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H0022_ListOfDrugs15R2_Approved 09222014
2015 List of Covered Drugs
(Formulary)
H0022_ListOfDrugs15R2_Approved 09222014
Buckeye Health Plan – MyCare Ohio
2015 List of Covered Drugs (Formulary)
This List of Drugs is current as of April 1, 201.
This is a list of drugs that members can get in Buckeye Health Plan – MyCare Ohio. ™
Buckeye Health Plan – MyCare Ohio is a health plan that contracts with both Medicare and
Ohio Medicaid to provide benefits of both programs to enrollees.
™
Benefits, List of Covered Drugs, and pharmacy and provider networks, and/or copayments
may change from time to time throughout the year and on January 1 of each year.
™
You can always check Buckeye’s up-to-date List of Covered Drugs online at
http://mmp.bchpohio.com.
™
Limitations, co-pays, and restrictions may apply. For more information, call Buckeye Member
Services or read the Buckeye Member Handbook.
™
Copays for prescription drugs may vary based on the level of Extra Help you receive. Please
contact the plan for more details.
™
You can ask for this information in other formats, such as large print. Call (866) 549-8289. The
call is free.
™
™
You can get this information for free in other languages. Call (866) 549-8289. The call is free.
Usted puede obtener este documento en español, o hablar con alguien acerca de esta
información en otros idiomas de forma gratuita. Llame al (866) 549-8289. La llamada es
gratuita.
00015548, Version Number 18
Updated4 ?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
1
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of
the FAQ to learn more, or look for a question and answer.
1. What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by Buckeye.
These drugs are available at pharmacies within our network. A pharmacy is in our network if we
have an agreement with them to work with us and provide you services. We refer to these
pharmacies as “network pharmacies.”
→ Buckeye will cover all medically necessary drugs on the Drug List if:
• your doctor or other prescriber says you need them to get better or stay healthy, and
• you fill the prescription at a Buckeye network pharmacy.
→ Buckeye may have additional steps to access certain drugs (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website at
http://mmp.bchpohio.com or call Member Services at (866) 549-8289.
2. Does the Drug List ever change?
Yes. Buckeye may add or remove drugs on the Drug List during the year. Generally, the
Drug List will only change if:
• a cheaper drug comes along that works as well as a drug on the Drug List now, or
• we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
• Decide to require or not require prior approval for a drug. (Prior approval is permission from
Buckeye before you can get a drug.)
• Add or change the amount of a drug you can get (called “quantity limits”).
• Add or change step therapy restrictions on a drug. (Step therapy means you must try one
drug before we will cover another drug.)
(For more information on these drug rules, see page 4.)
?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
2
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you
when we change our rules for covering a drug. Questions 3, 4, and 7 below have more
information on what happens when the Drug List changes.
→ You can always check Buckeye’s up to date Drug List online at http://mmp.bchpohio.com.
You can also call Member Services to check the current Drug List at (866) 549-8289.
3. What happens when a cheaper drug comes along that works as
well as a drug on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes
along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or
when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the
Drug List is made.
We will mail you a notice if you are taking a drug, and we change our rules for covering it. You will
receive the notice by mail at least 60 days before we change the drug rules or remove the drug
from our List of Covered Drugs. For example, if you are taking a drug, and we add prior
authorization (approval) or quantity limits, the notice you receive will explain the new rules. We
must tell you of this change at least 60 days before it becomes effective. Or, we have to tell you
when you request a refill of the drug. If we tell you when you refill your drug, you will receive a 60­
day supply of the drug. For more information on these drug rules, see page 4. If you have
questions about the notice you receive from Buckeye, call Member Services at (866) 549-8289.
TTY Users should call 711. Hours are from 8 a.m. to 8 p.m., seven days a week.
4. What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it
off the Drug List right away. We will also send you a letter telling you that. If you have any
questions after being notified of the change, you should contact the doctor who prescribed the
drug for you.
?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
3
5. Are there any restrictions or limits on drug coverage? Or are there
any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases
you must do something before you can get the drug. For example:
• Prior approval (or prior authorization): For some drugs, you or your doctor or other
prescriber must get approval from Buckeye before you fill your prescription. If you don’t get
approval, Buckeye may not cover the drug.
• Quantity limits: Sometimes Buckeye limits the amount of a drug you can get.
• Step therapy: Sometimes Buckeye requires you to do step therapy. This means you will
have to try drugs in a certain order for your medical condition. You might have to try one
drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for
you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on
page 10 to 151. You can also get more information by visiting our web site at
http://mmp.bchpohio.com. We have posted online a document that explains our prior
authorization restriction or step therapy restriction or prior authorization and step therapy
restrictions. You may also ask us to send you a copy.
You can ask for an “exception” from these limits. Please see question 11 for more information on
exceptions.
→ If you are in a nursing home or other long-term care facility and need a drug that is not on the
Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day
emergency supply of the drug you need (unless you have a prescription for fewer days),
whether or not you are a new Buckeye member. This will give you time to talk to your doctor
or other prescriber. He or she can help you decide if there is a similar drug on the Drug List
you can take instead or whether to request an exception. Please see question 11 for more
information about exceptions.
6.
How will you know if the drug you want has limitations or if there
are required actions to take to get the drug?
The List of Covered Drugs on page 10 has a column labeled “Necessary actions, restrictions, or
limits on use.”
?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
4
7. What happens if we change our rules on how we cover some
drugs? For example, if we add prior authorization (approval),
quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug.
We will tell you at least 60 days before the restriction is added or when you next ask for a refill.
Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This
gives you time to talk to your doctor or other prescriber about what to do next.
8. How can you find a drug on the Drug List?
There are two ways to find a drug:
• You can search alphabetically (if you know how to spell the drug), or
• You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing
the index of drugs that begins on page 68.
To search by medical condition, find the section labeled “List of drugs by medical condition” on
page 10. Then find your medical condition. For example, if you have a heart condition, you should
look in that category. That is where you will find drugs that treat heart conditions.
9. What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at (866) 549-8289 and ask
about it. If you learn that Buckeye will not cover the drug, you can do one of these things:
• Ask Member Services for a list of drugs like the one you want to take. Then show the list to
your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like
the one you want to take. Or
• You can ask the health plan to make an exception to cover your drug. Please see question
11 for more information about exceptions.
?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
5
10. What if you are a new Buckeye member and can’t find your drug on
the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you
are a member of Buckeye. This will give you time to talk to your doctor or other prescriber. He or
she can help you decide if there is a similar drug on the Drug List you can take instead or whether
to request an exception.
We will cover a 30-day supply of your drug if:
• you are taking a drug that is not on our Drug List, or
• health plan rules do not let you get the amount ordered by your prescriber, or
• the drug requires prior approval by Buckeye, or
• you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription
for as long as 91 to 98 days. You may refill the drug multiple times during the 91 to 98 days. This
gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.
Under certain circumstances our plan can offer a temporary supply of a drug to you when your
drug is not on the List of Drugs or when it is restricted in some way. This temporary supply allows
you time to speak to your doctor about a different medication or dose which is covered within the
plan guidelines.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The drug you have been taking is no longer on the Buckeye List of Drugs or the drug
you have been taking is now restricted in some way.
2. You must be in one of the situations described below:
• For those members who are new to our plan and aren’t in a long-term care facility:
We will cover a temporary supply of your drug one time only during the first 90
days of your membership in Buckeye. This temporary supply will be for a maximum
of a 30-day supply, or less if your prescription is written for fewer days. The
prescription must be filled at a network pharmacy.
?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
6
•
For those who are new Buckeye members, and are residents in a long-term care
facility: We will cover a temporary supply of your drug during the first 90 days of
your membership in our plan. The first supply will be for a maximum of a 31-day
supply, or less if your prescription is written for fewer days. If needed, we will cover
additional refills during your first 90 days in Buckeye up to a maximum of 91 to 98
day supply.
•
For those who have been a member of Buckeye or more than 90 days, are a
resident of a long-term care facility and need a supply right away; we will cover one
31-day supply or less if your prescription is written for fewer days. This is in
addition to the above long-term care transition supply. An exception or prior
authorization should also be requested at the time the prescription is filled.
11. Can you ask for an exception to cover your drug?
Yes. You can ask Buckeye to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
• For example, Buckeye may limit the amount of a drug we will cover. If your drug has
a limit, you can ask us to change the limit and cover more.
• Other examples: You can ask us to drop step therapy restrictions or prior approval
requirements.
12. How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an
exception. After we receive the statement, we will give you a decision on your exception request
within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a
decision, you can ask for an expedited exception. This is a faster decision. If your prescriber
supports your request, we will give you a decision within 24 hours of receiving your prescriber’s
supporting statement.
?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
7
13. How can you ask for an exception?
To ask for an exception, call Member Services at (866) 549-8289, TTY users call 711. A Member
Services representative will work with you and your provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less
than the brand name drug and usually don’t have well-known names. Generic drugs are approved
by the Food and Drug Administration (FDA).
Buckeye covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. You can buy OTC drugs without a prescription.
Buckeye covers some OTC drugs. You can read the Buckeye Drug List to see what OTC drugs are covered. 16. What is your copay?
You can read the Buckeye Drug List to learn about the copay for each drug. Buckeye members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay.
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Drug Tier
LIS Level 1
LIS Level 2
LIS Level 3
Tier 1 – Medicare-Covered Generic Drugs
Tier 2 – Medicare-Covered Brand Name
Drugs
Tier 3 – Medicaid Covered Drugs
$0
$2.65 (generic)
$6.60 (brand)
$0
$0
$1.20 (generic)
$3.60 (brand)
$0
$0
$0
$0
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
8
List of Covered Drugs
The list of covered drugs that begins on the next page gives you information about the drugs
covered by Buckeye. If you have trouble finding your drug in the list, turn to the Index that begins
on page 68.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,
HUMALOG) and generic drugs are listed in lower-case italics (e.g., amoxicillin).
The information in the necessary actions, restrictions, or limits on use column tells you if Buckeye
has any rules for covering your drug.
Abbreviations
Descriptions
B/D
This prescription drug has a Part B versus Part D administrative prior
authorization requirement. This drug may be covered under Medicare Part B or
Part D depending upon the circumstances. Information may need to be
submitted describing the use and setting of the drug to make the determination.
DP
Drug is not a Part D drug
LA
Limited Access. This prescription may be available only at certain pharmacies.
For more information call Member Service at (866) 549-0482. TTY users
should call 711.
PA
Prior Authorization. Buckeye requires your doctor to get prior authorization for
certain drugs. This means that you will need to get approval from Buckeye
before you fill your prescriptions. If you don’t get approval, Buckeye may not
cover the drug.
QL
Quantity Limit. For certain drugs, Buckeye limits the amount of the drug that will
be covered. For example, only 30 tablets of ABILIFY per 30 days. This may be
in addition to a standard one-month or three-month supply.
MO
Maintenance Drug. This prescription drug is eligible for a 90-day supply through
our mail order service as well as through certain retail network pharmacies.
Consider using mail order for your long-term (maintenance) medications (such
as high blood pressure medications). Retail network pharmacies may be more
appropriate for short-term prescriptions (such as antibiotics).
Note: The “DP” next to a drug means the drug is not a “Part D drug.” The amount you pay when
you fill a prescription for this drug does not count towards your total drug costs (that is, the
amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these
drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us
to review a coverage decision and to change it if you think we made a mistake. For example, we
might decide that a drug that you want is not covered or is no longer covered by Medicare or
Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for
instructions on how to appeal, call Member Services at (866) 549-8289. You can also read the
Member Handbook to learn how to appeal a decision.
?
If you have questions, please call Buckeye at (866) 549-8289. TTY users call 711. Hours are
from 8 a.m. to 8 p.m., seven days a week The call is free. For more information, visit
http://mmp.bchpohio.com.
9
Drug Name
Analgesics
Analgesics
butalbital/acetaminophen
butalbital/acetaminophen/caffeine/codeine capsule 325mg;
50mg; 40mg; 30mg
butalbital/acetaminophen/caffeine capsule
butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg
butalbital/aspirin/caffeine
GRALISE
GRALISE STARTER
Nonsteroidal Anti-inflammatory Drugs
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diflunisal tablet
etodolac er
etodolac capsule, tablet
fenoprofen calcium tablet
flurbiprofen tablet
ibuprofen suspension
ibuprofen tablet 400mg, 600mg, 800mg
indomethacin er
indomethacin capsule
ketoprofen er
ketoprofen capsule
ketorolac tromethamine injection 15mg/ml, 30mg/ml
meclofenamate sodium capsule
meloxicam suspension
meloxicam tablet
nabumetone
naproxen dr
naproxen sodium tablet 275mg, 550mg
naproxen suspension, tablet
oxaprozin
piroxicam capsule
sulindac tablet
tolmetin sodium capsule
tolmetin sodium tablet 600mg
tolmetin sodium tablet 200mg
Opioid Analgesics, Long-acting
fentanyl
levorphanol tartrate tablet
METHADONE HCL INJECTION
methadone hcl oral solution, tablet
methadose tablet 10mg
morphine sulfate er tablet extended release 15mg, 200mg,
30mg, 60mg
morphine sulfate er tablet extended release 100mg
Opioid Analgesics, Short-acting
Page 1 of 93
Drug
Tier
Requirements/Limits
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MO
1
1
2
1
1
1
QL (10 EA per 30 days)
QL (240 EA per 30 days)
1
QL (180 EA per 30 days)
PA (Anti-inflammatory Agents)
PA (Anti-inflammatory Agents)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
MO
QL (120 EA per 30 days)
Drug Name
acetaminophen/codeine #3
acetaminophen/codeine tablet 300mg; 15mg, 300mg; 60mg
ascomp/codeine
butorphanol tartrate
DEMEROL INJECTION 50MG/ML
duramorph
endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg
fentanyl citrate oral transmucosal
Drug
Tier
1
1
1
1
2
1
1
1
hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg
hydrocodone bitartrate/acetaminophen tablet 325mg; 2.5mg
hydrocodone/acetaminophen tablet 650mg; 10mg
hydrocodone/acetaminophen tablet 750mg; 7.5mg
hydrocodone/acetaminophen tablet 650mg; 7.5mg, 660mg;
10mg
hydrocodone/acetaminophen tablet 500mg; 10mg, 500mg;
5mg, 500mg; 7.5mg
hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydromorphone hcl tablet
hydromorphone hcl injection 500mg/50ml
LAZANDA SOLUTION 400MCG/ACT
1
1
1
1
1
LAZANDA SOLUTION 100MCG/ACT
2
meperidine hcl injection 100mg/ml, 25mg/ml, 50mg/ml
morphine sulfate solution, tablet
nalbuphine hcl injection
oxycodone hcl tablet
oxycodone/acetaminophen capsule
oxycodone/acetaminophen tablet 650mg; 10mg
oxycodone/acetaminophen tablet 500mg; 7.5mg
oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg,
325mg; 7.5mg
roxicet tablet 325mg; 5mg
stagesic
TALWIN
tramadol hcl tablet
tramadol hydrochloride/acetaminophen
Anesthetics
Local Anesthetics
lidocaine hcl jelly
lidocaine hcl external solution
lidocaine hcl injection 0.5%, 1%
lidocaine viscous
lidocaine/prilocaine cream
lidocaine ointment
Page 2 of 93
Requirements/Limits
QL (390 EA per 30 days)
QL (390 EA per 30 days)
QL (360 EA per 30 days)
QL (120 EA per 30 days) PA
(Fentanyl Citrate Oral
Transmucosal)
QL (150 EA per 30 days)
QL (360 EA per 30 days)
QL (150 EA per 30 days)
QL (180 EA per 30 days)
1
QL (240 EA per 30 days)
1
QL (360 EA per 30 days)
1
1
2
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
QL (150 EA per 30 days) PA
(Lazanda)
QL (600 EA per 30 days) PA
(Lazanda)
QL (240 EA per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
QL (240 EA per 30 days)
Drug Name
lidocaine patch
XYLOCAINE-MPF INJECTION 1%
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr
disulfiram tablet
Opioid Dependence Treatments
buprenorphine hcl injection, tablet sublingual
naltrexone hcl tablet
SUBOXONE
ZUBSOLV
Opioid Reversal Agents
naloxone hcl injection 1mg/ml
Smoking Cessation Agents
buproban
CHANTIX STARTING MONTH PAK
CHANTIX TABLET 0.5MG, 1MG
NICOTROL NS
Antibacterials
Aminoglycosides
AMIKACIN SULFATE INJECTION 50MG/ML
amikacin sulfate injection 500mg/2ml
gentak
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE
INJECTION 0.9MG/ML; 0.9%, 1.4MG/ML; 0.9%
gentamicin sulfate/0.9% sodium chloride injection 1.6mg/ml;
0.9%, 1mg/ml; 0.9%
gentamicin sulfate cream, injection, external ointment,
ophthalmic ointment, ophthalmic solution
isotonic gentamicin injection 0.8mg/ml; 0.9%, 1.2mg/ml;
0.9%
neomycin sulfate
neomycin/polymyxin b sulfates
paromomycin sulfate
STREPTOMYCIN SULFATE INJECTION
TOBRAMYCIN SULFATE/SODIUM CHLORIDE
INJECTION 0.9%; 0.8MG/ML
tobramycin sulfate ophthalmic solution
tobramycin sulfate injection 10mg/ml, 80mg/2ml
Antibacterials, Other
alcohol preps
baciim
BACITRACIN INJECTION
CHLORAMPHENICOL SODIUM SUCCINATE
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
clindamycin hcl capsule
clindamycin palmitate hcl
Page 3 of 93
Drug
Tier
1
Requirements/Limits
QL (90 EA per 30 days) PA
(Anesthetics)
2
1
1
1
1
2
2
1
1
2
2
2
2
1
1
2
1
1
1
1
1
1
2
2
1
1
1
1
2
2
2
2
1
1
QL (56 EA per 28 days)
Drug Name
clindamycin phosphate add-vantage
clindamycin phosphate in d5w
clindamycin phosphate cream, gel, lotion, solution, swab
colistimethate sodium
CUBICIN
LINCOCIN
linezolid
methenamine hippurate
metronidazole in nacl 0.79%
metronidazole vaginal
metronidazole gel 0.75%
metronidazole cream, lotion, tablet
mupirocin ointment
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/hydrocortisone ophthalmic suspension
1%; 3.5mg/ml; 10000unit/ml
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
polymyxin b sulfate injection
PRIMSOL
silver sulfadiazine cream
ssd
SYNERCID
trimethoprim tablet
TYGACIL
vancomycin hcl capsule
vancomycin hcl injection 1000mg, 10gm, 500mg
vandazole
XIFAXAN TABLET 200MG
ZYVOX INJECTION
ZYVOX TABLET
ZYVOX SUSPENSION RECONSTITUTED
Beta-lactam, Cephalosporins
cefaclor er
cefaclor capsule
cefadroxil
CEFAZOLIN SODIUM INJECTION 1GM; 5%
cefazolin sodium injection 10gm, 1gm, 500mg
cefdinir
cefepime injection 1gm, 2gm
cefotaxime sodium injection 10gm, 1gm, 2gm, 500mg
cefoxitin sodium injection 10gm, 1gm, 2gm
cefpodoxime proxetil tablet
cefprozil
ceftazidime injection 1gm, 2gm, 6gm
ceftriaxone sodium
cefuroxime axetil tablet
cefuroxime sodium injection 1.5gm, 7.5gm, 750mg
cephalexin capsule 250mg, 500mg
Page 4 of 93
Drug
Tier
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
2
1
2
1
1
1
2
2
2
2
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
B/D
PA (Antibacterials)
PA (Antibacterials)
QL (20 EA per 10 days)
QL (600 ML per 10 days)
Drug Name
cephalexin suspension reconstituted, tablet
CLAFORAN
FORTAZ INJECTION 1GM, 2GM
SUPRAX
TEFLARO
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE
AZACTAM INJECTION 1GM
aztreonam injection 1gm
imipenem/cilastatin
INVANZ
meropenem injection 500mg
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amoxicillin capsule, suspension reconstituted, tablet
amoxicillin tablet chewable 125mg, 250mg
ampicillin
AMPICILLIN SODIUM INJECTION 125MG
ampicillin sodium injection 10gm, 1gm
ampicillin-sulbactam injection 10gm; 5gm, 2gm; 1gm
BACTOCILL IN DEXTROSE
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium injection 10gm, 1gm
NALLPEN/DEXTROSE INJECTION 0; 1GM/50ML
oxacillin sodium injection 10gm, 2gm
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE INJECTION 0; 40000UNIT/ML, 0;
60000UNIT/ML
penicillin g potassium injection 5000000unit
PENICILLIN G PROCAINE
PENICILLIN G SODIUM
penicillin v potassium
PFIZERPEN-G INJECTION 5000000UNIT
piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm
TIMENTIN INJECTION 0.1GM; 3GM
ZOSYN INJECTION 3GM; 0.375GM, 5%; 2GM/50ML;
0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML
Macrolides
azithromycin injection 500mg
azithromycin suspension reconstituted 100mg/5ml
azithromycin suspension reconstituted 200mg/5ml
azithromycin tablet 500mg
azithromycin tablet 250mg
azithromycin tablet 600mg
clarithromycin er
clarithromycin suspension reconstituted
Page 5 of 93
Drug
Tier
1
2
2
2
2
Requirements/Limits
2
2
1
1
2
1
1
1
1
1
1
2
1
1
2
2
2
1
1
2
1
2
1
2
2
1
2
1
2
2
1
1
1
1
1
1
1
1
QL (15 ML per 5 days)
QL (22.5 ML per 5 days)
QL (3 EA per 3 days)
QL (6 EA per 5 days)
QL (8 EA per 28 days)
Drug Name
clarithromycin tablet 250mg
clarithromycin tablet 500mg
e.e.s. 400
e.e.s. granules
ERY-TAB
ERYPED 400
ERYTHROCIN LACTOBIONATE INJECTION 500MG
erythrocin stearate
erythromycin base tablet
erythromycin ointment, solution
KETEK TABLET 300MG
KETEK TABLET 400MG
ZMAX
Quinolones
AVELOX INJECTION
ciprofloxacin hcl solution, tablet
ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5%
ciprofloxacin injection 400mg/40ml
LEVAQUIN INJECTION 5%; 750MG/150ML
levofloxacin in d5w injection 5%; 500mg/100ml
levofloxacin injection, oral solution
levofloxacin tablet 250mg
levofloxacin tablet 500mg, 750mg
ofloxacin
Sulfonamides
sodium sulfacetamide solution
sulfacetamide sodium suspension
sulfadiazine tablet
sulfamethoxazole/trimethoprim ds
SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION
sulfamethoxazole/trimethoprim suspension, tablet
Tetracyclines
demeclocycline hcl tablet
doxycycline hyclate capsule, tablet
minocycline hcl capsule
Anticonvulsants
Anticonvulsants, Other
APTIOM TABLET 200MG, 400MG, 800MG
APTIOM TABLET 600MG
FYCOMPA
levetiracetam oral solution
levetiracetam injection 500mg/5ml
levetiracetam tablet 750mg
levetiracetam tablet 500mg
levetiracetam tablet 250mg
levetiracetam tablet 1000mg
POTIGA TABLET 50MG
POTIGA TABLET 200MG, 300MG, 400MG
Calcium Channel Modifying Agents
Page 6 of 93
Drug
Tier
1
1
1
1
2
2
2
1
1
1
2
2
2
2
1
1
1
2
1
1
1
1
1
Requirements/Limits
QL (28 EA per 14 days)
QL (42 EA per 21 days)
QL (20 EA per 10 days)
QL (10 EA per 10 days)
QL (14 EA per 14 days)
1
1
1
1
2
1
1
1
1
2
2
2
1
1
1
1
1
1
2
2
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (120 EA per 30 days)
QL (180 EA per 30 days)
QL (180 EA per 30 days) MO
QL (90 EA per 30 days)
QL (180 EA per 30 days) MO
QL (90 EA per 30 days)
Drug
Drug Name
Tier
CELONTIN
2
ethosuximide
1
LYRICA SOLUTION
2
LYRICA CAPSULE 150MG, 200MG, 225MG, 300MG
2
LYRICA CAPSULE 100MG, 25MG, 50MG, 75MG
2
zonisamide
1
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tablet dispersible 0.125mg, 0.25mg, 0.5mg, 1
1mg
clonazepam odt tablet dispersible 2mg
1
clonazepam tablet 0.5mg, 1mg
1
clonazepam tablet 2mg
1
diazepam gel 20mg
1
diazepam gel 2.5mg
1
diazepam gel 10mg
1
divalproex sodium
1
divalproex sodium dr
1
divalproex sodium er
1
gabapentin capsule, solution, tablet
1
GABITRIL TABLET 12MG, 16MG
2
ONFI TABLET
2
ONFI SUSPENSION
2
phenobarbital
1
primidone tablet
1
SABRIL
2
tiagabine hydrochloride tablet 4mg
1
tiagabine hydrochloride tablet 2mg
1
valproate sodium injection
1
valproic acid capsule, syrup
1
Glutamate Reducing Agents
felbamate
1
lamotrigine
1
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG, 2
25MG, 50MG
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG, 2
200MG
topiramate er capsule er 24 hour sprinkle 100mg, 25mg, 50mg 1
topiramate er capsule er 24 hour sprinkle 150mg, 200mg
1
topiramate capsule sprinkle, tablet
1
TROKENDI XR CAPSULE EXTENDED RELEASE 24
2
HOUR 25MG, 50MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
2
HOUR 200MG
TROKENDI XR CAPSULE EXTENDED RELEASE 24
2
HOUR 100MG
Sodium Channel Agents
BANZEL SUSPENSION
2
BANZEL TABLET
2
carbamazepine er
1
Page 7 of 93
Requirements/Limits
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (150 EA per 30 days)
QL (300 EA per 30 days)
QL (100 EA per 30 days)
QL (24.9 EA per 30 days)
QL (50 EA per 30 days)
QL (90 EA per 30 days)
MO
QL (360 EA per 30 days)
QL (90 EA per 30 days)
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (240 EA per 30 days)
Drug Name
carbamazepine tablet chewable, suspension, tablet
CARBATROL
CEREBYX INJECTION 500MG PE/10ML
DILANTIN
DILANTIN INFATABS
DILANTIN-125
epitol
fosphenytoin sodium injection 100mg pe/2ml
oxcarbazepine
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 600MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 150MG
OXTELLAR XR TABLET EXTENDED RELEASE 24
HOUR 300MG
PEGANONE
PHENYTEK
phenytoin infatabs
phenytoin sodium extended
phenytoin sodium injection
phenytoin tablet chewable, suspension
TEGRETOL-XR
TEGRETOL SUSPENSION, TABLET
VIMPAT INJECTION, ORAL SOLUTION
VIMPAT TABLET 100MG, 50MG
VIMPAT TABLET 150MG, 200MG
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates tablet
Cholinesterase Inhibitors
donepezil hcl tablet dispersible
donepezil hcl tablet 10mg, 5mg
galantamine hydrobromide solution
galantamine hydrobromide capsule extended release 24 hour
galantamine hydrobromide tablet 4mg
galantamine hydrobromide tablet 12mg
galantamine hydrobromide tablet 8mg
rivastigmine tartrate
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA TITRATION PAK
NAMENDA SOLUTION
NAMENDA TABLET
Antidepressants
Antidepressants, Other
BRINTELLIX
budeprion sr
bupropion hcl sr
bupropion hcl xl
bupropion hcl tablet
Page 8 of 93
Drug
Tier
1
2
2
2
2
2
1
1
1
2
QL (120 EA per 30 days) MO
2
QL (60 EA per 30 days) MO
2
QL (90 EA per 30 days) MO
2
2
1
1
1
1
2
2
2
2
2
QL (60 EA per 30 days)
Requirements/Limits
1
1
1
1
1
1
1
1
1
2
2
2
2
1
1
1
1
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (180 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (60 EA per 30 days)
QL (360 ML per 30 days)
QL (60 EA per 30 days)
MO
QL (30 EA per 30 days)
Drug
Drug Name
Tier
maprotiline hcl
1
mirtazapine
1
mirtazapine odt tablet dispersible 30mg, 45mg
1
nefazodone hcl
1
trazodone hcl tablet
1
Monoamine Oxidase Inhibitors
EMSAM
2
MARPLAN
2
phenelzine sulfate tablet
1
tranylcypromine sulfate
1
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide
1
desvenlafaxine er
1
duloxetine hcl capsule delayed release particles
1
escitalopram oxalate solution
1
escitalopram oxalate tablet
1
FETZIMA
2
FETZIMA TITRATION PACK
2
fluoxetine hcl capsule, solution
1
fluoxetine hcl tablet 10mg
1
fluvoxamine maleate
1
KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 2
100MG
KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 2
50MG
paroxetine hcl er tablet extended release 24 hour 37.5mg
1
paroxetine hcl tablet
1
PAXIL SUSPENSION
2
sertraline hcl concentrate, tablet
1
venlafaxine hcl
1
venlafaxine hcl er
1
VIIBRYD
2
Tricyclics
amitriptyline hcl tablet
1
amoxapine
1
chlordiazepoxide/amitriptyline
1
clomipramine hcl capsule
1
desipramine hcl tablet
1
doxepin hcl capsule 100mg, 10mg, 25mg, 50mg, 75mg
1
doxepin hcl concentrate
1
imipramine hcl tablet
1
imipramine pamoate
1
nortriptyline hcl capsule
1
nortriptyline hcl solution
1
perphenazine/amitriptyline
1
protriptyline hcl
1
SURMONTIL
2
trimipramine maleate capsule
1
Page 9 of 93
Requirements/Limits
QL (30 EA per 30 days)
QL (60 EA per 30 days) MO
QL (30 EA per 30 days)
MO
QL (120 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (90 EA per 30 days)
QL (30 EA per 30 days)
MO
MO
Drug Name
Antiemetics
Antiemetics, Other
meclizine hcl tablet
phenadoz
promethazine hcl injection, suppository, syrup, tablet
promethegan suppository 25mg
TRANSDERM-SCOP
trimethobenzamide hcl capsule
Emetogenic Therapy Adjuncts
dronabinol
EMEND CAPSULE 40MG
EMEND CAPSULE 0
granisetron hcl injection 0.1mg/ml, 1mg/ml
ondansetron hcl oral solution
ondansetron hcl injection 4mg/2ml
ondansetron hcl tablet 24mg
ondansetron hcl tablet 4mg, 8mg
ondansetron odt
Antifungals
Antifungals
ABELCET
AMBISOME
AMPHOTERICIN B
CANCIDAS
ciclopirox olamine cream
ciclopirox suspension
clotrimazole external cream, solution, troche
econazole nitrate cream
fluconazole in dextrose injection 56mg/ml; 400mg/200ml
fluconazole suspension reconstituted
fluconazole tablet 100mg, 200mg, 50mg
fluconazole tablet 150mg
flucytosine
griseofulvin microsize tablet
griseofulvin ultramicrosize
itraconazole capsule
ketoconazole cream, shampoo, tablet
miconazole 3 suppository
MYCAMINE
NAFTIN CREAM 1%
NAFTIN GEL 1%
NATACYN
NOXAFIL SUSPENSION, TABLET DELAYED RELEASE
nyamyc
nystatin/triamcinolone
nystatin cream, ointment, powder, suspension, tablet
nystop
pedi-dri
SPORANOX SOLUTION
Page 10 of 93
Drug
Tier
Requirements/Limits
1
1
1
1
2
1
PA (High Risk Medications)
PA (High Risk Medications)
PA (High Risk Medications)
QL (10 EA per 30 days)
PA (High Risk Medications)
1
2
2
1
1
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
1
1
1
1
1
2
B/D
QL (1 EA per 14 days) B/D
QL (3 EA per 14 days) B/D
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (1 EA per 10 days)
QL (12 EA per 30 days)
Drug Name
terbinafine hcl tablet
terconazole cream 0.8%
terconazole cream 0.4%
terconazole suppository
voriconazole injection, tablet
Antigout Agents
Antigout Agents
allopurinol tablet
ALOPRIM
colchicine capsule
COLCRYS
mitigare
probenecid/colchicine
probenecid tablet
Antimigraine Agents
Antimigraine Agents
BOTOX
Ergot Alkaloids
dihydroergotamine mesylate injection
ERGOMAR
migergot
Serotonin (5-HT) 1b/1d Receptor Agonists
IMITREX STATDOSE REFILL INJECTION 4MG/0.5ML
IMITREX SOLUTION
naratriptan hcl
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan succinate tablet
sumatriptan succinate injection 6mg/0.5ml
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL
MESTINON TIMESPAN
MESTINON SYRUP
pyridostigmine bromide tablet
Antimycobacterials
Antimycobacterials, Other
DAPSONE TABLET
MYCOBUTIN
rifabutin
Antituberculars
CAPASTAT SULFATE
ethambutol hcl tablet
ISONIAZID INJECTION
isoniazid syrup, tablet
PASER
PRIFTIN
pyrazinamide tablet
Page 11 of 93
Drug
Tier
1
1
1
1
1
1
2
1
2
1
1
1
2
1
2
1
2
2
1
1
1
1
1
2
2
2
1
2
2
1
2
1
2
1
2
2
1
Requirements/Limits
QL (90 GM per 30 days)
QL (3 EA per 30 days)
MO
MO
MO
PA (Miscellaneous Therapeutic
Agents - Botox)
Drug Name
rifampin capsule, injection
RIFATER
SEROMYCIN
TRECATOR
Antineoplastics
Alkylating Agents
ALKERAN INJECTION
BICNU
BUSULFEX
cyclophosphamide capsule, tablet
dacarbazine injection 200mg
HEXALEN
IFEX INJECTION 1GM
ifosfamide injection 1gm
LEUKERAN
lomustine
MATULANE
melphalan hydrochloride
MUSTARGEN
thiotepa
TREANDA INJECTION 100MG, 45MG/0.5ML
VALCHLOR
ZANOSAR
Antiandrogens
bicalutamide
flutamide
NILANDRON
XTANDI
ZYTIGA
Antiangiogenic Agents
POMALYST
REVLIMID CAPSULE 2.5MG, 20MG
REVLIMID CAPSULE 10MG, 15MG, 25MG, 5MG
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX
SOLTAMOX
tamoxifen citrate tablet
Antimetabolites
ALIMTA INJECTION 500MG
ARRANON
cladribine
CLOLAR
cytarabine aqueous
cytarabine injection 500mg
DROXIA
ELITEK INJECTION 1.5MG
Page 12 of 93
Drug
Tier
1
2
2
2
Requirements/Limits
2
2
2
1
1
2
2
1
2
1
2
1
2
1
2
2
2
B/D
1
1
2
2
2
QL (30 EA per 30 days)
2
2
2
2
2
2
2
2
1
2
2
1
2
1
1
2
2
B/D
QL (60 EA per 30 days)
QL (120 EA per 30 days)
LA
Drug Name
fluorouracil injection 2.5gm/50ml
FOLOTYN INJECTION 40MG/2ML
gemcitabine hcl injection 1gm
hydroxyurea capsule
mercaptopurine tablet
pentostatin
PURIXAN
TABLOID
Antineoplastics, Other
ABRAXANE
adriamycin injection 2mg/ml
amifostine
azacitidine
BELEODAQ
bleomycin sulfate injection 30unit
CAMPTOSAR INJECTION 100MG/5ML
carboplatin injection 150mg/15ml
cisplatin injection 100mg/100ml
COSMEGEN
DACOGEN
dactinomycin
DAUNORUBICIN HCL INJECTION 5MG/ML
decitabine
dexrazoxane injection 250mg
DOCEFREZ
DOCETAXEL INJECTION 80MG/4ML, 80MG/8ML
DOXIL
doxorubicin hcl injection 2mg/ml
ELLENCE INJECTION 200MG/100ML
epirubicin hcl injection 50mg/25ml
fludarabine phosphate injection 50mg
FUSILEV
GILOTRIF
HALAVEN
IDAMYCIN PFS INJECTION 20MG/20ML
idarubicin hcl injection 10mg/10ml
irinotecan injection 100mg/5ml
ISTODAX
IXEMPRA KIT INJECTION 45MG
JEVTANA
leucovorin calcium tablet
leucovorin calcium injection 100mg, 350mg
lipodox
lipodox 50
LYNPARZA
mesna
MESNEX
mitomycin injection 20mg
mitoxantrone hcl
Page 13 of 93
Drug
Tier
1
2
1
1
1
1
2
2
2
1
1
1
2
1
2
1
1
2
2
1
2
1
1
2
2
2
1
2
1
1
2
2
2
2
1
1
2
2
2
1
1
1
1
2
1
2
1
1
Requirements/Limits
QL (480 EA per 30 days)
Drug Name
ONCASPAR
oxaliplatin injection 100mg/20ml
paclitaxel injection 300mg/50ml
PROLEUKIN
SYLATRON
SYNRIBO
TRISENOX
VELCADE
VINBLASTINE SULFATE INJECTION 1MG/ML
vincristine sulfate
vinorelbine tartrate injection 50mg/5ml
ZINECARD INJECTION 250MG
ZOLINZA
Antineoplastics
ZALTRAP INJECTION 100MG/4ML
ZYKADIA
Aromatase Inhibitors, 3rd Generation
anastrozole tablet
exemestane
letrozole
Enzyme Inhibitors
ETOPOPHOS
etoposide injection 500mg/25ml
toposar injection 1gm/50ml
topotecan hcl injection 4mg
ZYDELIG
Molecular Target Inhibitors
AFINITOR
AFINITOR DISPERZ
BOSULIF
CAPRELSA
COMETRIQ
ERIVEDGE
GLEEVEC
ICLUSIG TABLET 15MG
IMBRUVICA
INLYTA
JAKAFI
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
Page 14 of 93
Drug
Tier
2
1
1
2
2
2
2
2
2
1
1
2
2
2
2
1
1
1
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
QL (150 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
Drug Name
ZELBORAF
Monoclonal Antibodies
ARZERRA INJECTION 100MG/5ML
AVASTIN INJECTION 100MG/4ML
ERBITUX INJECTION 100MG/50ML
HERCEPTIN
KADCYLA INJECTION 100MG
KEYTRUDA INJECTION 50MG
OPDIVO
PERJETA
RITUXAN
SYLVANT INJECTION 100MG
VECTIBIX INJECTION 100MG/5ML
YERVOY INJECTION 50MG/10ML
Retinoids
PANRETIN
TARGRETIN
tretinoin capsule 10mg
Antiparasitics
Anthelmintics
ALBENZA
ivermectin tablet
STROMECTOL
Antiprotozoals
ALINIA
atovaquone
atovaquone/proguanil hcl tablet 250mg; 100mg
chloroquine phosphate tablet
COARTEM
DARAPRIM
hydroxychloroquine sulfate tablet
mefloquine hcl
MEPRON
NEBUPENT
PENTAM 300
PRIMAQUINE PHOSPHATE TABLET
quinine sulfate
tinidazole tablet
Pediculicides/Scabicides
lindane lotion
malathion lotion
permethrin cream
Antiparkinson Agents
Anticholinergics
benztropine mesylate injection
benztropine mesylate tablet
trihexyphenidyl hcl
Antiparkinson Agents, Other
entacapone
Page 15 of 93
Drug
Tier
2
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
2
2
1
1
1
2
2
1
1
2
2
2
2
1
1
B/D
QL (80 EA per 365 days)
1
1
1
1
1
1
PA (High Risk Medications)
PA (High Risk Medications)
1
QL (240 EA per 30 days)
Drug Name
TASMAR
Dopamine Agonists
APOKYN
bromocriptine mesylate capsule, tablet
NEUPRO
pramipexole dihydrochloride
ropinirole hcl
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
ELDEPRYL
selegiline hcl capsule, tablet
ZELAPAR
Antipsychotics
1st Generation/Typical
CHLORPROMAZINE HCL INJECTION
chlorpromazine hcl tablet
compro
FLUPHENAZINE DECANOATE INJECTION
FLUPHENAZINE HCL INJECTION
fluphenazine hcl concentrate, elixir, tablet
haloperidol decanoate
haloperidol lactate
haloperidol concentrate, tablet
loxapine succinate capsule
ORAP
perphenazine tablet
PROCHLORPERAZINE EDISYLATE INJECTION
prochlorperazine maleate tablet
thioridazine hcl tablet
thiothixene capsule
trifluoperazine hcl tablet
2nd Generation/Atypical
ABILIFY DISCMELT
ABILIFY MAINTENA INJECTION 300MG
ABILIFY INJECTION, ORAL SOLUTION
ABILIFY TABLET
FANAPT
FANAPT TITRATION PACK
GEODON INJECTION
Page 16 of 93
Drug
Tier
2
Requirements/Limits
2
1
2
1
1
QL (30 EA per 30 days)
1
1
1
2
2
2
2
2
2
2
2
1
2
QL (30 EA per 30 days)
2
1
1
2
2
1
1
1
1
1
2
1
2
1
1
1
1
2
2
2
2
2
2
2
QL (60 EA per 30 days)
QL (1 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
Drug Name
INVEGA SUSTENNA INJECTION 39MG/0.25ML
INVEGA SUSTENNA INJECTION 78MG/0.5ML
INVEGA SUSTENNA INJECTION 117MG/0.75ML
INVEGA SUSTENNA INJECTION 156MG/ML
INVEGA SUSTENNA INJECTION 234MG/1.5ML
INVEGA TABLET EXTENDED RELEASE 24 HOUR
1.5MG, 3MG, 9MG
INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG
LATUDA
olanzapine
olanzapine odt
quetiapine fumarate
RISPERDAL CONSTA
risperidone
risperidone odt
SAPHRIS
ziprasidone hcl
Treatment-Resistant
clozapine
clozapine odt
FAZACLO TABLET DISPERSIBLE 200MG
FAZACLO TABLET DISPERSIBLE 150MG
FAZACLO TABLET DISPERSIBLE 100MG, 12.5MG,
25MG
VERSACLOZ
Antispasticity Agents
Antispasticity Agents
baclofen tablet
dantrolene sodium capsule
tizanidine hcl tablet
Antivirals
Anti-cytomegalovirus (CMV) Agents
cidofovir
FOSCARNET SODIUM
ganciclovir injection
VALCYTE
valganciclovir
VISTIDE
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
BARACLUDE
entecavir
EPIVIR HBV SOLUTION
INTRON A INJECTION 18MU, 50MU
INTRON-A W/DILUENT INJECTION 10MU
INTRON-A INJECTION 6000000UNIT/ML
lamivudine tablet 100mg
TYZEKA
Anti-hepatitis C (HCV) Agents
Page 17 of 93
Drug
Tier
2
2
2
2
2
2
2
2
1
1
1
2
1
1
2
1
1
1
2
2
2
Requirements/Limits
QL (0.25 ML per 28 days)
QL (0.5 ML per 28 days)
QL (0.75 ML per 28 days)
QL (1 ML per 28 days)
QL (1.5 ML per 28 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (120 EA per 30 days)
QL (180 EA per 30 days)
QL (90 EA per 30 days)
2
1
1
1
1
2
1
2
1
2
1
2
1
2
2
2
2
1
2
MO
MO
MO
Drug Name
INCIVEK
INFERGEN INJECTION 15MCG/0.5ML
Drug
Tier
2
2
OLYSIO
2
PEG-INTRON
2
PEG-INTRON REDIPEN
2
PEGASYS
2
PEGASYS PROCLICK INJECTION 135MCG/0.5ML
2
REBETOL SOLUTION
ribasphere ribapak
ribasphere tablet
ribavirin
SOVALDI
2
1
1
1
2
VICTRELIS
VIRAZOLE
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ISENTRESS TABLET CHEWABLE, TABLET
ISENTRESS PACKET
TIVICAY
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA
EDURANT
INTELENCE TABLET 100MG, 200MG
INTELENCE TABLET 25MG
nevirapine
nevirapine er
RESCRIPTOR
STRIBILD
SUSTIVA
VIRAMUNE XR
VIRAMUNE SUSPENSION
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir
abacavir sulfate/lamivudine/zidovudine
didanosine
EMTRIVA
EPIVIR SOLUTION
EPZICOM
lamivudine/zidovudine
lamivudine solution 10mg/ml
lamivudine tablet 150mg, 300mg
Page 18 of 93
Requirements/Limits
PA (Immunological Agents Infergen)
QL (28 EA per 28 days) PA
(Immunological Agents - Olysio)
PA (Immunological Agents Peg-Intron, Pegasys)
PA (Immunological Agents Peg-Intron, Pegasys)
PA (Immunological Agents Peg-Intron, Pegasys)
PA (Immunological Agents Peg-Intron, Pegasys)
QL (28 EA per 28 days) PA
(Immunological Agents - Sovaldi)
2
2
2
2
2
2
2
2
2
1
1
2
2
2
2
2
1
1
1
2
2
2
1
1
1
MO
MO
MO
MO
MO
MO
Drug Name
RETROVIR IV INFUSION
stavudine
TRIUMEQ
TRUVADA
VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM
VIREAD
ZIAGEN SOLUTION
zidovudine
Anti-HIV Agents, Other
FUZEON
SELZENTRY
TYBOST
Anti-HIV Agents, Protease Inhibitors
APTIVUS
CRIXIVAN CAPSULE 200MG, 400MG
INVIRASE
KALETRA
LEXIVA
NORVIR
PREZISTA
REYATAZ
VIRACEPT TABLET
Anti-influenza Agents
amantadine hcl capsule, syrup, tablet
RELENZA DISKHALER
rimantadine hcl
TAMIFLU CAPSULE 75MG
TAMIFLU CAPSULE 45MG
TAMIFLU CAPSULE 30MG
TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML
Antiherpetic Agents
acyclovir sodium injection 50mg/ml
acyclovir capsule, suspension, tablet
DENAVIR
famciclovir tablet
trifluridine solution
valacyclovir hcl
ZOVIRAX CREAM, OINTMENT
Antivirals
ATRIPLA
Anxiolytics
Anxiolytics, Other
buspirone hcl tablet
meprobamate
Benzodiazepines
ALPRAZOLAM INTENSOL
alprazolam tablet 0.25mg
alprazolam tablet 0.5mg, 1mg, 2mg
clorazepate dipotassium
Page 19 of 93
Drug
Tier
2
1
2
2
2
2
2
1
2
2
2
Requirements/Limits
MO
MO
2
2
2
2
2
2
2
2
2
1
2
1
2
2
2
2
1
1
2
1
1
1
2
QL (56 EA per 180 days)
QL (28 EA per 180 days)
QL (42 EA per 180 days)
QL (84 EA per 180 days)
QL (540 ML per 180 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 GM per 30 days)
2
1
1
PA (High Risk Medications)
2
1
1
1
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (90 EA per 30 days)
Drug Name
DIAZEPAM INTENSOL
diazepam tablet 10mg, 2mg, 5mg
LORAZEPAM INTENSOL
lorazepam tablet 0.5mg
lorazepam tablet 1mg, 2mg
triazolam
Bipolar Agents
Mood Stabilizers
lithium
lithium carbonate er
lithium carbonate capsule, tablet
LITHOBID
Blood Glucose Regulators
Antidiabetic Agents
acarbose
AVANDARYL
BYETTA INJECTION 5MCG/0.02ML
BYETTA INJECTION 10MCG/0.04ML
Drug
Tier
2
1
2
1
1
1
Requirements/Limits
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (150 EA per 30 days)
QL (30 EA per 30 days)
1
1
1
2
1
2
2
2
QL (90 EA per 30 days)
QL (30 EA per 30 days)
PA (Blood Glucose Regulators)
QL (2.4 ML per 30 days) PA (Blood
Glucose Regulators)
CYCLOSET
DUETACT
FARXIGA
glimepiride tablet 1mg, 2mg
glimepiride tablet 4mg
glipizide er tablet extended release 24 hour 2.5mg, 5mg
glipizide er tablet extended release 24 hour 10mg
glipizide/metformin hcl
glipizide tablet 10mg
glipizide tablet 5mg
glyburide micronized tablet 1.5mg, 3mg
2
2
2
1
1
1
1
1
1
1
1
glyburide micronized tablet 6mg
1
glyburide/metformin hcl
1
glyburide tablet 5mg
1
glyburide tablet 1.25mg, 2.5mg
1
GLYSET
JANUVIA
JENTADUETO
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 5MG, 500MG; 5MG
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 2.5MG
metformin hcl er tablet extended release 24 hour 500mg
metformin hcl er tablet extended release 24 hour 750mg
metformin hcl tablet 500mg
2
2
2
2
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
QL (120 EA per 30 days)
QL (90 EA per 30 days)
QL (30 EA per 30 days) PA (High
Risk Medication - Glyburide)
QL (60 EA per 30 days) PA (High
Risk Medication - Glyburide)
QL (120 EA per 30 days) PA (High
Risk Medication - Glyburide)
PA (High Risk Medication Glyburide)
QL (30 EA per 30 days) PA (High
Risk Medication - Glyburide)
QL (90 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
2
QL (60 EA per 30 days)
1
1
1
QL (120 EA per 30 days)
QL (90 EA per 30 days)
QL (120 EA per 30 days)
Page 20 of 93
Drug Name
metformin hcl tablet 1000mg
metformin hcl tablet 850mg
nateglinide
ONGLYZA
pioglitazone hcl
pioglitazone hcl/metformin hcl
repaglinide
SYMLINPEN 120
SYMLINPEN 60
tolbutamide
TRADJENTA
Glycemic Agents
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM
Insulins
APIDRA
APIDRA SOLOSTAR
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMULIN 70/30
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN
enoxaparin sodium
fondaparinux sodium
Page 21 of 93
Drug
Tier
1
1
1
2
1
1
1
2
2
1
2
Requirements/Limits
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (90 EA per 30 days)
MO
PA (Blood Glucose Regulators Amylinomimetics)
PA (Blood Glucose Regulators Amylinomimetics)
QL (30 EA per 30 days)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
QL (40 ML per 30 days)
QL (30 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (30 ML per 30 days)
QL (30 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
QL (40 ML per 30 days)
Drug Name
FRAGMIN INJECTION 10000UNIT/ML, 25000UNIT/ML,
2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML
heparin sodium/d5w
heparin sodium/nacl 0.9%
heparin sodium injection 10000unit/ml, 1000unit/ml,
20000unit/ml, 5000unit/ml
jantoven
PRADAXA
warfarin sodium tablet
XARELTO
XARELTO STARTER PACK
Blood Formation Modifiers
anagrelide hydrochloride
ARANESP ALBUMIN FREE INJECTION 100MCG/ML,
150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML,
25MCG/0.42ML, 25MCG/ML, 300MCG/ML,
40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/ML
EPOGEN
Drug
Tier
2
1
1
1
1
2
1
2
2
1
2
2
GRANIX
LEUKINE INJECTION 250MCG
NEULASTA
NEUMEGA
NEUPOGEN INJECTION 300MCG/0.5ML,
480MCG/0.8ML, 480MCG/1.6ML
PROCRIT
2
2
2
2
2
PROMACTA TABLET 50MG
2
PROMACTA TABLET 25MG
2
Coagulants
tranexamic acid injection, tablet
Platelet Modifying Agents
AGGRENOX
BRILINTA
cilostazol
clopidogrel tablet 300mg
clopidogrel tablet 75mg
dipyridamole tablet
EFFIENT
ticlopidine hcl
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl er
clonidine hcl tablet
Page 22 of 93
Requirements/Limits
2
PA (Blood Products/Modifiers/
Volume Expanders)
PA (Blood Products/Modifiers/
Volume Expanders)
PA (Blood Products/Modifiers/
Volume Expanders)
QL (30 EA per 30 days) PA (Blood
Products/Modifiers/ Volume
Expanders - Promacta)
QL (90 EA per 30 days) PA (Blood
Products/Modifiers/ Volume
Expanders - Promacta)
1
2
2
1
1
1
1
2
1
QL (60 EA per 30 days)
QL (60 EA per 30 days)
1
1
MO
QL (30 EA per 30 days)
PA (High Risk Medications)
QL (30 EA per 30 days)
QL (60 EA per 30 days) PA (High
Risk Medications)
Drug Name
guanfacine hcl
methyldopa/hydrochlorothiazide
methyldopa tablet
METHYLDOPATE HCL
midodrine hcl
Alpha-adrenergic Blocking Agents
prazosin hcl
reserpine tablet 0.25mg
Angiotensin II Receptor Antagonists
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
eprosartan mesylate
irbesartan/hydrochlorothiazide
irbesartan tablet 150mg, 75mg
irbesartan tablet 300mg
losartan potassium
losartan potassium/hydrochlorothiazide
telmisartan
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazide
valsartan
valsartan/hydrochlorothiazide
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide
benazepril hcl tablet 10mg, 20mg, 5mg
benazepril hcl tablet 40mg
captopril/hydrochlorothiazide
captopril tablet
enalapril maleate/hydrochlorothiazide
enalapril maleate tablet
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
quinapril hcl
quinapril/hydrochlorothiazide
ramipril
trandolapril tablet 1mg, 2mg
trandolapril tablet 4mg
Antiarrhythmics
amiodarone hcl injection 50mg/ml
amiodarone hcl tablet 200mg, 400mg
disopyramide phosphate capsule
flecainide acetate
mexiletine hcl
MULTAQ
pacerone
PROCAINAMIDE HCL INJECTION
propafenone hcl
Page 23 of 93
Drug
Tier
1
1
1
2
1
Requirements/Limits
PA (High Risk Medications)
PA (High Risk Medications)
1
1
PA (High Risk Medications) MO
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
1
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
Drug Name
quinidine gluconate cr
QUINIDINE GLUCONATE INJECTION
quinidine sulfate
quinidine sulfate er
sorine
sotalol hcl (af) tablet 120mg
sotalol hcl tablet 160mg, 240mg, 80mg
TIKOSYN
Beta-adrenergic Blocking Agents
acebutolol hcl capsule
atenolol/chlorthalidone
atenolol tablet
betaxolol hcl tablet 10mg, 20mg
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
carvedilol
labetalol hcl injection, tablet
metoprolol succinate er
metoprolol tartrate injection, tablet
metoprolol/hydrochlorothiazide
nadolol/bendroflumethiazide
nadolol tablet 20mg, 40mg, 80mg
pindolol
propranolol hcl er
propranolol hcl injection, oral solution, tablet
propranolol/hydrochlorothiazide
timolol maleate tablet 10mg, 20mg, 5mg
Calcium Channel Blocking Agents
afeditab cr
amlodipine besylate/benazepril hcl
amlodipine besylate/benazepril hydrochloride
amlodipine besylate/valsartan
amlodipine besylate tablet
amlodipine/valsartan/hctz
cartia xt
dilt-cd capsule extended release 24 hour 300mg
dilt-xr capsule extended release 24 hour 120mg, 240mg
dilt-xr capsule extended release 24 hour 180mg
diltiazem cd capsule extended release 24 hour 240mg
diltiazem hcl er capsule extended release 24 hour 180mg
diltiazem hcl er capsule extended release 24 hour 120mg,
300mg, 360mg, 420mg
diltiazem hcl er capsule extended release 12 hour
diltiazem hcl tablet
DILTIAZEM HCL INJECTION 100MG
diltiazem hcl injection 50mg/10ml
felodipine er
matzim la tablet extended release 24 hour 180mg, 240mg,
300mg
Page 24 of 93
Drug
Tier
1
2
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
Requirements/Limits
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (90 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
Drug Name
matzim la tablet extended release 24 hour 360mg, 420mg
nicardipine hcl capsule
nifediac cc tablet extended release 24 hour 90mg
nifedical xl
nifedipine er
taztia xt
verapamil hcl er capsule extended release 24 hour
verapamil hcl er tablet extended release 180mg, 240mg
verapamil hcl sr capsule extended release 24 hour 360mg
verapamil hcl injection, tablet
Cardiovascular Agents, Other
DEMSER
digitek
Drug
Tier
1
1
1
1
1
1
1
1
1
1
2
1
digoxin injection, oral solution
1
digoxin tablet 125mcg
digoxin tablet 250mcg
1
1
LANOXIN PEDIATRIC
2
LANOXIN INJECTION
2
LANOXIN TABLET 125MCG
LANOXIN TABLET 250MCG
2
2
pentoxifylline er
RANEXA TABLET EXTENDED RELEASE 12 HOUR
1000MG
RANEXA TABLET EXTENDED RELEASE 12 HOUR
500MG
TEKTURNA
TEKTURNA HCT
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide sodium
acetazolamide tablet
Diuretics, Loop
bumetanide injection, tablet
furosemide injection, oral solution, tablet
torsemide tablet
TORSEMIDE INJECTION 20MG/2ML
Diuretics, Potassium-sparing
amiloride hcl tablet
amiloride/hydrochlorothiazide
eplerenone
spironolactone/hydrochlorothiazide
spironolactone tablet
triamterene/hydrochlorothiazide capsule 25mg; 37.5mg
triamterene/hydrochlorothiazide capsule 25mg; 50mg
Page 25 of 93
1
2
2
2
2
Requirements/Limits
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
PA (High Risk Medication Digoxin) MO
PA (High Risk Medication Digoxin)
PA (High Risk Medication Digoxin)
PA (High Risk Medication Digoxin)
PA (High Risk Medication Digoxin)
PA (High Risk Medication Digoxin)
QL (60 EA per 30 days) PA
(Cardiovascular Agents) MO
QL (90 EA per 30 days) PA
(Cardiovascular Agents) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days)
1
1
1
1
1
2
1
1
1
1
1
1
1
MO
Drug Name
triamterene/hydrochlorothiazide tablet
Diuretics, Thiazide
chlorothiazide
chlorothiazide sodium
chlorthalidone tablet 25mg, 50mg
hydrochlorothiazide capsule, tablet
indapamide tablet
methyclothiazide tablet
metolazone
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized
fenofibrate capsule 130mg, 43mg
fenofibrate tablet
gemfibrozil tablet
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
lovastatin tablet 10mg, 20mg
lovastatin tablet 40mg
pravastatin sodium
simvastatin
Dyslipidemics, Other
cholestyramine light packet
colestipol hcl
niacin er tablet extended release 500mg
niacin er tablet extended release 1000mg, 750mg
niacor
omega-3-acid ethyl esters
prevalite powder
WELCHOL
ZETIA
Vasodilators, Direct-acting Arterial/Venous
BIDIL
isosorbide dinitrate er
isosorbide dinitrate tablet
isosorbide dinitrate tablet sublingual 2.5mg
isosorbide mononitrate
isosorbide mononitrate er
NITRO-DUR PATCH 24 HOUR 0.3MG/HR, 0.8MG/HR
nitroglycerin transdermal patch 24 hour 0.1mg/hr
NITROGLYCERIN INJECTION
nitroglycerin patch 24 hour 0.2mg/hr, 0.4mg/hr, 0.6mg/hr
NITROSTAT
Vasodilators, Direct-acting Arterial
hydralazine hcl injection, tablet
minoxidil tablet
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg;
5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg
Page 26 of 93
Drug
Tier
1
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
1
1
1
1
1
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
1
1
1
1
1
1
1
2
2
2
1
1
1
1
1
2
1
2
1
2
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (30 EA per 30 days)
QL (180 EA per 30 days)
1
1
1
QL (60 EA per 30 days)
Drug
Drug Name
Tier
amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg;
1
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg,
2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg
dextroamphetamine sulfate tablet
1
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
guanfacine er
1
INTUNIV
2
METADATE CD CAPSULE EXTENDED RELEASE 30MG 2
METADATE CD CAPSULE EXTENDED RELEASE 20MG 2
methylphenidate hcl cd
1
methylphenidate hcl er tablet extended release 20mg
1
methylphenidate hcl tablet
1
STRATTERA
2
Central Nervous System, Other
NUEDEXTA
2
riluzole
1
XENAZINE TABLET 25MG
2
XENAZINE TABLET 12.5MG
Fibromyalgia Agents
SAVELLA
SAVELLA TITRATION PACK
Multiple Sclerosis Agents
AUBAGIO
AVONEX
BETASERON
COPAXONE INJECTION 20MG/ML
GILENYA
REBIF
REBIF TITRATION PACK
TYSABRI
Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate oral rinse
KEPIVANCE
periogard
pilocarpine hcl
pilocarpine hydrochloride
triamcinolone in orabase
Dermatological Agents
Dermatological Agents
adapalene gel 0.1%
adapalene cream
ammonium lactate cream, lotion
Page 27 of 93
2
Requirements/Limits
QL (90 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (30 EA per 30 days)
QL (90 EA per 30 days)
QL (90 EA per 30 days)
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days) PA
(Miscellaneous Therapeutic Agents Xenazine)
QL (180 EA per 30 days) PA
(Miscellaneous Therapeutic Agents Xenazine)
2
2
QL (60 EA per 30 days)
2
2
2
2
2
2
2
2
QL (30 EA per 30 days)
1
2
1
1
1
1
1
1
1
Drug Name
calcipotriene cream
calcipotriene solution
claravis
clindamycin/benzoyl peroxide gel 5%; 1%
clotrimazole/betamethasone dipropionate
curity gauze pads 2"x2"
ELIDEL
Drug
Tier
1
1
1
1
1
1
2
erythromycin/benzoyl peroxide
fluorouracil cream 5%
fluorouracil external solution 2%, 5%
imiquimod cream
laclotion
methoxsalen capsule
OXSORALEN
PICATO
podofilox solution
PROTOPIC
1
1
1
1
1
1
2
2
1
2
SANTYL
selenium sulfide lotion
SORIATANE
tacrolimus ointment 0.03%, 0.1%
2
1
2
1
TAZORAC
tretinoin cream 0.025%, 0.05%, 0.1%
tretinoin gel 0.01%, 0.025%
UVADEX
VEREGEN
VOLTAREN
ZONALON
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABLET
CEREZYME INJECTION 400UNIT
CREON
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME INJECTION 35MG
KUVAN TABLET SOLUBLE
LUMIZYME
NAGLAZYME
PANCREAZE
sodium phenylbutyrate powder
Page 28 of 93
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
Requirements/Limits
QL (240 GM per 30 days)
QL (60 ML per 30 days)
QL (204 EA per 30 days)
QL (60 GM per 30 days) PA
(Dermatological Agents)
QL (24 EA per 30 days)
QL (60 GM per 30 days) PA
(Dermatological Agents)
QL (60 GM per 30 days) PA
(Dermatological Agents)
QL (90 GM per 30 days)
QL (15 GM per 30 days)
PA (Enzyme Replacements/
Modifiers - Kuvan)
Drug Name
SUCRAID
VPRIV
ZAVESCA
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
109000UNIT; 20000UNIT; 68000UNIT, 136000UNIT;
25000UNIT; 85000UNIT, 16000UNIT; 3000UNIT;
10000UNIT, 27000UNIT; 5000UNIT; 17000UNIT,
55000UNIT; 10000UNIT; 34000UNIT, 82000UNIT;
15000UNIT; 51000UNIT
ZENPEP CAPSULE DELAYED RELEASE PARTICLES
218000UNIT; 40000UNIT; 136000UNIT
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ATROPINE SULFATE INJECTION 0.05MG/ML
atropine sulfate injection 0.1mg/ml
dicyclomine hcl capsule, solution, tablet
glycopyrrolate tablet
glycopyrrolate injection 4mg/20ml
methscopolamine bromide tablet 2.5mg
Gastrointestinal Agents, Other
cromolyn sodium concentrate 100mg/5ml
diphenoxylate/atropine tablet
loperamide hcl capsule
metoclopramide hcl injection, oral solution, tablet
RELISTOR INJECTION 12MG/0.6ML
ursodiol capsule, tablet
Histamine2 (H2) Receptor Antagonists
cimetidine hcl solution
cimetidine tablet
FAMOTIDINE PREMIXED
famotidine injection 20mg/2ml
famotidine tablet 20mg, 40mg
ranitidine hcl capsule, syrup
ranitidine hcl injection 150mg/6ml
ranitidine hcl tablet 150mg, 300mg
ZANTAC INJECTION 25MG/ML, 50MG/50ML; 0.45%
Irritable Bowel Syndrome Agents
AMITIZA
LOTRONEX
Laxatives
constulose
enulose
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
lactulose solution
NULYTELY/FLAVOR PACKS
Page 29 of 93
Drug
Tier
2
2
2
2
2
Requirements/Limits
MO
2
1
1
1
1
1
1
1
1
1
2
1
1
1
2
1
1
1
1
1
2
2
2
1
1
1
1
1
1
1
2
QL (60 EA per 30 days) PA
(Irritable Bowel Syndrome Agents)
Drug Name
polyethylene glycol 3350 powder
trilyte
Protectants
misoprostol tablet
sucralfate tablet
Proton Pump Inhibitors
esomeprazole sodium injection 40mg
esomeprazole sodium injection 20mg
omeprazole capsule delayed release 10mg
omeprazole capsule delayed release 20mg, 40mg
pantoprazole sodium tablet delayed release 20mg
pantoprazole sodium tablet delayed release 40mg
PROTONIX INJECTION
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
oxybutynin chloride er
oxybutynin chloride tablet
tolterodine tartrate
tolterodine tartrate er
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
AVODART
doxazosin mesylate
finasteride tablet 5mg
tamsulosin hcl
terazosin hcl
Genitourinary Agents, Other
bethanechol chloride
ELMIRON
Phosphate Binders
calcium acetate capsule
calcium acetate tablet 667mg
ELIPHOS
FOSRENOL
RENVELA TABLET
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort
alclometasone dipropionate
amcinonide
augmented betamethasone dipropionate
betamethasone dipropionate cream, lotion, ointment
betamethasone valerate cream, lotion, ointment
budesonide capsule extended release 24 hour 3mg
clobetasol propionate e
clobetasol propionate gel, ointment, shampoo, solution
clodan
cortisone acetate tablet
Page 30 of 93
Drug
Tier
1
1
Requirements/Limits
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
2
2
2
1
1
1
1
1
1
1
1
1
1
1
MO
QL (30 EA per 30 days)
QL (90 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days) MO
QL (60 EA per 30 days)
QL (30 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (60 EA per 30 days)
Drug Name
DEPO-MEDROL INJECTION 20MG/ML
desonide cream, lotion, ointment
desoximetasone cream, gel, ointment
dexamethasone sodium phosphate injection 120mg/30ml
dexamethasone elixir, tablet
fludrocortisone acetate tablet
fluocinolone acetonide cream, oil, ointment, solution
fluocinonide-e
fluocinonide gel, ointment, solution
fluticasone propionate cream 0.05%
fluticasone propionate ointment 0.005%
halobetasol propionate
hydrocortisone butyrate cream, ointment, solution
hydrocortisone valerate
hydrocortisone cream 1%, 2.5%
hydrocortisone enema, tablet
hydrocortisone lotion 2.5%
hydrocortisone ointment 1%, 2.5%
methylprednisolone acetate injection
methylprednisolone dose pack
methylprednisolone sodiumsuccinate injection 125mg, 1gm,
40mg
methylprednisolone tablet
mometasone furoate cream, ointment
prednicarbate cream
prednisolone sodium phosphate oral solution 15mg/5ml,
25mg/5ml, 5mg/5ml
prednisone solution, tablet
PROCTO-PAK
proctocream hc
proctosol hc
proctozone-hc
SOLU-CORTEF INJECTION 100MG, 250MG
SOLU-MEDROL INJECTION 125MG, 2GM, 40MG,
500MG
triamcinolone acetonide cream 0.025%, 0.1%, 0.5%
triamcinolone acetonide lotion 0.025%, 0.1%
triamcinolone acetonide ointment 0.025%, 0.1%, 0.5%
triderm cream
u-cort
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
chorionic gonadotropin
desmopressin acetate injection, tablet
INCRELEX
NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML,
5MG/1.5ML
NORDITROPIN NORDIFLEX PEN INJECTION
30MG/3ML
Page 31 of 93
Drug
Tier
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
1
1
1
1
1
2
1
1
1
2
2
1
1
1
1
1
1
1
2
2
2
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary))
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary))
Drug Name
NUTROPIN INJECTION 10MG
Drug
Tier
2
Requirements/Limits
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary))
pregnyl w/diluent benzyl alcohol/nacl
SAIZEN CLICK.EASY
1
2
SAIZEN INJECTION 5MG
2
SEROSTIM
2
STIMATE
TEV-TROPIN
2
2
ZORBTIVE
2
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary))
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary) Zorbtive)
2
QL (120 EA per 30 days)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
oxandrolone tablet
Androgens
ANDRODERM PATCH 24 HOUR 2MG/24HR, 4MG/24HR
ANDROXY
danazol capsule
METHITEST
testosterone cypionate injection
testosterone enanthate injection
Estrogens
ALORA
1
2
2
1
2
1
1
2
apri
aranelle
aubra
aviane
balziva
CLIMARA PRO
1
1
1
1
1
2
cryselle-28
cyclafem 1/35
delyla
DEPO-ESTRADIOL
desogestrel/ethinyl estradiol tablet 0; 0
enpresse-28
ESTRACE CREAM
1
1
1
2
1
1
2
Page 32 of 93
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary))
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary))
PA (Hormonal Agents, Stimulant/
Replacement/ Modifying (Pituitary) Serostim)
QL (8 EA per 28 days) PA (High
Risk Medications)
MO
QL (4 EA per 28 days) PA (High
Risk Medications)
MO
MO
Drug Name
estradiol valerate injection 20mg/ml
estradiol tablet
estradiol patch weekly
Drug
Tier
1
1
1
estropipate tablet
falmina
gildess 1.5/30
introvale
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
larin 1.5/30
leena
lessina
levora 0.15/30-28
loestrin 24 fe
low-ogestrel
lutera
marlissa
MENEST
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mononessa
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
OGESTREL
portia-28
PREMARIN CREAM, INJECTION
PREMARIN TABLET
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
2
PREMPHASE
PREMPRO
2
2
previfem
quasense
sprintec 28
sronyx
tri-previfem
tri-sprintec
1
1
1
1
1
1
Page 33 of 93
Requirements/Limits
PA (High Risk Medications)
QL (4 EA per 28 days) PA (High
Risk Medications)
PA (High Risk Medications)
MO
MO
MO
PA (High Risk Medications)
QL (30 EA per 30 days) PA (High
Risk Medications)
PA (High Risk Medications)
QL (30 EA per 30 days) PA (High
Risk Medications)
QL (91 EA per 91 days)
Drug Name
trinessa
trivora-28
velivet
xulane
zovia 1/35e
zovia 1/50e
Progesterone Agonists/Antagonists
ELLA
Progestins
camila
deblitane
DEPO-SUBQ PROVERA 104
errin
jolivette
lyza
medroxyprogesterone acetate injection, tablet
megestrol acetate tablet
megestrol acetate suspension
nora-be
norethindrone acetate tablet
norethindrone tablet
norlyroc
progesterone capsule
PROMETRIUM
sharobel
Selective Estrogen Receptor Modifying Agents
EVISTA
raloxifene hydrochloride
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
CYTOMEL
levothyroxine sodium tablet
levoxyl
liothyronine sodium injection, tablet
SYNTHROID
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
unithroid
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABLET 90MG
SENSIPAR TABLET 30MG, 60MG
Hormonal Agents, Suppressant (Pituitary)
Page 34 of 93
Drug
Tier
1
1
1
1
1
1
2
1
1
2
1
1
1
1
1
1
1
1
1
1
1
2
1
2
1
Requirements/Limits
QL (3 EA per 28 days) MO
QL (30 EA per 30 days)
MO
MO
PA (High Risk Medications)
MO
MO
MO
QL (30 EA per 30 days)
QL (30 EA per 30 days) MO
2
1
1
1
2
2
2
2
2
2
1
2
2
2
QL (120 EA per 30 days)
QL (60 EA per 30 days)
Drug
Drug Name
Tier
Hormonal Agents, Suppressant (Pituitary)
cabergoline
1
ELIGARD
2
FIRMAGON
2
leuprolide acetate injection
1
LUPRON DEPOT-PED INJECTION 11.25MG, 15MG
2
LUPRON DEPOT INJECTION 11.25MG, 22.5MG, 3.75MG, 2
30MG, 7.5MG
octreotide acetate
1
SOMATULINE DEPOT INJECTION 120MG/0.5ML,
2
90MG/0.3ML
SOMAVERT
2
SYNAREL
TRELSTAR DEPOT MIXJECT
TRELSTAR LA MIXJECT
TRELSTAR MIXJECT
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole tablet
propylthiouracil tablet
Immunological Agents
Angioedema (HAE) Agents
CINRYZE
FIRAZYR
Immune Suppressants
azathioprine tablet
CELLCEPT INTRAVENOUS
CELLCEPT SUSPENSION RECONSTITUTED
cyclosporine modified
cyclosporine capsule, injection
ENBREL
gengraf
HUMIRA
HUMIRA PEN-CROHNS DISEASESTARTER
KINERET
methotrexate sodium injection 1gm
methotrexate tablet
mycophenolate mofetil
NULOJIX
ORENCIA
PROGRAF
RAPAMUNE
REMICADE
sirolimus tablet
Page 35 of 93
Requirements/Limits
PA (Hormonal Agents, Suppressant
(Pituitary) - Somavert)
2
2
2
2
1
1
2
2
1
2
2
1
1
2
1
2
2
2
1
1
1
2
2
2
2
2
1
QL (100 EA per 30 days) PA (Blood
Products/Modifiers/ Volume
Expanders - Cinryze)
QL (270 ML per 30 days) PA
(Firazyr)
B/D
B/D
B/D
B/D
B/D
PA (Immunological Agents)
B/D
PA (Immunological Agents)
PA (Immunological Agents)
QL (28 ML per 28 days) PA
(Immunological Agents)
B/D
B/D
PA (Immunological Agents)
B/D
B/D
PA (Immunological Agents)
B/D
Drug Name
tacrolimus capsule 0.5mg, 1mg, 5mg
TORISEL
ZORTRESS
Immunizing Agents, Passive
CARIMUNE NANOFILTERED INJECTION 6GM
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C INJECTION 1GM/10ML
THYMOGLOBULIN
Immunomodulators
ACTIMMUNE
ARCALYST
ILARIS
leflunomide
SIMULECT INJECTION 20MG
SYNAGIS INJECTION 50MG/0.5ML
Vaccines
ACTHIB
ADACEL
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
DECAVAC
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC
ENGERIX-B
GARDASIL
GARDASIL 9
HAVRIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
M-M-R II W/DILUENT 10 DOSE
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
PEDVAX HIB
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT
TRUMENBA
TWINRIX
Page 36 of 93
Drug
Tier
1
2
2
2
2
2
2
2
2
2
2
1
2
2
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
B/D
QL (1 EA per 28 days) PA
(Immunological Agents - Ilaris)
QL (30 EA per 30 days)
B/D
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
B/D
B/D
Drug Name
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
DELZICOL
DIPENTUM
mesalamine kit
Sulfonamides
sulfasalazine tablet
sulfazine ec
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium tablet 10mg, 40mg, 5mg
alendronate sodium tablet 70mg
calcitonin-salmon
calcitriol capsule, oral solution
calcitriol injection 1mcg/ml
etidronate disodium
FORTEO
fortical
HECTOROL CAPSULE 0.5MCG, 2.5MCG
HECTOROL INJECTION 4MCG/2ML
ibandronate sodium tablet
MIACALCIN INJECTION
PAMIDRONATE DISODIUM INJECTION 6MG/ML
pamidronate disodium injection 30mg/10ml, 90mg/10ml
PROLIA
XGEVA
zoledronic acid injection 4mg/5ml, 5mg/100ml
ZOMETA INJECTION 4MG/100ML
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"
BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
INTRALIPID INJECTION 30GM/100ML
intralipid injection 20gm/100ml
lactated ringers irrigation
levocarnitine injection, oral solution, tablet
liposyn iii injection 2.5%; 30%
Page 37 of 93
Drug
Tier
2
2
2
2
2
1
2
2
1
Requirements/Limits
MO
QL (180 EA per 30 days)
1
1
1
1
1
1
1
1
2
1
2
2
1
2
2
1
2
QL (30 EA per 30 days)
QL (4 EA per 28 days)
QL (4 ML per 30 days)
PA (metabolic bone disease agents IV osteoporosis)
QL (4 ML per 30 days)
QL (1 EA per 30 days) MO
QL (1 ML per 180 days) PA
(Metabolic Bone Disease Agents Prolia)
2
1
2
2
2
2
2
2
2
1
1
1
1
QL (200 EA per 30 days)
QL (200 EA per 30 days)
QL (200 EA per 30 days)
QL (200 EA per 30 days)
B/D
B/D
B/D
Drug Name
methylergonovine maleate tablet
nutrilipid
physiolyte
physiosol irrigation
ringers irrigation
sterile water irrigation
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
COMBIGAN
latanoprost
LUMIGAN
Ophthalmic Agents, Other
bacitracin/polymyxin b
naphazoline hcl
neomycin/bacitracin/polymyxin
neomycin/polymyxin/gramicidin
polymyxin b sulfate/trimethoprim sulfate
RESTASIS
Ophthalmic Anti-allergy Agents
cromolyn sodium solution 4%
PATANOL
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate ophthalmic solution 0.1%
diclofenac sodium
fluor-op
fluorometholone
flurbiprofen sodium
ketorolac tromethamine ophthalmic solution 0.4%, 0.5%
LOTEMAX SUSPENSION
neomycin/polymyxin/dexamethasone
PRED-G
PRED-G S.O.P.
prednisolone acetate
prednisolone sodium phosphate ophthalmic solution 1%
sulfacetamide sodium/prednisolone sodium phosphate
TOBRADEX OINTMENT
tobramycin/dexamethasone
Ophthalmic Antiglaucoma Agents
acetazolamide er
ALPHAGAN P SOLUTION 0.1%
betaxolol hcl solution 0.5%
brimonidine tartrate
carteolol hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
levobunolol hcl solution 0.25%, 0.5%
levobunolol hcl solution 0.25%
methazolamide tablet
metipranolol
Page 38 of 93
Drug
Tier
1
1
1
1
1
1
Requirements/Limits
B/D
2
1
2
1
1
1
1
1
2
1
2
1
1
1
1
1
1
2
1
2
2
1
1
1
2
1
1
2
1
1
1
1
1
1
1
1
1
QL (5 ML per 15 days)
QL (20 ML per 30 days)
QL (20 ML per 30 days)
QL (30 ML per 30 days)
Drug Name
PHOSPHOLINE IODIDE
PILOPINE HS
timolol maleate ophthalmic gel forming
timolol maleate solution 0.25%, 0.5%
Otic Agents
Otic Agents
acetasol hc
acetic acid
CIPRODEX
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone otic suspension 1%;
3.5mg/ml; 10000unit/ml
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT,
45MCG/ACT; 21MCG/ACT
ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT
ASMANEX HFA
ASMANEX TWISTHALER 120 METERED DOSES
ASMANEX TWISTHALER 14 METERED DOSES
ASMANEX TWISTHALER 30 ME TERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
ASMANEX TWISTHALER 60 METERED DOSES
budesonide suspension 32mcg/act
DULERA
FLOVENT DISKUS
FLOVENT HFA AEROSOL 44MCG/ACT
FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT
flunisolide solution 0.025%
flunisolide solution 29mcg/act
fluticasone propionate suspension 50mcg/act
SYMBICORT
triamcinolone acetonide aerosol 55mcg/act
Antihistamines
azelastine hcl solution 0.15%
azelastine hcl solution 137mcg/spray
cyproheptadine hcl syrup, tablet
diphenhydramine hcl capsule 50mg
diphenhydramine hcl injection
hydroxyzine hcl oral solution, tablet
HYDROXYZINE HCL INJECTION 25MG/ML
hydroxyzine hcl injection 50mg/ml
hydroxyzine pamoate capsule
levocetirizine dihydrochloride solution
levocetirizine dihydrochloride tablet
olopatadine hcl
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
Page 39 of 93
Drug
Tier
2
2
1
1
Requirements/Limits
1
1
2
1
1
1
2
2
QL (60 EA per 30 days)
2
2
2
2
2
2
2
1
2
2
2
2
1
1
1
2
1
QL (12 GM per 30 days)
MO
1
1
1
1
1
1
2
1
1
1
1
1
3
MO
QL (30 ML per 30 days)
PA (High Risk Medications)
PA (High Risk Medications)
MO
QL (21.2 GM per 30 days)
QL (24 GM per 30 days)
MO
QL (50 ML per 30 days)
QL (32 GM per 30 days)
QL (10.2 GM per 30 days)
QL (33 GM per 30 days) MO
PA (High Risk Medications)
PA (High Risk Medications)
PA (High Risk Medications)
PA (High Risk Medications)
QL (30 EA per 30 days)
DP
Drug Name
Antileukotrienes
montelukast sodium
zafirlukast
ZYFLO CR
Bronchodilators, Anticholinergic
ATROVENT HFA
COMBIVENT RESPIMAT
ipratropium bromide/albuterol sulfate
ipratropium bromide inhalation solution
ipratropium bromide nasal solution 0.06%
ipratropium bromide nasal solution 0.03%
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
Bronchodilators, Sympathomimetic
albuterol sulfate er
albuterol sulfate syrup, tablet
albuterol sulfate nebulization solution 0.083%
albuterol sulfate nebulization solution 0.63mg/3ml,
1.25mg/3ml
albuterol sulfate nebulization solution 0.5%
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
levalbuterol hcl nebulization solution 0.31mg/3ml,
0.63mg/3ml
metaproterenol sulfate syrup, tablet
PROAIR HFA
SEREVENT DISKUS
terbutaline sulfate injection, tablet
VENTOLIN HFA
XOPENEX HFA
XOPENEX NEBULIZATION SOLUTION 1.25MG/3ML
Cystic Fibrosis Agents
CAYSTON
Drug
Tier
Requirements/Limits
1
1
2
QL (30 EA per 30 days)
QL (60 EA per 30 days)
QL (120 EA per 30 days)
2
2
1
1
1
1
2
2
QL (39 GM per 30 days)
QL (8 GM per 30 days) MO
QL (540 ML per 30 days) B/D
QL (300 ML per 30 days) B/D
QL (15 ML per 30 days)
QL (30 ML per 30 days)
QL (30 EA per 30 days)
QL (8 GM per 30 days) MO
1
1
1
1
QL (1170 ML per 30 days) B/D
QL (1200 ML per 30 days) B/D
1
2
2
1
QL (200 ML per 30 days) B/D
QL (2 EA per 10 days)
QL (2 EA per 10 days)
B/D
1
2
2
1
2
2
2
2
PULMOZYME
2
TOBI PODHALER
2
tobramycin
1
Mast Cell Stabilizers
cromolyn sodium nebulization solution 20mg/2ml
1
Phosphodiesterase Inhibitors, Airways Disease
aminophylline injection
1
DALIRESP
2
ELIXOPHYLLIN
2
LUFYLLIN
2
THEO-24
2
theophylline cr tablet extended release 12 hour 100mg, 200mg 1
theophylline er tablet extended release 24 hour
1
theophylline er tablet extended release 12 hour 300mg, 450mg 1
theophylline solution
1
Page 40 of 93
QL (36 GM per 30 days)
QL (60 EA per 30 days)
QL (36 GM per 30 days)
QL (45 GM per 30 days)
QL (450 ML per 30 days) B/D
PA (Antibacterials - Beta lactam,
Other)
B/D
B/D
QL (305 ML per 30 days) B/D
MO
Drug Name
Pulmonary Antihypertensives
LETAIRIS
ORENITRAM
sildenafil
TRACLEER
TYVASO
Respiratory Tract Agents, Other
acetylcysteine solution
ARALAST NP INJECTION 400MG
benzonatate
bromfed dm
hydrocodone bitartrate/homatropine methylbromide
hydrocodone polistirex/chlorpheniramine polistirex
hydrocodone/homatropine
hydromet
PROLASTIN-C
promethazine vc plain
promethazine vc/codeine
promethazine-dm
promethazine/codeine syrup 10mg/5ml; 6.25mg/5ml
promethazine/dextromethorphan
sodium chloride nebulization solution 0.9%
TESSALON PERLES
tussigon
TUSSIONEX PENNKINETIC EXTENDED RELEASE
TYZINE PEDIATRIC NASAL DROPS
XOLAIR
ZEMAIRA
ZONATUSS
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone tablet
cyclobenzaprine hcl tablet 10mg, 5mg
methocarbamol tablet
orphenadrine citrate er
orphenadrine citrate injection
Sleep Disorder Agents
GABA Receptor Modulators
flurazepam hcl
temazepam capsule 15mg, 30mg
zaleplon
zolpidem tartrate
Page 41 of 93
Drug
Tier
2
2
1
2
2
Requirements/Limits
QL (90 EA per 30 days) PA
(sildenafil - PAH)
QL (60 EA per 30 days) LA
B/D
1
2
3
3
3
3
3
3
2
1
3
3
3
3
3
3
3
3
2
2
2
3
B/D
1
1
PA (High Risk Medications)
QL (90 EA per 30 days) PA (High
Risk Medications)
PA (High Risk Medications)
PA (High Risk Medications)
1
1
1
1
1
1
1
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
PA (Respiratory Tract Agents)
DP
QL (30 EA per 30 days)
QL (30 EA per 30 days)
QL (90 EA per 365 days) PA (High
Risk Medication Nonbenzodiazepine Hypnotics)
QL (90 EA per 365 days) PA (High
Risk Medication Nonbenzodiazepine Hypnotics)
Drug Name
zolpidem tartrate er
Sleep Disorders, Other
modafinil tablet 200mg
ROZEREM
XYREM
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CHEMET
DEPEN TITRATABS
EXJADE
kionex powder
SODIUM LACTATE
sodium polystyrene sulfonate suspension
SYPRINE
Electrolyte/Mineral Replacement
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
AMINOSYN II
aminosyn ii 8.5%/electrolytes
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
AMMONIUM CHLORIDE
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
dexferrum
DEXTROSE 10%/NACL 0.45%
dextrose 10% flex container
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/sodium chloride 0.45%
Page 42 of 93
Drug
Tier
1
1
2
2
Requirements/Limits
QL (90 EA per 365 days) PA (High
Risk Medication Nonbenzodiazepine Hypnotics)
QL (30 EA per 30 days) PA (Central
Nervous System Agents)
QL (30 EA per 30 days)
QL (540 ML per 30 days) LA
2
2
2
1
2
1
2
2
1
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
1
2
1
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
DP
Drug Name
dextrose 5%
dextrose 5%/nacl 0.2%
DEXTROSE 5%/NACL 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium chloride 0.15%
FREAMINE HBC 6.9%
FREAMINE III 3%
hepatamine
infed
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
kcl 0.075%/d5w/nacl 0.45%
KCL 0.15%/D5W/LR
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
lactated ringers dextrose 5% viaflex
lactated ringers viaflex
magnesium sulfate injection 50%
MOZOBIL
NEPHRAMINE
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
polysaccharide iron
potassium chloride 0.15% /nacl 0.45% viaflex
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.15%/nacl 0.9%
potassium chloride 0.22% d5w/nacl 0.45%
POTASSIUM CHLORIDE 0.3%/ NACL 0.9%
potassium chloride 0.3%/d5w
potassium chloride er capsule extended release
potassium chloride er tablet extended release 10meq, 20meq
potassium chloride er tablet extended release 8meq
Page 43 of 93
Drug
Tier
1
1
2
1
1
1
1
2
2
1
3
2
2
2
2
1
2
1
2
1
1
2
1
1
1
1
1
1
1
1
2
2
1
2
2
2
2
2
3
1
1
1
1
1
2
1
1
1
1
Requirements/Limits
B/D
B/D
B/D
DP
PA (Mozobil)
B/D
DP
MO
Drug Name
potassium chloride sr tablet extended release 8meq
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML,
20MEQ/100ML, 30MEQ/100ML, 40MEQ/100ML
potassium chloride injection 2meq/ml
potassium citrate er tablet extended release 1080mg, 540mg
potassium citrate er tablet extended release 15meq
PREMASOL INJECTION 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
premasol injection 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml;
120mg/100ml; 140mg/100ml; 470mg/100ml
PROCALAMINE
PROSOL
ringers injection
sodium chloride 0.45% viaflex
sodium chloride 0.9%
sodium chloride injection 0.9%, 2.5meq/ml, 3%, 5%
sodium fluoride tablet 1mg
tpn electrolytes
TRAVASOL
TROPHAMINE
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
VENOFER
Vitamins
cyanocobalamin injection
FOLIC ACID INJECTION
folic acid tablet 1mg
HYDROXOCOBALAMIN
infuvite pediatric
M.V.I. ADULT
M.V.I. PEDIATRIC
M.V.I.-12 WITHOUT VITAMIN K
MEPHYTON
NASCOBAL
phytonadione
PRENAPLUS
PRENATABS OBN
prenatabs rx
prenatal plus iron
thiamine hcl injection
Page 44 of 93
Drug
Tier
1
2
Requirements/Limits
1
1
1
2
MO
B/D
1
B/D
2
2
1
1
1
1
1
1
2
2
2
2
2
3
B/D
B/D
3
3
3
3
3
3
3
3
3
3
3
2
2
1
1
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
B/D
B/D
DP
QL (30 EA per 30 days)
QL (30 EA per 30 days)
DP
Drug Name
VINATE ONE
vitamin d capsule 50000unit
VITAMIN K1 INJECTION 10MG/ML
vol-tab rx
Unclassified
No Classification
FERAHEME
PRO-CLEAR
sterile water for injection
Page 45 of 93
Drug
Tier
2
3
3
1
DP
DP
QL (30 EA per 30 days)
3
3
3
DP
DP
DP
Requirements/Limits
OTC products
Drug Name
Analgesics
Analgesics
acephen
acetaminophen suppository 120mg, 650mg
feverall
Nonsteroidal Anti-inflammatory Drugs
aspir-81
aspir-low
aspirin adult low strength tablet chewable
aspirin childrens
aspirin ec lo-dose
aspirin ec low dose
aspirin ec tablet delayed release 325mg, 81mg
aspirin enteric coated adult low strength
aspirin low dose tablet chewable
aspirin low strength
aspirin tablet chewable
aspirin tablet delayed release 325mg, 81mg
childrens aspirin
childrens aspirin low strength
ecpirin
enteric coated aspirin
gnp adult aspirin low strength
gnp aspirin low dose
gnp aspirin tablet delayed release 325mg
hm aspirin
hm aspirin ec
miniprin low dose
qc aspirin
qc aspirin low dose
qc childrens aspirin
sb aspirin tablet delayed release
sm aspirin adult low strength
sm aspirin enteric coated
sm aspirin low dose
sm childrens aspirin
Anesthetics
Local Anesthetics
lidocream cream
lmx 4
qc azo
Anti-Addiction/Substance Abuse Treatment Agents
Smoking Cessation Agents
gnp nicotine polacrilex
nicoderm cq
nicorelief
nicorette
nicorette mini
Page 46 of 93
Drug
Tier
Requirements/Limits
3
3
3
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
DP
DP
DP
3
3
3
3
3
DP
DP
DP
DP
DP
Drug Name
nicorette starter kit
nicotine polacrilex gum, lozenge
nicotine transdermal system patch 24 hour
nicotine patch 24 hour
sm nicotine polacrilex
sm nicotine gum, lozenge
sm nicotine patch 24 hour 7mg/24hr
Antibacterials
Antibacterials, Other
bacitracin zinc ointment
bacitracin/neomycin/polymyxin ointment
bacitracin ointment
betadine surgical scrub
double antibiotic
gnp bacitracin zinc
gnp povidone-iodine
gnp triple antibiotic
hm bacitracin
hm povidone-iodine
povidone-iodine ointment
povidone-iodine solution 10%
qc bacitracin
sm double antibiotic
sm triple antibiotic
triple antibiotic ointment 400unit/gm; 3.5mg/gm;
5000unit/gm, 400unit/gm; 5mg/gm; 5000unit/gm
Antifungals
Antifungals
anti-fungal powder
antifungal cream
athletes foot af cream
baza antifungal
carrington antifungal
clotrimazole 3 day
clotrimazole vaginal cream 1%
desenex shake powder
fungoid tincture solution
gnp clotrimazole 3
gnp miconazole 1
gnp miconazole 3
gnp terbinafine hydrochloride
gnp tioconazole 1
gnp tolnaftate
jock itch spray
lamisil af defense powder
lamisil at
lamisil at jock itch
lamisil at spray
lotrimin ultra
Page 47 of 93
Drug
Tier
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug
Drug Name
Tier
miconazole 1
3
miconazole 3 combo pack
3
miconazole 7
3
miconazole nitrate external cream, vaginal cream, suppository3
miconazole cream
3
micro guard powder
3
mitrazol
3
qc tolnaftate
3
remedy antifungal
3
sm 3-day vaginal
3
sm antifungal miconazole
3
sm antifungal tolnaftate
3
sm athletes foot cream
3
sm clotrimazole vaginal
3
sm miconazole 7
3
sm tioconazole-1
3
soothe & cool inzo antifungal cream
3
terbinafine hcl cream
3
3
tioconazole-1
tolnaftate cream, powder, solution
3
vagistat-3
3
Antiparasitics
Pediculicides/Scabicides
gnp lice solution kit
3
hm lice killing maximum strength
3
lice killing maximum strength shampoo
3
lice solution kit
3
lice treatment creme rinse
3
permethrin lotion
3
sm lice killing maximum strength
3
sm lice treatment
3
Blood Glucose Regulators
Glycemic Agents
glucose tablet chewable 4gm
3
glutose 15
3
sm glucose tablet chewable 6mg; 4gm
3
Dermatological Agents
Dermatological Agents
aloe vesta protective
3
aluminum acetate astringent packet 1191mg; 839mg
3
baza protect
3
beta care betatar gel
3
carmol 10
3
dermaphor
3
gnp hemorrhoidal
3
hem-prep
3
hemorrhoid
3
hemorrhoidal suppositories
3
hemorrhoidal ointment 14%; 71.9%; 0.25%; 3%
3
Page 48 of 93
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
hemorrhoidal suppository 85.5%; 0.25%; 3%
ionil-t
minerin cream
nutraplus
pedi-boro soak paks
peleverus
peleverus clear
peleverus gold
periguard
preparation h ointment
preparation h suppository 85.5%; 0.25%; 3%
qc hemorrhoidal ointment
remedy nutrashield
remedy skin repair
sm hemorrhoidal ointment
soothe & cool protect moisture barrier
trixaicin hp
ureacin-10
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
icaps
Gastrointestinal Agents
Gastrointestinal Agents, Other
acid gone suspension
almacone double strength
aluminum hydroxide suspension 320mg/5ml
antacid anti-gas maximum strength
antacid suspension
bisac-evac suppository
bisacodyl
bisacodyl ec
biscolax
bismatrol maximum strength
bismatrol suspension
calcium carbonate tablet 648mg
diocto
disposable enema
docqlace capsule 100mg
docu
docusate calcium
docusate sodium capsule 100mg
docusil
docusol mini
dok
ducodyl
enema ready-to-use enema 7gm/118ml; 19gm/118ml
enemeez mini
fiber laxative tablet 625mg
fiber tabs
Page 49 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
fiber therapy powder
fiber-lax
fleet bisacodyl
fleet enema enema 7gm/118ml; 19gm/118ml
fleet laxative tablet delayed release
fleet pediatric
gas relief extra strength tablet chewable
gas relief suspension
gas-x extra strength tablet chewable
gnp bisa-lax
gnp gas relief
gnp gas relief extra strength tablet chewable
gnp gas relief maximum strength
gnp infants gas relief
gnp k-pec
gnp laxative
gnp natural fiber powder 28.3%, 48.57%
gnp stomach relief maximum strength
gnp stomach relief suspension 262mg/15ml
gnp stool softener
gnp stool softener extra strength
hm fiber powder 28.3%
hm gas relief infants drops
hm gas relief tablet chewable
hm laxative
hm senna
hm stomach relief suspension
hm stool softener
hm stool softener maximum strength
infants gas relief
infants simethicone
kao-tin
konsyl-d powder
laxative suppository, tablet delayed release
magnesium citrate solution 1.745gm/30ml
magnesium oxide tablet 241.3mg, 400mg
mi-acid gas relief
mi-acid maximum strength
mi-acid suspension
milantex
milantex extra strength
milk of magnesia concentrate
milk of magnesia suspension 400mg/5ml
mintox maximum strength
mintox suspension
mytab gas
mytab gas max str
natural fiber laxative powder 30.9%
natural fiber therapy
Page 50 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
pedia-lax liquid
peptic relief suspension
pepto-bismol suspension 524mg/30ml
phosphate laxative
pink bismuth maximum strength
pink bismuth regular strength suspension 527mg/30ml
qc gas relief
qc gas relief extra strength
qc gentle laxative
qc natural vegetable
qc pink bismuth suspension
qc senna
qc stool softener
reguloid
rulox
sb bismuth suspension
senexon
senna prompt
senna-gen
senna-tabs
senna-time
senna syrup 8.8mg/5ml
senna tablet 8.6mg
senno
senokot
silace
simethicone tablet chewable, suspension
sm fiber
sm foaming antacid
sm gas relief
sm gas relief infants drops
sm gentle laxative
sm stomach relief suspension
sm stool softener
sm womans laxative
sodium bicarbonate tablet
stimulant laxative
stomach relief maximum strength
stomach relief suspension 262mg/15ml, 524mg/30ml
stool softener extra strength
stool softener laxative dc
stool softener capsule
womans laxative
Laxatives
doc-q-lax
docqlace capsule 100mg
docusate sodium & senna stimulant laxative/stool softener
docusate sodium capsule 100mg
dok plus
Page 51 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
DP
DP
DP
DP
DP
Drug Name
enema ready-to-use enema 7gm/118ml; 19gm/118ml
fleet enema six pack
fleet enema enema 7gm/118ml; 19gm/118ml
gnp docusate calcium
gnp enema
gnp magnesium citrate solution 1.745gm/30ml
gnp milk of magnesia
gnp senna plus
gnp stool softener/stimulant laxative
hm enema
hm milk of magnesia
hm senna-s
hm stool softener/laxative
milk of magnesia suspension 1200mg/15ml
qc docusate calcium
qc enema
qc magnesium citrate
qc milk of magnesia
qc senna-s
qc stool softener plus laxative
senna plus
senna s
senna-s
sennalax-s
senokot s
senokot to go
sm docusate calcium
sm enema
sm fiber laxative tablet 500mg
sm milk of magnesia
sm natural laxative plus stool softener
sm oral saline laxative solution 2.7gm/5ml; 7.2gm/5ml
sm stool softener plus laxative
stool softener laxative
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
1st choice pen needles 31gx8mm
bd insulin syringe ultrafine/1ml/30g x 1/2"
bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
bd pen needles short/ultrafine/31g x 5/16"
chew q tablet chewable 100mg
co q-10 capsule 200mg
co-enzyme q-10 capsule 30mg
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
exel insulin pen needles 31gx1/3"
fish oil capsule delayed release 0; 0; 1000mg; 300mg
Page 52 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
3
3
3
1
1
1
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
fish oil capsule 0; 0; 1000mg; 300mg, 1000mg, 120mg;
180mg; 1000mg; 340mg; 1unit
gnp fish oil capsule 175mg; 260mg; 435mg
gnp fish oil capsule delayed release
insupen ultrafin 31gx8mm
lite touch pen needles/31g x 3/16"
monoject insulin syringe/detach needle/1ml/25g x 5/8"
monoject insulin syringe/softpack/1ml/25g x 58"
novofine 32gx6mm
prodigy insulin mini pen needles/31g x 3/16"
prodigy insulin short penneedles/31g x 5/16"
sea-omega 30
sea-omega 50
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
Ophthalmic Agents
Ophthalmic Agents, Other
akwa tears renewed
artificial tears ointment
artificial tears solution 1.4%
bion tears
dry eyes
genteal mild
genteal mild to moderate
genteal pm
isopto tears
muro 128 ointment
muro 128 solution 5%
puralube
refresh celluvisc
refresh p.m.
refresh plus
sm artificial tears
sodium chloride ointment 5%
sodium chloride ophthalmic solution 5%
systane
systane balance restorative formula
systane gel
systane nighttime
systane ultra
systane ultra home & away pack
tears naturale
tears naturale forte
tears naturale ii
tears pure
Ophthalmic Anti-inflammatories
alaway
Page 53 of 93
Drug
Tier
3
Requirements/Limits
DP
3
3
1
1
1
1
1
1
1
3
3
1
1
1
1
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
DP
DP
Drug Name
alaway childrens allergy eye itch relief
eye itch relief
gnp eye itch relief
gnp itchy eye
ketotifen fumarate
sm eye itch relief solution 0.025%
zaditor
Otic Agents
Otic Agents
debrox
ear drops
ear wax removal aid
ear wax removal drops
ear wax removal kit
ear wax removal system
earwax treatment drops
gnp ear drops
gnp ear systems
hm earwax removal aid
hm earwax removal kit
qc ear wax removal drops
Respiratory Tract/Pulmonary Agents
Antihistamines
alavert allergy/sinus
alavert tablet dispersible
all day allergy childrens tablet chewable
all day allergy d
all day allergy d-12
all day allergy-d
all day allergy tablet
aller-chlor
aller-ease
allergy 4 hour
allergy childrens
allergy relief child
allergy relief d-24
allergy relief/nasal decongestant
allergy relief tablet dispersible
allergy relief tablet 10mg, 25mg
allergy tablets
allergy/congestion relief
allergy tablet, tablet dispersible
allerhist-1
banophen capsule 25mg
banophen liquid, tablet
brotapp
brovex peb
brovex psb
cardec
Page 54 of 93
Drug
Tier
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
cetirizine hcl/pseudoephedrine hcl er
cetirizine hcl tablet chewable, tablet
childrens allergy
childrens cold & allergy
childrens loratadine
chlorpheniramine maleate tablet, tablet extended release
claritin
claritin reditabs
claritin-d 12 hour
claritin-d 24 hour
clemastine fumarate tablet 1.34mg
cold/allergy childrens
complete allergy
complete allergy medicine capsule
cpm/pse
dallergy liquid 1mg/ml; 2mg/ml
dimaphen childrens
dimetapp cold & allergy elixir
diphenhist capsule, liquid
diphenhydramine hcl capsule 25mg
diphenhydramine hcl tablet 25mg
ed a-hist pse
ed a-hist liquid
ed chlorped d liquid
ed chlorped jr
ed chlorped liquid
fexofenadine hcl tablet 180mg, 60mg
gnp all day allergy
gnp all day allergy-d
gnp allergy
gnp allergy relief for kids tablet dispersible
gnp allergy relief tablet
gnp childrens allergy
gnp cold & allergy childrens
gnp dayhist allergy
gnp loratadine
gnp loratadine-d 12hr
gnp loratadine-d 24 hour
hm all day allergy
hm allergy
hm allergy & congestion
hm allergy childrens
hm allergy complete-d
hm allergy relief
hm allergy relief & nasaldecongestant
hm allgery multi symptom
hm fexofenadine hcl tablet 180mg
hm loratadine childrens
j-tan d pd
Page 55 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
lohist-d
lohist-peb
loratadine childrens
loratadine hives relief
loratadine-d 12hr
loratadine-d 24hr
loratadine tablet
multi-symptom allergy
nohist-lq
pharbedryl capsule 25mg
q-dryl
q-tapp
qc all day allergy
qc allergy relief
qc chlor-pheniramine
qc complete allergy medicine tablet
qc loratadine allergy relief
qc loratadine-d
quenalin
robitussin mucus+chest congestion
rynex pe
rynex pse
sb loratadine tablet
siladryl allergy
sm all day allergy
sm all day allergy-d
sm allergy 4 hour
sm allergy relief
sm allergy relief loratadine
sm childrens loratadine
sm cold & allergy childrens elixir 1mg/5ml; 2.5mg/5ml
sm fexofenadine hcl tablet 180mg
sm lorata-dine d
sm loratadine allergy relief
sm loratadine d 12hr
sm loratadine syrup
sudogest sinus & allergy
tavist allergy
tl-hist pd
triaminic night time cold & cough
trigofen
virdec
Mast Cell Stabilizers
cromolyn sodium aerosol solution 5.2mg/act
Respiratory Tract Agents, Other
12 hour nasal spray
allfen
ambi 40pse/400gfn/20dm
aprodine
Page 56 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
DP
DP
DP
DP
Drug Name
brotapp dm
capmist dm tablet 30mg; 400mg; 30mg
cheratussin ac syrup
cheratussin dac
chest congestion relief
childrens mucus relief cough
childrens mucus relief expectorant
childrens pain relief plus multi-symptom cold
cold head congestion daytime
cold head congestion nighttime
cold head congestion nighttime multi-symptom
cold multi-symptom nighttime
cold multi-symptom severe daytime tablet 325mg; 10mg;
200mg; 5mg
cold/cough childrens
cold/cough dm childrens
corfen-dm
coricidin hbp nighttime multi-symptom cold liquid
325mg/15ml; 15mg/15ml; 6.25mg/15ml
cough dm liquid extended release 30mg/5ml
cough syrup
coughtab
day time cold/flu relief
day time cough
decongestant 12hour maximum strength
deep sea nasal spray
delsym
delsym night time cough/cold childrens
delsym night time cough/cold liquid 6.25mg/5ml; 2.5mg/5ml
delsym night time multi-symptom liquid 325mg/15ml;
15mg/15ml; 6.25mg/15ml
dextromethorphan polistirex
dextromethorphan/guaifenesin solution
diabetic siltussin das-na
diabetic siltussin-dm
diabetic siltussin-dm maximum strength
diabetic tussin
diabetic tussin dm
diabetic tussin maximum strength
dimaphen dm cold/cough childrens
dimetapp dm cold & cough
dimetapp multi-symptom cold & flu
donatussin dm liquid
dristan cold
ed a-hist dm liquid
endacof-dm
excedrin sinus headache
exefen dmx
extra action cough
Page 57 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
gnp allergy plus severe sinus headache maximum strength
gnp childrens pain relief plus cold
gnp childrens plus multi-symptom cold
gnp cold & cough childrens
gnp cold head congestion night time
gnp cold multi-symptom daytime
gnp cold multi-symptom nighttime
gnp cold relief multi-symptom daytime
gnp cough relief
gnp day time mucus reliefdm
gnp flu relief therapy seere cold daytime
gnp flu relief therapy severe cold nighttime
gnp mucus relief
gnp mucus relief cough childrens
gnp mucus relief dm
gnp night time cold/flu relief
gnp night time cough
gnp nose drops extra strength
gnp triacting night time cold & cough childrens
gnp tussin
gnp tussin cf cough & cold
gnp tussin cough long acting
gnp tussin dm
gnp tussin dm cough
gnp tussin dm max
guaifenesin ac
guaifenesin er
guaifenesin-dm
guaifenesin/codeine
guaifenesin solution
guaifenesin tablet 200mg
hm day time
hm daytime cold & flu
hm night time cold & flu
intense cough reliever extra strength
iophen c-nr
iophen dm-nr
iophen-nr
kidkare cough/cold
liquituss gg
lohist-dm
m-clear
m-clear wc
m-end dm
m-end wc
mapap sinus maximum strength congestion and pain
mesehist dm
mesehist wc
mucinex
Page 58 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
mucinex chest congestion childrens
mucinex childrens cold cough & sore throat
mucinex childrens multi-symptom cold
mucinex childrens multi-symptom cold & fever
mucinex cold for kids
mucinex cough childrens
mucinex cough for kids liquid
mucinex d
mucinex dm
mucinex dm maximum strength
mucinex fast-max cold & sinus
mucinex fast-max cold flu& sore throat
mucinex fast-max dm max
mucinex fast-max severe congestion & cold
mucinex fast-max severe congestion & cough liquid
mucinex for kids
mucinex maximum strength
mucinex nasal spray full force
mucinex nasal spray moisture smart
mucus relief
mucus relief childrens
mucus relief cough childrens
mucusrelief dm
mytussin dac
nasal decongestant pe maximum strength
nasal decongestant spray
nasal decongestant liquid 30mg/5ml
nasal decongestant solution 1%
nasal decongestant syrup 30mg/5ml
nasohist dm
nite time cough
nite time multi-symptom cold/flu relief liquid
nite-time multi-symptom cold/flu relief liquid 500mg/15ml;
15mg/15ml; 6.25mg/15ml
nohist-dm
nrs nasal relief
ocean nasal spray
organ-i nr
pedia relief cough/cold
pediatric cough/cold
phenylhistine dh
pseudoephedrine hcl tablet 30mg
q-tapp dm
q-tussin
q-tussin dm
qc cold relief plus multi-symptom childrens
qc cough relief
qc cough/sore throat nighttime
qc nighttime cold/flu relief
Page 59 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
qc nighttime cough
qc tussin cf
relcof c
rescon dm
rescon-gg
robafen
robafen dm
robafen dm cough clear
robitussin childrens cough & cold cf
robitussin childrens cough long-acting
robitussin childrens cough/cold long-acting
robitussin cold+flu daytime
robitussin cold+flu nighttime
robitussin lingering coldlong-acting cough
robitussin peak cold cough+ chest congestion dm
robitussin peak cold cough+ chest congestion dm max
strength
robitussin peak cold dm
robitussin peak cold multi-symptom cold
robitussin peak cold multi-symptom cold maximum strength
robitussin peak cold nasal relief
robitussin peak cold nighttime multi-symptom cold
robitussin peak cold nighttime nasal relief
rynex dm
saline mist
saline nasal mist
sea soft nasal mist
siltussin sa
siltussin-dm
sinus nasal spray
sm childrens pain relief plus multi-symptom cold
sm cold & cough dm childrens
sm cough relief
sm day time cold & flu relief
sm mucus er
sm mucus relief cough childrens
sm nasal spray saline
sm nite time cold & flu relief liquid
sm nite time cough
sm nose drops nasal decongestant extra strength
sm tussin
sm tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
sm tussin dm
sm tussin dm cough/chest congestion
sudogest
sudogest 12 hour
sudogest pe
tri-dex pe
triacting nightime cold& cough childrens
Page 60 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
triaminic cold & cough day time childrens syrup
trigofen dm
tusnel diabetic
tusnel pediatric liquid 5mg/5ml; 50mg/5ml; 15mg/5ml
tusnel liquid
tussin
tussin cf cough & cold
tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml
tussin chest congestion
tussin cough syrup
tussin dm
tussin dm max
tussin mucus + chest congestion
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
mykidz iron 10
Electrolyte/Mineral Replacement
calci-chew
calcium carbonate suspension 1250mg/5ml
calcium carbonate tablet 1250mg
calcium gluconate tablet 648mg
calcium high potency + vitamin d
calcium lactate tablet 648mg
calcium oyster shell tablet 1250mg
calcium/vitamin d tablet 600mg; 200unit, 600mg; 400unit
caltrate 600+d plus minerals tablet chewable
citrus calcium/vitamin d
duofer
fer-iron
ferrex 150
ferrous gluconate tablet 324mg
ferrous sulfate elixir, liquid, tablet extended release
ferrous sulfate tablet 325mg
ferus
gnp calcium 500/d
gnp calcium 600 +d
gnp calcuim/vitamin d/minerals
gnp slow release iron tablet extended release 47.5mg
mag-delay
mag-g
mag-tab sr
novaferrum 125
novaferrum pediatric drops
os-cal
oysco 500+d tablet chewable
oyster shell calcium/vitamin d tablet 250mg; 125unit; 0,
500mg; 400unit
poly-iron 150
profe
Page 61 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
DP
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
3
3
DP
DP
Drug Name
qc ferrous sulfate
slow release iron tablet extended release 140mg
sm iron tablet 325mg
zinc sulfate capsule
Vitamins
aquadeks capsule
aqueous vitamin d infants
calciferol
centamin
centavite a-z complete multivitamin/minerals
cerovite advanced formula
certa plus tablet 60mg; 0; 30mcg; 162mg; 10mg; 72mg;
400unit; 120mg; 2mg; 6mcg; 18mg; 400mcg; 250mcg;
100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg; 80mg; 150mcg;
2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg; 20mcg; 10mcg;
1.5mg; 30unit; 5000unit; 15mg
certavite/antioxidants tablet
chewable vite childrens
chewable vite with iron/childrens
childrens chewable vitamins
childrens chewable vitamins/iron tablet chewable 400unit;
4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg;
1.05mg; 15unit; 2500unit
complete
d-vita
d3 high potency
d3 super strength
d3-50
daily multiple vitamins tablet 50mg; 7mg; 1mcg; 400unit;
20mg; 1mg; 2.5mg; 2mg; 5000unit
daily vitamin formula
daily vitamin formula+iron tablet 60mg; 0; 10mg; 400unit;
6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit;
5000unit
daily vitamin formula+minerals tablet 50mg; 11.6mg; 1mg;
5mcg; 1mcg; 4.5mg; 10mg; 1mg; 20mg; 9mg; 150mcg; 1mg;
2.5mg; 5mcg; 2mg; 5000unit; 400unit; 3.75mg
daily vite tablet 60mg; 0; 23mg; 10mg; 400unit; 6mcg;
400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit
daily-vite/iron/beta-carotene
dialyvite 800
drisdol solution
ergocalciferol solution
folic acid tablet 800mcg
fosfree
geri-tonic
geriaton
gnp century adults 50+ senior
gnp niacin tr tablet extended release 250mg
Page 62 of 93
Drug
Tier
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
3
3
3
3
3
DP
DP
DP
DP
DP
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
3
3
DP
DP
3
DP
3
DP
3
3
3
3
3
3
3
3
3
3
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug
Drug Name
Tier
golden age vitamin/minerals
3
i-vite
3
maximum d3
3
multi-delyn
3
multi-delyn/iron
3
multi-vitamins
3
multilex
3
nephro-vite
3
niacin er capsule extended release 250mg
3
niacin sr capsule extended release
3
niacin td tablet extended release
3
niacin tr tablet extended release 500mg, 750mg
3
once daily/iron
3
once daily tablet 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 2mg; 3
5000unit; 400unit
poly vitamin
3
poly-vitamin drops
3
poly-vitamin/iron drops
3
polyvitamin/iron tablet chewable
3
polyvitamin/iron solution 35mg/ml; 400unit/ml; 10mg/ml;
3
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
polyvitamin solution 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 3
0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
qc childrens chewable vitamins/extra c
3
qc childrens chewable vitamins/iron
3
qc daily multivitamins/iron
3
qc multi-vite
3
qc multi-vite 50 & over
3
qc womens daily multivitamin
3
rena-vite
3
slo-niacin
3
stress formula/zinc tablet 600mg; 45mg; 3mg; 12mcg;
3
400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg
stress formula tablet 500mg; 45mcg; 12mcg; 400mcg; 100mg; 3
20mg; 3mg; 10mg; 10mg; 30unit
thera-m tablet 120mg; 15mcg; 40mg; 10mg; 7.5mg; 400unit; 3
15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg;
31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg;
30unit; 5500unit; 15mg, 90mg; 0; 30mcg; 150mcg; 40mg;
7.5mg; 26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg;
3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg;
3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit;
30unit; 28mcg; 15mg, 90mg; 0; 30mcg; 30mg; 10mg; 50mcg;
2mg; 12mcg; 400unit; 9mg; 400mcg; 100mg; 2mg; 20mg;
5mcg; 23mg; 28mcg; 7.5mg; 7mg; 150mcg; 6mg; 3.4mg;
6mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit;
5000unit; 15mg
thera-plus
3
Page 63 of 93
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug
Drug Name
Tier
therapeutic formula/hematinics
3
thera tablet 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3mg; 3
3.4mg; 3mg; 5000unit; 400unit; 30unit
therems
3
therems-h
3
therems-m
3
tri-vitamin solution 35mg/ml; 1500unit/ml; 400unit/ml
3
unicomplex-m
3
vigomar forte
3
vita-bee/c tablet 300mg; 300mcg; 10mg; 400mcg; 50mg;
3
5mg; 10.2mg; 15mg
vitamin b complex-c
3
vitamin c tablet 500mg
3
vitamin d3 super strength
3
vitamin d3 capsule 10000unit, 5000unit
3
vitamin d3 liquid 400unit/ml
3
vitamin d3 tablet 1000unit, 5000unit
3
vitamin d capsule 1000unit, 2000unit
3
vitamin d liquid
3
zoo friends
3
zoo friends complete
3
zoo friends plus extra c
3
zoo friends plus iron
3
Unclassified
No Classification
12 hour decongestant
3
allergy eye drops
3
allergy multi-symptom
3
antacid fast relief
3
antacid maximum strength
3
antacid plus anti-gas fast acting
3
aqua-e
3
cold head congestion severe daytime
3
cold multi-symptom severe daytime tablet 325mg; 10mg;
3
200mg; 5mg
cough & sore throat day time
3
cough dm liquid extended release 30mg/5ml
3
de-chlor dm
3
dermamed
3
enema mineral oil
3
exefen-ir
3
eye drops allergy relief
3
fast acting antacid plus anti-gas maximum strength
3
fiber laxative tablet 625mg
3
gnp 12 hour nasal spray
3
gnp allergy multi-symptom
3
gnp antacid anti-gas
3
gnp antacid maximum strength
3
gnp calcium 500 +d3
3
Page 64 of 93
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
gnp capsaicin
gnp childrens chewables/extra c
gnp childrens chewables/iron
gnp childrens plus cough & sore throat
gnp cold & allergy maximum strength
gnp cold head congestion severe daytime
gnp cold relief head congestion severe daytime
gnp cold relief multi-symptom severe daytime
gnp cold severe congestion/daytime
gnp cough dm er
gnp day time sinus
gnp fiber-caps
gnp foaming antacid
gnp little ones childrens
gnp masanti maximum strength
gnp masanti regular strength
gnp miconazorb af
gnp nasal decongestant
gnp nasal decongestant pemaximum strength
gnp nasal spray extra moisturizing
gnp night time cold & flu multisymptom
gnp no drip nasal spray
gnp pseudoephedrine hcl 12 hour
gnp sinus congestion & pain daytime
gnp sinus congestion/pain nighttime
gnp sinus relief congestion & pain daytime/nighttime
gnp sinus relief congestion & pain nighttime
gnp suphedrin
gnp tab tussin
gnp tab tussin dm
hm advanced antacid maximum strength
hm antacid anti-gas extrastrength
hm antacid/antigas
hm artificial tears
hm chest congestion relief
hm chest congestion relief dm
hm cold & allergy childrens
hm cold & cough childrens
hm cough relief
hm enema mineral oil
hm eye itch relief
hm fexofenadine hcl tablet 60mg
hm fiber capsule 0.52gm
hm fiber tablet 500mg
hm fish oil
hm nasal decongestant
hm nasal decongestant 12 hour
hm nasal decongestant pe
hm nasal spray
Page 65 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
hm night time multi symptom cold & flu
hm nose drops extra strength
hm saline nasal spray
hm sinus nasal spray
hm stomach relief maximumstrength
hm triple antibiotic
hm tussin adult
hm tussin adult cough & chest congestion dm
hm tussin adult multi-symptom cold
long acting nasal spray
lubricant eye drops dry eye therapy
medi-phedrine
metamucil smooth texture
miconazorb af
nasal decongestant pe
nasal decongestant tablet 30mg
nasal spray 12 hour
nasal spray x-moist
neutrahist
nighttime sinus congestion & pain
pain relief cold severe congestion
pain relief sinus pe daytime
pro-red ac
pseudoephedrine hcl tablet 30mg
qc 3 day vaginal cream
qc allergy relief multi-symptom daytime
qc antacid
qc antacid/anti-gas
qc antacid/anti-gas maximum strength
qc athletes foot
qc fiber laxative
qc medifin mucus relief childrens
qc no drip nasal relief
qc sinus pain relief
qc suphedrine
qc suphedrine maximum strength
qc suphedrine pe
rhinaris
sentry
sinus congestion & pain daytime
slow-mag
sm 12 hour sinus decongestant
sm 12-hour no drip
sm allergy multi-symptom
sm antacid anti-gas
sm antacid maximum strength
sm antacid/antigas
sm cold head congestion severe day time
sm eye itch relief solution 0.025%
Page 66 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
DP
Drug Name
sm fexofenadine hcl tablet 60mg
sm fiber laxative capsule 0.52gm
sm fiber laxative tablet 625mg
sm nasal decongestant maximum strength
sm nasal decongestant pe
sm nasal spray moisturizing
sm nasal spray sinus
sm stomach relief maximumstrength
z-tuss e
Page 67 of 93
Drug
Tier
3
3
3
3
3
3
3
3
3
Requirements/Limits
DP
DP
DP
DP
DP
DP
DP
DP
DP
Index
Drug Name
12 hour decongestant
12 hour nasal spray
1st choice pen needles 31gx8mm
abacavir
abacavir sulfate/lamivudine/zidovudine
ABELCET
ABILIFY
ABILIFY DISCMELT
ABILIFY MAINTENA
ABRAXANE
acamprosate calcium dr
acarbose
acebutolol hcl
acephen
acetaminophen
acetaminophen/codeine
acetaminophen/codeine #3
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine
acid gone
ACTHIB
ACTIMMUNE
acyclovir
acyclovir sodium
ADACEL
ADAGEN
adapalene
adefovir dipivoxil
adriamycin
ADVAIR DISKUS
ADVAIR HFA
afeditab cr
AFINITOR
AFINITOR DISPERZ
AGGRENOX
a-hydrocort
akwa tears renewed
alavert
alavert allergy/sinus
alaway
alaway childrens allergy eye itch relief
ALBENZA
albuterol sulfate
Page 68 of 93
Page #
64
56
52
18
18
10
16
16
16
13
3
20
24
46
46
2
2
39
25
38
25
39
41
49
36
36
19
19
36
28
27
17
13
39
39
24
14
14
22
30
53
54
54
53
54
15
40
Drug Name
albuterol sulfate er
alclometasone dipropionate
alcohol preps
ALDURAZYME
alendronate sodium
alfuzosin hcl er
ALIMTA
ALINIA
ALKERAN
all day allergy
all day allergy childrens
all day allergy d
all day allergy d-12
all day allergy-d
aller-chlor
aller-ease
allergy
allergy 4 hour
allergy childrens
allergy eye drops
allergy multi-symptom
allergy relief
allergy relief child
allergy relief d-24
allergy relief/nasal decongestant
allergy tablets
allergy/congestion relief
allerhist-1
allfen
allopurinol
almacone double strength
aloe vesta protective
ALOPRIM
ALORA
ALPHAGAN P
alprazolam
ALPRAZOLAM INTENSOL
aluminum acetate astringent
aluminum hydroxide
amantadine hcl
ambi 40pse/400gfn/20dm
AMBISOME
amcinonide
amifostine
AMIKACIN SULFATE
amiloride hcl
amiloride/hydrochlorothiazide
aminophylline
AMINOSYN 7%/ELECTROLYTES
aminosyn 8.5%/electrolytes
Page #
40
30
3
28
37
30
12
15
12
54
54
54
54
54
54
54
54
54
54
64
64
54
54
54
54
54
54
54
56
11
49
48
11
32
38
19
19
48
49
19
56
10
30
13
3
25
25
40
42
42
Drug Name
AMINOSYN II
aminosyn ii 8.5%/electrolytes
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
amiodarone hcl
AMITIZA
amitriptyline hcl
amlodipine besylate
amlodipine besylate/benazepril hcl
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
AMMONIUM CHLORIDE
ammonium lactate
amoxapine
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium er
amphetamine/dextroamphetamine
AMPHOTERICIN B
ampicillin
AMPICILLIN SODIUM
ampicillin-sulbactam
anagrelide hydrochloride
anastrozole
ANDRODERM
ANDROXY
antacid
antacid anti-gas maximum strength
antacid fast relief
antacid maximum strength
antacid plus anti-gas fast acting
antifungal
anti-fungal powder
APIDRA
APIDRA SOLOSTAR
APOKYN
apri
aprodine
APTIOM
APTIVUS
aquadeks
aqua-e
aqueous vitamin d infants
ARALAST NP
aranelle
Page 69 of 93
Page #
42
42
42
42
42
42
42
23
29
9
24
24
24
24
24
42
27
9
5
5
5
26
10
5
5
5
22
14
32
32
49
49
64
64
64
47
47
21
21
16
32
56
6
19
62
64
62
41
32
Drug Name
ARANESP ALBUMIN FREE
ARCALYST
ARRANON
artificial tears
ARZERRA
ascomp/codeine
ASMANEX HFA
ASMANEX TWISTHALER 120
METERED DOSES
ASMANEX TWISTHALER 14 METERED
DOSES
ASMANEX TWISTHALER 30 ME
TERED DOSES
ASMANEX TWISTHALER 30 METERED
DOSES
ASMANEX TWISTHALER 60 METERED
DOSES
aspir-81
aspirin
aspirin adult low strength
aspirin childrens
aspirin ec
aspirin ec lo-dose
aspirin ec low dose
aspirin enteric coated adult low strength
aspirin low dose
aspirin low strength
aspir-low
atenolol
atenolol/chlorthalidone
athletes foot af cream
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
ATROPINE SULFATE
ATROVENT HFA
AUBAGIO
aubra
augmented betamethasone dipropionate
AVANDARYL
AVASTIN
AVELOX
aviane
AVODART
AVONEX
azacitidine
AZACTAM
AZACTAM IN ISO-OSMOTIC
DEXTROSE
Page #
22
36
12
53
15
2
39
39
39
39
39
39
46
46
46
46
46
46
46
46
46
46
46
24
24
47
26
15
15
19
29
40
27
32
30
20
15
6
32
30
27
13
5
5
Drug Name
azathioprine
azelastine hcl
AZILECT
azithromycin
aztreonam
baciim
BACITRACIN
bacitracin
bacitracin zinc
bacitracin/neomycin/polymyxin
bacitracin/polymyxin b
baclofen
BACTOCILL IN DEXTROSE
balsalazide disodium
balziva
banophen
BANZEL
BARACLUDE
baza antifungal
baza protect
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2"
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16"
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2"
bd insulin syringe ultrafine/1ml/30g x 1/2"
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16"
bd insulin syringe/detachable
needle/u-100/1ml/25g x 5/8"
bd pen needle/mini/ultrafine/31g x 3/16"
bd pen needle/short/ultrafine/31g x 5/16"
BD PEN NEEDLE/ULTRAFINE/29G X
12.7MM
bd pen needles short/ultrafine/31g x 5/16"
BELEODAQ
benazepril hcl
benazepril hcl/hydrochlorothiazide
benzonatate
benztropine mesylate
beta care betatar gel
betadine surgical scrub
betamethasone dipropionate
betamethasone valerate
BETASERON
betaxolol hcl
betaxolol hcl
bethanechol chloride
bicalutamide
Page 70 of 93
Page #
35
39
16
5
5
3
3
47
47
47
38
17
5
37
32
54
7
17
47
48
37
37
37
52
37
52
52
52
37
52
13
23
23
41
15
48
47
30
30
27
24
38
30
12
Drug Name
BICILLIN C-R
BICILLIN L-A
BICNU
BIDIL
bion tears
bisac-evac
bisacodyl
bisacodyl ec
biscolax
bismatrol
bismatrol maximum strength
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
bleomycin sulfate
BOOSTRIX
BOSULIF
BOTOX
BRILINTA
brimonidine tartrate
BRINTELLIX
bromfed dm
bromocriptine mesylate
brotapp
brotapp dm
brovex peb
brovex psb
budeprion sr
budesonide
budesonide
bumetanide
BUPHENYL
buprenorphine hcl
buproban
bupropion hcl
bupropion hcl sr
bupropion hcl xl
buspirone hcl
BUSULFEX
butalbital/acetaminophen
butalbital/acetaminophen/caffeine
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine
butorphanol tartrate
BYETTA
cabergoline
calci-chew
calciferol
calcipotriene
calcitonin-salmon
calcitriol
Page #
5
5
12
26
53
49
49
49
49
49
49
24
24
13
36
14
11
22
38
8
41
16
54
57
54
54
8
30
39
25
28
3
3
8
8
8
19
12
1
1
1
1
2
20
35
61
62
28
37
37
Drug Name
calcium acetate
calcium carbonate
calcium carbonate
calcium gluconate
calcium high potency + vitamin d
calcium lactate
calcium oyster shell
calcium/vitamin d
caltrate 600+d plus minerals
camila
CAMPTOSAR
CANCIDAS
candesartan cilexetil
candesartan cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
capmist dm
CAPRELSA
captopril
captopril/hydrochlorothiazide
carbamazepine
carbamazepine er
CARBATROL
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carboplatin
cardec
CARIMUNE NANOFILTERED
carmol 10
carrington antifungal
carteolol hcl
cartia xt
carvedilol
CAYSTON
cefaclor
cefaclor er
cefadroxil
CEFAZOLIN SODIUM
cefdinir
cefepime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CELLCEPT
CELLCEPT INTRAVENOUS
Page 71 of 93
Page #
30
49
61
61
61
61
61
61
61
34
13
10
23
23
11
57
14
23
23
8
7
8
16
16
16
13
54
36
48
47
38
24
24
40
4
4
4
4
4
4
4
4
4
4
4
4
4
4
35
35
Drug Name
CELONTIN
centamin
centavite a-z complete
multivitamin/minerals
cephalexin
CEREBYX
CEREZYME
cerovite advanced formula
certa plus
certavite/antioxidants
CERVARIX
cetirizine hcl
cetirizine hcl/pseudoephedrine hcl er
CHANTIX
CHANTIX STARTING MONTH PAK
CHEMET
cheratussin ac
cheratussin dac
chest congestion relief
chew q
chewable vite childrens
chewable vite with iron/childrens
childrens allergy
childrens aspirin
childrens aspirin low strength
childrens chewable vitamins
childrens chewable vitamins/iron
childrens cold & allergy
childrens loratadine
childrens mucus relief cough
childrens mucus relief expectorant
childrens pain relief plus multi-symptom
cold
CHLORAMPHENICOL SODIUM
SUCCINATE
chlordiazepoxide/amitriptyline
chlorhexidine gluconate oral rinse
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpheniramine maleate
CHLORPROMAZINE HCL
chlorthalidone
chlorzoxazone
cholestyramine light
chorionic gonadotropin
ciclopirox
ciclopirox olamine
cidofovir
cilostazol
Page #
7
62
62
4
8
28
62
62
62
36
55
55
3
3
42
57
57
57
52
62
62
55
46
46
62
62
55
55
57
57
57
3
9
27
15
26
26
55
16
26
41
26
31
10
10
17
22
Drug Name
cimetidine
cimetidine hcl
CINRYZE
CIPRODEX
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
cisplatin
citalopram hydrobromide
citrus calcium/vitamin d
cladribine
CLAFORAN
claravis
clarithromycin
clarithromycin er
claritin
claritin reditabs
claritin-d 12 hour
claritin-d 24 hour
clemastine fumarate
CLEOCIN IN D5W
CLEOCIN PEDIATRIC GRANULES
CLIMARA PRO
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phosphate add-vantage
clindamycin phosphate in d5w
clindamycin/benzoyl peroxide
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 10%
CLINIMIX 4.25%/DEXTROSE 20%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/DEXTROSE 10%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/DEXTROSE 10%
CLINIMIX E 4.25%/DEXTROSE 25%
CLINIMIX E 4.25%/DEXTROSE 5%
CLINIMIX E 5%/DEXTROSE 15%
CLINIMIX E 5%/DEXTROSE 20%
CLINIMIX E 5%/DEXTROSE 25%
clobetasol propionate
clobetasol propionate e
clodan
CLOLAR
clomipramine hcl
Page 72 of 93
Page #
29
29
35
39
6
6
6
13
9
61
12
5
28
5
5
55
55
55
55
55
3
3
32
3
3
4
4
4
28
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
30
30
30
12
9
Drug Name
clonazepam
clonazepam odt
clonidine hcl
clonidine hcl er
clopidogrel
clorazepate dipotassium
clotrimazole
clotrimazole
clotrimazole 3 day
clotrimazole/betamethasone dipropionate
clozapine
clozapine odt
co q-10
COARTEM
co-enzyme q-10
colchicine
COLCRYS
cold head congestion daytime
cold head congestion nighttime
cold head congestion nighttime
multi-symptom
cold head congestion severe daytime
cold multi-symptom nighttime
cold multi-symptom severe daytime
cold multi-symptom severe daytime
cold/allergy childrens
cold/cough childrens
cold/cough dm childrens
colestipol hcl
colistimethate sodium
COMBIGAN
COMBIVENT RESPIMAT
COMETRIQ
COMPLERA
complete
complete allergy
complete allergy medicine
compro
COMVAX
constulose
COPAXONE
corfen-dm
coricidin hbp nighttime multi-symptom cold
cortisone acetate
COSMEGEN
cough & sore throat day time
cough dm
cough dm
cough syrup
coughtab
Page #
7
7
22
22
22
19
10
47
47
28
17
17
52
15
52
11
11
57
57
57
64
57
64
57
55
57
57
26
4
38
40
14
18
62
55
55
16
36
29
27
57
57
30
13
64
64
57
57
57
Drug Name
COUMADIN
cpm/pse
CREON
CRIXIVAN
cromolyn sodium
cromolyn sodium
cromolyn sodium
cromolyn sodium
cryselle-28
CUBICIN
curity gauze pads 2"x2"
cyanocobalamin
cyclafem 1/35
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
cyproheptadine hcl
CYSTADANE
CYSTAGON
cytarabine
cytarabine aqueous
CYTOMEL
d3 high potency
d3 super strength
d3-50
dacarbazine
DACOGEN
dactinomycin
daily multiple vitamins
daily vitamin formula
daily vitamin formula+iron
daily vitamin formula+minerals
daily vite
daily-vite/iron/beta-carotene
DALIRESP
dallergy
danazol
dantrolene sodium
DAPSONE
DAPTACEL
DARAPRIM
DAUNORUBICIN HCL
day time cold/flu relief
day time cough
deblitane
debrox
DECAVAC
de-chlor dm
Page 73 of 93
Page #
21
55
28
19
29
38
40
56
32
4
28
44
32
41
12
20
35
35
39
28
28
12
12
34
62
62
62
12
13
13
62
62
62
62
62
62
40
55
32
17
11
36
15
13
57
57
34
54
36
64
Drug Name
decitabine
decongestant 12hour maximum strength
deep sea nasal spray
delsym
delsym night time cough/cold
delsym night time cough/cold childrens
delsym night time multi-symptom
delyla
DELZICOL
demeclocycline hcl
DEMEROL
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL
DEPO-SUBQ PROVERA 104
dermamed
dermaphor
desenex shake powder
desipramine hcl
desmopressin acetate
desogestrel/ethinyl estradiol
desonide
desoximetasone
desvenlafaxine er
dexamethasone
dexamethasone sodium phosphate
dexamethasone sodium phosphate
dexferrum
dexrazoxane
dextroamphetamine sulfate
dextromethorphan polistirex
dextromethorphan/guaifenesin
DEXTROSE 10%/NACL 0.45%
dextrose 10% flex container
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/sodium chloride 0.45%
dextrose 5%
dextrose 5%/nacl 0.2%
DEXTROSE 5%/NACL 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium chloride 0.15%
diabetic siltussin das-na
diabetic siltussin-dm
diabetic siltussin-dm maximum strength
diabetic tussin
diabetic tussin dm
Page #
13
57
57
57
57
57
57
32
37
6
2
25
19
42
32
31
34
64
48
47
9
31
32
31
31
9
31
31
38
42
13
27
57
57
42
42
42
42
43
43
43
43
43
43
43
57
57
57
57
57
Drug Name
diabetic tussin maximum strength
dialyvite 800
diazepam
diazepam
DIAZEPAM INTENSOL
diclofenac potassium
diclofenac sodium
diclofenac sodium dr
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflunisal
digitek
digoxin
dihydroergotamine mesylate
DILANTIN
DILANTIN INFATABS
DILANTIN-125
dilt-cd
diltiazem cd
diltiazem hcl
diltiazem hcl er
dilt-xr
dimaphen childrens
dimaphen dm cold/cough childrens
dimetapp cold & allergy
dimetapp dm cold & cough
dimetapp multi-symptom cold & flu
diocto
DIPENTUM
diphenhist
diphenhydramine hcl
diphenhydramine hcl
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC
dipyridamole
disopyramide phosphate
disposable enema
disulfiram
divalproex sodium
divalproex sodium dr
divalproex sodium er
DOCEFREZ
DOCETAXEL
docqlace
docqlace
doc-q-lax
docu
Page 74 of 93
Page #
57
62
7
20
20
1
38
1
1
5
29
18
1
25
25
11
8
8
8
24
24
24
24
24
55
57
55
57
57
49
37
55
39
55
29
36
22
23
49
3
7
7
7
13
13
49
51
51
49
Drug Name
docusate calcium
docusate sodium
docusate sodium
docusate sodium & senna stimulant
laxative/stool softener
docusil
docusol mini
dok
dok plus
donatussin dm
donepezil hcl
dorzolamide hcl
dorzolamide hcl/timolol maleate
double antibiotic
doxazosin mesylate
doxepin hcl
DOXIL
doxorubicin hcl
doxycycline hyclate
drisdol
dristan cold
dronabinol
DROXIA
dry eyes
ducodyl
DUETACT
DULERA
duloxetine hcl
duofer
duramorph
d-vita
e.e.s. 400
e.e.s. granules
ear drops
ear wax removal aid
ear wax removal drops
ear wax removal kit
ear wax removal system
earwax treatment drops
easy touch pen needles 31gx5/16"
easy touch pen needles/31g x 3/16"
econazole nitrate
ecpirin
ed a-hist
ed a-hist dm
ed a-hist pse
ed chlorped
ed chlorped d
ed chlorped jr
EDURANT
Page #
49
49
51
51
49
49
49
51
57
8
38
38
47
30
9
13
13
6
62
57
10
12
53
49
20
39
9
61
2
62
6
6
54
54
54
54
54
54
52
52
10
46
55
57
55
55
55
55
18
Drug Name
EFFIENT
ELAPRASE
ELDEPRYL
ELELYSO
ELIDEL
ELIGARD
ELIPHOS
ELITEK
ELIXOPHYLLIN
ELLA
ELLENCE
ELMIRON
EMCYT
EMEND
EMSAM
EMTRIVA
enalapril maleate
enalapril maleate/hydrochlorothiazide
ENBREL
endacof-dm
endocet
enema mineral oil
enema ready-to-use
enema ready-to-use
enemeez mini
ENGERIX-B
enoxaparin sodium
enpresse-28
entacapone
entecavir
enteric coated aspirin
enulose
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl
epitol
EPIVIR
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
EPZICOM
ERBITUX
ergocalciferol
ergoloid mesylates
ERGOMAR
ERIVEDGE
errin
ERYPED 400
ERY-TAB
Page 75 of 93
Page #
22
28
16
28
28
35
30
12
40
34
13
30
12
10
9
18
23
23
35
57
2
64
49
52
49
36
21
32
15
17
46
29
40
40
13
8
18
17
25
22
23
18
15
62
8
11
14
34
6
6
Drug Name
ERYTHROCIN LACTOBIONATE
erythrocin stearate
erythromycin
erythromycin base
erythromycin/benzoyl peroxide
escitalopram oxalate
esomeprazole sodium
ESTRACE
estradiol
estradiol valerate
estropipate
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
etodolac er
ETOPOPHOS
etoposide
EVISTA
excedrin sinus headache
exefen dmx
exefen-ir
exel insulin pen needles 31gx1/3"
exemestane
EXJADE
extra action cough
eye drops allergy relief
eye itch relief
FABRAZYME
falmina
famciclovir
famotidine
FAMOTIDINE PREMIXED
FANAPT
FANAPT TITRATION PACK
FARESTON
FARXIGA
FASLODEX
fast acting antacid plus anti-gas maximum
strength
FAZACLO
felbamate
felodipine er
fenofibrate
fenofibrate micronized
fenoprofen calcium
fentanyl
fentanyl citrate oral transmucosal
FERAHEME
fer-iron
Page #
6
6
6
6
28
9
30
32
33
33
33
11
7
37
1
1
14
14
34
57
57
64
52
14
42
57
64
54
28
33
19
29
29
16
16
12
20
12
64
17
7
24
26
26
1
1
2
45
61
Drug Name
ferrex 150
ferrous gluconate
ferrous sulfate
ferus
FETZIMA
FETZIMA TITRATION PACK
feverall
fexofenadine hcl
fiber laxative
fiber laxative
fiber tabs
fiber therapy
fiber-lax
finasteride
FIRAZYR
FIRMAGON
fish oil
flavoxate hcl
flecainide acetate
fleet bisacodyl
fleet enema
fleet enema
fleet enema six pack
fleet laxative
fleet pediatric
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fluconazole in dextrose
flucytosine
fludarabine phosphate
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluorometholone
fluor-op
fluorouracil
fluorouracil
fluoxetine hcl
FLUPHENAZINE DECANOATE
FLUPHENAZINE HCL
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluticasone propionate
fluvoxamine maleate
Page 76 of 93
Page #
61
61
61
61
9
9
46
55
64
49
49
50
50
30
35
35
52
30
23
50
50
52
52
50
50
39
39
10
10
10
13
31
39
31
31
31
38
38
13
28
9
16
16
41
1
38
12
31
39
9
Drug Name
FOLIC ACID
folic acid
FOLOTYN
fondaparinux sodium
FORTAZ
FORTEO
fortical
FOSCARNET SODIUM
fosfree
fosinopril sodium
fosinopril sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
FREAMINE HBC 6.9%
FREAMINE III 3%
fungoid tincture
furosemide
FUSILEV
FUZEON
FYCOMPA
gabapentin
GABITRIL
galantamine hydrobromide
GAMASTAN S/D
GAMMAGARD LIQUID
GAMUNEX-C
ganciclovir
GARDASIL
GARDASIL 9
gas relief
gas relief extra strength
gas-x extra strength
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE
genteal mild
genteal mild to moderate
genteal pm
GEODON
geriaton
geri-tonic
Page #
44
62
13
21
5
37
37
17
62
23
23
8
30
22
43
43
47
25
13
19
6
7
7
8
36
36
36
17
36
36
50
50
50
29
29
29
13
26
29
35
3
3
3
53
53
53
16
62
62
Drug Name
gildess 1.5/30
GILENYA
GILOTRIF
GLEEVEC
glimepiride
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glucose
glutose 15
glyburide
glyburide micronized
glyburide/metformin hcl
glycopyrrolate
GLYSET
gnp 12 hour nasal spray
gnp adult aspirin low strength
gnp all day allergy
gnp all day allergy-d
gnp allergy
gnp allergy multi-symptom
gnp allergy plus severe sinus headache
maximum strength
gnp allergy relief
gnp allergy relief for kids
gnp antacid anti-gas
gnp antacid maximum strength
gnp aspirin
gnp aspirin low dose
gnp bacitracin zinc
gnp bisa-lax
gnp calcium 500 +d3
gnp calcium 500/d
gnp calcium 600 +d
gnp calcuim/vitamin d/minerals
gnp capsaicin
gnp century adults 50+ senior
gnp childrens allergy
gnp childrens chewables/extra c
gnp childrens chewables/iron
gnp childrens pain relief plus cold
gnp childrens plus cough & sore throat
gnp childrens plus multi-symptom cold
gnp clotrimazole 3
gnp cold & allergy childrens
gnp cold & allergy maximum strength
gnp cold & cough childrens
gnp cold head congestion night time
Page 77 of 93
Page #
33
27
13
14
20
20
20
20
21
21
48
48
20
20
20
29
20
64
46
55
55
55
64
58
55
55
64
64
46
46
47
50
64
61
61
61
65
62
55
65
65
58
65
58
47
55
65
58
58
Drug Name
gnp cold head congestion severe daytime
gnp cold multi-symptom daytime
gnp cold multi-symptom nighttime
gnp cold relief head congestion severe
daytime
gnp cold relief multi-symptom daytime
gnp cold relief multi-symptom severe
daytime
gnp cold severe congestion/daytime
gnp cough dm er
gnp cough relief
gnp day time mucus reliefdm
gnp day time sinus
gnp dayhist allergy
gnp docusate calcium
gnp ear drops
gnp ear systems
gnp enema
gnp eye itch relief
gnp fiber-caps
gnp fish oil
gnp flu relief therapy seere cold daytime
gnp flu relief therapy severe cold nighttime
gnp foaming antacid
gnp gas relief
gnp gas relief extra strength
gnp gas relief maximum strength
gnp hemorrhoidal
gnp infants gas relief
gnp itchy eye
gnp k-pec
gnp laxative
gnp lice solution kit
gnp little ones childrens
gnp loratadine
gnp loratadine-d 12hr
gnp loratadine-d 24 hour
gnp magnesium citrate
gnp masanti maximum strength
gnp masanti regular strength
gnp miconazole 1
gnp miconazole 3
gnp miconazorb af
gnp milk of magnesia
gnp mucus relief
gnp mucus relief cough childrens
gnp mucus relief dm
gnp nasal decongestant
gnp nasal decongestant pemaximum
strength
Page #
65
58
58
65
58
65
65
65
58
58
65
55
52
54
54
52
54
65
53
58
58
65
50
50
50
48
50
54
50
50
48
65
55
55
55
52
65
65
47
47
65
52
58
58
58
65
65
Drug Name
gnp nasal spray extra moisturizing
gnp natural fiber
gnp niacin tr
gnp nicotine polacrilex
gnp night time cold & flu multisymptom
gnp night time cold/flu relief
gnp night time cough
gnp no drip nasal spray
gnp nose drops extra strength
gnp povidone-iodine
gnp pseudoephedrine hcl 12 hour
gnp senna plus
gnp sinus congestion & pain daytime
gnp sinus congestion/pain nighttime
gnp sinus relief congestion & pain
daytime/nighttime
gnp sinus relief congestion & pain nighttime
gnp slow release iron
gnp stomach relief
gnp stomach relief maximum strength
gnp stool softener
gnp stool softener extra strength
gnp stool softener/stimulant laxative
gnp suphedrin
gnp tab tussin
gnp tab tussin dm
gnp terbinafine hydrochloride
gnp tioconazole 1
gnp tolnaftate
gnp triacting night time cold & cough
childrens
gnp triple antibiotic
gnp tussin
gnp tussin cf cough & cold
gnp tussin cough long acting
gnp tussin dm
gnp tussin dm cough
gnp tussin dm max
golden age vitamin/minerals
GRALISE
GRALISE STARTER
granisetron hcl
GRANIX
griseofulvin microsize
griseofulvin ultramicrosize
guaifenesin
guaifenesin ac
guaifenesin er
guaifenesin/codeine
guaifenesin-dm
Page 78 of 93
Page #
65
50
62
46
65
58
58
65
58
47
65
52
65
65
65
65
61
50
50
50
50
52
65
65
65
47
47
47
58
47
58
58
58
58
58
58
63
1
1
10
22
10
10
58
58
58
58
58
Drug Name
guanfacine er
guanfacine hcl
GUANIDINE HCL
HALAVEN
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
HECTOROL
hemorrhoid
hemorrhoidal
hemorrhoidal suppositories
hem-prep
heparin sodium
heparin sodium/d5w
heparin sodium/nacl 0.9%
hepatamine
HERCEPTIN
HEXALEN
hm advanced antacid maximum strength
hm all day allergy
hm allergy
hm allergy & congestion
hm allergy childrens
hm allergy complete-d
hm allergy relief
hm allergy relief & nasaldecongestant
hm allgery multi symptom
hm antacid anti-gas extrastrength
hm antacid/antigas
hm artificial tears
hm aspirin
hm aspirin ec
hm bacitracin
hm chest congestion relief
hm chest congestion relief dm
hm cold & allergy childrens
hm cold & cough childrens
hm cough relief
hm day time
hm daytime cold & flu
hm earwax removal aid
hm earwax removal kit
hm enema
hm enema mineral oil
hm eye itch relief
hm fexofenadine hcl
hm fexofenadine hcl
hm fiber
Page #
27
23
11
13
31
16
16
16
36
37
48
48
48
48
22
22
22
43
15
12
65
55
55
55
55
55
55
55
55
65
65
65
46
46
47
65
65
65
65
65
58
58
54
54
52
65
65
65
55
65
Drug Name
hm fiber
hm fish oil
hm gas relief
hm gas relief infants drops
hm laxative
hm lice killing maximum strength
hm loratadine childrens
hm milk of magnesia
hm nasal decongestant
hm nasal decongestant 12 hour
hm nasal decongestant pe
hm nasal spray
hm night time cold & flu
hm night time multi symptom cold & flu
hm nose drops extra strength
hm povidone-iodine
hm saline nasal spray
hm senna
hm senna-s
hm sinus nasal spray
hm stomach relief
hm stomach relief maximumstrength
hm stool softener
hm stool softener maximum strength
hm stool softener/laxative
hm triple antibiotic
hm tussin adult
hm tussin adult cough & chest congestion
dm
hm tussin adult multi-symptom cold
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMIRA
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMULIN 70/30
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500 (CONCENTRATED)
hydralazine hcl
hydrochlorothiazide
hydrocodone bitartrate/acetaminophen
hydrocodone bitartrate/homatropine
methylbromide
Page 79 of 93
Page #
50
65
50
50
50
48
55
52
65
65
65
65
58
66
66
47
66
50
52
66
50
66
50
50
52
66
66
66
66
21
21
21
21
21
21
35
35
21
21
21
21
21
21
26
26
2
41
Drug Name
hydrocodone polistirex/chlorpheniramine
polistirex
hydrocodone/acetaminophen
hydrocodone/homatropine
hydrocortisone
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone/acetic acid
hydromet
hydromorphone hcl
HYDROXOCOBALAMIN
hydroxychloroquine sulfate
hydroxyurea
hydroxyzine hcl
hydroxyzine pamoate
ibandronate sodium
ibuprofen
icaps
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
IFEX
ifosfamide
ILARIS
IMBRUVICA
imipenem/cilastatin
imipramine hcl
imipramine pamoate
imiquimod
IMITREX
IMITREX STATDOSE REFILL
IMOVAX RABIES (H.D.C.V.)
INCIVEK
INCRELEX
indapamide
indomethacin
indomethacin er
INFANRIX
infants gas relief
infants simethicone
infed
INFERGEN
infuvite pediatric
INLYTA
insupen ultrafin 31gx8mm
INTELENCE
intense cough reliever extra strength
INTRALIPID
INTRON A
INTRON-A
Page #
41
2
41
31
31
31
39
41
2
44
15
13
39
39
37
1
49
14
13
13
12
12
36
14
5
9
9
28
11
11
36
18
31
26
1
1
36
50
50
43
18
44
14
53
18
58
37
17
17
Drug Name
INTRON-A W/DILUENT
introvale
INTUNIV
INVANZ
INVEGA
INVEGA SUSTENNA
INVIRASE
ionil-t
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
iophen c-nr
iophen dm-nr
iophen-nr
IPOL INACTIVATED IPV
ipratropium bromide
ipratropium bromide/albuterol sulfate
irbesartan
irbesartan/hydrochlorothiazide
irinotecan
ISENTRESS
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
ISONIAZID
isopto tears
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin
ISTODAX
itraconazole
ivermectin
i-vite
IXEMPRA KIT
IXIARO
JAKAFI
jantoven
JANUVIA
JENTADUETO
JEVTANA
jock itch spray
jolivette
j-tan d pd
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
KADCYLA
KALETRA
kao-tin
Page 80 of 93
Page #
17
33
27
5
17
17
19
49
43
43
58
58
58
36
40
40
23
23
13
18
43
43
11
53
26
26
26
26
3
13
10
15
63
13
36
14
22
20
20
13
47
34
55
33
33
33
33
15
19
50
Drug Name
kariva
kcl 0.075%/d5w/nacl 0.45%
KCL 0.15%/D5W/LR
kcl 0.15%/d5w/nacl 0.2%
KCL 0.15%/D5W/NACL 0.225%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
KCL 0.3%/D5W/NACL 0.9%
kelnor 1/35
KEPIVANCE
KETEK
ketoconazole
ketoprofen
ketoprofen er
ketorolac tromethamine
ketorolac tromethamine
ketotifen fumarate
KEYTRUDA
KHEDEZLA
kidkare cough/cold
KINERET
kionex
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
KOMBIGLYZE XR
konsyl-d
KORLYM
KUVAN
labetalol hcl
laclotion
lactated ringers dextrose 5% viaflex
lactated ringers irrigation
lactated ringers viaflex
lactulose
lamisil af defense
lamisil at
lamisil at jock itch
lamisil at spray
lamivudine
lamivudine
lamivudine/zidovudine
lamotrigine
LANOXIN
LANOXIN PEDIATRIC
LANTUS
LANTUS SOLOSTAR
larin 1.5/30
Page #
33
43
43
43
43
43
43
43
33
27
6
10
1
1
1
38
54
15
9
58
35
42
43
43
43
43
43
20
50
32
28
24
28
43
37
43
29
47
47
47
47
17
18
18
7
25
25
21
21
33
Drug Name
latanoprost
LATUDA
laxative
LAZANDA
leena
leflunomide
lessina
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide acetate
levalbuterol hcl
LEVAQUIN
LEVEMIR
LEVEMIR FLEXTOUCH
levetiracetam
levobunolol hcl
levocarnitine
levocetirizine dihydrochloride
levofloxacin
levofloxacin in d5w
levora 0.15/30-28
levorphanol tartrate
levothyroxine sodium
levoxyl
LEXIVA
lice killing maximum strength
lice solution kit
lice treatment creme rinse
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine viscous
lidocaine/prilocaine
lidocream
LINCOCIN
lindane
linezolid
liothyronine sodium
lipodox
lipodox 50
liposyn iii
liquituss gg
lisinopril
lisinopril/hydrochlorothiazide
lite touch pen needles/31g x 3/16"
lithium
lithium carbonate
Page 81 of 93
Page #
38
17
50
2
33
36
33
41
14
13
12
22
35
40
6
21
21
6
38
37
39
6
6
33
1
34
34
19
48
48
48
2
2
2
2
2
46
4
15
4
34
13
13
37
58
23
23
53
20
20
Drug Name
lithium carbonate er
LITHOBID
lmx 4
loestrin 24 fe
lohist-d
lohist-dm
lohist-peb
lomustine
long acting nasal spray
loperamide hcl
loratadine
loratadine childrens
loratadine hives relief
loratadine-d 12hr
loratadine-d 24hr
lorazepam
LORAZEPAM INTENSOL
losartan potassium
losartan potassium/hydrochlorothiazide
LOTEMAX
lotrimin ultra
LOTRONEX
lovastatin
low-ogestrel
loxapine succinate
lubricant eye drops dry eye therapy
LUFYLLIN
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
lutera
LYNPARZA
LYRICA
LYSODREN
lyza
M.V.I. ADULT
M.V.I. PEDIATRIC
M.V.I.-12 WITHOUT VITAMIN K
mag-delay
mag-g
magnesium citrate
magnesium oxide
magnesium sulfate
mag-tab sr
malathion
mapap sinus maximum strength congestion
and pain
maprotiline hcl
marlissa
Page #
20
20
46
33
56
58
56
12
66
29
56
56
56
56
56
20
20
23
23
38
47
29
26
33
16
66
40
38
28
35
35
33
13
7
34
34
44
44
44
61
61
50
50
43
61
15
58
9
33
Drug Name
MARPLAN
MATULANE
matzim la
maximum d3
m-clear
m-clear wc
meclizine hcl
meclofenamate sodium
medi-phedrine
medroxyprogesterone acetate
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
melphalan hydrochloride
MENACTRA
m-end dm
m-end wc
MENEST
MENOMUNE-A/C/Y/W-135
MENVEO
meperidine hcl
MEPHYTON
meprobamate
MEPRON
mercaptopurine
meropenem
mesalamine
mesehist dm
mesehist wc
mesna
MESNEX
MESTINON
MESTINON TIMESPAN
METADATE CD
metamucil smooth texture
metaproterenol sulfate
metformin hcl
metformin hcl er
METHADONE HCL
methadose
methazolamide
methenamine hippurate
methimazole
METHITEST
methocarbamol
methotrexate
methotrexate sodium
methoxsalen
methscopolamine bromide
Page 82 of 93
Page #
9
12
24
63
58
58
10
1
66
34
15
34
14
1
12
36
58
58
33
36
36
2
44
19
15
13
5
37
58
58
13
13
11
11
27
66
40
20
20
1
1
38
4
35
32
41
35
35
28
29
Drug Name
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
METHYLDOPATE HCL
methylergonovine maleate
methylphenidate hcl
methylphenidate hcl cd
methylphenidate hcl er
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone sodiumsuccinate
metipranolol
metoclopramide hcl
metolazone
metoprolol succinate er
metoprolol tartrate
metoprolol/hydrochlorothiazide
metronidazole
metronidazole in nacl 0.79%
metronidazole vaginal
mexiletine hcl
MIACALCIN
mi-acid
mi-acid gas relief
mi-acid maximum strength
miconazole
miconazole 1
miconazole 3
miconazole 3 combo pack
miconazole 7
miconazole nitrate
miconazorb af
micro guard
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
midodrine hcl
migergot
milantex
milantex extra strength
milk of magnesia
milk of magnesia
milk of magnesia concentrate
minerin
miniprin low dose
minocycline hcl
minoxidil
mintox
Page #
26
23
23
23
38
27
27
27
31
31
31
31
38
29
26
24
24
24
4
4
4
23
37
50
50
50
48
48
10
48
48
48
66
48
33
33
33
33
23
11
50
50
50
52
50
49
46
6
26
50
Drug Name
mintox maximum strength
mirtazapine
mirtazapine odt
misoprostol
mitigare
mitomycin
mitoxantrone hcl
mitrazol
M-M-R II W/DILUENT 10 DOSE
modafinil
mometasone furoate
monoject insulin syringe/detach
needle/1ml/25g x 5/8"
monoject insulin syringe/softpack/1ml/25g x
58"
mononessa
montelukast sodium
morphine sulfate
morphine sulfate er
MOZOBIL
mucinex
mucinex chest congestion childrens
mucinex childrens cold cough & sore throat
mucinex childrens multi-symptom cold
mucinex childrens multi-symptom cold &
fever
mucinex cold for kids
mucinex cough childrens
mucinex cough for kids
mucinex d
mucinex dm
mucinex dm maximum strength
mucinex fast-max cold & sinus
mucinex fast-max cold flu& sore throat
mucinex fast-max dm max
mucinex fast-max severe congestion & cold
mucinex fast-max severe congestion &
cough
mucinex for kids
mucinex maximum strength
mucinex nasal spray full force
mucinex nasal spray moisture smart
mucus relief
mucus relief childrens
mucus relief cough childrens
mucusrelief dm
MULTAQ
multi-delyn
multi-delyn/iron
multilex
Page 83 of 93
Page #
50
9
9
30
11
13
13
48
36
42
31
53
53
33
40
2
1
43
58
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
59
23
63
63
63
Drug Name
multi-symptom allergy
multi-vitamins
mupirocin
muro 128
MUSTARGEN
MYCAMINE
MYCOBUTIN
mycophenolate mofetil
mykidz iron 10
mytab gas
mytab gas max str
mytussin dac
nabumetone
nadolol
nadolol/bendroflumethiazide
nafcillin sodium
NAFTIN
NAGLAZYME
nalbuphine hcl
NALLPEN/DEXTROSE
naloxone hcl
naltrexone hcl
NAMENDA
NAMENDA TITRATION PAK
naphazoline hcl
naproxen
naproxen dr
naproxen sodium
naratriptan hcl
nasal decongestant
nasal decongestant
nasal decongestant pe
nasal decongestant pe maximum strength
nasal decongestant spray
nasal spray 12 hour
nasal spray x-moist
NASCOBAL
nasohist dm
NATACYN
nateglinide
natural fiber laxative
natural fiber therapy
NEBUPENT
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
Page #
56
63
4
53
12
10
11
35
61
50
50
59
1
24
24
5
10
28
2
5
3
3
8
8
38
1
1
1
11
66
59
66
59
59
66
66
44
59
10
21
50
50
15
33
33
33
33
9
3
38
Drug Name
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin/hydrocortis
one
neomycin/polymyxin/dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/hydrocortisone
NEPHRAMINE
nephro-vite
NEULASTA
NEUMEGA
NEUPOGEN
NEUPRO
neutrahist
nevirapine
nevirapine er
NEXAVAR
niacin er
niacin er
niacin sr
niacin td
niacin tr
niacor
nicardipine hcl
nicoderm cq
nicorelief
nicorette
nicorette mini
nicorette starter kit
nicotine
nicotine polacrilex
nicotine transdermal system
NICOTROL NS
nifediac cc
nifedical xl
nifedipine er
nighttime sinus congestion & pain
NILANDRON
nite time cough
nite time multi-symptom cold/flu relief
nite-time multi-symptom cold/flu relief
NITRO-DUR
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
NITROGLYCERIN
nitroglycerin transdermal
NITROSTAT
nohist-dm
nohist-lq
Page 84 of 93
Page #
3
4
38
38
39
4
39
43
63
22
22
22
16
66
18
18
14
26
63
63
63
63
26
25
46
46
46
46
47
47
47
47
3
25
25
25
66
12
59
59
59
26
4
4
26
26
26
59
56
Drug Name
nora-be
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX PEN
norethindrone
norethindrone acetate
norlyroc
normosol-m in d5w
NORMOSOL-R
NORMOSOL-R IN D5W
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
nortriptyline hcl
NORVIR
novaferrum 125
novaferrum pediatric drops
novofine 32gx6mm
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
NOXAFIL
nrs nasal relief
NUEDEXTA
NULOJIX
NULYTELY/FLAVOR PACKS
nutraplus
nutrilipid
NUTROPIN
nyamyc
nystatin
nystatin/triamcinolone
nystop
ocean nasal spray
octreotide acetate
ofloxacin
OGESTREL
olanzapine
olanzapine odt
olopatadine hcl
OLYSIO
omega-3-acid ethyl esters
omeprazole
ONCASPAR
once daily
once daily/iron
Page #
34
31
31
34
34
34
43
43
43
33
33
33
9
19
61
61
53
21
21
21
21
21
21
21
10
59
27
35
29
49
38
32
10
10
10
10
59
35
6
33
17
17
39
18
26
30
14
63
63
Drug Name
ondansetron hcl
ondansetron odt
ONFI
ONGLYZA
OPDIVO
ORAP
ORENCIA
ORENITRAM
organ-i nr
orphenadrine citrate
orphenadrine citrate er
os-cal
oxacillin sodium
oxaliplatin
oxandrolone
oxaprozin
oxcarbazepine
OXSORALEN
OXTELLAR XR
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone/acetaminophen
oysco 500+d
oyster shell calcium/vitamin d
pacerone
paclitaxel
pain relief cold severe congestion
pain relief sinus pe daytime
PAMIDRONATE DISODIUM
PANCREAZE
PANRETIN
pantoprazole sodium
paromomycin sulfate
paroxetine hcl
paroxetine hcl er
PASER
PATANOL
PAXIL
pedia relief cough/cold
pedia-lax
pediatric cough/cold
pedi-boro soak paks
pedi-dri
PEDVAX HIB
PEGANONE
PEGASYS
PEGASYS PROCLICK
PEG-INTRON
PEG-INTRON REDIPEN
Page 85 of 93
Page #
10
10
7
21
15
16
35
41
59
41
41
61
5
14
32
1
8
28
8
30
30
2
2
61
61
23
14
66
66
37
28
15
30
3
9
9
11
38
9
59
51
59
49
10
36
8
18
18
18
18
Drug Name
peleverus
peleverus clear
peleverus gold
penicillin g potassium
PENICILLIN G POTASSIUM IN
ISO-OSMOTIC DEXTROSE
PENICILLIN G PROCAINE
PENICILLIN G SODIUM
penicillin v potassium
PENTAM 300
pentostatin
pentoxifylline er
peptic relief
pepto-bismol
periguard
periogard
PERJETA
permethrin
permethrin
perphenazine
perphenazine/amitriptyline
PFIZERPEN-G
pharbedryl
phenadoz
phenelzine sulfate
phenobarbital
phenylhistine dh
PHENYTEK
phenytoin
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
phosphate laxative
PHOSPHOLINE IODIDE
physiolyte
physiosol irrigation
phytonadione
PICATO
pilocarpine hcl
pilocarpine hydrochloride
PILOPINE HS
pindolol
pink bismuth maximum strength
pink bismuth regular strength
pioglitazone hcl
pioglitazone hcl/metformin hcl
piperacillin sodium/tazobactam sodium
piroxicam
PLASMA-LYTE A
PLASMA-LYTE-148
Page #
49
49
49
5
5
5
5
5
15
13
25
51
51
49
27
15
15
48
16
9
5
56
10
9
7
59
8
8
8
8
8
51
39
38
38
44
28
27
27
39
24
51
51
21
21
5
1
43
43
Drug Name
PLASMA-LYTE-56/D5W
podofilox
poly vitamin
polyethylene glycol 3350
poly-iron 150
polymyxin b sulfate
polymyxin b sulfate/trimethoprim sulfate
polysaccharide iron
polyvitamin
poly-vitamin drops
polyvitamin/iron
poly-vitamin/iron drops
POMALYST
portia-28
POTASSIUM CHLORIDE
potassium chloride 0.15% /nacl 0.45%
viaflex
potassium chloride 0.15% d5w/nacl 0.33%
potassium chloride 0.15% d5w/nacl 0.45%
potassium chloride 0.15%/nacl 0.9%
potassium chloride 0.22% d5w/nacl 0.45%
POTASSIUM CHLORIDE 0.3%/ NACL
0.9%
potassium chloride 0.3%/d5w
potassium chloride er
potassium chloride sr
potassium citrate er
POTIGA
povidone-iodine
PRADAXA
pramipexole dihydrochloride
pravastatin sodium
prazosin hcl
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone acetate
prednisolone sodium phosphate
prednisolone sodium phosphate
prednisone
pregnyl w/diluent benzyl alcohol/nacl
PREMARIN
PREMASOL
PREMPHASE
PREMPRO
PRENAPLUS
PRENATABS OBN
prenatabs rx
prenatal plus iron
preparation h
Page 86 of 93
Page #
43
28
63
30
61
4
38
43
63
63
63
63
12
33
44
43
43
43
43
43
43
43
43
44
44
6
47
22
16
26
23
38
38
31
38
31
38
31
32
33
44
33
33
44
44
44
44
49
Drug Name
prevalite
previfem
PREZISTA
PRIFTIN
PRIMAQUINE PHOSPHATE
primidone
PRIMSOL
PROAIR HFA
probenecid
probenecid/colchicine
PROCAINAMIDE HCL
PROCALAMINE
PROCHLORPERAZINE EDISYLATE
prochlorperazine maleate
PRO-CLEAR
PROCRIT
proctocream hc
PROCTO-PAK
proctosol hc
proctozone-hc
prodigy insulin mini pen needles/31g x
3/16"
prodigy insulin short penneedles/31g x
5/16"
profe
progesterone
PROGLYCEM
PROGRAF
PROLASTIN-C
PROLEUKIN
PROLIA
PROMACTA
promethazine hcl
promethazine vc plain
promethazine vc/codeine
promethazine/codeine
promethazine/codeine
promethazine/dextromethorphan
promethazine-dm
promethegan
PROMETRIUM
propafenone hcl
propranolol hcl
propranolol hcl er
propranolol/hydrochlorothiazide
propylthiouracil
PROQUAD
pro-red ac
PROSOL
PROTONIX
Page #
26
33
19
11
15
7
4
40
11
11
23
44
16
16
45
22
31
31
31
31
53
53
61
34
21
35
41
14
37
22
10
41
41
39
41
41
41
10
34
23
24
24
24
35
36
66
44
30
Drug Name
PROTOPIC
protriptyline hcl
pseudoephedrine hcl
pseudoephedrine hcl
PULMOZYME
puralube
PURIXAN
pyrazinamide
pyridostigmine bromide
qc 3 day vaginal cream
qc all day allergy
qc allergy relief
qc allergy relief multi-symptom daytime
qc antacid
qc antacid/anti-gas
qc antacid/anti-gas maximum strength
qc aspirin
qc aspirin low dose
qc athletes foot
qc azo
qc bacitracin
qc childrens aspirin
qc childrens chewable vitamins/extra c
qc childrens chewable vitamins/iron
qc chlor-pheniramine
qc cold relief plus multi-symptom childrens
qc complete allergy medicine
qc cough relief
qc cough/sore throat nighttime
qc daily multivitamins/iron
qc docusate calcium
qc ear wax removal drops
qc enema
qc ferrous sulfate
qc fiber laxative
qc gas relief
qc gas relief extra strength
qc gentle laxative
qc hemorrhoidal
qc loratadine allergy relief
qc loratadine-d
qc magnesium citrate
qc medifin mucus relief childrens
qc milk of magnesia
qc multi-vite
qc multi-vite 50 & over
qc natural vegetable
qc nighttime cold/flu relief
qc nighttime cough
qc no drip nasal relief
Page 87 of 93
Page #
28
9
66
59
40
53
13
11
11
66
56
56
66
66
66
66
46
46
66
46
47
46
63
63
56
59
56
59
59
63
52
54
52
62
66
51
51
51
49
56
56
52
66
52
63
63
51
59
60
66
Drug Name
qc pink bismuth
qc senna
qc senna-s
qc sinus pain relief
qc stool softener
qc stool softener plus laxative
qc suphedrine
qc suphedrine maximum strength
qc suphedrine pe
qc tolnaftate
qc tussin cf
qc womens daily multivitamin
q-dryl
q-tapp
q-tapp dm
q-tussin
q-tussin dm
quasense
QUDEXY XR
quenalin
quetiapine fumarate
quinapril hcl
quinapril/hydrochlorothiazide
QUINIDINE GLUCONATE
quinidine gluconate cr
quinidine sulfate
quinidine sulfate er
quinine sulfate
RABAVERT
raloxifene hydrochloride
ramipril
RANEXA
ranitidine hcl
RAPAMUNE
REBETOL
REBIF
REBIF TITRATION PACK
RECOMBIVAX HB
refresh celluvisc
refresh p.m.
refresh plus
reguloid
relcof c
RELENZA DISKHALER
RELISTOR
remedy antifungal
remedy nutrashield
remedy skin repair
REMICADE
rena-vite
Page #
51
51
52
66
51
52
66
66
66
48
60
63
56
56
59
59
59
33
7
56
17
23
23
24
24
24
24
15
36
34
23
25
29
35
18
27
27
36
53
53
53
51
60
19
29
48
49
49
35
63
Drug Name
RENVELA
repaglinide
rescon dm
rescon-gg
RESCRIPTOR
reserpine
RESTASIS
RETROVIR IV INFUSION
REVLIMID
REYATAZ
rhinaris
ribasphere
ribasphere ribapak
ribavirin
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
ringers irrigation
RISPERDAL CONSTA
risperidone
risperidone odt
RITUXAN
rivastigmine tartrate
rizatriptan benzoate
rizatriptan benzoate odt
robafen
robafen dm
robafen dm cough clear
robitussin childrens cough & cold cf
robitussin childrens cough long-acting
robitussin childrens cough/cold long-acting
robitussin cold+flu daytime
robitussin cold+flu nighttime
robitussin lingering coldlong-acting cough
robitussin mucus+chest congestion
robitussin peak cold cough+ chest
congestion dm
robitussin peak cold cough+ chest
congestion dm max strength
robitussin peak cold dm
robitussin peak cold multi-symptom cold
robitussin peak cold multi-symptom cold
maximum strength
robitussin peak cold nasal relief
robitussin peak cold nighttime
multi-symptom cold
robitussin peak cold nighttime nasal relief
Page 88 of 93
Page #
30
21
60
60
18
23
38
19
12
19
66
18
18
18
11
12
12
27
19
44
38
17
17
17
15
8
11
11
60
60
60
60
60
60
60
60
60
56
60
60
60
60
60
60
60
60
Drug Name
ropinirole hcl
ROTARIX
ROTATEQ
roxicet
ROZEREM
rulox
rynex dm
rynex pe
rynex pse
SABRIL
SAIZEN
SAIZEN CLICK.EASY
saline mist
saline nasal mist
SANTYL
SAPHRIS
SAVELLA
SAVELLA TITRATION PACK
sb aspirin
sb bismuth
sb loratadine
sea soft nasal mist
sea-omega 30
sea-omega 50
selegiline hcl
selenium sulfide
SELZENTRY
senexon
senna
senna plus
senna prompt
senna s
senna-gen
sennalax-s
senna-s
senna-tabs
senna-time
senno
senokot
senokot s
senokot to go
SENSIPAR
sentry
SEREVENT DISKUS
SEROMYCIN
SEROSTIM
sertraline hcl
sharobel
silace
siladryl allergy
Page #
16
36
36
2
42
51
60
56
56
7
32
32
60
60
28
17
27
27
46
51
56
60
53
53
16
28
19
51
51
52
51
52
51
52
52
51
51
51
51
52
52
34
66
40
12
32
9
34
51
56
Drug Name
sildenafil
siltussin sa
siltussin-dm
silver sulfadiazine
simethicone
SIMULECT
simvastatin
sinus congestion & pain daytime
sinus nasal spray
sirolimus
slo-niacin
slow release iron
slow-mag
sm 12 hour sinus decongestant
sm 12-hour no drip
sm 3-day vaginal
sm all day allergy
sm all day allergy-d
sm allergy 4 hour
sm allergy multi-symptom
sm allergy relief
sm allergy relief loratadine
sm antacid anti-gas
sm antacid maximum strength
sm antacid/antigas
sm antifungal miconazole
sm antifungal tolnaftate
sm artificial tears
sm aspirin adult low strength
sm aspirin enteric coated
sm aspirin low dose
sm athletes foot
sm childrens aspirin
sm childrens loratadine
sm childrens pain relief plus multi-symptom
cold
sm clotrimazole vaginal
sm cold & allergy childrens
sm cold & cough dm childrens
sm cold head congestion severe day time
sm cough relief
sm day time cold & flu relief
sm docusate calcium
sm double antibiotic
sm enema
sm eye itch relief
sm eye itch relief
sm fexofenadine hcl
sm fexofenadine hcl
sm fiber
Page 89 of 93
Page #
41
60
60
4
51
36
26
66
60
35
63
62
66
66
66
48
56
56
56
66
56
56
66
66
66
48
48
53
46
46
46
48
46
56
60
48
56
60
66
60
60
52
47
52
66
54
67
56
51
Drug Name
sm fiber laxative
sm fiber laxative
sm foaming antacid
sm gas relief
sm gas relief infants drops
sm gentle laxative
sm glucose
sm hemorrhoidal
sm iron
sm lice killing maximum strength
sm lice treatment
sm loratadine
sm loratadine allergy relief
sm lorata-dine d
sm loratadine d 12hr
sm miconazole 7
sm milk of magnesia
sm mucus er
sm mucus relief cough childrens
sm nasal decongestant maximum strength
sm nasal decongestant pe
sm nasal spray moisturizing
sm nasal spray saline
sm nasal spray sinus
sm natural laxative plus stool softener
sm nicotine
sm nicotine polacrilex
sm nite time cold & flu relief
sm nite time cough
sm nose drops nasal decongestant extra
strength
sm oral saline laxative
sm stomach relief
sm stomach relief maximumstrength
sm stool softener
sm stool softener plus laxative
sm tioconazole-1
sm triple antibiotic
sm tussin
sm tussin cf
sm tussin dm
sm tussin dm cough/chest congestion
sm womans laxative
sodium bicarbonate
sodium chloride
sodium chloride
sodium chloride
sodium chloride 0.45% viaflex
sodium chloride 0.9%
sodium fluoride
Page #
67
52
51
51
51
51
48
49
62
48
48
56
56
56
56
48
52
60
60
67
67
67
60
67
52
47
47
60
60
60
52
51
67
51
52
48
47
60
60
60
60
51
51
53
41
44
44
44
44
Drug Name
SODIUM LACTATE
sodium phenylbutyrate
sodium polystyrene sulfonate
sodium sulfacetamide
SOLTAMOX
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE DEPOT
SOMAVERT
soothe & cool inzo antifungal cream
soothe & cool protect moisture barrier
SORIATANE
sorine
sotalol hcl
sotalol hcl (af)
SOVALDI
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/hydrochlorothiazide
SPORANOX
sprintec 28
SPRYCEL
sronyx
ssd
stagesic
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
stavudine
sterile water for injection
sterile water irrigation
STIMATE
stimulant laxative
STIVARGA
stomach relief
stomach relief maximum strength
stool softener
stool softener extra strength
stool softener laxative
stool softener laxative dc
STRATTERA
STREPTOMYCIN SULFATE
stress formula
stress formula/zinc
STRIBILD
STROMECTOL
Page 90 of 93
Page #
42
28
42
6
12
31
31
35
35
48
49
28
24
24
24
18
40
40
25
25
10
33
14
33
4
2
16
16
16
16
16
16
19
45
38
32
51
14
51
51
51
51
52
51
27
3
63
63
18
15
Drug Name
SUBOXONE
SUCRAID
sucralfate
sudogest
sudogest 12 hour
sudogest pe
sudogest sinus & allergy
sulfacetamide sodium
sulfacetamide sodium/prednisolone sodium
phosphate
sulfadiazine
SULFAMETHOXAZOLE/TRIMETHOPRI
M
sulfamethoxazole/trimethoprim ds
sulfasalazine
sulfazine ec
sulindac
sumatriptan succinate
SUPRAX
sure-fine pen needles 31gx3/16" 5mm
sure-fine pen needles 31gx5/16" 8mm
SURMONTIL
SUSTIVA
SUTENT
SYLATRON
SYLVANT
SYMBICORT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS
SYNAREL
SYNERCID
SYNRIBO
SYNTHROID
SYPRINE
systane
systane balance restorative formula
systane gel
systane nighttime
systane ultra
systane ultra home & away pack
TABLOID
tacrolimus
tacrolimus
TAFINLAR
TALWIN
TAMIFLU
tamoxifen citrate
tamsulosin hcl
TARCEVA
Page #
3
29
30
60
60
60
56
6
38
6
6
6
37
37
1
11
5
53
53
9
18
14
14
15
39
21
21
36
35
4
14
34
42
53
53
53
53
53
53
13
28
36
14
2
19
12
30
14
Drug Name
TARGRETIN
TASIGNA
TASMAR
tavist allergy
TAZORAC
taztia xt
tears naturale
tears naturale forte
tears naturale ii
tears pure
TEFLARO
TEGRETOL
TEGRETOL-XR
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazide
temazepam
terazosin hcl
terbinafine hcl
terbinafine hcl
terbutaline sulfate
terconazole
TESSALON PERLES
testosterone cypionate
testosterone enanthate
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED ADULT
TEV-TROPIN
THALOMID
THEO-24
theophylline
theophylline cr
theophylline er
thera
thera-m
therapeutic formula/hematinics
thera-plus
therems
therems-h
therems-m
thiamine hcl
thioridazine hcl
thiotepa
thiothixene
THYMOGLOBULIN
THYROLAR-1
THYROLAR-1/2
Page 91 of 93
Page #
15
14
16
56
28
25
53
53
53
53
5
8
8
25
25
23
23
23
41
30
11
48
40
11
41
32
32
36
36
32
12
40
40
40
40
64
63
64
63
64
64
64
44
16
12
16
36
34
34
Drug Name
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
tiagabine hydrochloride
ticlopidine hcl
TIKOSYN
TIMENTIN
timolol maleate
timolol maleate
timolol maleate ophthalmic gel forming
tinidazole
tioconazole-1
TIVICAY
tizanidine hcl
tl-hist pd
TOBI PODHALER
TOBRADEX
tobramycin
tobramycin sulfate
TOBRAMYCIN SULFATE/SODIUM
CHLORIDE
tobramycin/dexamethasone
tolbutamide
tolmetin sodium
tolnaftate
tolterodine tartrate
tolterodine tartrate er
topiramate
topiramate er
toposar
topotecan hcl
TORISEL
torsemide
tpn electrolytes
TRACLEER
TRADJENTA
tramadol hcl
tramadol hydrochloride/acetaminophen
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVASOL
trazodone hcl
TREANDA
TRECATOR
TRELSTAR DEPOT MIXJECT
TRELSTAR LA MIXJECT
TRELSTAR MIXJECT
tretinoin
Page #
34
34
34
7
22
24
5
24
39
39
15
48
18
17
56
40
38
40
3
3
38
21
1
48
30
30
7
7
14
14
36
25
44
41
21
2
2
23
22
10
9
44
9
12
12
35
35
35
15
Drug Name
tretinoin
triacting nightime cold& cough childrens
triamcinolone acetonide
triamcinolone acetonide
triamcinolone in orabase
triaminic cold & cough day time childrens
triaminic night time cold & cough
triamterene/hydrochlorothiazide
triazolam
triderm
tri-dex pe
trifluoperazine hcl
trifluridine
trigofen
trigofen dm
trihexyphenidyl hcl
trilyte
trimethobenzamide hcl
trimethoprim
trimipramine maleate
trinessa
triple antibiotic
tri-previfem
TRISENOX
tri-sprintec
TRIUMEQ
tri-vitamin
trivora-28
trixaicin hp
TROKENDI XR
TROPHAMINE
TRUMENBA
TRUVADA
tusnel
tusnel diabetic
tusnel pediatric
tussigon
tussin
tussin cf
tussin cf cough & cold
tussin chest congestion
tussin cough
tussin dm
tussin dm max
tussin mucus + chest congestion
TUSSIONEX PENNKINETIC
EXTENDED RELEASE
TWINRIX
TYBOST
TYGACIL
Page 92 of 93
Page #
28
60
31
39
27
61
56
25
20
31
60
16
19
56
61
15
30
10
4
9
34
47
33
14
33
19
64
34
49
7
44
36
19
61
61
61
41
61
61
61
61
61
61
61
61
41
36
19
4
Drug Name
TYKERB
TYPHIM VI
TYSABRI
TYVASO
TYZEKA
TYZINE PEDIATRIC NASAL DROPS
u-cort
ulticare short pen needles 31gx8mm
ulticare short pen needles ulti-fine iv
unicomplex-m
unithroid
ureacin-10
UROCIT-K 10
UROCIT-K 15
UROCIT-K 5
ursodiol
UVADEX
vagistat-3
valacyclovir hcl
VALCHLOR
VALCYTE
valganciclovir
valproate sodium
valproic acid
valsartan
valsartan/hydrochlorothiazide
vancomycin hcl
vandazole
VAQTA
VARIVAX
VECTIBIX
VELCADE
velivet
venlafaxine hcl
venlafaxine hcl er
VENOFER
VENTOLIN HFA
verapamil hcl
verapamil hcl er
verapamil hcl sr
VEREGEN
VERSACLOZ
VICTRELIS
VIDEX PEDIATRIC
vigomar forte
VIIBRYD
VIMPAT
VINATE ONE
VINBLASTINE SULFATE
vincristine sulfate
Page #
14
37
27
41
17
41
31
53
53
64
34
49
44
44
44
29
28
48
19
12
17
17
7
7
23
23
4
4
37
37
15
14
34
9
9
44
40
25
25
25
28
17
18
19
64
9
8
45
14
14
Drug Name
vinorelbine tartrate
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIRAZOLE
virdec
VIREAD
VISTIDE
vita-bee/c
vitamin b complex-c
vitamin c
vitamin d
vitamin d
vitamin d3
vitamin d3 super strength
VITAMIN K1
vol-tab rx
VOLTAREN
voriconazole
VOTRIENT
VPRIV
warfarin sodium
WELCHOL
womans laxative
XALKORI
XARELTO
XARELTO STARTER PACK
XENAZINE
XGEVA
XIFAXAN
XOLAIR
XOPENEX
XOPENEX HFA
XTANDI
xulane
XYLOCAINE-MPF
XYREM
YERVOY
YF-VAX
zaditor
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZANTAC
ZAVESCA
ZELAPAR
ZELBORAF
ZEMAIRA
ZENPEP
Page 93 of 93
Page #
14
19
18
18
18
56
19
17
64
64
64
45
64
64
64
45
45
28
11
14
29
22
26
51
14
22
22
27
37
4
41
40
40
12
34
3
42
15
37
54
40
41
14
12
29
29
16
15
41
29
Drug Name
ZETIA
ZIAGEN
zidovudine
zinc sulfate
ZINECARD
ziprasidone hcl
ZMAX
zoledronic acid
ZOLINZA
zolpidem tartrate
zolpidem tartrate er
ZOMETA
ZONALON
ZONATUSS
zonisamide
zoo friends
zoo friends complete
zoo friends plus extra c
zoo friends plus iron
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOSYN
zovia 1/35e
zovia 1/50e
ZOVIRAX
z-tuss e
ZUBSOLV
ZYDELIG
ZYFLO CR
ZYKADIA
ZYTIGA
ZYVOX
Page #
26
19
19
62
14
17
6
37
14
41
42
37
28
41
7
64
64
64
64
32
36
37
5
34
34
19
67
3
14
40
14
12
4
4349 Easton Way, Suite 200
Columbus, OH 43219
Phone: 866-389-7690
TTY: 711
http://mmp.bchpohio.com