER 01 QL
amethia lo TIER 01 QL
amethyst TIER 01
ANGELIQ TIER 03
apri TIER 01
aranelle TIER 01
ashlyna TIER 01 QL
aubra TIER 01
aubra eq TIER 01
aurovela 1.5/30 TIER 01
aurovela 1/20 TIER 01
aurovela 24 fe TIER 01
aurovela fe 1.5/30 TIER 01
aurovela fe 1/20 TIER 01
aviane TIER 01
AYGESTIN TIER 03
ayuna TIER 01
azurette TIER 01
balziva TIER 01
bekyree TIER 01
BIJUVA TIER 03
blisovi 24 fe TIER 01
blisovi fe 1.5/30 TIER 01
blisovi fe 1/20 TIER 01
briellyn TIER 01
camila TIER 01
camrese TIER 01 QL
camrese lo TIER 01 QL
caziant TIER 01
charlotte 24 fe TIER 01
Drug Name Drug Tier Notes
chateal TIER 01
chateal eq TIER 01
CLIMARA PRO TIER 02
COMBIPATCH TIER 03
CRINONE TIER 03 QL
cryselle-28 TIER 01
cyclafem 1/35 TIER 01
cyclafem 7/7/7 TIER 01
cyred TIER 01
cyred eq TIER 01
dasetta 1/35 TIER 01
dasetta 7/7/7 TIER 01
daysee TIER 01 QL
deblitane TIER 01
DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML
TIER 03
delyla TIER 01
DEPO-ESTRADIOL TIER 03
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML
TIER 03
desogestrel-ethinyl estradiol
TIER 01
DIVIGEL TIER 03
dotti TIER 01
drospiren-eth estrad-levomefol
TIER 01
drospirenone-ethinyl estradiol
TIER 01
DUAVEE TIER 02
ELESTRIN TIER 03
elinest TIER 01
ELLA TIER 03
emoquette TIER 01
ENDOMETRIN TIER 02
enpresse-28 TIER 01
enskyce TIER 01
errin TIER 01
estarylla TIER 01
estradiol oral TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
49
Drug Name Drug Tier Notes
estradiol transdermal TIER 01
estradiol vaginal TIER 01
estradiol valerate intramuscular
TIER 01
estradiol-norethindrone acet
TIER 01
ESTRING TIER 03 QL
ESTROGEL TIER 03
ESTROSTEP FE TIER 03
ethynodiol diac-eth estradiol
TIER 01
EVAMIST TIER 03
falmina TIER 01
fayosim TIER 01 QL
FEMHRT LOW DOSE TIER 03
FEMRING TIER 03 QL
femynor TIER 01
fyavolv TIER 01
gianvi TIER 01
hailey 1.5/30 TIER 01
hailey 24 fe TIER 01
hailey fe 1.5/30 TIER 01
hailey fe 1/20 TIER 01
heather TIER 01
hydroxyprogesterone caproate intramuscular oil
SPECIALTY
hydroxyprogesterone caproate intramuscular solution
SPECIALTY PA
IMVEXXY MAINTENANCE PACK
TIER 03
IMVEXXY STARTER PACK
TIER 03
incassia TIER 01
introvale TIER 01 QL
isibloom TIER 01
jaimiess TIER 01 QL
jasmiel TIER 01
jencycla TIER 01
jinteli TIER 01
jolessa TIER 01 QL
Drug Name Drug Tier Notes
juleber TIER 01
junel 1.5/30 TIER 01
junel 1/20 TIER 01
junel fe 1.5/30 TIER 01
junel fe 1/20 TIER 01
junel fe 24 TIER 01
kaitlib fe TIER 01
kalliga TIER 01
kariva TIER 01
kelnor 1/35 TIER 01
kelnor 1/50 TIER 01
kurvelo TIER 01
larin 1.5/30 TIER 01
larin 1/20 TIER 01
larin 24 fe TIER 01
larin fe 1.5/30 TIER 01
larin fe 1/20 TIER 01
larissia TIER 01
layolis fe TIER 01
leena TIER 01
lessina TIER 01
levonest TIER 01
levonorgest-eth est & eth est
TIER 01 QL
levonorgest-eth estrad 91-day
TIER 01 QL
levonorgestrel-ethinyl estrad
TIER 01
levonorg-eth estrad triphasic
TIER 01
levora 0.15/30 (28) TIER 01
lillow TIER 01
lojaimiess TIER 01 QL
lopreeza TIER 01
loryna TIER 01
LOSEASONIQUE TIER 03 QL
low-ogestrel TIER 01
lo-zumandimine TIER 01
lutera TIER 01
lyza TIER 01
MAKENA SPECIALTY
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
50
Drug Name Drug Tier Notes
marlissa TIER 01
medroxyprogesterone acetate oral
TIER 01
megestrol acetate oral TIER 01
melodetta 24 fe TIER 01
MENEST TIER 02
MENOSTAR TIER 03
mibelas 24 fe TIER 01
microgestin 1.5/30 TIER 01
microgestin 1/20 TIER 01
microgestin fe 1.5/30 TIER 01
microgestin fe 1/20 TIER 01
mili TIER 01
mimvey TIER 01
MINIVELLE TIER 03
MIRCETTE TIER 03
mono-linyah TIER 01
NATAZIA TIER 02
necon 0.5/35 (28) TIER 01
nikki TIER 01
nora-be TIER 01
norethin ace-eth estrad-fe
TIER 01
norethindrone acetate oral
TIER 01
norethindrone acet-ethinyl est
TIER 01
norethindrone oral TIER 01
norethindrone-eth estradiol
TIER 01
norethin-eth estradiol-fe TIER 01
norgestimate-eth estradiol
TIER 01
norgestimate-ethinyl estradiol triphasic
TIER 01
norlyda TIER 01
norlyroc TIER 01
nortrel 0.5/35 (28) TIER 01
nortrel 1/35 (21) TIER 01
nortrel 1/35 (28) TIER 01
nortrel 7/7/7 TIER 01
NUVARING TIER 03
Drug Name Drug Tier Notes
ocella TIER 01
orsythia TIER 01
philith TIER 01
pimtrea TIER 01
pirmella 1/35 TIER 01
pirmella 7/7/7 TIER 01
portia-28 TIER 01
PREFEST TIER 03
PREMARIN INJECTION TIER 03
PREMARIN ORAL TIER 02
PREMARIN VAGINAL TIER 02
PREMPHASE TIER 02
PREMPRO TIER 02
previfem TIER 01
progesterone intramuscular
TIER 01
progesterone micronized oral
TIER 01
PROVERA TIER 03
QUARTETTE TIER 03 QL
reclipsen TIER 01
rivelsa TIER 01 QL
setlakin TIER 01 QL
sharobel TIER 01
simliya TIER 01
simpesse TIER 01 QL
sprintec 28 TIER 01
sronyx TIER 01
syeda TIER 01
tarina 24 fe TIER 01
tarina fe 1/20 TIER 01
tarina fe 1/20 eq TIER 01
tilia fe TIER 01
tri femynor TIER 01
tri-estarylla TIER 01
tri-legest fe TIER 01
tri-linyah TIER 01
tri-lo-estarylla TIER 01
tri-lo-marzia TIER 01
tri-lo-mili TIER 01
tri-lo-sprintec TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
51
Drug Name Drug Tier Notes
tri-mili TIER 01
tri-previfem TIER 01
tri-sprintec TIER 01
trivora (28) TIER 01
tri-vylibra TIER 01
tri-vylibra lo TIER 01
tulana TIER 01
tydemy TIER 01
velivet TIER 01
vienva TIER 01
viorele TIER 01
volnea TIER 01
vyfemla TIER 01
vylibra TIER 01
wera TIER 01
wymzya fe TIER 01
yuvafem TIER 01
zarah TIER 01
zovia 1/35e (28) TIER 01
zumandimine TIER 01
Hormonal Agents - Thyroid
ARMOUR THYROID TIER 03
euthyrox TIER 01
levo-t TIER 01
levothyroxine sodium intravenous
TIER 01
levothyroxine sodium oral
TIER 01
levoxyl TIER 01
liothyronine sodium intravenous
TIER 01
liothyronine sodium oral TIER 01
methimazole oral TIER 01
NATURE-THROID TIER 03
np thyroid TIER 01
propylthiouracil oral TIER 01
TAPAZOLE TIER 03
TRIOSTAT TIER 03
unithroid TIER 01
WESTHROID TIER 03
Drug Name Drug Tier Notes
WP THYROID TIER 03
Immunological Agents - Drugs for Immune System Stimulation or Suppression
ACTEMRA SPECIALTY PA
ACTEMRA ACTPEN SPECIALTY PA
ACTIMMUNE SPECIALTY
ALFERON N SPECIALTY
ARCALYST SPECIALTY PA
ASTAGRAF XL SPECIALTY
ATGAM TIER 02
AZASAN TIER 03
azathioprine oral TIER 01
azathioprine sodium TIER 01
BENLYSTA SPECIALTY PA
BERINERT SPECIALTY PA
BIVIGAM SPECIALTY PA
CARIMUNE NF SPECIALTY PA
CELLCEPT SPECIALTY
CELLCEPT INTRAVENOUS
SPECIALTY
CIMZIA SPECIALTY PA
CIMZIA PREFILLED KIT SPECIALTY PA
CIMZIA STARTER KIT SPECIALTY PA
CINRYZE SPECIALTY PA
CUVITRU SPECIALTY PA
cyclosporine intravenous TIER 01
cyclosporine modified TIER 01
cyclosporine oral TIER 01
CYTOGAM SPECIALTY PA
ENBREL SPECIALTY PA
ENBREL MINI SPECIALTY PA
ENBREL SURECLICK SPECIALTY PA
ENTYVIO SPECIALTY PA
ENVARSUS XR SPECIALTY
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg
SPECIALTY PA
FIRAZYR SPECIALTY PA
FLEBOGAMMA DIF SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
52
Drug Name Drug Tier Notes
GAMASTAN SPECIALTY PA
GAMIFANT SPECIALTY
GAMMAGARD SPECIALTY PA
GAMMAGARD S/D LESS IGA
SPECIALTY PA
GAMMAKED SPECIALTY PA
GAMMAPLEX SPECIALTY PA
GAMUNEX-C SPECIALTY PA
gengraf TIER 01
HAEGARDA SPECIALTY PA
HEPAGAM B TIER 03
HIZENTRA SPECIALTY PA
HUMIRA SPECIALTY PA
HUMIRA PEDIATRIC CROHNS START
SPECIALTY PA
HUMIRA PEN SPECIALTY PA
HUMIRA PEN-CD/UC/HS STARTER
SPECIALTY PA
HUMIRA PEN-PS/UV/ADOL HS START
SPECIALTY PA
HYPERHEP B S/D TIER 03
HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML
TIER 02
HYPERRAB INJECTION SOLUTION 900 UNIT/3ML
TIER 03
HYPERRAB S/D TIER 02
HYPERRHO S/D SPECIALTY
HYPERTET S/D TIER 03
HYQVIA SPECIALTY PA
icatibant acetate SPECIALTY PA
ILARIS SPECIALTY PA; QL
ILUMYA SPECIALTY PA
IMOGAM RABIES-HT TIER 02
IMURAN TIER 03
INFLECTRA SPECIALTY PA
KALBITOR SPECIALTY PA
KEDRAB TIER 02
KEVZARA SPECIALTY PA
KINERET SPECIALTY PA
leflunomide oral TIER 01
Drug Name Drug Tier Notes
methotrexate (anti-rheumatic)
TIER 01
methotrexate oral TIER 01
methotrexate sodium TIER 01
methotrexate sodium (pf) TIER 01
MICRHOGAM ULTRA-FILTERED PLUS
SPECIALTY
mycophenolate mofetil SPECIALTY
mycophenolate mofetil hcl
SPECIALTY
mycophenolate sodium SPECIALTY
MYFORTIC SPECIALTY
NABI-HB TIER 03
NEORAL TIER 03
NULOJIX TIER 03 PA
OCTAGAM SPECIALTY PA
ORENCIA SPECIALTY PA
ORENCIA CLICKJECT SPECIALTY PA
OTEZLA SPECIALTY PA
OTREXUP SPECIALTY PA; QL
PRIVIGEN SPECIALTY PA
PROGRAF SPECIALTY
RAPAMUNE SPECIALTY
RASUVO SPECIALTY PA; QL
RENFLEXIS SPECIALTY PA
RHOGAM ULTRA-FILTERED PLUS
SPECIALTY
RHOPHYLAC TIER 02
RIDAURA SPECIALTY
RINVOQ SPECIALTY PA
RUCONEST SPECIALTY PA
SANDIMMUNE INTRAVENOUS
TIER 02
SANDIMMUNE ORAL CAPSULE
TIER 03
SANDIMMUNE ORAL SOLUTION
TIER 02
SILIQ SPECIALTY PA
SIMPONI SPECIALTY PA
SIMPONI ARIA SPECIALTY PA
SIMULECT TIER 03
sirolimus oral SPECIALTY
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
53
Drug Name Drug Tier Notes
SKYRIZI (150 MG DOSE)
SPECIALTY PA
STELARA SPECIALTY PA
SYNAGIS SPECIALTY PA
tacrolimus oral SPECIALTY
TAKHZYRO SPECIALTY PA
TALTZ SPECIALTY PA
temsirolimus SPECIALTY
THYMOGLOBULIN TIER 03
TICE BCG SPECIALTY
TORISEL SPECIALTY
TREMFYA SPECIALTY PA
TREXALL TIER 03
VARIZIG TIER 03 PA
WINRHO SDF SPECIALTY
XATMEP SPECIALTY
XELJANZ SPECIALTY PA
XELJANZ XR SPECIALTY PA
XEMBIFY SPECIALTY PA
ZINPLAVA TIER 03
ZORTRESS SPECIALTY PA
Immunological Agents - Drugs for Vaccination
ACTHIB TIER 03
ADACEL TIER 03
AFLURIA QUADRIVALENT
TIER 03
BCG VACCINE TIER 03
BEXSERO TIER 03
BIOTHRAX TIER 03
BOOSTRIX TIER 03
DAPTACEL TIER 03
DIPHTHERIA-TETANUS TOXOIDS DT
TIER 03
ENGERIX-B INJECTION TIER 03
FLUAD TIER 03
FLUAD QUADRIVALENT
TIER 03
FLUARIX QUADRIVALENT
TIER 03
Drug Name Drug Tier Notes
FLUBLOK QUADRIVALENT
TIER 03
FLUCELVAX QUADRIVALENT
TIER 03
FLULAVAL QUADRIVALENT
TIER 03
FLUMIST QUADRIVALENT
TIER 03
FLUZONE HIGH-DOSE QUADRIVALENT
TIER 03
FLUZONE QUADRIVALENT
TIER 03
GARDASIL 9 TIER 03
HAVRIX TIER 03
HEPLISAV-B TIER 03
HIBERIX TIER 03
IMOVAX RABIES TIER 03
INFANRIX TIER 03
IPOL TIER 03
IXIARO TIER 03
KINRIX TIER 03
MENACTRA TIER 03
MENQUADFI TIER 03
MENVEO TIER 03
M-M-R II TIER 03
PEDIARIX TIER 03
PEDVAX HIB TIER 03
PENTACEL TIER 03
PNEUMOVAX 23 TIER 03
PREVNAR 13 TIER 03
PROQUAD TIER 03
QUADRACEL TIER 03
RABAVERT TIER 03
RECOMBIVAX HB TIER 03
ROTARIX TIER 03
ROTATEQ TIER 03
SHINGRIX TIER 03
STAMARIL TIER 03
TDVAX TIER 03
TENIVAC TIER 03
TETANUS-DIPHTHERIA TOXOIDS TD
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
54
Drug Name Drug Tier Notes
TRUMENBA TIER 03
TWINRIX TIER 03
TYPHIM VI TIER 03
VAQTA TIER 03
VARIVAX TIER 03
VAXCHORA TIER 03
VIVOTIF TIER 03
YF-VAX TIER 03
Inflammatory Bowel Disease Agents
ANUSOL-HC EXTERNAL
TIER 03
APRISO TIER 02
AZULFIDINE TIER 03
AZULFIDINE EN-TABS TIER 03
balsalazide disodium TIER 01
budesonide er TIER 01
budesonide oral TIER 01
CORTENEMA TIER 03
CORTIFOAM TIER 03
ENTOCORT EC TIER 03
hydrocortisone (perianal) TIER 01
hydrocortisone ace-pramoxine external cream 1-1 %
TIER 01
hydrocortisone rectal TIER 01
mesalamine er TIER 01
mesalamine oral TIER 01
mesalamine rectal TIER 01
mesalamine-cleanser TIER 01
PENTASA TIER 03
PROCTOFOAM HC TIER 02
procto-med hc TIER 01
procto-pak TIER 01
proctosol hc TIER 01
proctozone-hc TIER 01
ROWASA TIER 03
SFROWASA TIER 02
sulfasalazine oral TIER 01
UCERIS RECTAL TIER 03
Drug Name Drug Tier Notes
Metabolic Bone Disease Agents - Drugs for Osteoporosis
ACTONEL ORAL TABLET 150 MG, 35 MG
TIER 03 QL
ACTONEL ORAL TABLET 30 MG, 5 MG
TIER 03
alendronate sodium oral solution
TIER 01
alendronate sodium oral tablet 10 mg, 5 mg
TIER 01
alendronate sodium oral tablet 35 mg, 70 mg
TIER 01 QL
ATELVIA TIER 03 QL
BINOSTO TIER 03 QL
BONIVA TIER 03 QL
calcitonin (salmon) TIER 01 QL
EVENITY SPECIALTY PA; QL
FORTEO SPECIALTY PA
FOSAMAX TIER 03 QL
FOSAMAX PLUS D TIER 03 QL
ibandronate sodium TIER 01 QL
MIACALCIN INJECTION TIER 03
pamidronate disodium SPECIALTY
PROLIA SPECIALTY PA; QL
RAYALDEE TIER 03
RECLAST SPECIALTY
risedronate sodium oral tablet 150 mg, 35 mg
TIER 01 QL
risedronate sodium oral tablet 30 mg, 5 mg
TIER 01
risedronate sodium oral tablet delayed release
TIER 01 QL
TERIPARATIDE (RECOMBINANT)
SPECIALTY PA
TYMLOS SPECIALTY PA
XGEVA SPECIALTY PA
zoledronic acid SPECIALTY
Metabolic Bone Disease Agents - Other
calcitriol intravenous TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
55
Drug Name Drug Tier Notes
calcitriol oral TIER 01
cinacalcet hcl SPECIALTY PA
doxercalciferol intravenous
TIER 01
HECTOROL TIER 03
NATPARA SPECIALTY PA; QL
paricalcitol SPECIALTY
PARSABIV SPECIALTY
ROCALTROL TIER 03
ZEMPLAR SPECIALTY
Miscellaneous Therapeutic Agents
ACCU-CHEK FLEXLINK PLUS 6MM
TIER 03
ACCU-CHEK ULTRAFLEX INF SET
TIER 03
ACETADOTE TIER 03
acetylcysteine intravenous
TIER 01
ADAKVEO SPECIALTY
ALBUKED 25 TIER 03
ALBUKED 5 TIER 03
albumin human TIER 01
ALBUMINEX TIER 03
albumin-zlb TIER 01
alburx TIER 01
ALBUTEIN TIER 03
ALCOHOL PREP PADS PAD
TIER 03
ALCOHOL PREP PADS PAD 70 %
TIER 03
ALPHA-LIPOIC ACID INJECTION
TIER 03
AMD FOAM DRESSING TIER 03
AMD FOAM DRESSING TOPSHEET
TIER 03
AMPHADASE TIER 03
ANASCORP TIER 03
ANAVIP TIER 03
ANTIVENIN LATRODECTUS MACTANS
TIER 03
Drug Name Drug Tier Notes
ANTIVENIN MICRURUS FULVIUS
TIER 03
ARTISS TIER 03
AUTOSOFT 30 INFUSION SET
TIER 03
AUTOSOFT 90 INFUSION SET
TIER 03
AUTOSOFT XC INFUSION SET
TIER 03
BACTERIOSTATIC WATER(BENZ ALC)
TIER 03
bal in oil TIER 01
BIOGUARD GAUZE SPONGES PAD 4"X4"
TIER 03
BIOGUARD ISLAND DRESSINGS
TIER 03
BIOGUARD NON-ADHERENT DRESSING
TIER 03
BOTOX SPECIALTY PA
BREATHE EASE LARGE
TIER 02
BREATHE EASE MEDIUM
TIER 02
BREATHE EASE SMALL TIER 02
BREATHERITE TIER 02
BRIDION TIER 03
CALCIUM DISODIUM VERSENATE
TIER 03
CARTICEL TIER 03
CAYA TIER 03
CHLORHEXIDINE GLUCONATE SOLUTION 20 %
TIER 03
CLEVER CHOICE HOLDING CHAMBER
TIER 02
COMPACT SPACE CHAMBER/LG MASK
TIER 02
COMPACT SPACE CHAMBER/MED MASK
TIER 02
COMPACT SPACE CHAMBER/SM MASK
TIER 02
CROFAB TIER 03
CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
56
Drug Name Drug Tier Notes
CURITY AMD ANTIMICROBIAL STRIP
TIER 03
CURITY IODOFORM PACKING STRIP
TIER 03
CYANOKIT TIER 03
CYTOTINE ORAL POWDER
TIER 03
deferoxamine mesylate TIER 01
DELTEC COZMO CLEO SET 24" 6MM
TIER 03
DESFERAL TIER 03
dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml, 80 mcg/20ml
TIER 01
DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 MCG/10ML, 400 MCG/4ML
TIER 03
dexmedetomidine hcl intravenous solution 200 mcg/2ml
TIER 01
DEXMEDETOMIDINE HCL-DEXTROSE
TIER 03
DIGIFAB TIER 03
diluent for treprostinil TIER 01
DUODOTE TIER 03
DUROLANE SPECIALTY PA
DYSPORT SPECIALTY PA
EASIVENT TIER 02
ENDARI SPECIALTY PA
ergoloid mesylates oral TIER 01
EROS-CTD TIER 03
EUFLEXXA SPECIALTY PA
EXCILON AMD DRAIN SPONGES
TIER 03
FEMCAP TIER 03
FLEXBUMIN TIER 03
FLEXICHAMBER ADULT MASK/SMALL
TIER 02
FLEXICHAMBER CHILD MASK/LARGE
TIER 02
FLEXICHAMBER CHILD MASK/SMALL
TIER 02
Drug Name Drug Tier Notes
flumazenil intravenous TIER 01
fomepizole TIER 01
FORA D40G GLUCOSE/PRESSURE
TIER 03
formaldehyde external solution 37 %
TIER 01
GELSYN-3 SPECIALTY PA
glutaraldehyde external TIER 01
GRASTEK SPECIALTY PA; QL
heparin lock flush TIER 01
heparin sodium lock flush
TIER 01
HUMAN ALBUMIN GRIFOLS
TIER 03
HYLENEX TIER 03
INSPIREASE RESERVOIR BAGS
TIER 02
IV STABILIZER FOR LUMOXITI
TIER 03
J-TIP KIT W/VIAL ADAPTERS
TIER 03
kedbumin TIER 01
KERLIX AMD ANTIMICROBIAL
TIER 03
KERLIX AMD SUPER SPONGES
TIER 03
MASK VORTEX TIER 02
methergine TIER 01
methylergonovine maleate
TIER 01
MICROCHAMBER DEVICE
TIER 02
MINIMED MIO ADVANCE INFUSE SET
TIER 03
MINIMED MIO INFUSION SET
TIER 03
MINIMED PUMP RESERVOIR 3ML
TIER 03
MINIMED QUICK SET INF SET 18"
TIER 03
MINIMED QUICK SET INF SET 23"
TIER 03
MINIMED QUICK SET INF SET 32"
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
57
Drug Name Drug Tier Notes
MINIMED QUICK SET INF SET 43"
TIER 03
MINIMED SILHOUETTE INF SET 32"
TIER 03
MINIMED SILHOUETTE INF SET 43"
TIER 03
MYOBLOC SPECIALTY PA
NEOKE RA LIPOIC TIER 03
NEXAVIR TIER 03
NITHIODOTE TIER 03
NOZIN NASAL SANITIZER POPSWAB
TIER 03
OCTAPLAS BLOOD GROUP A
TIER 03
OCTAPLAS BLOOD GROUP AB
TIER 03
OCTAPLAS BLOOD GROUP B
TIER 03
OCTAPLAS BLOOD GROUP O
TIER 03
ODACTRA TIER 03 PA; QL
OMNIPOD 5 PACK TIER 03
OMNIPOD DASH 5 PACK PODS
TIER 03
ORALAIR SPECIALTY PA; QL
ORALAIR ADULT SAMPLE KIT
SPECIALTY PA; QL
ORALAIR ADULT STARTER PACK
SPECIALTY PA; QL
ORALAIR CHILDRENS STARTER PACK
SPECIALTY PA; QL
PANDA MASK LARGE TIER 02
PANDA MASK MEDIUM TIER 02
PANDA MASK SMALL TIER 02
PARADIGM QUICK-SET 23" 9MM
TIER 03
PEDIATRIC PANDA MASK
TIER 02
PENTETATE CALCIUM TRISODIUM
TIER 03
PENTETATE ZINC TRISODIUM
TIER 03
PHOTREXA VISCOUS TIER 03
Drug Name Drug Tier Notes
PHOTREXA-PHOTREXA VISCOUS KIT
TIER 03
PLASBUMIN-25 TIER 03
PLASBUMIN-5 TIER 03
PLASMANATE TIER 03
POCKET SPACER TIER 02
PRECEDEX INTRAVENOUS SOLUTION 200 MCG/2ML
TIER 03
PRO COMFORT SPACER ADULT
TIER 02
PRO COMFORT SPACER CHILD
TIER 02
PRO COMFORT SPACER INFANT
TIER 02
PROCARE SPACER/ADULT MASK
TIER 02
PROCARE SPACER/CHILD MASK
TIER 02
PROTOPAM CHLORIDE TIER 03
PROVAYBLUE TIER 03
RADIOGARDASE SPECIALTY
RAGWITEK SPECIALTY PA; QL
RAPPORT RLS TIER 03
RAPPORT VTD TIER 03
RUZURGI SPECIALTY
SILHOUETTE 23" INFUSION SET
TIER 03
SILHOUETTE 43" INFUSION SET
TIER 03
SILHOUETTE INFUSION SET 18"
TIER 03
sodium nitrite intravenous
TIER 01
sodium saccharin powder
TIER 01
sodium thiosulfate intravenous
TIER 01
SORBITOL IRRIGATION SOLUTION 3 %
TIER 03
sorbitol irrigation solution 3.3 %
TIER 01
sorbitol-mannitol TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
58
Drug Name Drug Tier Notes
STERILE DILUENT FLOLAN PH 12
TIER 03
sterile diluent/epoprostenol
TIER 01
sterile water for injection TIER 01
SURE T INFUSION SET 18"/6MM
TIER 03
SURE T INFUSION SET 23"/10MM
TIER 03
SURE T INFUSION SET 23"/6MM
TIER 03
SURE T INFUSION SET 23"/8MM
TIER 03
SURE T INFUSION SET 32"/10MM
TIER 03
SURE T INFUSION SET 32"/6MM
TIER 03
SURE T INFUSION SET 32"/8MM
TIER 03
T: SLIM X2 INS PMP/CONTROL 7.4
TIER 03
T:SLIM X2 3ML CARTRIDGE
TIER 03
T:SLIM X2 INS PUMP/CONTROL-IQ
TIER 03
T:SLIM X2 INSULIN PMP BASAL IQ
TIER 03
T:SLIM X2 INSULIN PMP BASAL6.4
TIER 03
T:SLIM X2 INSULIN PMP/RFURB IQ
TIER 03
T:SLIM X2/CONTROL-IQ/REFURB
TIER 03
TACHOSIL TIER 03
TELFA AMD ISLAND DRESSING
TIER 03
TELFA AMD NON-ADHERENT
TIER 03
TISSEEL TIER 03
TRUSTEEL INFUSION SET
TIER 03
VARISOFT INFUSION SET
TIER 03
VISTOGARD TIER 03
VITRASE TIER 03
Drug Name Drug Tier Notes
WIDE-SEAL DIAPHRAGM 60
TIER 03
WIDE-SEAL DIAPHRAGM 65
TIER 03
WIDE-SEAL DIAPHRAGM 70
TIER 03
WIDE-SEAL DIAPHRAGM 75
TIER 03
WIDE-SEAL DIAPHRAGM 80
TIER 03
WIDE-SEAL DIAPHRAGM 85
TIER 03
WIDE-SEAL DIAPHRAGM 90
TIER 03
WIDE-SEAL DIAPHRAGM 95
TIER 03
XEOMIN SPECIALTY PA
XIAFLEX SPECIALTY PA
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation
ACULAR TIER 03
ACULAR LS TIER 03
ALOMIDE TIER 03
AZASITE TIER 03
azelastine hcl ophthalmic TIER 01
bacitracin ophthalmic TIER 01
BEPREVE TIER 03 ST
BESIVANCE TIER 03
BETADINE OPHTHALMIC PREP
TIER 03
BLEPH-10 TIER 03
bromfenac sodium (once-daily)
TIER 01 QL
CILOXAN TIER 03
ciprofloxacin hcl ophthalmic
TIER 01
cromolyn sodium ophthalmic
TIER 01
dexamethasone sodium phosphate ophthalmic
TIER 01
diclofenac sodium ophthalmic
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
59
Drug Name Drug Tier Notes
epinastine hcl TIER 01
erythromycin ophthalmic TIER 01
FLAREX TIER 03
fluorometholone TIER 01
flurbiprofen sodium TIER 01
FML TIER 02
FML FORTE TIER 03
FML LIQUIFILM TIER 03
gatifloxacin ophthalmic TIER 01
gentak TIER 01
gentamicin sulfate ophthalmic
TIER 01
INVELTYS TIER 03
ketorolac tromethamine ophthalmic
TIER 01
levofloxacin ophthalmic TIER 01
LOTEMAX SM TIER 03
loteprednol etabonate TIER 01
MAXIDEX TIER 03
MITOSOL TIER 03
MOXEZA TIER 02
moxifloxacin hcl (2x day) TIER 01
moxifloxacin hcl ophthalmic
TIER 01
NATACYN TIER 02
OCUFLOX TIER 03
ofloxacin ophthalmic TIER 01
olopatadine hcl ophthalmic
TIER 01
OZURDEX SPECIALTY
POVIDONE-IODINE OPHTHALMIC
TIER 03
PRED MILD TIER 03
prednisolone acetate ophthalmic
TIER 01
prednisolone sodium phosphate ophthalmic
TIER 01
PROLENSA TIER 02 QL
sulfacetamide sodium ophthalmic
TIER 01
tobramycin ophthalmic TIER 01
TOBREX TIER 03
Drug Name Drug Tier Notes
trifluridine TIER 01
ZIRGAN TIER 03
ZYMAXID TIER 03
Ophthalmic Agents - Drugs for Glaucoma
acetazolamide er TIER 01
acetazolamide oral TIER 01
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
TIER 02
apraclonidine hcl TIER 01
AZOPT TIER 02
betaxolol hcl ophthalmic TIER 01
BETIMOL TIER 03
BETOPTIC-S TIER 03
bimatoprost ophthalmic TIER 01 QL
brimonidine tartrate ophthalmic
TIER 01
carteolol hcl TIER 01
COMBIGAN TIER 02
DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC
TIER 03
dorzolamide hcl solution 2 % ophthalmic
TIER 01
dorzolamide hcl-timolol mal
TIER 01
dorzolamide hcl-timolol mal pf
TIER 01
IOPIDINE TIER 03
ISOPTO CARPINE TIER 03
ISTALOL TIER 03
KEVEYIS SPECIALTY PA; QL
latanoprost ophthalmic TIER 01
levobunolol hcl TIER 01
LUMIGAN TIER 02 QL
methazolamide oral TIER 01
PHOSPHOLINE IODIDE TIER 02
pilocarpine hcl ophthalmic
TIER 01
RHOPRESSA TIER 02
ROCKLATAN TIER 02 QL
SIMBRINZA TIER 02
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
60
Drug Name Drug Tier Notes
timolol maleate ophthalmic
TIER 01
TRAVATAN Z TIER 03 QL
travoprost (bak free) TIER 01 QL
TRUSOPT TIER 03
XELPROS TIER 03 QL
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions
ak-poly-bac TIER 01
AKTEN TIER 03
ALCAINE TIER 03
altacaine TIER 01
altafrin TIER 01
atropine sulfate ophthalmic ointment
TIER 01
atropine sulfate ophthalmic solution 1 %
TIER 01
bacitracin-polymyxin b ophthalmic
TIER 01
bacitra-neomycin-polymyxin-hc
TIER 01
BLEPHAMIDE TIER 03
BLEPHAMIDE S.O.P. TIER 03
CYCLOGYL TIER 03
CYCLOMYDRIL TIER 03
cyclopentolate hcl ophthalmic
TIER 01
CYSTARAN SPECIALTY PA; QL
EYLEA SPECIALTY
homatropaire TIER 01
ISOPTO ATROPINE TIER 03
LACRISERT TIER 03
LASTACAFT TIER 03 ST
LUCENTIS SPECIALTY
MAXITROL TIER 03
MEMBRANEBLUE TIER 03
neomycin-bacitracin zn-polymyx
TIER 01
neomycin-polymyxin-dexameth ophthalmic ointment
TIER 01
Drug Name Drug Tier Notes
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
TIER 01
neomycin-polymyxin-gramicidin
TIER 01
neomycin-polymyxin-hc ophthalmic
TIER 01
neo-polycin TIER 01
neo-polycin hc TIER 01
OXERVATE SPECIALTY PA; QL
phenylephrine hcl ophthalmic
TIER 01
polycin TIER 01
polymyxin b-trimethoprim TIER 01
POLYTRIM TIER 03
PRED-G TIER 03
PRED-G S.O.P. TIER 03
proparacaine hcl ophthalmic
TIER 01
RESTASIS TIER 02 PA
RESTASIS MULTIDOSE TIER 02 PA
sulfacetamide-prednisolone ophthalmic solution
TIER 01
tetracaine hcl ophthalmic TIER 01
TOBRADEX OPHTHALMIC OINTMENT
TIER 03
TOBRADEX ST TIER 03
tobramycin-dexamethasone
TIER 01
TROPICAMIDE-CYCLOPENTOLATE-PE
TIER 03
TROPIC-CYCLOP-PE-KETO-PROPAR
TIER 03
VISIONBLUE TIER 03
VISUDYNE SPECIALTY
XIIDRA TIER 02 PA
ZYLET TIER 03
Otic Agents - Drugs for Ear Conditions
acetic acid otic TIER 01
CETRAXAL TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
61
Drug Name Drug Tier Notes
CIPRO HC TIER 03
CIPRODEX TIER 02
ciprofloxacin hcl otic TIER 01
ciprofloxacin-dexamethasone
TIER 01
DERMOTIC TIER 03
flac TIER 01
fluocinolone acetonide otic
TIER 01
hydrocortisone-acetic acid
TIER 01
neomycin-polymyxin-hc otic
TIER 01
ofloxacin otic TIER 01
PRAMOTIC TIER 03
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold
azelastine hcl nasal TIER 01 QL
azelastine-fluticasone TIER 01
BECONASE AQ TIER 03 QL
benzonatate TIER 01
bromfed dm TIER 01
brompheniramine tannate
TIER 01
carbinoxamine maleate oral solution
TIER 01
carbinoxamine maleate oral tablet 4 mg
TIER 01
cetirizine hcl oral solution TIER 01
CINQAIR SPECIALTY PA
clemastine fumarate oral tablet 2.68 mg
TIER 01
CUROSURF TIER 03
cyproheptadine hcl oral TIER 01
desloratadine TIER 01
diphenhydramine hcl injection
TIER 01
diphenhydramine hcl oral elixir
TIER 01
DYMISTA TIER 02
FASENRA SPECIALTY
Drug Name Drug Tier Notes
FASENRA PEN SPECIALTY
flunisolide nasal TIER 01 QL
fluticasone propionate nasal
TIER 01
guaiatussin ac TIER 01 PA; QL
guaifenesin ac TIER 01 PA; QL
hydrocodone polst-chlorphen polst er susp
TIER 01 PA; QL
hydrocodone-homatropine
TIER 01 PA; QL
hydromet TIER 01 PA; QL
HYPERSAL TIER 03
INFASURF TIER 03
ipratropium bromide nasal
TIER 01
levocetirizine dihydrochloride oral
TIER 01
maxi-tuss ac TIER 01 PA; QL
mometasone furoate nasal
TIER 01 QL
nebusal inhalation nebulization solution 3 %
TIER 01
NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %
TIER 03
NUCALA SPECIALTY QL
olopatadine hcl nasal TIER 01 QL
OMNARIS TIER 03 QL
PATANASE TIER 03 QL
PHENERGAN TIER 03
promethazine hcl injection
TIER 01
promethazine hcl oral TIER 01
promethazine hcl rectal TIER 01
promethazine-codeine TIER 01 PA; QL
promethazine-dm TIER 01
promethazine-phenyleph-codeine
TIER 01 PA; QL
promethazine-phenylephrine
TIER 01
promethegan TIER 01
pseudoephedrine-bromphen-dm
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
62
Drug Name Drug Tier Notes
pulmosal TIER 01
QNASL TIER 03 QL
QNASL CHILDRENS TIER 03 QL
RYCLORA TIER 03
ryvent TIER 01
SINUVA TIER 03
sodium chloride inhalation
TIER 01
SURVANTA TIER 03
TESSALON PERLES TIER 03
virtussin ac w/alc TIER 01 PA; QL
XOLAIR SPECIALTY
ZETONNA TIER 03 QL
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
ACCOLATE TIER 03
acetylcysteine inhalation TIER 01
ADRENALIN INJECTION TIER 03
ADVAIR DISKUS TIER 02 QL
ADVAIR HFA TIER 02 QL
albuterol sulfate er TIER 01
albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation
TIER 01 QL
ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION
TIER 03 QL
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml
TIER 01 QL
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml
TIER 01
albuterol sulfate oral TIER 01
aminophylline intravenous
TIER 01
ANORO ELLIPTA TIER 02 QL
Drug Name Drug Tier Notes
ARALAST NP SPECIALTY PA
ARCAPTA NEOHALER TIER 03 ST
ARNUITY ELLIPTA TIER 02 QL
ATROVENT HFA TIER 03 QL
AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML
TIER 03
BREO ELLIPTA TIER 02 QL
BROVANA TIER 03 QL
budesonide inhalation TIER 01 QL
COMBIVENT RESPIMAT
TIER 02 QL
cromolyn sodium inhalation
TIER 01
DALIRESP TIER 03 PA
difil-g forte TIER 01
ELIXOPHYLLIN TIER 02
epinephrine injection solution
TIER 01
epinephrine injection solution auto-injector
TIER 01
EPIPEN 2-PAK TIER 03
ESBRIET SPECIALTY PA
FLOVENT DISKUS TIER 02 QL
FLOVENT HFA TIER 02 QL
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
TIER 01 QL
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
TIER 01 QL
GLASSIA SPECIALTY PA
INCRUSE ELLIPTA TIER 02 QL
ipratropium bromide inhalation
TIER 01 QL
ipratropium-albuterol TIER 01 QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
63
Drug Name Drug Tier Notes
levalbuterol hcl inhalation TIER 01 QL
LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT
TIER 03 QL
LONHALA MAGNAIR REFILL KIT
TIER 03 QL
LONHALA MAGNAIR STARTER KIT
TIER 03 QL
metaproterenol sulfate oral
TIER 01
montelukast sodium oral TIER 01
OFEV SPECIALTY PA
PERFOROMIST TIER 03 QL
PROAIR DIGIHALER TIER 03 QL
PROAIR HFA TIER 02 QL
PROAIR RESPICLICK TIER 02 QL
PROLASTIN-C SPECIALTY PA
PROVENTIL HFA TIER 03 QL
PULMICORT FLEXHALER
TIER 02 QL
SCLEROSOL INTRAPLEURAL
TIER 03
SEREVENT DISKUS TIER 02 QL
SPIRIVA HANDIHALER TIER 02 QL
SPIRIVA RESPIMAT TIER 02 QL
STERILE TALC POWDER
TIER 03
STERITALC TIER 03
STIOLTO RESPIMAT TIER 02 QL
STRIVERDI RESPIMAT TIER 02 QL
SYMBICORT TIER 02 QL
SYMJEPI TIER 03
terbutaline sulfate injection
TIER 01
terbutaline sulfate oral TIER 01
THEO-24 TIER 03
theophylline TIER 01
theophylline er TIER 01
theophylline in d5w TIER 01
TRELEGY ELLIPTA TIER 02 QL
VENTOLIN HFA TIER 02 QL
wixela inhub TIER 01 QL
Drug Name Drug Tier Notes
XOPENEX TIER 03 QL
XOPENEX CONCENTRATE
TIER 03 QL
XOPENEX HFA TIER 03 QL
YUPELRI TIER 03 QL
zafirlukast TIER 01
ZEMAIRA SPECIALTY PA
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis
BETHKIS SPECIALTY
CAYSTON SPECIALTY PA
KALYDECO SPECIALTY PA
ORKAMBI SPECIALTY PA; QL
PULMOZYME SPECIALTY PA
SYMDEKO SPECIALTY PA; QL
TOBI PODHALER SPECIALTY QL
tobramycin inhalation SPECIALTY
TRIKAFTA SPECIALTY PA; QL
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension
ADEMPAS SPECIALTY PA; QL
alyq SPECIALTY PA; QL
ambrisentan SPECIALTY PA; QL
bosentan SPECIALTY PA; QL
epoprostenol sodium SPECIALTY PA
FLOLAN SPECIALTY PA
OPSUMIT SPECIALTY PA; QL
ORENITRAM SPECIALTY PA
REVATIO INTRAVENOUS
SPECIALTY PA
REVATIO ORAL SUSPENSION RECONSTITUTED
SPECIALTY PA; QL
sildenafil citrate intravenous
SPECIALTY PA
sildenafil citrate oral suspension reconstituted
SPECIALTY PA; QL
sildenafil citrate oral tablet 20 mg
SPECIALTY PA; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
64
Drug Name Drug Tier Notes
tadalafil (pah) SPECIALTY PA; QL
TRACLEER 32 MG SPECIALTY PA; QL
treprostinil SPECIALTY PA
TYVASO SPECIALTY PA; QL
TYVASO REFILL SPECIALTY PA; QL
TYVASO STARTER SPECIALTY PA; QL
UPTRAVI SPECIALTY PA; QL
VELETRI SPECIALTY PA
VENTAVIS SPECIALTY PA; QL
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm
baclofen oral TIER 01
carisoprodol oral TIER 01
chlorzoxazone oral tablet 500 mg
TIER 01
cyclobenzaprine hcl oral TIER 01
DANTRIUM TIER 03
dantrolene sodium intravenous
TIER 01
dantrolene sodium oral TIER 01
FEXMID TIER 03
LORZONE TIER 03
metaxalone TIER 01
methocarbamol injection TIER 01
methocarbamol oral TIER 01
orphenadrine citrate er TIER 01
orphenadrine citrate injection
TIER 01
orphenadrine-asa-caffeine
TIER 01
revonto TIER 01
ROBAXIN TIER 03
ROBAXIN-750 TIER 03
RYANODEX TIER 03
tizanidine hcl oral TIER 01
Sleep Disorder Agents
armodafinil TIER 01 PA; QL
BELSOMRA TIER 03 ST; QL
doxepin hcl oral tablet TIER 01 QL
Drug Name Drug Tier Notes
eszopiclone TIER 01 QL
flurazepam hcl TIER 01 PA; QL
HETLIOZ SPECIALTY PA; QL
modafinil TIER 01 PA; QL
ramelteon TIER 01 QL
ROZEREM TIER 03 QL
SECONAL TIER 03
SILENOR TIER 03 QL
SUNOSI TIER 02 PA; QL
temazepam TIER 01 QL
WAKIX SPECIALTY
XYREM SPECIALTY PA; QL
XYWAV SPECIALTY
zaleplon TIER 01 QL
zolpidem tartrate er TIER 01 QL
zolpidem tartrate oral TIER 01 QL
ZOLPIMIST TIER 03 ST; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
65
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY
66
Index of Drugs
abacavir sulfate.............................22abacavir sulfate-lamivudine.......... 22abacavir-lamivudine-zidovudine... 22ABELCET..................................... 14ABILIFY MAINTENA.....................22abiraterone acetate.......................16ABRAXANE.................................. 16ABSORICA LD..............................33acamprosate calcium......................6acarbose.......................................36ACCOLATE.................................. 63ACCU-CHEK FASTCLIX LANCET KIT.................................37ACCU-CHEK FLEXLINK PLUS 6MM..............................................56ACCU-CHEK MULTICLIX LANCET DEVICE KIT...................37ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...................37ACCU-CHEK ULTRAFLEX INF SET...............................................56ACCUPRIL....................................26ACCURETIC.................................26ACD FORMULA A........................ 11ACD-A NOCLOT-50..................... 11acebutolol hcl ................................26ACETADOTE................................56acetaminophen-codeine................. 3acetaminophen-codeine #2............ 3acetaminophen-codeine #3............ 3acetaminophen-codeine #4............ 3acetazolamide...............................60acetazolamide er.......................... 60acetazolamide sodium..................26acetic acid...............................45, 61acetylcysteine......................... 56, 63acitretin......................................... 33ACTEMRA.................................... 52ACTEMRA ACTPEN.....................52ACTHAR.......................................48ACTHIB.........................................54ACTIGALL.................................... 44ACTIMMUNE................................52ACTIQ.............................................3ACTIVE FE................................... 39ACTIVELLA.................................. 49ACTONEL.....................................55ACTOPLUS MET..........................36ACTOS......................................... 36ACULAR....................................... 59ACULAR LS..................................59acyclovir ........................................22acyclovir sodium........................... 22ACZONE.......................................33ADACEL....................................... 54ADAKVEO.................................... 56
adapalene.....................................33ADAPALENE................................ 33adapalene-benzoyl peroxide.........33ADASUVE.....................................22ADCETRIS....................................16ADDYI...........................................32adefovir dipivoxil ........................... 22ADEMPAS.................................... 64ADENOCARD...............................26adenosine..................................... 26ADRENALIN................................. 63adriamycin.................................... 16ADVAIR DISKUS..........................63ADVAIR HFA................................ 63ADVATE....................................... 25ADYNOVATE................................25ADZENYS ER...............................31ADZENYS XR-ODT......................31AEMCOLO......................................7AFINITOR.....................................16AFINITOR DISPERZ.................... 16afirmelle........................................ 49AFLURIA QUADRIVALENT..........54AFREZZA..................................... 38AFSTYLA......................................25AGGRASTAT................................21AGGRENOX.................................21AGRYLIN......................................25AIMOVIG...................................... 15AKOVAZ....................................... 26ak-poly-bac................................... 61AKTEN..........................................61AKYNZEO.....................................14ala-cort ..........................................33albendazole.................................. 20ALBUKED 25................................56ALBUKED 5..................................56albumin human............................. 56ALBUMINEX.................................56albumin-zlb................................... 56alburx............................................56ALBUTEIN.................................... 56albuterol sulfate............................ 63albuterol sulfate er........................ 63albuterol sulfate hfa...................... 63ALBUTEROL SULFATE HFA.......63ALCAINE...................................... 61alclometasone dipropionate..........33ALCOHOL PREP PADS.........33, 56ALDACTAZIDE.............................26ALDACTONE................................26ALDURAZYME............................. 45ALECENSA...................................16alendronate sodium...................... 55alfentanil hcl ....................................3ALFERON N................................. 52
alfuzosin hcl er..............................46ALIMTA.........................................16ALINIA.......................................... 20ALIQOPA......................................16aliskiren fumarate......................... 26ALKERAN.....................................16allopurinol..................................... 15allopurinol sodium.........................15almotriptan malate........................ 15ALOMIDE......................................59ALOPRIM......................................15ALORA..........................................49alosetron hcl ................................. 44ALOXI........................................... 14ALPHAGAN P...............................60ALPHA-LIPOIC ACID................... 56ALPHANATE/VWF COMPLEX/HUMAN......................25ALPHANINE SD........................... 25alprazolam.................................... 24alprazolam er................................24alprazolam intensol.......................24alprazolam xr................................ 24ALPROLIX.................................... 25alprostadil ..................................... 26ALTABAX........................................7altacaine....................................... 61altafrin...........................................61altavera.........................................49ALTRENO.....................................33ALUNBRIG................................... 16alyacen 1/35................................. 49alyacen 7/7/7................................ 49alyq............................................... 64amabelz........................................ 49amantadine hcl............................. 21AMARYL.......................................36AMBISOME.................................. 14ambrisentan..................................64amcinonide................................... 33AMD FOAM DRESSING...............56AMD FOAM DRESSING TOPSHEET.................................. 56AMERGE...................................... 15amethia.........................................49amethia lo..................................... 49amethyst....................................... 49AMICAR........................................25amikacin sulfate..............................7amiloride hcl ..................................26amiloride-hydrochlorothiazide.......26AMINO ACID................................ 39aminoacetic acid...........................45aminocaproic acid.........................25aminophylline................................63AMINOPROTECT.........................39
67
AMINOSYN II ................................39AMINOSYN-PF.............................39amiodarone hcl............................. 26amitriptyline hcl .............................13amlodipine besylate......................26amlodipine besylate-benazepril hcl ................................................. 26amlodipine besylate-valsartan...... 26amlodipine-atorvastatin.................26amlodipine-olmesartan................. 26amlodipine-valsartan-hctz.............26ammonium lactate........................ 33AMMONUL................................... 45amnesteem...................................33amoxapine.................................... 13amoxicill-clarithro-lansopraz......... 44amoxicillin....................................... 7amoxicillin-potassium clavulanate.. 7amoxicillin-potassium clavulanate er.....................................................7AMPHADASE............................... 56AMPHETAMINE ER..................... 31amphetamine sulfate.................... 31amphetamine-dextroamphetamine......................31amphetamine-dextroamphetamine er..................31amphotericin b.............................. 14ampicillin.........................................7ampicillin sodium............................ 7ampicillin-sulbactam sodium...........7AMPYRA.......................................31AMZEEQ.......................................33anagrelide hcl............................... 25ANASCORP..................................56ANASPAZ.....................................44anastrozole................................... 16ANAVIP.........................................56ANCOBON....................................14ANDRODERM.............................. 47ANECTINE....................................32ANGELIQ......................................49ANGIOMAX.................................. 11ANORO ELLIPTA......................... 63ANTABUSE.................................... 7anticoagulant cit dext soln a......... 11anticoagulant sodium citrate.........11ANTIVENIN LATRODECTUS MACTANS.................................... 56ANTIVENIN MICRURUS FULVIUS.......................................56ANUSOL-HC.................................55ANZEMET.....................................14apap-caff-dihydrocodeine............... 3APLENZIN.................................... 13APOKYN.......................................21apraclonidine hcl...........................60
aprepitant......................................14apri ................................................49APRISO........................................ 55APTENSIO XR..............................31APTIVUS...................................... 22AQUASOL A.................................39ARAKODA.................................... 20ARALAST NP............................... 63aranelle.........................................49ARANESP (ALBUMIN FREE).......25ARCALYST...................................52ARCAPTA NEOHALER................63argatroban.................................... 11ARGININE HCL............................ 39argyle sterile saline.......................39argyle sterile water........................39ARICEPT...................................... 12ARIKAYCE......................................7aripiprazole................................... 22ARISTADA....................................22ARISTADA INITIO........................ 22ARIXTRA...................................... 11armodafinil .................................... 65ARMOUR THYROID.....................52ARNUITY ELLIPTA.......................63AROMASIN...................................16ARRANON....................................16arsenic trioxide..............................16ARTICADENT DENTAL..................5ARTISS.........................................56ARZERRA.....................................16ASCLERA.....................................26ascomp-codeine............................. 3ashlyna......................................... 49ASPARLAS...................................16aspirin-dipyridamole er................. 21ASTAGRAF XL.............................52ASTRINGYN.................................25ATABEX OB................................. 39ATACAND HCT............................ 26atazanavir sulfate..........................22ATELVIA.......................................55atenolol ......................................... 26atenolol-chlorthalidone..................26ATGAM.........................................52ATIVAN.........................................24atomoxetine hcl.............................31atorvastatin calcium......................26atovaquone...................................20atovaquone-proguanil hcl ............. 20atracurium besylate...................... 32ATRALIN.......................................33ATROPEN.................................... 44atropine sulfate....................... 44, 61ATROPINE SULFATE.................. 44ATROVENT HFA..........................63AUBAGIO..................................... 31
aubra.............................................49aubra eq........................................49AUGMENTIN.................................. 7AUGMENTIN ES-600..................... 7aurovela 1.5/30.............................49aurovela 1/20................................49aurovela 24 fe...............................49aurovela fe 1.5/30.........................49aurovela fe 1/20............................49AURYXIA......................................45AUSTEDO.................................... 32AUTOLET II CLINISAFE...............37AUTOLET LANCING DEVICE......37AUTOSOFT 30 INFUSION SET...56AUTOSOFT 90 INFUSION SET...56AUTOSOFT XC INFUSION SET..56AUVI-Q......................................... 63AVALIDE.......................................26AVANDIA......................................36AVASTIN...................................... 16aviane........................................... 49avidoxy............................................7avita.............................................. 33AVONEX PEN.............................. 31AVONEX PREFILLED.................. 31AVYCAZ......................................... 7AYGESTIN....................................49ayuna............................................49AYVAKIT.......................................16azacitidine.....................................16AZACTAM.......................................7AZASAN....................................... 52AZASITE.......................................59azathioprine.................................. 52azathioprine sodium......................52azelaic acid...................................33azelastine hcl..........................59, 62azelastine-fluticasone................... 62AZELEX........................................33AZILECT.......................................21azithromycin....................................7AZOPT..........................................60aztreonam.......................................7AZULFIDINE.................................55AZULFIDINE EN-TABS................ 55azurette.........................................49baciim............................................. 7bacitracin.................................. 7, 59bacitracin-polymyxin b.................. 61bacitra-neomycin-polymyxin-hc.... 61baclofen........................................ 65BACTERIOSTATIC WATER(BENZ ALC).....................56BACTRIM........................................7BACTRIM DS..................................7BAFIERTAM................................. 31bal in oil .........................................56
68
balsalazide disodium.................... 55balsam peru-castor oil .................. 33BALVERSA...................................16balziva...........................................49BANZEL........................................11BAQSIMI ONE PACK................... 38BAQSIMI TWO PACK...................38BARACLUDE................................22BAVENCIO................................... 16BAXDELA....................................... 7BCG VACCINE.............................54BD AUTOSHIELD DUO PEN NEEDLES.....................................38BD ULTRA-FINE INSULIN SYRINGES................................... 38BD ULTRA-FINE PEN NEEDLES 38BD VEO INSULIN SYR U/F 1/2UNIT........................................ 38BECONASE AQ............................62bekyree.........................................49BELBUCA.......................................3BELEODAQ..................................16BELSOMRA..................................65benazepril hcl ................................26benazepril-hydrochlorothiazide.....26BENDEKA.....................................16BENEFIX...................................... 25BENLYSTA...................................52BENTYL........................................44benzalkonium chloride....................7BENZNIDAZOLE.......................... 20benzonatate..................................62benzoyl peroxide-erythromycin.....33benztropine mesylate....................21BEPREVE.....................................59BERINERT....................................52beser.............................................33BESIVANCE................................. 59BESPONSA..................................17BETADINE OPHTHALMIC PREP 59betamethasone dipropionate........ 33betamethasone dipropionate aug. 33betamethasone sod phos & acet.. 46betamethasone valerate............... 33BETAPACE AF.............................26BETASERON................................31betaxolol hcl ............................26, 60bethanechol chloride.....................45BETHKIS...................................... 64BETIMOL......................................60BETOPTIC-S................................ 60bexarotene....................................17BEXSERO.................................... 54bicalutamide..................................17BICILLIN C-R..................................7BICILLIN C-R 900/300....................7BICILLIN L-A...................................7
BICNU...........................................17BIDIL.............................................26BIJUVA......................................... 49BIKTARVY....................................22BILTRICIDE..................................20bimatoprost...................................60BINOSTO......................................55BIOGUARD GAUZE SPONGES.. 56BIOGUARD ISLAND DRESSINGS.................................56BIOGUARD NON-ADHERENT DRESSING...................................56BIORPHEN...................................26BIO-STATIN..................................14BIOTHRAX................................... 54bisoprolol fumarate....................... 26bisoprolol-hydrochlorothiazide......26bivalirudin trifluoroacetate.............11BIVIGAM.......................................52bleomycin sulfate..........................17BLEPH-10.....................................59BLEPHAMIDE...............................61BLEPHAMIDE S.O.P....................61BLINCYTO....................................17blisovi 24 fe...................................49blisovi fe 1.5/30.............................49blisovi fe 1/20................................49BLOXIVERZ..................................16BONIVA........................................ 55BONJESTA...................................14BOOSTRIX................................... 54BORTEZOMIB..............................17bosentan.......................................64BOSULIF...................................... 17BOTOX......................................... 56BPCO............................................33BRAFTOVI....................................17BREATHE EASE LARGE.............56BREATHE EASE MEDIUM...........56BREATHE EASE SMALL............. 56BREATHERITE.............................56BREO ELLIPTA............................ 63BREVIBLOC................................. 26BREVIBLOC IN NACL..................26BREVIBLOC PREMIXED............. 26BREVIBLOC PREMIXED DS....... 26BRIDION.......................................56briellyn.......................................... 49BRILINTA......................................21brimonidine tartrate.......................60BRIVIACT..................................... 11bromfed dm...................................62bromfenac sodium (once-daily).... 59bromocriptine mesylate.................21brompheniramine tannate.............62BROVANA.................................... 63BRUKINSA................................... 17
budesonide............................. 55, 63budesonide er...............................55bumetanide...................................26BUMEX.........................................26BUNAVAIL......................................7BUPHENYL.................................. 45bupivacaine fisiopharma.................5bupivacaine hcl...............................5bupivacaine hcl (pf) .........................5bupivacaine-epinephrine.................5bupivacaine-epinephrine (pf) .......... 5BUPRENEX....................................3buprenorphine.................................3buprenorphine hcl.......................3, 7buprenorphine hcl-naloxone hcl......7bupropion hcl................................ 13bupropion hcl er (smoking det)....... 7bupropion hcl er (sr)......................13bupropion hcl er (xl) ......................13BUPROPION HCL ER (XL).......... 13buspirone hcl................................ 24busulfan........................................ 17BUSULFEX...................................17butalbital-acetaminophen................3butalbital-apap-caff-cod.................. 3butalbital-apap-caffeine.................. 3butalbital-asa-caff-codeine..............3butalbital-aspirin-caffeine................3butorphanol tartrate........................ 3BUTRANS.......................................3BYDUREON................................. 36BYDUREON BCISE AUTOINJECTOR..........................36BYETTA 10 MCG PEN.................36BYETTA 5 MCG PEN...................36BYSTOLIC....................................26cabergoline................................... 48CABLIVI........................................22CABOMETYX............................... 17CADUET.......................................26CAFCIT.........................................32CAFERGOT..................................15caffeine citrate.............................. 32CAFFEINE-SODIUM BENZOATE.................................. 32CALAN SR....................................26CALCIFOL.................................... 39calcipotriene..................................33calcipotriene-betameth diprop...... 33calcitonin (salmon)........................55CALCITRENE...............................33calcitriol .............................33, 55, 56calcium acetate.............................45calcium acetate (phos binder).......45CALCIUM CHLORIDE..................39calcium chloride............................39
69
CALCIUM DISODIUM VERSENATE................................56calcium gluconate.........................39CALCIUM GLUCONATE-NACL... 39CALDOLOR....................................5CALQUENCE............................... 17camila........................................... 49CAMPATH.................................... 17CAMPTOSAR...............................17camrese........................................49camrese lo.................................... 49CANCIDAS................................... 14candesartan cilexetil ..................... 26candesartan cilexetil-hctz............. 26CAPASTAT SULFATE..................16capecitabine..................................17CAPLYTA..................................... 22CAPRELSA...................................17captopril ........................................ 26captopril-hydrochlorothiazide........26CARAC......................................... 33CARAFATE...................................43CARBAGLU..................................39carbamazepine............................. 11carbamazepine er.........................11carbidopa......................................21carbidopa-levodopa...................... 21carbidopa-levodopa er..................21carbidopa-levodopa-entacapone.. 21carbinoxamine maleate.................62CARBOCAINE................................5CARBOCAINE PRESERVATIVE-FREE................. 5carboplatin.................................... 17CARDENE IV................................26CARDIZEM...................................26CARDIZEM LA..............................26CARDURA....................................26CARDURA XL...............................46CARETOUCH LANCING/EJECTOR....................37CARIMUNE NF.............................52carisoprodol.................................. 65carisoprodol-aspirin-codeine...........3carmustine.................................... 17CARNITOR...................................39CAROSPIR...................................26carteolol hcl ...................................60cartia xt......................................... 26CARTICEL....................................56carvedilol .......................................27carvedilol phosphate er.................27cascara sagrada........................... 44CASODEX.................................... 17caspofungin acetate......................14CATAPRES.................................. 27CAYA............................................56
CAYSTON.................................... 64caziant.......................................... 49cefaclor........................................... 7cefaclor er.......................................7cefadroxil ........................................ 7CEFAZOLIN IN SODIUM CHLORIDE..................................... 7cefazolin sodium.............................7CEFAZOLIN SODIUM.................... 7cefazolin sodium-dextrose..............7cefdinir ............................................ 7cefditoren pivoxil .............................7cefepime hcl....................................7cefepime-dextrose.......................... 7cefixime...........................................7CEFOTAN.......................................7cefotaxime sodium..........................7cefotetan disodium..........................7cefotetan disodium-dextrose...........8cefoxitin sodium..............................8CEFOXITIN SODIUM-DEXTROSE....................................8cefpodoxime proxetil .......................8cefprozil .......................................... 8ceftazidime......................................8ceftazidime and dextrose................8ceftriaxone sodium..........................8ceftriaxone sodium in dextrose.......8ceftriaxone sodium-dextrose...........8cefuroxime axetil .............................8cefuroxime sodium..........................8celecoxib.........................................5CELESTONE SOLUSPAN........... 46CELLCEPT................................... 52CELLCEPT INTRAVENOUS........ 52CELONTIN....................................11CENTANY.......................................8CENTRATEX................................39cephalexin.......................................8CEPROTIN................................... 25CEQUR SIMPLICITY 2U.............. 37CEQUR SIMPLICITY STARTER..37CERDELGA..................................45CEREBYX.....................................11CEREZYME..................................45cetirizine hcl ..................................62CETRAXAL...................................61cevimeline hcl ............................... 32CHANTIX........................................7CHANTIX CONTINUING MONTH PAK.................................. 7CHANTIX STARTING MONTH PAK.................................................7charlotte 24 fe...............................49chateal.......................................... 49chateal eq..................................... 49CHEMET.......................................39
CHEMSTRIP UGK........................37CHENODAL..................................44chloramphenicol sod succinate.......8chlordiazepoxide hcl..................... 24chlordiazepoxide-amitriptyline...... 13chlordiazepoxide-clidinium............44chlorhexidine gluconate................33CHLORHEXIDINE GLUCONATE.56chloroprocaine hcl (pf) .................... 5chloroquine phosphate................. 20chlorothiazide sodium...................27chlorpromazine hcl........................22chlorthalidone............................... 27chlorzoxazone...............................65CHOLBAM....................................45cholestyramine..............................27cholestyramine light......................27chromagen....................................39chromic chloride............................39ciclodan.........................................14ciclopirox.......................................14ciclopirox olamine......................... 14cidofovir ........................................ 22cilostazol.......................................22CILOXAN......................................59CIMDUO....................................... 22cimetidine......................................43cimetidine hcl................................43CIMZIA..........................................52CIMZIA PREFILLED KIT.............. 52CIMZIA STARTER KIT................. 52cinacalcet hcl ................................ 56CINQAIR.......................................62CINRYZE......................................52CINVANTI.....................................14CIPRO............................................ 8CIPRO HC.................................... 62CIPRODEX...................................62ciprofloxacin hcl .................. 8, 59, 62ciprofloxacin in d5w........................ 8ciprofloxacin-dexamethasone.......62cisatracurium besylate..................32cisatracurium besylate (pf) ............32cisplatin.........................................17CISPLATIN................................... 17citalopram hydrobromide.............. 13CITANEST FORTE DENTAL..........5CITANEST PLAIN DENTAL........... 5cladribine...................................... 17claravis..........................................33clarithromycin..................................8clarithromycin er............................. 8clemastine fumarate..................... 62CLENPIQ......................................44CLEOCIN........................................8CLEOCIN PHOSPHATE.................8CLEOCIN-T.................................. 33
70
CLEVER CHOICE HOLDING CHAMBER....................................56CLEVIPREX..................................27CLIMARA PRO.............................49clindacin etz..................................33clindacin-p.....................................34clindamycin hcl............................... 8clindamycin palmitate hcl ................8clindamycin phosphate............. 8, 34clindamycin phosphate in d5w........8CLINDAMYCIN PHOSPHATE IN NACL.............................................. 8clindamycin phosphate-benzoyl peroxide........................................34clindamycin-tretinoin.....................34CLINDESSE................................... 8CLINIMIX E/DEXTROSE (2.75/5).39CLINIMIX E/DEXTROSE (4.25/10)....................................... 39CLINIMIX E/DEXTROSE (4.25/5).39CLINIMIX E/DEXTROSE (5/15)....39CLINIMIX E/DEXTROSE (5/20)....39CLINIMIX/DEXTROSE (4.25/10)..39CLINIMIX/DEXTROSE (4.25/5)....39CLINIMIX/DEXTROSE (5/15).......39CLINIMIX/DEXTROSE (5/20).......39CLINISOL SF................................39CLINOLIPID..................................39clobazam...................................... 11clobetasol prop emollient base..... 34clobetasol propionate....................34clobetasol propionate e.................34clobetasol propionate emulsion.... 34clocortolone pivalate.....................34clodan........................................... 34clofarabine.................................... 17CLOLAR....................................... 17clomipramine hcl...........................13clonazepam.................................. 24clonidine........................................27clonidine hcl..................................27clonidine hcl er..............................31clopidogrel bisulfate......................22clorazepate dipotassium...............24clotrimazole...................................14clotrimazole-betamethasone.........14clovique.........................................39clozapine.......................................22CLOZARIL.................................... 22COAGADEX................................. 25coal tar..........................................34COARTEM....................................21codeine sulfate................................3COGENTIN...................................21colchicine......................................15colchicine-probenecid...................15COLCRYS.................................... 15
colesevelam hcl............................ 27colestipol hcl ................................. 27colistimethate sodium (cba)............8COLY-MYCIN M............................. 8COMBIGAN.................................. 60COMBIPATCH..............................49COMBIVENT RESPIMAT.............63COMBIVIR....................................22COMETRIQ (100 MG DAILY DOSE).......................................... 17COMETRIQ (140 MG DAILY DOSE).......................................... 17COMETRIQ (60 MG DAILY DOSE).......................................... 17COMPACT SPACE CHAMBER/LG MASK...................56COMPACT SPACE CHAMBER/MED MASK................56COMPACT SPACE CHAMBER/SM MASK.................. 56COMPLERA..................................23compro..........................................14COMTAN...................................... 21CONDYLOX..................................34CONJUPRI................................... 27constulose.....................................44COPAXONE................................. 31COPIKTRA................................... 17CORIFACT................................... 25CORLANOR................................. 27CORLOPAM................................. 27CORTENEMA...............................55CORTIFOAM................................ 55cortisone acetate.......................... 46CORTISPORIN.............................34CORVERT.................................... 27corvita 150.................................... 39CORVITE 150...............................39CORVITE FE................................ 39COSMEGEN.................................17COTELLIC.................................... 17COTEMPLA XR-ODT................... 31CREON.........................................45CRESEMBA..................................14CRINONE..................................... 49CRIXIVAN.....................................23CROFAB.......................................56cromolyn sodium...............44, 59, 63crotan............................................21cryselle-28.................................... 49CRYSVITA....................................45CUPRIC CHLORIDE.................... 40CUPRIMINE..................................45CURITY AMD ANTIMICROBIAL SPNGE......................................... 56CURITY AMD ANTIMICROBIAL STRIP........................................... 57
CURITY IODOFORM PACKING STRIP........................................... 57curity sterile saline........................ 40CUROSURF................................. 62CUTIVATE....................................34CUVITRU......................................52CUVPOSA.................................... 44cyanocobalamin............................40CYANOCOBALAMIN....................40CYANOKIT................................... 57cyclafem 1/35................................49cyclafem 7/7/7...............................49cyclobenzaprine hcl ...................... 65CYCLOGYL.................................. 61CYCLOMYDRIL............................61cyclopentolate hcl ......................... 61cyclophosphamide........................17cycloserine....................................16CYCLOSET.................................. 36cyclosporine..................................52cyclosporine modified................... 52CYKLOKAPRON.......................... 25cyproheptadine hcl ........................62CYRAMZA.................................... 17cyred.............................................49cyred eq........................................49CYSTADANE................................45CYSTAGON..................................45CYSTARAN.................................. 61cytarabine..................................... 17cytarabine (pf)...............................17CYTOGAM....................................52CYTOTEC.....................................43CYTOTINE....................................57CYTOVENE..................................23D.H.E. 45...................................... 15dacarbazine.................................. 17DACOGEN....................................17dactinomycin.................................17dalfampridine er............................31DALIRESP....................................63DALVANCE.................................... 8DANTRIUM...................................65dantrolene sodium........................ 65dapsone..................................16, 34DAPTACEL...................................54daptomycin..................................... 8DARAPRIM...................................21darifenacin hydrobromide er.........45DARZALEX...................................17dasetta 1/35..................................49dasetta 7/7/7.................................49daunorubicin hcl ............................17DAURISMO.................................. 17DAYPRO.........................................5daysee.......................................... 49DAYTRANA.................................. 31
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D-CARE 100X.................................5DDAVP......................................... 48DDAVP RHINAL TUBE.................48DEBACTEROL............................. 33deblitane....................................... 49decitabine..................................... 17deferasirox....................................40deferasirox granules..................... 40deferiprone....................................40deferoxamine mesylate.................57dehydrated alcohol....................... 40DELESTROGEN...........................49DELSTRIGO.................................23DELTEC COZMO CLEO SET 24" 6MM....................................... 57delyla............................................ 49demeclocycline hcl..........................8DEMEROL......................................3DEMSER...................................... 27DEPEN TITRATABS.....................45DEPO-ESTRADIOL......................49DEPO-MEDROL...........................46DEPO-PROVERA.........................49DERMA-SMOOTHE/FS BODY.....34DERMA-SMOOTHE/FS SCALP...34DERMOTIC...................................62DERMULCERA.............................34DESCOVY.................................... 23DESFERAL...................................57desipramine hcl.............................13desloratadine................................ 62desmopressin ace spray refrig......48desmopressin acetate...................48desmopressin acetate spray.........48desogestrel-ethinyl estradiol .........49desonide....................................... 34DESOWEN................................... 34desoximetasone............................34DESVENLAFAXINE ER................13desvenlafaxine succinate er......... 13DETROL....................................... 45DETROL LA..................................45dexamethasone............................ 46DEXAMETHASONE (LA)............. 46dexamethasone intensol...............46dexamethasone sod phosphate pf...................................................46dexamethasone sodium phosphate.........................46, 47, 59DEXAMETHASONE SODIUM PHOSPHATE................................47DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)................................. 37DEXILANT.................................... 43
DEXMEDETOMIDINE HCL.......... 57dexmedetomidine hcl ....................57dexmedetomidine hcl in nacl........ 57DEXMEDETOMIDINE HCL-DEXTROSE..................................57dexmethylphenidate hcl ................31dexmethylphenidate hcl er............31DEXONTO 0.4%...........................47DEXPANTHENOL........................ 40dexrazoxane hcl ............................17dextroamphetamine sulfate.......... 31dextroamphetamine sulfate er...... 31dextrose........................................40DEXTROSE..................................40DIACOMIT.................................... 11DIASTAT ACUDIAL......................11DIASTAT PEDIATRIC.................. 11DIATHRIVE LANCING DEVICE... 37DIATHRIVE PEN NEEDLE...........38diazepam................................ 11, 24DIAZEPAM................................... 24diazepam intensol.........................24diazoxide.......................................38DIBENZYLINE.............................. 27DICLEGIS.....................................14DICLOFENAC EPOLAMINE...........5diclofenac potassium...................... 5diclofenac sodium...............5, 34, 59diclofenac sodium er.......................5diclofenac-misoprostol ....................5DICLOFONO.................................. 5dicloxacillin sodium.........................8dicyclomine hcl............................. 44didanosine.................................... 23DIFICID...........................................8difil-g forte.....................................63DIFLUCAN....................................14diflunisal..........................................5DIGIFAB....................................... 57digitek........................................... 27digox............................................. 27digoxin.......................................... 27dihydroergotamine mesylate.........15DILANTIN..................................... 11DILATRATE-SR............................27DILAUDID.......................................3diltiazem hcl..................................27diltiazem hcl er..............................27diltiazem hcl er beads...................27diltiazem hcl er coated beads....... 27DILTIAZEM HCL-DEXTROSE......27DILTIAZEM HCL-SODIUM CHLORIDE................................... 27dilt-xr.............................................27DILUENT FOR LEFAMULIN.........40diluent for treprostinil .................... 57dimenhydrinate............................. 14
dimethyl fumarate......................... 31diphenhydramine hcl.....................62diphenoxylate-atropine................. 44DIPHTHERIA-TETANUS TOXOIDS DT................................54DIPROLENE.................................34DIPROLENE AF........................... 34dipyridamole................................. 22disopyramide phosphate...............27disulfiram........................................ 7DITROPAN XL..............................46DIURIL..........................................27divalproex sodium.........................11divalproex sodium er.....................11DIVIGEL........................................49dobutamine hcl............................. 27dobutamine in d5w........................27docetaxel...................................... 17dofetilide....................................... 27DOLOPHINE...................................3donepezil hcl .................................12dopamine hcl................................ 27dopamine in d5w...........................27DOPRAM......................................32DOPTELET...................................25DORAL......................................... 24DORZOLAMIDE HCL................... 60dorzolamide hcl.............................60dorzolamide hcl-timolol mal.......... 60dorzolamide hcl-timolol mal pf...... 60dotti ...............................................49DOVATO.......................................23DOVONEX....................................34doxazosin mesylate...................... 27doxepin hcl ..............................13, 65doxercalciferol ...............................56DOXIL...........................................17doxorubicin hcl ..............................17doxorubicin hcl liposomal..............17doxy 100......................................... 8doxycycline hyclate.........................8doxycycline monohydrate............... 8doxylamine-pyridoxine..................14DRISDOL......................................40DRIZALMA SPRINKLE.................13dronabinol.....................................14droperidol......................................14DROPLET MICRON..................... 38drospiren-eth estrad-levomefol.....49drospirenone-ethinyl estradiol .......49DROXIA........................................17DRYSOL.......................................34DUAVEE.......................................49DUETACT.....................................36duloxetine hcl................................13DUODOTE....................................57DUOPA.........................................21
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DUPIXENT....................................34duramorph...................................... 3duraxin............................................3DUROLANE..................................57dutasteride....................................46dutasteride-tamsulosin hcl............46DYANAVEL XR.............................31DYMISTA......................................62DYRENIUM...................................27DYSPORT.................................... 57E.E.S. GRANULES.........................8EASIVENT....................................57EC-NAPROSYN............................. 5ec-naproxen....................................5econazole nitrate.......................... 14EDARBI........................................ 27EDARBYCLOR.............................27EDECRIN......................................27EDETATE DISODIUM.................. 40ed-spaz.........................................44EDURANT.................................... 23efavirenz....................................... 23efavirenz-lamivudine-tenofovir ......23EFFER-K...................................... 40effer-k............................................40EFFIENT.......................................22EFUDEX....................................... 34EGATEN.......................................21EGRIFTA SV................................ 48ELAPRASE...................................45ELELYSO..................................... 45ELESTRIN.................................... 49eletriptan hydrobromide................15ELIGARD......................................48ELIMITE........................................21elinest........................................... 49ELIQUIS........................................11ELIQUIS DVT/PE STARTER PACK............................................11ELITEK......................................... 17ELITE-OB..................................... 40ELIXOPHYLLIN............................ 63ELLA.............................................49ELLENCE..................................... 17ELMIRON..................................... 46ELOCTATE...................................25EMCYT......................................... 17EMEND.........................................14EMEND TRI-PACK.......................14EMFLAZA..................................... 15EMGALITY....................................15EMGALITY (300 MG DOSE)........ 15emoquette.....................................49EMPLICITI.................................... 17EMSAM.........................................13emtricitabine................................. 23EMTRIVA......................................23
EMVERM......................................21ENABLEX..................................... 46enalapril maleate.......................... 27enalaprilat ..................................... 27enalapril-hydrochlorothiazide........27ENBREL....................................... 52ENBREL MINI...............................52ENBREL SURECLICK..................52ENDARI........................................ 57endocet...........................................3ENDOMETRIN..............................49ENGERIX-B..................................54ENHERTU.................................... 17ENLITE GLUCOSE SENSOR...... 37enoxaparin sodium....................... 11enpresse-28..................................49enskyce.........................................49entacapone...................................21entecavir ....................................... 23ENTEREG.................................... 44ENTOCORT EC............................55ENTRESTO.................................. 27ENTYVIO......................................52enulose......................................... 44ENVARSUS XR............................52EPCLUSA.....................................23ephedrine sulfate.......................... 27EPHEDRINE SULFATE................27EPHEDRINE SULFATE (PRESSORS)............................... 27EPHEDRINE SULFATE-NACL.....27EPIDIOLEX...................................11EPIDUO FORTE...........................34EPIFOAM......................................34epinastine hcl ................................60EPINEPHRINE............................. 27epinephrine.............................27, 63EPINEPHRINE HCL-DEXTROSE..................................27EPINEPHRINE HCL-NACL.......... 27epinephrine pf...............................27EPINEPHRINE-DEXTROSE........ 27EPINEPHRINE-NACL.............27, 28EPIPEN 2-PAK............................. 63epirubicin hcl .................................17epitol ............................................. 11EPIVIR..........................................23EPIVIR HBV..................................23eplerenone....................................28epoprostenol sodium.................... 64eptifibatide.................................... 22EPZICOM..................................... 23EQUETRO....................................24ERAXIS.........................................14ERBITUX...................................... 17ergocalciferol ................................ 40ergoloid mesylates........................57
ERGOMAR................................... 15ergotamine-caffeine......................15ERIVEDGE................................... 17erlotinib hcl ....................................17EROS-CTD...................................57errin...............................................49ertapenem sodium..........................8ERWINAZE...................................17ery.................................................34ERYGEL....................................... 34ERYPED 200..................................8ERYPED 400..................................8ERY-TAB........................................ 8ERYTHROCIN LACTOBIONATE... 8ERYTHROCIN STEARATE............8erythromycin....................... 8, 34, 60erythromycin base.......................... 8erythromycin ethylsuccinate........... 8ESBRIET...................................... 63escitalopram oxalate.....................13ESGIC.............................................3esmolol hcl ....................................28ESMOLOL HCL............................ 28esmolol hcl-sodium chloride......... 28esomeprazole magnesium............43esomeprazole sodium...................43estarylla........................................ 49estazolam..................................... 24estradiol .................................. 49, 50estradiol valerate.......................... 50estradiol-norethindrone acet.........50ESTRING......................................50ESTROGEL.................................. 50ESTROSTEP FE.......................... 50eszopiclone...................................65ethacrynate sodium...................... 28ethacrynic acid..............................28ethambutol hcl .............................. 16ETHAMOLIN.................................28ethosuximide.................................11ethyl chloride...................................5ethynodiol diac-eth estradiol .........50ETHYOL....................................... 17etodolac.......................................... 5etodolac er......................................5ETOPOPHOS...............................17etoposide...................................... 17EUCRISA......................................34EUFLEXXA...................................57euthyrox........................................52EVAMIST......................................50EVEKEO ODT.............................. 31EVENITY...................................... 55everolimus.............................. 17, 52EVERSENSE SENSOR/HOLDER.......................37
73
EVERSENSE SMART TRANSMITTER............................ 37EVISTA.........................................48EVOCLIN......................................34EVOMELA.................................... 17EVOTAZ....................................... 23EVOXAC.......................................33EXCILON AMD DRAIN SPONGES....................................57EXELON....................................... 12exemestane.................................. 17EXJADE........................................40EXODERM....................................15EXPAREL....................................... 5EYLEA.......................................... 61EZALLOR SPRINKLE...................28ezetimibe...................................... 28ezetimibe-simvastatin................... 28FABRAZYME................................45falmina.......................................... 50famciclovir .....................................23famotidine..................................... 43famotidine premixed..................... 43FANAPT........................................22FANAPT TITRATION PACK.........22FARESTON.................................. 17FARXIGA......................................36FARYDAK.....................................18FASENRA.....................................62FASENRA PEN............................ 62FASLODEX...................................18FAVIPIRAVIR............................... 23fayosim......................................... 50febuxostat..................................... 15FEIBA........................................... 25felbamate......................................11FELDENE....................................... 5felodipine er.................................. 28FEMARA.......................................18FEMCAP.......................................57FEMHRT LOW DOSE.................. 50FEMRING..................................... 50femynor.........................................50fenofibrate.....................................28fenofibrate micronized.................. 28fenofibric acid................................28fentanyl........................................... 3fentanyl citrate................................ 3FENTANYL CITRATE-NACL..........3FERAHEME..................................40ferocon..........................................40ferotrinsic...................................... 40FERRALET 90..............................40FERRAPLUS 90........................... 40FERRIPROX.................................40FERRIPROX TWICE-A-DAY........40FERRLECIT..................................40
ferrocite plus................................. 40FERRO-PLEX HEMATINIC..........40FERROTRIN.................................40FETROJA....................................... 8FETZIMA...................................... 13FETZIMA TITRATION.................. 13FEXMID........................................ 65FIBRICOR.....................................28FIBRYGA......................................25FINACEA...................................... 34finasteride..................................... 46FIORINAL....................................... 3FIORINAL/CODEINE #3.................3FIRAZYR...................................... 52FIRMAGON.................................. 48FIRMAGON (240 MG DOSE).......48FIRST-LANSOPRAZOLE............. 43FIRST-OMEPRAZOLE................. 43FIRVANQ........................................8flac................................................ 62FLAGYL..........................................8FLAREX........................................60flavoxate hcl ..................................46FLEBOGAMMA DIF......................52flecainide acetate..........................28FLEXBUMIN................................. 57FLEXICHAMBER ADULT MASK/SMALL...............................57FLEXICHAMBER CHILD MASK/LARGE.............................. 57FLEXICHAMBER CHILD MASK/SMALL...............................57FLOLAN........................................64FLOLIPID......................................28FLOVENT DISKUS.......................63FLOVENT HFA.............................63floxuridine..................................... 18FLUAD..........................................54FLUAD QUADRIVALENT.............54FLUARIX QUADRIVALENT..........54FLUBLOK QUADRIVALENT........ 54FLUCELVAX QUADRIVALENT....54fluconazole....................................15fluconazole in sodium chloride......15flucytosine.....................................15fludarabine phosphate.................. 18fludrocortisone acetate................. 47FLULAVAL QUADRIVALENT.......54flumazenil ......................................57FLUMIST QUADRIVALENT......... 54flunisolide......................................62fluocinolone acetonide............34, 62fluocinolone acetonide body......... 34fluocinolone acetonide scalp.........34fluocinonide...................................34fluocinonide emulsified base.........34fluoridex sensitivity relief ...............33
fluorometholone............................60FLUOROPLEX..............................34fluorouracil .............................. 18, 34FLUOROURACIL..........................34fluoxetine hcl .................................13fluoxetine hcl (pmdd).................... 13fluphenazine decanoate................22fluphenazine hcl............................22flurazepam hcl.............................. 65flurbiprofen......................................5flurbiprofen sodium....................... 60flutamide....................................... 18fluticasone propionate.............34, 62fluticasone-salmeterol ...................63FLUTICASONE-SALMETEROL... 63fluvoxamine maleate.....................13fluvoxamine maleate er.................13FLUZONE HIGH-DOSE QUADRIVALENT..........................54FLUZONE QUADRIVALENT........54FML...............................................60FML FORTE................................. 60FML LIQUIFILM............................60folic acid........................................40FOLIVANE-F.................................40FOLIVANE-PLUS......................... 40FOLOTYN.....................................18foltrin.............................................40fomepizole.................................... 57fondaparinux sodium.................... 11FORA D40G GLUCOSE/PRESSURE............... 57FORFIVO XL................................ 13formaldehyde................................57FORTAZ......................................... 8FORTEO.......................................55FOSAMAX.................................... 55FOSAMAX PLUS D...................... 55fosamprenavir calcium..................23fosaprepitant dimeglumine............14FOSCAVIR................................... 23fosinopril sodium...........................28fosinopril sodium-hctz...................28fosphenytoin sodium.....................11FOSRENOL..................................46FRAGMIN..................................... 11FREAMINE HBC...........................40FREAMINE III ............................... 40FREESTYLE LIBRE 14 DAY READER.......................................37FREESTYLE LIBRE 14 DAY SENSOR.......................................37fulvestrant..................................... 18furosemide....................................28FUROSEMIDE IN SODIUM CHLORIDE................................... 28FUSION PLUS..............................40
74
FUZEON.......................................23fyavolv...........................................50FYCOMPA....................................11gabapentin....................................11GABITRIL..................................... 12GALAFOLD...................................45galantamine hydrobromide........... 12galantamine hydrobromide er.......12GALZIN.........................................40GAMASTAN..................................53GAMIFANT................................... 53GAMMAGARD..............................53GAMMAGARD S/D LESS IGA..... 53GAMMAKED.................................53GAMMAPLEX...............................53GAMUNEX-C................................53GANCICLOVIR.............................23ganciclovir sodium........................ 23GARDASIL 9.................................54GASTROCROM............................44gatifloxacin....................................60GATTEX....................................... 44gavilyte-c.......................................44gavilyte-g...................................... 44gavilyte-h...................................... 44gavilyte-n with flavor pack.............44GAZYVA....................................... 18GEBAUERS PAIN EASE................6GEBAUERS SPRAY AND STRETCH.......................................6GELNIQUE................................... 46GELSYN-3....................................57gemcitabine hcl.............................18gemfibrozil .................................... 28generlac........................................44gengraf..........................................53gentak...........................................60gentamicin in saline........................ 9gentamicin sulfate.....................9, 60GENTEEL LANCING KIT (BLUE).37GENVOYA....................................23GEODON......................................22gianvi............................................ 50GILENYA...................................... 31GILOTRIF..................................... 18GLASSIA...................................... 63glatiramer acetate.........................31glatopa..........................................31GLEOSTINE................................. 18glimepiride.................................... 36glipizide er.....................................36glipizide ir ......................................36glipizide xl ..................................... 36glipizide-metformin hcl ..................36GLUCAGEN HYPOKIT.................38GLUCAGON EMERGENCY KIT.. 38GLUCOTROL............................... 36
GLUCOTROL XL..........................36glutaraldehyde.............................. 57GLUTATHIONE............................ 40glyburide....................................... 36glyburide micronized.....................36glyburide-metformin......................36GLYCINE......................................40glycine...........................................46glycine urologic.............................46GLYCOPHOS...............................40glycopyrrolate............................... 44GLYCOPYRROLATE................... 44glycopyrrolate pf........................... 44glydo............................................... 6GLYNASE.....................................36GLYRX-PF....................................44GLYSET........................................36GLYXAMBI................................... 36GOJJI LANCING DEVICE/CLEAR CAP...................37GONITRO.....................................28GORDOFILM................................34GRALISE...................................... 32granisetron hcl .............................. 14GRASTEK.....................................57griseofulvin microsize................... 15griseofulvin ultramicrosize............ 15guaiatussin ac...............................62guaifenesin ac...............................62guanfacine hcl ...............................28guanfacine hcl er.......................... 31GUANIDINE HCL..........................16GUARDIAN CONNECT TRANSMITTER............................ 37GUARDIAN LINK 3 TRANSMITTER............................ 37GUARDIAN SENSOR (3)............. 37GVOKE HYPOPEN 1-PACK........ 38GVOKE HYPOPEN 2-PACK........ 38GVOKE PFS.................................38GYNAZOLE-1...............................15HAEGARDA..................................53hailey 1.5/30................................. 50hailey 24 fe................................... 50hailey fe 1.5/30............................. 50hailey fe 1/20................................ 50HALAVEN.....................................18HALCION......................................24HALDOL....................................... 22HALDOL DECANOATE................22halobetasol propionate................. 34HALOG......................................... 34haloperidol.................................... 22haloperidol decanoate.................. 22haloperidol lactate.........................22HARVONI..................................... 23HAVRIX........................................ 54
heather..........................................50HECTOROL..................................56HELIDAC THERAPY.................... 44HEMANGEOL...............................28hematinic plus vit/minerals............40hematinic/folic acid....................... 40hematogen....................................40hematogen forte............................40HEMATRON-AF........................... 40HEMLIBRA................................... 25HEMOCYTE PLUS.......................40hemocyte-f ....................................40hemocyte-plus.............................. 40HEMOFIL M..................................25HEPAGAM B................................ 53heparin (porcine) in nacl............... 11HEPARIN (PORCINE) IN NACL...11heparin lock flush..........................57heparin sod (porcine) in d5w........ 11heparin sodium (porcine)..............11heparin sodium (porcine) pf..........11heparin sodium lock flush............. 57HEPATAMINE.............................. 40HEPLISAV-B.................................54HEPSERA.....................................23HERCEPTIN.................................18HERCEPTIN HYLECTA............... 18HESPAN.......................................25hetastarch-nacl............................. 25HETLIOZ.......................................65HEXTEND.....................................25HIBERIX....................................... 54HIPREX.......................................... 9HIZENTRA....................................53homatropaire.................................61HORIZANT................................... 32HUMALOG KWIKPEN..................38HUMALOG MIX 50/50 KWIKPEN.38HUMALOG MIX 50/50 VIAL......... 38HUMALOG MIX 75/25 KWIKPEN.38HUMALOG MIX 75/25 VIAL......... 38HUMALOG U-100 JUNIOR KWIKPEN..................................... 38HUMALOG VIAL...........................38HUMAN ALBUMIN GRIFOLS.......57HUMATE-P...................................25HUMIRA........................................53HUMIRA PEDIATRIC CROHNS START..........................................53HUMIRA PEN............................... 53HUMIRA PEN-CD/UC/HS STARTER.....................................53HUMIRA PEN-PS/UV/ADOL HS START..........................................53HUMULIN 70/30 KWIKPEN..........38HUMULIN 70/30 VIAL...................38HUMULIN N KWIKPEN................ 38
75
HUMULIN N VIAL.........................38HUMULIN R U-500 KWIKPEN..... 38HUMULIN R U-500 VIAL.............. 38HUMULIN R VIAL.........................39HYCAMTIN...................................18hydralazine hcl..............................28HYDREA.......................................18hydrochlorothiazide.......................28hydrocodone bitartrate er................3hydrocodone polst-chlorphen polst er susp................................. 62hydrocodone-acetaminophen......... 3hydrocodone-homatropine............62hydrocodone-ibuprofen...................3hydrocortisone.................. 35, 47, 55hydrocortisone (perianal)..............55hydrocortisone ace-pramoxine..... 55hydrocortisone butyrate.......... 34, 35hydrocortisone valerate................ 35hydrocortisone-acetic acid............62hydrogen peroxide..........................9hydromet.......................................62HYDROMORPHONE HCL............. 3hydromorphone hcl.........................3hydromorphone hcl er.....................3hydromorphone hcl pf.....................3HYDROMORPHONE HCL-NACL...4hydroxocobalamin acetate............40hydroxychloroquine sulfate...........21hydroxyprogesterone caproate.....50hydroxyurea..................................18hydroxyzine hcl.............................24hydroxyzine pamoate....................24HYLENEX.....................................57hyoscyamine sulfate..................... 44hyoscyamine sulfate sl ..................44HYPERHEP B S/D........................53HYPERRAB..................................53HYPERRAB S/D...........................53HYPERRHO S/D.......................... 53HYPERSAL...................................62HYPERTET S/D............................53HYQVIA........................................ 53HYSINGLA ER................................4ibandronate sodium...................... 55IBRANCE......................................18ibu...................................................5ibuprofen.........................................5ibuprofen lysine...............................5ibutilide fumarate.......................... 28ICAR-C PLUS...............................40icatibant acetate............................53ICLUSIG....................................... 18IDAMYCIN PFS............................ 18idarubicin hcl .................................18IDELVION.....................................25IDHIFA..........................................18
iferex 150 forte..............................40IFEX..............................................18ifosfamide..................................... 18ILARIS.......................................... 53ILUMYA........................................ 53imatinib mesylate..........................18IMBRUVICA..................................18IMFINZI.........................................18imipenem-cilastatin.........................9imipramine hcl ...............................13imipramine pamoate..................... 13imiquimod..................................... 35IMOGAM RABIES-HT...................53IMOVAX RABIES..........................54IMPAVIDO.................................... 21IMURAN........................................53IMVEXXY MAINTENANCE PACK............................................50IMVEXXY STARTER PACK......... 50INBRIJA........................................21incassia.........................................50INCRELEX....................................48INCRUSE ELLIPTA...................... 63indapamide................................... 28INDOCIN.........................................5indomethacin.................................. 5indomethacin er.............................. 5indomethacin sodium......................5INFANRIX.....................................54INFASURF....................................62INFED...........................................40INFLECTRA..................................53INFUGEM..................................... 18INFUMORPH 200...........................4INFUMORPH 500...........................4INGREZZA....................................32INJECTAFER................................40INLYTA......................................... 18INPEN 100-BLUE-LILLY...............37INPEN 100-BLUE-NOVO............. 37INPEN 100-GRAY-LILLY..............37INPEN 100-GREY-NOVO.............37INPEN 100-PINK-LILLY................37INPEN 100-PINK-NOVO.............. 37INREBIC....................................... 18INSPIREASE RESERVOIR BAGS............................................57INSPRA........................................ 28INSULIN PEN NEEDLES............. 39INSULIN SYRINGES....................39INTEGRA F...................................40INTEGRA PLUS........................... 40INTEGRILIN..................................22INTELENCE..................................23intralipid........................................ 41INTRALIPID..................................41INTRAROSA.................................46
INTRON A.....................................23introvale........................................ 50INVANZ...........................................9INVEGA........................................ 22INVEGA SUSTENNA....................22INVEGA TRINZA.......................... 22INVELTYS.................................... 60INVIRASE.....................................23iodine strong................................. 41IOPIDINE......................................60IPOL..............................................54ipratropium bromide................62, 63ipratropium-albuterol .....................63irbesartan......................................28irbesartan-hydrochlorothiazide..... 28IRESSA.........................................18irinotecan hcl.................................18IS 24/6.......................................... 41ISENTRESS................................. 23ISENTRESS HD........................... 23isibloom.........................................50isoniazid........................................16isoproterenol hcl ........................... 28ISOPTO ATROPINE.....................61ISOPTO CARPINE....................... 60ISORDIL TITRADOSE..................28isosorbide dinitrate........................28isosorbide mononitrate................. 28isosorbide mononitrate er............. 28isotretinoin.................................... 35isradipine...................................... 28ISTALOL.......................................60ISTODAX (OVERFILL)................. 18ISUPREL...................................... 28itraconazole.................................. 15IV STABILIZER FOR LUMOXITI.. 57ivermectin..................................... 21IXEMPRA KIT...............................18IXIARO..........................................54IXINITY......................................... 25JADENU....................................... 41JADENU SPRINKLE.....................41jaimiess.........................................50JAKAFI..........................................18JALYN...........................................46jantoven........................................ 11JANUMET.....................................36JANUMET XR...............................36JANUVIA.......................................36JARDIANCE................................. 36jasmiel...........................................50jencycla.........................................50JENTADUETO..............................36JENTADUETO XR........................36JEVTANA......................................18jinteli ..............................................50JIVI................................................25
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jolessa...........................................50JORNAY PM.................................31J-TIP KIT W/VIAL ADAPTERS.....57juleber...........................................50JULUCA........................................23junel 1.5/30................................... 50junel 1/20...................................... 50junel fe 1.5/30............................... 50junel fe 1/20.................................. 50junel fe 24..................................... 50JUXTAPID.................................... 28JYNARQUE.................................. 41KABIVEN...................................... 41KADCYLA.....................................18kaitlib fe.........................................50KALBITOR....................................53KALETRA..................................... 23kalliga............................................50KALYDECO.................................. 64KANJINTI......................................18KANUMA...................................... 45KAPVAY....................................... 31kariva............................................ 50KCENTRA.....................................25kedbumin...................................... 57KEDRAB.......................................53KEFLEX..........................................9kelnor 1/35....................................50kelnor 1/50....................................50KENALOG.................................... 47KENALOG-80............................... 47KENGREAL.................................. 22KEPIVANCE................................. 33KEPPRA....................................... 12KERAMATRIX REPLICINE 5CMX5CM.................................... 35KERLIX AMD ANTIMICROBIAL...57KERLIX AMD SUPER SPONGES....................................57KERYDIN......................................15ketoconazole.................................15KETONE TEST.............................37ketoprofen.......................................5ketoprofen er...................................5ketorolac tromethamine............ 5, 60KETOROLAC TROMETHAMINE... 5KETOSTIX....................................37KEVEYIS...................................... 60KEVZARA.....................................53KEYTRUDA.................................. 18KHAPZORY..................................18KINERET...................................... 53KINRIX..........................................54kionex........................................... 41KISQALI (200 MG DOSE)............ 18KISQALI (400 MG DOSE)............ 18KISQALI (600 MG DOSE)............ 18
KISQALI FEMARA (400 MG DOSE).......................................... 18KISQALI FEMARA (600 MG DOSE).......................................... 18KISQALI FEMARA(200 MG DOSE).......................................... 18KLARON.......................................35klor-con.........................................41klor-con 10....................................41klor-con m10.................................41KLOR-CON M15...........................41klor-con m20.................................41klor-con sprinkle............................41klor-con/ef.....................................41KOATE..........................................25KOATE-DVI.................................. 25KOGENATE FS............................ 25KORLYM.......................................48KOSELUGO..................................18KOVALTRY...................................25K-PHOS........................................41K-PHOS-NEUTRAL......................41k-prime..........................................41KRINTAFEL..................................21KRYSTEXXA................................ 15k-tan plus...................................... 41kurvelo.......................................... 50KUVAN......................................... 45KYPROLIS....................................18L.E.T............................................... 6LABETALOL HCL.........................28labetalol hcl ...................................28LACRISERT..................................61lactated ringers............................. 41lactic acid......................................35lactic acid e...................................35lactulose........................................44lactulose encephalopathy............. 44LAMICTAL XR.............................. 12lamivudine.....................................23lamivudine-zidovudine.................. 23lamotrigine.................................... 12lamotrigine er................................12lamotrigine starter kit-blue............ 12lamotrigine starter kit-green..........12lamotrigine starter kit-orange........12LANCETS..................................... 37LANOXIN......................................28LANOXIN PEDIATRIC..................28lansoprazole................................. 43lanthanum carbonate....................46LANTUS SOLOSTAR...................39LANTUS U-100 VIAL....................39larin 1.5/30....................................50larin 1/20.......................................50larin 24 fe......................................50larin fe 1.5/30................................50
larin fe 1/20...................................50larissia...........................................50LARTRUVO.................................. 18LASTACAFT.................................61latanoprost....................................60LATUDA........................................22layolis fe........................................50leena.............................................50leflunomide................................... 53LEMTRADA.................................. 31LENVIMA (10 MG DAILY DOSE). 18LENVIMA (12 MG DAILY DOSE). 18LENVIMA (14 MG DAILY DOSE). 18LENVIMA (18 MG DAILY DOSE). 18LENVIMA (20 MG DAILY DOSE). 18LENVIMA (24 MG DAILY DOSE). 18LENVIMA (4 MG DAILY DOSE)... 18LENVIMA (8 MG DAILY DOSE)... 18lessina...........................................50letrozole........................................ 18leucovorin calcium........................ 18LEUKERAN.................................. 18LEUKINE...................................... 25leuprolide acetate......................... 48LEUPROLIDE ACETATE-BUPIVACAINE..............................48levalbuterol hcl ..............................64LEVALBUTEROL HFA................. 64levetiracetam................................ 12levetiracetam er............................ 12levetiracetam in nacl.....................12levobunolol hcl ..............................60LEVOCARNITINE.........................41levocarnitine..................................41levocarnitine sf..............................41levocetirizine dihydrochloride........62levofloxacin...............................9, 60levofloxacin in d5w..........................9levoleucovorin calcium..................18levoleucovorin calcium pf..............19levonest........................................ 50levonorgest-eth est & eth est........50levonorgest-eth estrad 91-day......50levonorgestrel-ethinyl estrad.........50levonorg-eth estrad triphasic........ 50LEVOPHED.................................. 28levora 0.15/30 (28)........................50levo-t.............................................52levothyroxine sodium....................52levoxyl...........................................52LEVULAN KERASTICK................35LEXIVA......................................... 23LIBTAYO.......................................19lidocaine..........................................6lidocaine hcl ..............................6, 33LIDOCAINE HCL............................ 6lidocaine hcl (cardiac).....................6
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lidocaine hcl (cardiac) pf.................6lidocaine hcl (pf) ..............................6lidocaine hcl urethral/mucosal........ 6LIDOCAINE IN D5W.......................6lidocaine in d5w.............................. 6LIDOCAINE IN DEXTROSE...........6lidocaine viscous hcl.....................33lidocaine-epinephrine......................6lidocaine-prilocaine.........................6LIDOCAINE-SODIUM BICARBONATE..............................6LIDO-EPINEPHRINE-TETRACAINE.................................6lillow..............................................50LINCOCIN.......................................9lincomycin hcl ................................. 9lindane.......................................... 21linezolid...........................................9linezolid in sodium chloride.............9LINZESS.......................................44liothyronine sodium.......................52LIPO..............................................41LIPO-C..........................................41LIPOFEN...................................... 28lisinopril .........................................28lisinopril-hydrochlorothiazide........ 28lithium........................................... 24lithium carbonate.......................... 25lithium carbonate er...................... 25LITHOBID..................................... 25LITHOSTAT..................................46LIVALO......................................... 28LMD IN D5W.................................25LMD IN NACL...............................25LODINE.......................................... 5lojaimiess......................................50LOKELMA.....................................41LOMOTIL......................................44LONHALA MAGNAIR REFILL KIT................................................ 64LONHALA MAGNAIR STARTER KIT................................................ 64LONSURF.....................................19loperamide hcl.............................. 44LOPID...........................................28lopinavir-ritonavir .......................... 23lopreeza........................................50LOPRESSOR............................... 28LOPRESSOR HCT.......................28LOPROX.......................................15lorazepam.....................................24lorazepam intensol........................24LORBRENA..................................19LORTAB......................................... 4loryna............................................50LORZONE.................................... 65losartan potassium........................29
losartan potassium-hctz................29LOSEASONIQUE......................... 50LOTEMAX SM.............................. 60LOTENSIN....................................29LOTENSIN HCT........................... 29loteprednol etabonate...................60lovastatin.......................................29LOVENOX.................................... 11low-ogestrel .................................. 50loxapine succinate........................ 22lo-zumandimine............................ 50LUCEMYRA....................................7LUCENTIS....................................61LUMIGAN..................................... 60LUMIZYME................................... 45LUMOXITI.....................................19LUPANETA PACK........................48LUPRON DEPOT (1-MONTH)......48LUPRON DEPOT (3-MONTH)......48LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..... 48LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..... 48LUPRON DEPOT-PED (1-MONTH)....................................... 48LUPRON DEPOT-PED (3-MONTH)....................................... 48lutera.............................................50LUXIQ...........................................35LYNPARZA...................................19LYRICA CR...................................32LYSINE HCL.................................41LYSODREN..................................19LYSTEDA..................................... 25lyza............................................... 50MACROBID.................................... 9MACRODANTIN.............................9mafenide acetate............................ 9MAGNEBIND 400.........................41magnesium chloride......................41MAGNESIUM SULFATE.............. 41magnesium sulfate........................41magnesium sulfate in d5w............ 41MAGNESIUM SULFATE-NACL....41MAKENA.......................................50MALARONE..................................21malathion...................................... 21MANGANESE CHLORIDE........... 41mannitol ........................................ 29maprotiline hcl ...............................13MARCAINE.....................................6MARCAINE PRESERVATIVE FREE.............................................. 6MARCAINE/EPINEPHRINE........... 6MARCAINE/EPINEPHRINE PF......6MARINOL..................................... 14marlissa........................................ 51
MARPLAN.................................... 13MARQIBO.....................................19MASK VORTEX............................57MATULANE.................................. 19matzim la...................................... 29MAVENCLAD (10 TABS)..............31MAVENCLAD (4 TABS)................32MAVENCLAD (5 TABS)................32MAVENCLAD (6 TABS)................32MAVENCLAD (7 TABS)................32MAVENCLAD (8 TABS)................32MAVENCLAD (9 TABS)................32MAVYRET.................................... 23MAXICOMFORT SYR 27G X 1/2"............................................... 39MAXIDEX......................................60MAXITROL................................... 61maxi-tuss ac..................................62MAXZIDE......................................29MAXZIDE-25.................................29MAYZENT.....................................32MAYZENT STARTER PACK........32meclizine hcl ................................. 14meclofenamate sodium...................5MEDROL...................................... 47MEDROX-RX..................................4medroxyprogesterone acetate......51mefloquine hcl ...............................21megestrol acetate......................... 51MEKINIST.....................................19MEKTOVI......................................19melodetta 24 fe.............................51meloxicam.......................................5melphalan..................................... 19melphalan hcl................................19memantine hcl .............................. 12memantine hcl er.......................... 12MEMBRANEBLUE........................61MENACTRA..................................54MENEST.......................................51MENOSTAR................................. 51MENQUADFI................................ 54MENVEO...................................... 54meperidine hcl ................................ 4MEPHYTON................................. 41meprobamate................................24MEPRON......................................21MEPSEVII.....................................45mercaptopurine.............................19meropenem.....................................9MEROPENEM-SODIUM CHLORIDE..................................... 9MERREM........................................9mesalamine.................................. 55mesalamine er.............................. 55mesalamine-cleanser....................55mesna...........................................19
78
MESNEX.......................................19MESTINON...................................16metadate er...................................31metaproterenol sulfate..................64metaxalone................................... 65metformin hcl er............................36metformin hcl ir ............................. 36methadone hcl................................ 4methadone hcl intensol...................4METHADONE HCL-NACL..............4METHADOSE.................................4methadose......................................4METHADOSE SUGAR-FREE........ 4methazolamide............................. 60methenamine hippurate..................9methergine....................................57methimazole................................. 52methocarbamol.............................65methotrexate.................................53methotrexate (anti-rheumatic).......53methotrexate sodium.................... 53methotrexate sodium (pf)..............53methoxsalen rapid........................ 35methscopolamine bromide............44METHYLCOBALAMIN..................41methyldopa................................... 29methyldopa-hydrochlorothiazide...29methylergonovine maleate............57METHYLIN....................................31methylphenidate hcl ......................31methylphenidate hcl er..................31methylphenidate hcl er (cd).......... 31methylphenidate hcl er (la)........... 31methylprednisolone.......................47METHYLPREDNISOLONE ACETATE..................................... 47methylprednisolone acetate..........47methylprednisolone sodium succ..47METHYLPREDNISOLONE-BUPIVACAINE..............................47metoclopramide hcl.......................14metolazone................................... 29metoprolol succinate er.................29metoprolol tartrate.........................29metoprolol-hydrochlorothiazide.....29METROCREAM............................35METROLOTION........................... 35metronidazole........................... 9, 35metronidazole in nacl......................9metyrosine.................................... 29mexiletine hcl................................29MI PASTE.....................................33MI PASTE PLUS...........................33MIACALCIN.................................. 55mibelas 24 fe................................ 51micafungin sodium........................15miconazole 3.................................15
MICRHOGAM ULTRA-FILTERED PLUS..........................53MICROCHAMBER........................57MICROCYN.................................. 35microgestin 1.5/30........................ 51microgestin 1/20........................... 51microgestin fe 1.5/30.................... 51microgestin fe 1/20....................... 51MICROLET NEXT LANCING DEVICE........................................ 37midodrine hcl................................ 29MIGERGOT.................................. 15miglitol ...........................................36miglustat....................................... 45MIGRANAL...................................15mili ................................................ 51MILLIPRED...................................47MILLIPRED DP 12-DAY............... 47milrinone lactate............................29milrinone lactate in dextrose.........29mimvey......................................... 51mineral oil heavy...........................44MINIMED GUARDIAN SENSOR 3....................................................37MINIMED MIO ADVANCE INFUSE SET.................................57MINIMED MIO INFUSION SET.... 57MINIMED PUMP RESERVOIR 3ML...............................................57MINIMED QUICK SET INF SET 18"................................................ 57MINIMED QUICK SET INF SET 23"................................................ 57MINIMED QUICK SET INF SET 32"................................................ 57MINIMED QUICK SET INF SET 43"................................................ 58MINIMED SILHOUETTE INF SET 32"........................................ 58MINIMED SILHOUETTE INF SET 43"........................................ 58MINIPRESS..................................29MINIVELLE...................................51MINOCIN........................................ 9minocycline hcl ............................... 9minoxidil ........................................29MIRAPEX......................................21MIRAPEX ER................................21MIRCERA..................................... 25MIRCETTE................................... 51mirtazapine................................... 13MIRVASO..................................... 35misoprostol ................................... 43mitigo.............................................. 4mitomycin......................................19MITOSOL......................................60mitoxantrone hcl ........................... 19
M-M-R II ........................................54M-NATAL PLUS............................41modafinil ....................................... 65moexipril hcl ..................................29molindone hcl................................22mometasone furoate...............35, 62mondoxyne nl................................. 9monoject flush syringe..................41monoject sodium chloride flush.... 41mono-linyah.................................. 51MONONINE..................................25montelukast sodium......................64MONUROL..................................... 9morgidox.........................................9MORPHINE SULFATE................... 4morphine sulfate............................. 4morphine sulfate (concentrate).......4morphine sulfate (pf) .......................4morphine sulfate er.........................4morphine sulfate er beads.............. 4MORPHINE SULFATE-NACL........ 4MOTEGRITY................................ 44MOXEZA.......................................60MOXIFLOXACIN HCL.................... 9moxifloxacin hcl ........................ 9, 60moxifloxacin hcl (2x day).............. 60moxifloxacin hcl in nacl...................9MOZOBIL......................................25MULPLETA...................................25MULTAQ.......................................29MULTIGEN................................... 41MULTIGEN FOLIC........................41MULTIGEN PLUS.........................41mupirocin........................................ 9MUSE........................................... 46mutamycin.................................... 19MVASI...........................................19MYALEPT.....................................45MYAMBUTOL...............................16MYCAMINE.................................. 15MYCOBUTIN................................ 16mycophenolate mofetil ..................53mycophenolate mofetil hcl ............ 53mycophenolate sodium.................53MYDAYIS......................................31myferon 150 forte..........................41MYFORTIC...................................53MYLERAN.................................... 19MYLOTARG..................................19MYOBLOC....................................58myorisan....................................... 35MYRBETRIQ................................ 46MYTESI........................................ 44MYXREDLIN.................................39na ferric gluc cplx in sucrose........ 41NABI-HB....................................... 53nabumetone....................................5
79
n-acetyl-l-cysteine.........................41nafcillin sodium............................... 9NAFCILLIN SODIUM IN DEXTROSE....................................9NAFRINSE DAILY ACIDULATED 33naftifine hcl....................................15NAFTIN.........................................15NAGLAZYME................................45nalbuphine hcl.................................4naloxone hcl....................................7naltrexone hcl................................. 7NAMENDA....................................12NAMENDA TITRATION PAK........12NAMENDA XR..............................12NAMENDA XR TITRATION PACK............................................12NAMZARIC...................................12naproxen.........................................5naproxen dr.....................................5naproxen sodium............................ 5naratriptan hcl...............................15NARCAN.........................................7NARDIL.........................................13NAROPIN....................................... 6NASCOBAL.................................. 41NATACYN.....................................60NATAZIA.......................................51nateglinide.................................... 36NATESTO.....................................47NATPARA.....................................56NATURE-THROID........................52NAVELBINE..................................19NAYZILAM....................................12NEBUPENT.................................. 21nebusal......................................... 62NEBUSAL.....................................62necon 0.5/35 (28)..........................51nefazodone hcl............................. 13NEMBUTAL.................................. 12NEOKE ALCAR............................ 41NEOKE RA LIPOIC...................... 58neomycin sulfate.............................9neomycin-bacitracin zn-polymyx...61neomycin-polymyxin b gu............... 9neomycin-polymyxin-dexameth.... 61neomycin-polymyxin-gramicidin....61neomycin-polymyxin-hc.......... 61, 62NEONATAL PLUS........................41neo-polycin................................... 61neo-polycin hc...............................61NEOPROFEN.................................5NEORAL.......................................53neostigmine methylsulfate............ 16NEOSTIGMINE METHYLSULFATE.......................16NEO-SYNALAR............................35NEPHRAMINE..............................41
NEPHRON FA.............................. 41NERLYNX.....................................19NESACAINE...................................6NESACAINE-MPF.......................... 6NESTABS.....................................41neuac............................................35NEULASTA...................................25NEULASTA ONPRO.....................25NEUPRO...................................... 21nevirapine..................................... 23nevirapine er.................................23NEXAVAR.....................................19NEXAVIR......................................58NEXIUM........................................43NEXIUM I.V.................................. 43NEXLETOL...................................29NEXLIZET.....................................29NEXTERONE............................... 29niacin er (antihyperlipidemic)........29nicardipine hcl ...............................29NICARDIPINE HCL IN NACL....... 29NICOTROL..................................... 7NICOTROL NS............................... 7nifedipine...................................... 29nifedipine er.................................. 29nifedipine er osmotic release........29NIFEREX...................................... 41nikki ...............................................51NILANDRON.................................19nilutamide..................................... 19NIMBEX........................................32nimodipine.................................... 29NINLARO......................................19NIPENT.........................................19nisoldipine er.................................29NITHIODOTE................................58nitisinone.......................................45NITRO-BID................................... 29NITRO-DUR..................................29nitrofurantoin...................................9nitrofurantoin macrocrystal ............. 9nitrofurantoin monohydrate macrocrystals..................................9nitroglycerin.................................. 29nitroglycerin in d5w.......................29NITROLINGUAL........................... 29NITROMIST..................................29NITROPRESS.............................. 29nitroprusside sodium.....................29nitro-time.......................................29NITYR...........................................45NIVESTYM................................... 25nizatidine.......................................43NOCDURNA.................................48nora-be......................................... 51NORDITROPIN FLEXPRO...........48norepinephrine bitartrate...............29
NOREPINEPHRINE-DEXTROSE 29NOREPINEPHRINE-SODIUM CHLORIDE................................... 29norethin ace-eth estrad-fe.............51norethindrone................................51norethindrone acetate...................51norethindrone acet-ethinyl est...... 51norethindrone-eth estradiol ...........51norethin-eth estradiol-fe................51norgestimate-eth estradiol ............ 51norgestimate-ethinyl estradiol triphasic........................................ 51norlyda..........................................51norlyroc.........................................51normal saline flush........................41NORPACE....................................29NORPACE CR..............................29NORPRAMIN................................13NORTHERA..................................29nortrel 0.5/35 (28)......................... 51nortrel 1/35 (21)............................ 51nortrel 1/35 (28)............................ 51nortrel 7/7/7...................................51nortriptyline hcl ..............................13NORVIR........................................23NOURIANZ...................................21NOVOEIGHT................................ 25NOVOFINE AUTOCOVER PEN NEEDLE....................................... 39NOVOFINE PEN NEEDLE........... 39NOVOFINE PLUS PEN NEEDLE.39NOVOPEN ECHO........................ 37NOVOSEVEN RT......................... 25NOVOTWIST PEN NEEDLE........ 39NOXAFIL...................................... 15NOZIN NASAL SANITIZER POPSWAB....................................58np thyroid......................................52NPLATE........................................25NUBEQA.......................................19NUCALA....................................... 62NUEDEXTA.................................. 32NUFERA.......................................41nulev............................................. 44NULOJIX.......................................53NUPLAZID....................................22NURTEC.......................................15nutrilipid........................................ 42NUTRIVIT..................................... 42NUTROPIN AQ NUSPIN 10......... 48NUTROPIN AQ NUSPIN 20......... 48NUTROPIN AQ NUSPIN 5........... 48NUVARING...................................51NUWIQ......................................... 25NUZYRA.........................................9nyamyc......................................... 15NYMALIZE....................................29
80
nystatin......................................... 15nystatin-triamcinolone...................15nystop........................................... 15OBIZUR........................................ 25OCALIVA...................................... 45ocella............................................ 51OCREVUS....................................32OCTAGAM....................................53OCTAPLAS BLOOD GROUP A... 58OCTAPLAS BLOOD GROUP AB.58OCTAPLAS BLOOD GROUP B... 58OCTAPLAS BLOOD GROUP O...58octreotide acetate......................... 48OCUFLOX.................................... 60ODACTRA.................................... 58ODEFSEY.....................................23ODOMZO......................................19OFEV............................................64ofloxacin..............................9, 60, 62olanzapine.................................... 22olanzapine-fluoxetine hcl.............. 13olmesartan medoxomil ..................29olmesartan medoxomil-hctz..........29olmesartan-amlodipine-hctz..........29olopatadine hcl........................60, 62OLUX............................................35OLUX-E........................................ 35OMECLAMOX-PAK......................44omega-3-acid ethyl esters............ 29omeprazole...................................43OMEPRAZOLE+SYRSPEND SF ALKA.............................................43OMNARIS.....................................62OMNIPOD 5 PACK.......................58OMNIPOD DASH 5 PACK PODS.58OMNIPOD DASH SYSTEM..........38OMNIPOD STARTER...................38ONCASPAR..................................19ondansetron hcl............................ 14ondansetron odt............................14ONE VITE WOMENS PLUS.........42ONETOUCH DELICA LANCING DEV.............................................. 38ONETOUCH DELICA PLUS LANCING......................................38ONETOUCH ULTRA.................... 38ONETOUCH ULTRA 2 KIT W/DEVICE....................................38ONETOUCH ULTRA MINI KIT W/DEVICE....................................38ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..............38ONETOUCH VERIO IQ SYSTEM 38ONETOUCH VERIO KIT W/DEVICE....................................38ONETOUCH VERIO REFLECT....38
ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..............38ONEXTON....................................35ONIVYDE......................................19ONPATTRO..................................32OPDIVO........................................19OPSUMIT..................................... 64ORABLOC...................................... 6ORACIT........................................ 42ORALAIR......................................58ORALAIR ADULT SAMPLE KIT...58ORALAIR ADULT STARTER PACK............................................58ORALAIR CHILDRENS STARTER PACK.......................... 58oralone..........................................33ORAPRED ODT........................... 47ORBACTIV..................................... 9ORENCIA..................................... 53ORENCIA CLICKJECT.................53ORENITRAM................................ 64ORFADIN......................................45ORILISSA..................................... 48ORKAMBI..................................... 64orphenadrine citrate......................65orphenadrine citrate er..................65orphenadrine-asa-caffeine............65orsythia......................................... 51oscimin..........................................44oseltamivir phosphate...................23OSMITROL...................................29osmitrol ......................................... 29OSMOPREP.................................44OSPHENA.................................... 48OTEZLA........................................53OTREXUP.................................... 53OVIDE...........................................21oxacillin sodium.............................. 9OXACILLIN SODIUM IN DEXTROSE....................................9oxaliplatin......................................19oxaprozin........................................ 5oxazepam..................................... 24oxcarbazepine.............................. 12OXERVATE.................................. 61OXSORALEN ULTRA...................35oxybutynin chloride.......................46oxybutynin chloride er...................46oxycodone hcl.................................4oxycodone-acetaminophen.............4oxycodone-aspirin...........................4OXYCONTIN.................................. 4oxymorphone hcl............................ 4oxymorphone hcl er........................ 4oxytocin.........................................48OXYTOCIN-LACTATED RINGERS..................................... 48
OXYTOCIN-SODIUM CHLORIDE................................... 48OXYTROL.....................................46OZEMPIC..................................... 36OZURDEX.................................... 60PACERONE..................................29pacerone.......................................29paclitaxel.......................................19PADCEV.......................................19paliperidone er..............................22palonosetron hcl........................... 14PALYNZIQ....................................45pamidronate disodium.................. 55pancuronium bromide...................32PANDA MASK LARGE.................58PANDA MASK MEDIUM...............58PANDA MASK SMALL................. 58PANHEMATIN.............................. 25PANRETIN....................................19pantoprazole sodium.................... 43PARADIGM QUICK-SET 23" 9MM..............................................58paraplatin......................................19paricalcitol .....................................56PARLODEL...................................21PARNATE.....................................13paroex...........................................33paromomycin sulfate.......................9paroxetine hcl............................... 13paroxetine hcl er........................... 13paroxetine mesylate......................13PARSABIV....................................56PASER..........................................16PATANASE...................................62PAXIL............................................13PEDIAPRED.................................47PEDIARIX.....................................54PEDIATRIC PANDA MASK..........58PEDVAX HIB................................ 54peg 3350-kcl-na bicarb-nacl......... 44peg-3350/electrolytes................... 44peg-3350/electrolytes/ascorbat.....44PEGANONE................................. 12PEGASYS.....................................23PEGASYS PROCLICK................. 23PEGINTRON................................ 23peg-kcl-nacl-nasulf-na asc-c.........44peg-prep....................................... 44penicillamine.................................46PENICILLIN G POT IN DEXTROSE....................................9penicillin g potassium......................9penicillin g procaine........................ 9penicillin g sodium.......................... 9penicillin v potassium......................9PENTACEL...................................54PENTAM.......................................21
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pentamidine isethionate................21PENTASA.....................................55pentazocine-naloxone hcl...............4PENTETATE CALCIUM TRISODIUM..................................58PENTETATE ZINC TRISODIUM..58pentobarbital sodium.................... 12pentoxifylline er.............................29PERFOROMIST........................... 64PERIDEX......................................33PERIKABIVEN..............................42perindopril erbumine.....................29periogard.......................................33PERJETA......................................19permethrin.....................................21perphenazine................................14perphenazine-amitriptyline............13PERSERIS....................................22PEXEVA....................................... 13PFIZERPEN....................................9phenazo........................................46phenazopyridine hcl......................46phenelzine sulfate.........................13PHENERGAN...............................62phenobarbital ................................12phenobarbital sodium................... 12phenoxybenzamine hcl.................30phentolamine mesylate.................30phenylephrine hcl....................30, 61PHENYLEPHRINE HCL............... 30PHENYLEPHRINE HCL (PRESSORS)............................... 30PHENYLEPHRINE HCL-NACL.... 30PHENYTEK.................................. 12phenytoin...................................... 12phenytoin infatabs.........................12phenytoin sodium..........................12phenytoin sodium extended..........12philith............................................ 51PHOSLYRA.................................. 46phospha 250 neutral .....................42PHOSPHOLINE IODIDE.............. 60phosphorous.................................42phospho-trin 250 neutral ...............42PHOTOFRIN.................................19PHOTREXA VISCOUS.................58PHOTREXA-PHOTREXA VISCOUS KIT...............................58PHYSIOLYTE............................... 42PHYSIOSOL IRRIGATION...........42phytonadione................................ 42PICATO........................................ 35PIFELTRO.................................... 23pilocarpine hcl.........................33, 60pimecrolimus.................................35pimozide....................................... 22pimtrea..........................................51
pindolol ......................................... 30pioglitazone hcl.............................36pioglitazone hcl-glimepiride.......... 36pioglitazone hcl-metformin hcl ...... 36piperacillin sod-tazobactam so....... 9PIQRAY (200 MG DAILY DOSE). 19PIQRAY (250 MG DAILY DOSE). 19PIQRAY (300 MG DAILY DOSE). 19pirmella 1/35................................. 51pirmella 7/7/7................................ 51piroxicam........................................ 5PITOCIN....................................... 48PLAQUENIL..................................21PLASBUMIN-25............................58PLASBUMIN-5..............................58PLASMANATE..............................58PLENAMINE.................................42PLENVU....................................... 45PNEUMOVAX 23..........................54POCKET SPACER....................... 58podofilox....................................... 35POLIVY.........................................19polocaine........................................ 6polocaine-mpf................................. 6polycin...........................................61poly-iron 150 forte.........................42polymyxin b sulfate......................... 9polymyxin b-trimethoprim..............61polysaccharide iron forte...............42POLYTRIM................................... 61POMALYST.................................. 19portia-28........................................51PORTRAZZA................................19posaconazole................................15pot bicarb-pot chloride.................. 42potassium acetate.........................42potassium bicarbonate..................42potassium chloride........................42potassium chloride crys er............42potassium chloride er....................42potassium citrate er...................... 42potassium phosphates(71 meq k).42POTELIGEO.................................19POVIDONE-IODINE..................... 60PRADAXA.....................................11PRALUENT...................................30pramipexole dihydrochloride.........21pramipexole dihydrochloride er.....21PRAMOTIC...................................62prasugrel hcl ................................. 22pravastatin sodium........................30praziquantel .................................. 21prazosin hcl ...................................30PRECEDEX..................................58PRECOSE.................................... 36PRED MILD.................................. 60PRED-G........................................61
PRED-G S.O.P............................. 61prednicarbate................................35prednisolone................................. 47prednisolone acetate.................... 60prednisolone sodium phosphate................................................ 47, 60prednisone....................................47prednisone intensol.......................47PREFEST..................................... 51pregabalin.....................................32PREMARIN...................................51PREMASOL..................................42PREMPHASE............................... 51PREMPRO....................................51prenatal .........................................42prenatal plus iron.......................... 42PRENATVITE PLUS.....................42PRENATVITE RX......................... 42PREPIV SUPPLY........................... 6PRESTALIA..................................30PRETOMANID..............................16prevalite........................................ 30PREVIDENT 5000 ENAMEL PROTECT.....................................33PREVIDENT 5000 SENSITIVE.... 33previfem........................................51PREVNAR 13............................... 54PREVYMIS................................... 23PREZCOBIX.................................23PREZISTA.................................... 23PRIFTIN........................................16PRILOSEC....................................43primaquine phosphate.................. 21PRIMAXIN IV..................................9primidone......................................12PRIMSOL........................................9PRISMASOL B22GK 4/0.............. 42PRISMASOL BGK 0/2.5............... 42PRISMASOL BGK 2/0.................. 42PRISMASOL BGK 2/3.5............... 42PRISMASOL BGK 4/2.5............... 42PRISMASOL BK 0/0/1.2...............42PRIVIGEN.....................................53PRO COMFORT SPACER ADULT..........................................58PRO COMFORT SPACER CHILD...........................................58PRO COMFORT SPACER INFANT.........................................58PROAIR DIGIHALER....................64PROAIR HFA................................64PROAIR RESPICLICK..................64probenecid....................................15PROBUPHINE IMPLANT KIT.........4procainamide hcl...........................30PROCALAMINE............................42PROCARDIA................................ 30
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PROCARDIA XL...........................30PROCARE SPACER/ADULT MASK............................................58PROCARE SPACER/CHILD MASK............................................58PROCENTRA............................... 31prochlorperazine...........................14prochlorperazine edisylate............14prochlorperazine maleate............. 14PROCTOFOAM HC......................55procto-med hc...............................55procto-pak.....................................55proctosol hc.................................. 55proctozone-hc...............................55PROCYSBI................................... 45PROFILNINE................................ 25progesterone.................................51progesterone micronized.............. 51PROGLYCEM...............................38PROGRAF....................................53PROLASTIN-C..............................64PROLENSA.................................. 60PROLEUKIN.................................19PROLIA.........................................55PROMACTA................................. 25promethazine hcl.......................... 62promethazine-codeine.................. 62promethazine-dm..........................62promethazine-phenyleph-codeine 62promethazine-phenylephrine........ 62promethegan.................................62propafenone hcl............................30propafenone hcl er........................30propantheline bromide..................45proparacaine hcl........................... 61propranolol hcl .............................. 30propranolol hcl er..........................30propranolol-hctz............................30propylthiouracil ..............................52PROQUAD....................................54PROSCAR....................................46PROSOL.......................................42PROSTIN VR................................30protamine sulfate.......................... 25PROTONIX.............................43, 44PROTOPAM CHLORIDE..............58PROTOPIC...................................35protriptyline hcl..............................13PROVAYBLUE............................. 58PROVENTIL HFA......................... 64PROVERA.................................... 51pseudoephedrine-bromphen-dm.. 62PULMICORT FLEXHALER...........64pulmosal....................................... 63PULMOZYME...............................64purevit dualfe plus.........................42PURIXAN......................................19
PYLERA........................................45pyrazinamide................................ 16pyridostigmine bromide.................16pyridostigmine bromide er............ 16PYRIDOXINE HCL....................... 42pyridoxine hcl................................42pyrimethamine.............................. 21PYRIMETHAMINE-LEUCOVORIN..............................21PYROGALLIC ACID..................... 35QBREXZA.....................................35QINLOCK......................................19QNASL..........................................63QNASL CHILDRENS....................63QUADRACEL............................... 54QUADRAMET...............................19QUALAQUIN.................................21QUARTETTE................................51quazepam.....................................24QUELICIN.....................................32quetiapine fumarate......................22quetiapine fumarate er..................22QUILLICHEW ER......................... 31QUILLIVANT XR...........................31quinapril hcl ...................................30quinapril-hydrochlorothiazide........30quinidine gluconate er...................30quinidine sulfate............................30quinine sulfate...............................21RABAVERT.................................. 54rabeprazole sodium...................... 44RADIAPLEXRX.............................35RADICAVA................................... 32RADIOGARDASE.........................58RAGWITEK...................................58raloxifene hcl.................................48ramelteon......................................65ramipril ..........................................30ranolazine er.................................30RAPAFLO.....................................46RAPAMUNE................................. 53RAPIVAB...................................... 23RAPPORT RLS............................ 58RAPPORT VTD............................ 58rasagiline mesylate.......................21RASUVO.......................................53RAVICTI........................................45RAYALDEE...................................55RAZADYNE ER............................ 12REBIF........................................... 32REBIF REBIDOSE........................32REBIF REBIDOSE TITRATION PACK............................................32REBIF TITRATION PACK............ 32REBINYN......................................25REBLOZYL...................................25RECARBRIO.................................. 9
RECLAST..................................... 55reclipsen....................................... 51RECOMBINATE........................... 25RECOMBIVAX HB........................54RECOTHROM.............................. 25RECOTHROM SPRAY KIT.......... 25RECTIV.........................................30REGENECARE.............................35REGLAN.......................................14REGONOL....................................16REGRANEX..................................35RELENZA DISKHALER................23relexxii ...........................................31RELNATE DHA.............................42REMERON................................... 13REMERON SOLTAB.................... 13REMESENSE............................... 33remifentanil hcl ................................4RENACIDIN..................................46RENATABS WITH IRON.............. 42RENFLEXIS..................................53repaglinide.................................... 36REPATHA.....................................30REPATHA PUSHTRONEX SYSTEM.......................................30REPATHA SURECLICK............... 30REQUIP XL...................................21RESTASIS....................................61RESTASIS MULTIDOSE..............61RESTORA RX.............................. 45RETACRIT....................................25RETAVASE...................................11RETAVASE HALF-KIT..................11RETIN-A MICRO PUMP...............35RETROVIR................................... 23REVATIO......................................64REVCOVI......................................45REVLIMID.....................................19revonto..........................................65REXULTI.......................................22REYATAZ..................................... 23RHOFADE.................................... 35RHOGAM ULTRA-FILTERED PLUS............................................ 53RHOPHYLAC............................... 53RHOPRESSA............................... 60RIASTAP...................................... 25ribavirin......................................... 23RIDAURA......................................53rifabutin.........................................16RIFADIN....................................... 16rifampin.........................................16RILUTEK.......................................32riluzole.......................................... 32rimantadine hcl............................. 23RIMSO-50.....................................46ringers irrigation............................42
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RINVOQ........................................53RIOMET........................................37RIOMET ER..................................37risedronate sodium....................... 55RISPERDAL CONSTA................. 22risperidone....................................22ritonavir .........................................23RITUXAN......................................19RITUXAN HYCELA.......................19rivastigmine...................................13rivastigmine tartrate...................... 13rivelsa........................................... 51RIXUBIS....................................... 25rizatriptan benzoate...................... 15ROBAXIN......................................65ROBAXIN-750.............................. 65ROCALTROL................................56ROCKLATAN................................60rocuronium bromide......................32ROCURONIUM BROMIDE...........32ropinirole hcl................................. 21ropinirole hcl er............................. 21ropivacaine hcl................................6rosadan.........................................35rosuvastatin calcium..................... 30ROTARIX......................................54ROTATEQ.................................... 54ROWASA......................................55roweepra.......................................12roweepra xr...................................12ROZEREM....................................65ROZLYTREK................................ 19RUBRACA.................................... 19RUCONEST..................................53RUXIENCE................................... 19RUZURGI..................................... 58RYANODEX..................................65RYBELSUS...................................37RYCLORA.................................... 63RYDAPT....................................... 19RYTARY....................................... 21RYTHMOL SR.............................. 30ryvent............................................63SALAGEN.....................................33saline bacteriostatic...................... 42saline flush....................................42saline flush zr................................42SALINE-PHENOL.........................42SAMSCA.......................................42SANDIMMUNE............................. 53SANTYL........................................35SAPHRIS......................................22sapropterin dihydrochloride.......... 45SARAFEM.................................... 13SAVAYSA.....................................11SAVELLA......................................32SAVELLA TITRATION PACK.......32
SCENESSE.................................. 35SCLEROSOL INTRAPLEURAL....64scopolamine..................................14SECONAL.....................................65selegiline hcl ................................. 21selenium sulfide............................35SELZENTRY.................................24sensorcaine.................................... 6sensorcaine/epinephrine.................6sensorcaine-mpf............................. 6sensorcaine-mpf/epinephrine......... 6SENSORCAINE-MPF/EPINEPHRINE.......................6SEREVENT DISKUS....................64SERNIVO......................................35SEROSTIM...................................45sertraline hcl ................................. 13se-tan plus.................................... 42setlakin..........................................51sevelamer carbonate.................... 46sevelamer hcl ................................46SEYSARA.......................................9SFROWASA................................. 55sharobel........................................51SHINGRIX.................................... 54SIGNIFOR.................................... 48SIGNIFOR LAR............................ 48SIKLOS.........................................19sildenafil citrate.......................46, 64SILENOR......................................65SILHOUETTE 23" INFUSION SET...............................................58SILHOUETTE 43" INFUSION SET...............................................58SILHOUETTE INFUSION SET 18"................................................ 58SILIQ.............................................53silodosin........................................46silver sulfadiazine........................... 9SIMBRINZA.................................. 60simliya...........................................51simpesse.......................................51SIMPONI.......................................53SIMPONI ARIA............................. 53SIMULECT....................................53simvastatin....................................30SINEMET......................................21SINUVA........................................ 63sirolimus........................................53SIRTURO......................................16SITAVIG........................................24SIVEXTRO......................................9SKLICE.........................................21SKYRIZI (150 MG DOSE)............ 54SMOFLIPID.................................. 42sod benz-sod phenylacet..............45sod citrate-citric acid.....................42
sodium acetate............................. 42sodium bicarbonate................ 42, 45SODIUM BICARBONATE.............42sodium chloride.......................42, 63sodium chloride (pf) ...................... 42sodium chloride bacteriostatic...... 42sodium chloride flush....................42SODIUM CITRATE.......................11SODIUM CITRATE LOCK FLUSH..........................................11SODIUM DIURIL...........................30SODIUM EDECRIN...................... 30sodium fluoride 5000 sensitive..... 33sodium nitrite................................ 58sodium phenylbutyrate..................45sodium phosphates.......................42sodium polystyrene sulfonate....... 42sodium saccharin..........................58sodium thiosulfate.........................58solifenacin succinate.....................46SOLIQUA......................................37SOLIRIS........................................25SOLOSEC...................................... 9SOLTAMOX..................................19SOLU-CORTEF............................47SOLU-MEDROL........................... 47SOMATULINE DEPOT.................48SOMAVERT..................................48SOOLANTRA................................35SORBITOL....................................58sorbitol .......................................... 58sorbitol-mannitol ........................... 58SORIATANE.................................35sorine............................................30SOTALOL HCL.............................30sotalol hcl ......................................30sotalol hcl (af) ............................... 30SOTYLIZE.................................... 30SOVALDI...................................... 24spinosad....................................... 21SPIRIVA HANDIHALER............... 64SPIRIVA RESPIMAT.................... 64spironolactone.............................. 30spironolactone-hctz.......................30SPORANOX................................. 15SPORANOX PULSEPAK............. 15SPRAVATO (56 MG DOSE).........13SPRAVATO (84 MG DOSE).........13sprintec 28.................................... 51SPRYCEL.....................................19sps................................................ 42sronyx........................................... 51ssd................................................ 10STALEVO 100.............................. 21STALEVO 125.............................. 21STALEVO 150.............................. 21STALEVO 200.............................. 21
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STALEVO 50................................ 21STALEVO 75................................ 21STAMARIL....................................54STARLIX.......................................37stavudine...................................... 24STELARA..................................... 54STERILE DILUENT FLOLAN PH 12..................................................59sterile diluent/epoprostenol...........59STERILE TALC POWDER........... 64sterile water for injection...............59sterile water for irrigation.............. 43STERITALC..................................64STIMATE...................................... 48STIOLTO RESPIMAT...................64STIVARGA....................................19STRENSIQ................................... 45streptomycin sulfate......................10STRIBILD......................................24STRIVERDI RESPIMAT............... 64STROMECTOL.............................21SUBLOCADE..................................7subvenite...................................... 12subvenite starter kit-blue...............12subvenite starter kit-green............ 12subvenite starter kit-orange.......... 12SUCCINYLCHOLINE CHLORIDE................................... 32succinylcholine chloride................32SUCRAID......................................45sucralfate...................................... 44SULAR..........................................30sulfacetamide sodium...................60sulfacetamide sodium (acne)........35sulfacetamide-prednisolone..........61sulfadiazine...................................10sulfamethoxazole-trimethoprim.....10SULFAMYLON............................. 10sulfasalazine.................................55sulfatrim pediatric..........................10sulfurated lime.............................. 21sulindac...........................................5sumatriptan...................................16sumatriptan succinate...................16sumatriptan succinate refill ........... 16SUNOSI........................................65SUPPRELIN LA............................48SUPRAX.......................................10SUPREP BOWEL PREP KIT........45SURE T INFUSION SET 18"/6MM....................................... 59SURE T INFUSION SET 23"/10MM..................................... 59SURE T INFUSION SET 23"/6MM....................................... 59SURE T INFUSION SET 23"/8MM....................................... 59
SURE T INFUSION SET 32"/10MM..................................... 59SURE T INFUSION SET 32"/6MM....................................... 59SURE T INFUSION SET 32"/8MM....................................... 59SURESTEP PRO HIGH GLUCOSE.................................... 38SURESTEP PRO LOW GLUCOSE.................................... 38SURESTEP PRO NORMAL GLUCOSE.................................... 38SURVANTA.................................. 63SUSTIVA...................................... 24SUSTOL....................................... 14SUTENT....................................... 19swabflush saline flush...................43syeda............................................ 51SYLVANT..................................... 19SYMBICORT................................ 64SYMBYAX.................................... 13SYMDEKO....................................64SYMFI...........................................24SYMFI LO.....................................24SYMJEPI...................................... 64SYMLINPEN 120..........................37SYMLINPEN 60............................37SYMPAZAN..................................12SYMPROIC...................................45SYMTUZA.....................................24SYNAGIS......................................54SYNALAR.....................................35SYNAREL.....................................48SYNDROS....................................14SYNERCID................................... 10SYNJARDY...................................37SYNJARDY XR.............................37SYNRIBO......................................19T: SLIM X2 INS PMP/CONTROL 7.4.................................................59T:SLIM X2 3ML CARTRIDGE.......59T:SLIM X2 INS PUMP/CONTROL-IQ....................59T:SLIM X2 INSULIN PMP BASAL IQ..................................... 59T:SLIM X2 INSULIN PMP BASAL6.4..................................... 59T:SLIM X2 INSULIN PMP/RFURB IQ............................59T:SLIM X2/CONTROL-IQ/REFURB.................................. 59TABLOID...................................... 19TACHOSIL....................................59TACLONEX.................................. 35tacrolimus............................... 35, 54tadalafil ......................................... 46tadalafil (pah)................................65
TAFINLAR.................................... 19TAGRISSO................................... 19TAKHZYRO.................................. 54TALICIA........................................ 45TALTZ...........................................54TALZENNA...................................19tamoxifen citrate........................... 19tamsulosin hcl...............................46TAPAZOLE...................................52TARCEVA.....................................19TARGRETIN.................................20tarina 24 fe....................................51tarina fe 1/20.................................51tarina fe 1/20 eq............................51TARKA..........................................30TARON FORTE............................43TASIGNA......................................20TASMAR.......................................21TAURINE......................................43TAVALISSE.................................. 25TAXOTERE.................................. 20tazarotene.....................................35tazicef........................................... 10TAZICEF.......................................10TAZORAC.....................................35taztia xt......................................... 30TDVAX..........................................54TECENTRIQ.................................20TECFIDERA................................. 32TEFLARO..................................... 10TEGSEDI......................................32TEKTURNA.................................. 30TEKTURNA HCT..........................30TELFA AMD ISLAND DRESSING...................................59TELFA AMD NON-ADHERENT....59telmisartan.................................... 30telmisartan-amlodipine..................30telmisartan-hctz............................ 30temazepam...................................65TEMODAR....................................20TEMOVATE..................................35temozolomide............................... 20temsirolimus..................................54tencon.............................................4teniposide..................................... 20TENIVAC...................................... 54tenofovir disoproxil fumarate.........24TENORETIC 100..........................30TENORETIC 50............................30TEPADINA....................................20TEPEZZA......................................48terazosin hcl ..................................46terbinafine hcl............................... 15terbutaline sulfate......................... 64terconazole................................... 15
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TERIPARATIDE (RECOMBINANT).........................55TESSALON PERLES................... 63testosterone..................................47testosterone cypionate..................47testosterone enanthate.................47TETANUS-DIPHTHERIA TOXOIDS TD................................54tetrabenazine................................32tetracaine hcl................................ 61tetracycline hcl..............................10TEXACORT.................................. 35THALOMID................................... 20THAM............................................43THE LIQUILIFT TRACE................43THEO-24.......................................64theophylline...................................64theophylline er.............................. 64theophylline in d5w....................... 64THERAHONEY.............................35thiamine hcl...................................43THIOLA.........................................46THIOLA EC...................................46thioridazine hcl..............................22thiotepa.........................................20thiothixene.................................... 22THROMBATE III ........................... 11THROMBIN-JMI............................25THROMBIN-JMI EPISTAXIS........25THROMBOGEN............................25THYMOGLOBULIN.......................54tiadylt er........................................ 30tiagabine hcl..................................12TIAZAC.........................................30TIBSOVO......................................20TICE BCG.....................................54TIGAN...........................................14tigecycline.....................................10TIGLUTIK......................................32tilia fe............................................ 51timolol maleate........................30, 61tinidazole.......................................10TISSEEL.......................................59tis-u-sol......................................... 43TIVICAY........................................24TIVICAY PD..................................24tizanidine hcl .................................65tl-hem 150.....................................43TNKASE....................................... 11TOBI PODHALER.........................64TOBRADEX..................................61TOBRADEX ST............................ 61tobramycin.............................. 60, 64tobramycin sulfate.........................10tobramycin-dexamethasone......... 61TOBREX.......................................60TOLAK..........................................35
tolbutamide................................... 37tolcapone...................................... 21tolmetin sodium...............................5tolterodine tartrate.........................46tolterodine tartrate er.................... 46tolvaptan....................................... 43TOPEX TOPICAL ANESTHETIC. 33TOPICORT................................... 35topiramate.....................................12topiramate er.................................12toposar..........................................20topotecan hcl................................ 20toremifene citrate..........................20TORISEL...................................... 54torsemide......................................30TOTECT....................................... 20TOUJEO MAX SOLOSTAR..........39TOUJEO SOLOSTAR...................39tovet..............................................35TOVIAZ.........................................46TRACLEER...................................65TRADJENTA.................................37TRALEMENT................................43tramadol hcl er................................4tramadol hcl er (biphasic)............... 4tramadol hcl ir ................................. 4tramadol-acetaminophen................4trandolapril ....................................30trandolapril-verapamil hcl er......... 30tranexamic acid.............................26TRANEXAMIC ACID-NACL..........26TRANSDERM SCOP (1.5 MG).....14TRANSDERM-SCOP (1.5 MG).... 14TRANXENE-T...............................24tranylcypromine sulfate.................13TRAVASOL...................................43TRAVATAN Z............................... 61travoprost (bak free)..................... 61TRAZIMERA.................................20trazodone hcl................................ 13TRECATOR..................................16TRELEGY ELLIPTA......................64TRELSTAR MIXJECT...................48TREMFYA.....................................54treprostinil ..................................... 65tretinoin...................................20, 35tretinoin microsphere.................... 36tretinoin microsphere pump.......... 36TRETTEN..................................... 26TREXALL......................................54TREZIX...........................................4tri femynor.....................................51triamcinolone acetonide....33, 36, 47TRIAMCINOLONE ACETONIDE..47TRIAMCINOLONE DIACETATE...47TRIAMCINOLONE-BUPIVACAINE..............................47
TRI-AMINO...................................43triamterene....................................30triamterene-hctz............................30trianex...........................................36triazolam....................................... 24TRICARE PRENATAL DHA ONE.43TRI-CHLOR.................................. 36TRICITRASOL..............................11tricon.............................................43triderm...........................................36TRIDESILON................................ 36trientine hcl................................... 43tri-estarylla.................................... 51TRIFERIC..................................... 43trifluoperazine hcl..........................22trifluridine...................................... 60trigels-f forte..................................43trihexyphenidyl hcl ........................ 21TRIJARDY XR.............................. 37TRIKAFTA.................................... 64tri-legest fe....................................51tri-linyah........................................ 51TRILIPIX....................................... 31tri-lo-estarylla................................ 51tri-lo-marzia...................................51tri-lo-mili ........................................ 51tri-lo-sprintec.................................51trilyte............................................. 45trimethobenzamide hcl..................14trimethoprim..................................10tri-mili ............................................ 52trimipramine maleate.................... 13trinate............................................43TRINTELLIX................................. 13TRIOSTAT....................................52tri-previfem....................................52TRIPTODUR.................................48TRISENOX................................... 20TRISODIUM CITRATE/CRRT...... 43tri-sprintec.....................................52TRIUMEQ..................................... 24trivora (28).................................... 52tri-vylibra....................................... 52tri-vylibra lo................................... 52TRIZIVIR.......................................24TROGARZO................................. 24TROKENDI XR............................. 12TROPHAMINE..............................43TROPICAMIDE-CYCLOPENTOLATE-PE..............61TROPIC-CYCLOP-PE-KETO-PROPAR.......................................61trospium chloride.......................... 46trospium chloride er...................... 46TRULICITY................................... 37TRUMENBA..................................55TRUSOPT.....................................61
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TRUSTEEL INFUSION SET.........59TRUVADA.....................................24TUKYSA....................................... 20tulana............................................52TURALIO...................................... 20TWINRIX.......................................55TWYNSTA.................................... 31TYBOST....................................... 24tydemy.......................................... 52TYGACIL...................................... 10TYKERB....................................... 20TYMLOS.......................................55TYPHIM VI....................................55TYSABRI...................................... 32TYVASO....................................... 65TYVASO REFILL..........................65TYVASO STARTER..................... 65UBRELVY.....................................16UCERIS........................................ 55UDENYCA.................................... 26ULORIC........................................ 15ULTIVA........................................... 4ULTOMIRIS.................................. 26UNASYN.......................................10unithroid........................................52UNITUXIN.....................................20UPTRAVI...................................... 65uretron d/s.....................................46urin ds...........................................46UROCIT-K 10............................... 43UROCIT-K 15............................... 43UROCIT-K 5................................. 43URSO 250.................................... 45URSO FORTE.............................. 45ursodiol ......................................... 45utrona-c.........................................46VABOMERE................................. 10valacyclovir hcl ..............................24VALCHLOR.................................. 20valganciclovir hcl ...........................24valproate sodium.......................... 12valproic acid..................................12valrubicin.......................................20valsartan....................................... 31valsartan-hydrochlorothiazide.......31VALSTAR..................................... 20VALTOCO 10 MG DOSE..............12VALTOCO 15 MG DOSE..............12VALTOCO 20 MG DOSE..............12VALTOCO 5 MG DOSE................12VANCOCIN...................................10VANCOCIN HCL...........................10VANCOMYCIN HCL..................... 10vancomycin hcl ............................. 10VANCOMYCIN HCL IN DEXTROSE..................................10vancomycin hcl in dextrose...........10
vancomycin hcl in nacl..................10VANCOMYCIN HCL IN NACL......10vandazole..................................... 10VANTAS....................................... 48VAPRISOL....................................48VAQTA..........................................55vardenafil hcl .................................46VARISOFT INFUSION SET..........59VARITHENA................................. 31VARIVAX...................................... 55VARIZIG....................................... 54VARUBI (180 MG DOSE).............14VASCEPA.....................................31VASERETIC................................. 31vashe cleansing............................36VASOSTRICT...............................48VAXCHORA..................................55VAZCULEP...................................31VECAMYL.....................................31VECTIBIX..................................... 20VECURONIUM BROMIDE........... 32vecuronium bromide..................... 32VELCADE.....................................20VELETRI.......................................65velivet............................................52VELPHORO..................................46VELTASSA................................... 43VEMLIDY......................................24VENCLEXTA................................ 20VENCLEXTA STARTING PACK.. 20VENELEX..................................... 36VENIPUNCTURE PX1 PHLEBOTOMY...............................6venlafaxine hcl ..............................13venlafaxine hcl er..........................13VENOFER.................................... 43VENTAVIS....................................65VENTOLIN HFA............................64verapamil hcl .................................31verapamil hcl er............................ 31VERELAN.....................................31VERELAN PM...............................31VERSACLOZ................................22VERZENIO................................... 20VFEND..........................................15VFEND IV..................................... 15V-GO 20........................................38V-GO 30........................................38V-GO 40........................................38VIBATIV........................................10VIBERZI........................................45VIBRAMYCIN............................... 10VICTOZA...................................... 37VIDAZA.........................................20VIEKIRA PAK............................... 24vienva........................................... 52vigabatrin...................................... 12
vigadrone......................................12VIIBRYD....................................... 14VIIBRYD STARTER PACK...........14VIMIZIM........................................ 45VIMPAT........................................ 12vinblastine sulfate......................... 20vincristine sulfate.......................... 20vinorelbine tartrate........................20viorele........................................... 52VIRACEPT....................................24VIRAMUNE...................................24VIRAMUNE XR.............................24VIRAZOLE....................................24VIREAD........................................ 24VIRT-FEFA PLUS.........................43virt-phos 250 neutral .....................43virtussin ac w/alc...........................63VISIONBLUE................................ 61VISTARIL......................................24VISTOGARD.................................59VISUDYNE................................... 61vitamin d (ergocalciferol) ...............43vitamin k1......................................43VITRAKVI..................................... 20VITRASE...................................... 59VIVAGUARD LANCING DEVICE. 38VIVITROL....................................... 7VIVOTIF........................................55VIZIMPRO.................................... 20volnea........................................... 52VONVENDI...................................26VORAXAZE.................................. 20voriconazole..................................15VOSEVI........................................ 24VOTRIENT....................................20vp-pnv-dha....................................43VPRIV...........................................45VRAYLAR.....................................22VUMERITY................................... 32VUMERITY (STARTER)...............32VYEPTI.........................................16vyfemla......................................... 52VYLEESI.......................................32vylibra........................................... 52VYNDAMAX..................................31VYNDAQEL.................................. 31VYVANSE.....................................31VYXEOS.......................................20WAKIX.......................................... 65warfarin sodium............................ 11water for irrigation, sterile............. 43wera..............................................52WESTHROID................................52WIDE-SEAL DIAPHRAGM 60...... 59WIDE-SEAL DIAPHRAGM 65...... 59WIDE-SEAL DIAPHRAGM 70...... 59WIDE-SEAL DIAPHRAGM 75...... 59
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WIDE-SEAL DIAPHRAGM 80...... 59WIDE-SEAL DIAPHRAGM 85...... 59WIDE-SEAL DIAPHRAGM 90...... 59WIDE-SEAL DIAPHRAGM 95...... 59WILATE........................................ 26WINRHO SDF...............................54wixela inhub..................................64WP THYROID...............................52wymzya fe.....................................52XADAGO...................................... 21XALKORI...................................... 20XARELTO.....................................11XARELTO STARTER PACK........ 11XATMEP.......................................54XCOPRI........................................12XCOPRI (250 MG DAILY DOSE). 12XCOPRI (350 MG DAILY DOSE). 12XELJANZ......................................54XELJANZ XR................................54XELODA....................................... 20XELPROS.....................................61XEMBIFY......................................54XENLETA..................................... 10XEOMIN........................................59XEPI..............................................10XERAC AC................................... 36XERAVA....................................... 10XERMELO.................................... 45XEROFORM OIL EMULSION 2"X2".............................................36XEROFORM OIL EMULSION GAUZE......................................... 36XEROFORM OIL EMULSION STRIP........................................... 36XEROFORM OIL ROLL 4"X9'...... 36XEROFORM PETROLAT GAUZE 1"X8"............................... 36XEROFORM PETROLAT GAUZE 5"X9"............................... 36XEROFORM PETROLAT PATCH 2"X2"................................36XEROFORM PETROLAT PATCH 4"X4"................................36XEROFORM PETROLATUM ROLL 4"X9'................................... 36XGEVA......................................... 55XIAFLEX.......................................59XIFAXAN...................................... 10XIGDUO XR..................................37XIIDRA..........................................61XIMINO.........................................10XOFIGO........................................20XOFLUZA (40 MG DOSE)............24XOFLUZA (80 MG DOSE)............24XOLAIR.........................................63XOPENEX.................................... 64XOPENEX CONCENTRATE........64
XOPENEX HFA............................ 64XOSPATA.....................................20XPOVIO (100 MG ONCE WEEKLY)......................................20XPOVIO (40 MG ONCE WEEKLY)......................................20XPOVIO (40 MG TWICE WEEKLY)......................................20XPOVIO (60 MG ONCE WEEKLY)......................................20XPOVIO (60 MG TWICE WEEKLY)......................................20XPOVIO (80 MG ONCE WEEKLY)......................................20XPOVIO (80 MG TWICE WEEKLY)......................................20XTAMPZA ER.................................4XTANDI.........................................20XULTOPHY.................................. 37XURIDEN......................................45XYLOCAINE................................... 6xylocaine dental ..............................6XYLOCAINE/EPINEPHRINE..........6XYLOCAINE-MPF.......................... 6XYLOCAINE-MPF/EPINEPHRINE.......................6XYNTHA....................................... 26XYNTHA SOLOFUSE...................26XYOSTED.....................................47XYREM.........................................65XYWAV.........................................65YERVOY.......................................20YF-VAX.........................................55YONDELIS....................................20YUPELRI...................................... 64yuvafem........................................ 52zafirlukast......................................64zaleplon........................................ 65ZALTRAP......................................20ZANOSAR.................................... 20zarah.............................................52ZARONTIN................................... 12ZARXIO........................................ 26ZAVESCA.....................................45ZEBUTAL........................................4ZEJULA........................................ 20ZELAPAR..................................... 21ZELBORAF...................................20ZELNORM.................................... 45ZEMAIRA......................................64ZEMDRI........................................11ZEMPLAR.....................................56zenatane.......................................36ZENPEP....................................... 45ZENZEDI...................................... 31ZEPATIER.................................... 24ZERBAXA.....................................11
ZETONNA.....................................63ZEVALIN Y-90.............................. 20ZIAC..............................................31ZIAGEN........................................ 24zidovudine.....................................24ZIEXTENZO..................................26ZILRETTA.....................................47ZINC CHLORIDE..........................43ZINC SULFATE............................ 43ZINPLAVA.................................... 54ziprasidone hcl..............................22ziprasidone mesylate....................22ZIRABEV...................................... 20ZIRGAN........................................ 60ZITHROMAX.................................11ZITHROMAX TRI-PAK................. 11ZITHROMAX Z-PAK.....................11ZOLADEX.....................................48zoledronic acid..............................55ZOLINZA.......................................20zolmitriptan................................... 16zolpidem tartrate...........................65zolpidem tartrate er.......................65ZOLPIMIST...................................65ZOMIG..........................................16zonisamide....................................12ZONTIVITY...................................22ZORBTIVE....................................45ZORTRESS.................................. 54ZOSYN......................................... 11zovia 1/35e (28)............................52ZUBSOLV.......................................7ZULRESSO.................................. 14zumandimine................................ 52ZYDELIG...................................... 20ZYKADIA...................................... 20ZYLET...........................................61ZYLOPRIM................................... 15ZYMAXID......................................60ZYPREXA RELPREVV.................22ZYPREXA ZYDIS......................... 22ZYVOX..........................................11
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