1. No category

April 2015
Prominence Health Plan
2015 FORMULARY REFERENCE GUIDE
prominencehealthplan.com
151178 FNL_10APR15
Introduction
Prominence Health Plan develops a medically sound formulary that supports patient health and that
is reviewed by a Pharmacy and Therapeutics Committee (P & T Committee), made up of practicing
physicians, pharmacists, and nurses. The committee reviews and evaluates medications on the formulary
based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.
FORMULARY DESIGN
Prominence Health Plan has a closed, incentive-based formulary structure for members.
• Closed Formulary: features copayments for medications that are preferred and non-preferred
brands, plus lower copayments for generic drugs. The closed formulary includes a higher
copayment for Specialty medications, as well as no copayment for medications that fall within the
Preventive Categories as required under the healthcare reform laws. The closed formulary limits
coverage to only those products listed.
• Incentive Based: features different copayments for medications in tiers:
- Tier 1 - Generic
- Tier 2 - Preferred Brand
- Tier 3 - Non-Preferred Brand
- Tier 4 - Specialty
The incentive-based formulary also uses utilization management functions to promote use of
specific cost-effective agents. These utilization management functions include step therapy, prior
authorization, quantity limits and partial fills.
• Partial fill consists of a limit on the initial three months of selected medications to a 14 or 15-day
supply. These specific medications are targeted for partial fill (PF) due to high discontinuation rates,
poor response, adverse effects and/or noncompliance.
• For detailed descriptions of prior authorization (PA), step therapy (ST) and quantity limits (QL),
please consult the Prominence Health Plan Pharmacy Administrative Manual.
USING THE FORMULARY REFERENCE GUIDE TO HELP CONTAIN COSTS
Prominence Health Plan uses this formulary to help manage the overall cost of providing prescription
drug benefits. This formulary offers a wide range of medications from which to choose. This formulary
reference guide may not include every drug from every manufacturer. However, choosing a preferred
drug when it is appropriate can provide access to the necessary medications to stay healthy, at a cost
that is more affordable.
UNDERSTANDING HOW THE FORMULARY INFORMATION IS ORGANIZED
The formulary reference guide is designed so that generic products are listed first in each drug category.
The preferred brand name products are listed next, and non-preferred brand products are listed last.
NOTE:
If a brand-name product is listed in the “preferred brand-name” section and its corresponding
generic product is not listed in the “generics” section, then a generic version of the medication is
not available.
Prominence Health Plan Formulary Reference Guide | April 2015
Introduction
Prominence Health Plan develops a medically sound formulary that supports patient health and that
is reviewed by a Pharmacy and Therapeutics Committee (P & T Committee), made up of practicing
physicians, pharmacists, and nurses. The committee reviews and evaluates medications on the formulary
based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.
FORMULARY DESIGN
Prominence Health Plan has a closed, incentive-based formulary structure for members.
• Closed Formulary: features copayments for medications that are preferred and non-preferred
brands, plus lower copayments for generic drugs. The closed formulary includes a higher
copayment for Specialty medications, as well as no copayment for medications that fall within the
Preventive Categories as required under the healthcare reform laws. The closed formulary limits
coverage to only those products listed.
• Incentive Based: features different copayments for medications in tiers:
- Tier 1 - Generic
- Tier 2 - Preferred Brand
- Tier 3 - Non-Preferred Brand
- Tier 4 - Specialty
The incentive-based formulary also uses utilization management functions to promote use of
specific cost-effective agents. These utilization management functions include step therapy, prior
authorization, quantity limits and partial fills.
• Partial fill consists of a limit on the initial three months of selected medications to a 14 or 15-day
supply. These specific medications are targeted for partial fill (PF) due to high discontinuation rates,
poor response, adverse effects and/or noncompliance.
• For detailed descriptions of prior authorization (PA), step therapy (ST) and quantity limits (QL),
please consult the Prominence Health Plan Pharmacy Administrative Manual.
USING THE FORMULARY REFERENCE GUIDE TO HELP CONTAIN COSTS
Prominence Health Plan uses this formulary to help manage the overall cost of providing prescription
drug benefits. This formulary offers a wide range of medications from which to choose. This formulary
reference guide may not include every drug from every manufacturer. However, choosing a preferred
drug when it is appropriate can provide access to the necessary medications to stay healthy, at a cost
that is more affordable.
UNDERSTANDING HOW THE FORMULARY INFORMATION IS ORGANIZED
The formulary reference guide is designed so that generic products are listed first in each drug category.
The preferred brand name products are listed next, and non-preferred brand products are listed last.
NOTE:
If a brand-name product is listed in the “preferred brand-name” section and its corresponding
generic product is not listed in the “generics” section, then a generic version of the medication is
not available.
Prominence Health Plan Formulary Reference Guide | April 2015
CONSIDER PREFERRED ALTERNATIVES
The medications on the formulary may not always be appropriate for all patients. However, by referring
to the formulary reference guide, you can help ensure you receive the full advantage of coverage
provided by the prescription drug plan.
Although pharmacists are required by law to dispense a generic when a generic alternative to a branded
drug is available, pharmacists are not allowed to substitute a preferred brand-name drug without the
prescriber’s approval. Therefore, a pharmacist may contact the prescriber to obtain authorization to
dispense an alternative preferred product when a non-preferred product is prescribed.
SAVING ON OUT-OF-POCKET COSTS
The prescription drug plan determines the cost for generic, preferred brand-name, and non-preferred
brand-name medications. Benefit providers often design prescription drug plans to encourage the use
of generic and preferred brand-name drugs. Choosing non-preferred drugs may mean paying higher
out-of-pocket expenses (such as coinsurance, copayments, and deductible amounts) or not receiving
coverage at all. Patients may also pay less for generic drugs, or they may be asked to pay the cost
difference between brand-name drugs and their generic alternatives, which are preferred by the plan.
CONSULTING THE PRESCRIBER’S OFFICE WHEN APPROPRIATE
When employers and other benefit sponsors design their prescription drug plans, they may choose to
provide coverage only for certain medications or for particular uses, time periods, doses, or quantities
(e.g. they may exclude coverage for medications for unapproved, unproven, or cosmetic indications,
as well as over-the-counter medications). When coverage for medications is provided based on use or
quantity, Catamaran may contact your prescriber’s office for additional information to determine whether
coverage is available under your plan. Patients who are unsure whether these coverage rules apply for
a particular medication can consult a Catamaran Member Services representative to determine specific
coverage requirements.
Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is
covered and the applicable copayment. The medications listed on this formulary are subject to change pursuant to the formulary management activities
of Prominence Health Plan. The presence of a medication on this formulary list does not guarantee coverage. To see the most up-to-date formulary,
please visit your member website. You may also call Member Services at the number listed on your ID card to request a copy be mailed to you.
Prominence Health Plan Formulary Reference Guide | April 2015
Table of Contents
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
FOURTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
FIFTH GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANTINEOPLASTICS, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
ANTIBIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTINEOPLASTIC ENZYMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANGIOGENESIS INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ANTIBODIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
CHEMOTHERAPY ADJUNCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
PHOSPHODIESTERASE INHBTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
DIRECT RENIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIPRURITICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
AMYLIN ANALOGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
RANK LIGAND INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
GNRH/LHRH ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
GHRH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
SOMATOMEDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
GH RECEPTOR ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
CORTICOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
VASOPRESSIN ANTAGONISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
HEMATOLOGICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
ARTIFICIAL TEAR/LUBRICANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
LOCAL ANESTHETICS-INJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
MEDICAL DEVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
DIABETIC SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
MISCELLANEOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
ACA PREVENTIVE DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
ASPIRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
FLUORIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
FOLIC ACID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
IRON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
SMOKING CESSATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
VITAMIN D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
BOWEL PREPARATION AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28
BREAST CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28
TIER 03
April 2015
ANTI-INFECTIVES
PENICILLINS
TIER 01
TIER 02
TIER 03
GENERIC
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium ER
ampicillin
ampicillin sodiumPA
ampicillin-sulbactamPA
dicloxacillin sodium
nafcillin sodiumPA
oxacillin sodiumPA
penicillin v potassium
penicillin G potassiumPA
piperacillin sodium/ tazobactam sodiumPA
piperacillin sodium/tazobactam sodiumPA
piperacillin/tazobactamPA
Amoxicillin
Ampicillin
Ampicillin SodiumPA
Ampicillin-sulbactamPA
Nafcillin SodiumPA
Penicillin G Potassium IN Iso-osmotic DextrosePA
Penicillin G ProcainePA
Penicillin G SodiumPA
Pfizerpen-GPA
PREFERRED
Nallpen Iso-osmotic IN DextrosePA
Nallpen/DextrosePA
NON PREFERRED
Amoxicillin ER
Augmentin
Bactocill IN DextrosePA
Bicillin C-RPA
Bicillin L-aPA
Moxatag
TimentinPA
UnasynPA
Unasyn Bulk PackPA
THIRD GENERATION
GENERIC
TIER 01
TIER 03
TIER 03
cefadroxil
cefazolin sodiumPA
cephalexin
Cefazolin SodiumPA
Cefazolin Sodium/DextrosePA
Cephalexin
NON PREFERRED
Keflex
TIER 03
cefepimePA
CefepimePA
NON PREFERRED
MaxipimePA
FIFTH GENERATION
NON PREFERRED
TIER 03
TeflaroPA
MACROLIDES
TIER 01
TIER 02
TIER 03
SECOND GENERATION
GENERIC
TIER 01
cefaclor
cefoxitin sodiumPA
cefprozil
cefuroxime axetil
Cefaclor
Cefaclor ER
CefotetanPA
Cefotetan/DextrosePA
Cefoxitin SodiumPA
cefdinir
cefotaxime sodiumPA
cefpodoxime proxetil
ceftazidimePA
ceftriaxone sodiumPA
Cefditoren Pivoxil
CeftazidimePA
Ceftazidime/DextrosePA
Ceftriaxone IN Iso-osmotic DextrosePA
Ceftriaxone/DextrosePA
NON PREFERRED
Cedax
Ceftibuten
ClaforanPA
FortazPA
RocephinPA
Spectracef
Suprax
FOURTH GENERATION
GENERIC
TIER 01
CEPHALOSPORIN
FIRST GENERATION
GENERIC
TIER 01
Cefuroxime SodiumPA
Cefuroxime/DextrosePA
NON PREFERRED
cefuroxime sodiumPA
Ceftin
MefoxinPA
ZinacefPA
Zinacef IN Iso-osmotic DiluentPA
GENERIC
azithromycin
clarithromycin
clarithromycin ERQL
erythromycin
AzithromycinPA
E.e.s. 400
Erythromycin Base
Erythromycin Ethylsuccinate
PREFERRED
Ery-TAB
NON PREFERRED
Biaxin XLQL
Biaxin XL PACQL
DificidQL
E.e.s. Granules
Eryped 200
Eryped 400
Erythrocin LactobionatePA
Erythrocin Stearate
PCE
Zithromax
Zithromax Tri-PAK
Zithromax Z-PAK
Zmax
TETRACYCLINES
TIER 01
GENERIC
demeclocycline HCL
doxycycline
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
1
TIER 03
doxycycline hyclatePA
doxycycline hyclate DR
doxycycline monohydrate
minocycline HCL
minocycline HCL ER
NON PREFERRED
Minocin
Tetracycline HCL
Vibramycin
Rifater
Trecator
ANTIFUNGALS
TIER 01
QUINOLONES
TIER 01
TIER 03
GENERIC
ciprofloxacinPA
ciprofloxacin ER
ciprofloxacin HCL
ciprofloxacin I.V.-IN D5WPA
levofloxacin
levofloxacin IN D5WPA
moxifloxacin HCL
ofloxacin
NON PREFERRED
Avelox
Avelox Abc Pack
Cipro
Cipro XRQL
Factive
Levaquin
Noroxin
TIER 03
TIER 04
AMINOGLYCOSIDES
TIER 01
TIER 04
GENERIC
amikacin sulfatePA
gentamicin sulfatePA
gentamicin sulfate pediatricPA
gentamicin sulfate/sodium chloridePA
gentamicin sulfate/0.9% sodium chloridePA
isotonic gentamicinPA
neomycin sulfate
paromomycin sulfate
tobramycin sulfatePA
Gentamicin Sulfate/0.9% Sodium ChloridePA
Isotonic GentamicinPA
Streptomycin SulfatePA
Tobramycin Sulfate/Sodium ChloridePA
SPECIALTY
tobramycinPA
Kitabis PAKPA
TobiPA
ANTIVIRALS
TIER 01
TIER 02
TIER 03
SULFONAMIDES
TIER 01
GENERIC
Sulfadiazine
ANTIMYCOBACTERIAL AGENTS
TIER 01
TIER 03
GENERIC
ethambutol HCL
isoniazid
pyrazinamide
rifabutin
rifampinPA
IsoniazidPA
NON PREFERRED
Capastat SulfatePA
Cycloserine
Myambutol
Mycobutin
Paser
Priftin
Rifamate
GENERIC
fluconazole
fluconazole IN dextrosePA
fluconazole IN NACLPA
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazolePA
ketoconazole
nystatin
terbinafine HCLQL
voriconazole
Amphotericin BPA
Fluconazole IN NACLPA
NON PREFERRED
AbelcetPA
AmbisomePA
CancidasPA
EraxisPA
LamisilQL
SporanoxPA
Sporanox PulsepakPA
Terbinex
Vfend
SPECIALTY
MycaminePA
Noxafil
TIER 04
GENERIC
abacavir sulfate/lamivudine/zidovudineQL
acyclovir
acyclovir sodiumPA
cidofovirPA
famciclovirQL
rimantadine HCL
valacyclovir HCLQL
valganciclovirPA
Acyclovir SodiumPA
PREFERRED
FoscavirPA
NON PREFERRED
FamvirQL
Moderiba
Relenza DiskhalerQL
Rescriptor
SelzentryPA
TamifluQL
TrizivirQL
ValcytePA
ValtrexQL
Videx Pediatric
Virazole
Viread
SPECIALTY
abacavir
adefovir dipivoxilQL,PA
didanosine
entecavirQL,PA
ganciclovirPA
lamivudine
lamivudine/zidovudinePA
nevirapine
nevirapine ER
ribavirinPA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
2
stavudine
zidovudine
AptivusPA
AtriplaQL
BaracludeQL,PA
CombivirPA
CompleraQL
CopegusPA
Crixivan
CytovenePA
Edurant
Emtriva
Epivir
Epivir HBV
Epzicom
HarvoniQL,PA
HepseraQL,PA
InfergenPA
Intelence
Invirase
Isentress
Kaletra
Lexiva
Moderiba 1200 Dose PackPA
Moderiba 800 Dose PackPA
Nevirapine
Norvir
Peg-intronPA
Peg-intron RedipenPA
Peg-intron Redipen PAK 4PA
PegasysPA
Pegasys ProclickPA
PegintronPA
Prezista
RebetolPA
RetrovirPA
Retrovir IV InfusionPA
Reyataz
RibaspherePA
Ribasphere RibapakPA
RibatabPA
SovaldiPA
Sustiva
TruvadaPA
TyzekaQL,PA
VictrelisPA
Videx EC
Viracept
Viramune
Viramune XR
Zerit
Ziagen
ANTHELMINTICS
TIER 01
TIER 03
MISC. ANTI-INFECTIVES
TIER 01
TIER 02
TIER 03
ANTIMALARIALS
TIER 01
TIER 02
TIER 03
GENERIC
atovaquone/proguanil HCL
chloroquine phosphate
hydroxychloroquine sulfate
mefloquine HCL
Primaquine Phosphate
PREFERRED
Daraprim
NON PREFERRED
quinine sulfateQL
Coartem
Malarone
QualaquinQL
GENERIC
ivermectin
NON PREFERRED
Albenza
Biltricide
Stromectol
TIER 04
GENERIC
atovaquone
aztreonamPA
bacitracinPA
clindamycin palmitate HCL
clindamycin phosphatePA
clindamycin phosphate add-vantagePA
clindamycin phosphate pharmacy bulk packagePA
clindamycin phosphate IN D5W PA
clindamycin HCL
colistimethate sodiumPA
imipenem/cilastatinPA
linezolidPA
meropenemPA
metronidazole
metronidazole IN NACL 0.79%PA
polymyxin b sulfatePA
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim DS
tinidazole
trimethoprim
vancomycin HCL
BacitracinPA
Chloramphenicol Sodium SuccinatePA
Dapsone
Sulfamethoxazole/TrimethoprimPA
Vancomycin HCL
Vancomycin HCL IN Dextrose
PREFERRED
Alinia
NON PREFERRED
AzactamPA
Azactam IN Iso-osmotic DextrosePA
Cleocin PhosphatePA
Coly-mycin MPA
DoribaxPA
Flagyl
Flagyl ER
InvanzPA
KetekPA
Mepron
Nebupent
Primsol
SivextroQL
Vancocin HCL
XifaxanPA
ZyvoxQL
SPECIALTY
CaystonPA
Pentam 300PA
TygacilPA
ANTINEOPLASTICS, ETC
ALKYLATING AGENTS
TIER 01
GENERIC
carboplatinPA
cisplatinPA
cyclophosphamidePA
ifosfamidePA
oxaliplatinPA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
3
TIER 03
TIER 04
Cyclophosphamide
Lomustine
NON PREFERRED
Gleostine
Leukeran
SPECIALTY
melphalan hydrochloridePA
temozolomidePA
AlkeranPA
Hexalen
MustargenPA
TemodarPA
TreandaPA
ANTIBODIES
TIER 04
HORMONAL AGENTS
TIER 01
ANTIBIOTICS
TIER 01
TIER 04
GENERIC
idarubicin HCLPA
SPECIALTY
bleomycin sulfatePA
daunorubicin HCLPA
doxorubicin HCLPA
doxorubicin HCL liposomePA
epirubicin HCLPA
mitomycinPA
mitoxantrone HCLPA
DoxilPA
Doxorubicin HCLPA
EllencePA
MitomycinPA
TIER 03
TIER 04
ANTINEOPLASTIC ENZYMES
TIER 03
TIER 04
NON PREFERRED
OncasparPA
SPECIALTY
ElsparPA
ANTIMETABOLITES
TIER 01
TIER 03
TIER 04
GENERIC
cytarabinePA
cytarabine aqueousPA
decitabinePA
mercaptopurine
methotrexate
methotrexate sodiumPA
CytarabinePA
NON PREFERRED
Tabloid
Trexall
SPECIALTY
azacitidinePA
capecitabinePA
cladribinePA
floxuridinePA
fludarabine phosphatePA
fluorouracilPA
gemcitabine HCLPA
ArranonPA
ClolarPA
FloxuridinePA
FludaraPA
Fludarabine PhosphatePA
FolotynPA
GemzarPA
VidazaPA
XelodaPA
SPECIALTY
ArzerraPA
ErbituxPA
GazyvaPA
KadcylaPA
PerjetaPA
RituxanPA
YervoyQL,PA
GENERIC
anastrozole
bicalutamide
exemestane
flutamide
letrozole
megestrol acetate
PREVENTIVE
tamoxifen citrate
NON PREFERRED
Depo-provera
Emcyt
Fareston
Nilandron
SPECIALTY
leuprolide acetateQL,PA
EligardQL,PA
FaslodexPA
FirmagonQL,PA
Lupron DepotQL,PA
Lysodren
TrelstarQL,PA
Trelstar MixjectQL,PA
VantasQL,PA
XtandiPA
ZoladexQL,PA
ZytigaPA
IMMUNOMODULATORS
TIER 01
TIER 03
TIER 04
GENERIC
azathioprine
cyclosporinePA
Cyclosporine Modified
NON PREFERRED
Azasan
Sandimmune
SPECIALTY
cyclosporine modifiedPA
mycophenolate mofetil
mycophenolic acid DR
sirolimus
tacrolimus
CellceptPA
Cellcept IntravenousPA
Myfortic
NeoralPA
NulojixPA
PomalystPA
Prograf
Rapamune
RevlimidPA
ThalomidPA
ZortressPA
MITOTIC INHIBITORS
ANGIOGENESIS INHIBITORS
TIER 04
TIER 01
SPECIALTY
CyramzaPA
GENERIC
docetaxelPA
etoposidePA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
4
TIER 04
SPECIALTY
paclitaxelPA
vincristine sulfatePA
vinorelbine tartratePA
AbraxanePA
HalavenPA
JevtanaPA
NavelbinePA
TIER 04
ENZYME INHIBITORS
TIER 04
SPECIALTY
AfinitorQL,PA
BosulifPA
CaprelsaQL,PA
Cometriq
GilotrifQL
GleevecPA
IclusigPA
Imbruvica
InlytaPA
IstodaxPA
JakafiPA
Mekinist
NexavarPA
SprycelPA
StivargaPA
SutentPA
Tafinlar
TarcevaQL,PA
TasignaPA
ToriselPA
TykerbPA
VotrientPA
XalkoriPA
ZelborafPA
ZolinzaPA
ZydeligQL
ZykadiaPA
CHEMOTHERAPY ADJUNCTS
TIER 04
SPECIALTY
irinotecanPA
topotecan HCLPA
CamptosarPA
HycamtinPA
Topotecan HCLPA
CARDIOVASCULAR DRUGS
TIER 01
TIER 03
TIER 04
GENERIC
hydroxyurea
tretinoin
NON PREFERRED
Alferon NPA
Matulane
SPECIALTY
dacarbazinePA
ActimmunePA
ErivedgePA
Intron APA
Intron-aPA
Intron-a W/DiluentPA
ProleukinPA
SylatronPA
SynriboPA
TargretinPA
TIER 01
GENERIC
digoxin
TIER 02
PREFERRED
Digoxin
Lanoxin
Lanoxin PediatricPA
ANTIANGINAL AGENTS
TIER 01
TIER 02
TIER 03
GENERIC
isosorbide dinitrate
isosorbide dinitrate ER
isosorbide mononitrate
isosorbide mononitrate ER
nitroglycerin
nitroglycerin lingual
nitroglycerin transdermal
nitroglycerin ER
nitroglycerin IN dextrose 5%PA
nitroglycerin IN 5% dextrosePA
Isosorbide Dinitrate
Nitroglycerin Lingual
PREFERRED
Dilatrate SR
Isordil Titradose
Nitro-dur
Nitrostat
NON PREFERRED
Nitro-bid
Nitrolingual Pumpspray
Nitromist
RanexaST
BETA BLOCKERS
TIER 01
CHEMOTHERAPY RESCUE
TIER 01
GENERIC
milrinone lactatePA
milrinone IN dextrosePA
CARDIAC GLYCOSIDES
ANTINEOPLASTICS MISC.
TIER 01
SPECIALTY
KepivancePA
PHOSPHODIESTERASE INHBTR
TOPOISOMERASE I INHIBITOR
TIER 04
Calcium FolinatePA
Leucovorin Calcium
SPECIALTY
amifostinePA
dexrazoxanePA
mesnaPA
EthyolPA
MesnexPA
TotectPA
ZinecardPA
GENERIC
leucovorin calcium
GENERIC
acebutolol HCL
atenolol
betaxolol HCL
bisoprolol fumarate
carvedilol
labetalol HCL
metoprolol succinate ER
metoprolol tartrate
nadolol
pindolol
propranolol HCLPA
propranolol HCL ER
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
5
TIER 03
TIER 04
sotalol HCL
sotalol HCL (AF)
Propranolol HCL
Timolol Maleate
NON PREFERRED
Bystolic
Coreg CR
Inderal XL
Innopran XL
Levatol
SPECIALTY
esmolol HCLPA
BreviblocPA
TIER 04
ANGIOTENSIN RCPTR BLOCKER
TIER 01
CALCIUM CHANNEL BLOCKERS
TIER 01
TIER 03
GENERIC
amlodipine besylate
diltiazem CD
diltiazem HCL
diltiazem HCL ER
felodipine ER
isradipine
nicardipine HCLPA
nifedipine
nifedipine ER
nimodipine
nisoldipine
verapamil HCL
verapamil HCL ER
verapamil HCL SR
Nisoldipine
Nisoldipine ER
Verapamil HCL
NON PREFERRED
Cardizem LA
TIER 03
TIER 03
GENERIC
adenosinePA
amiodarone HCL
disopyramide phosphate
flecainide acetate
ibutilide fumaratePA
lidocaine HCLPA
lidocaine HCL IN D5WPA
lidocaine HCL/dextrosePA
mexiletine HCL
propafenone HCL
propafenone HCL ER
quinidine gluconate CR
quinidine gluconate ER
quinidine sulfate
Amiodarone HCLPA
Procainamide HCLPA
Quinidine GluconatePA
Quinidine Sulfate ER
NON PREFERRED
Multaq
Norpace CR
Tikosyn
TIER 02
PREFERRED
Tekturna
ANTIHYPERTENSIVES MISC.
TIER 01
TIER 02
TIER 03
GENERIC
clonidine HCL
doxazosin mesylate
eplerenone
fenoldopam mesylatePA
guanfacine HCL
hydralazine HCLPA
methyldopa
minoxidil
prazosin HCL
terazosin HCL
Methyldopate HCLPA
Phentolamine MesylatePA
Reserpine
PREFERRED
Dibenzyline
NON PREFERRED
Catapres-tts-1
Catapres-tts-2
Catapres-tts-3
Demser
ANTIHYPERTENSIVE COMBO
TIER 01
ACE INHIBITORS
TIER 01
GENERIC
candesartan cilexetil
eprosartan mesylate
irbesartan
losartan potassium
telmisartan
valsartan
NON PREFERRED
Atacand
Benicar
Diovan
EdarbiST
Micardis
DIRECT RENIN INHIBITORS
ANTIARRHYTHMICS
TIER 01
quinapril HCL
ramipril
trandolapril
SPECIALTY
enalapril maleate
enalaprilatPA
Vasotec
GENERIC
benazepril HCL
captopril
fosinopril sodium
lisinopril
moexipril HCL
perindopril erbumine
GENERIC
amlodipine besylate/benazepril hydrochloride
amlodipine besylate/benazepril HCL
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
atenolol/chlorthalidone
benazepril HCL/hydrochlorothiazide
bisoprolol fumarate/hydrochlorothiazide
candesartan cilexetil/hydrochlorothiazide
enalapril maleate/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
irbesartan/hydrochlorothiazide
lisinopril/hydrochlorothiazide
losartan potassium/hydrochlorothiazide
metoprolol/hydrochlorothiazide
moexipril/hydrochlorothiazide
nadolol/bendroflumethiazide
quinapril/hydrochlorothiazide
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
6
TIER 02
TIER 03
telmisartan/amlodipine
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazide
trandolapril/verapamil HCL
trandolapril/verapamil HCL ER
valsartan/hydrochlorothiazide
Captopril/Hydrochlorothiazide
Methyldopa/Hydrochlorothiazide
PREFERRED
Tekturna HCT
NON PREFERRED
Azor
Benicar HCTST
EdarbyclorST
Exforge
Exforge HCT
Micardis HCT
Teveten HCTST
Tribenzor
Twynsta
Auvi-q
Epinephrine
Epipen 2-PAK
Epipen-JR 2-PAK
LevophedPA
ANTIHYPERLIPIDEMICS
TIER 01
DIURETICS
TIER 01
TIER 02
TIER 03
GENERIC
acetazolamide
acetazolamide sodiumPA
acetazolamide ER
amiloride HCL
amiloride/hydrochlorothiazide
bumetanide
chlorothiazide
chlorothiazide sodiumPA
furosemide
hydrochlorothiazide
indapamide
mannitolPA
methazolamide
metolazone
spironolactone
spironolactone/hydrochlorothiazide
torsemide
triamterene/hydrochlorothiazide
Acetazolamide
Chlorthalidone
Furosemide
Methyclothiazide
PREFERRED
Aldactazide
NON PREFERRED
Diuril
Dyrenium
Edecrin
TIER 02
TIER 03
CARDIOVASCULAR - MISC.
TIER 01
TIER 03
VASOPRESSORS
TIER 01
TIER 03
GENERIC
dobutamine HCLPA
dobutamine HCL/D5WPA
dobutamine/dextrose 5%PA
dopamine HCLPA
dopamine HCL-dextrose 5%PA
dopamine HCL/dextrose 5%PA
dopamine/D5WPA
ephedrine sulfatePA
midodrine HCL
norepinephrine bitartratePA
phenylephrine HCLPA
Phenylephrine HCLPA
NON PREFERRED
Adrenaclick
Adrenalin
GENERIC
atorvastatin calcium
cholestyramine
cholestyramine light
colestipol HCL
colestipol HCL for oral suspension
fenofibrate
fenofibrate micronized
fenofibric acid DR
fluvastatin
gemfibrozil
lovastatin
niacin ER
omega-3-acid ethyl esters
pravastatin sodium
simvastatin
Fenofibric AcidST
Niacor
PREFERRED
Lescol XLST
Simcor
Zetia
NON PREFERRED
Advicor
AltoprevST
CrestorST
FenofibrateST
FenoglideST
FibricorST
LipofenST
LiptruzetST
LivaloST
Lovaza
Niaspan
Trilipix
VytorinST
Welchol
ZocorPA
TIER 04
GENERIC
amlodipine besylate/atorvastatin calcium
papaverine HCLPA
NON PREFERRED
AdempasQL,PA
CialisQL,PA,GL
SPECIALTY
epoprostenol sodiumPA
sildenafilQL,PA
sildenafil citrateQL,PA
AdcircaQL
FlolanPA
LetairisQL,PA
RemodulinPA
RevatioQL,PA
TracleerQL,PA
VeletriPA
VentavisQL,PA
DERMATOLOGICALS
ACNE PRODUCTS
TIER 01
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
7
TIER 02
TIER 03
GENERIC
adapalenePA
benzoyl peroxide
benzoyl peroxide SHORT contact
clindamycin phosphate
clindamycin/benzoyl peroxide
erythromycin
erythromycin/benzoyl peroxide
sodium sulfacetamide
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur cleanser
sodium sulfacetamide/sulfur cleansing cloths
sodium sulfacetamide/sulfur green
sodium sulfacetamide/sulfur w/sunscreen
sodium sulfacetamide/sulfur wash
sulfacetamide sodium
sulfacetamide sodium/sulfur cleanser
tretinoinPA
tretinoin microspherePA
tretinoin microsphere P.M.PA
Claravis
PREFERRED
Benzamycinpak
NON PREFERRED
Absorica
Acanya
AdapalenePA
Akne-mycin
AtralinPA
Azelex
Cleocin-t
Clindagel
DifferinPA
EpiduoPA
Retin-aPA
Retin-a MicroPA
Retin-a Micro P.M.PA
Tretin-xPA
VeltinPA
Zenatane
ZianaPA
TIER 02
TIER 03
ANTIVIRALS - TOPICAL
TIER 01
TIER 03
TIER 03
GENERIC
metronidazole
Rosadan Kit
NON PREFERRED
DoxycyclinePA
Finacea
Metrogel
Noritate
OraceaPA
GENERIC
acyclovir
NON PREFERRED
Denavir
Zovirax
ANTI-INFLAMMATORY AGENTS
TIER 01
TIER 03
GENERIC
diclofenac sodiumQL
NON PREFERRED
FlectorQL
VoltarenQL
ANTIPRURITICS
TIER 01
TIER 03
GENERIC
Prudoxin
NON PREFERRED
Zonalon
ANTIPSORIATICS
TIER 01
ROSACEA AGENTS
TIER 01
clotrimazole/betamethasone dipropionate
econazole nitrate
ketoconazole
nystatin
nystatin/triamcinolone
Ciclodan Cream Kit
PREFERRED
Oxistat
NON PREFERRED
Cnl8 Nail Kit
Ertaczo
Exelderm
Mentax
Naftin
Pedipirox-4 Nail
Penlac Nail Lacquer
Xolegel
TIER 03
TIER 04
GENERIC
acitretin
calcipotriene
methoxsalen
Calcitriol
NON PREFERRED
Dovonex
Oxsoralen Ultra
Soriatane
TazoracQL,PA
Vectical
8-mop
SPECIALTY
StelaraQL,PA
ANTIBIOTICS - TOPICAL
TIER 01
TIER 03
GENERIC
mupirocin
mupirocin calcium
Gentamicin Sulfate
NON PREFERRED
Altabax
Bactroban
Cortisporin
ANTIFUNGALS - TOPICAL
TIER 01
ANTISEBORRHEIC AGENTS
TIER 01
GENERIC
selenium sulfide
sodium sulfacetamide
sodium sulfacetamide wash
Selenium Sulfide
CORTICOSTEROIDS - TOPICAL
TIER 01
GENERIC
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
clotrimazole
GENERIC
alclometasone dipropionate
augmented betamethasone dipropionate
betamethasone dipropionate
betamethasone valerate
calcipotriene/betamethasone dipropionateQL
clobetasol propionate
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
8
TIER 02
TIER 03
clobetasol propionate emollient
desonide
desoximetasone
diflorasone diacetate
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluticasone propionate
halobetasol propionate
hydrocortisone
hydrocortisone acetate/aloe
hydrocortisone butyrate
hydrocortisone butyrate (lipid)
hydrocortisone butyrate (lipophilic)
hydrocortisone valerate
hydrocortisone IN absorbase
mometasone furoate
prednicarbate
triamcinolone acetonide
Amcinonide
Apexicon E
Desoximetasone
Diflorasone Diacetate
Triamcinolone Acetonide
Trianex
PREFERRED
Topicort
NON PREFERRED
Capex
Clobex
Clocortolone Pivalate
Clocortolone Pivalate P.M.
Cloderm
Cloderm P.M.
Cordran
Cordran Tape
Derma-smoothe/FS Body
Derma-smoothe/FS Scalp
Desonate
Desowen
Halog
Kenalog
Luxiq
Olux
Olux-e
Synalar Cream Kit
TaclonexQL
Texacort
Vanos
Verdeso
TIER 02
TIER 03
TIER 04
ENDOCRINE AND METABOLIC
CORTICOSTEROIDS
TIER 01
IMMUNOMODULATING AGENTS
TIER 01
TIER 03
GENERIC
imiquimod
tacrolimus
NON PREFERRED
Elidel
Protopic
Zyclara
Zyclara P.M.
DERMATOLOGICALS - MISC.
TIER 01
GENERIC
ammonium lactate
diclofenac sodium
fluorouracil
lactic acid
lactic acid e
lactic acid w/vitamin e
lidocaine
lidocaine HCL
lidocaine HCL jelly
lidocaine/prilocaine
lindane
mafenide acetate
malathion
permethrin
podofilox
salicylic acid
salicylic acid cream
salicylic acid lotion
silver sulfadiazine
sodium hyaluronate
urea
urea topical
urea IN zinc undecylenate/lactic acid vehicle
urea 40% nail film
PREFERRED
Eurax
NON PREFERRED
Carac
Condylox
Fluoroplex
Fluorouracil
Lac-hydrin
Oxsoralen
Panretin
Picato
Regranex
Sklice
Solaraze
Sulfamylon
Synera
TargretinPA
Veregen
SPECIALTY
episone CRE
Nivatopic Plus
Xclair
TIER 02
TIER 03
GENERIC
betamethasone sodium phosphate/betamethasone
acetatePA
budesonide
dexamethasone
dexamethasone sodium phosphatePA
fludrocortisone acetate
hydrocortisone
methylprednisolone
methylprednisolone acetatePA
methylprednisolone dose pack
methylprednisolone sodiumsuccinatePA
prednisolone
prednisolone sodium phosphate
prednisolone sodium phosphate odt
prednisone
Cortisone Acetate
Dexamethasone
Prednisolone Sodium Phosphate
Prednisone
PREFERRED
Prednisone Intensol
NON PREFERRED
A-hydrocortPA
Aristospan Intra-articularPA
Aristospan IntralesionalPA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
9
Celestone
Celestone-soluspanPA
Depo-medrolPA
Dexamethasone Intensol
Dexamethasone Sodium PhosphatePA
Dexpak 10 Day
Dexpak 13 Day
Dexpak 6 Day
FLO-pred
Kenalog-10PA
Kenalog-40PA
Millipred
Orapred Odt
Solu-cortefPA
Solu-medrolPA
Uceris
Veripred 20
Femhrt Low Dose
Menest
Minivelle
Vivelle-dot
CONTRACEPTIVES
TIER 01
ANDROGENS-ANABOLIC
TIER 01
TIER 02
TIER 03
TIER 04
GENERIC
danazol
oxandroloneQL,PA
testosterone enanthatePA
PREFERRED
AndrogelPA
Androgel P.M.PA
Androxy
Testosterone P.M.PA
VogelxoST
Vogelxo P.M.PA
NON PREFERRED
Anadrol-50PA
AndrodermST
AndroidPA
AxironST
FortestaST
OxandrinQL,PA
StriantST
TestimST
TestosteroneST
TestredPA
SPECIALTY
testosterone cypionatePA
Depo-testosteronePA
TIER 02
TIER 03
TIER 03
TIER 04
PROGESTINS
TIER 01
TIER 03
TIER 04
GENERIC
medroxyprogesterone acetate
norethindrone acetate
progesterone
NON PREFERRED
Megace ES
SPECIALTY
MakenaPA
ANTIDIABETIC AGENTS
ESTROGENS
TIER 01
TIER 02
PREVENTIVE
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
levonorgestrel and ethinyl estradiolQL
levonorgestrel/ethinyl estradiol
medroxyprogesterone acetateQL,PA
norethindrone
norethindrone & ethinyl estradiol ferrous fumarate
norethindrone acetate/ethinyl estradiol
norethindrone acetate/ethinyl estradiol/ferrous fumarate
norgestimate/ethinyl estradiol
EllaQL
NuvaringQL
Ortho Evra
PREFERRED
Necon 10/11-28
Ogestrel
Ortho Tri-cyclen LO
Zovia 1/50e
NON PREFERRED
Depo-subq Provera 104QL
LO Loestrin FE
Natazia
Safyral
SeasoniqueQL
PREVENTIVE
Paragard Intrauterine Copper Contraceptive T380a
GENERIC
estradiol
estradiol valeratePA
estradiol/norethindrone acetate
estropipate
Estropipate
Jinteli
PREFERRED
Angeliq
Cenestin
Enjuvia
Menostar
Prefest
PremarinPA
Premphase
Prempro
NON PREFERRED
Alora
Climara Pro
Combipatch
Divigel
Elestrin
Evamist
INSULIN
TIER 02
TIER 03
PREFERRED
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 R U-500 (concentrated)
Lantus
Lantus Solostar
Novolog
Novolog Flexpen
Novolog Mix 70/30
Novolog Mix 70/30 Prefilled Flexpen
Novolog Penfill
NON PREFERRED
Afrezza
Levemir
Levemir Flexpen
Levemir Flextouch
Toujeo Solostar
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
10
AMYLIN ANALOGS
NON PREFERRED
TIER 03
TIER 02
INCRETIN MIMETIC AGENTS
SPECIALTY
TIER 04
TIER 03
Symlinpen 120PA
Symlinpen 60PA
BydureonPA
ByettaPA
VictozaPA
SULFONYLUREAS
GENERIC
TIER 01
TIER 02
BIGUANIDES
TIER 01
TIER 02
TIER 03
glimepiride
glipizide
glipizide ER
glyburide
glyburide micronized
tolazamide
Chlorpropamide
Glyburide
Tolazamide
Tolbutamide
PREFERRED
Diabeta
GENERIC
metformin HCL
metformin HCL ER
PREFERRED
Glumetza
NON PREFERRED
Riomet
MEGLITINIDE ANALOGUES
GENERIC
TIER 01
TIER 03
nateglinide
repaglinide
NON PREFERRED
Prandin
DIABETIC OTHER
PREFERRED
TIER 02
TIER 03
Glucagon Emergency Kit
NON PREFERRED
Cycloset
FarxigaPA
Glucagen
Glucagen Hypokit
InvokanaPA
Proglycem
BISPHOSPHONATES
TIER 01
TIER 03
TIER 04
acarbose
NON PREFERRED
Glyset
DPP-4 INHIBITORS
PREFERRED
TIER 02
TIER 01
TIER 03
TIER 03
INSULIN SENSITIZING AGENT
GENERIC
TIER 01
TIER 02
pioglitazone HCL
PREFERRED
Avandia
ANTIDIABETIC COMBINATIONS
GENERIC
TIER 01
GENERIC
calcitonin salmonQL
calcitonin-salmonQL
ForticalQL
NON PREFERRED
MiacalcinPA
PARATHYROID HORMONE
TIER 04
SPECIALTY
ForteoQL,PA
RANK LIGAND INHIBITORS
TIER 04
SPECIALTY
ProliaQL,PA
XgevaQL,PA
HORMONE RECEPTOR MDLTR
TIER 01
TIER 02
ST
Januvia
OnglyzaST
NON PREFERRED
NesinaST
Tradjenta
GENERIC
alendronate sodium
ibandronate sodiumQL
risedronate sodiumQL,ST
Alendronate Sodium
Etidronate Disodium
Zoledronic AcidQL,PA
NON PREFERRED
ActonelST
AtelviaQL,ST
BinostoQL
BonivaQL
FosamaxQL
Fosamax Plus DQL
SPECIALTY
pamidronate disodiumPA
zoledronic acidPA
Pamidronate DisodiumPA
ReclastQL,PA
ZometaPA
CALCITONINS
ALPHA-GLUCOSIDASE INHIBIT
GENERIC
TIER 01
TIER 03
PREFERRED
Janumet
Janumet XR
Kombiglyze XR
NON PREFERRED
Actoplus Met XR
Jentadueto
KazanoST
OseniST
TIER 03
GENERIC
raloxifene hydrochloride
PREFERRED
Osphena
NON PREFERRED
Evista
FERTILITY REGULATORS
TIER 01
TIER 03
TIER 04
glipizide/metformin HCL
glyburide/metformin HCL
pioglitazone HCL-glimepiride
pioglitazone HCL/metformin HCL
GENERIC
chorionic gonadotropinQL,PA
clomiphene citrate
NON PREFERRED
RepronexQL,PA
SPECIALTY
BravelleQL,PA
Follistim AQQL,PA
Gonal-fQL,PA
MenopurPA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
11
SPECIALTY
SamscaQL,PA
LHRH/GNRH AGONIST
TIER 04
SPECIALTY
Lupron Depot-PEDQL,PA
SynarelPA
METABOLIC MODIFIERS
TIER 01
GNRH/LHRH ANTAGONISTS
TIER 04
SPECIALTY
CetrotideQL,PA
GROWTH HORMONES
TIER 04
SPECIALTY
GenotropinPA
Genotropin MiniquickPA
HumatropePA
Humatrope Combo PackPA
Norditropin CartridgePA
Norditropin FlexproPA
Norditropin Nordiflex PenPA
NutropinPA
Nutropin AQ Nuspin 10PA
Nutropin AQ Nuspin 20PA
Nutropin AQ Nuspin 5PA
Nutropin AQ PenPA
OmnitropePA
SaizenPA
Saizen Click.easyPA
SerostimPA
Tev-tropinPA
ZorbtivePA
TIER 04
THYROID AGENTS
GHRH
TIER 04
TIER 03
SPECIALTY
EgriftaQL,PA
TIER 01
SOMATOMEDINS
TIER 04
SPECIALTY
IncrelexPA
TIER 02
SOMATOSTATIC AGENTS
TIER 04
SPECIALTY
octreotide acetatePA
SandostatinPA
Sandostatin Lar DepotPA
SigniforQL,PA
Somatuline DepotPA
GH RECEPTOR ANTAGONISTS
TIER 04
SPECIALTY
SomavertPA
TIER 03
TIER 03
GENERIC
desmopressin acetate
vasopressinPA
NON PREFERRED
Ddavp
Pitressin SyntheticPA
GASTROINTESTINAL
TIER 01
TIER 03
CORTICOTROPIN
TIER 04
SPECIALTY
H.p. ActharPA
PROLACTIN INHIBITORS
TIER 01
GENERIC
cabergoline
VASOPRESSIN ANTAGONISTS
GENERIC
levothyroxine sodium
liothyronine sodium
methimazole
propylthiouracil
PREFERRED
Levothyroxine SodiumPA
Synthroid
Tirosint
NON PREFERRED
Thyrolar-1
Thyrolar-1/4
Thyrolar-2
Thyrolar-3
LAXATIVES
POSTERIOR PITUITARY
TIER 01
GENERIC
calcitriol
doxercalciferol
levocarnitinePA
paricalcitol
sodium phenylbutyrate
NON PREFERRED
Cystadane
Hectorol
Orfadin
ParicalcitolPA
ZemplarPA
SPECIALTY
AldurazymePA
Buphenyl
CarbagluPA
ElaprasePA
FabrazymePA
KuvanPA
LumizymePA
MyaleptPA
MyozymePA
NaglazymePA
SensiparPA
VimizimPA
TIER 04
GENERIC
lactulose
PREVENTIVE
peg 3350/electrolytes
peg-3350/electrolytes
peg-3350/NACL/NA bicarbonate/KCL
NON PREFERRED
Colyte-flavor Packs
Golytely
Kristalose
Moviprep
Osmoprep
Prepopik
Suprep Bowel Prep
SPECIALTY
polyethylene glycol 3350
ANTIDIARRHEALS
TIER 01
TIER 04
GENERIC
diphenoxylate/atropine
loperamide HCL
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
12
TIER 03
opium
opium tincture
Diphenoxylate/Atropine
NON PREFERRED
Lomotil
Motofen
TIER 04
ULCER DRUGS
TIER 01
TIER 02
TIER 03
GENERIC
atropine sulfatePA
cimetidine
cimetidine HCL
dicyclomine HCL
esomeprazole magnesiumQL,ST
esomeprazole sodiumST
famotidinePA
glycopyrrolate
hyoscyamine sulfate
hyoscyamine sulfate odt
hyoscyamine sulfate ER
hyoscyamine sulfate SR
lansoprazoleQL
lansoprazole/amoxicillin/clarithromycin
methscopolamine bromide
misoprostol
nizatidine
omeprazoleQL
omeprazole/sodium bicarbonateQL
pantoprazole sodiumQL
rabeprazole sodiumQL,ST
ranitidine HCL
sucralfate
Atropine SulfatePA
Dicyclomine HCL
Propantheline Bromide
Scopolamine HydrobromidePA
PREFERRED
Carafate
Prevacid SolutabQL
NON PREFERRED
AciphexQL,ST
BentylPA
Cantil
Cuvposa
DexilantQL,ST
Esomeprazole SodiumST
LevsinPA
NexiumQL,ST
Nexium I.v.ST
PrevacidQL
PrilosecQL
ProtonixQL
RobinulPA
ZantacPA
ZegeridQL,ST
DIGESTIVE AIDS
TIER 01
TIER 03
TIER 03
GENERIC
dronabinolQL,PA
granisetron HCLQL
meclizine HCL
trimethobenzamide HCLPA
DimenhydrinatePA
NON PREFERRED
AnzemetQL
CesametQL,PA
DiclegisQL
GranisolQL
MarinolQL,PA
GENERIC
Pancrelipase
NON PREFERRED
Creon
Pancreaze
Pertzye
Sucraid
Ultresa
Viokace
Zenpep
GASTROINTESTINAL - MISC.
TIER 01
TIER 02
TIER 03
ANTIEMETICS
TIER 01
SancusoQL
Transderm-scop
ZuplenzQL
SPECIALTY
ondansetron odtQL
ondansetron HCLQL
AloxiPA
EmendQL
ZofranQL,PA
Zofran OdtQL
TIER 04
GENERIC
balsalazide disodium
calcium acetate
hydrocort ene 100MG
hydrocortisone
hydrocortisone acetate/lidocaine HCL
hydrocortisone acetate/pramoxine
lactulose
lidocaine HCL/hydrocortisone acetate
mesalamine
metoclopramide HCL
sulfasalazine
ursodiol
DexpanthenolPA
PREFERRED
Canasa
Dipentum
Pentasa
Renagel
Renvela
Sevelamer Carbonate
NON PREFERRED
Actigall
AmitizaQL,PA
Anusol-HC
Apriso
Asacol HD
Chenodal
Cortenema
Cortifoam
Delzicol
Fosrenol
Giazo
Lialda
LinzessQL,PA
Lotronex
Metozolv Odt
Phoslyra
Rectiv
Sfrowasa
Urso 250
SPECIALTY
cromolyn sodiumPA
CimziaQL,PA
Cimzia Starter KitQL,PA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
13
EntyvioQL,PA
GastrocromPA
RelistorPA
RemicadePA
GENITOURINARY
URINARY ANTI-INFECTIVES
TIER 01
TIER 02
TIER 03
GENERIC
methenamine hippurate
methenamine mandelate
nitrofurantoin
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitrofurantoin monohydrate/macrocrystals
PREFERRED
Macrodantin
NON PREFERRED
Monurol
TIER 04
HEMATOLOGICAL
HEMATOPOIETIC AGENTS
TIER 01
URINARY ANTISPASMODICS
TIER 01
TIER 02
TIER 03
GENERIC
bethanechol chloride
flavoxate HCL
oxybutynin chloride
oxybutynin chloride ER
tolterodine tartrate
tolterodine tartrate ER
trospium chloride
trospium chloride ER
PREFERRED
Enablex
OxytrolQL
NON PREFERRED
Detrol LA
GelniqueST
Myrbetriq
Toviaz
Vesicare
TIER 03
VAGINAL PRODUCTS
TIER 01
TIER 02
TIER 03
GENERIC
clindamycin phosphate
metronidazole vaginal
terconazole
PREFERRED
Estrace
FemringQL
Premarin
Vagifem
NON PREFERRED
Cleocin
Crinone
EstringQL
GENITOURINARY - MISC.
TIER 01
NON PREFERRED
Avodart
Cardura XL
Elmiron
Jalyn
Rapaflo
Urocit-k 10
Urocit-k 15
Urocit-k 5
SPECIALTY
Cystagon
GENERIC
alfuzosin HCL ER
citric acid/sodium citrate
finasteride
hydrochloric acidPA
phenazopyridine HCL
potassium citrate ER
potassium citrate-citric acid crystals
potassium citrate/citric acid
potassium citrate/sodium citrate/citric acid
sodium citrate/citric acid
tamsulosin HCL
tricitrates
TIER 03
GENERIC
cyanocobalaminPA
folic acid
folic acid/vitamin b-6/vitamin b-12
sodium ferric gluconate complex/sucrosePA
PREVENTIVE
ferrous drops
ferrous fumarate 324
ferrous gluconate
ferrous sulfate
iron
FE gluconate
NON PREFERRED
AlbafortPA
Animi-3
Animi-3/Vitamin D
B-6 Folic Acid
Biferarx
Cenfol
Centratex
Ciferex
Corvite 150
Divista
Droxia
Ed Cyte F
FerahemePA
Feriva
Feriva 21/7
Ferivafa
Ferralet 90
Ferrex 150 Forte Plus
Ferrex 28
FerrlecitPA
Ferro-plex Hematinic
Ferrotrin
Folgard RX
Folic AcidPA
Folivane-f
Folivane-plus
Foltrate
Fusion Plus
Hematogen Fa
Hematron-AF
Hemocyte Plus
Hemocyte-f
HydroxocobalaminPA
Icar-c Plus
InjectaferPA
Integra F
Integra Plus
Iron Asp Gly/ Polysacch Compl/Ascorb CAL/B12/Fa/C
Threon/Suc
Irospan 24/6
Is 24/6
Maxaron Forte
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
14
TIER 04
Maxfe
Multigen
Multigen Folic
Multigen Plus
MV FE Asparto Gly/FE Fum/Succ Acid/Vit C/Threonic
Acd/B12/Fa
MV FE Asparto Gly/Vit C/Vit B12/CA Threonate/Succ
Acd/Stomac
Nascobal
Natalvirt Flt
Nephron Fa
Novaferrum
Pre-folic
Proferrin-forte
Protectiron
Tandem F
Tandem Plus
VenoferPA
PREVENTIVE
Elite Iron
Fa-8
Femiron
Feosol
Ferrimin 150
Ferro-sequels
Ferrous Fumarate
Ferrous Gluconate
Ferrous Sulfate
FE Aspartate
Iron
Iron Up
Mykidz Iron 10
Novaferrum Pediatric Drops
Perfect Iron
Profe
Proferrin ES
SPECIALTY
Aranesp Albumin FreePA
CerdelgaPA
CerezymePA
ElelysoPA
EpogenPA
LeukinePA
MozobilQL,PA
NeulastaPA
Neulasta Delivery KitPA
NeumegaPA
NeupogenPA
ProcritPA
PromactaQL,PA
VprivPA
ZavescaPA
TIER 02
TIER 03
TIER 04
HEMOSTATICS
TIER 01
GENERIC
argatrobanPA
enoxaparin sodiumQL
heparin lockPA
heparin lock flushPA
heparin lock flush for flushing vascular access devicesPA
heparin lock flush/NACL for flushing vascular access
devicesPA
heparin sodiumPA
heparin sodium dcuPA
heparin sodium lock flushPA
heparin sodium/sodium chloride 0.9% premixPA
heparin sodium/D5WPA
heparin sodium/NACL 0.9%PA
warfarin sodium
ArgatrobanPA
GENERIC
aminocaproic acidPA
tranexamic acidPA
HEMATOLOGICAL - MISC.
TIER 01
TIER 02
TIER 03
TIER 04
GENERIC
anagrelide hydrochloride
cilostazol
clopidogrel
dipyridamole
hetastarch 6%/NACLPA
pentoxifylline ER
ticlopidine HCL
PREFERRED
Effient
NON PREFERRED
Aggrenox
Brilinta
Cathflo ActivasePA
KinlyticPA
SPECIALTY
FirazyrPA
KalbitorPA
MOUTH/THROAT/DENTAL AGENT
TIER 01
ANTICOAGULANTS
TIER 01
Heparin SodiumPA
Heparin Sodium/D5WPA
Heparin Sodium/NACL 0.45%PA
Heparin Sodium/Sodium Chloride 0.9%PA
PREFERRED
Coumadin
EliquisQL
PradaxaQL
XareltoQL
NON PREFERRED
LovenoxQL
SPECIALTY
fondaparinux sodiumQL
ArixtraQL
FragminQL
TIER 03
GENERIC
cevimeline HCL
chlorhexidine gluconate
chlorhexidine gluconate oral rinse
clotrimazole
lidocaine viscous
lidocaine HCL
lidocaine HCL viscous
nystatin
pilocarpine hydrochloride
pilocarpine HCL
stannous fluoride oral rinse
triamcinolone acetonide
triamcinolone IN orabase
NON PREFERRED
Gel-kam Oral Care Rinse
Nafrinse Daily/Neutral
Nafrinse Weekly
Oravig
Prevident
NEUROLOGY, CNS, PSYCH
ANTIANXIETY AGENTS
TIER 01
GENERIC
alprazolam
alprazolam odt
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
15
TIER 02
TIER 03
alprazolam ER
buspirone HCL
chlordiazepoxide HCL
clorazepate dipotassium
diazepam
droperidolPA
gene-xene TAB 15MG
gene-xene TAB 3.75MG
gene-xene TAB 7.5MG
hydroxyzine pamoate
hydroxyzine HCL
lorazepam
meprobamate
oxazepam
Diazepam
Hydroxyzine HCLPA
Hydroxyzine Pamoate
PREFERRED
Alprazolam Intensol
NON PREFERRED
AtivanPA
FetzimaQL,ST
Forfivo XLQL
LexaproQL
Marplan
OleptroQL,PA
Paxil CRQL
PexevaQL,ST
PristiqQL,PA
ProzacQL
Prozac WeeklyQL
ViibrydQL,ST
Wellbutrin SRQL
Wellbutrin XLQL
ZoloftQL
ANTIPSYCHOTICS
TIER 01
ANTIDEPRESSANTS
TIER 01
TIER 02
TIER 03
GENERIC
amitriptyline HCL
bupropion HCL
bupropion HCL ERQL
bupropion HCL SRQL
bupropion HCL XLQL
citalopram hydrobromideQL
clomipramine HCL
desipramine HCL
doxepin HCL
duloxetine HCLQL
escitalopram oxalateQL
fluoxetine DRQL
fluoxetine HCLQL
fluvoxamine maleateQL
fluvoxamine maleate ERQL
imipramine pamoate
imipramine HCL
mirtazapine
mirtazapine odt
nefazodone HCL
nortriptyline HCL
paroxetine HCLQL
paroxetine HCL ERQL
phenelzine sulfate
protriptyline HCL
sertraline HCLQL
tranylcypromine sulfate
trazodone HCL
venlafaxine HCLQL
venlafaxine HCL ERQL
Amoxapine
Doxepin HCL
Fluoxetine HCLQL
Maprotiline HCL
Nefazodone HCL
Nortriptyline HCL
Venlafaxine HCL ERQL
PREFERRED
PaxilQL
NON PREFERRED
BrintellixQL,ST
CelexaQL
CymbaltaQL
Effexor XRQL
EmsamQL,PA
TIER 02
TIER 03
GENERIC
chlorpromazine HCL
clozapineQL
fluphenazine decanoatePA
fluphenazine HCL
haloperidol
haloperidol decanoatePA
haloperidol lactatePA
lithium carbonate
lithium carbonate ER
loxapine
loxapine succinate
olanzapineQL
olanzapine odtQL
perphenazine
prochlorperazine
prochlorperazine edisylatePA
prochlorperazine maleate
quetiapine fumarateQL
risperidoneQL
risperidone odtQL
thioridazine HCL
thiothixene
trifluoperazine HCL
ziprasidone HCLQL
Chlorpromazine HCLPA
Clozapine OdtQL
Fluphenazine HCL
PREFERRED
Lithium
Lithium Carbonate
Lithobid
Seroquel XRQL
NON PREFERRED
AbilifyQL,ST
Abilify DiscmeltQL,ST
ClozarilQL
Equetro
FanaptQL,ST
Fanapt Titration PackQL,ST
FazacloQL
GeodonPA
HaldolPA
InvegaQL,ST
Invega SustennaST
LatudaQL
RisperdalQL
Risperdal ConstaPA
Risperdal M-TABQL
SaphrisQL,ST
SeroquelQL
ZyprexaQL
Zyprexa ZydisQL
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
16
HYPNOTICS
TIER 01
TIER 03
GENERIC
dexmedetomidine HCLPA
estazolam
eszopicloneQL,ST
flurazepam HCL
phenobarbital
temazepam
triazolam
zaleplonQL
zolpidem tartrateQL
zolpidem tartrate ERQL
Phenobarbital SodiumPA
NON PREFERRED
AmbienQL
Ambien CRQL
Amytal SodiumPA
EdluarQL,ST
IntermezzoQL
LunestaQL,ST
Nembutal SodiumPA
RozeremQL,ST
SonataQL
ADHD, NARCOLEPSY, ETC.
TIER 01
TIER 02
TIER 03
GENERIC
amphetamine/dextroamphetamineQL
caffeine citratePA
clonidine HCL ER
dexmethylphenidate HCLQL
dexmethylphenidate HCL ERQL
dextroamphetamine sulfateQL
dextroamphetamine sulfate ERQL
doxapram HCLPA
guanfacine ER
methamphetamine HCLQL
methylphenidate hydrochloride
methylphenidate HCLQL
methylphenidate HCL CDQL
methylphenidate HCL ERQL
methylphenidate HCL SRQL
modafinilQL,PA
Caffeine/Sodium BenzoatePA
PREFERRED
ConcertaQL
NON PREFERRED
AdderallQL
Adderall XRQL
DesoxynQL
DexedrineQL
FocalinQL
Focalin XRQL
Intuniv
Kapvay
Metadate CDQL
MethylinQL
Methylphenidate HCL ERQL
NuvigilQL,PA
ProvigilQL,PA
RitalinQL
Ritalin LAQL
Ritalin SRQL
StratteraQL
VyvanseQL
TIER 02
TIER 03
TIER 04
ANTIPARKINSON AGENTS
TIER 01
ANTICONVULSANTS
TIER 01
clonazepam
clonazepam odt
divalproex sodium
divalproex sodium DR
divalproex sodium ER
ethosuximide
felbamate
fosphenytoin sodiumPA
gabapentin
lamotrigine
lamotrigine odt
lamotrigine ER
levetiracetam
levetiracetam ER
oxcarbazepine
phenytoin
phenytoin sodiumPA
phenytoin sodium extended
primidone
tiagabine hydrochloride
topiramate
valproate sodiumPA
valproic acid
zonisamide
Diazepam
LevetiracetamPA
PREFERRED
BanzelPA
Carbatrol
Dilantin
Dilantin Infatabs
Dilantin-125
Phenytek
Tegretol
Tegretol-XR
NON PREFERRED
Celontin
Diastat Acudial
Diastat Pediatric
Gabitril
Keppra
Keppra XR
Lamictal Odt
Lamictal Starter/Not Taking Carbamazepine
Lamictal Starter/Taking Carbamazepine/Not Taking
Valproate
Lamictal Starter/Taking Valproate
Lamictal XR
LyricaQL,PA
OnfiPA
Peganone
Potiga
Vimpat
SPECIALTY
SabrilPA
GENERIC
carbamazepine
carbamazepine ER
GENERIC
amantadine HCL
benztropine mesylatePA
bromocriptine mesylate
carbidopa
carbidopa/levodopa
carbidopa/levodopa odt
carbidopa/levodopa ER
entacapone
pramipexole dihydrochloride
pramipexole dihydrochloride ER
ropinirole ER
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
17
TIER 03
TIER 04
ropinirole HCL
selegiline HCL
trihexyphenidyl HCL
Amantadine HCL
NON PREFERRED
Azilect
Carbidopa/Levodopa/Entacapone
CogentinPA
Lodosyn
Mirapex ER
Neupro
Stalevo 100
Stalevo 125
Stalevo 150
Stalevo 200
Stalevo 50
Stalevo 75
Tasmar
Zelapar
SPECIALTY
ApokynPA
NEUROLOGY, PSYCH - MISC.
TIER 01
TIER 02
TIER 03
TIER 04
GENERIC
acamprosate calcium DR
disulfiram
donepezil HCL
ergoloid mesylates
fluoxetine
galantamine
galantamine hydrobromide
olanzapine/fluoxetineQL
rivastigmine tartrate
PREVENTIVE
bupropion HCL SRQL
nicotineQL
nicotine polacrilexQL
nicotine polacrilex refillQL
nicotine polacrilex starter kitQL
nicotine transdermal systemQL
PREVENTIVE
ChantixQL
Chantix Continuing Month PAKQL
Chantix Starting Month PAKQL
Nicotine Transdermal SystemQL
NON PREFERRED
Aricept
Campral
Exelon
GraliseQL,PA
Gralise StarterQL,PA
HorizantQL,PA
Namenda
Namenda Titration PAK
Nuedexta
Orap
SarafemQL
SavellaQL
Savella Titration PackQL
SymbyaxQL
ZybanQL
PREVENTIVE
Nicotrol InhalerQL
Nicotrol NsQL
SPECIALTY
AmpyraQL,PA
AubagioQL,PA
AvonexQL,PA
Avonex PenQL,PA
BetaseronQL,PA
CopaxoneQL,PA
ExtaviaQL,PA
GilenyaQL,PA
RebifQL,PA
Rebif RebidoseQL,PA
Rebif Rebidose Titration PackQL,PA
Rebif Titration PackQL,PA
TecfideraQL,PA
Tecfidera Starter PackQL,PA
TysabriQL,PA
XenazineQL,PA
XyremQL,PA
NEUROMUSCULAR AGENTS
TIER 01
TIER 03
TIER 04
GENERIC
atracurium besylatePA
cisatracurium besylatePA
pancuronium bromidePA
riluzoleQL,PA
rocuronium bromidePA
vecuronium bromidePA
NON PREFERRED
AnectinePA
QuelicinPA
Quelicin 1000PA
RilutekQL,PA
SPECIALTY
BotoxPA
DysportPA
XeominPA
MUSCULOSKELETAL AGENTS
TIER 01
TIER 03
TIER 04
GENERIC
baclofen
carisoprodol
carisoprodol/aspirin
carisoprodol/aspirin/codeine
chlorzoxazone
cyclobenzaprine HCL
dantrolene sodium
metaxalone
methocarbamol
orphenadrine citratePA
orphenadrine citrate ER
orphenadrine/asa/caffeine
tizanidine HCL
Carisoprodol
NON PREFERRED
Amrix
Lorzone
NorflexPA
RobaxinPA
Soma
SPECIALTY
HyalganPA
SynviscPA
Synvisc OnePA
ANTIMYASTHENIC AGENTS
TIER 01
TIER 03
GENERIC
neostigmine methylsulfatePA
pyridostigmine bromide
Guanidine HCL
NON PREFERRED
EnlonPA
Mestinon
Mestinon Timespan
ProstigminPA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
18
RegonolPA
OPHTHALMOLOGY AND OTIC
ANTI-INFECTIVES
TIER 01
TIER 02
TIER 03
GENERIC
bacitracin/polymyxin b
ciprofloxacin HCL
erythromycin
gatifloxacin
gentamicin sulfate
levofloxacin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin zinc
neomycin/polymyxin/gramicidin
ofloxacin
polymyxin b sulfate/trimethoprim sulfate
sodium sulfacetamide
sulfacetamide sodium
tobramycin sulfate
trifluridine
trimethoprim sulfate/polymyxin b sulfate
Bacitracin
PREFERRED
Sulfacetamide Sodium
Tobrex
NON PREFERRED
Azasite
Besivance
Ciloxan
Moxeza
Natacyn
Vigamox
Zirgan
Zymaxid
TIER 03
PROSTAGLANDINS
TIER 01
TIER 02
TIER 03
GENERIC
latanoprostQL
PREFERRED
LumiganQL
Travatan ZQL
NON PREFERRED
ResculaQL
XalatanQL
ZioptanQL
CYCLOPLEGIC MYDRIATICS
TIER 01
GENERIC
atropine sulfate
cyclopentolate HCL
homatropine HBR
DECONGESTANTS
TIER 01
ARTIFICIAL TEAR/LUBRICANT
TIER 03
PREFERRED
Blephamide
Blephamide S.o.p.
FML
Pred Mild
NON PREFERRED
Alrex
Durezol
Flarex
FML Forte
Lotemax
Maxidex
Tobradex
Tobradex ST
Vexol
NON PREFERRED
Lacrisert
GENERIC
phenylephrine HCL
Naphazoline HCL
MIOTICS
BETA-BLOCKERS
TIER 01
TIER 02
TIER 03
GENERIC
betaxolol HCL
carteolol HCL
dorzolamide HCL/timolol maleate
levobunolol HCL
timolol maleate
timolol maleate ophthalmic gel forming
Istalol
Levobunolol HCL
PREFERRED
Betimol
Timoptic Ocudose
NON PREFERRED
Betoptic-s
Combigan
Cosopt PF
TIER 01
TIER 02
TIER 03
GENERIC
pilocarpine HCL
PREFERRED
Phospholine Iodide
NON PREFERRED
Pilopine HS
ADRENERGIC AGENTS
TIER 01
TIER 02
TIER 03
GENERIC
apraclonidine
brimonidine tartrate
PREFERRED
Simbrinza
NON PREFERRED
Alphagan P
Iopidine
IMMUNOMODULATORS
OPHTHALMIC STEROIDS
TIER 01
GENERIC
dexamethasone sodium phosphate
fluorometholone
neomycin/polymyxin/bacitracin/hydrocortisone
neomycin/polymyxin/dexamethasone
prednisolone acetate
sulfacetamide sodium/prednisolone sodium phosphate
tobramycin/dexamethasone
Neomycin/Polymyxin/Hydrocortisone
Prednisolone Sodium Phosphate
TIER 03
NON PREFERRED
RestasisQL
LOCAL ANESTHETICS
TIER 01
GENERIC
proparacaine HCL
tetracaine HCL
OPHTHALMICS - MISC.
TIER 01
TIER 02
GENERIC
azelastine HCL
bromfenac
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
19
TIER 03
TIER 04
cromolyn sodium
diclofenac sodium
dorzolamide HCL
epinastine HCL
flurbiprofen sodium
ketorolac tromethamine
NON PREFERRED
Acular
Acuvail
Alocril
Alomide
Azopt
Bepreve
Emadine
NevanacQL
Pataday
Patanol
SPECIALTY
CystaranQL,PA
OTIC AGENTS
TIER 01
TIER 03
GENERIC
acetic acid
antipyrine/benzocaine
fluocinolone acetonide
fluocinolone acetonide ear drops
hydrocortisone/acetic acid
neomycin/polymyxin/hydrocortisone
neomycin/polymyxin/HC
ofloxacin
Acetic Acid/Aluminum Acetate
NON PREFERRED
Cipro HC
Ciprodex
Coly-mycin S
Cortisporin-tc
OXYTOCICS
TIER 01
TIER 03
GENERIC
methylergonovine maleatePA
oxytocinPA
NON PREFERRED
PitocinPA
PAIN MANAGEMENT
TIER 02
TIER 03
ANALGESICS - NONNARCOTIC
TIER 01
TIER 02
GENERIC
butalbital/acetaminophen
butalbital/acetaminophen/caffeine
butalbital/apap/caffeine
butalbital/aspirin/caffeine
choline magnesium trisalicylate
diflunisal
salsalate
Butalbital/Aspirin/Caffeine
PREVENTIVE
aspirin
aspirin EC
aspirin EC low dose
aspirin 81
coated aspirin
enteric coated aspirin
PREFERRED
Phrenilin Forte
ANALGESICS - OPIOID
TIER 01
GENERIC
acetaminophen/codeine
acetaminophen/codeine #2
acetaminophen/codeine #3
acetaminophen/codeine #4
acetaminophen/codeine phosphate
alfentanilPA
buprenorphine HCLQL,PA
buprenorphine HCL/naloxone HCLQL,PA
butalbital/acetaminophen/caffeine/codeine
butalbital/aspirin/caffeine/codeine
butorphanol tartrateQL
codeine sulfate
fentanylQL
fentanyl citrate oral transmucosalQL,PA
hydrocodone bitartrate/acetaminophen
hydrocodone/acetaminophen
hydrocodone/ibuprofen
hydromorphone HCL
hydromorphone HCL ERQL,PA
meperidine HCL
methadone HCL
morphine sulfate
morphine sulfate ERQL,ST
nalbuphine HCLPA
oxycodone HCL
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofenQL
oxymorphone hydrochlorideQL,ST
oxymorphone hydrochloride ERQL
pentazocine/acetaminophen
pentazocine/naloxone HCL
tramadol hydrochloride/acetaminophenQL
tramadol HCLQL
tramadol HCL ERQL
Codeine Sulfate
Hydromorphone HCLPA
Hydromorphone HCL DosettePA
Levorphanol Tartrate
Meperidine HCL
Methadone HCLPA
Morphine Sulfate
Oxycodone HCL
Tramadol HCL ERQL
PREFERRED
ButransQL,PA
NON PREFERRED
AbstralQL,PA
ActiqQL,PA
AlfentaPA
AvinzaQL,ST
BuprenexPA
ConzipQL
DemerolPA
DilaudidPA
Dilaudid-HPPA
DuragesicQL
ExalgoQL,PA
FentoraQL,PA
Hydromorphone HCL ERQL,PA
Infumorph 200PA
Infumorph 500PA
KadianQL
LazandaQL,PA
MS ContinQL
NucyntaQL
Nucynta ERQL
OpanaQL,ST
Opana ER (crush Resistant)QL
Oxecta
Oxycodone HCL ERQL,ST
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
20
OxycontinQL,ST
Roxicet
SuboxoneQL,PA
SubsysQL,PA
TalwinPA
UltracetQL
UltramQL
Ultram ERQL
MIGRAINE PRODUCTS
TIER 01
ANTI-INFLAMMATORY
TIER 01
TIER 02
TIER 03
TIER 04
GENERIC
celecoxibQL
diclofenac potassium
diclofenac sodium DR
diclofenac sodium ER
diclofenac sodium/misoprostol
etodolac
etodolac ER
flurbiprofen
ibuprofen
indomethacin
indomethacin sodiumPA
indomethacin ER
ketoprofen
ketorolac tromethamineQL
leflunomide
mefenamic acid
meloxicam
nabumetone
naproxen
naproxen sodium
naproxen sodium ER
oxaprozin
piroxicam
sulindac
tolmetin sodium
Fenoprofen Calcium
Ketoprofen ER
Ketorolac TromethaminePA
Meclofenamate Sodium
Meloxicam
Tolmetin Sodium
PREFERRED
Indocin
Rheumatrex
NON PREFERRED
CelebrexQL
Mobic
Nalfon
Naprelan
Ridaura
SprixQL,PA
SPECIALTY
ActemraPA
ArcalystQL,PA
EnbrelQL,PA
Enbrel SureclickQL,PA
HumiraQL,PA
Humira Pediatric Crohns Disease Starter PackQL,PA
Humira PenQL,PA
Humira Pen-crohns DiseasestarterQL,PA
Humira Pen-psoriasis StarterQL,PA
IlarisQL,PA
KineretQL,PA
OrenciaQL,PA
OtezlaPA
SimponiQL,PA
XeljanzPA
TIER 02
TIER 03
GENERIC
dihydroergotamine mesylatePA
naratriptan HCLQL
rizatriptan benzoateQL
rizatriptan benzoate odtQL
sumatriptan succinateQL
sumatriptan succinate refillQL
zolmitriptanQL,ST
zolmitriptan odtQL,ST
Dihydroergotamine MesylateQL
SumatriptanQL
PREFERRED
AlsumaQL
MigergotPA
RelpaxQL
NON PREFERRED
AmergeQL
AxertQL,ST
Cambia
D.h.e. 45PA
Ergomar
FrovaQL,ST
ImitrexQL
Imitrex Statdose RefillQL
Imitrex Statdose SystemQL
MaxaltQL
Maxalt-MLTQL
MigranalQL
Sumatriptan SuccinateQL
Sumavel DoseproQL,ST
ZomigQL,ST
Zomig Nasal SprayQL,ST
Zomig ZMTQL,ST
GOUT AGENTS
TIER 01
TIER 03
GENERIC
allopurinol
probenecid
probenecid/colchicine
NON PREFERRED
Colchicine
Colcrys
Uloric
LOCAL ANESTHETICS-INJ
TIER 01
TIER 03
GENERIC
bupivacaine HCLPA
bupivacaine/epinephrinePA
chloroprocaine HCLPA
lidocaine HCLPA
lidocaine/epinephrinePA
ropivacainePA
ropivacaine HCLPA
BD Pudendal/Local Block Tray 1% LidocainePA
Mepivacaine HCLPA
NON PREFERRED
CarbocainePA
DuocainePA
Durasafe Spinal/Epidural Tray/1% Xylocaine/19GX36"close
CATHPA
Durasafe Spinal/Epidural Tray/1% Xylocaine/19GX36"open
CATHPA
Durasafe Spinal/Epidural Tray/1% Xylocaine/20GX36"close
CATHPA
Durasafe Spinal/Epidural Tray/1% Xylocaine/20GX36"open
CATHPA
ExparelPA
MarcainePA
Marcaine/EpinephrinePA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
21
Monoject Bone Marrow Biopsy Prepping TrayPA
Monoject Bone Marrow Biopsy Tray/Biop Aspir Needle
11GX4"PA
Monoject Bone Marrow Biopsy Tray/Biop Aspir Needle
8GX4"PA
Monoject Bone Marrow Biopsy Tray/Sternal-iliac Needle
16GPA
NaropinPA
NesacainePA
Nesacaine-mpfPA
Sensorcaine-mpf/EpinephrinePA
Tetracaine HCLPA
Turkel Paracentesis Procedure Tray/8frenchPA
Xylocaine-mpfPA
Xylocaine-mpf/EpinephrinePA
Xylocaine/EpinephrinePA
TIER 03
ANTIASTHMATIC/COPD AGENTS
TIER 01
RESPIRATORY, ALLERGY, ETC
ANTIHISTAMINES
TIER 01
TIER 03
GENERIC
carbinoxamine maleate
cetirizine HCL
clemastine fumarate
cyproheptadine HCL
desloratadine
desloratadine odt
diphenhydramine HCL
levocetirizine dihydrochloride
promethazine HCL
promethazine HCL plain
Clemastine Fumarate
Dexchlorpheniramine Maleate
NON PREFERRED
Clarinex
PhenerganPA
NASAL AGENTS
TIER 01
TIER 02
TIER 03
GENERIC
azelastine HCLQL
budesonideQL,ST
flunisolideQL
fluticasone propionateQL
ipratropium bromideQL
olopatadine HCLQL
triamcinolone acetonideQL
FlunisolideQL
PREFERRED
NasonexQL
NON PREFERRED
AstelinQL
AsteproQL
AtroventQL
Bactroban Nasal
Beconase AQQL,ST
DymistaQL
FlonaseQL
Nasacort AQQL
OmnarisQL,ST
PatanaseQL
QnaslQL,ST
Rhinocort AquaQL,ST
Tyzine
Tyzine Pediatric Nasal Drops
VeramystQL,ST
ZetonnaQL
TIER 02
TIER 03
COUGH/COLD/ALLERGY
TIER 01
benzonatate
bromphen/pseudoephedrine HCL/dextromethorphan HBR
hydrocodone bitartrate/chlorpheniramine maleate/PSE
hydrocodone bitartrate/homatropine methylbromide
hydrocodone polistirex/chlorpheniramine polistirex
hydrocodone/homatropine
phenylephrine/guaifenesin
promethazine-DM
promethazine/codeine
promethazine/dextromethorphan
sodium chloride
NON PREFERRED
Clarinex-d 12 HOUR
GENERIC
acetylcysteine
GENERIC
albuterol sulfate
albuterol sulfate ER
albuterol TAB 4MG
aminophyllinePA
budesonide
epinephrine HCLPA
ipratropium bromideQL
ipratropium bromide/albuterol sulfateQL
levalbuterolQL
levalbuterol HCLQL
montelukast sodium
terbutaline sulfate
theophylline
theophylline CR
theophylline ER
theophylline/D5WPA
zafirlukast
Metaproterenol Sulfate
Proair HFAQL
PREFERRED
Advair DiskusQL
Advair HFAQL
Breo ElliptaQL
DuleraQL
Elixophyllin
Flovent DiskusQL
Flovent HFAQL
Foradil AerolizerQL
Proventil HFAQL
Pulmicort FlexhalerQL
QvarQL
Serevent DiskusQL
Spiriva HandihalerQL
SymbicortQL
Theo-24
Theophylline/D5WPA
Tudorza PressairQL
Ventolin HFAQL
Xopenex HFAQL
NON PREFERRED
AccunebQL
AlvescoQL
Anoro ElliptaQL
Arcapta NeohalerQL
Asmanex Twisthaler 120 Metered DosesQL
Asmanex Twisthaler 14 Metered DosesQL
Asmanex Twisthaler 30 Metered DosesQL
Asmanex Twisthaler 60 Metered DosesQL
Asmanex Twisthaler 7 Metered DosesQL
Atrovent HFAQL
BrovanaQL
CombiventQL
Combivent RespimatQL
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
22
TIER 04
DalirespPA
DuonebQL
IsuprelPA
Lufyllin
Maxair AutohalerQL
PerforomistQL
PulmicortQL
XopenexQL
Xopenex ConcentrateQL
Zyflo CR
SPECIALTY
XolairPA
RESPIRATORY AGENTS - MISC
TIER 04
SPECIALTY
Aralast NPPA
GlassiaPA
KalydecoPA
Prolastin-cPA
PulmozymePA
ZemairaPA
VITAMINS
VITAMINS
TIER 01
TIER 03
GENERIC
ascorbic acidPA
ergocalciferol
phytonadionePA
thiamine HCLPA
vitamin c 222MGPA
vitamin d
vitamin k1PA
Vitamin K1PA
PREVENTIVE
d3
d3 ultra strength
vitamin d 400
vitamin d-1000
vitamin d-3
vitamin d3
NON PREFERRED
Drisdol
Pyridoxine HCLPA
PREVENTIVE
Ddrops
Dialyvite Vitamin D3 Max
D3
D3 Dots
Replesta
Replesta Childrens
Replesta Nx
Thera-d 4000
Vitamelts Vitamin D
Vitamin D
Vitamin D3
Vitamin D3 400
Wellesse Vitamin D3
MULTIVITAMINS
TIER 01
TIER 03
GENERIC
b-complexPA
b-complex 100PA
niacinamide/azelaic ac/ turmer/fa/b6/zinc ox/copper
NON PREFERRED
AlbafortPA
Atabex EC
Bacmin
Bal-care DHA
Bal-care DHA Essential
Cavan-alpha Kit
Citranatal Assure
Citranatal B-calm
Citranatal DHA
Citranatal Harmony
Citranatal RX
Citranatal 90 DHA
Cod Liver Oil
Concept DHA
Concept OB
Corvite
Crnatal
CO-natal Fa
Dialyvite Supreme D
Dialyvite 3000
Dialyvite 5000
Dialyvite/Zinc
Diatx ZN
Duet DHA Balanced
Duet DHA 400
Duet DHA 400EC
Duet DHA 430
Duet DHA 430EC
Elite-OB
Escavite
Escavite D
Floriva
Folbecal
Folcaps Omega 3
Folet DHA
Folet One
Folgard OS
Folivane-prx DHA NF
Folivane-OB
Fortavit
Gesticare DHA
Inatal Advance
Inatal GT
Inatal Ultra
M.v.i. AdultPA
M.v.i. PediatricPA
M.v.i.-12 Without Vitamin KPA
M-vit
Macnatal CN DHA
Marnatal-f
Moms Choice RX
Mykidz Iron Fl
Mynatal
Mynatal Advance
Mynatal Ultracaplet
Natachew
Natafort
Natalvirt CA
Natalvirt 90 DHA
Natalvit
Natelle One
Neevo DHA
Nephplex RX
Nephro-vite RX
Nephrocaps
Nephrocaps QT
Nestabs
Nestabs Abc
Nestabs DHA
Newgen
Nexa Plus
Nicadan
Nicazel
Nicazel Forte
Nicomide
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
23
Niva-plus
Nutricap
Nutrivit
O-CAL Fa
O-CAL Prenatal
Obstetrix DHA
Obstetrix EC
Ocuvel
OB Complete
OB Complete One
OB Complete Petite
OB Complete Premier
OB Complete 400
OB Complete/DHA
OB-natal One
Paire OB
Poly-VI-flor
Poly-VI-flor FS
Poly-VI-flor/Iron
Pr Natal 400
Pr Natal 400 EC
Pr Natal 430
Pr Natal 430 EC
Prefera OB
Prefera OB + DHA
Preferaob +dha
Preferaob One
Prefol-DHA
Prenata
Prenatabs RX
Prenatal Ad
Prenatal-u
Prenate
Prenate AM
Prenate DHA
Prenate Elite
Prenate Enhance
Prenate Essential
Prenate Mini
Prenate Pixie
Prenate Restore
Prenate Star
Preque 10
Protect Plus
Protectbone
Protectnatal
Provida OB
Quflora Pediatric
R-natal OB
Renatabs
Renatabs With Iron
Req 49+
Select-ob+dha
Select-OB
Siderol
Strovite
Strovite Forte
Strovite One
Supervite
Supervite EC
Support-500
Synagex
Synatek
Taron-bc
Taron-c DHA
Taron-prex
Tri-VI-flor
Tricare
Tricare Prenatal Compleat
Tricare Prenatal DHA One
TIER 04
Trinate
Triveen-duo DHA
Triveen-prx RNF
TL G-FOL OS
Udamin
Udamin SP
Vemavite-prx 2
Vinacal
Vinacal B
Vinate AZ Extra
Vinate C
Vinate Calcium
Vinate Care
Vinate DHA
Vinate DHA RF
Vinate GT
Vinate IC
Vinate II
Vinate M
Vinate One
Vinate Pn Care
Vita-pren
Vitafol
Vitafol Ultra
Vitafol-nano
Vitafol-ob+dha
Vitafol-one
Vitafol-pn
Vitafol-OB
Vital-d RX
Vitamedmd One RX/Quatrefolic
Vitamedmd Plus RX/Quatre Folic
Vitamedmd Redichew RX
Vitamedmd Redichew RX/Quatrefolic
Vitapearl
Vitaroca Plus
Viva CT Prenatal
Viva DHA
Zatean-pn
Zatean-pn DHA
Zatean-pn Plus
Zatean-CH
PREVENTIVE
Atabex Prenatal
Brainstrong Prenatal
Centrum Specialist Prenatal
Enfamil Expecta
Healthy Mama Be Well Rounded
Mission Prenatal
Mission Prenatal HP
One A Day Womens Prenatal/DHA
One A Day Womens Prenatal1
One-a-day Womens Prenatal
Perry Prenatal
Prenatal Multivitamin + DHA
Prenatal Plus DHA
Prenatal Vitamin
Prenatal Vitamins
Right Step Prenatal
Similac Prenatal Early Shield
Stuart One
Stuart Prenatal
Stuart Prenatal + DHA
Your Life Multi Prenatal
SPECIALTY
Adrenal C Formula
MEDICAL DEVICES
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
24
DIABETIC SUPPLIES
TIER 02
TIER 03
PREFERRED
Accu-chek Active StripsQL
Accu-chek AvivaQL
Accu-chek Aviva PlusQL
Accu-chek Comfort Curve Test StripsQL
Accu-chek Compact PlusQL
Accu-chek Compact Test DrumQL
Accu-chek Multiclix Lanc Et Device Kit
Accu-chek Multiclix LancetsQL
Accu-chek Nano SmartviewQL
Accu-chek Smartview StripsQL
Ascensia Autodisc Test StripsQL
Bayer Breeze 2 Test DiscQL
Bayer Contour Blood Glucose Test StripsQL
Bayer Contour Next Blood Glucose TestQL
Bayer Microlet LancetsQL
NON PREFERRED
Accu-chek Softclix LancetsQL
Advance Micro-draw Test StripsQL
Advocate Redi-codeQL
Agamatrix PrestoQL
Agamatrix Presto Test StripsQL
Bg Star Blood Glucose TestQL
Clever Chek Auto-code Voice Test StripsQL
Element Test StripsQL
Embrace Blood Glucose Test StripsQL
Fasttake Test StripsQL
Fora V12 Blood Glucose Test StripsQL
Freestyle Freedom LiteQL
Freestyle Insulinx Blood Glucose TestQL
Freestyle Lite Blood Glucose Monitoring SystemQL
Freestyle Lite Test StripsQL
Freestyle System KitQL
Freestyle Test StripsQL
Glucocard Vital Test StripsQL
G4 Sensor Kit
Inset 30 Infusion Set 23"
Insulin Syringe/0.5ML/30G X 5/16"QL
Lancets 30G Twist TopQL
Liberty Glucose Control Level 1
Liberty Glucose Control Normal
Liberty Next Generation Blood Glucose Test StripsQL
Nova Max Glucose Test StripsQL
Onetouch Basic/Profile Test StripsQL
Onetouch Delica Lancets Fine 30GQL
Onetouch Finepoint LancetsQL
Onetouch Ultra BlueQL
Onetouch Ultra MiniQL
Onetouch Ultra 2QL
Onetouch Verio Test StripsQL
Optium Test StripsQL
Precision QID Test StripsQL
Precision XTRA Blood Glucose Test StripsQL
Prodigy NO Coding Blood Glucose Test StripsQL
Relion Blood Glucose TeststripsQL
Relion Confirm/Micro Test StripsQL
Relion Insulin Syringe/U-100/0.5ML/29G X 1/2"QL
Relion Prime Blood Glucose Test StripsQL
Relion Ultima Blood Glucose Test StripsQL
Relion Ultima Test StripsQL
Solus V2 Audible TestQL
Trueresult Blood Glucose Monitoring SystemQL
Truetest StripsQL
Truetrack TestQL
Ultima Test StripsQL
Wavesense Presto Test StripsQL
MISCELLANEOUS
TIER 01
QL
GENERIC
acetylcysteinePA
calcium chloridePA
calcium gluconatePA
chromium chloridePA
cysteine HCLPA
dehydrated alcoholPA
dextrose 10%PA
dextrose 10% flex containerPA
dextrose 30%PA
dextrose 30% partial fillPA
dextrose 5%PA
dextrose 5% viaflexPA
dextrose 50%PA
dextrose 70%PA
effervescent potassium
effervescent potassium/chloride
flumazenilPA
fomepizolePA
formaldehyde
l-cysteine HCLPA
lanolin
magnesium chloridePA
magnesium sulfatePA
methylene bluePA
morrhuate sodiumPA
n-acetyl-l-cysteine
naloxone HCLPA
naltrexone HCL
normal saline flushPA
normal saline flush for flushing vascular access devicesPA
normal saline i.v. flushPA
potassium acetatePA
potassium bicarbonate
potassium chloride
potassium chloride CR
potassium chloride ER
potassium chloride SR
potassium phosphatePA
potassium phosphatesPA
saline flushPA
sodium acetatePA
sodium bicarbonatePA
sodium bicarbonate partial fillPA
sodium chloridePA
sodium chloride bacteriostaticPA
sodium chloride flushPA
sodium chloride pabPA
sodium chloride 0.45%PA
sodium chloride 0.45% viaflexPA
sodium phosphatePA
sodium polystyrene sulfonate
sodium thiosulfatePA
sterile diluent for epoprostenol sodiumPA
sterile water for injectionPA
zinc sulfate
Bacteriostatic Water ParabensPA
Calcium Disodium VersenatePA
Hsa Sterile DiluentPA
Magnesium SulfatePA
Magnesium Sulfate IN D5WPA
Physostigmine SalicylatePA
Potassium ChloridePA
Saline/PhenolPA
Sodium Chloride Bacteriostatic/Benzyl AlcoholPA
PREVENTIVE
fluoride
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
25
TIER 03
sodium fluoride
NON PREFERRED
AminosynPA
Aminosyn IIPA
Aminosyn MPA
Aminosyn 7%/ElectrolytesPA
Aminosyn-HBCPA
Aminosyn-PFPA
Aminosyn-PF 7%PA
Aminosyn-RFPA
AmphadasePA
Availnex
Axona
Bacteriostatic Water For Injection/Benzyl AlcoholPA
Cardiotek-RX
Cerefolin
Cerefolin NAC
Chemet
Clinimix E 2.75%/Dextrose 10%PA
Clinimix E 2.75%/Dextrose 5%PA
Clinimix E 4.25%/Dextrose 10%PA
Clinimix E 4.25%/Dextrose 25%PA
Clinimix E 4.25%/Dextrose 5%PA
Clinimix E 5%/Dextrose 15%PA
Clinimix E 5%/Dextrose 20%PA
Clinimix E 5%/Dextrose 25%PA
Clinimix 2.75%/Dextrose 5%PA
Clinimix 4.25%/Dextrose 10%PA
Clinimix 4.25%/Dextrose 20%PA
Clinimix 4.25%/Dextrose 25%PA
Clinimix 4.25%/Dextrose 5%PA
Clinimix 5%/Dextrose 15%PA
Clinimix 5%/Dextrose 20%PA
Clinimix 5%/Dextrose 25%PA
Cyanocobalamin/Levomefolate Calcium/Pyridoxine HCL
Cysteine HCLPA
Depen Titratabs
Deplin
Deplin 15
Deplin 7.5
Dermanic
Eligen B12
Enlyte
Enteragam
Falessa
Fluor-a-day
Fluorabon
Flura-drops
Folbee AR
Folbic RF
Foltanx
Foltanx RF
Foltx
Fosteum
Fosteum Plus
Fovex
Freamine HBC 6.9%PA
Freamine IiiPA
Freamine Iii 3%PA
Gabadone
HylenexPA
Hypertensa
Ketocare
Ketostix
Klor-CON M15
L-methyl-b6-b12
L-methylfolate
L-methylfolate Calcium
L-methylfolate CA/P-5-P.M.-CBL
Lecithin
TIER 04
Levomefolate Calcium/Acetylcysteine/Mecobalamin/Algal
Powder
Levomefolate Calcium/Algal Powder
Levomefolate Calcium/Pyridoxal
Phosphate/Mecobalamin/Algal
Limbrel
Limbrel250
Limbrel500
Lipichol 540
Liposyn IiiPA
Lister-v
Lmthf/Pyridoxine HCL/Cyanocobalamin
Lozi-flur
Lukaid GLA
Lunglaid
Luride
Macutek
Metafolbic
Metafolbic Plus
Metafolbic Plus RF
Metanx
Methylfol-algae-b12-acetylcyst
NephraminePA
Neurepa
Nutrestore
Percura
Podiapn
PremasolPA
ProcalaminePA
ProsolPA
Proteolin
Pulmona
Puralor
Puralor Ci
Relion Ketone
Sentra AM
Sentra PM
Sodium Fluoride
Syprine
Tears Again Hydrate
Theramine
Theramine Plus
Tozal
TravasolPA
Trepadone
TrophaminePA
Tryptophan
Vascazen
Vasculera
Vayacog
Vayarin
Vayarol
Virilex
Vita-respa
VitrasePA
VivitrolPA
SPECIALTY
alprostadilPA
deferoxamine mesylatePA
BenlystaPA
BivigamPA
Carimune NanofilteredPA
DesferalPA
ExjadePA
FerriproxPA
Flebogamma DifPA
Gamastan S/DPA
Gammagard LiquidPA
Gammagard S/DPA
Gammagard S/D Iga Less Than 1mcg/MLPA
GammakedPA
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
26
GammaplexPA
Gamunex-cPA
HizentraPA
Hyperhep B S/DPA
Hyperrho S/DPA
Hyperrho S/D Mini-dosePA
Micrhogam Ultra-filtered PlusPA
Nabi-HBPA
OctagamPA
PrivigenPA
Prostin VR PediatricPA
Rhogam Ultra-filtered PlusPA
RhophylacPA
SynagisPA
Winrho SDFPA
XiaflexPA
ACA PREVENTIVE DRUGS
ASPIRIN
TIER 01
PREVENTIVE
aspirin
aspirin EC
aspirin EC low dose
aspirin 81
coated aspirin
enteric coated aspirin
TIER 03
IRON
TIER 01
TIER 03
CONTRACEPTIVES
TIER 01
TIER 02
TIER 03
PREVENTIVE
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
levonorgestrel and ethinyl estradiolQL
levonorgestrel/ethinyl estradiol
medroxyprogesterone acetateQL,PA
norethindrone
norethindrone & ethinyl estradiol ferrous fumarate
norethindrone acetate/ethinyl estradiol
norethindrone acetate/ethinyl estradiol/ferrous fumarate
norgestimate/ethinyl estradiol
NuvaringQL
Ortho Evra
PREFERRED
Necon 10/11-28
Ogestrel
Ortho Tri-cyclen LO
Zovia 1/50e
NON PREFERRED
Depo-subq Provera 104QL
LO Loestrin FE
Natazia
Safyral
SeasoniqueQL
TIER 01
TIER 02
TIER 03
PREVENTIVE
fluoride
sodium fluoride
NON PREFERRED
Floriva
Fluor-a-day
Fluorabon
Flura-drops
Lozi-flur
Luride
Sodium Fluoride
TIER 03
PREVENTIVE
bupropion HCL SRQL
nicotineQL
nicotine polacrilexQL
nicotine polacrilex refillQL
nicotine polacrilex starter kitQL
nicotine transdermal systemQL
PREVENTIVE
ChantixQL
Chantix Continuing Month PAKQL
Chantix Starting Month PAKQL
Nicotine Transdermal SystemQL
NON PREFERRED
ZybanQL
PREVENTIVE
Nicotrol InhalerQL
Nicotrol NsQL
VITAMIN D
TIER 01
FOLIC ACID
TIER 01
PREVENTIVE
ferrous drops
ferrous fumarate 324
ferrous gluconate
ferrous sulfate
iron
FE gluconate
PREVENTIVE
Elite Iron
Femiron
Feosol
Ferrimin 150
Ferro-sequels
Ferrous Fumarate
Ferrous Gluconate
Ferrous Sulfate
FE Aspartate
Iron
Iron Up
Mykidz Iron 10
Novaferrum Pediatric Drops
Perfect Iron
Profe
Proferrin ES
SMOKING CESSATION
FLUORIDE
TIER 01
NON PREFERRED
M-vit
Niva-plus
O-CAL Fa
Tricare
PREVENTIVE
Atabex Prenatal
Fa-8
Mission Prenatal
Mission Prenatal HP
One-a-day Womens Prenatal
Perry Prenatal
Prenatal Vitamin
Prenatal Vitamins
Right Step Prenatal
Stuart Prenatal
Stuart Prenatal + DHA
PREVENTIVE
folic acid
PREVENTIVE
d3
d3 ultra strength
vitamin d
vitamin d 400
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
27
TIER 03
vitamin d-1000
vitamin d-3
vitamin d3
PREVENTIVE
Ddrops
Dialyvite Vitamin D3 Max
D3
D3 Dots
Replesta
Replesta Childrens
Replesta Nx
Thera-d 4000
Vitamelts Vitamin D
Vitamin D
Vitamin D3
Vitamin D3 400
Wellesse Vitamin D3
BOWEL PREPARATION AGENTS
TIER 01
TIER 03
PREVENTIVE
peg 3350/electrolytes
peg-3350/electrolytes
peg-3350/NACL/NA bicarbonate/KCL
NON PREFERRED
Colyte-flavor Packs
Golytely
BREAST CANCER
TIER 01
PREVENTIVE
tamoxifen citrate
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; GL=Gender Limits;
28
Index
A
A-hydrocort, 9
abacavir, 2
abacavir sulfate/lamivudine/zidovudine, 2
Abelcet, 2
Abilify, 16
Abilify Discmelt, 16
Abraxane, 5
Absorica, 8
Abstral, 20
acamprosate calcium DR, 18
Acanya, 8
acarbose, 11
Accu-chek Active Strips, 25
Accu-chek Aviva, 25
Accu-chek Aviva Plus, 25
Accu-chek Comfort Curve Test Strips, 25
Accu-chek Compact Plus, 25
Accu-chek Compact Test Drum, 25
Accu-chek Multiclix Lanc Et Device Kit,
25
Accu-chek Multiclix Lancets, 25
Accu-chek Nano Smartview, 25
Accu-chek Smartview Strips, 25
Accu-chek Softclix Lancets, 25
Accuneb, 22
acebutolol HCL, 5
acetaminophen/codeine, 20
acetaminophen/codeine #2, 20
acetaminophen/codeine #3, 20
acetaminophen/codeine #4, 20
acetaminophen/codeine phosphate, 20
acetazolamide, 7
Acetazolamide, 7
acetazolamide ER, 7
acetazolamide sodium, 7
acetic acid, 20
Acetic Acid/Aluminum Acetate, 20
acetylcysteine, 22, 25
Aciphex, 13
acitretin, 8
Actemra, 21
Actigall, 13
Actimmune, 5
Actiq, 20
Actonel, 11
Actoplus Met XR, 11
Acular, 20
Acuvail, 20
acyclovir, 2, 8
acyclovir sodium, 2
Acyclovir Sodium, 2
adapalene, 8
Adapalene, 8
Adcirca, 7
Adderall, 17
Adderall XR, 17
adefovir dipivoxil, 2
Adempas, 7
adenosine, 6
Adrenaclick, 7
Adrenal C Formula, 24
Adrenalin, 7
Advair Diskus, 22
Advair HFA, 22
Advance Micro-draw Test Strips, 25
Advicor, 7
Advocate Redi-code, 25
Afinitor, 5
Afrezza, 10
Agamatrix Presto, 25
Agamatrix Presto Test Strips, 25
Aggrenox, 15
Akne-mycin, 8
Albafort, 14, 23
Albenza, 3
albuterol sulfate, 22
albuterol sulfate ER, 22
albuterol TAB 4MG, 22
alclometasone dipropionate, 8
Aldactazide, 7
Aldurazyme, 12
alendronate sodium, 11
Alendronate Sodium, 11
Alfenta, 20
alfentanil, 20
Alferon N, 5
alfuzosin HCL ER, 14
Alinia, 3
Alkeran, 4
allopurinol, 21
Alocril, 20
Alomide, 20
Alora, 10
Aloxi, 13
Alphagan P, 19
alprazolam, 15
alprazolam ER, 16
Alprazolam Intensol, 16
alprazolam odt, 15
alprostadil, 26
Alrex, 19
Alsuma, 21
Altabax, 8
Altoprev, 7
Alvesco, 22
amantadine HCL, 17
Amantadine HCL, 18
Ambien, 17
Ambien CR, 17
Ambisome, 2
Amcinonide, 9
Amerge, 21
amifostine, 5
amikacin sulfate, 2
amiloride HCL, 7
amiloride/hydrochlorothiazide, 7
aminocaproic acid, 15
aminophylline, 22
Aminosyn, 26
Aminosyn 7%/Electrolytes, 26
Aminosyn II, 26
Aminosyn M, 26
Aminosyn-HBC, 26
Aminosyn-PF, 26
Aminosyn-PF 7%, 26
Aminosyn-RF, 26
amiodarone HCL, 6
Amiodarone HCL, 6
Amitiza, 13
amitriptyline HCL, 16
amlodipine besylate, 6
amlodipine besylate/atorvastatin calcium,
7
amlodipine besylate/benazepril HCL, 6
amlodipine besylate/benazepril
hydrochloride, 6
amlodipine besylate/valsartan, 6
amlodipine/valsartan/hctz, 6
ammonium lactate, 9
Amoxapine, 16
amoxicillin, 1
Amoxicillin, 1
Amoxicillin ER, 1
amoxicillin/clavulanate potassium, 1
amoxicillin/clavulanate potassium ER, 1
Amphadase, 26
amphetamine/dextroamphetamine, 17
Amphotericin B, 2
ampicillin, 1
Ampicillin, 1
ampicillin sodium, 1
Ampicillin Sodium, 1
ampicillin-sulbactam, 1
Ampicillin-sulbactam, 1
Ampyra, 18
Amrix, 18
Amytal Sodium, 17
Anadrol-50, 10
anagrelide hydrochloride, 15
anastrozole, 4
Androderm, 10
Androgel, 10
Androgel P.M., 10
Android, 10
Androxy, 10
Anectine, 18
Angeliq, 10
Animi-3, 14
Animi-3/Vitamin D, 14
Anoro Ellipta, 22
antipyrine/benzocaine, 20
Anusol-HC, 13
Anzemet, 13
Apexicon E, 9
Apidra, 10
Apidra Solostar, 10
Apokyn, 18
apraclonidine, 19
Apriso, 13
Aptivus, 3
Aralast NP, 23
Aranesp Albumin Free, 15
Arcalyst, 21
Arcapta Neohaler, 22
argatroban, 15
Argatroban, 15
Aricept, 18
Aristospan Intra-articular, 9
Aristospan Intralesional, 9
Arixtra, 15
Arranon, 4
Arzerra, 4
Asacol HD, 13
Ascensia Autodisc Test Strips, 25
ascorbic acid, 23
Asmanex Twisthaler 120 Metered Doses,
22
Asmanex Twisthaler 14 Metered Doses,
22
Asmanex Twisthaler 30 Metered Doses,
22
Asmanex Twisthaler 60 Metered Doses,
22
Asmanex Twisthaler 7 Metered Doses,
22
aspirin, 20, 27
aspirin 81, 20, 27
aspirin EC, 20, 27
aspirin EC low dose, 20, 27
Astelin, 22
Astepro, 22
Atabex EC, 23
Atabex Prenatal, 24, 27
Atacand, 6
Atelvia, 11
atenolol, 5
atenolol/chlorthalidone, 6
Ativan, 16
atorvastatin calcium, 7
atovaquone, 3
atovaquone/proguanil HCL, 3
atracurium besylate, 18
Atralin, 8
Atripla, 3
atropine sulfate, 13, 19
Atropine Sulfate, 13
Atrovent, 22
Atrovent HFA, 22
Aubagio, 18
augmented betamethasone dipropionate,
8
Augmentin, 1
Auvi-q, 7
Availnex, 26
Avandia, 11
Avelox, 2
Avelox Abc Pack, 2
Avinza, 20
Avodart, 14
Avonex, 18
Avonex Pen, 18
Axert, 21
Axiron, 10
Axona, 26
azacitidine, 4
Azactam, 3
Azactam IN Iso-osmotic Dextrose, 3
Azasan, 4
Azasite, 19
azathioprine, 4
azelastine HCL, 19, 22
Azelex, 8
Azilect, 18
azithromycin, 1
Azithromycin, 1
Azopt, 20
Azor, 7
aztreonam, 3
B
B-6 Folic Acid, 14
b-complex, 23
b-complex 100, 23
bacitracin, 3
Bacitracin, 3, 19
bacitracin/polymyxin b, 19
baclofen, 18
Bacmin, 23
Bacteriostatic Water For Injection/Benzyl
Alcohol, 26
Bacteriostatic Water Parabens, 25
Bactocill IN Dextrose, 1
Bactroban, 8
Bactroban Nasal, 22
Bal-care DHA, 23
Bal-care DHA Essential, 23
balsalazide disodium, 13
Banzel, 17
Baraclude, 3
Bayer Breeze 2 Test Disc, 25
Bayer Contour Blood Glucose Test Strips,
25
Bayer Contour Next Blood Glucose Test,
25
Bayer Microlet Lancets, 25
BD Pudendal/Local Block Tray 1%
Lidocaine, 21
Beconase AQ, 22
benazepril HCL, 6
benazepril HCL/hydrochlorothiazide, 6
Benicar, 6
Benicar HCT, 7
Benlysta, 26
Bentyl, 13
Benzamycinpak, 8
benzonatate, 22
benzoyl peroxide, 8
benzoyl peroxide SHORT contact, 8
benztropine mesylate, 17
Bepreve, 20
Besivance, 19
betamethasone dipropionate, 8
betamethasone sodium
phosphate/betamethasone acetate, 9
betamethasone valerate, 8
Betaseron, 18
betaxolol HCL, 5, 19
bethanechol chloride, 14
Betimol, 19
Betoptic-s, 19
Bg Star Blood Glucose Test, 25
Biaxin XL, 1
Biaxin XL PAC, 1
bicalutamide, 4
Bicillin C-R, 1
Bicillin L-a, 1
Biferarx, 14
Biltricide, 3
Binosto, 11
bisoprolol fumarate, 5
bisoprolol fumarate/hydrochlorothiazide,
6
Bivigam, 26
bleomycin sulfate, 4
Blephamide, 19
Blephamide S.o.p., 19
Boniva, 11
Bosulif, 5
Botox, 18
Brainstrong Prenatal, 24
Bravelle, 11
Breo Ellipta, 22
Brevibloc, 6
Brilinta, 15
brimonidine tartrate, 19
Brintellix, 16
bromfenac, 19
bromocriptine mesylate, 17
bromphen/pseudoephedrine
HCL/dextromethorphan HBR, 22
Brovana, 22
budesonide, 9, 22(2)
bumetanide, 7
Buphenyl, 12
bupivacaine HCL, 21
bupivacaine/epinephrine, 21
Buprenex, 20
buprenorphine HCL, 20
buprenorphine HCL/naloxone HCL, 20
bupropion HCL, 16
bupropion HCL ER, 16
bupropion HCL SR, 16, 18, 27
bupropion HCL XL, 16
buspirone HCL, 16
butalbital/acetaminophen, 20
butalbital/acetaminophen/caffeine, 20
butalbital/acetaminophen/caffeine/codein
e, 20
butalbital/apap/caffeine, 20
butalbital/aspirin/caffeine, 20
Butalbital/Aspirin/Caffeine, 20
butalbital/aspirin/caffeine/codeine, 20
butorphanol tartrate, 20
Butrans, 20
Bydureon, 11
Byetta, 11
Bystolic, 6
C
cabergoline, 12
caffeine citrate, 17
Caffeine/Sodium Benzoate, 17
calcipotriene, 8
calcipotriene/betamethasone
dipropionate, 8
calcitonin salmon, 11
calcitonin-salmon, 11
Calcitriol, 8
calcitriol, 12
calcium acetate, 13
calcium chloride, 25
Calcium Disodium Versenate, 25
Calcium Folinate, 5
calcium gluconate, 25
Cambia, 21
Campral, 18
Camptosar, 5
Canasa, 13
Cancidas, 2
candesartan cilexetil, 6
candesartan cilexetil/hydrochlorothiazide,
6
Cantil, 13
Capastat Sulfate, 2
capecitabine, 4
Capex, 9
Caprelsa, 5
captopril, 6
Captopril/Hydrochlorothiazide, 7
Carac, 9
Carafate, 13
Carbaglu, 12
carbamazepine, 17
carbamazepine ER, 17
Carbatrol, 17
carbidopa, 17
carbidopa/levodopa, 17
carbidopa/levodopa ER, 17
carbidopa/levodopa odt, 17
Carbidopa/Levodopa/Entacapone, 18
carbinoxamine maleate, 22
Carbocaine, 21
carboplatin, 3
Cardiotek-RX, 26
Cardizem LA, 6
Cardura XL, 14
Carimune Nanofiltered, 26
carisoprodol, 18
Carisoprodol, 18
carisoprodol/aspirin, 18
carisoprodol/aspirin/codeine, 18
carteolol HCL, 19
carvedilol, 5
Catapres-tts-1, 6
Catapres-tts-2, 6
Catapres-tts-3, 6
Cathflo Activase, 15
Cavan-alpha Kit, 23
Cayston, 3
Cedax, 1
cefaclor, 1
Cefaclor, 1
Cefaclor ER, 1
cefadroxil, 1
cefazolin sodium, 1
Cefazolin Sodium, 1
Cefazolin Sodium/Dextrose, 1
cefdinir, 1
Cefditoren Pivoxil, 1
cefepime, 1
Cefepime, 1
cefotaxime sodium, 1
Cefotetan, 1
Cefotetan/Dextrose, 1
cefoxitin sodium, 1
Cefoxitin Sodium, 1
cefpodoxime proxetil, 1
cefprozil, 1
ceftazidime, 1
Ceftazidime, 1
Ceftazidime/Dextrose, 1
Ceftibuten, 1
Ceftin, 1
Ceftriaxone IN Iso-osmotic Dextrose, 1
ceftriaxone sodium, 1
Ceftriaxone/Dextrose, 1
cefuroxime axetil, 1
Cefuroxime Sodium, 1
cefuroxime sodium, 1
Cefuroxime/Dextrose, 1
Celebrex, 21
celecoxib, 21
Celestone, 10
Celestone-soluspan, 10
Celexa, 16
Cellcept, 4
Cellcept Intravenous, 4
Celontin, 17
Cenestin, 10
Cenfol, 14
Centratex, 14
Centrum Specialist Prenatal, 24
cephalexin, 1
Cephalexin, 1
Cerdelga, 15
Cerefolin, 26
Cerefolin NAC, 26
Cerezyme, 15
Cesamet, 13
cetirizine HCL, 22
Cetrotide, 12
cevimeline HCL, 15
Chantix, 18, 27
Chantix Continuing Month PAK, 18, 27
Chantix Starting Month PAK, 18, 27
Chemet, 26
Chenodal, 13
Chloramphenicol Sodium Succinate, 3
chlordiazepoxide HCL, 16
chlorhexidine gluconate, 15
chlorhexidine gluconate oral rinse, 15
chloroprocaine HCL, 21
chloroquine phosphate, 3
chlorothiazide, 7
chlorothiazide sodium, 7
chlorpromazine HCL, 16
Chlorpromazine HCL, 16
Chlorpropamide, 11
Chlorthalidone, 7
chlorzoxazone, 18
cholestyramine, 7
cholestyramine light, 7
choline magnesium trisalicylate, 20
chorionic gonadotropin, 11
chromium chloride, 25
Cialis, 7
Ciclodan Cream Kit, 8
ciclopirox, 8
ciclopirox nail lacquer, 8
ciclopirox olamine, 8
cidofovir, 2
Ciferex, 14
cilostazol, 15
Ciloxan, 19
cimetidine, 13
cimetidine HCL, 13
Cimzia, 13
Cimzia Starter Kit, 13
Cipro, 2
Cipro HC, 20
Cipro XR, 2
Ciprodex, 20
ciprofloxacin, 2
ciprofloxacin ER, 2
ciprofloxacin HCL, 2, 19
ciprofloxacin I.V.-IN D5W, 2
cisatracurium besylate, 18
cisplatin, 3
citalopram hydrobromide, 16
Citranatal 90 DHA, 23
Citranatal Assure, 23
Citranatal B-calm, 23
Citranatal DHA, 23
Citranatal Harmony, 23
Citranatal RX, 23
citric acid/sodium citrate, 14
cladribine, 4
Claforan, 1
Claravis, 8
Clarinex, 22
Clarinex-d 12 HOUR, 22
clarithromycin, 1
clarithromycin ER, 1
clemastine fumarate, 22
Clemastine Fumarate, 22
Cleocin, 14
Cleocin Phosphate, 3
Cleocin-t, 8
Clever Chek Auto-code Voice Test Strips,
25
Climara Pro, 10
Clindagel, 8
clindamycin HCL, 3
clindamycin palmitate HCL, 3
clindamycin phosphate, 3, 8, 14
clindamycin phosphate add-vantage, 3
clindamycin phosphate IN D5W, 3
clindamycin phosphate pharmacy bulk
package, 3
clindamycin/benzoyl peroxide, 8
Clinimix 2.75%/Dextrose 5%, 26
Clinimix 4.25%/Dextrose 10%, 26
Clinimix 4.25%/Dextrose 20%, 26
Clinimix 4.25%/Dextrose 25%, 26
Clinimix 4.25%/Dextrose 5%, 26
Clinimix 5%/Dextrose 15%, 26
Clinimix 5%/Dextrose 20%, 26
Clinimix 5%/Dextrose 25%, 26
Clinimix E 2.75%/Dextrose 10%, 26
Clinimix E 2.75%/Dextrose 5%, 26
Clinimix E 4.25%/Dextrose 10%, 26
Clinimix E 4.25%/Dextrose 25%, 26
Clinimix E 4.25%/Dextrose 5%, 26
Clinimix E 5%/Dextrose 15%, 26
Clinimix E 5%/Dextrose 20%, 26
Clinimix E 5%/Dextrose 25%, 26
clobetasol propionate, 8
clobetasol propionate emollient, 9
Clobex, 9
Clocortolone Pivalate, 9
Clocortolone Pivalate P.M., 9
Cloderm, 9
Cloderm P.M., 9
Clolar, 4
clomiphene citrate, 11
clomipramine HCL, 16
clonazepam, 17
clonazepam odt, 17
clonidine HCL, 6
clonidine HCL ER, 17
clopidogrel, 15
clorazepate dipotassium, 16
clotrimazole, 8, 15
clotrimazole/betamethasone dipropionate,
8
clozapine, 16
Clozapine Odt, 16
Clozaril, 16
Cnl8 Nail Kit, 8
CO-natal Fa, 23
Coartem, 3
coated aspirin, 20, 27
Cod Liver Oil, 23
codeine sulfate, 20
Codeine Sulfate, 20
Cogentin, 18
Colchicine, 21
Colcrys, 21
colestipol HCL, 7
colestipol HCL for oral suspension, 7
colistimethate sodium, 3
Coly-mycin M, 3
Coly-mycin S, 20
Colyte-flavor Packs, 12, 28
Combigan, 19
Combipatch, 10
Combivent, 22
Combivent Respimat, 22
Combivir, 3
Cometriq, 5
Complera, 3
Concept DHA, 23
Concept OB, 23
Concerta, 17
Condylox, 9
Conzip, 20
Copaxone, 18
Copegus, 3
Cordran, 9
Cordran Tape, 9
Coreg CR, 6
Cortenema, 13
Cortifoam, 13
Cortisone Acetate, 9
Cortisporin, 8
Cortisporin-tc, 20
Corvite, 23
Corvite 150, 14
Cosopt PF, 19
Coumadin, 15
Creon, 13
Crestor, 7
Crinone, 14
Crixivan, 3
Crnatal, 23
cromolyn sodium, 13, 20
Cuvposa, 13
cyanocobalamin, 14
Cyanocobalamin/Levomefolate
Calcium/Pyridoxine HCL, 26
cyclobenzaprine HCL, 18
cyclopentolate HCL, 19
cyclophosphamide, 3
Cyclophosphamide, 4
Cycloserine, 2
Cycloset, 11
cyclosporine, 4
Cyclosporine Modified, 4
cyclosporine modified, 4
Cymbalta, 16
cyproheptadine HCL, 22
Cyramza, 4
Cystadane, 12
Cystagon, 14
Cystaran, 20
cysteine HCL, 25
Cysteine HCL, 26
cytarabine, 4
Cytarabine, 4
cytarabine aqueous, 4
Cytovene, 3
D
D.h.e. 45, 21
d3, 23, 27
D3, 23, 28
D3 Dots, 23, 28
d3 ultra strength, 23, 27
dacarbazine, 5
Daliresp, 23
danazol, 10
dantrolene sodium, 18
Dapsone, 3
Daraprim, 3
daunorubicin HCL, 4
Ddavp, 12
Ddrops, 23, 28
decitabine, 4
deferoxamine mesylate, 26
dehydrated alcohol, 25
Delzicol, 13
demeclocycline HCL, 1
Demerol, 20
Demser, 6
Denavir, 8
Depen Titratabs, 26
Deplin, 26
Deplin 15, 26
Deplin 7.5, 26
Depo-medrol, 10
Depo-provera, 4
Depo-subq Provera 104, 10, 27
Depo-testosterone, 10
Derma-smoothe/FS Body, 9
Derma-smoothe/FS Scalp, 9
Dermanic, 26
Desferal, 26
desipramine HCL, 16
desloratadine, 22
desloratadine odt, 22
desmopressin acetate, 12
desogestrel/ethinyl estradiol, 10, 27
Desonate, 9
desonide, 9
Desowen, 9
desoximetasone, 9
Desoximetasone, 9
Desoxyn, 17
Detrol LA, 14
dexamethasone, 9
Dexamethasone, 9
Dexamethasone Intensol, 10
dexamethasone sodium phosphate, 9,
19
Dexamethasone Sodium Phosphate, 10
Dexchlorpheniramine Maleate, 22
Dexedrine, 17
Dexilant, 13
dexmedetomidine HCL, 17
dexmethylphenidate HCL, 17
dexmethylphenidate HCL ER, 17
Dexpak 10 Day, 10
Dexpak 13 Day, 10
Dexpak 6 Day, 10
Dexpanthenol, 13
dexrazoxane, 5
dextroamphetamine sulfate, 17
dextroamphetamine sulfate ER, 17
dextrose 10%, 25
dextrose 10% flex container, 25
dextrose 30%, 25
dextrose 30% partial fill, 25
dextrose 5%, 25
dextrose 5% viaflex, 25
dextrose 50%, 25
dextrose 70%, 25
Diabeta, 11
Dialyvite 3000, 23
Dialyvite 5000, 23
Dialyvite Supreme D, 23
Dialyvite Vitamin D3 Max, 23, 28
Dialyvite/Zinc, 23
Diastat Acudial, 17
Diastat Pediatric, 17
Diatx ZN, 23
diazepam, 16
Diazepam, 16, 17
Dibenzyline, 6
Diclegis, 13
diclofenac potassium, 21
diclofenac sodium, 8, 9, 20
diclofenac sodium DR, 21
diclofenac sodium ER, 21
diclofenac sodium/misoprostol, 21
dicloxacillin sodium, 1
dicyclomine HCL, 13
Dicyclomine HCL, 13
didanosine, 2
Differin, 8
Dificid, 1
diflorasone diacetate, 9
Diflorasone Diacetate, 9
diflunisal, 20
digoxin, 5
Digoxin, 5
dihydroergotamine mesylate, 21
Dihydroergotamine Mesylate, 21
Dilantin, 17
Dilantin Infatabs, 17
Dilantin-125, 17
Dilatrate SR, 5
Dilaudid, 20
Dilaudid-HP, 20
diltiazem CD, 6
diltiazem HCL, 6
diltiazem HCL ER, 6
Dimenhydrinate, 13
Diovan, 6
Dipentum, 13
diphenhydramine HCL, 22
diphenoxylate/atropine, 12
Diphenoxylate/Atropine, 13
dipyridamole, 15
disopyramide phosphate, 6
disulfiram, 18
Diuril, 7
divalproex sodium, 17
divalproex sodium DR, 17
divalproex sodium ER, 17
Divigel, 10
Divista, 14
dobutamine HCL, 7
dobutamine HCL/D5W, 7
dobutamine/dextrose 5%, 7
docetaxel, 4
donepezil HCL, 18
dopamine HCL, 7
dopamine HCL-dextrose 5%, 7
dopamine HCL/dextrose 5%, 7
dopamine/D5W, 7
Doribax, 3
dorzolamide HCL, 20
dorzolamide HCL/timolol maleate, 19
Dovonex, 8
doxapram HCL, 17
doxazosin mesylate, 6
doxepin HCL, 16
Doxepin HCL, 16
doxercalciferol, 12
Doxil, 4
doxorubicin HCL, 4
Doxorubicin HCL, 4
doxorubicin HCL liposome, 4
doxycycline, 1
Doxycycline, 8
doxycycline hyclate, 2
doxycycline hyclate DR, 2
doxycycline monohydrate, 2
Drisdol, 23
dronabinol, 13
droperidol, 16
drospirenone/ethinyl estradiol, 10, 27
Droxia, 14
Duet DHA 400, 23
Duet DHA 400EC, 23
Duet DHA 430, 23
Duet DHA 430EC, 23
Duet DHA Balanced, 23
Dulera, 22
duloxetine HCL, 16
Duocaine, 21
Duoneb, 23
Duragesic, 20
Durasafe Spinal/Epidural Tray/1%
Xylocaine/19GX36"close CATH, 21
Durasafe Spinal/Epidural Tray/1%
Xylocaine/19GX36"open CATH, 21
Durasafe Spinal/Epidural Tray/1%
Xylocaine/20GX36"close CATH, 21
Durasafe Spinal/Epidural Tray/1%
Xylocaine/20GX36"open CATH, 21
Durezol, 19
Dymista, 22
Dyrenium, 7
Dysport, 18
E
E.e.s. 400, 1
E.e.s. Granules, 1
econazole nitrate, 8
Ed Cyte F, 14
Edarbi, 6
Edarbyclor, 7
Edecrin, 7
Edluar, 17
Edurant, 3
effervescent potassium, 25
effervescent potassium/chloride, 25
Effexor XR, 16
Effient, 15
Egrifta, 12
Elaprase, 12
Elelyso, 15
Element Test Strips, 25
Elestrin, 10
Elidel, 9
Eligard, 4
Eligen B12, 26
Eliquis, 15
Elite Iron, 15, 27
Elite-OB, 23
Elixophyllin, 22
Ella, 10
Ellence, 4
Elmiron, 14
Elspar, 4
Emadine, 20
Embrace Blood Glucose Test Strips, 25
Emcyt, 4
Emend, 13
Emsam, 16
Emtriva, 3
Enablex, 14
enalapril maleate, 6
enalapril maleate/hydrochlorothiazide, 6
enalaprilat, 6
Enbrel, 21
Enbrel Sureclick, 21
Enfamil Expecta, 24
Enjuvia, 10
Enlon, 18
Enlyte, 26
enoxaparin sodium, 15
entacapone, 17
entecavir, 2
Enteragam, 26
enteric coated aspirin, 20, 27
Entyvio, 14
ephedrine sulfate, 7
Epiduo, 8
epinastine HCL, 20
Epinephrine, 7
epinephrine HCL, 22
Epipen 2-PAK, 7
Epipen-JR 2-PAK, 7
epirubicin HCL, 4
episone CRE, 9
Epivir, 3
Epivir HBV, 3
eplerenone, 6
Epogen, 15
epoprostenol sodium, 7
eprosartan mesylate, 6
Epzicom, 3
Equetro, 16
Eraxis, 2
Erbitux, 4
ergocalciferol, 23
ergoloid mesylates, 18
Ergomar, 21
Erivedge, 5
Ertaczo, 8
Ery-TAB, 1
Eryped 200, 1
Eryped 400, 1
Erythrocin Lactobionate, 1
Erythrocin Stearate, 1
erythromycin, 1, 8, 19
Erythromycin Base, 1
Erythromycin Ethylsuccinate, 1
erythromycin/benzoyl peroxide, 8
Escavite, 23
Escavite D, 23
escitalopram oxalate, 16
esmolol HCL, 6
esomeprazole magnesium, 13
esomeprazole sodium, 13
Esomeprazole Sodium, 13
estazolam, 17
Estrace, 14
estradiol, 10
estradiol valerate, 10
estradiol/norethindrone acetate, 10
Estring, 14
estropipate, 10
Estropipate, 10
eszopiclone, 17
ethambutol HCL, 2
ethosuximide, 17
Ethyol, 5
Etidronate Disodium, 11
etodolac, 21
etodolac ER, 21
etoposide, 4
Eurax, 9
Evamist, 10
Evista, 11
Exalgo, 20
Exelderm, 8
Exelon, 18
exemestane, 4
Exforge, 7
Exforge HCT, 7
Exjade, 26
Exparel, 21
Extavia, 18
F
Fa-8, 15, 27
Fabrazyme, 12
Factive, 2
Falessa, 26
famciclovir, 2
famotidine, 13
Famvir, 2
Fanapt, 16
Fanapt Titration Pack, 16
Fareston, 4
Farxiga, 11
Faslodex, 4
Fasttake Test Strips, 25
Fazaclo, 16
FE Aspartate, 15, 27
FE gluconate, 14, 27
felbamate, 17
felodipine ER, 6
Femhrt Low Dose, 10
Femiron, 15, 27
Femring, 14
fenofibrate, 7
Fenofibrate, 7
fenofibrate micronized, 7
Fenofibric Acid, 7
fenofibric acid DR, 7
Fenoglide, 7
fenoldopam mesylate, 6
Fenoprofen Calcium, 21
fentanyl, 20
fentanyl citrate oral transmucosal, 20
Fentora, 20
Feosol, 15, 27
Feraheme, 14
Feriva, 14
Feriva 21/7, 14
Ferivafa, 14
Ferralet 90, 14
Ferrex 150 Forte Plus, 14
Ferrex 28, 14
Ferrimin 150, 15, 27
Ferriprox, 26
Ferrlecit, 14
Ferro-plex Hematinic, 14
Ferro-sequels, 15, 27
Ferrotrin, 14
ferrous drops, 14, 27
Ferrous Fumarate, 15, 27
ferrous fumarate 324, 14, 27
ferrous gluconate, 14, 27
Ferrous Gluconate, 15, 27
ferrous sulfate, 14, 27
Ferrous Sulfate, 15, 27
Fetzima, 16
Fibricor, 7
Finacea, 8
finasteride, 14
Firazyr, 15
Firmagon, 4
Flagyl, 3
Flagyl ER, 3
Flarex, 19
flavoxate HCL, 14
Flebogamma Dif, 26
flecainide acetate, 6
Flector, 8
FLO-pred, 10
Flolan, 7
Flonase, 22
Floriva, 23, 27
Flovent Diskus, 22
Flovent HFA, 22
floxuridine, 4
Floxuridine, 4
fluconazole, 2
fluconazole IN dextrose, 2
fluconazole IN NACL, 2
Fluconazole IN NACL, 2
flucytosine, 2
Fludara, 4
fludarabine phosphate, 4
Fludarabine Phosphate, 4
fludrocortisone acetate, 9
flumazenil, 25
flunisolide, 22
Flunisolide, 22
fluocinolone acetonide, 9, 20
fluocinolone acetonide ear drops, 20
fluocinonide, 9
fluocinonide-e, 9
Fluor-a-day, 26, 27
Fluorabon, 26, 27
fluoride, 25, 27
fluorometholone, 19
Fluoroplex, 9
fluorouracil, 4, 9
Fluorouracil, 9
fluoxetine, 18
fluoxetine DR, 16
fluoxetine HCL, 16
Fluoxetine HCL, 16
fluphenazine decanoate, 16
fluphenazine HCL, 16
Fluphenazine HCL, 16
Flura-drops, 26, 27
flurazepam HCL, 17
flurbiprofen, 21
flurbiprofen sodium, 20
flutamide, 4
fluticasone propionate, 9, 22
fluvastatin, 7
fluvoxamine maleate, 16
fluvoxamine maleate ER, 16
FML, 19
FML Forte, 19
Focalin, 17
Focalin XR, 17
Folbecal, 23
Folbee AR, 26
Folbic RF, 26
Folcaps Omega 3, 23
Folet DHA, 23
Folet One, 23
Folgard OS, 23
Folgard RX, 14
folic acid, 14, 27
Folic Acid, 14
folic acid/vitamin b-6/vitamin b-12, 14
Folivane-f, 14
Folivane-OB, 23
Folivane-plus, 14
Folivane-prx DHA NF, 23
Follistim AQ, 11
Folotyn, 4
Foltanx, 26
Foltanx RF, 26
Foltrate, 14
Foltx, 26
fomepizole, 25
fondaparinux sodium, 15
Fora V12 Blood Glucose Test Strips, 25
Foradil Aerolizer, 22
Forfivo XL, 16
formaldehyde, 25
Fortavit, 23
Fortaz, 1
Forteo, 11
Fortesta, 10
Fortical, 11
Fosamax, 11
Fosamax Plus D, 11
Foscavir, 2
fosinopril sodium, 6
fosinopril sodium/hydrochlorothiazide, 6
fosphenytoin sodium, 17
Fosrenol, 13
Fosteum, 26
Fosteum Plus, 26
Fovex, 26
Fragmin, 15
Freamine HBC 6.9%, 26
Freamine Iii, 26
Freamine Iii 3%, 26
Freestyle Freedom Lite, 25
Freestyle Insulinx Blood Glucose Test,
25
Freestyle Lite Blood Glucose Monitoring
System, 25
Freestyle Lite Test Strips, 25
Freestyle System Kit, 25
Freestyle Test Strips, 25
Frova, 21
furosemide, 7
Furosemide, 7
Fusion Plus, 14
G
G4 Sensor Kit, 25
Gabadone, 26
gabapentin, 17
Gabitril, 17
galantamine, 18
galantamine hydrobromide, 18
Gamastan S/D, 26
Gammagard Liquid, 26
Gammagard S/D, 26
Gammagard S/D Iga Less Than
1mcg/ML, 26
Gammaked, 26
Gammaplex, 27
Gamunex-c, 27
ganciclovir, 2
Gastrocrom, 14
gatifloxacin, 19
Gazyva, 4
Gel-kam Oral Care Rinse, 15
Gelnique, 14
gemcitabine HCL, 4
gemfibrozil, 7
Gemzar, 4
gene-xene TAB 15MG, 16
gene-xene TAB 3.75MG, 16
gene-xene TAB 7.5MG, 16
Genotropin, 12
Genotropin Miniquick, 12
gentamicin sulfate, 2, 19
Gentamicin Sulfate, 8
gentamicin sulfate pediatric, 2
gentamicin sulfate/0.9% sodium chloride,
2
Gentamicin Sulfate/0.9% Sodium
Chloride, 2
gentamicin sulfate/sodium chloride, 2
Geodon, 16
Gesticare DHA, 23
Giazo, 13
Gilenya, 18
Gilotrif, 5
Glassia, 23
Gleevec, 5
Gleostine, 4
glimepiride, 11
glipizide, 11
glipizide ER, 11
glipizide/metformin HCL, 11
Glucagen, 11
Glucagen Hypokit, 11
Glucagon Emergency Kit, 11
Glucocard Vital Test Strips, 25
Glumetza, 11
glyburide, 11
Glyburide, 11
glyburide micronized, 11
glyburide/metformin HCL, 11
glycopyrrolate, 13
Glyset, 11
Golytely, 12, 28
Gonal-f, 11
Gralise, 18
Gralise Starter, 18
granisetron HCL, 13
Granisol, 13
griseofulvin microsize, 2
griseofulvin ultramicrosize, 2
guanfacine ER, 17
guanfacine HCL, 6
Guanidine HCL, 18
H
H.p. Acthar, 12
Halaven, 5
Haldol, 16
halobetasol propionate, 9
Halog, 9
haloperidol, 16
haloperidol decanoate, 16
haloperidol lactate, 16
Harvoni, 3
Healthy Mama Be Well Rounded, 24
Hectorol, 12
Hematogen Fa, 14
Hematron-AF, 14
Hemocyte Plus, 14
Hemocyte-f, 14
heparin lock, 15
heparin lock flush, 15
heparin lock flush for flushing vascular
access devices, 15
heparin lock flush/NACL for flushing
vascular access devices, 15
heparin sodium, 15
Heparin Sodium, 15
heparin sodium dcu, 15
heparin sodium lock flush, 15
heparin sodium/D5W, 15
Heparin Sodium/D5W, 15
Heparin Sodium/NACL 0.45%, 15
heparin sodium/NACL 0.9%, 15
Heparin Sodium/Sodium Chloride 0.9%,
15
heparin sodium/sodium chloride 0.9%
premix, 15
Hepsera, 3
hetastarch 6%/NACL, 15
Hexalen, 4
Hizentra, 27
homatropine HBR, 19
Horizant, 18
Hsa Sterile Diluent, 25
Humalog, 10
Humalog Kwikpen, 10
Humalog Mix 50/50, 10
Humalog Mix 50/50 Kwikpen, 10
Humalog Mix 75/25, 10
Humalog Mix 75/25 Kwikpen, 10
Humatrope, 12
Humatrope Combo Pack, 12
Humira, 21
Humira Pediatric Crohns Disease Starter
Pack, 21
Humira Pen, 21
Humira Pen-crohns Diseasestarter, 21
Humira Pen-psoriasis Starter, 21
Humulin R U-500 (concentrated), 10
Hyalgan, 18
Hycamtin, 5
hydralazine HCL, 6
hydrochloric acid, 14
hydrochlorothiazide, 7
hydrocodone bitartrate/acetaminophen,
20
hydrocodone bitartrate/chlorpheniramine
maleate/PSE, 22
hydrocodone bitartrate/homatropine
methylbromide, 22
hydrocodone polistirex/chlorpheniramine
polistirex, 22
hydrocodone/acetaminophen, 20
hydrocodone/homatropine, 22
hydrocodone/ibuprofen, 20
hydrocort ene 100MG, 13
hydrocortisone, 9(2), 13
hydrocortisone acetate/aloe, 9
hydrocortisone acetate/lidocaine HCL, 13
hydrocortisone acetate/pramoxine, 13
hydrocortisone butyrate, 9
hydrocortisone butyrate (lipid), 9
hydrocortisone butyrate (lipophilic), 9
hydrocortisone IN absorbase, 9
hydrocortisone valerate, 9
hydrocortisone/acetic acid, 20
hydromorphone HCL, 20
Hydromorphone HCL, 20
Hydromorphone HCL Dosette, 20
hydromorphone HCL ER, 20
Hydromorphone HCL ER, 20
Hydroxocobalamin, 14
hydroxychloroquine sulfate, 3
hydroxyurea, 5
hydroxyzine HCL, 16
Hydroxyzine HCL, 16
hydroxyzine pamoate, 16
Hydroxyzine Pamoate, 16
Hylenex, 26
hyoscyamine sulfate, 13
hyoscyamine sulfate ER, 13
hyoscyamine sulfate odt, 13
hyoscyamine sulfate SR, 13
Hyperhep B S/D, 27
Hyperrho S/D, 27
Hyperrho S/D Mini-dose, 27
Hypertensa, 26
I
ibandronate sodium, 11
ibuprofen, 21
ibutilide fumarate, 6
Icar-c Plus, 14
Iclusig, 5
idarubicin HCL, 4
ifosfamide, 3
Ilaris, 21
Imbruvica, 5
imipenem/cilastatin, 3
imipramine HCL, 16
imipramine pamoate, 16
imiquimod, 9
Imitrex, 21
Imitrex Statdose Refill, 21
Imitrex Statdose System, 21
Inatal Advance, 23
Inatal GT, 23
Inatal Ultra, 23
Increlex, 12
indapamide, 7
Inderal XL, 6
Indocin, 21
indomethacin, 21
indomethacin ER, 21
indomethacin sodium, 21
Infergen, 3
Infumorph 200, 20
Infumorph 500, 20
Injectafer, 14
Inlyta, 5
Innopran XL, 6
Inset 30 Infusion Set 23", 25
Insulin Syringe/0.5ML/30G X 5/16", 25
Integra F, 14
Integra Plus, 14
Intelence, 3
Intermezzo, 17
Intron A, 5
Intron-a, 5
Intron-a W/Diluent, 5
Intuniv, 17
Invanz, 3
Invega, 16
Invega Sustenna, 16
Invirase, 3
Invokana, 11
Iopidine, 19
ipratropium bromide, 22(2)
ipratropium bromide/albuterol sulfate, 22
irbesartan, 6
irbesartan/hydrochlorothiazide, 6
irinotecan, 5
iron, 14, 27
Iron, 15, 27
Iron Asp Gly/ Polysacch Compl/Ascorb
CAL/B12/Fa/C Threon/Suc, 14
Iron Up, 15, 27
Irospan 24/6, 14
Is 24/6, 14
Isentress, 3
isoniazid, 2
Isoniazid, 2
Isordil Titradose, 5
isosorbide dinitrate, 5
Isosorbide Dinitrate, 5
isosorbide dinitrate ER, 5
isosorbide mononitrate, 5
isosorbide mononitrate ER, 5
isotonic gentamicin, 2
Isotonic Gentamicin, 2
isradipine, 6
Istalol, 19
Istodax, 5
Isuprel, 23
itraconazole, 2
ivermectin, 3
J
Jakafi, 5
Jalyn, 14
Janumet, 11
Janumet XR, 11
Januvia, 11
Jentadueto, 11
Jevtana, 5
Jinteli, 10
K
Kadcyla, 4
Kadian, 20
Kalbitor, 15
Kaletra, 3
Kalydeco, 23
Kapvay, 17
Kazano, 11
Keflex, 1
Kenalog, 9
Kenalog-10, 10
Kenalog-40, 10
Kepivance, 5
Keppra, 17
Keppra XR, 17
Ketek, 3
Ketocare, 26
ketoconazole, 2, 8
ketoprofen, 21
Ketoprofen ER, 21
ketorolac tromethamine, 20, 21
Ketorolac Tromethamine, 21
Ketostix, 26
Kineret, 21
Kinlytic, 15
Kitabis PAK, 2
Klor-CON M15, 26
Kombiglyze XR, 11
Kristalose, 12
Kuvan, 12
L
l-cysteine HCL, 25
L-methyl-b6-b12, 26
L-methylfolate, 26
L-methylfolate CA/P-5-P.M.-CBL, 26
L-methylfolate Calcium, 26
labetalol HCL, 5
Lac-hydrin, 9
Lacrisert, 19
lactic acid, 9
lactic acid e, 9
lactic acid w/vitamin e, 9
lactulose, 12, 13
Lamictal Odt, 17
Lamictal Starter/Not Taking
Carbamazepine, 17
Lamictal Starter/Taking
Carbamazepine/Not Taking Valproate,
17
Lamictal Starter/Taking Valproate, 17
Lamictal XR, 17
Lamisil, 2
lamivudine, 2
lamivudine/zidovudine, 2
lamotrigine, 17
lamotrigine ER, 17
lamotrigine odt, 17
Lancets 30G Twist Top, 25
lanolin, 25
Lanoxin, 5
Lanoxin Pediatric, 5
lansoprazole, 13
lansoprazole/amoxicillin/clarithromycin,
13
Lantus, 10
Lantus Solostar, 10
latanoprost, 19
Latuda, 16
Lazanda, 20
Lecithin, 26
leflunomide, 21
Lescol XL, 7
Letairis, 7
letrozole, 4
leucovorin calcium, 5
Leucovorin Calcium, 5
Leukeran, 4
Leukine, 15
leuprolide acetate, 4
levalbuterol, 22
levalbuterol HCL, 22
Levaquin, 2
Levatol, 6
Levemir, 10
Levemir Flexpen, 10
Levemir Flextouch, 10
levetiracetam, 17
Levetiracetam, 17
levetiracetam ER, 17
levobunolol HCL, 19
Levobunolol HCL, 19
levocarnitine, 12
levocetirizine dihydrochloride, 22
levofloxacin, 2, 19
levofloxacin IN D5W, 2
Levomefolate
Calcium/Acetylcysteine/Mecobalamin/Alg
al Powder, 26
Levomefolate Calcium/Algal Powder, 26
Levomefolate Calcium/Pyridoxal
Phosphate/Mecobalamin/Algal, 26
levonorgestrel and ethinyl estradiol, 10,
27
levonorgestrel/ethinyl estradiol, 10, 27
Levophed, 7
Levorphanol Tartrate, 20
levothyroxine sodium, 12
Levothyroxine Sodium, 12
Levsin, 13
Lexapro, 16
Lexiva, 3
Lialda, 13
Liberty Glucose Control Level 1, 25
Liberty Glucose Control Normal, 25
Liberty Next Generation Blood Glucose
Test Strips, 25
lidocaine, 9
lidocaine HCL, 6, 9, 15, 21
lidocaine HCL IN D5W, 6
lidocaine HCL jelly, 9
lidocaine HCL viscous, 15
lidocaine HCL/dextrose, 6
lidocaine HCL/hydrocortisone acetate, 13
lidocaine viscous, 15
lidocaine/epinephrine, 21
lidocaine/prilocaine, 9
Limbrel, 26
Limbrel250, 26
Limbrel500, 26
lindane, 9
linezolid, 3
Linzess, 13
liothyronine sodium, 12
Lipichol 540, 26
Lipofen, 7
Liposyn Iii, 26
Liptruzet, 7
lisinopril, 6
lisinopril/hydrochlorothiazide, 6
Lister-v, 26
Lithium, 16
lithium carbonate, 16
Lithium Carbonate, 16
lithium carbonate ER, 16
Lithobid, 16
Livalo, 7
Lmthf/Pyridoxine HCL/Cyanocobalamin,
26
LO Loestrin FE, 10, 27
Lodosyn, 18
Lomotil, 13
Lomustine, 4
loperamide HCL, 12
lorazepam, 16
Lorzone, 18
losartan potassium, 6
losartan potassium/hydrochlorothiazide,
6
Lotemax, 19
Lotronex, 13
lovastatin, 7
Lovaza, 7
Lovenox, 15
loxapine, 16
loxapine succinate, 16
Lozi-flur, 26, 27
Lufyllin, 23
Lukaid GLA, 26
Lumigan, 19
Lumizyme, 12
Lunesta, 17
Lunglaid, 26
Lupron Depot, 4
Lupron Depot-PED, 12
Luride, 26, 27
Luxiq, 9
Lyrica, 17
Lysodren, 4
M
M-vit, 23, 27
M.v.i. Adult, 23
M.v.i. Pediatric, 23
M.v.i.-12 Without Vitamin K, 23
Macnatal CN DHA, 23
Macrodantin, 14
Macutek, 26
mafenide acetate, 9
magnesium chloride, 25
magnesium sulfate, 25
Magnesium Sulfate, 25
Magnesium Sulfate IN D5W, 25
Makena, 10
Malarone, 3
malathion, 9
mannitol, 7
Maprotiline HCL, 16
Marcaine, 21
Marcaine/Epinephrine, 21
Marinol, 13
Marnatal-f, 23
Marplan, 16
Matulane, 5
Maxair Autohaler, 23
Maxalt, 21
Maxalt-MLT, 21
Maxaron Forte, 14
Maxfe, 15
Maxidex, 19
Maxipime, 1
meclizine HCL, 13
Meclofenamate Sodium, 21
medroxyprogesterone acetate, 10(2), 27
mefenamic acid, 21
mefloquine HCL, 3
Mefoxin, 1
Megace ES, 10
megestrol acetate, 4
Mekinist, 5
meloxicam, 21
Meloxicam, 21
melphalan hydrochloride, 4
Menest, 10
Menopur, 11
Menostar, 10
Mentax, 8
meperidine HCL, 20
Meperidine HCL, 20
Mepivacaine HCL, 21
meprobamate, 16
Mepron, 3
mercaptopurine, 4
meropenem, 3
mesalamine, 13
mesna, 5
Mesnex, 5
Mestinon, 18
Mestinon Timespan, 18
Metadate CD, 17
Metafolbic, 26
Metafolbic Plus, 26
Metafolbic Plus RF, 26
Metanx, 26
Metaproterenol Sulfate, 22
metaxalone, 18
metformin HCL, 11
metformin HCL ER, 11
methadone HCL, 20
Methadone HCL, 20
methamphetamine HCL, 17
methazolamide, 7
methenamine hippurate, 14
methenamine mandelate, 14
methimazole, 12
methocarbamol, 18
methotrexate, 4
methotrexate sodium, 4
methoxsalen, 8
methscopolamine bromide, 13
Methyclothiazide, 7
methyldopa, 6
Methyldopa/Hydrochlorothiazide, 7
Methyldopate HCL, 6
methylene blue, 25
methylergonovine maleate, 20
Methylfol-algae-b12-acetylcyst, 26
Methylin, 17
methylphenidate HCL, 17
methylphenidate HCL CD, 17
methylphenidate HCL ER, 17
Methylphenidate HCL ER, 17
methylphenidate HCL SR, 17
methylphenidate hydrochloride, 17
methylprednisolone, 9
methylprednisolone acetate, 9
methylprednisolone dose pack, 9
methylprednisolone sodiumsuccinate, 9
metoclopramide HCL, 13
metolazone, 7
metoprolol succinate ER, 5
metoprolol tartrate, 5
metoprolol/hydrochlorothiazide, 6
Metozolv Odt, 13
Metrogel, 8
metronidazole, 3, 8
metronidazole IN NACL 0.79%, 3
metronidazole vaginal, 14
mexiletine HCL, 6
Miacalcin, 11
Micardis, 6
Micardis HCT, 7
Micrhogam Ultra-filtered Plus, 27
midodrine HCL, 7
Migergot, 21
Migranal, 21
Millipred, 10
milrinone IN dextrose, 5
milrinone lactate, 5
Minivelle, 10
Minocin, 2
minocycline HCL, 2
minocycline HCL ER, 2
minoxidil, 6
Mirapex ER, 18
mirtazapine, 16
mirtazapine odt, 16
misoprostol, 13
Mission Prenatal, 24, 27
Mission Prenatal HP, 24, 27
mitomycin, 4
Mitomycin, 4
mitoxantrone HCL, 4
Mobic, 21
modafinil, 17
Moderiba, 2
Moderiba 1200 Dose Pack, 3
Moderiba 800 Dose Pack, 3
moexipril HCL, 6
moexipril/hydrochlorothiazide, 6
mometasone furoate, 9
Moms Choice RX, 23
Monoject Bone Marrow Biopsy Prepping
Tray, 22
Monoject Bone Marrow Biopsy Tray/Biop
Aspir Needle 11GX4", 22
Monoject Bone Marrow Biopsy Tray/Biop
Aspir Needle 8GX4", 22
Monoject Bone Marrow Biopsy
Tray/Sternal-iliac Needle 16G, 22
montelukast sodium, 22
Monurol, 14
morphine sulfate, 20
Morphine Sulfate, 20
morphine sulfate ER, 20
morrhuate sodium, 25
Motofen, 13
Moviprep, 12
Moxatag, 1
Moxeza, 19
moxifloxacin HCL, 2
Mozobil, 15
MS Contin, 20
Multaq, 6
Multigen, 15
Multigen Folic, 15
Multigen Plus, 15
mupirocin, 8
mupirocin calcium, 8
Mustargen, 4
MV FE Asparto Gly/FE Fum/Succ Acid/Vit
C/Threonic Acd/B12/Fa, 15
MV FE Asparto Gly/Vit C/Vit B12/CA
Threonate/Succ Acd/Stomac, 15
Myalept, 12
Myambutol, 2
Mycamine, 2
Mycobutin, 2
mycophenolate mofetil, 4
mycophenolic acid DR, 4
Myfortic, 4
Mykidz Iron 10, 15, 27
Mykidz Iron Fl, 23
Mynatal, 23
Mynatal Advance, 23
Mynatal Ultracaplet, 23
Myozyme, 12
Myrbetriq, 14
N
n-acetyl-l-cysteine, 25
Nabi-HB, 27
nabumetone, 21
nadolol, 5
nadolol/bendroflumethiazide, 6
nafcillin sodium, 1
Nafcillin Sodium, 1
Nafrinse Daily/Neutral, 15
Nafrinse Weekly, 15
Naftin, 8
Naglazyme, 12
nalbuphine HCL, 20
Nalfon, 21
Nallpen Iso-osmotic IN Dextrose, 1
Nallpen/Dextrose, 1
naloxone HCL, 25
naltrexone HCL, 25
Namenda, 18
Namenda Titration PAK, 18
Naphazoline HCL, 19
Naprelan, 21
naproxen, 21
naproxen sodium, 21
naproxen sodium ER, 21
naratriptan HCL, 21
Naropin, 22
Nasacort AQ, 22
Nascobal, 15
Nasonex, 22
Natachew, 23
Natacyn, 19
Natafort, 23
Natalvirt 90 DHA, 23
Natalvirt CA, 23
Natalvirt Flt, 15
Natalvit, 23
Natazia, 10, 27
nateglinide, 11
Natelle One, 23
Navelbine, 5
Nebupent, 3
Necon 10/11-28, 10, 27
Neevo DHA, 23
nefazodone HCL, 16
Nefazodone HCL, 16
Nembutal Sodium, 17
neomycin sulfate, 2
neomycin/bacitracin/polymyxin, 19
neomycin/polymyxin/bacitracin zinc, 19
neomycin/polymyxin/bacitracin/hydrocorti
sone, 19
neomycin/polymyxin/dexamethasone, 19
neomycin/polymyxin/gramicidin, 19
neomycin/polymyxin/HC, 20
Neomycin/Polymyxin/Hydrocortisone, 19
neomycin/polymyxin/hydrocortisone, 20
Neoral, 4
neostigmine methylsulfate, 18
Nephplex RX, 23
Nephramine, 26
Nephro-vite RX, 23
Nephrocaps, 23
Nephrocaps QT, 23
Nephron Fa, 15
Nesacaine, 22
Nesacaine-mpf, 22
Nesina, 11
Nestabs, 23
Nestabs Abc, 23
Nestabs DHA, 23
Neulasta, 15
Neulasta Delivery Kit, 15
Neumega, 15
Neupogen, 15
Neupro, 18
Neurepa, 26
Nevanac, 20
nevirapine, 2
Nevirapine, 3
nevirapine ER, 2
Newgen, 23
Nexa Plus, 23
Nexavar, 5
Nexium, 13
Nexium I.v., 13
niacin ER, 7
niacinamide/azelaic ac/ turmer/fa/b6/zinc
ox/copper, 23
Niacor, 7
Niaspan, 7
Nicadan, 23
nicardipine HCL, 6
Nicazel, 23
Nicazel Forte, 23
Nicomide, 23
nicotine, 18, 27
nicotine polacrilex, 18, 27
nicotine polacrilex refill, 18, 27
nicotine polacrilex starter kit, 18, 27
nicotine transdermal system, 18, 27
Nicotine Transdermal System, 18, 27
Nicotrol Inhaler, 18, 27
Nicotrol Ns, 18, 27
nifedipine, 6
nifedipine ER, 6
Nilandron, 4
nimodipine, 6
nisoldipine, 6
Nisoldipine, 6
Nisoldipine ER, 6
Nitro-bid, 5
Nitro-dur, 5
nitrofurantoin, 14
nitrofurantoin macrocrystals, 14
nitrofurantoin monohydrate, 14
nitrofurantoin
monohydrate/macrocrystals, 14
nitroglycerin, 5
nitroglycerin ER, 5
nitroglycerin IN 5% dextrose, 5
nitroglycerin IN dextrose 5%, 5
nitroglycerin lingual, 5
Nitroglycerin Lingual, 5
nitroglycerin transdermal, 5
Nitrolingual Pumpspray, 5
Nitromist, 5
Nitrostat, 5
Niva-plus, 24, 27
Nivatopic Plus, 9
nizatidine, 13
Norditropin Cartridge, 12
Norditropin Flexpro, 12
Norditropin Nordiflex Pen, 12
norepinephrine bitartrate, 7
norethindrone, 10, 27
norethindrone & ethinyl estradiol ferrous
fumarate, 10, 27
norethindrone acetate, 10
norethindrone acetate/ethinyl estradiol,
10, 27
norethindrone acetate/ethinyl
estradiol/ferrous fumarate, 10, 27
Norflex, 18
norgestimate/ethinyl estradiol, 10, 27
Noritate, 8
normal saline flush, 25
normal saline flush for flushing vascular
access devices, 25
normal saline i.v. flush, 25
Noroxin, 2
Norpace CR, 6
nortriptyline HCL, 16
Nortriptyline HCL, 16
Norvir, 3
Nova Max Glucose Test Strips, 25
Novaferrum, 15
Novaferrum Pediatric Drops, 15, 27
Novolog, 10
Novolog Flexpen, 10
Novolog Mix 70/30, 10
Novolog Mix 70/30 Prefilled Flexpen, 10
Novolog Penfill, 10
Noxafil, 2
Nucynta, 20
Nucynta ER, 20
Nuedexta, 18
Nulojix, 4
Nutrestore, 26
Nutricap, 24
Nutrivit, 24
Nutropin, 12
Nutropin AQ Nuspin 10, 12
Nutropin AQ Nuspin 20, 12
Nutropin AQ Nuspin 5, 12
Nutropin AQ Pen, 12
Nuvaring, 10, 27
Nuvigil, 17
nystatin, 2, 8, 15
nystatin/triamcinolone, 8
O
O-CAL Fa, 24, 27
O-CAL Prenatal, 24
OB Complete, 24
OB Complete 400, 24
OB Complete One, 24
OB Complete Petite, 24
OB Complete Premier, 24
OB Complete/DHA, 24
OB-natal One, 24
Obstetrix DHA, 24
Obstetrix EC, 24
Octagam, 27
octreotide acetate, 12
Ocuvel, 24
ofloxacin, 2, 19, 20
Ogestrel, 10, 27
olanzapine, 16
olanzapine odt, 16
olanzapine/fluoxetine, 18
Oleptro, 16
olopatadine HCL, 22
Olux, 9
Olux-e, 9
omega-3-acid ethyl esters, 7
omeprazole, 13
omeprazole/sodium bicarbonate, 13
Omnaris, 22
Omnitrope, 12
Oncaspar, 4
ondansetron HCL, 13
ondansetron odt, 13
One A Day Womens Prenatal/DHA, 24
One A Day Womens Prenatal1, 24
One-a-day Womens Prenatal, 24, 27
Onetouch Basic/Profile Test Strips, 25
Onetouch Delica Lancets Fine 30G, 25
Onetouch Finepoint Lancets, 25
Onetouch Ultra 2, 25
Onetouch Ultra Blue, 25
Onetouch Ultra Mini, 25
Onetouch Verio Test Strips, 25
Onfi, 17
Onglyza, 11
Opana, 20
Opana ER (crush Resistant), 20
opium, 13
opium tincture, 13
Optium Test Strips, 25
Oracea, 8
Orap, 18
Orapred Odt, 10
Oravig, 15
Orencia, 21
Orfadin, 12
orphenadrine citrate, 18
orphenadrine citrate ER, 18
orphenadrine/asa/caffeine, 18
Ortho Evra, 10, 27
Ortho Tri-cyclen LO, 10, 27
Oseni, 11
Osmoprep, 12
Osphena, 11
Otezla, 21
oxacillin sodium, 1
oxaliplatin, 3
Oxandrin, 10
oxandrolone, 10
oxaprozin, 21
oxazepam, 16
oxcarbazepine, 17
Oxecta, 20
Oxistat, 8
Oxsoralen, 9
Oxsoralen Ultra, 8
oxybutynin chloride, 14
oxybutynin chloride ER, 14
oxycodone HCL, 20
Oxycodone HCL, 20
Oxycodone HCL ER, 20
oxycodone/acetaminophen, 20
oxycodone/aspirin, 20
oxycodone/ibuprofen, 20
Oxycontin, 21
oxymorphone hydrochloride, 20
oxymorphone hydrochloride ER, 20
oxytocin, 20
Oxytrol, 14
P
paclitaxel, 5
Paire OB, 24
pamidronate disodium, 11
Pamidronate Disodium, 11
Pancreaze, 13
Pancrelipase, 13
pancuronium bromide, 18
Panretin, 9
pantoprazole sodium, 13
papaverine HCL, 7
Paragard Intrauterine Copper
Contraceptive T380a, 10
paricalcitol, 12
Paricalcitol, 12
paromomycin sulfate, 2
paroxetine HCL, 16
paroxetine HCL ER, 16
Paser, 2
Pataday, 20
Patanase, 22
Patanol, 20
Paxil, 16
Paxil CR, 16
PCE, 1
Pedipirox-4 Nail, 8
peg 3350/electrolytes, 12, 28
peg-3350/electrolytes, 12, 28
peg-3350/NACL/NA bicarbonate/KCL,
12, 28
Peg-intron, 3
Peg-intron Redipen, 3
Peg-intron Redipen PAK 4, 3
Peganone, 17
Pegasys, 3
Pegasys Proclick, 3
Pegintron, 3
penicillin G potassium, 1
Penicillin G Potassium IN Iso-osmotic
Dextrose, 1
Penicillin G Procaine, 1
Penicillin G Sodium, 1
penicillin v potassium, 1
Penlac Nail Lacquer, 8
Pentam 300, 3
Pentasa, 13
pentazocine/acetaminophen, 20
pentazocine/naloxone HCL, 20
pentoxifylline ER, 15
Percura, 26
Perfect Iron, 15, 27
Perforomist, 23
perindopril erbumine, 6
Perjeta, 4
permethrin, 9
perphenazine, 16
Perry Prenatal, 24, 27
Pertzye, 13
Pexeva, 16
Pfizerpen-G, 1
phenazopyridine HCL, 14
phenelzine sulfate, 16
Phenergan, 22
phenobarbital, 17
Phenobarbital Sodium, 17
Phentolamine Mesylate, 6
phenylephrine HCL, 7, 19
Phenylephrine HCL, 7
phenylephrine/guaifenesin, 22
Phenytek, 17
phenytoin, 17
phenytoin sodium, 17
phenytoin sodium extended, 17
Phoslyra, 13
Phospholine Iodide, 19
Phrenilin Forte, 20
Physostigmine Salicylate, 25
phytonadione, 23
Picato, 9
pilocarpine HCL, 15, 19
pilocarpine hydrochloride, 15
Pilopine HS, 19
pindolol, 5
pioglitazone HCL, 11
pioglitazone HCL-glimepiride, 11
pioglitazone HCL/metformin HCL, 11
piperacillin sodium/ tazobactam sodium,
1
piperacillin sodium/tazobactam sodium, 1
piperacillin/tazobactam, 1
piroxicam, 21
Pitocin, 20
Pitressin Synthetic, 12
Podiapn, 26
podofilox, 9
Poly-VI-flor, 24
Poly-VI-flor FS, 24
Poly-VI-flor/Iron, 24
polyethylene glycol 3350, 12
polymyxin b sulfate, 3
polymyxin b sulfate/trimethoprim sulfate,
19
Pomalyst, 4
potassium acetate, 25
potassium bicarbonate, 25
potassium chloride, 25
Potassium Chloride, 25
potassium chloride CR, 25
potassium chloride ER, 25
potassium chloride SR, 25
potassium citrate ER, 14
potassium citrate-citric acid crystals, 14
potassium citrate/citric acid, 14
potassium citrate/sodium citrate/citric
acid, 14
potassium phosphate, 25
potassium phosphates, 25
Potiga, 17
Pr Natal 400, 24
Pr Natal 400 EC, 24
Pr Natal 430, 24
Pr Natal 430 EC, 24
Pradaxa, 15
pramipexole dihydrochloride, 17
pramipexole dihydrochloride ER, 17
Prandin, 11
pravastatin sodium, 7
prazosin HCL, 6
Pre-folic, 15
Precision QID Test Strips, 25
Precision XTRA Blood Glucose Test
Strips, 25
Pred Mild, 19
prednicarbate, 9
prednisolone, 9
prednisolone acetate, 19
prednisolone sodium phosphate, 9
Prednisolone Sodium Phosphate, 9, 19
prednisolone sodium phosphate odt, 9
prednisone, 9
Prednisone, 9
Prednisone Intensol, 9
Prefera OB, 24
Prefera OB + DHA, 24
Preferaob +dha, 24
Preferaob One, 24
Prefest, 10
Prefol-DHA, 24
Premarin, 10, 14
Premasol, 26
Premphase, 10
Prempro, 10
Prenata, 24
Prenatabs RX, 24
Prenatal Ad, 24
Prenatal Multivitamin + DHA, 24
Prenatal Plus DHA, 24
Prenatal Vitamin, 24, 27
Prenatal Vitamins, 24, 27
Prenatal-u, 24
Prenate, 24
Prenate AM, 24
Prenate DHA, 24
Prenate Elite, 24
Prenate Enhance, 24
Prenate Essential, 24
Prenate Mini, 24
Prenate Pixie, 24
Prenate Restore, 24
Prenate Star, 24
Prepopik, 12
Preque 10, 24
Prevacid, 13
Prevacid Solutab, 13
Prevident, 15
Prezista, 3
Priftin, 2
Prilosec, 13
Primaquine Phosphate, 3
primidone, 17
Primsol, 3
Pristiq, 16
Privigen, 27
Proair HFA, 22
probenecid, 21
probenecid/colchicine, 21
Procainamide HCL, 6
Procalamine, 26
prochlorperazine, 16
prochlorperazine edisylate, 16
prochlorperazine maleate, 16
Procrit, 15
Prodigy NO Coding Blood Glucose Test
Strips, 25
Profe, 15, 27
Proferrin ES, 15, 27
Proferrin-forte, 15
progesterone, 10
Proglycem, 11
Prograf, 4
Prolastin-c, 23
Proleukin, 5
Prolia, 11
Promacta, 15
promethazine HCL, 22
promethazine HCL plain, 22
promethazine-DM, 22
promethazine/codeine, 22
promethazine/dextromethorphan, 22
propafenone HCL, 6
propafenone HCL ER, 6
Propantheline Bromide, 13
proparacaine HCL, 19
propranolol HCL, 5
Propranolol HCL, 6
propranolol HCL ER, 5
propylthiouracil, 12
Prosol, 26
Prostigmin, 18
Prostin VR Pediatric, 27
Protect Plus, 24
Protectbone, 24
Protectiron, 15
Protectnatal, 24
Proteolin, 26
Protonix, 13
Protopic, 9
protriptyline HCL, 16
Proventil HFA, 22
Provida OB, 24
Provigil, 17
Prozac, 16
Prozac Weekly, 16
Prudoxin, 8
Pulmicort, 23
Pulmicort Flexhaler, 22
Pulmona, 26
Pulmozyme, 23
Puralor, 26
Puralor Ci, 26
pyrazinamide, 2
pyridostigmine bromide, 18
Pyridoxine HCL, 23
Q
Qnasl, 22
Qualaquin, 3
Quelicin, 18
Quelicin 1000, 18
quetiapine fumarate, 16
Quflora Pediatric, 24
quinapril HCL, 6
quinapril/hydrochlorothiazide, 6
Quinidine Gluconate, 6
quinidine gluconate CR, 6
quinidine gluconate ER, 6
quinidine sulfate, 6
Quinidine Sulfate ER, 6
quinine sulfate, 3
Qvar, 22
R
R-natal OB, 24
rabeprazole sodium, 13
raloxifene hydrochloride, 11
ramipril, 6
Ranexa, 5
ranitidine HCL, 13
Rapaflo, 14
Rapamune, 4
Rebetol, 3
Rebif, 18
Rebif Rebidose, 18
Rebif Rebidose Titration Pack, 18
Rebif Titration Pack, 18
Reclast, 11
Rectiv, 13
Regonol, 19
Regranex, 9
Relenza Diskhaler, 2
Relion Blood Glucose Teststrips, 25
Relion Confirm/Micro Test Strips, 25
Relion Insulin Syringe/U-100/0.5ML/29G
X 1/2", 25
Relion Ketone, 26
Relion Prime Blood Glucose Test Strips,
25
Relion Ultima Blood Glucose Test Strips,
25
Relion Ultima Test Strips, 25
Relistor, 14
Relpax, 21
Remicade, 14
Remodulin, 7
Renagel, 13
Renatabs, 24
Renatabs With Iron, 24
Renvela, 13
repaglinide, 11
Replesta, 23, 28
Replesta Childrens, 23, 28
Replesta Nx, 23, 28
Repronex, 11
Req 49+, 24
Rescriptor, 2
Rescula, 19
Reserpine, 6
Restasis, 19
Retin-a, 8
Retin-a Micro, 8
Retin-a Micro P.M., 8
Retrovir, 3
Retrovir IV Infusion, 3
Revatio, 7
Revlimid, 4
Reyataz, 3
Rheumatrex, 21
Rhinocort Aqua, 22
Rhogam Ultra-filtered Plus, 27
Rhophylac, 27
Ribasphere, 3
Ribasphere Ribapak, 3
Ribatab, 3
ribavirin, 2
Ridaura, 21
rifabutin, 2
Rifamate, 2
rifampin, 2
Rifater, 2
Right Step Prenatal, 24, 27
Rilutek, 18
riluzole, 18
rimantadine HCL, 2
Riomet, 11
risedronate sodium, 11
Risperdal, 16
Risperdal Consta, 16
Risperdal M-TAB, 16
risperidone, 16
risperidone odt, 16
Ritalin, 17
Ritalin LA, 17
Ritalin SR, 17
Rituxan, 4
rivastigmine tartrate, 18
rizatriptan benzoate, 21
rizatriptan benzoate odt, 21
Robaxin, 18
Robinul, 13
Rocephin, 1
rocuronium bromide, 18
ropinirole ER, 17
ropinirole HCL, 18
ropivacaine, 21
ropivacaine HCL, 21
Rosadan Kit, 8
Roxicet, 21
Rozerem, 17
S
Sabril, 17
Safyral, 10, 27
Saizen, 12
Saizen Click.easy, 12
salicylic acid, 9
salicylic acid cream, 9
salicylic acid lotion, 9
saline flush, 25
Saline/Phenol, 25
salsalate, 20
Samsca, 12
Sancuso, 13
Sandimmune, 4
Sandostatin, 12
Sandostatin Lar Depot, 12
Saphris, 16
Sarafem, 18
Savella, 18
Savella Titration Pack, 18
Scopolamine Hydrobromide, 13
Seasonique, 10, 27
Select-OB, 24
Select-ob+dha, 24
selegiline HCL, 18
selenium sulfide, 8
Selenium Sulfide, 8
Selzentry, 2
Sensipar, 12
Sensorcaine-mpf/Epinephrine, 22
Sentra AM, 26
Sentra PM, 26
Serevent Diskus, 22
Seroquel, 16
Seroquel XR, 16
Serostim, 12
sertraline HCL, 16
Sevelamer Carbonate, 13
Sfrowasa, 13
Siderol, 24
Signifor, 12
sildenafil, 7
sildenafil citrate, 7
silver sulfadiazine, 9
Simbrinza, 19
Simcor, 7
Similac Prenatal Early Shield, 24
Simponi, 21
simvastatin, 7
sirolimus, 4
Sivextro, 3
Sklice, 9
sodium acetate, 25
sodium bicarbonate, 25
sodium bicarbonate partial fill, 25
sodium chloride, 22, 25
sodium chloride 0.45%, 25
sodium chloride 0.45% viaflex, 25
sodium chloride bacteriostatic, 25
Sodium Chloride Bacteriostatic/Benzyl
Alcohol, 25
sodium chloride flush, 25
sodium chloride pab, 25
sodium citrate/citric acid, 14
sodium ferric gluconate complex/sucrose,
14
sodium fluoride, 26, 27
Sodium Fluoride, 26, 27
sodium hyaluronate, 9
sodium phenylbutyrate, 12
sodium phosphate, 25
sodium polystyrene sulfonate, 25
sodium sulfacetamide, 8(2), 19
sodium sulfacetamide wash, 8
sodium sulfacetamide/sulfur, 8
sodium sulfacetamide/sulfur cleanser, 8
sodium sulfacetamide/sulfur cleansing
cloths, 8
sodium sulfacetamide/sulfur green, 8
sodium sulfacetamide/sulfur w/sunscreen,
8
sodium sulfacetamide/sulfur wash, 8
sodium thiosulfate, 25
Solaraze, 9
Solu-cortef, 10
Solu-medrol, 10
Solus V2 Audible Test, 25
Soma, 18
Somatuline Depot, 12
Somavert, 12
Sonata, 17
Soriatane, 8
sotalol HCL, 6
sotalol HCL (AF), 6
Sovaldi, 3
Spectracef, 1
Spiriva Handihaler, 22
spironolactone, 7
spironolactone/hydrochlorothiazide, 7
Sporanox, 2
Sporanox Pulsepak, 2
Sprix, 21
Sprycel, 5
Stalevo 100, 18
Stalevo 125, 18
Stalevo 150, 18
Stalevo 200, 18
Stalevo 50, 18
Stalevo 75, 18
stannous fluoride oral rinse, 15
stavudine, 3
Stelara, 8
sterile diluent for epoprostenol sodium,
25
sterile water for injection, 25
Stivarga, 5
Strattera, 17
Streptomycin Sulfate, 2
Striant, 10
Stromectol, 3
Strovite, 24
Strovite Forte, 24
Strovite One, 24
Stuart One, 24
Stuart Prenatal, 24, 27
Stuart Prenatal + DHA, 24, 27
Suboxone, 21
Subsys, 21
Sucraid, 13
sucralfate, 13
sulfacetamide sodium, 8, 19
Sulfacetamide Sodium, 19
sulfacetamide sodium/prednisolone
sodium phosphate, 19
sulfacetamide sodium/sulfur cleanser, 8
Sulfadiazine, 2
sulfamethoxazole/trimethoprim, 3
Sulfamethoxazole/Trimethoprim, 3
sulfamethoxazole/trimethoprim DS, 3
Sulfamylon, 9
sulfasalazine, 13
sulindac, 21
Sumatriptan, 21
sumatriptan succinate, 21
Sumatriptan Succinate, 21
sumatriptan succinate refill, 21
Sumavel Dosepro, 21
Supervite, 24
Supervite EC, 24
Support-500, 24
Suprax, 1
Suprep Bowel Prep, 12
Sustiva, 3
Sutent, 5
Sylatron, 5
Symbicort, 22
Symbyax, 18
Symlinpen 120, 11
Symlinpen 60, 11
Synagex, 24
Synagis, 27
Synalar Cream Kit, 9
Synarel, 12
Synatek, 24
Synera, 9
Synribo, 5
Synthroid, 12
Synvisc, 18
Synvisc One, 18
Syprine, 26
T
Tabloid, 4
Taclonex, 9
tacrolimus, 4, 9
Tafinlar, 5
Talwin, 21
Tamiflu, 2
tamoxifen citrate, 4, 28
tamsulosin HCL, 14
Tandem F, 15
Tandem Plus, 15
Tarceva, 5
Targretin, 5, 9
Taron-bc, 24
Taron-c DHA, 24
Taron-prex, 24
Tasigna, 5
Tasmar, 18
Tazorac, 8
Tears Again Hydrate, 26
Tecfidera, 18
Tecfidera Starter Pack, 18
Teflaro, 1
Tegretol, 17
Tegretol-XR, 17
Tekturna, 6
Tekturna HCT, 7
telmisartan, 6
telmisartan/amlodipine, 7
telmisartan/hydrochloroth, 7
telmisartan/hydrochlorothiazide, 7
temazepam, 17
Temodar, 4
temozolomide, 4
terazosin HCL, 6
terbinafine HCL, 2
Terbinex, 2
terbutaline sulfate, 22
terconazole, 14
Testim, 10
Testosterone, 10
testosterone cypionate, 10
testosterone enanthate, 10
Testosterone P.M., 10
Testred, 10
tetracaine HCL, 19
Tetracaine HCL, 22
Tetracycline HCL, 2
Tev-tropin, 12
Teveten HCT, 7
Texacort, 9
Thalomid, 4
Theo-24, 22
theophylline, 22
theophylline CR, 22
theophylline ER, 22
theophylline/D5W, 22
Theophylline/D5W, 22
Thera-d 4000, 23, 28
Theramine, 26
Theramine Plus, 26
thiamine HCL, 23
thioridazine HCL, 16
thiothixene, 16
Thyrolar-1, 12
Thyrolar-1/4, 12
Thyrolar-2, 12
Thyrolar-3, 12
tiagabine hydrochloride, 17
ticlopidine HCL, 15
Tikosyn, 6
Timentin, 1
Timolol Maleate, 6
timolol maleate, 19
timolol maleate ophthalmic gel forming,
19
Timoptic Ocudose, 19
tinidazole, 3
Tirosint, 12
tizanidine HCL, 18
TL G-FOL OS, 24
Tobi, 2
Tobradex, 19
Tobradex ST, 19
tobramycin, 2
tobramycin sulfate, 2, 19
Tobramycin Sulfate/Sodium Chloride, 2
tobramycin/dexamethasone, 19
Tobrex, 19
tolazamide, 11
Tolazamide, 11
Tolbutamide, 11
tolmetin sodium, 21
Tolmetin Sodium, 21
tolterodine tartrate, 14
tolterodine tartrate ER, 14
Topicort, 9
topiramate, 17
topotecan HCL, 5
Topotecan HCL, 5
Torisel, 5
torsemide, 7
Totect, 5
Toujeo Solostar, 10
Toviaz, 14
Tozal, 26
Tracleer, 7
Tradjenta, 11
tramadol HCL, 20
tramadol HCL ER, 20
Tramadol HCL ER, 20
tramadol hydrochloride/acetaminophen,
20
trandolapril, 6
trandolapril/verapamil HCL, 7
trandolapril/verapamil HCL ER, 7
tranexamic acid, 15
Transderm-scop, 13
tranylcypromine sulfate, 16
Travasol, 26
Travatan Z, 19
trazodone HCL, 16
Treanda, 4
Trecator, 2
Trelstar, 4
Trelstar Mixject, 4
Trepadone, 26
Tretin-x, 8
tretinoin, 5, 8
tretinoin microsphere, 8
tretinoin microsphere P.M., 8
Trexall, 4
Tri-VI-flor, 24
triamcinolone acetonide, 9, 15, 22
Triamcinolone Acetonide, 9
triamcinolone IN orabase, 15
triamterene/hydrochlorothiazide, 7
Trianex, 9
triazolam, 17
Tribenzor, 7
Tricare, 24, 27
Tricare Prenatal Compleat, 24
Tricare Prenatal DHA One, 24
tricitrates, 14
trifluoperazine HCL, 16
trifluridine, 19
trihexyphenidyl HCL, 18
Trilipix, 7
trimethobenzamide HCL, 13
trimethoprim, 3
trimethoprim sulfate/polymyxin b sulfate,
19
Trinate, 24
Triveen-duo DHA, 24
Triveen-prx RNF, 24
Trizivir, 2
Trophamine, 26
trospium chloride, 14
trospium chloride ER, 14
Trueresult Blood Glucose Monitoring
System, 25
Truetest Strips, 25
Truetrack Test, 25
Truvada, 3
Tryptophan, 26
Tudorza Pressair, 22
Turkel Paracentesis Procedure
Tray/8french, 22
Twynsta, 7
Tygacil, 3
Tykerb, 5
Tysabri, 18
Tyzeka, 3
Tyzine, 22
Tyzine Pediatric Nasal Drops, 22
U
Uceris, 10
Udamin, 24
Udamin SP, 24
Uloric, 21
Ultima Test Strips, 25
Ultracet, 21
Ultram, 21
Ultram ER, 21
Ultresa, 13
Unasyn, 1
Unasyn Bulk Pack, 1
urea, 9
urea 40% nail film, 9
urea IN zinc undecylenate/lactic acid
vehicle, 9
urea topical, 9
Urocit-k 10, 14
Urocit-k 15, 14
Urocit-k 5, 14
Urso 250, 13
ursodiol, 13
V
Vagifem, 14
valacyclovir HCL, 2
Valcyte, 2
valganciclovir, 2
valproate sodium, 17
valproic acid, 17
valsartan, 6
valsartan/hydrochlorothiazide, 7
Valtrex, 2
Vancocin HCL, 3
vancomycin HCL, 3
Vancomycin HCL, 3
Vancomycin HCL IN Dextrose, 3
Vanos, 9
Vantas, 4
Vascazen, 26
Vasculera, 26
vasopressin, 12
Vasotec, 6
Vayacog, 26
Vayarin, 26
Vayarol, 26
Vectical, 8
vecuronium bromide, 18
Veletri, 7
Veltin, 8
Vemavite-prx 2, 24
venlafaxine HCL, 16
venlafaxine HCL ER, 16
Venlafaxine HCL ER, 16
Venofer, 15
Ventavis, 7
Ventolin HFA, 22
Veramyst, 22
verapamil HCL, 6
Verapamil HCL, 6
verapamil HCL ER, 6
verapamil HCL SR, 6
Verdeso, 9
Veregen, 9
Veripred 20, 10
Vesicare, 14
Vexol, 19
Vfend, 2
Vibramycin, 2
Victoza, 11
Victrelis, 3
Vidaza, 4
Videx EC, 3
Videx Pediatric, 2
Vigamox, 19
Viibryd, 16
Vimizim, 12
Vimpat, 17
Vinacal, 24
Vinacal B, 24
Vinate AZ Extra, 24
Vinate C, 24
Vinate Calcium, 24
Vinate Care, 24
Vinate DHA, 24
Vinate DHA RF, 24
Vinate GT, 24
Vinate IC, 24
Vinate II, 24
Vinate M, 24
Vinate One, 24
Vinate Pn Care, 24
vincristine sulfate, 5
vinorelbine tartrate, 5
Viokace, 13
Viracept, 3
Viramune, 3
Viramune XR, 3
Virazole, 2
Viread, 2
Virilex, 26
Vita-pren, 24
Vita-respa, 26
Vitafol, 24
Vitafol Ultra, 24
Vitafol-nano, 24
Vitafol-OB, 24
Vitafol-ob+dha, 24
Vitafol-one, 24
Vitafol-pn, 24
Vital-d RX, 24
Vitamedmd One RX/Quatrefolic, 24
Vitamedmd Plus RX/Quatre Folic, 24
Vitamedmd Redichew RX, 24
Vitamedmd Redichew RX/Quatrefolic, 24
Vitamelts Vitamin D, 23, 28
vitamin c 222MG, 23
vitamin d, 23, 27
Vitamin D, 23, 28
vitamin d 400, 23, 27
vitamin d-1000, 23, 28
vitamin d-3, 23, 28
vitamin d3, 23, 28
Vitamin D3, 23, 28
Vitamin D3 400, 23, 28
vitamin k1, 23
Vitamin K1, 23
Vitapearl, 24
Vitaroca Plus, 24
Vitrase, 26
Viva CT Prenatal, 24
Viva DHA, 24
Vivelle-dot, 10
Vivitrol, 26
Vogelxo, 10
Vogelxo P.M., 10
Voltaren, 8
voriconazole, 2
Votrient, 5
Vpriv, 15
Vytorin, 7
Vyvanse, 17
W
warfarin sodium, 15
Wavesense Presto Test Strips, 25
Welchol, 7
Wellbutrin SR, 16
Wellbutrin XL, 16
Wellesse Vitamin D3, 23, 28
Winrho SDF, 27
X
Xalatan, 19
Xalkori, 5
Xarelto, 15
Xclair, 9
Xeljanz, 21
Xeloda, 4
Xenazine, 18
Xeomin, 18
Xgeva, 11
Xiaflex, 27
Xifaxan, 3
Xolair, 23
Xolegel, 8
Xopenex, 23
Xopenex Concentrate, 23
Xopenex HFA, 22
Xtandi, 4
Xylocaine-mpf, 22
Xylocaine-mpf/Epinephrine, 22
Xylocaine/Epinephrine, 22
Xyrem, 18
Y
Yervoy, 4
Your Life Multi Prenatal, 24
Z
zafirlukast, 22
zaleplon, 17
Zantac, 13
Zatean-CH, 24
Zatean-pn, 24
Zatean-pn DHA, 24
Zatean-pn Plus, 24
Zavesca, 15
Zegerid, 13
Zelapar, 18
Zelboraf, 5
Zemaira, 23
Zemplar, 12
Zenatane, 8
Zenpep, 13
Zerit, 3
Zetia, 7
Zetonna, 22
Ziagen, 3
Ziana, 8
zidovudine, 3
Zinacef, 1
Zinacef IN Iso-osmotic Diluent, 1
zinc sulfate, 25
Zinecard, 5
Zioptan, 19
ziprasidone HCL, 16
Zirgan, 19
Zithromax, 1
Zithromax Tri-PAK, 1
Zithromax Z-PAK, 1
Zmax, 1
Zocor, 7
Zofran, 13
Zofran Odt, 13
Zoladex, 4
Zoledronic Acid, 11
zoledronic acid, 11
Zolinza, 5
zolmitriptan, 21
zolmitriptan odt, 21
Zoloft, 16
zolpidem tartrate, 17
zolpidem tartrate ER, 17
Zometa, 11
Zomig, 21
Zomig Nasal Spray, 21
Zomig ZMT, 21
Zonalon, 8
zonisamide, 17
Zorbtive, 12
Zortress, 4
Zovia 1/50e, 10, 27
Zovirax, 8
Zuplenz, 13
Zyban, 18, 27
Zyclara, 9
Zyclara P.M., 9
Zydelig, 5
Zyflo CR, 23
Zykadia, 5
Zymaxid, 19
Zyprexa, 16
Zyprexa Zydis, 16
Zytiga, 4
Zyvox, 3
8
8-mop, 8