1. No category

Blue MedicareRx (PDP)
SM
Blue MedicareRxSM Value Plus (PDP) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 07/01/2015. For more recent information or other
questions, please contact Blue MedicareRx Value Plus, at 1­888­543­4917 or, for
TTY/TDD users, 1­866­236­1069, 24 hours a day, 7 days a week, or visit
www.RxMedicarePlans.com.
Note to existing members: This formulary has changed since last year.
Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue
MedicareRxSM (PDP). When it refers to “plan” or “our plan,” it means Blue
MedicareRx Value Plus.
This document includes a list of the drugs (formulary) for our plan which is current as
of July 1, 2015.
For an updated
formulary,
please
contact
us. Our contact
information, along with the date we last updated the formulary, appears on the front
and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on
January 1, 2016, and from time to time during the year.
S2893_1418 Accepted 07192014 00015129_v13_07/2015 What is the MedicareRx Value Plus Formulary? A formulary is a list of covered drugs selected by Blue MedicareRx Value Plus in Consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue MedicareRx Value Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue MedicareRx Value Plus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost­sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost­sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60­day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of July 1, 2015. To get updated
information about the drugs covered by Blue MedicareRx Value Plus, please contact us. Our contact information appears on the front and back cover pages. If we have a mid­year non­maintenance formulary change, we will provide a notice in the monthly Explanation of Benefits or mail you a formulary update which provides a complete list of changes that have occurred since the printing of the formulary. You may also access our formulary and information showing changes to, additions, and/or deletions of formulary medications on our Web site at www.RxMedicarePlans.com. To get updated information about the drugs covered by Blue MedicareRx Value Plus, please contact us. Our contact information appears on the front and back cover pages. 1
How do I use the Formulary?
There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins on page number 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 79. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Blue MedicareRx Value Plus covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: Blue MedicareRx Value Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, we may not cover the drug. • Quantity Limits: For certain drugs, Blue MedicareRx Value Plus limits the amount of the drug that we will cover. For example, our plan provides 12 units per prescription for RELPAX. This may be in addition to a standard one­month or three­month supply. • Step Therapy: In some cases, Blue MedicareRx Value Plus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 2
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Blue MedicareRx Value Plus to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Blue MedicareRx Value Plus formulary?” on page 3 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Care and ask if your drug is covered. If you learn that Blue MedicareRx Value Plus does not cover your drug, you have two options: • You can ask Customer Care for a list of similar drugs that are covered by Blue MedicareRx Value Plus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. • You can ask Blue MedicareRx Value Plus to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Blue MedicareRx Value Plus Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover a drug even if it is not on our formulary. If approved, this
drug will be covered at a pre­determined cost­sharing level, and you would not be able to ask us to provide the drug at a lower cost­sharing level.
• You can ask us to cover a formulary drug at a lower cost­sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue MedicareRx Value Plus limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Blue MedicareRx Value Plus will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower cost­sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. 3
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30­day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30­day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long­term care facility, we will allow you to refill your prescription until we have provided you with a 98­day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31­day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30­day supply (or 31­day supply if you are a long­term care resident) when you go to a network pharmacy. After your first 30­day supply, you are required to use the plan's exception process. Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover or drugs that are covered under Medicare Part B. 4
For more information For more detailed information about your Blue MedicareRx Value Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Blue MedicareRx Value Plus, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1­800­MEDICARE (1­800­633­4227) 24 hours a day/7 days a week. TTY users should call 1­877­486­2048. Or, visit http://www.medicare.gov. Blue MedicareRx Value Plus Formulary The formulary that begins on page 7 provides coverage information about the drugs covered by Blue MedicareRx Value Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 79. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower­case italics (e.g., levothyroxine sodium). The information in the Requirement/Limits column tells you if Blue MedicareRx Value Plus has any special requirements for coverage of your drug. The abbreviations you may see in the drug listing include: o B/D stands for drugs covered under Medicare Part B or D. o QL stands for Quantity Limits. o PA stands for Prior Authorization. o ST stands for Step Therapy. o LA stands for Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at 1­888­543­4917, 24 hours a day, 7 days a week. TTY/TDD users should call 1­866­236­1069. o NMO stands for No Mail Order. This prescription drug is not available through mail order service. 5
Explanation of Tiers and Copayments/Coinsurance: Blue MedicareRx Value Plus Initial Coverage Stage Tier Label/Description Retail Cost­Sharing or Out­of­Network Cost­Sharing* Mail Order Cost­Sharing 90­day supply 30­day supply/ Long­term Care 31­day supply Preferred Retail Cost­Sharing Standard Retail Cost­Sharing Tier 1: Preferred Generics Certain generic drugs that are available at the lowest copayment $1 $6 $1 Tier 2: Non­Preferred Generics Higher cost generic drugs available at a higher copayment than Tier 1 generic drugs $6 Tier 3: Preferred Brands Many common brand name drugs and some higher cost generic drugs, many of which may have lower cost options available on Tier 1 or Tier 2 $35 Tier 4: Non­Preferred Brands Non­preferred generic and non­
preferred brand name drugs, many of which may have lower cost options available on Tier 1, Tier 2 and Tier 3 40% Tier 5: Specialty Tier Unique and/or very high­cost drugs of which you pay a percentage of the total drug cost 25% $16 $12 $45 $70 50% 40% 25% Not Applicable.† * In addition to your copayment, at an out­of­network pharmacy you will pay the difference between the actual charge and what you would have paid at a network pharmacy. Amounts you pay may vary at out­of­network pharmacies. † Specialty Tier drugs are not available for a 90­day retail or mail order supply.
6
Drug Name
Blue MedicareRx Value Plus
2015 Complete Drug List
Drug Name
Drug Requirements/
Tier
Limits
ANALGESICS
GOUT
allopurinol tab 100 mg
Tier 1
(generic of ZYLOPRIM)
allopurinol tab 300 mg
Tier 1
(generic of ZYLOPRIM)
colchicine w/ probenecid tab Tier 3
0.5-500 mg
COLCRYS TAB 0.6MG
Tier 3
QL (120 tabs / 30
days)
probenecid tab 500 mg
Tier 3
ULORIC TAB 40MG
Tier 3
ULORIC TAB 80MG
Tier 3
QL
ST
ST
NSAIDS
celecoxib cap 50 mg
Tier 4
(generic of CELEBREX)
QL (60 caps / 30 days)
celecoxib cap 100 mg
Tier 4
(generic of CELEBREX)
QL (60 caps / 30 days)
celecoxib cap 200 mg
Tier 4
(generic of CELEBREX)
QL (60 caps / 30 days)
celecoxib cap 400 mg
Tier 4
(generic of CELEBREX)
QL (60 caps / 30 days)
diclofenac potassium tab 50 Tier 2
mg
diclofenac sodium tab
Tier 2
delayed release 25 mg
diclofenac sodium tab
Tier 2
delayed release 50 mg
diclofenac sodium tab
Tier 2
delayed release 75 mg
diclofenac sodium tab sr
Tier 3
24hr 100 mg (generic of
VOLTAREN-XR)
diflunisal tab 500 mg
Tier 3
etodolac cap 200 mg
Tier 3
etodolac cap 300 mg
Tier 3
etodolac tab 400 mg
Tier 3
etodolac tab 500 mg
Tier 3
etodolac tab sr 24hr 400 mg Tier 4
QL
QL
QL
QL
Drug Requirements/
Tier
Limits
etodolac tab sr 24hr 500 mg Tier 4
etodolac tab sr 24hr 600 mg Tier 4
flurbiprofen tab 50 mg
Tier 2
flurbiprofen tab 100 mg
Tier 2
ibuprofen susp 100 mg/5ml Tier 3
ibuprofen tab 400 mg
Tier 1
ibuprofen tab 600 mg
Tier 1
ibuprofen tab 800 mg
Tier 1
ketoprofen cap 50 mg
Tier 2
ketoprofen cap 75 mg
Tier 2
MELOXICAM SUSP 7.5
Tier 4
MG/5ML
meloxicam tab 7.5 mg
Tier 1
(generic of MOBIC)
meloxicam tab 15 mg
Tier 1
(generic of MOBIC)
nabumetone tab 500 mg
Tier 2
nabumetone tab 750 mg
Tier 2
naproxen dr tab 375mg
Tier 2
(generic of EC-NAPROSYN)
naproxen dr tab 500mg
Tier 2
(generic of EC-NAPROSYN)
naproxen sodium tab 275 Tier 2
mg (generic of ANAPROX)
naproxen sodium tab 550 Tier 2
mg (generic of ANAPROX
DS)
naproxen susp 125 mg/5ml Tier 3
naproxen tab 250 mg
Tier 1
(generic of NAPROSYN)
naproxen tab 375 mg
Tier 1
(generic of NAPROSYN)
naproxen tab 500 mg
Tier 1
(generic of NAPROSYN)
piroxicam cap 10 mg
Tier 3
(generic of FELDENE)
piroxicam cap 20 mg
Tier 3
(generic of FELDENE)
sulindac tab 150 mg
Tier 2
sulindac tab 200 mg
Tier 2
OPIOID ANALGESICS
acetaminophen w/ codeine Tier 2
soln 120-12 mg/5ml
QL (5000 mL / 30
days)
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
7
Drug Name
Drug Requirements/
Tier
Limits
acetaminophen w/ codeine Tier 2
tab 300-15 mg
QL (400 tabs / 30
days)
acetaminophen w/ codeine Tier 2
tab 300-30 mg (generic of
TYLENOL/CODEINE #3)
QL (400 tabs / 30
days)
acetaminophen w/ codeine Tier 2
tab 300-60 mg (generic of
TYLENOL/CODEINE #4)
QL (400 tabs / 30
days)
butorphanol tartrate inj 1
Tier 3
mg/ml
butorphanol tartrate inj 2
Tier 3
mg/ml
hydrocodone-acetaminophe Tier 4
n soln 7.5-325 mg/15ml
(generic of HYCET)
QL (5400 mL / 30
days)
hydrocodone-acetaminophe Tier 2
n tab 5-325 mg (generic of
NORCO, LORCET)
QL (360 tabs / 30
days)
hydrocodone-acetaminophe Tier 2
n tab 7.5-325 mg (generic of
NORCO, LORCET PLUS)
QL (360 tabs / 30
days)
hydrocodone-acetaminophe Tier 2
n tab 10-325 mg (generic of
NORCO, LORCET HD)
QL (360 tabs / 30
days)
hydrocodone-ibuprofen tab Tier 3
7.5-200 mg (generic of
VICOPROFEN)
QL (150 tabs / 30
days)
tramadol hcl tab 50 mg
Tier 2
(generic of ULTRAM)
QL (240 tabs / 30
days)
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
tramadol-acetaminophen
Tier 3
tab 37.5-325 mg (generic of
ULTRACET)
QL (240 tabs / 30
days)
QL
OPIOID ANALGESICS, CII
QL
QL
QL
QL
QL
QL
QL
DURAMORPH INJ
Tier 2
0.5MG/ML
DURAMORPH INJ 1MG/ML Tier 2
endocet tab 5-325mg
Tier 3
(generic of PERCOCET)
QL (360 tabs / 30
days)
endocet tab 7.5-325 (genericTier 3
of PERCOCET)
QL (360 tabs / 30
days)
endocet tab 10-325mg
Tier 3
(generic of PERCOCET)
QL (360 tabs / 30
days)
fentanyl citrate lozenge on a Tier 5
handle 200 mcg (generic of
ACTIQ)
QL (120 lozenges / 30
days)
fentanyl citrate lozenge on a Tier 5
handle 400 mcg (generic of
ACTIQ)
QL (120 lozenges / 30
days)
fentanyl citrate lozenge on a Tier 5
handle 600 mcg (generic of
ACTIQ)
QL (120 lozenges / 30
days)
fentanyl citrate lozenge on a Tier 5
handle 800 mcg (generic of
ACTIQ)
QL (120 lozenges / 30
days)
fentanyl citrate lozenge on a Tier 5
handle 1200 mcg (generic of
ACTIQ)
QL (120 lozenges / 30
days)
B/D
B/D
QL
QL
QL
QL PA
QL PA
QL PA
QL PA
QL PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
8
Drug Name
Drug Requirements/
Tier
Limits
fentanyl citrate lozenge on a Tier 5
handle 1600 mcg (generic of
ACTIQ)
QL (120 lozenges / 30
days)
fentanyl td patch 72hr 12
Tier 4
mcg/hr (generic of
DURAGESIC)
QL (10 patches / 30
days)
fentanyl td patch 72hr 25
Tier 4
mcg/hr (generic of
DURAGESIC)
QL (10 patches / 30
days)
fentanyl td patch 72hr 50
Tier 4
mcg/hr (generic of
DURAGESIC)
QL (10 patches / 30
days)
fentanyl td patch 72hr 75
Tier 4
mcg/hr (generic of
DURAGESIC)
QL (10 patches / 30
days)
fentanyl td patch 72hr 100 Tier 4
mcg/hr (generic of
DURAGESIC)
QL (10 patches / 30
days)
FENTORA TAB 100MCG Tier 5
QL (120 tabs / 30
days)
FENTORA TAB 200MCG Tier 5
QL (120 tabs / 30
days)
FENTORA TAB 400MCG Tier 5
QL (120 tabs / 30
days)
FENTORA TAB 600MCG Tier 5
QL (120 tabs / 30
days)
FENTORA TAB 800MCG Tier 5
QL (120 tabs / 30
days)
hydromorphone hcl liqd 1 Tier 3
mg/ml (generic of
DILAUDID)
QL PA
QL
QL
QL PA
QL PA
QL PA
QL PA
QL PA
QL PA
QL PA
QL PA
Drug Name
Drug Requirements/
Tier
Limits
hydromorphone hcl
Tier 4
preservative free (pf) inj 10
mg/ml (generic of
DILAUDID-HP)
hydromorphone hcl tab 2 mgTier 3
(generic of DILAUDID)
QL (270 tabs / 30
days)
hydromorphone hcl tab 4 mgTier 3
(generic of DILAUDID)
QL (270 tabs / 30
days)
hydromorphone hcl tab 8 mgTier 3
(generic of DILAUDID)
QL (270 tabs / 30
days)
LAZANDA SPR 100MCG Tier 5
QL (30 bottles / 30
days)
LAZANDA SPR 400MCG Tier 5
QL (30 bottles / 30
days)
methadone con 10mg/ml
Tier 3
(generic of METHADOSE)
QL (120 mL / 30 days)
methadone hcl soln 5
Tier 3
mg/5ml
QL (600 mL / 30 days)
methadone hcl soln 10
Tier 3
mg/5ml
QL (600 mL / 30 days)
methadone hcl tab 5 mg
Tier 2
(generic of DOLOPHINE
HCL)
QL (240 tabs / 30
days)
methadone hcl tab 10 mg Tier 2
(generic of DOLOPHINE)
QL (240 tabs / 30
days)
MORPHINE SUL INJ
Tier 3
2MG/ML
MORPHINE SUL INJ
Tier 3
4MG/ML
MORPHINE SUL INJ
Tier 3
8MG/ML
MORPHINE SULFATE
Tier 3
(CONCENTRATE) ORAL
SOLN 20 MG/ML
B/D
QL
QL
QL
QL PA
QL PA
QL
QL
QL
QL
QL
B/D
B/D
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
9
Drug Name
Drug Requirements/
Tier
Limits
morphine sulfate beads cap Tier 4
sr 24hr 30 mg (generic of
AVINZA)
QL (60 caps / 30 days)
morphine sulfate beads cap Tier 4
sr 24hr 45 mg (generic of
AVINZA)
QL (60 caps / 30 days)
morphine sulfate beads cap Tier 4
sr 24hr 60 mg (generic of
AVINZA)
QL (60 caps / 30 days)
morphine sulfate beads cap Tier 4
sr 24hr 75 mg (generic of
AVINZA)
QL (60 caps / 30 days)
morphine sulfate beads cap Tier 4
sr 24hr 90 mg (generic of
AVINZA)
QL (60 caps / 30 days)
morphine sulfate beads cap Tier 4
sr 24hr 120 mg (generic of
AVINZA)
QL (60 caps / 30 days)
morphine sulfate cap sr 24hrTier 4
10 mg (generic of KADIAN)
QL (60 caps / 30 days)
morphine sulfate cap sr 24hrTier 4
20 mg (generic of KADIAN)
QL (60 caps / 30 days)
morphine sulfate cap sr 24hrTier 4
30 mg (generic of KADIAN)
QL (60 caps / 30 days)
morphine sulfate cap sr 24hrTier 4
50 mg (generic of KADIAN)
QL (60 caps / 30 days)
morphine sulfate cap sr 24hrTier 4
60 mg (generic of KADIAN)
QL (60 caps / 30 days)
morphine sulfate cap sr 24hrTier 5
80 mg (generic of KADIAN)
QL (60 caps / 30 days)
morphine sulfate cap sr 24hrTier 5
100 mg (generic of KADIAN)
QL (60 caps / 30 days)
morphine sulfate inj pf 0.5 Tier 2
mg/ml
morphine sulfate inj pf 1
Tier 2
mg/ml
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
B/D
Drug Name
Drug Requirements/
Tier
Limits
MORPHINE SULFATE IV Tier 2
SOLN 1 MG/ML
MORPHINE SULFATE IV Tier 2
SOLN PF 10 MG/ML
MORPHINE SULFATE IV Tier 2
SOLN PF 15 MG/ML
MORPHINE SULFATE
Tier 3
ORAL SOLN 10 MG/5ML
MORPHINE SULFATE
Tier 3
ORAL SOLN 20 MG/5ML
MORPHINE SULFATE TAB Tier 2
15 MG
QL (180 tabs / 30
days)
MORPHINE SULFATE TAB Tier 2
30 MG
QL (180 tabs / 30
days)
morphine sulfate tab cr 15 Tier 3
mg (generic of MS CONTIN)
QL (90 tabs / 30 days)
morphine sulfate tab cr 30 Tier 3
mg (generic of MS CONTIN)
QL (90 tabs / 30 days)
morphine sulfate tab cr 60 Tier 3
mg (generic of MS CONTIN)
QL (90 tabs / 30 days)
morphine sulfate tab cr 100 Tier 3
mg (generic of MS CONTIN)
QL (90 tabs / 30 days)
morphine sulfate tab cr 200 Tier 3
mg (generic of MS CONTIN)
QL (60 tabs / 30 days)
oxycodone hcl cap 5 mg
Tier 2
QL (180 caps / 30
days)
oxycodone hcl conc 100
Tier 4
mg/5ml (20 mg/ml)
oxycodone hcl soln 5
Tier 4
mg/5ml
oxycodone hcl tab 5 mg
Tier 3
(generic of ROXICODONE)
QL (180 tabs / 30
days)
oxycodone hcl tab 10 mg
Tier 3
QL (180 tabs / 30
days)
B/D
B/D
B/D
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
10
Drug Name
Drug Requirements/
Tier
Limits
oxycodone hcl tab 15 mg
Tier 3
(generic of ROXICODONE)
QL (180 tabs / 30
days)
oxycodone hcl tab 20 mg
Tier 3
QL (180 tabs / 30
days)
oxycodone hcl tab 30 mg
Tier 3
(generic of ROXICODONE)
QL (180 tabs / 30
days)
oxycodone w/
Tier 3
acetaminophen tab 2.5-325
mg (generic of PERCOCET)
QL (360 tabs / 30
days)
oxycodone w/
Tier 3
acetaminophen tab 5-325
mg (generic of PERCOCET)
QL (360 tabs / 30
days)
oxycodone w/
Tier 3
acetaminophen tab 7.5-325
mg (generic of PERCOCET)
QL (360 tabs / 30
days)
oxycodone w/
Tier 3
acetaminophen tab 10-325
mg (generic of PERCOCET)
QL (360 tabs / 30
days)
roxicet sol 5-325/5
Tier 3
QL (1800 mL / 30
days)
roxicet tab 5-325mg (genericTier 3
of PERCOCET)
QL (360 tabs / 30
days)
QL
QL
QL
Drug Requirements/
Tier
Limits
lidocaine hcl local
Tier 2
preservative free (pf) inj
0.5% (generic of
XYLOCAINE-MPF)
lidocaine hcl local
Tier 2
preservative free (pf) inj 1%
(generic of
XYLOCAINE-MPF)
B/D
B/D
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
QL
QL
QL
QL
QL
QL
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl local inj 0.5%
(generic of XYLOCAINE)
lidocaine hcl local inj 1%
(generic of XYLOCAINE)
lidocaine hcl local inj 1.5%
(generic of
XYLOCAINE-MPF)
lidocaine hcl local inj 2%
(generic of XYLOCAINE)
Drug Name
Tier 2
B/D
Tier 2
B/D
Tier 2
B/D
Tier 2
B/D
amikacin sulfate inj 1 gm/4mlTier 4
(250 mg/ml)
amikacin sulfate inj 500
Tier 4
mg/2ml (250 mg/ml)
gentam/nacl inj 0.9mg/ml
Tier 2
gentam/nacl inj 1.4mg/ml
Tier 2
gentamicin in saline inj 0.8 Tier 2
mg/ml
gentamicin in saline inj 1
Tier 2
mg/ml
gentamicin in saline inj 1.2 Tier 2
mg/ml
gentamicin in saline inj 1.6 Tier 2
mg/ml
gentamicin in saline inj 2
Tier 2
mg/ml
gentamicin sulfate inj 10
Tier 2
mg/ml
gentamicin sulfate inj 40
Tier 2
mg/ml
gentamicin sulfate iv soln 10 Tier 2
mg/ml
neomycin sulfate tab 500 mgTier 3
paromomycin sulfate cap
Tier 4
250 mg
streptomycin sulfate for inj 1 Tier 4
gm
sulfadiazine tab 500mg
Tier 4
tobra/nacl inj 80/0.9
Tier 3
tobramycin nebu soln 300 Tier 5
mg/5ml (generic of TOBI)
tobramycin sulfate for inj 1.2 Tier 4
gm
tobramycin sulfate inj 1.2
Tier 3
gm/30ml (40 mg/ml)
tobramycin sulfate inj 2
Tier 3
gm/50ml (40 mg/ml)
B/D NM
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
11
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
tobramycin sulfate inj 10
mg/ml
tobramycin sulfate inj 80
mg/2ml (40 mg/ml)
Tier 3
clindamycin phosphate iv Tier 3
soln 900 mg/6ml (generic of
CLEOCIN PHOSPHATE)
colistimethate sodium for inj Tier 4
150 mg (generic of
COLY-MYCIN M)
CUBICIN SOL 500MG
Tier 5
dapsone tab 25 mg
Tier 3
dapsone tab 100 mg
Tier 3
DARAPRIM TAB 25MG
Tier 4
imipenem-cilastatin
Tier 4
intravenous for soln 250 mg
(generic of PRIMAXIN IV)
imipenem-cilastatin
Tier 4
intravenous for soln 500 mg
(generic of PRIMAXIN IV)
INVANZ INJ 1GM
Tier 4
ivermectin tab 3 mg (generic Tier 3
of STROMECTOL)
linezolid iv soln 2 mg/ml
Tier 5
(generic of ZYVOX)
meropenem iv for soln 1 gm Tier 4
(generic of MERREM)
meropenem iv for soln 500 Tier 4
mg (generic of MERREM)
methenamine hippurate tab Tier 3
1 gm (generic of HIPREX)
metronidazole in nacl 0.79% Tier 2
iv soln 500 mg/100ml
metronidazole tab 250 mg Tier 2
(generic of FLAGYL)
metronidazole tab 500 mg Tier 2
(generic of FLAGYL)
NEBUPENT INH 300MG
Tier 4
nitrofurantoin
Tier 4
macrocrystalline cap 50 mg
(generic of
MACRODANTIN)
90 day limit if >64 yr
nitrofurantoin
Tier 4
macrocrystalline cap 100 mg
(generic of
MACRODANTIN)
90 day limit if >64 yr
nitrofurantoin monohydrate Tier 4
macrocrystalline cap 100 mg
(generic of MACROBID)
90 day limit if >64 yr
Tier 3
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA TAB 200MG
Tier 4
ALINIA SUS 100/5ML
Tier 4
ALINIA TAB 500MG
Tier 4
atovaquone susp 750
Tier 5
mg/5ml (generic of
MEPRON)
AZACTAM INJ 1GM
Tier 4
AZACTAM INJ 2GM
Tier 4
AZACTAM/DEX INJ 1GM Tier 4
AZACTAM/DEX INJ 2GM Tier 5
aztreonam for inj 1 gm
Tier 3
(generic of AZACTAM)
aztreonam for inj 2 gm
Tier 3
(generic of AZACTAM)
BILTRICIDE TAB 600MG Tier 3
CAYSTON INH 75MG
Tier 5
clindamycin hcl cap 75 mg Tier 2
(generic of CLEOCIN)
clindamycin hcl cap 150 mg Tier 2
(generic of CLEOCIN)
clindamycin hcl cap 300 mg Tier 2
(generic of CLEOCIN)
clindamycin palmitate hcl for Tier 4
soln 75 mg/5ml (base equiv)
(generic of CLEOCIN
PEDIATRIC GRANULE)
clindamycin phosphate inj 9 Tier 3
gm/60ml (generic of
CLEOCIN PHOSPHATE)
clindamycin phosphate inj Tier 3
300 mg/2ml (generic of
CLEOCIN PHOSPHATE)
clindamycin phosphate inj Tier 3
600 mg/4ml (generic of
CLEOCIN PHOSPHATE)
clindamycin phosphate inj Tier 3
900 mg/6ml (generic of
CLEOCIN PHOSPHATE)
clindamycin phosphate iv Tier 3
soln 300 mg/2ml
clindamycin phosphate iv Tier 3
soln 600 mg/4ml (generic of
CLEOCIN PHOSPHATE)
NM LA PA
Drug Requirements/
Tier
Limits
B/D
PA
PA
PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
12
Drug Name
Drug Requirements/
Tier
Limits
PENTAM 300 INJ 300MG Tier 4
SIVEXTRO INJ 200MG
Tier 5
SIVEXTRO TAB 200MG
Tier 5
sulfamethoxazole-trimethopr Tier 3
im iv soln 400-80 mg/5ml
sulfamethoxazole-trimethopr Tier 2
im susp 200-40 mg/5ml
sulfamethoxazole-trimethopr Tier 1
im tab 400-80 mg (generic of
BACTRIM)
sulfamethoxazole-trimethopr Tier 1
im tab 800-160 mg (generic
of BACTRIM DS)
SYNERCID INJ 500MG
Tier 5
trimethoprim tab 100 mg
Tier 2
TYGACIL INJ 50MG
Tier 5
vancomycin hcl cap 125 mg Tier 5
(generic of VANCOCIN
HCL)
vancomycin hcl cap 250 mg Tier 5
(generic of VANCOCIN
HCL)
vancomycin hcl for inj 10 gm Tier 3
vancomycin hcl for inj 500 Tier 3
mg
vancomycin hcl for inj 1000 Tier 3
mg
vancomycin hcl for inj 5000 Tier 3
mg
vancomycin inj 750mg
Tier 3
ZYVOX SUS 100MG/5M
Tier 5
ZYVOX TAB 600MG
Tier 5
ANTIFUNGALS
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
amphotericin b for inj 50 mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ERAXIS INJ 50MG
ERAXIS INJ 100MG
fluconazole for susp 10
mg/ml (generic of
DIFLUCAN)
fluconazole for susp 40
mg/ml (generic of
DIFLUCAN)
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 3
B/D
B/D
B/D
Drug Name
Drug Requirements/
Tier
Limits
fluconazole in dextrose inj
200 mg/100ml
fluconazole in dextrose inj
400 mg/200ml
fluconazole in nacl 0.9% inj
200 mg/100ml
fluconazole in nacl 0.9% inj
400 mg/200ml
fluconazole tab 50 mg
(generic of DIFLUCAN)
fluconazole tab 100 mg
(generic of DIFLUCAN)
fluconazole tab 150 mg
(generic of DIFLUCAN)
fluconazole tab 200 mg
(generic of DIFLUCAN)
flucytosine cap 250 mg
(generic of ANCOBON)
flucytosine cap 500 mg
(generic of ANCOBON)
griseofulvin microsize susp
125 mg/5ml
griseofulvin microsize tab
500 mg (generic of
GRIFULVIN V)
griseofulvin ultramicrosize
tab 125 mg (generic of
GRIS-PEG)
griseofulvin ultramicrosize
tab 250 mg (generic of
GRIS-PEG)
itraconazole cap 100 mg
(generic of SPORANOX)
ketoconazole tab 200 mg
MYCAMINE INJ 50MG
MYCAMINE INJ 100MG
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
(generic of LAMISIL)
QL (90 tabs / 365
days)
voriconazole for inj 200 mg
(generic of VFEND IV)
voriconazole for susp 40
mg/ml (generic of VFEND)
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
PA
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 2
PA
QL
Tier 4
Tier 5
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
13
Drug Name
Drug Requirements/
Tier
Limits
voriconazole tab 50 mg
(generic of VFEND)
voriconazole tab 200 mg
(generic of VFEND)
Tier 5
Drug Name
Drug Requirements/
Tier
Limits
INTELENCE TAB 100MG Tier 5
INTELENCE TAB 200MG Tier 5
Tier 5
INVIRASE CAP 200MG
Tier 4
INVIRASE TAB 500MG
Tier 5
ANTIMALARIALS
ISENTRESS CHW 25MG Tier 3
atovaquone-proguanil hcl Tier 4
ISENTRESS CHW 100MG Tier 5
tab 62.5-25 mg (generic of
ISENTRESS POW 100MG Tier 3
MALARONE)
ISENTRESS TAB 400MG Tier 5
atovaquone-proguanil hcl Tier 4
lamivudine oral soln 10
Tier 3
tab 250-100 mg (generic of
mg/ml
(generic
of
EPIVIR)
MALARONE)
lamivudine tab 150 mg
Tier 3
chloroquine phosphate tab Tier 3
(generic of EPIVIR)
250 mg
lamivudine tab 300 mg
Tier 3
chloroquine phosphate tab Tier 3
(generic
of
EPIVIR)
500 mg (generic of
LEXIVA SUS 50MG/ML
Tier 4
ARALEN)
COARTEM TAB 20-120MG Tier 3
LEXIVA TAB 700MG
Tier 5
mefloquine hcl tab 250 mg Tier 3
NEVIRAPINE SUSP 50
Tier 4
MG/5ML
PRIMAQUINE TAB 26.3MG Tier 3
nevirapine tab 200 mg
Tier 3
quinine sulfate cap 324 mg Tier 4
PA
(generic of VIRAMUNE)
(generic of QUALAQUIN)
nevirapine tab sr 24hr 400 Tier 4
ANTIRETROVIRAL AGENTS
mg (generic of VIRAMUNE
abacavir sulfate tab 300 mg Tier 4
XR)
(base equiv) (generic of
NORVIR CAP 100MG
Tier 3
ZIAGEN)
NORVIR
SOL
80MG/ML
Tier 3
APTIVUS CAP 250MG
Tier 5
NORVIR TAB 100MG
Tier 3
APTIVUS SOL
Tier 5
PREZISTA SUS 100MG/ML Tier 5
CRIXIVAN CAP 200MG
Tier 4
PREZISTA TAB 75MG
Tier 3
CRIXIVAN CAP 400MG
Tier 4
PREZISTA TAB 150MG
Tier 3
didanosine delayed release Tier 4
PREZISTA
TAB
600MG
Tier 5
capsule 125 mg (generic of
VIDEX EC)
PREZISTA TAB 800MG
Tier 5
didanosine delayed release Tier 4
RESCRIPTOR TAB 100 MG Tier 4
capsule 200 mg (generic of
RESCRIPTOR TAB 200MG Tier 4
VIDEX EC)
RETROVIR INJ 10MG/ML Tier 3
didanosine delayed release Tier 4
REYATAZ CAP 150MG
Tier 5
capsule 250 mg (generic of
REYATAZ
CAP
200MG
Tier 5
VIDEX EC)
REYATAZ CAP 300MG
Tier 5
didanosine delayed release Tier 4
REYATAZ POW 50MG
Tier 5
capsule 400 mg (generic of
VIDEX EC)
SELZENTRY TAB 150MG Tier 5
EDURANT TAB 25MG
Tier 5
SELZENTRY TAB 300MG Tier 5
EMTRIVA CAP 200MG
Tier 3
stavudine cap 15 mg
Tier 3
EMTRIVA SOL 10MG/ML Tier 3
(generic of ZERIT)
stavudine cap 20 mg
Tier 3
EPIVIR SOL 10MG/ML
Tier 3
(generic
of
ZERIT)
FUZEON INJ 90MG
Tier 5
NM
stavudine cap 30 mg
Tier 3
INTELENCE TAB 25MG
Tier 4
(generic of ZERIT)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
14
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
stavudine cap 40 mg
Tier 3
(generic of ZERIT)
stavudine for oral soln 1
Tier 4
mg/ml (generic of ZERIT)
SUSTIVA CAP 50MG
Tier 3
SUSTIVA CAP 200MG
Tier 3
SUSTIVA TAB 600MG
Tier 5
TIVICAY TAB 50MG
Tier 5
TYBOST TAB 150MG
Tier 4
VIDEX SOL 2GM
Tier 4
VIDEX SOL 4GM
Tier 4
VIRACEPT TAB 250MG
Tier 5
VIRACEPT TAB 625MG
Tier 5
VIRAMUNE XR TAB 100MGTier 4
VIREAD POW 40MG/GM Tier 5
VIREAD TAB 150MG
Tier 5
VIREAD TAB 200MG
Tier 5
VIREAD TAB 250MG
Tier 5
VIREAD TAB 300MG
Tier 5
VITEKTA TAB 85MG
Tier 5
VITEKTA TAB 150MG
Tier 5
ZIAGEN SOL 20MG/ML
Tier 4
zidovudine cap 100 mg
Tier 3
(generic of RETROVIR)
zidovudine syrup 10 mg/ml Tier 3
(generic of RETROVIR)
zidovudine tab 300 mg
Tier 3
TRIUMEQ TAB
Tier 5
TRUVADA TAB 200-300
Tier 5
QL (30 tabs / 30 days)
ANTIRETROVIRAL COMBINATION
AGENTS
ANTIVIRALS
abacavir
Tier 5
sulfate-lamivudine-zidovudin
e tab 300-150-300 mg
(generic of TRIZIVIR)
ATRIPLA TAB
Tier 5
COMPLERA TAB
Tier 5
EPZICOM TAB 600-300
Tier 5
EVOTAZ TAB 300-150
Tier 5
KALETRA SOL
Tier 5
KALETRA TAB 100-25MG Tier 3
KALETRA TAB 200-50MG Tier 5
lamivudine-zidovudine tab Tier 5
150-300 mg (generic of
COMBIVIR)
PREZCOBIX TAB 800-150 Tier 5
STRIBILD TAB
Tier 5
QL
ANTITUBERCULAR AGENTS
CAPASTAT SUL INJ 1GM
cycloserine cap 250 mg
ethambutol hcl tab 100 mg
(generic of MYAMBUTOL)
ethambutol hcl tab 400 mg
(generic of MYAMBUTOL)
isoniazid inj 100 mg/ml
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
paser gra 4gm
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifabutin cap 150 mg
(generic of MYCOBUTIN)
rifampin cap 150 mg
(generic of RIFADIN)
rifampin cap 300 mg
(generic of RIFADIN)
rifampin for inj 600 mg
(generic of RIFADIN)
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
Tier 5
Tier 4
Tier 3
Tier 3
Tier 3
Tier 4
Tier 1
Tier 1
Tier 3
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Tier 4
Tier 4
Tier 5
Tier 4
acyclovir cap 200 mg
Tier 1
(generic of ZOVIRAX)
acyclovir sodium for inj 500 Tier 4
mg
acyclovir sodium for inj 1000 Tier 4
mg
acyclovir sodium iv soln 50 Tier 4
mg/ml
acyclovir susp 200 mg/5ml Tier 3
(generic of ZOVIRAX)
acyclovir tab 400 mg
Tier 2
(generic of ZOVIRAX)
acyclovir tab 800 mg
Tier 2
(generic of ZOVIRAX)
adefovir dipivoxil tab 10 mg Tier 5
(generic of HEPSERA)
BARACLUDE SOL
Tier 3
.05MG/ML
LA PA
B/D
B/D
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
15
Drug Name
Drug Requirements/
Tier
Limits
entecavir tab 0.5 mg
Tier 5
(generic of BARACLUDE)
entecavir tab 1 mg (generic Tier 5
of BARACLUDE)
EPIVIR HBV SOL 5MG/ML Tier 4
famciclovir tab 125 mg
Tier 3
(generic of FAMVIR)
famciclovir tab 250 mg
Tier 3
(generic of FAMVIR)
famciclovir tab 500 mg
Tier 3
(generic of FAMVIR)
foscarnet sodium inj 24
Tier 4
mg/ml
ganciclovir sodium for inj
Tier 3
500 mg (generic of
CYTOVENE)
HARVONI TAB 90-400MG Tier 5
lamivudine tab 100 mg (hbv) Tier 4
(generic of EPIVIR HBV)
moderiba pak 600/day
Tier 5
moderiba pak 800/day
Tier 5
moderiba pak 1000/day
Tier 5
moderiba pak 1200/day
Tier 5
OLYSIO CAP 150MG
Tier 5
REBETOL SOL 40MG/ML Tier 5
RELENZA MIS DISKHALE Tier 3
ribapak pak 600/day
Tier 5
ribapak pak 800/day
Tier 5
ribapak pak 1000/day
Tier 5
ribapak pak 1200/day
Tier 5
ribasphere cap 200mg
Tier 3
(generic of REBETOL)
ribasphere tab 200mg
Tier 3
(generic of COPEGUS)
ribasphere tab 400mg
Tier 4
ribasphere tab 600mg
Tier 5
ribavirin cap 200 mg
Tier 3
(generic of REBETOL)
ribavirin tab 200 mg (genericTier 3
of COPEGUS)
rimantadine hydrochloride Tier 3
tab 100 mg (generic of
FLUMADINE)
SOVALDI TAB 400MG
Tier 5
TAMIFLU CAP 30MG
Tier 3
TAMIFLU CAP 45MG
Tier 3
TAMIFLU CAP 75MG
Tier 3
TAMIFLU SUS 6MG/ML
Tier 3
Drug Name
Drug Requirements/
Tier
Limits
TYZEKA TAB 600MG
Tier 5
valacyclovir hcl tab 1 gm
Tier 3
(generic of VALTREX)
valacyclovir hcl tab 500 mg Tier 3
(generic of VALTREX)
VALCYTE SOL 50MG/ML Tier 5
valganciclovir hcl tab 450 mgTier 5
(base equivalent) (generic of
VALCYTE)
VICTRELIS CAP 200MG
Tier 5
NM PA
CEPHALOSPORINS
B/D
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
cefaclor cap 250 mg
Tier 3
cefaclor cap 500 mg
Tier 3
cefaclor er tab 500mg
Tier 3
cefaclor for susp 125 mg/5mlTier 4
cefaclor for susp 250 mg/5mlTier 4
cefaclor for susp 375 mg/5mlTier 4
cefadroxil cap 500 mg
Tier 2
cefadroxil for susp 250
Tier 3
mg/5ml
cefadroxil for susp 500
Tier 3
mg/5ml
cefadroxil tab 1 gm
Tier 4
cefazolin inj 1gm/50ml
Tier 3
cefazolin sodium for inj 1 gmTier 3
cefazolin sodium for inj 10 Tier 3
gm
cefazolin sodium for inj 20 Tier 3
gm
cefazolin sodium for inj 500 Tier 3
mg
cefazolin sodium for iv soln 1Tier 3
gm
cefdinir cap 300 mg
Tier 3
cefdinir for susp 125 mg/5ml Tier 4
cefdinir for susp 250 mg/5ml Tier 4
cefepime hcl for inj 1 gm
Tier 4
(generic of MAXIPIME)
cefepime hcl for inj 2 gm
Tier 4
(generic of MAXIPIME)
cefixime for susp 100
Tier 3
mg/5ml (generic of
SUPRAX)
cefixime for susp 200
Tier 3
mg/5ml (generic of
SUPRAX)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
16
Drug Name
Drug Requirements/
Tier
Limits
cefotaxime sodium for inj 1 Tier 2
gm (generic of CLAFORAN)
cefotaxime sodium for inj 2 Tier 2
gm (generic of CLAFORAN)
cefotaxime sodium for inj
Tier 3
500 mg (generic of
CLAFORAN)
cefoxitin sodium for inj 10 Tier 4
gm
cefoxitin sodium for iv soln 1 Tier 4
gm
cefoxitin sodium for iv soln 2 Tier 4
gm
cefpodoxime proxetil for
Tier 4
susp 50 mg/5ml
cefpodoxime proxetil for
Tier 4
susp 100 mg/5ml
cefpodoxime proxetil tab 100Tier 4
mg
cefpodoxime proxetil tab 200Tier 4
mg
cefprozil for susp 125
Tier 3
mg/5ml
cefprozil for susp 250
Tier 3
mg/5ml
cefprozil tab 250 mg
Tier 3
cefprozil tab 500 mg
Tier 3
ceftazidime for inj 1 gm
Tier 3
(generic of FORTAZ)
ceftazidime for inj 2 gm
Tier 3
(generic of FORTAZ)
ceftazidime for inj 6 gm
Tier 3
(generic of FORTAZ)
CEFTAZIDIME/ SOL D5W Tier 4
1GM
CEFTAZIDIME/ SOL D5W Tier 4
2GM
ceftriaxone sodium for inj 1 Tier 3
gm (generic of ROCEPHIN)
ceftriaxone sodium for inj 2 Tier 3
gm
ceftriaxone sodium for inj 10 Tier 3
gm
ceftriaxone sodium for inj
Tier 3
250 mg
ceftriaxone sodium for inj
Tier 3
500 mg (generic of
ROCEPHIN)
Drug Name
Drug Requirements/
Tier
Limits
ceftriaxone sodium for iv
Tier 3
soln 1 gm
ceftriaxone sodium for iv
Tier 3
soln 2 gm
cefuroxime axetil tab 250 mgTier 2
(generic of CEFTIN)
cefuroxime axetil tab 500 mgTier 2
(generic of CEFTIN)
cefuroxime inj 7.5gm
Tier 3
cefuroxime sodium for inj 1.5Tier 3
gm (generic of ZINACEF)
cefuroxime sodium for inj 7.5Tier 3
gm (generic of ZINACEF)
cefuroxime sodium for inj
Tier 3
750 mg (generic of
ZINACEF)
cefuroxime sodium for iv
Tier 3
soln 1.5 gm (generic of
ZINACEF)
cephalexin cap 250 mg
Tier 1
(generic of KEFLEX)
cephalexin cap 500 mg
Tier 1
(generic of KEFLEX)
cephalexin for susp 125
Tier 2
mg/5ml
cephalexin for susp 250
Tier 2
mg/5ml
SUPRAX CAP 400MG
Tier 3
suprax chw 100mg
Tier 4
suprax chw 200mg
Tier 4
suprax sus 100/5ml
Tier 3
suprax sus 200/5ml
Tier 3
SUPRAX SUS 500/5ML
Tier 3
tazicef inj 1gm (generic of Tier 3
FORTAZ)
tazicef inj 2gm (generic of Tier 3
FORTAZ)
tazicef inj 6gm (generic of Tier 3
FORTAZ)
TEFLARO INJ 400MG
Tier 4
TEFLARO INJ 600MG
Tier 4
ERYTHROMYCINS/MACROLIDES
azithromycin for susp 100 Tier 3
mg/5ml (generic of
ZITHROMAX)
azithromycin for susp 200 Tier 3
mg/5ml (generic of
ZITHROMAX)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
17
Drug Name
Drug Requirements/
Tier
Limits
azithromycin iv for soln 500 Tier 3
mg (generic of
ZITHROMAX)
AZITHROMYCIN POWD
Tier 2
PACK FOR SUSP 1 GM
azithromycin tab 250 mg
Tier 2
(generic of ZITHROMAX)
azithromycin tab 500 mg
Tier 2
(generic of ZITHROMAX)
azithromycin tab 600 mg
Tier 2
(generic of ZITHROMAX)
clarithromycin for susp 125 Tier 4
mg/5ml
clarithromycin for susp 250 Tier 4
mg/5ml (generic of BIAXIN)
clarithromycin tab 250 mg Tier 3
(generic of BIAXIN)
clarithromycin tab 500 mg Tier 3
(generic of BIAXIN)
clarithromycin tab sr 24hr Tier 3
500 mg (generic of BIAXIN
XL)
DIFICID TAB 200MG
Tier 5
e.e.s. 400 tab 400mg
Tier 4
E.E.S. GRAN SUS 200/5ML Tier 4
ery-tab tab 250mg ec
Tier 4
ery-tab tab 333mg ec
Tier 4
ery-tab tab 500mg ec
Tier 4
ERYPED SUS 200/5ML
Tier 4
ERYPED SUS 400/5ML
Tier 4
erythrocin inj 500mg
Tier 4
erythrocin tab 250mg
Tier 4
erythromycin ethylsuccinate Tier 4
tab 400 mg
erythromycin tab 250 mg
Tier 4
erythromycin tab 500 mg
Tier 4
erythromycin w/ delayed
Tier 4
release particles cap 250 mg
ZMAX SUS 2GM
Tier 3
FLUOROQUINOLONES
ciprofloxacin 200 mg/100ml Tier 3
in d5w (generic of CIPRO
I.V.-IN D5W)
ciprofloxacin 400 mg/200ml Tier 3
in d5w (generic of CIPRO
I.V.-IN D5W)
Drug Name
Drug Requirements/
Tier
Limits
ciprofloxacin for oral susp Tier 4
250 mg/5ml (5%) (5
gm/100ml) (generic of
CIPRO)
ciprofloxacin for oral susp Tier 4
500 mg/5ml (10%) (10
gm/100ml) (generic of
CIPRO)
ciprofloxacin hcl tab 100 mg Tier 1
(base equiv)
ciprofloxacin hcl tab 250 mg Tier 1
(base equiv) (generic of
CIPRO)
ciprofloxacin hcl tab 500 mg Tier 1
(base equiv) (generic of
CIPRO)
ciprofloxacin hcl tab 750 mg Tier 1
(base equiv)
ciprofloxacin iv soln 200
Tier 3
mg/20ml (1%)
ciprofloxacin iv soln 400
Tier 3
mg/40ml (1%)
ciprofloxacin-ciprofloxacin Tier 3
hcl tab sr 24hr 500 mg (base
eq) (generic of CIPRO XR)
ciprofloxacin-ciprofloxacin Tier 3
hcl tab sr 24hr 1000
mg(base eq) (generic of
CIPRO XR)
levofloxacin in d5w iv soln Tier 3
250 mg/50ml
levofloxacin in d5w iv soln Tier 3
500 mg/100ml (generic of
LEVAQUIN)
levofloxacin in d5w iv soln Tier 3
750 mg/150ml (generic of
LEVAQUIN)
levofloxacin iv soln 25 mg/mlTier 4
levofloxacin oral soln 25
Tier 4
mg/ml (generic of
LEVAQUIN)
levofloxacin tab 250 mg
Tier 3
(generic of LEVAQUIN)
levofloxacin tab 500 mg
Tier 3
(generic of LEVAQUIN)
levofloxacin tab 750 mg
Tier 3
(generic of LEVAQUIN)
PENICILLINS
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
18
Drug Name
Drug Requirements/
Tier
Limits
amoxicillin & k clavulanate
chew tab 200-28.5 mg
(generic of AUGMENTIN)
amoxicillin & k clavulanate
chew tab 400-57 mg
amoxicillin & k clavulanate
for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(generic of AUGMENTIN)
amoxicillin & k clavulanate
for susp 400-57 mg/5ml
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(generic of AUGMENTIN
ES-600)
amoxicillin & k clavulanate
tab 250-125 mg
amoxicillin & k clavulanate
tab 500-125 mg (generic of
AUGMENTIN)
amoxicillin & k clavulanate
tab 875-125 mg (generic of
AUGMENTIN)
amoxicillin & k clavulanate
tab sr 12hr 1000-62.5 mg
(generic of AUGMENTIN
XR)
amoxicillin (trihydrate) cap
250 mg
amoxicillin (trihydrate) cap
500 mg
amoxicillin (trihydrate) chew
tab 125 mg
amoxicillin (trihydrate) chew
tab 250 mg
amoxicillin (trihydrate) for
susp 125 mg/5ml
amoxicillin (trihydrate) for
susp 200 mg/5ml
amoxicillin (trihydrate) for
susp 250 mg/5ml
amoxicillin (trihydrate) for
susp 400 mg/5ml
amoxicillin (trihydrate) tab
500 mg
amoxicillin (trihydrate) tab
875 mg
Tier 3
Drug Name
Drug Requirements/
Tier
Limits
ampicillin & sulbactam
Tier 3
sodium for inj 1-0.5 gm
(generic of UNASYN)
Tier 3
ampicillin & sulbactam
Tier 3
sodium for inj 2-1 gm
(generic of UNASYN)
Tier 3
ampicillin & sulbactam
Tier 3
sodium for inj 10-5 gm
Tier 3
(generic of UNASYN BULK
PACK)
ampicillin & sulbactam
Tier 3
Tier 3
sodium for iv soln 1-0.5 gm
ampicillin & sulbactam
Tier 3
Tier 3
sodium for iv soln 2-1 gm
ampicillin & sulbactam
Tier 3
sodium for iv soln 10-5 gm
Tier 2
ampicillin cap 250 mg
Tier 1
ampicillin cap 500 mg
Tier 1
Tier 2
ampicillin for susp 125
Tier 2
mg/5ml
ampicillin for susp 250
Tier 2
Tier 2
mg/5ml
ampicillin sodium for inj 1 gmTier 4
ampicillin sodium for inj 2 gmTier 4
Tier 4
ampicillin sodium for inj 125 Tier 4
mg
ampicillin sodium for inj 250 Tier 4
mg
Tier 1
ampicillin sodium for inj 500 Tier 4
mg
Tier 1
ampicillin sodium for iv soln Tier 4
1 gm
Tier 2
ampicillin sodium for iv soln Tier 4
2 gm
Tier 2
ampicillin sodium for iv soln Tier 4
10 gm
Tier 1
BICILLIN L-A INJ 600000 Tier 4
BICILLIN L-A INJ 1200000 Tier 4
Tier 1
BICILLIN L-A INJ 2400000 Tier 4
dicloxacillin sodium cap 250 Tier 2
Tier 1
mg
dicloxacillin sodium cap 500 Tier 2
Tier 1
mg
nafcillin sodium for inj 1 gm Tier 4
Tier 1
nafcillin sodium for inj 2 gm Tier 5
Tier 1
nafcillin sodium for inj 10 gm Tier 5
nafcillin sodium for iv soln 1 Tier 4
gm
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
19
Drug Name
Drug Requirements/
Tier
Limits
nafcillin sodium for iv soln 2 Tier 5
gm
oxacillin sodium for inj 1 gm Tier 4
oxacillin sodium for inj 2 gm Tier 4
oxacillin sodium for inj 10 gmTier 5
pen g proc inj 600000
Tier 4
PENICILL GK/ INJ DEX
Tier 4
2MU
PENICILL GK/ INJ DEX
Tier 4
3MU
penicillin g potassium for inj Tier 4
5000000 unit
penicillin g potassium for inj Tier 4
20000000 unit
penicillin g sodium for inj
Tier 4
5000000 unit
penicillin v potassium for
Tier 1
soln 125 mg/5ml
penicillin v potassium for
Tier 1
soln 250 mg/5ml
penicillin v potassium tab
Tier 1
250 mg
penicillin v potassium tab
Tier 1
500 mg
piperacillin
Tier 4
sodium-tazobactam sodium
for inj 2-0.25 gm (generic of
ZOSYN)
piperacillin
Tier 4
sodium-tazobactam sodium
for inj 3-0.375 gm (generic of
ZOSYN)
piperacillin
Tier 4
sodium-tazobactam sodium
for inj 4-0.5 gm (generic of
ZOSYN)
piperacillin
Tier 4
sodium-tazobactam sodium
for inj 36-4.5 gm (generic of
ZOSYN)
TETRACYCLINES
doxycycline hyclate cap 50 Tier 3
mg
doxycycline hyclate cap 100 Tier 3
mg (generic of
VIBRAMYCIN)
doxycycline hyclate for inj Tier 4
100 mg
Drug Name
Drug Requirements/
Tier
Limits
doxycycline hyclate tab 20
mg
doxycycline hyclate tab 100
mg
doxycycline monohydrate
cap 50 mg
doxycycline monohydrate
cap 100 mg (generic of
MONODOX)
doxycycline monohydrate
tab 50 mg (generic of
ADOXA)
doxycycline monohydrate
tab 75 mg (generic of
ADOXA)
doxycycline monohydrate
tab 100 mg (generic of
ADOXA)
doxycycline monohydrate
tab 150 mg (generic of
ADOXA PAK 1/150)
minocycline hcl cap 50 mg
(generic of MINOCIN)
minocycline hcl cap 75 mg
(generic of MINOCIN)
minocycline hcl cap 100 mg
(generic of MINOCIN)
VIBRAMYCIN SYP
50MG/5ML
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 4
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
CYCLOPHOSPH CAP
25MG
CYCLOPHOSPH CAP
50MG
cyclophosphamide for inj 1
gm
cyclophosphamide for inj 2
gm
cyclophosphamide for inj
500 mg
dacarbazine for inj 200 mg
EMCYT CAP 140MG
HEXALEN CAP 50MG
IFEX INJ 3GM
Tier 4
Tier 4
Tier 4
B/D
B/D
B/D
Tier 4
B/D
Tier 4
B/D
Tier 4
B/D
Tier 4
B/D
Tier 4
Tier 4
Tier 5
Tier 4
B/D
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
20
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
ifosfamide for inj 1 gm
(generic of IFEX)
IFOSFAMIDE INJ 3GM
ifosfamide iv inj 1 gm/20ml
(50 mg/ml) (generic of
IFOSFAMIDE)
ifosfamide iv inj 3 gm/60ml
(50 mg/ml) (generic of
IFOSFAMIDE)
LEUKERAN TAB 2MG
LOMUSTINE CAP 10 MG
LOMUSTINE CAP 40 MG
LOMUSTINE CAP 100 MG
melphalan hcl for inj 50 mg
(base equiv) (generic of
ALKERAN)
MUSTARGEN INJ 10MG
TREANDA INJ 25MG
TREANDA INJ 45/0.5ML
TREANDA INJ 100MG
TREANDA INJ 180/2ML
Tier 4
B/D
Tier 4
B/D
Tier 4
Tier 3
B/D
B/D
bleomycin sulfate for inj 30
unit
mitomycin for iv soln 5 mg
mitomycin for iv soln 20 mg
mitomycin for iv soln 40 mg
Tier 4
Tier 4
Tier 4
B/D
B/D
B/D
Tier 3
B/D
ANTIMETABOLITES
Tier 4
Tier 3
Tier 3
Tier 3
Tier 5
B/D
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
B/D
B/D NM
B/D NM
B/D NM
B/D NM
ANTHRACYCLINES
adriamyc inj 50mg
Tier 4
daunorubicin hcl inj 5 mg/ml Tier 3
(base equiv)
doxorubicin hcl for inj 50 mg Tier 4
doxorubicin hcl inj 2 mg/ml Tier 3
doxorubicin hcl liposomal inj Tier 5
(for iv infusion) 2 mg/ml
(generic of DOXIL)
epirubicin hcl iv soln 50
Tier 4
mg/25ml (2 mg/ml) (generic
of ELLENCE)
epirubicin hcl iv soln 200
Tier 4
mg/100ml (2 mg/ml) (generic
of ELLENCE)
idarubicin hcl iv inj 5 mg/5ml Tier 5
(1 mg/ml) (generic of
IDAMYCIN PFS)
idarubicin hcl iv inj 10
Tier 5
mg/10ml (1 mg/ml) (generic
of IDAMYCIN PFS)
idarubicin hcl iv inj 20
Tier 5
mg/20ml (1 mg/ml) (generic
of IDAMYCIN PFS)
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D NM
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ANTIMITOTIC, TAXOIDS
ANTIBIOTICS
bleomycin sulfate for inj 15 Tier 4
unit
adrucil inj 500/10ml
Tier 3
ALIMTA INJ 100MG
Tier 5
ALIMTA INJ 500MG
Tier 5
azacitidine for inj 100 mg
Tier 5
(generic of VIDAZA)
cladribine inj 1 mg/ml
Tier 5
cytarabine inj 20 mg/ml
Tier 3
fludarabine phosphate for inj Tier 4
50 mg (generic of
FLUDARA)
fludarabine phosphate inj 25 Tier 4
mg/ml
fluorouracil inj 1 gm/20ml (50Tier 3
mg/ml)
fluorouracil inj 2.5 gm/50ml Tier 3
(50 mg/ml)
fluorouracil inj 5 gm/100ml Tier 3
(50 mg/ml)
fluorouracil inj 500 mg/10ml Tier 3
(50 mg/ml)
gemcitabine hcl for inj 1 gm Tier 5
(generic of GEMZAR)
gemcitabine hcl for inj 2 gm Tier 5
gemcitabine hcl for inj 200 Tier 5
mg (generic of GEMZAR)
GEMCITABINE INJ 1GM
Tier 5
GEMCITABINE INJ 2GM
Tier 5
GEMCITABINE INJ 200MG Tier 5
mercaptopurine tab 50 mg Tier 3
methotrexate sodium for inj Tier 2
1 gm
methotrexate sodium inj 25 Tier 2
mg/ml
methotrexate sodium inj pf Tier 2
25 mg/ml
NIPENT INJ 10MG
Tier 5
PURIXAN SUS 20MG/ML Tier 5
TABLOID TAB 40MG
Tier 4
B/D
DOCETAXEL FOR INJ
CONC 20 MG/ML
Tier 5
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
21
Drug Name
Drug Requirements/
Tier
Limits
DOCETAXEL FOR INJ
Tier 5
CONC 80 MG/4ML (20
MG/ML)
DOCETAXEL INJ
Tier 5
80MG/8ML
docetaxel inj 140/7ml
Tier 5
DOCETAXEL INJ
Tier 5
200MG/20
paclitaxel iv conc 30 mg/5ml Tier 4
(6 mg/ml)
paclitaxel iv conc 100
Tier 4
mg/16.7ml (6 mg/ml)
paclitaxel iv conc 150
Tier 4
mg/25ml (6 mg/ml)
paclitaxel iv conc 300
Tier 4
mg/50ml (6 mg/ml)
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine inj 1mg/ml
Tier 4
vincasar pfs inj 1mg/ml
Tier 2
vincristine sulfate iv soln 1 Tier 2
mg/ml
vinorelbine tartrate inj 10
Tier 4
mg/ml (base equiv) (generic
of NAVELBINE)
vinorelbine tartrate inj 50
Tier 4
mg/5ml (10 mg/ml) (base
equiv) (generic of
NAVELBINE)
B/D
B/D
B/D
B/D
B/D
BIOLOGIC RESPONSE MODIFIERS
AVASTIN INJ
AVASTIN INJ 400/16ML
ERIVEDGE CAP 150MG
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
HERCEPTIN INJ 440MG
IBRANCE CAP 75MG
IBRANCE CAP 100MG
IBRANCE CAP 125MG
ISTODAX INJ 10MG
KADCYLA INJ 100MG
KADCYLA INJ 160MG
LYNPARZA CAP 50MG
PROLEUKIN INJ 22MU
RITUXAN INJ 500MG
VELCADE INJ 3.5MG
ZOLINZA CAP 100MG
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
B/D NM
B/D NM
NM LA PA
NM LA PA
NM LA PA
NM LA PA
B/D NM
NM LA PA
NM LA PA
NM LA PA
B/D NM
B/D NM
B/D NM
NM PA
B/D NM
NM PA
B/D NM
NM PA
HORMONAL ANTINEOPLASTIC AGENTS
Drug Name
Drug Requirements/
Tier
Limits
anastrozole tab 1 mg
Tier 3
(generic of ARIMIDEX)
bicalutamide tab 50 mg
Tier 3
(generic of CASODEX)
DEPO-PROVERA INJ
Tier 4
400/ML
exemestane tab 25 mg
Tier 4
(generic of AROMASIN)
FARESTON TAB 60MG
Tier 5
FASLODEX INJ 250MG
Tier 5
flutamide cap 125 mg
Tier 3
letrozole tab 2.5 mg (genericTier 3
of FEMARA)
leuprolide acetate inj kit 5 Tier 3
mg/ml
LUPR DEP-PED INJ 7.5MG Tier 5
LUPR DEP-PED INJ
Tier 5
11.25MG
LUPR DEP-PED INJ 15MG Tier 5
LUPR DEP-PED INJ 30MG Tier 5
LUPRON DEPOT INJ
Tier 5
3.75MG
LUPRON DEPOT INJ
Tier 5
11.25MG
LYSODREN TAB 500MG Tier 3
MEGACE ES SUS 625/5ML Tier 5
megestrol acetate susp 40 Tier 4
mg/ml (generic of MEGACE
ORAL)
megestrol acetate tab 20 mgTier 4
megestrol acetate tab 40 mgTier 4
NILANDRON TAB 150MG Tier 5
SOLTAMOX SOL
Tier 4
10MG/5ML
tamoxifen citrate tab 10 mg Tier 1
(base equivalent)
tamoxifen citrate tab 20 mg Tier 1
(base equivalent)
TRELSTAR MIX INJ
Tier 5
3.75MG
TRELSTAR MIX INJ
Tier 5
11.25MG
XTANDI CAP 40MG
Tier 5
ZYTIGA TAB 250MG
Tier 5
B/D
B/D
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
PA
PA
PA
PA
NM PA
NM PA
NM LA PA
NM PA
KINASE INHIBITORS
AFINITOR DIS TAB 2MG
AFINITOR DIS TAB 3MG
AFINITOR DIS TAB 5MG
Tier 5
Tier 5
Tier 5
NM PA
NM PA
NM PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
22
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
JAKAFI TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
LENVIMA CAP 10MG
LENVIMA CAP 14MG
LENVIMA CAP 20MG
LENVIMA CAP 24MG
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TARCEVA TAB 25MG
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TYKERB TAB 250MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM LA PA
NM LA PA
NM PA
NM PA
NM PA
NM LA PA
NM LA PA
NM LA PA
NM PA
NM PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM PA
NM PA
NM LA PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM LA PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM LA PA
NM PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
MISCELLANEOUS
DROXIA CAP 200MG
Tier 3
DROXIA CAP 300MG
Tier 3
DROXIA CAP 400MG
Tier 3
hydroxyurea cap 500 mg
Tier 3
(generic of HYDREA)
MATULANE CAP 50MG
Tier 5
mitoxantrone hcl inj conc 20 Tier 3
mg/10ml (2 mg/ml)
mitoxantrone hcl inj conc 25 Tier 3
mg/12.5ml (2 mg/ml)
mitoxantrone hcl inj conc 30 Tier 3
mg/15ml (2 mg/ml)
POMALYST CAP 1MG
Tier 5
POMALYST CAP 2MG
Tier 5
POMALYST CAP 3MG
Tier 5
POMALYST CAP 4MG
Tier 5
SYLATRON KIT 200MCG Tier 5
SYLATRON KIT 300MCG Tier 5
SYLATRON KIT 600MCG Tier 5
TARGRETIN CAP 75MG
Tier 5
tretinoin cap 10 mg
Tier 5
TRISENOX SOL 10MG/10M Tier 5
B/D NM
B/D NM
B/D NM
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM PA
NM PA
NM PA
NM PA
B/D
PLATINUM-BASED AGENTS
carboplatin iv soln 50
mg/5ml
carboplatin iv soln 150
mg/15ml
carboplatin iv soln 450
mg/45ml
carboplatin iv soln 600
mg/60ml
cisplatin inj 50 mg/50ml (1
mg/ml)
Tier 3
B/D
Tier 3
B/D
Tier 3
B/D
Tier 3
B/D
Tier 3
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
23
Drug Name
Drug Requirements/
Tier
Limits
cisplatin inj 100 mg/100ml (1Tier 3
mg/ml)
cisplatin inj 200 mg/200ml (1Tier 3
mg/ml)
oxaliplatin for iv inj 50 mg Tier 5
oxaliplatin for iv inj 100 mg Tier 5
oxaliplatin iv soln 50
Tier 5
mg/10ml
oxaliplatin iv soln 100
Tier 5
mg/20ml
B/D
B/D
B/D
B/D
B/D
B/D
PROTECTIVE AGENTS
amifostine crystalline for inj Tier 5
500 mg (generic of
ETHYOL)
dexrazoxane for inj 250 mg Tier 5
(generic of ZINECARD)
ELITEK INJ 1.5MG
Tier 5
ELITEK INJ 7.5MG
Tier 5
leucovorin calcium for inj 50 Tier 4
mg
leucovorin calcium for inj
Tier 4
100 mg
leucovorin calcium for inj
Tier 4
200 mg
leucovorin calcium for inj
Tier 4
350 mg
leucovorin calcium tab 5 mg Tier 3
leucovorin calcium tab 10 Tier 3
mg
leucovorin calcium tab 15 Tier 3
mg
leucovorin calcium tab 25 Tier 3
mg
leucovorin inj calcium
Tier 4
mesna inj 100 mg/ml
Tier 4
(generic of MESNEX)
MESNEX TAB 400MG
Tier 5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
TOPOISOMERASE INHIBITORS
etoposide inj 500mg/25ml Tier 3
(20 mg/ml)
irinotecan hcl inj 40 mg/2ml Tier 5
(20 mg/ml) (generic of
CAMPTOSAR)
irinotecan hcl inj 100 mg/5mlTier 5
(20 mg/ml) (generic of
CAMPTOSAR)
irinotecan hcl inj 500
Tier 5
mg/25ml (20 mg/ml)
B/D
B/D
B/D
B/D
Drug Name
Drug Requirements/
Tier
Limits
toposar inj 1gm/50ml
topotecan hcl for inj 4 mg
(generic of HYCAMTIN)
Tier 3
Tier 5
B/D
B/D
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine
Tier 1
besylate-benazepril hcl cap
2.5-10 mg (generic of
LOTREL)
QL (30 caps / 30 days)
amlodipine
Tier 1
besylate-benazepril hcl cap
5-10 mg (generic of
LOTREL)
QL (30 caps / 30 days)
amlodipine
Tier 1
besylate-benazepril hcl cap
5-20 mg (generic of
LOTREL)
QL (30 caps / 30 days)
amlodipine
Tier 1
besylate-benazepril hcl cap
5-40 mg (generic of
LOTREL)
QL (30 caps / 30 days)
amlodipine
Tier 1
besylate-benazepril hcl cap
10-20 mg (generic of
LOTREL)
QL (30 caps / 30 days)
amlodipine
Tier 1
besylate-benazepril hcl cap
10-40 mg (generic of
LOTREL)
benazepril &
Tier 1
hydrochlorothiazide tab
5-6.25 mg
benazepril &
Tier 1
hydrochlorothiazide tab
10-12.5 mg (generic of
LOTENSIN HCT)
benazepril &
Tier 1
hydrochlorothiazide tab
20-12.5 mg (generic of
LOTENSIN HCT)
benazepril &
Tier 1
hydrochlorothiazide tab
20-25 mg (generic of
LOTENSIN HCT)
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
24
Drug Name
Drug Requirements/
Tier
Limits
captopril &
Tier 1
hydrochlorothiazide tab
25-15 mg
captopril &
Tier 1
hydrochlorothiazide tab
25-25 mg
captopril &
Tier 1
hydrochlorothiazide tab
50-15 mg
captopril &
Tier 1
hydrochlorothiazide tab
50-25 mg
enalapril maleate &
Tier 1
hydrochlorothiazide tab
5-12.5 mg
enalapril maleate &
Tier 1
hydrochlorothiazide tab
10-25 mg (generic of
VASERETIC)
fosinopril sodium &
Tier 1
hydrochlorothiazide tab
10-12.5 mg
fosinopril sodium &
Tier 1
hydrochlorothiazide tab
20-12.5 mg
lisinopril &
Tier 1
hydrochlorothiazide tab
10-12.5 mg (generic of
ZESTORETIC)
lisinopril &
Tier 1
hydrochlorothiazide tab
20-12.5 mg (generic of
ZESTORETIC)
lisinopril &
Tier 1
hydrochlorothiazide tab
20-25 mg (generic of
ZESTORETIC)
moexipril-hydrochlorothiazid Tier 1
e tab 7.5-12.5 mg
moexipril-hydrochlorothiazid Tier 1
e tab 15-12.5 mg
moexipril-hydrochlorothiazid Tier 1
e tab 15-25 mg
quinapril-hydrochlorothiazid Tier 1
e tab 10-12.5 mg (generic of
ACCURETIC)
quinapril-hydrochlorothiazid Tier 1
e tab 20-12.5 mg (generic of
ACCURETIC)
Drug Name
Drug Requirements/
Tier
Limits
quinapril-hydrochlorothiazid Tier 1
e tab 20-25 mg (generic of
ACCURETIC)
ACE INHIBITORS
benazepril hcl tab 5 mg
Tier 1
benazepril hcl tab 10 mg
Tier 1
(generic of LOTENSIN)
benazepril hcl tab 20 mg
Tier 1
(generic of LOTENSIN)
benazepril hcl tab 40 mg
Tier 1
(generic of LOTENSIN)
captopril tab 12.5 mg
Tier 1
captopril tab 25 mg
Tier 1
captopril tab 50 mg
Tier 1
captopril tab 100 mg
Tier 1
enalapril maleate tab 2.5 mg Tier 1
(generic of VASOTEC)
enalapril maleate tab 5 mg Tier 1
(generic of VASOTEC)
enalapril maleate tab 10 mg Tier 1
(generic of VASOTEC)
enalapril maleate tab 20 mg Tier 1
(generic of VASOTEC)
fosinopril sodium tab 10 mg Tier 1
fosinopril sodium tab 20 mg Tier 1
fosinopril sodium tab 40 mg Tier 1
lisinopril tab 2.5 mg (generic Tier 1
of ZESTRIL)
lisinopril tab 5 mg (generic ofTier 1
PRINIVIL)
lisinopril tab 10 mg (generic Tier 1
of PRINIVIL)
lisinopril tab 20 mg (generic Tier 1
of PRINIVIL)
lisinopril tab 30 mg (generic Tier 1
of ZESTRIL)
lisinopril tab 40 mg (generic Tier 1
of ZESTRIL)
moexipril hcl tab 7.5 mg
Tier 1
moexipril hcl tab 15 mg
Tier 1
perindopril erbumine tab 2 Tier 1
mg
perindopril erbumine tab 4 Tier 1
mg (generic of ACEON)
perindopril erbumine tab 8 Tier 1
mg (generic of ACEON)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
25
Drug Name
Drug Requirements/
Tier
Limits
quinapril hcl tab 5 mg
Tier 1
(generic of ACCUPRIL)
quinapril hcl tab 10 mg
Tier 1
(generic of ACCUPRIL)
quinapril hcl tab 20 mg
Tier 1
(generic of ACCUPRIL)
quinapril hcl tab 40 mg
Tier 1
(generic of ACCUPRIL)
ramipril cap 1.25 mg
Tier 1
(generic of ALTACE)
ramipril cap 2.5 mg (generic Tier 1
of ALTACE)
ramipril cap 5 mg (generic ofTier 1
ALTACE)
ramipril cap 10 mg (generic Tier 1
of ALTACE)
trandolapril tab 1 mg
Tier 1
(generic of MAVIK)
trandolapril tab 2 mg
Tier 1
(generic of MAVIK)
trandolapril tab 4 mg
Tier 1
(generic of MAVIK)
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
ALPHA BLOCKERS
doxazosin mesylate tab 1 Tier 3
mg (generic of CARDURA)
QL (30 tabs / 30 days)
doxazosin mesylate tab 2 Tier 3
mg (generic of CARDURA)
QL (30 tabs / 30 days)
doxazosin mesylate tab 4 Tier 3
mg (generic of CARDURA)
QL (30 tabs / 30 days)
doxazosin mesylate tab 8 Tier 3
mg (generic of CARDURA)
prazosin hcl cap 1 mg
Tier 2
(generic of MINIPRESS)
Drug Requirements/
Tier
Limits
prazosin hcl cap 2 mg
(generic of MINIPRESS)
prazosin hcl cap 5 mg
(generic of MINIPRESS)
terazosin hcl cap 1 mg
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
terazosin hcl cap 10 mg
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
ANGIOTENSIN II RECEPTOR
ANTAGONIST COMBINATIONS
ALDOSTERONE RECEPTOR
ANTAGONISTS
eplerenone tab 25 mg
(generic of INSPRA)
eplerenone tab 50 mg
(generic of INSPRA)
spironolactone tab 25 mg
(generic of ALDACTONE)
spironolactone tab 50 mg
(generic of ALDACTONE)
spironolactone tab 100 mg
(generic of ALDACTONE)
Drug Name
QL
QL
QL
amlodipine
Tier 1
besylate-valsartan tab 5-160
mg (generic of EXFORGE)
QL (30 tabs / 30 days)
amlodipine
Tier 1
besylate-valsartan tab 5-320
mg (generic of EXFORGE)
QL (30 tabs / 30 days)
amlodipine
Tier 1
besylate-valsartan tab
10-160 mg (generic of
EXFORGE)
QL (30 tabs / 30 days)
amlodipine
Tier 1
besylate-valsartan tab
10-320 mg (generic of
EXFORGE)
amlodipine-valsartan-hydroc Tier 1
hlorothiazide tab 5-160-12.5
mg (generic of EXFORGE
HCT)
QL (30 tabs / 30 days)
amlodipine-valsartan-hydroc Tier 1
hlorothiazide tab 5-160-25
mg (generic of EXFORGE
HCT)
QL (60 tabs / 30 days)
amlodipine-valsartan-hydroc Tier 1
hlorothiazide tab
10-160-12.5 mg (generic of
EXFORGE HCT)
QL (30 tabs / 30 days)
amlodipine-valsartan-hydroc Tier 1
hlorothiazide tab 10-160-25
mg (generic of EXFORGE
HCT)
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
26
Drug Name
Drug Requirements/
Tier
Limits
amlodipine-valsartan-hydroc Tier 1
hlorothiazide tab 10-320-25
mg (generic of EXFORGE
HCT)
AZOR TAB 5-20MG
Tier 3
QL (30 tabs / 30 days)
AZOR TAB 5-40MG
Tier 3
QL (30 tabs / 30 days)
AZOR TAB 10-20MG
Tier 3
QL (30 tabs / 30 days)
AZOR TAB 10-40MG
Tier 3
BENICAR HCT TAB 20-12.5Tier 3
QL (30 tabs / 30 days)
BENICAR HCT TAB 40-12.5Tier 3
QL (30 tabs / 30 days)
BENICAR HCT TAB
Tier 3
40-25MG
losartan potassium &
Tier 1
hydrochlorothiazide tab
50-12.5 mg (generic of
HYZAAR)
QL (30 tabs / 30 days)
losartan potassium &
Tier 1
hydrochlorothiazide tab
100-12.5 mg (generic of
HYZAAR)
QL (30 tabs / 30 days)
losartan potassium &
Tier 1
hydrochlorothiazide tab
100-25 mg (generic of
HYZAAR)
TRIBENZOR20- TAB
Tier 3
5-12.5MG
QL (30 tabs / 30 days)
TRIBENZOR40- TAB
Tier 3
5-12.5MG
QL (30 tabs / 30 days)
TRIBENZOR40- TAB
Tier 3
5-25MG
QL (30 tabs / 30 days)
TRIBENZOR40- TAB
Tier 3
10-12.5
QL (30 tabs / 30 days)
TRIBENZOR40- TAB
Tier 3
10-25MG
valsartan-hydrochlorothiazid Tier 1
e tab 80-12.5 mg (generic of
DIOVAN HCT)
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
valsartan-hydrochlorothiazid Tier 1
e tab 160-12.5 mg (generic
of DIOVAN HCT)
QL (30 tabs / 30 days)
valsartan-hydrochlorothiazid Tier 1
e tab 160-25 mg (generic of
DIOVAN HCT)
QL (30 tabs / 30 days)
valsartan-hydrochlorothiazid Tier 1
e tab 320-12.5 mg (generic
of DIOVAN HCT)
valsartan-hydrochlorothiazid Tier 1
e tab 320-25 mg (generic of
DIOVAN HCT)
QL
QL
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
BENICAR TAB 5MG
Tier 3
QL (60 tabs / 30 days)
BENICAR TAB 20MG
Tier 3
QL (30 tabs / 30 days)
BENICAR TAB 40MG
Tier 3
losartan potassium tab 25 Tier 1
mg (generic of COZAAR)
QL (60 tabs / 30 days)
losartan potassium tab 50 Tier 1
mg (generic of COZAAR)
QL (60 tabs / 30 days)
losartan potassium tab 100 Tier 1
mg (generic of COZAAR)
valsartan tab 40 mg (genericTier 1
of DIOVAN)
QL (60 tabs / 30 days)
valsartan tab 80 mg (genericTier 1
of DIOVAN)
QL (60 tabs / 30 days)
valsartan tab 160 mg
Tier 1
(generic of DIOVAN)
QL (60 tabs / 30 days)
valsartan tab 320 mg
Tier 1
(generic of DIOVAN)
QL
QL
QL
QL
QL
QL
QL
ANTIARRHYTHMICS
amiodarone hcl inj 150
mg/3ml (50 mg/ml)
amiodarone hcl inj 450
mg/9ml (50 mg/ml)
amiodarone hcl inj 900
mg/18ml (50 mg/ml)
amiodarone hcl tab 100 mg
Tier 2
Tier 2
Tier 2
Tier 4
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
27
Drug Name
Drug Requirements/
Tier
Limits
amiodarone hcl tab 200 mg Tier 1
(generic of CORDARONE)
amiodarone hcl tab 400 mg Tier 4
disopyramide phosphate
Tier 4
cap 100 mg (generic of
NORPACE)
disopyramide phosphate
Tier 4
cap 150 mg (generic of
NORPACE)
flecainide acetate tab 50 mg Tier 3
flecainide acetate tab 100 Tier 3
mg
flecainide acetate tab 150 Tier 3
mg
mexiletine hcl cap 150 mg Tier 3
mexiletine hcl cap 200 mg Tier 3
mexiletine hcl cap 250 mg Tier 3
MULTAQ TAB 400MG
Tier 4
NORPACE CAP 100MG CR Tier 4
NORPACE CAP 150MG CR Tier 4
pacerone tab 100mg
Tier 4
pacerone tab 200mg
Tier 1
(generic of CORDARONE)
pacerone tab 400mg
Tier 4
propafenone hcl cap sr 12hr Tier 4
225 mg (generic of
RYTHMOL SR)
propafenone hcl cap sr 12hr Tier 4
325 mg (generic of
RYTHMOL SR)
propafenone hcl cap sr 12hr Tier 4
425 mg (generic of
RYTHMOL SR)
propafenone hcl tab 150 mg Tier 3
(generic of RYTHMOL)
propafenone hcl tab 225 mg Tier 3
(generic of RYTHMOL)
propafenone hcl tab 300 mg Tier 3
quinidine gluconate tab cr Tier 4
324 mg
quinidine sulfate tab 200 mg Tier 2
quinidine sulfate tab 300 mg Tier 2
sorine tab 80mg (generic of Tier 2
BETAPACE)
sorine tab 120mg (generic ofTier 2
BETAPACE)
PA
PA
PA
PA
Drug Name
Drug Requirements/
Tier
Limits
sorine tab 160mg (generic ofTier 2
BETAPACE)
sorine tab 240mg
Tier 2
sotalol hcl (afib/afl) tab 80 Tier 3
mg (generic of BETAPACE
AF)
sotalol hcl (afib/afl) tab 120 Tier 3
mg (generic of BETAPACE
AF)
sotalol hcl (afib/afl) tab 160 Tier 3
mg (generic of BETAPACE
AF)
sotalol hcl tab 80 mg
Tier 2
(generic of BETAPACE)
sotalol hcl tab 120 mg
Tier 2
(generic of BETAPACE)
sotalol hcl tab 160 mg
Tier 2
(generic of BETAPACE)
sotalol hcl tab 240 mg
Tier 2
TIKOSYN CAP 125MCG
Tier 4
TIKOSYN CAP 250MCG
Tier 4
TIKOSYN CAP 500MCG
Tier 4
NM
NM
NM
ANTILIPEMICS, HMG-CoA REDUCTASE
INHIBITORS
atorvastatin calcium tab 10 Tier 1
mg (base equivalent)
(generic of LIPITOR)
QL (30 tabs / 30 days)
atorvastatin calcium tab 20 Tier 1
mg (base equivalent)
(generic of LIPITOR)
QL (30 tabs / 30 days)
atorvastatin calcium tab 40 Tier 1
mg (base equivalent)
(generic of LIPITOR)
QL (30 tabs / 30 days)
atorvastatin calcium tab 80 Tier 1
mg (base equivalent)
(generic of LIPITOR)
QL (30 tabs / 30 days)
CRESTOR TAB 5MG
Tier 3
QL (30 tabs / 30 days)
CRESTOR TAB 10MG
Tier 3
QL (30 tabs / 30 days)
CRESTOR TAB 20MG
Tier 3
QL (30 tabs / 30 days)
CRESTOR TAB 40MG
Tier 3
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
28
Drug Name
Drug Requirements/
Tier
Limits
lovastatin tab 10 mg
Tier 1
QL (30 tabs / 30 days)
lovastatin tab 20 mg
Tier 1
QL (120 tabs / 30
days)
lovastatin tab 40 mg (genericTier 1
of MEVACOR)
QL (60 tabs / 30 days)
pravastatin sodium tab 10 Tier 1
mg
QL (30 tabs / 30 days)
pravastatin sodium tab 20 Tier 1
mg (generic of
PRAVACHOL)
QL (30 tabs / 30 days)
pravastatin sodium tab 40 Tier 1
mg (generic of
PRAVACHOL)
QL (30 tabs / 30 days)
pravastatin sodium tab 80 Tier 1
mg (generic of
PRAVACHOL)
QL (30 tabs / 30 days)
simvastatin tab 5 mg
Tier 1
(generic of ZOCOR)
QL (30 tabs / 30 days)
simvastatin tab 10 mg
Tier 1
(generic of ZOCOR)
QL (30 tabs / 30 days)
simvastatin tab 20 mg
Tier 1
(generic of ZOCOR)
QL (30 tabs / 30 days)
simvastatin tab 40 mg
Tier 1
(generic of ZOCOR)
QL (30 tabs / 30 days)
simvastatin tab 80 mg
Tier 1
(generic of ZOCOR)
QL (30 tabs / 30 days)
ANTILIPEMICS, MISCELLANEOUS
cholestyramine light powder Tier 4
packets 4 gm
cholestyramine powder 4
Tier 4
gm/dose (generic of
QUESTRAN)
cholestyramine powder
Tier 4
packets 4 gm (generic of
QUESTRAN)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
choline fenofibrate cap dr 45 Tier 4
mg (fenofibric acid equiv)
(generic of TRILIPIX)
choline fenofibrate cap dr Tier 4
135 mg (fenofibric acid
equiv) (generic of TRILIPIX)
colestipol hcl granule
Tier 3
packets 5 gm (generic of
COLESTID)
colestipol hcl granules 5 gm Tier 3
(generic of COLESTID)
colestipol hcl tab 1 gm
Tier 3
(generic of COLESTID)
fenofibrate micronized cap Tier 3
43 mg
fenofibrate micronized cap Tier 3
67 mg (generic of LOFIBRA)
fenofibrate micronized cap Tier 3
130 mg
fenofibrate micronized cap Tier 3
134 mg (generic of
LOFIBRA)
fenofibrate micronized cap Tier 3
200 mg (generic of
LOFIBRA)
fenofibrate tab 48 mg
Tier 4
(generic of TRICOR)
fenofibrate tab 54 mg
Tier 3
(generic of LOFIBRA)
fenofibrate tab 145 mg
Tier 4
(generic of TRICOR)
fenofibrate tab 160 mg
Tier 3
(generic of LOFIBRA)
gemfibrozil tab 600 mg
Tier 3
(generic of LOPID)
niacin tab cr 500 mg
Tier 4
(antihyperlipidemic) (generic
of NIASPAN)
QL (90 tabs / 30 days)
niacin tab cr 750 mg
Tier 4
(antihyperlipidemic) (generic
of NIASPAN)
niacin tab cr 1000 mg
Tier 4
(antihyperlipidemic) (generic
of NIASPAN)
niacor tab 500mg
Tier 3
omega-3-acid ethyl esters Tier 4
cap 1 gm (generic of
LOVAZA)
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
29
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
prevalite pow 4gm (generic
of QUESTRAN LIGHT)
VASCEPA CAP 1GM
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
ZETIA TAB 10MG
Tier 4
atenolol tab 25 mg (generic Tier 1
of TENORMIN)
atenolol tab 50 mg (generic Tier 1
of TENORMIN)
atenolol tab 100 mg (genericTier 1
of TENORMIN)
bisoprolol fumarate tab 5 mgTier 3
(generic of ZEBETA)
bisoprolol fumarate tab 10 Tier 3
mg (generic of ZEBETA)
BYSTOLIC TAB 2.5MG
Tier 4
BYSTOLIC TAB 5MG
Tier 4
BYSTOLIC TAB 10MG
Tier 4
BYSTOLIC TAB 20MG
Tier 4
carvedilol tab 3.125 mg
Tier 2
(generic of COREG)
carvedilol tab 6.25 mg
Tier 2
(generic of COREG)
carvedilol tab 12.5 mg
Tier 2
(generic of COREG)
carvedilol tab 25 mg (genericTier 2
of COREG)
labetalol hcl tab 100 mg
Tier 3
(generic of TRANDATE)
labetalol hcl tab 200 mg
Tier 3
(generic of TRANDATE)
labetalol hcl tab 300 mg
Tier 3
(generic of TRANDATE)
metoprolol succinate tab sr Tier 3
24hr 25 mg (generic of
TOPROL XL)
QL (60 tabs / 30 days)
metoprolol succinate tab sr Tier 3
24hr 50 mg (generic of
TOPROL XL)
QL (60 tabs / 30 days)
metoprolol succinate tab sr Tier 3
24hr 100 mg (generic of
TOPROL XL)
QL (45 tabs / 30 days)
metoprolol succinate tab sr Tier 3
24hr 200 mg (generic of
TOPROL XL)
metoprolol tartrate inj 1
Tier 3
mg/ml (generic of
LOPRESSOR)
metoprolol tartrate tab 25 mgTier 1
Tier 4
Tier 3
Tier 3
Tier 3
BETA-BLOCKER/DIURETIC
COMBINATIONS
atenolol & chlorthalidone tab Tier 1
50-25 mg (generic of
TENORETIC 50)
atenolol & chlorthalidone tab Tier 1
100-25 mg (generic of
TENORETIC 100)
bisoprolol &
Tier 2
hydrochlorothiazide tab
2.5-6.25 mg (generic of
ZIAC)
bisoprolol &
Tier 2
hydrochlorothiazide tab
5-6.25 mg (generic of ZIAC)
bisoprolol &
Tier 2
hydrochlorothiazide tab
10-6.25 mg (generic of
ZIAC)
metoprolol &
Tier 3
hydrochlorothiazide tab
50-25 mg (generic of
LOPRESSOR HCT)
metoprolol &
Tier 3
hydrochlorothiazide tab
100-25 mg (generic of
LOPRESSOR HCT)
metoprolol &
Tier 3
hydrochlorothiazide tab
100-50 mg
propranolol &
Tier 3
hydrochlorothiazide tab
40-25 mg
propranolol &
Tier 3
hydrochlorothiazide tab
80-25 mg
BETA-BLOCKERS
acebutolol hcl cap 200 mg
(generic of SECTRAL)
acebutolol hcl cap 400 mg
(generic of SECTRAL)
Tier 2
Tier 2
Drug Requirements/
Tier
Limits
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
30
Drug Name
Drug Requirements/
Tier
Limits
metoprolol tartrate tab 50 mgTier 1
(generic of LOPRESSOR)
metoprolol tartrate tab 100 Tier 1
mg (generic of
LOPRESSOR)
nadolol tab 20 mg (generic Tier 4
of CORGARD)
nadolol tab 40 mg (generic Tier 4
of CORGARD)
nadolol tab 80 mg (generic Tier 4
of CORGARD)
pindolol tab 5 mg
Tier 3
pindolol tab 10 mg
Tier 3
propranolol hcl cap sr 24hr Tier 3
60 mg (generic of INDERAL
LA)
propranolol hcl cap sr 24hr Tier 3
80 mg (generic of INDERAL
LA)
propranolol hcl cap sr 24hr Tier 3
120 mg (generic of
INDERAL LA)
propranolol hcl cap sr 24hr Tier 3
160 mg (generic of
INDERAL LA)
propranolol hcl inj 1 mg/ml Tier 3
propranolol hcl oral soln 20 Tier 3
mg/5ml
propranolol hcl oral soln 40 Tier 3
mg/5ml
propranolol hcl tab 10 mg Tier 1
propranolol hcl tab 20 mg Tier 1
propranolol hcl tab 40 mg Tier 1
propranolol hcl tab 60 mg Tier 1
propranolol hcl tab 80 mg Tier 1
timolol maleate tab 5 mg
Tier 3
timolol maleate tab 10 mg Tier 3
timolol maleate tab 20 mg Tier 3
CALCIUM CHANNEL BLOCKERS
afeditab tab 30mg cr
Tier 3
(generic of ADALAT CC)
QL (60 tabs / 30 days)
afeditab tab 60mg cr
Tier 3
(generic of ADALAT CC)
amlodipine besylate tab 2.5 Tier 1
mg (generic of NORVASC)
QL (45 tabs / 30 days)
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
amlodipine besylate tab 5 Tier 1
mg (generic of NORVASC)
QL (45 tabs / 30 days)
amlodipine besylate tab 10 Tier 1
mg (generic of NORVASC)
diltiazem hcl cap sr 12hr 60 Tier 3
mg
diltiazem hcl cap sr 12hr 90 Tier 3
mg
diltiazem hcl cap sr 12hr 120Tier 3
mg
diltiazem hcl cap sr 24hr 120Tier 3
mg
diltiazem hcl cap sr 24hr 180Tier 3
mg
diltiazem hcl cap sr 24hr 240Tier 3
mg
diltiazem hcl coated beads Tier 3
cap sr 24hr 120 mg (generic
of CARDIZEM CD)
diltiazem hcl coated beads Tier 3
cap sr 24hr 180 mg (generic
of CARDIZEM CD)
diltiazem hcl coated beads Tier 3
cap sr 24hr 240 mg (generic
of CARDIZEM CD)
diltiazem hcl coated beads Tier 3
cap sr 24hr 300 mg (generic
of CARDIZEM CD)
diltiazem hcl coated beads Tier 4
cap sr 24hr 360 mg (generic
of CARDIZEM CD)
diltiazem hcl extended
Tier 3
release beads cap sr 24hr
120 mg (generic of TIAZAC)
diltiazem hcl extended
Tier 3
release beads cap sr 24hr
180 mg (generic of TIAZAC)
diltiazem hcl extended
Tier 3
release beads cap sr 24hr
240 mg (generic of TIAZAC)
diltiazem hcl extended
Tier 3
release beads cap sr 24hr
300 mg (generic of TIAZAC)
diltiazem hcl extended
Tier 3
release beads cap sr 24hr
360 mg (generic of TIAZAC)
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
31
Drug Name
Drug Requirements/
Tier
Limits
diltiazem hcl extended
Tier 3
release beads cap sr 24hr
420 mg (generic of TIAZAC)
diltiazem hcl iv soln 25
Tier 2
mg/5ml (5 mg/ml)
diltiazem hcl iv soln 50
Tier 2
mg/10ml (5 mg/ml)
diltiazem hcl iv soln 125
Tier 2
mg/25ml (5 mg/ml)
diltiazem hcl tab 30 mg
Tier 2
(generic of CARDIZEM)
diltiazem hcl tab 60 mg
Tier 2
(generic of CARDIZEM)
diltiazem hcl tab 90 mg
Tier 2
diltiazem hcl tab 120 mg
Tier 2
(generic of CARDIZEM)
felodipine tab sr 24hr 2.5 mgTier 3
QL (30 tabs / 30 days)
felodipine tab sr 24hr 5 mg Tier 3
QL (60 tabs / 30 days)
felodipine tab sr 24hr 10 mg Tier 3
isradipine cap 2.5 mg
Tier 4
isradipine cap 5 mg
Tier 4
nicardipine hcl cap 20 mg Tier 3
nicardipine hcl cap 30 mg Tier 3
nifedical xl tab 30mg
Tier 3
(generic of PROCARDIA XL)
QL (30 tabs / 30 days)
nifedical xl tab 60mg
Tier 3
(generic of PROCARDIA XL)
nifedipine tab sr 24hr 30 mg Tier 3
(generic of ADALAT CC)
QL (60 tabs / 30 days)
nifedipine tab sr 24hr 60 mg Tier 3
(generic of ADALAT CC)
nifedipine tab sr 24hr 90 mg Tier 3
(generic of ADALAT CC)
nifedipine tab sr 24hr
Tier 3
osmotic 30 mg (generic of
PROCARDIA XL)
QL (30 tabs / 30 days)
nifedipine tab sr 24hr
Tier 3
osmotic 60 mg (generic of
PROCARDIA XL)
nifedipine tab sr 24hr
Tier 3
osmotic 90 mg (generic of
PROCARDIA XL)
nimodipine cap 30 mg
Tier 4
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
NYMALIZE SOL 60/20ML
verapamil hcl cap sr 24hr
100 mg (generic of
VERELAN PM)
verapamil hcl cap sr 24hr
120 mg (generic of
VERELAN)
verapamil hcl cap sr 24hr
180 mg (generic of
VERELAN)
verapamil hcl cap sr 24hr
200 mg (generic of
VERELAN PM)
verapamil hcl cap sr 24hr
240 mg (generic of
VERELAN)
verapamil hcl cap sr 24hr
300 mg (generic of
VERELAN PM)
VERAPAMIL HCL CAP SR
24HR 360 MG
verapamil hcl iv soln 2.5
mg/ml
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg
(generic of CALAN)
verapamil hcl tab 120 mg
(generic of CALAN)
verapamil hcl tab cr 120 mg
(generic of CALAN SR)
verapamil hcl tab cr 180 mg
(generic of CALAN SR)
verapamil hcl tab cr 240 mg
(generic of CALAN SR)
Tier 5
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
DIGITALIS GLYCOSIDES
digitek tab 0.25mg (generic Tier 3
PA
of LANOXIN)
digitek tab 0.125mg (generic Tier 3
QL
QL
of LANOXIN)
QL (30 tabs / 30 days)
digoxin inj 0.25 mg/ml
Tier 3
(generic of LANOXIN)
DIGOXIN ORAL SOLN 0.05 Tier 3
PA
MG/ML
digoxin tab 125 mcg (0.125 Tier 3
QL
mg) (generic of LANOXIN)
QL (30 tabs / 30 days)
digoxin tab 250 mcg (0.25 Tier 3
PA
mg) (generic of LANOXIN)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
32
Drug Name
Drug Requirements/
Tier
Limits
LANOXIN TAB 0.25MG
Tier 3
LANOXIN TAB 0.125MG
Tier 3
QL (30 tabs / 30 days)
PA
QL
Drug Name
Drug Requirements/
Tier
Limits
EDECRIN TAB 25MG
Tier 4
furosemide inj 10 mg/ml
Tier 2
furosemide oral soln 10
Tier 1
DIRECT RENIN
mg/ml
INHIBITORS/COMBINATIONS
furosemide sol 8mg/ml
Tier 2
TEKAMLO TAB 150-5MG Tier 3
QL
furosemide tab 20 mg
Tier 1
QL (30 tabs / 30 days)
(generic of LASIX)
TEKAMLO TAB 150-10MG Tier 3
QL
furosemide tab 40 mg
Tier 1
QL (30 tabs / 30 days)
(generic of LASIX)
TEKAMLO TAB 300-5MG Tier 3
QL
furosemide tab 80 mg
Tier 1
QL (30 tabs / 30 days)
(generic of LASIX)
TEKAMLO TAB 300-10MG Tier 3
hydrochlorothiazide cap
Tier 1
TEKTURNA HCT TAB
Tier 3
QL
12.5 mg (generic of
150-12.5
MICROZIDE)
QL (30 tabs / 30 days)
hydrochlorothiazide tab 12.5 Tier 1
TEKTURNA HCT TAB
Tier 3
QL
mg
150-25MG
hydrochlorothiazide tab 25 Tier 1
QL (60 tabs / 30 days)
mg
TEKTURNA HCT TAB
Tier 3
QL
hydrochlorothiazide tab 50 Tier 1
300-12.5
mg
QL (30 tabs / 30 days)
indapamide tab 1.25 mg
Tier 1
TEKTURNA HCT TAB
Tier 3
indapamide tab 2.5 mg
Tier 1
300-25MG
methazolamide tab 25 mg Tier 4
TEKTURNA TAB 150MG Tier 3
QL
(generic of NEPTAZANE)
QL (30 tabs / 30 days)
methazolamide tab 50 mg Tier 4
TEKTURNA TAB 300MG Tier 3
(generic of NEPTAZANE)
DIURETICS
methyclothiazide tab 5 mg Tier 3
acetazolamide cap sr 12hr Tier 4
metolazone tab 2.5 mg
Tier 2
500 mg (generic of
metolazone tab 5 mg
Tier 2
DIAMOX)
metolazone tab 10 mg
Tier 2
acetazolamide tab 125 mg Tier 3
spironolactone &
Tier 2
acetazolamide tab 250 mg Tier 3
hydrochlorothiazide tab
amiloride &
Tier 1
25-25 mg (generic of
hydrochlorothiazide tab 5-50
ALDACTAZIDE)
mg
torsemide inj 20mg/2ml
Tier 2
amiloride hcl tab 5 mg
Tier 3
torsemide inj 50mg/5ml
Tier 2
bumetanide inj 0.25 mg/ml Tier 3
torsemide tab 5 mg (generic Tier 2
bumetanide tab 0.5 mg
Tier 2
of DEMADEX)
bumetanide tab 1 mg
Tier 2
torsemide tab 10 mg
Tier 2
bumetanide tab 2 mg
Tier 2
(generic of DEMADEX)
torsemide tab 20 mg
Tier 2
chlorothiazide tab 250 mg Tier 1
(generic
of
DEMADEX)
chlorothiazide tab 500 mg Tier 1
torsemide tab 100 mg
Tier 2
chlorthalidone tab 25 mg
Tier 2
(generic
of
DEMADEX)
chlorthalidone tab 50 mg
Tier 2
triamterene &
Tier 2
DIURIL SUS 250/5ML
Tier 3
hydrochlorothiazide cap
DYRENIUM CAP 50MG
Tier 4
37.5-25 mg (generic of
DYRENIUM CAP 100MG Tier 4
DYAZIDE)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
33
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
triamterene &
hydrochlorothiazide tab
37.5-25 mg (generic of
MAXZIDE-25)
triamterene &
hydrochlorothiazide tab
75-50 mg (generic of
MAXZIDE)
Tier 2
isosorbide dinitrate tab cr 40 Tier 3
mg
isosorbide mononitrate tab Tier 2
10 mg
isosorbide mononitrate tab Tier 2
20 mg
isosorbide mononitrate tab Tier 2
sr 24hr 30 mg (generic of
IMDUR)
isosorbide mononitrate tab Tier 2
sr 24hr 60 mg
isosorbide mononitrate tab Tier 2
sr 24hr 120 mg
minitran dis 0.1mg/hr
Tier 3
(generic of NITRO-DUR)
minitran dis 0.2mg/hr
Tier 3
(generic of NITRO-DUR)
minitran dis 0.4mg/hr
Tier 3
(generic of NITRO-DUR)
minitran dis 0.6mg/hr
Tier 3
(generic of NITRO-DUR)
nitro-bid oin 2%
Tier 3
NITRO-DUR DIS 0.3MG/HR Tier 4
NITRO-DUR DIS 0.8MG/HR Tier 4
nitroglycerin td patch 24hr Tier 3
0.1 mg/hr
nitroglycerin td patch 24hr Tier 3
0.2 mg/hr
nitroglycerin td patch 24hr Tier 3
0.4 mg/hr
nitroglycerin td patch 24hr Tier 3
0.6 mg/hr
NITROLINGUAL SPR
Tier 3
PUMPSPRA
NITROSTAT SUB 0.3MG Tier 3
NITROSTAT SUB 0.4MG Tier 3
NITROSTAT SUB 0.6MG Tier 3
Tier 2
MISCELLANEOUS
clonidine hcl tab 0.1 mg
Tier 1
(generic of CATAPRES)
clonidine hcl tab 0.2 mg
Tier 1
(generic of CATAPRES)
clonidine hcl tab 0.3 mg
Tier 1
(generic of CATAPRES)
clonidine hcl td patch weeklyTier 4
0.1 mg/24hr (generic of
CATAPRES-TTS-1)
clonidine hcl td patch weeklyTier 4
0.2 mg/24hr (generic of
CATAPRES-TTS-2)
clonidine hcl td patch weeklyTier 4
0.3 mg/24hr (generic of
CATAPRES-TTS-3)
DEMSER CAP 250MG
Tier 5
hydralazine hcl inj 20 mg/ml Tier 4
hydralazine hcl tab 10 mg Tier 3
hydralazine hcl tab 25 mg Tier 3
hydralazine hcl tab 50 mg Tier 3
hydralazine hcl tab 100 mg Tier 3
midodrine hcl tab 2.5 mg
Tier 4
midodrine hcl tab 5 mg
Tier 4
midodrine hcl tab 10 mg
Tier 4
minoxidil tab 2.5 mg
Tier 3
minoxidil tab 10 mg
Tier 3
RANEXA TAB 500MG
Tier 3
RANEXA TAB 1000MG
Tier 3
NITRATES
isosorbide dinitrate tab 5 mg Tier 3
(generic of ISORDIL
TITRADOSE)
isosorbide dinitrate tab 10 Tier 3
mg
isosorbide dinitrate tab 20 Tier 3
mg
isosorbide dinitrate tab 30 Tier 3
mg
Drug Requirements/
Tier
Limits
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA TAB 20MG
Tier 5
QL (60 tabs / 30 days)
ADEMPAS TAB 0.5MG
Tier 5
QL (90 tabs / 30 days)
ADEMPAS TAB 1.5MG
Tier 5
QL (90 tabs / 30 days)
ADEMPAS TAB 1MG
Tier 5
QL (90 tabs / 30 days)
ADEMPAS TAB 2.5MG
Tier 5
QL (90 tabs / 30 days)
QL NM PA
QL NM PA
QL NM PA
QL NM PA
QL NM PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
34
Drug Name
Drug Requirements/
Tier
Limits
ADEMPAS TAB 2MG
Tier 5 QL NM PA
QL (90 tabs / 30 days)
LETAIRIS TAB 5MG
Tier 5 QL NM LA PA
QL (30 tabs / 30 days)
LETAIRIS TAB 10MG
Tier 5 QL NM LA PA
QL (30 tabs / 30 days)
REMODULIN INJ 1MG/ML Tier 5 B/D NM LA
REMODULIN INJ 2.5MG/MLTier 5 B/D NM LA
REMODULIN INJ 5MG/ML Tier 5 B/D NM LA
REMODULIN INJ 10MG/ML Tier 5 B/D NM LA
REVATIO SUS 10MG/ML Tier 5 QL NM PA
QL (2 bottles / 30 days)
sildenafil citrate tab 20 mg Tier 5 QL NM PA
(generic of REVATIO)
QL (90 tabs / 30 days)
TRACLEER TAB 62.5MG Tier 5 QL NM LA PA
QL (120 tabs / 30
days)
TRACLEER TAB 125MG
Tier 5 QL NM LA PA
QL (60 tabs / 30 days)
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam con 1 mg/ml
Tier 3
QL (300 mL / 30 days)
alprazolam tab 0.5 mg
Tier 1
(generic of XANAX)
QL (240 tabs / 30
days)
alprazolam tab 0.25 mg
Tier 1
(generic of XANAX)
QL (480 tabs / 30
days)
alprazolam tab 1 mg
Tier 1
(generic of XANAX)
QL (120 tabs / 30
days)
alprazolam tab 2 mg
Tier 1
(generic of XANAX)
QL (150 tabs / 30
days)
buspirone hcl tab 5 mg
Tier 3
buspirone hcl tab 7.5 mg
Tier 3
buspirone hcl tab 10 mg
Tier 3
buspirone hcl tab 15 mg
Tier 3
buspirone hcl tab 30 mg
Tier 4
fluvoxamine maleate tab 25 Tier 3
mg
QL (45 tabs / 30 days)
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
fluvoxamine maleate tab 50 Tier 3
mg
QL (45 tabs / 30 days)
fluvoxamine maleate tab 100Tier 3
mg
lorazepam con 2mg/ml
Tier 3
QL (150 mL / 30 days)
lorazepam inj 2 mg/ml
Tier 3
(generic of ATIVAN)
lorazepam inj 4 mg/ml
Tier 3
(generic of ATIVAN)
lorazepam tab 0.5 mg
Tier 1
(generic of ATIVAN)
QL (150 tabs / 30
days)
lorazepam tab 1 mg (genericTier 1
of ATIVAN)
QL (150 tabs / 30
days)
lorazepam tab 2 mg (genericTier 1
of ATIVAN)
QL (150 tabs / 30
days)
QL
QL
QL
QL
QL
ANTICONVULSANTS
APTIOM TAB 200MG
Tier 4
QL (180 tabs / 30
days)
APTIOM TAB 400MG
Tier 4
QL (90 tabs / 30 days)
APTIOM TAB 600MG
Tier 4
QL (60 tabs / 30 days)
APTIOM TAB 800MG
Tier 4
QL (30 tabs / 30 days)
BANZEL SUS 40MG/ML
Tier 5
BANZEL TAB 200MG
Tier 4
BANZEL TAB 400MG
Tier 5
carbamazepine cap sr 12hr Tier 4
100 mg (generic of
CARBATROL)
carbamazepine cap sr 12hr Tier 4
200 mg (generic of
CARBATROL)
carbamazepine cap sr 12hr Tier 4
300 mg (generic of
CARBATROL)
carbamazepine chew tab
Tier 2
100 mg
QL
QL
QL
QL
PA
PA
PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
35
Drug Name
Drug Requirements/
Tier
Limits
carbamazepine susp 100 Tier 3
mg/5ml (generic of
TEGRETOL)
carbamazepine tab 200 mg Tier 2
(generic of TEGRETOL)
carbamazepine tab sr 12hr Tier 4
200 mg (generic of
TEGRETOL-XR)
carbamazepine tab sr 12hr Tier 4
400 mg (generic of
TEGRETOL-XR)
CELONTIN CAP 300MG
Tier 4
clonazepam orally
Tier 3
disintegrating tab 0.5 mg
QL (1200 tabs / 30
days)
clonazepam orally
Tier 3
disintegrating tab 0.25 mg
QL (2400 tabs / 30
days)
clonazepam orally
Tier 3
disintegrating tab 0.125 mg
QL (4800 tabs / 30
days)
clonazepam orally
Tier 3
disintegrating tab 1 mg
QL (600 tabs / 30
days)
clonazepam orally
Tier 3
disintegrating tab 2 mg
QL (300 tabs / 30
days)
clonazepam tab 0.5 mg
Tier 1
(generic of KLONOPIN)
QL (1200 tabs / 30
days)
clonazepam tab 1 mg
Tier 1
(generic of KLONOPIN)
QL (600 tabs / 30
days)
clonazepam tab 2 mg
Tier 1
(generic of KLONOPIN)
QL (300 tabs / 30
days)
clorazepate dipotassium tab Tier 3
3.75 mg (generic of
TRANXENE T)
QL (120 tabs / 30
days)
QL
QL
QL
QL
QL
QL
QL
QL
QL PA
Drug Name
Drug Requirements/
Tier
Limits
clorazepate dipotassium tab Tier 3
7.5 mg (generic of
TRANXENE T)
QL (120 tabs / 30
days)
clorazepate dipotassium tab Tier 3
15 mg (generic of
TRANXENE T)
QL (180 tabs / 30
days)
diazepam con 5mg/ml
Tier 3
QL (240 mL / 30 days)
diazepam inj 5 mg/ml
Tier 3
DIAZEPAM RECTAL GEL Tier 4
DELIVERY SYSTEM 2.5
MG
DIAZEPAM RECTAL GEL Tier 4
DELIVERY SYSTEM 10 MG
DIAZEPAM RECTAL GEL Tier 4
DELIVERY SYSTEM 20 MG
diazepam soln 1 mg/ml
Tier 3
QL (1200 mL / 30
days)
diazepam tab 2 mg (generic Tier 1
of VALIUM)
QL (120 tabs / 30
days)
diazepam tab 5 mg (generic Tier 1
of VALIUM)
QL (120 tabs / 30
days)
diazepam tab 10 mg
Tier 1
(generic of VALIUM)
QL (120 tabs / 30
days)
dilantin cap 30mg
Tier 3
dilantin cap 100mg
Tier 3
dilantin chw 50mg
Tier 3
DILANTIN-125 SUS
Tier 3
125/5ML
divalproex sodium cap
Tier 3
sprinkle 125 mg (generic of
DEPAKOTE SPRINKLES)
divalproex sodium tab
Tier 3
delayed release 125 mg
(generic of DEPAKOTE)
divalproex sodium tab
Tier 3
delayed release 250 mg
(generic of DEPAKOTE)
QL PA
QL PA
QL PA
QL PA
QL PA
QL PA
QL PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
36
Drug Name
Drug Requirements/
Tier
Limits
divalproex sodium tab
Tier 3
delayed release 500 mg
(generic of DEPAKOTE)
divalproex sodium tab sr 24 Tier 4
hr 250 mg (generic of
DEPAKOTE ER)
divalproex sodium tab sr 24 Tier 4
hr 500 mg (generic of
DEPAKOTE ER)
epitol tab 200mg (generic of Tier 2
TEGRETOL)
ethosuximide cap 250 mg Tier 4
(generic of ZARONTIN)
ethosuximide soln 250
Tier 4
mg/5ml (generic of
ZARONTIN)
felbamate susp 600 mg/5ml Tier 5
(generic of FELBATOL)
felbamate tab 400 mg
Tier 4
(generic of FELBATOL)
felbamate tab 600 mg
Tier 5
(generic of FELBATOL)
FYCOMPA TAB 2MG
Tier 4
QL (180 tabs / 30
days)
FYCOMPA TAB 4MG
Tier 4
QL (90 tabs / 30 days)
FYCOMPA TAB 6MG
Tier 4
QL (60 tabs / 30 days)
FYCOMPA TAB 8MG
Tier 4
QL (30 tabs / 30 days)
FYCOMPA TAB 10MG
Tier 4
QL (30 tabs / 30 days)
FYCOMPA TAB 12MG
Tier 4
QL (30 tabs / 30 days)
gabapentin cap 100 mg
Tier 2
(generic of NEURONTIN)
QL (1080 caps / 30
days)
gabapentin cap 300 mg
Tier 2
(generic of NEURONTIN)
QL (360 caps / 30
days)
gabapentin cap 400 mg
Tier 2
(generic of NEURONTIN)
QL (270 caps / 30
days)
QL PA
QL PA
QL PA
QL PA
QL PA
QL PA
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
gabapentin oral soln 250
Tier 3
mg/5ml (generic of
NEURONTIN)
QL (2160 mL / 30
days)
gabapentin tab 600 mg
Tier 3
(generic of NEURONTIN)
QL (180 tabs / 30
days)
gabapentin tab 800 mg
Tier 3
(generic of NEURONTIN)
QL (120 tabs / 30
days)
GABITRIL TAB 12MG
Tier 4
GABITRIL TAB 16MG
Tier 4
lamotrigine tab 25 mg
Tier 2
(generic of LAMICTAL)
lamotrigine tab 100 mg
Tier 2
(generic of LAMICTAL)
lamotrigine tab 150 mg
Tier 2
(generic of LAMICTAL)
lamotrigine tab 200 mg
Tier 2
(generic of LAMICTAL)
lamotrigine tab chewable
Tier 3
dispersible 5 mg (generic of
LAMICTAL CHEWABLE
DISPERS)
lamotrigine tab chewable
Tier 3
dispersible 25 mg (generic of
LAMICTAL CHEWABLE
DISPERS)
lamotrigine tab sr 24hr 25 Tier 4
mg (generic of LAMICTAL
XR)
lamotrigine tab sr 24hr 50 Tier 4
mg (generic of LAMICTAL
XR)
lamotrigine tab sr 24hr 100 Tier 4
mg (generic of LAMICTAL
XR)
lamotrigine tab sr 24hr 200 Tier 4
mg (generic of LAMICTAL
XR)
lamotrigine tab sr 24hr 250 Tier 4
mg (generic of LAMICTAL
XR)
lamotrigine tab sr 24hr 300 Tier 4
mg (generic of LAMICTAL
XR)
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
37
Drug Name
Drug Requirements/
Tier
Limits
LEVETIRACETA INJ
Tier 4
5MG/ML
LEVETIRACETA INJ
Tier 4
10MG/ML
LEVETIRACETA INJ
Tier 4
15MG/ML
levetiracetam inj 500 mg/5mlTier 4
(100 mg/ml) (generic of
KEPPRA)
levetiracetam oral soln 100 Tier 3
mg/ml (generic of KEPPRA)
levetiracetam tab 250 mg Tier 3
(generic of KEPPRA)
levetiracetam tab 500 mg Tier 3
(generic of KEPPRA)
levetiracetam tab 750 mg Tier 3
(generic of KEPPRA)
levetiracetam tab 1000 mg Tier 3
(generic of KEPPRA)
levetiracetam tab sr 24hr
Tier 4
500 mg (generic of KEPPRA
XR)
levetiracetam tab sr 24hr
Tier 4
750 mg (generic of KEPPRA
XR)
LYRICA CAP 25MG
Tier 3
QL (120 caps / 30
days)
LYRICA CAP 50MG
Tier 3
QL (120 caps / 30
days)
LYRICA CAP 75MG
Tier 3
QL (120 caps / 30
days)
LYRICA CAP 100MG
Tier 3
QL (120 caps / 30
days)
LYRICA CAP 150MG
Tier 3
QL (120 caps / 30
days)
LYRICA CAP 200MG
Tier 3
QL (90 caps / 30 days)
LYRICA CAP 225MG
Tier 3
QL (60 caps / 30 days)
LYRICA CAP 300MG
Tier 3
QL (60 caps / 30 days)
LYRICA SOL 20MG/ML
Tier 3
QL (946 mL / 30 days)
ONFI SUS 2.5MG/ML
Tier 4
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
ONFI TAB 10MG
Tier 4
ONFI TAB 20MG
Tier 4
oxcarbazepine susp 300
Tier 4
mg/5ml (60 mg/ml) (generic
of TRILEPTAL)
oxcarbazepine tab 150 mg Tier 3
(generic of TRILEPTAL)
oxcarbazepine tab 300 mg Tier 3
(generic of TRILEPTAL)
oxcarbazepine tab 600 mg Tier 3
(generic of TRILEPTAL)
PEGANONE TAB 250MG Tier 4
PHENOBARB INJ 65MG/MLTier 4
phenobarbital elixir 20
Tier 4
mg/5ml
phenobarbital sodium inj 130Tier 4
mg/ml
phenobarbital tab 15 mg
Tier 4
phenobarbital tab 16.2 mg Tier 4
phenobarbital tab 30 mg
Tier 4
phenobarbital tab 32.4 mg Tier 4
phenobarbital tab 60 mg
Tier 4
phenobarbital tab 64.8 mg Tier 4
phenobarbital tab 97.2 mg Tier 4
phenobarbital tab 100 mg Tier 4
phenytek cap 200mg
Tier 3
phenytek cap 300mg
Tier 3
phenytoin chew tab 50 mg Tier 3
(generic of DILANTIN
INFATABS)
phenytoin sodium extended Tier 2
cap 100 mg (generic of
DILANTIN)
phenytoin sodium extended Tier 2
cap 200 mg (generic of
PHENYTEK)
phenytoin sodium extended Tier 2
cap 300 mg (generic of
PHENYTEK)
phenytoin sodium inj 50
Tier 3
mg/ml
phenytoin susp 125 mg/5ml Tier 3
(generic of DILANTIN-125)
POTIGA TAB 50MG
Tier 4
POTIGA TAB 200MG
Tier 4
QL (180 tabs / 30
days)
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
38
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
POTIGA TAB 300MG
Tier 4
QL
VIMPAT SOL 10MG/ML
Tier 4
QL
QL (90 tabs / 30 days)
QL (1200 mL / 30
days)
POTIGA TAB 400MG
Tier 4
QL
QL (90 tabs / 30 days)
VIMPAT TAB 50MG
Tier 4
QL
QL (180 tabs / 30
primidone tab 50 mg
Tier 3
days)
(generic of MYSOLINE)
VIMPAT
TAB 100MG
Tier 4
QL
primidone tab 250 mg
Tier 3
QL (60 tabs / 30 days)
(generic of MYSOLINE)
VIMPAT TAB 150MG
Tier 4
QL
SABRIL POW 500MG
Tier 5 QL NM LA PA
QL (60 tabs / 30 days)
QL (180 packets / 30
days)
VIMPAT TAB 200MG
Tier 4
QL
QL (60 tabs / 30 days)
SABRIL TAB 500MG
Tier 5 QL NM LA PA
QL (180 tabs / 30
zonisamide cap 25 mg
Tier 3
days)
(generic of ZONEGRAN)
TEGRETOL SUS 100/5ML Tier 4
zonisamide cap 50 mg
Tier 3
TEGRETOL TAB 200MG Tier 4
zonisamide cap 100 mg
Tier 3
(generic
of
ZONEGRAN)
TEGRETOL-XR TAB
Tier 4
ANTIDEMENTIA
100MG
TEGRETOL-XR TAB
Tier 4
donepezil hydrochloride
Tier 4
QL
200MG
orally disintegrating tab 5 mg
QL (30 tabs / 30 days)
TEGRETOL-XR TAB
Tier 4
400MG
donepezil hydrochloride
Tier 4
orally disintegrating tab 10
tiagabine hcl tab 2 mg
Tier 4
mg
(generic of GABITRIL)
donepezil hydrochloride tab Tier 3
QL
tiagabine hcl tab 4 mg
Tier 4
5 mg (generic of ARICEPT)
(generic of GABITRIL)
QL (30 tabs / 30 days)
topiramate sprinkle cap 15 Tier 4
donepezil hydrochloride tab Tier 3
mg (generic of TOPAMAX
10 mg (generic of ARICEPT)
SPRINKLE)
donepezil hydrochloride tab Tier 4
topiramate sprinkle cap 25 Tier 4
23 mg (generic of ARICEPT)
mg (generic of TOPAMAX
SPRINKLE)
EXELON DIS 4.6MG/24
Tier 4
QL
QL
(30
patches
/
30
topiramate tab 25 mg
Tier 3
days)
(generic of TOPAMAX)
EXELON DIS 9.5MG/24
Tier 4
QL
topiramate tab 50 mg
Tier 3
QL (30 patches / 30
(generic of TOPAMAX)
days)
topiramate tab 100 mg
Tier 3
EXELON DIS 13.3/24
Tier 4
QL
(generic of TOPAMAX)
QL (30 patches / 30
topiramate tab 200 mg
Tier 3
days)
(generic of TOPAMAX)
galantamine
hydrobromide Tier 4
QL
valproate sodium inj 100
Tier 4
cap
sr
24hr
8
mg
(generic
of
mg/ml (generic of
RAZADYNE ER)
DEPACON)
QL (30 caps / 30 days)
valproate sodium syrup 250 Tier 2
galantamine hydrobromide Tier 4
QL
mg/5ml (base equiv)
cap
sr
24hr
16
mg
(generic
(generic of DEPAKENE)
of RAZADYNE ER)
valproic acid cap 250 mg
Tier 3
QL (30 caps / 30 days)
(generic of DEPAKENE)
VIMPAT INJ 200MG/20
Tier 4
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
39
Drug Name
Drug Requirements/
Tier
Limits
galantamine hydrobromide Tier 4
cap sr 24hr 24 mg (generic
of RAZADYNE ER)
galantamine hydrobromide Tier 4
oral soln 4 mg/ml
galantamine hydrobromide Tier 4
tab 4 mg (generic of
RAZADYNE)
QL (180 tabs / 30
days)
galantamine hydrobromide Tier 4
tab 8 mg (generic of
RAZADYNE)
QL (90 tabs / 30 days)
galantamine hydrobromide Tier 4
tab 12 mg (generic of
RAZADYNE)
NAMENDA SOL 10MG/5ML Tier 3
PA if <30 yr
NAMENDA TAB 5MG
Tier 4
PA if <30 yr
NAMENDA TAB 10MG
Tier 4
PA if <30 yr
NAMENDA XR CAP 7MG Tier 4
PA if <30 yr
NAMENDA XR CAP 14MG Tier 4
PA if <30 yr
NAMENDA XR CAP 21MG Tier 4
PA if <30 yr
NAMENDA XR CAP 28MG Tier 4
PA if <30 yr
NAMENDA XR CAP
Tier 4
TITRATIO
PA if <30 yr
rivastigmine tartrate cap 1.5 Tier 4
mg (generic of EXELON)
rivastigmine tartrate cap 3 Tier 4
mg (generic of EXELON)
rivastigmine tartrate cap 4.5 Tier 4
mg (generic of EXELON)
rivastigmine tartrate cap 6 Tier 4
mg (generic of EXELON)
ANTIDEPRESSANTS
QL
QL
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
Drug Requirements/
Tier
Limits
amoxapine tab 25 mg
Tier 3
amoxapine tab 50 mg
Tier 3
amoxapine tab 100 mg
Tier 3
amoxapine tab 150 mg
Tier 3
BRINTELLIX TAB 5MG
Tier 4
QL (120 tabs / 30
days)
BRINTELLIX TAB 10MG
Tier 4
QL (60 tabs / 30 days)
BRINTELLIX TAB 20MG
Tier 4
QL (30 tabs / 30 days)
bupropion hcl tab 75 mg
Tier 3
(generic of WELLBUTRIN)
bupropion hcl tab 100 mg Tier 3
(generic of WELLBUTRIN)
bupropion hcl tab sr 12hr
Tier 3
100 mg (generic of
WELLBUTRIN SR)
bupropion hcl tab sr 12hr
Tier 3
150 mg (generic of
WELLBUTRIN SR)
bupropion hcl tab sr 12hr
Tier 3
200 mg (generic of
WELLBUTRIN SR)
bupropion hcl tab sr 24hr
Tier 3
150 mg (generic of
WELLBUTRIN XL)
QL (90 tabs / 30 days)
bupropion hcl tab sr 24hr
Tier 3
300 mg (generic of
WELLBUTRIN XL)
QL (30 tabs / 30 days)
citalopram hydrobromide
Tier 3
oral soln 10 mg/5ml
citalopram hydrobromide tabTier 1
10 mg (base equiv) (generic
of CELEXA)
QL (45 tabs / 30 days)
citalopram hydrobromide tabTier 1
20 mg (base equiv) (generic
of CELEXA)
QL (45 tabs / 30 days)
citalopram hydrobromide tabTier 1
40 mg (base equiv) (generic
of CELEXA)
QL (30 tabs / 30 days)
clomipramine hcl cap 25 mg Tier 4
(generic of ANAFRANIL)
QL
QL
QL
QL
QL
QL
QL
QL
amitriptyline hcl tab 10 mg Tier 4
PA
amitriptyline hcl tab 25 mg Tier 4
PA
amitriptyline hcl tab 50 mg Tier 4
PA
amitriptyline hcl tab 75 mg Tier 4
PA
PA
amitriptyline hcl tab 100 mg Tier 4
PA
amitriptyline hcl tab 150 mg Tier 4
PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
40
Drug Name
Drug Requirements/
Tier
Limits
clomipramine hcl cap 50 mg Tier 4
(generic of ANAFRANIL)
clomipramine hcl cap 75 mg Tier 4
(generic of ANAFRANIL)
desipramine hcl tab 10 mg Tier 4
(generic of NORPRAMIN)
desipramine hcl tab 25 mg Tier 4
(generic of NORPRAMIN)
desipramine hcl tab 50 mg Tier 4
(generic of NORPRAMIN)
desipramine hcl tab 75 mg Tier 4
(generic of NORPRAMIN)
desipramine hcl tab 100 mg Tier 4
(generic of NORPRAMIN)
desipramine hcl tab 150 mg Tier 4
(generic of NORPRAMIN)
doxepin hcl cap 10 mg
Tier 4
doxepin hcl cap 25 mg
Tier 4
doxepin hcl cap 50 mg
Tier 4
doxepin hcl cap 75 mg
Tier 4
doxepin hcl cap 100 mg
Tier 4
doxepin hcl cap 150 mg
Tier 4
doxepin hcl conc 10 mg/ml Tier 4
duloxetine hcl enteric coatedTier 4
pellets cap 20 mg (generic of
CYMBALTA)
QL (60 caps / 30 days)
duloxetine hcl enteric coatedTier 4
pellets cap 30 mg (generic of
CYMBALTA)
QL (60 caps / 30 days)
duloxetine hcl enteric coatedTier 4
pellets cap 60 mg (generic of
CYMBALTA)
QL (60 caps / 30 days)
EMSAM DIS 6MG/24HR
Tier 5
QL (30 patches / 30
days)
EMSAM DIS 9MG/24HR
Tier 5
QL (30 patches / 30
days)
EMSAM DIS 12MG/24H
Tier 5
QL (30 patches / 30
days)
escitalopram oxalate soln 5 Tier 4
mg/5ml (base equiv)
(generic of LEXAPRO)
QL (600 mL / 30 days)
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL
QL
QL
QL PA
QL PA
QL PA
QL
Drug Name
Drug Requirements/
Tier
Limits
escitalopram oxalate tab 5 Tier 3
mg (base equiv) (generic of
LEXAPRO)
QL (45 tabs / 30 days)
escitalopram oxalate tab 10 Tier 3
mg (base equiv) (generic of
LEXAPRO)
QL (45 tabs / 30 days)
escitalopram oxalate tab 20 Tier 3
mg (base equiv) (generic of
LEXAPRO)
QL (60 tabs / 30 days)
FETZIMA CAP 20MG
Tier 4
QL (180 caps / 30
days)
FETZIMA CAP 40MG
Tier 4
QL (90 caps / 30 days)
FETZIMA CAP 80MG
Tier 4
QL (30 caps / 30 days)
FETZIMA CAP 120MG
Tier 4
QL (30 caps / 30 days)
FETZIMA CAP TITRATIO Tier 4
fluoxetine hcl cap 10 mg
Tier 2
(generic of PROZAC)
QL (30 caps / 30 days)
fluoxetine hcl cap 20 mg
Tier 2
(generic of PROZAC)
QL (120 caps / 30
days)
fluoxetine hcl cap 40 mg
Tier 2
(generic of PROZAC)
fluoxetine hcl solution 20
Tier 3
mg/5ml
fluoxetine hcl tab 10 mg
Tier 2
QL (45 tabs / 30 days)
fluoxetine hcl tab 20 mg
Tier 2
imipramine hcl tab 10 mg Tier 4
(generic of TOFRANIL)
imipramine hcl tab 25 mg Tier 4
(generic of TOFRANIL)
imipramine hcl tab 50 mg Tier 4
(generic of TOFRANIL)
maprotiline hcl tab 25 mg Tier 3
maprotiline hcl tab 50 mg Tier 3
maprotiline hcl tab 75 mg Tier 3
MARPLAN TAB 10MG
Tier 4
QL (180 tabs / 30
days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
PA
PA
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
41
Drug Name
Drug Requirements/
Tier
Limits
mirtazapine orally
Tier 3
disintegrating tab 15 mg
(generic of REMERON
SOLTAB)
QL (30 tabs / 30 days)
mirtazapine orally
Tier 3
disintegrating tab 30 mg
(generic of REMERON
SOLTAB)
mirtazapine orally
Tier 3
disintegrating tab 45 mg
(generic of REMERON
SOLTAB)
mirtazapine tab 7.5 mg
Tier 2
QL (45 tabs / 30 days)
mirtazapine tab 15 mg
Tier 2
(generic of REMERON)
QL (45 tabs / 30 days)
mirtazapine tab 30 mg
Tier 2
(generic of REMERON)
mirtazapine tab 45 mg
Tier 2
(generic of REMERON)
nefazodone hcl tab 50 mg Tier 3
nefazodone hcl tab 100 mg Tier 3
nefazodone hcl tab 150 mg Tier 3
nefazodone hcl tab 200 mg Tier 3
nefazodone hcl tab 250 mg Tier 3
nortriptyline hcl cap 10 mg Tier 1
(generic of PAMELOR)
nortriptyline hcl cap 25 mg Tier 1
(generic of PAMELOR)
nortriptyline hcl cap 50 mg Tier 1
(generic of PAMELOR)
nortriptyline hcl cap 75 mg Tier 1
(generic of PAMELOR)
nortriptyline hcl soln 10
Tier 4
mg/5ml
paroxetine hcl tab 10 mg
Tier 2
(generic of PAXIL)
QL (45 tabs / 30 days)
paroxetine hcl tab 20 mg
Tier 2
(generic of PAXIL)
QL (45 tabs / 30 days)
paroxetine hcl tab 30 mg
Tier 2
(generic of PAXIL)
QL (60 tabs / 30 days)
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
paroxetine hcl tab 40 mg
Tier 2
(generic of PAXIL)
QL (45 tabs / 30 days)
PAXIL SUS 10MG/5ML
Tier 4
QL (900 mL / 30 days)
phenelzine sulfate tab 15 mgTier 3
(generic of NARDIL)
PRISTIQ TAB 25MG
Tier 3
QL (30 tabs / 30 days)
PRISTIQ TAB 50MG
Tier 3
QL (30 tabs / 30 days)
PRISTIQ TAB 100MG
Tier 3
QL (30 tabs / 30 days)
protriptyline hcl tab 5 mg
Tier 4
protriptyline hcl tab 10 mg Tier 4
sertraline hcl oral conc 20 Tier 3
mg/ml (generic of ZOLOFT)
sertraline hcl tab 25 mg
Tier 1
(generic of ZOLOFT)
QL (45 tabs / 30 days)
sertraline hcl tab 50 mg
Tier 1
(generic of ZOLOFT)
QL (45 tabs / 30 days)
sertraline hcl tab 100 mg
Tier 1
(generic of ZOLOFT)
SURMONTIL CAP 25MG Tier 4
QL (240 caps / 30
days)
SURMONTIL CAP 50MG Tier 4
QL (120 caps / 30
days)
SURMONTIL CAP 100MG Tier 4
QL (60 caps / 30 days)
tranylcypromine sulfate tab Tier 4
10 mg (generic of
PARNATE)
trazodone hcl tab 50 mg
Tier 1
trazodone hcl tab 100 mg Tier 1
trazodone hcl tab 150 mg Tier 1
venlafaxine hcl cap sr 24hr Tier 3
37.5 mg (base equivalent)
(generic of EFFEXOR XR)
QL (30 caps / 30 days)
venlafaxine hcl cap sr 24hr Tier 3
75 mg (base equivalent)
(generic of EFFEXOR XR)
QL (30 caps / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL PA
QL PA
QL PA
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
42
Drug Name
Drug Requirements/
Tier
Limits
venlafaxine hcl cap sr 24hr Tier 3
150 mg (base equivalent)
(generic of EFFEXOR XR)
QL (60 caps / 30 days)
venlafaxine hcl tab 25 mg Tier 3
venlafaxine hcl tab 37.5 mg Tier 3
venlafaxine hcl tab 50 mg Tier 3
venlafaxine hcl tab 75 mg Tier 3
venlafaxine hcl tab 100 mg Tier 3
VIIBRYD KIT
Tier 4
VIIBRYD TAB 10MG
Tier 4
QL (30 tabs / 30 days)
VIIBRYD TAB 20MG
Tier 4
QL (30 tabs / 30 days)
VIIBRYD TAB 40MG
Tier 4
QL (30 tabs / 30 days)
QL
QL
QL
QL
ANTIPARKINSONIAN AGENTS
amantadine hcl cap 100 mg Tier 3
amantadine hcl syrup 50
Tier 2
mg/5ml
amantadine hcl tab 100 mg Tier 4
APOKYN INJ 10MG/ML
Tier 5
AZILECT TAB 0.5MG
Tier 3
AZILECT TAB 1MG
Tier 3
benztropine mesylate inj 1 Tier 4
mg/ml (generic of
COGENTIN)
benztropine mesylate tab Tier 4
0.5 mg
benztropine mesylate tab 1 Tier 4
mg
benztropine mesylate tab 2 Tier 4
mg
bromocriptine mesylate cap Tier 4
5 mg (generic of
PARLODEL)
bromocriptine mesylate tab Tier 4
2.5 mg
carbidopa & levodopa orally Tier 4
disintegrating tab 10-100 mg
carbidopa & levodopa orally Tier 4
disintegrating tab 25-100 mg
carbidopa & levodopa orally Tier 4
disintegrating tab 25-250 mg
carbidopa & levodopa tab Tier 3
10-100 mg (generic of
SINEMET)
NM LA PA
PA
PA
PA
Drug Name
Drug Requirements/
Tier
Limits
carbidopa & levodopa tab Tier 3
25-100 mg (generic of
SINEMET)
carbidopa & levodopa tab Tier 3
25-250 mg (generic of
SINEMET)
carbidopa & levodopa tab cr Tier 3
25-100 mg (generic of
SINEMET CR)
carbidopa & levodopa tab cr Tier 3
50-200 mg (generic of
SINEMET CR)
CARBIDOPA-LEVODOPA- Tier 4
ENTACAPONE TABS
12.5-50-200 MG
CARBIDOPA-LEVODOPA- Tier 4
ENTACAPONE TABS
18.75-75-200 MG
CARBIDOPA-LEVODOPA- Tier 4
ENTACAPONE TABS
25-100-200 MG
CARBIDOPA-LEVODOPA- Tier 4
ENTACAPONE TABS
31.25-125-200 MG
CARBIDOPA-LEVODOPA- Tier 4
ENTACAPONE TABS
37.5-150-200 MG
CARBIDOPA-LEVODOPA- Tier 4
ENTACAPONE TABS
50-200-200 MG
entacapone tab 200 mg
Tier 4
(generic of COMTAN)
NEUPRO DIS 1MG/24HR Tier 4
NEUPRO DIS 2MG/24HR Tier 4
NEUPRO DIS 3MG/24HR Tier 4
NEUPRO DIS 4MG/24HR Tier 4
NEUPRO DIS 6MG/24HR Tier 4
NEUPRO DIS 8MG/24HR Tier 4
pramipexole dihydrochloride Tier 3
tab 0.5 mg (generic of
MIRAPEX)
pramipexole dihydrochloride Tier 3
tab 0.25 mg (generic of
MIRAPEX)
pramipexole dihydrochloride Tier 3
tab 0.75 mg
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
43
Drug Name
Drug Requirements/
Tier
Limits
pramipexole dihydrochloride Tier 3
tab 0.125 mg (generic of
MIRAPEX)
pramipexole dihydrochloride Tier 3
tab 1 mg (generic of
MIRAPEX)
pramipexole dihydrochloride Tier 3
tab 1.5 mg (generic of
MIRAPEX)
ropinirole hydrochloride tab Tier 3
0.5 mg (generic of REQUIP)
ropinirole hydrochloride tab Tier 3
0.25 mg (generic of
REQUIP)
ropinirole hydrochloride tab Tier 3
1 mg (generic of REQUIP)
ropinirole hydrochloride tab Tier 3
2 mg (generic of REQUIP)
ropinirole hydrochloride tab Tier 3
3 mg (generic of REQUIP)
ropinirole hydrochloride tab Tier 3
4 mg (generic of REQUIP)
ropinirole hydrochloride tab Tier 3
5 mg (generic of REQUIP)
selegiline hcl cap 5 mg
Tier 4
(generic of ELDEPRYL)
selegiline hcl tab 5 mg
Tier 3
ANTIPSYCHOTICS
ABILIFY DISC TAB 10MG Tier 5
QL (60 tabs / 30 days)
ABILIFY DISC TAB 15MG Tier 5
QL (60 tabs / 30 days)
ABILIFY INJ 9.75MG
Tier 4
QL (4 mL / 1 day)
ABILIFY MAIN INJ 300MG Tier 5
QL (1 syringe / 28
days)
ABILIFY MAIN INJ 300MG Tier 5
QL (1 vial / 28 days)
ABILIFY MAIN INJ 400MG Tier 5
QL (1 syringe / 28
days)
ABILIFY MAIN INJ 400MG Tier 5
QL (1 vial / 28 days)
ABILIFY TAB 2MG
Tier 5
QL (30 tabs / 30 days)
ABILIFY TAB 5MG
Tier 5
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
ABILIFY TAB 10MG
Tier 5
QL (30 tabs / 30 days)
ABILIFY TAB 15MG
Tier 5
QL (30 tabs / 30 days)
ABILIFY TAB 20MG
Tier 5
QL (30 tabs / 30 days)
ABILIFY TAB 30MG
Tier 5
QL (30 tabs / 30 days)
aripiprazole tab 2 mg
Tier 5
(generic of ABILIFY)
QL (30 tabs / 30 days)
aripiprazole tab 5 mg
Tier 5
(generic of ABILIFY)
QL (30 tabs / 30 days)
aripiprazole tab 10 mg
Tier 5
(generic of ABILIFY)
QL (30 tabs / 30 days)
aripiprazole tab 15 mg
Tier 5
(generic of ABILIFY)
QL (30 tabs / 30 days)
aripiprazole tab 20 mg
Tier 5
(generic of ABILIFY)
QL (30 tabs / 30 days)
aripiprazole tab 30 mg
Tier 5
(generic of ABILIFY)
QL (30 tabs / 30 days)
chlorpromaz inj 50mg/2ml Tier 4
chlorpromazine hcl tab 10 Tier 4
mg
chlorpromazine hcl tab 25 Tier 4
mg
chlorpromazine hcl tab 50 Tier 4
mg
chlorpromazine hcl tab 100 Tier 4
mg
chlorpromazine hcl tab 200 Tier 4
mg
CLOZAPINE ORALLY
Tier 4
DISINTEGRATING TAB
12.5 MG
CLOZAPINE ORALLY
Tier 4
DISINTEGRATING TAB 25
MG
CLOZAPINE ORALLY
Tier 4
DISINTEGRATING TAB 100
MG
QL (270 tabs / 30
days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
PA
QL PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
44
Drug Name
Drug Requirements/
Tier
Limits
clozapine tab 25 mg (genericTier 3
of CLOZARIL)
clozapine tab 50 mg
Tier 3
clozapine tab 100 mg
Tier 4
(generic of CLOZARIL)
QL (270 tabs / 30
days)
clozapine tab 200 mg
Tier 4
QL (135 tabs / 30
days)
FANAPT PAK
Tier 4
FANAPT TAB 1MG
Tier 4
QL (60 tabs / 30 days)
FANAPT TAB 2MG
Tier 4
QL (60 tabs / 30 days)
FANAPT TAB 4MG
Tier 4
QL (60 tabs / 30 days)
FANAPT TAB 6MG
Tier 4
QL (60 tabs / 30 days)
FANAPT TAB 8MG
Tier 4
QL (60 tabs / 30 days)
FANAPT TAB 10MG
Tier 4
QL (60 tabs / 30 days)
FANAPT TAB 12MG
Tier 4
QL (60 tabs / 30 days)
FAZACLO TAB 12.5/ODT Tier 4
FAZACLO TAB 25MG ODT Tier 4
FAZACLO TAB 100/ODT Tier 4
QL (270 tabs / 30
days)
FAZACLO TAB 150MG
Tier 4
QL (180 tabs / 30
days)
FAZACLO TAB 200MG
Tier 4
QL (135 tabs / 30
days)
fluphenazine decanoate inj Tier 4
25 mg/ml
fluphenazine hcl elixir 2.5 Tier 4
mg/5ml
fluphenazine hcl inj 2.5
Tier 4
mg/ml
fluphenazine hcl oral conc 5 Tier 4
mg/ml
fluphenazine hcl tab 1 mg Tier 2
fluphenazine hcl tab 2.5 mg Tier 2
fluphenazine hcl tab 5 mg Tier 2
fluphenazine hcl tab 10 mg Tier 2
QL
QL
ST
QL ST
QL ST
QL ST
QL ST
QL ST
QL ST
QL ST
PA
PA
QL PA
QL PA
QL PA
Drug Name
Drug Requirements/
Tier
Limits
GEODON INJ 20MG
Tier 4
QL (6 mL / 3 days)
haloperidol decanoate im Tier 3
soln 50 mg/ml (generic of
HALDOL DECANOATE 50)
haloperidol decanoate im Tier 3
soln 100 mg/ml (generic of
HALDOL DECANOATE
100)
haloperidol lactate inj 5
Tier 3
mg/ml (generic of HALDOL)
haloperidol lactate oral conc Tier 3
2 mg/ml
haloperidol tab 0.5 mg
Tier 3
haloperidol tab 1 mg
Tier 3
haloperidol tab 2 mg
Tier 3
haloperidol tab 5 mg
Tier 3
haloperidol tab 10 mg
Tier 3
haloperidol tab 20 mg
Tier 3
INVEGA SUST INJ 39/0.25 Tier 4
QL (1 injection / 28
days)
INVEGA SUST INJ
Tier 5
78/0.5ML
QL (1 injection / 28
days)
INVEGA SUST INJ 117/0.75Tier 5
QL (1 injection / 28
days)
INVEGA SUST INJ
Tier 5
156MG/ML
QL (1 injection / 28
days)
INVEGA SUST INJ 234/1.5 Tier 5
QL (1 injection / 28
days)
INVEGA TAB 1.5MG
Tier 5
QL (30 tabs / 30 days)
INVEGA TAB 3MG
Tier 5
QL (30 tabs / 30 days)
INVEGA TAB 6MG
Tier 5
QL (60 tabs / 30 days)
INVEGA TAB 9MG
Tier 5
QL (30 tabs / 30 days)
LATUDA TAB 20MG
Tier 5
QL (240 tabs / 30
days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
45
Drug Name
Drug Requirements/
Tier
Limits
LATUDA TAB 40MG
Tier 5
QL (30 tabs / 30 days)
LATUDA TAB 60MG
Tier 5
QL (60 tabs / 30 days)
LATUDA TAB 80MG
Tier 5
QL (60 tabs / 30 days)
LATUDA TAB 120MG
Tier 5
QL (30 tabs / 30 days)
loxapine succinate cap 5 mg Tier 3
loxapine succinate cap 10 Tier 3
mg
loxapine succinate cap 25 Tier 3
mg
loxapine succinate cap 50 Tier 3
mg
olanzapine for im inj 10 mg Tier 4
(generic of ZYPREXA)
QL (3 vials / 1 day)
olanzapine orally
Tier 4
disintegrating tab 5 mg
(generic of ZYPREXA
ZYDIS)
QL (30 tabs / 30 days)
olanzapine orally
Tier 4
disintegrating tab 10 mg
(generic of ZYPREXA
ZYDIS)
QL (60 tabs / 30 days)
olanzapine orally
Tier 4
disintegrating tab 15 mg
(generic of ZYPREXA
ZYDIS)
QL (60 tabs / 30 days)
olanzapine orally
Tier 5
disintegrating tab 20 mg
(generic of ZYPREXA
ZYDIS)
QL (60 tabs / 30 days)
olanzapine tab 2.5 mg
Tier 4
(generic of ZYPREXA)
QL (30 tabs / 30 days)
olanzapine tab 5 mg
Tier 4
(generic of ZYPREXA)
QL (30 tabs / 30 days)
olanzapine tab 7.5 mg
Tier 4
(generic of ZYPREXA)
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
olanzapine tab 10 mg
Tier 4
(generic of ZYPREXA)
QL (60 tabs / 30 days)
olanzapine tab 15 mg
Tier 4
(generic of ZYPREXA)
QL (60 tabs / 30 days)
olanzapine tab 20 mg
Tier 4
(generic of ZYPREXA)
QL (60 tabs / 30 days)
ORAP TAB 1MG
Tier 4
ORAP TAB 2MG
Tier 4
perphenazine tab 2 mg
Tier 3
perphenazine tab 4 mg
Tier 3
perphenazine tab 8 mg
Tier 3
perphenazine tab 16 mg
Tier 3
quetiapine fumarate tab 25 Tier 4
mg (generic of SEROQUEL)
QL (90 tabs / 30 days)
quetiapine fumarate tab 50 Tier 4
mg (generic of SEROQUEL)
QL (90 tabs / 30 days)
quetiapine fumarate tab 100 Tier 4
mg (generic of SEROQUEL)
QL (90 tabs / 30 days)
quetiapine fumarate tab 200 Tier 4
mg (generic of SEROQUEL)
QL (90 tabs / 30 days)
quetiapine fumarate tab 300 Tier 4
mg (generic of SEROQUEL)
QL (90 tabs / 30 days)
quetiapine fumarate tab 400 Tier 4
mg (generic of SEROQUEL)
QL (90 tabs / 30 days)
RISPERDAL INJ 12.5MG Tier 4
QL (2 injections / 28
days)
RISPERDAL INJ 25MG
Tier 4
QL (2 injections / 28
days)
RISPERDAL INJ 37.5MG Tier 5
QL (2 injections / 28
days)
RISPERDAL INJ 50MG
Tier 5
QL (2 injections / 28
days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
46
Drug Name
Drug Requirements/
Tier
Limits
risperidone orally
Tier 4
disintegrating tab 0.5 mg
(generic of RISPERDAL
M-TAB)
QL (90 tabs / 30 days)
risperidone orally
Tier 4
disintegrating tab 0.25 mg
QL (90 tabs / 30 days)
risperidone orally
Tier 4
disintegrating tab 1 mg
(generic of RISPERDAL
M-TAB)
QL (60 tabs / 30 days)
risperidone orally
Tier 4
disintegrating tab 2 mg
(generic of RISPERDAL
M-TAB)
QL (60 tabs / 30 days)
risperidone orally
Tier 4
disintegrating tab 3 mg
(generic of RISPERDAL
M-TAB)
QL (60 tabs / 30 days)
risperidone orally
Tier 4
disintegrating tab 4 mg
(generic of RISPERDAL
M-TAB)
QL (120 tabs / 30
days)
risperidone soln 1 mg/ml
Tier 4
(generic of RISPERDAL)
QL (240 mL / 30 days)
risperidone tab 0.5 mg
Tier 3
(generic of RISPERDAL)
QL (90 tabs / 30 days)
risperidone tab 0.25 mg
Tier 3
(generic of RISPERDAL)
QL (90 tabs / 30 days)
risperidone tab 1 mg
Tier 3
(generic of RISPERDAL)
QL (60 tabs / 30 days)
risperidone tab 2 mg
Tier 3
(generic of RISPERDAL)
QL (60 tabs / 30 days)
risperidone tab 3 mg
Tier 3
(generic of RISPERDAL)
QL (60 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
risperidone tab 4 mg
Tier 3
(generic of RISPERDAL)
QL (120 tabs / 30
days)
SAPHRIS SUB 2.5MG
Tier 4
QL (240 tabs / 30
days)
SAPHRIS SUB 5MG
Tier 4
QL (120 tabs / 30
days)
SAPHRIS SUB 10MG
Tier 4
QL (60 tabs / 30 days)
SEROQUEL XR TAB 50MG Tier 4
QL (120 tabs / 30
days)
SEROQUEL XR TAB
Tier 4
150MG
QL (30 tabs / 30 days)
SEROQUEL XR TAB
Tier 4
200MG
QL (30 tabs / 30 days)
SEROQUEL XR TAB
Tier 4
300MG
QL (60 tabs / 30 days)
SEROQUEL XR TAB
Tier 4
400MG
QL (60 tabs / 30 days)
thioridazine hcl tab 10 mg Tier 4
thioridazine hcl tab 25 mg Tier 4
thioridazine hcl tab 50 mg Tier 4
thioridazine hcl tab 100 mg Tier 4
thiothixene cap 1 mg
Tier 3
thiothixene cap 2 mg
Tier 3
thiothixene cap 5 mg
Tier 3
thiothixene cap 10 mg
Tier 3
trifluoperazine hcl tab 1 mg Tier 3
trifluoperazine hcl tab 2 mg Tier 3
trifluoperazine hcl tab 5 mg Tier 3
trifluoperazine hcl tab 10 mg Tier 3
VERSACLOZ SUS
Tier 5
50MG/ML
QL (600 mL / 30 days)
ziprasidone hcl cap 20 mg Tier 4
(generic of GEODON)
QL (60 caps / 30 days)
ziprasidone hcl cap 40 mg Tier 4
(generic of GEODON)
QL (60 caps / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
PA
PA
PA
QL PA
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
47
Drug Name
Drug Requirements/
Tier
Limits
ziprasidone hcl cap 60 mg Tier 4
(generic of GEODON)
QL (90 caps / 30 days)
ziprasidone hcl cap 80 mg Tier 4
(generic of GEODON)
QL (90 caps / 30 days)
ZYPREXA RELP INJ
Tier 5
210MG
ZYPREXA RELP INJ
Tier 5
300MG
ZYPREXA RELP INJ
Tier 5
405MG
QL
QL
B/D
B/D
B/D
ATTENTION DEFICIT HYPERACTIVITY
DISORDER
amphetamine-dextroamphet Tier 4
amine cap sr 24hr 5 mg
(generic of ADDERALL XR)
QL (90 caps / 30 days)
amphetamine-dextroamphet Tier 4
amine cap sr 24hr 10 mg
(generic of ADDERALL XR)
QL (90 caps / 30 days)
amphetamine-dextroamphet Tier 4
amine cap sr 24hr 15 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroamphet Tier 4
amine cap sr 24hr 20 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroamphet Tier 4
amine cap sr 24hr 25 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroamphet Tier 4
amine cap sr 24hr 30 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroamphet Tier 3
amine tab 5 mg (generic of
ADDERALL)
QL (360 tabs / 30
days)
amphetamine-dextroamphet Tier 3
amine tab 7.5 mg (generic of
ADDERALL)
QL (240 tabs / 30
days)
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
amphetamine-dextroamphet Tier 3
amine tab 10 mg (generic of
ADDERALL)
QL (180 tabs / 30
days)
amphetamine-dextroamphet Tier 3
amine tab 12.5 mg (generic
of ADDERALL)
QL (144 tabs / 30
days)
amphetamine-dextroamphet Tier 3
amine tab 15 mg (generic of
ADDERALL)
QL (120 tabs / 30
days)
amphetamine-dextroamphet Tier 3
amine tab 20 mg (generic of
ADDERALL)
QL (90 tabs / 30 days)
amphetamine-dextroamphet Tier 3
amine tab 30 mg (generic of
ADDERALL)
QL (60 tabs / 30 days)
guanfacine hcl tab sr 24hr 1 Tier 4
mg (base equiv) (generic of
INTUNIV)
guanfacine hcl tab sr 24hr 2 Tier 4
mg (base equiv) (generic of
INTUNIV)
guanfacine hcl tab sr 24hr 3 Tier 4
mg (base equiv) (generic of
INTUNIV)
guanfacine hcl tab sr 24hr 4 Tier 4
mg (base equiv) (generic of
INTUNIV)
methylphenidate hcl soln 5 Tier 4
mg/5ml (generic of
METHYLIN)
QL (1800 mL / 30
days)
methylphenidate hcl soln 10 Tier 4
mg/5ml (generic of
METHYLIN)
QL (900 mL / 30 days)
methylphenidate hcl tab 5 Tier 3
mg (generic of RITALIN)
QL (180 tabs / 30
days)
QL
QL
QL
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
48
Drug Name
Drug Requirements/
Tier
Limits
methylphenidate hcl tab 10 Tier 3
mg (generic of RITALIN)
QL (180 tabs / 30
days)
methylphenidate hcl tab 20 Tier 3
mg (generic of RITALIN)
QL (90 tabs / 30 days)
methylphenidate hcl tab cr Tier 3
10 mg
QL (90 tabs / 30 days)
methylphenidate hcl tab cr Tier 3
20 mg
QL (90 tabs / 30 days)
STRATTERA CAP 10MG Tier 4
QL (120 caps / 30
days)
STRATTERA CAP 18MG Tier 4
QL (120 caps / 30
days)
STRATTERA CAP 25MG Tier 4
QL (120 caps / 30
days)
STRATTERA CAP 40MG Tier 4
QL (60 caps / 30 days)
STRATTERA CAP 60MG Tier 4
QL (30 caps / 30 days)
STRATTERA CAP 80MG Tier 4
QL (30 caps / 30 days)
STRATTERA CAP 100MG Tier 4
QL (30 caps / 30 days)
Drug Requirements/
Tier
Limits
QL
zolpidem tartrate tab 10 mg Tier 4
(generic of AMBIEN)
QL (30 tabs / 30 days)
90 day limit if >64 yr
QL
MIGRAINE
QL
QL
QL
QL
QL
QL
QL
QL
QL
HYPNOTICS
ROZEREM TAB 8MG
Tier 4
QL (30 tabs / 30 days)
SILENOR TAB 3MG
Tier 3
QL (60 tabs / 30 days)
SILENOR TAB 6MG
Tier 3
QL (30 tabs / 30 days)
temazepam cap 7.5 mg
Tier 2
(generic of RESTORIL)
QL (30 caps / 30 days)
90 day limit if >64 yr
temazepam cap 15 mg
Tier 2
(generic of RESTORIL)
QL (60 caps / 30 days)
90 day limit if >64 yr
zolpidem tartrate tab 5 mg Tier 4
(generic of AMBIEN)
QL (30 tabs / 30 days)
90 day limit if >64 yr
Drug Name
QL
QL
QL
QL PA
QL PA
QL PA
cafergot tab 1-100mg
Tier 4
dihydroergotamine mesylate Tier 3
inj 1 mg/ml (generic of
D.H.E. 45)
naratriptan hcl tab 1 mg
Tier 3
(base equiv) (generic of
AMERGE)
QL (9 tabs / 30 days)
naratriptan hcl tab 2.5 mg Tier 3
(base equiv) (generic of
AMERGE)
QL (9 tabs / 30 days)
RELPAX TAB 20MG
Tier 3
QL (12 tabs / 30 days)
RELPAX TAB 40MG
Tier 3
QL (12 tabs / 30 days)
rizatriptan benzoate orally Tier 4
disintegrating tab 5 mg
(generic of MAXALT-MLT)
QL (18 tabs / 30 days)
rizatriptan benzoate orally Tier 4
disintegrating tab 10 mg
(generic of MAXALT-MLT)
QL (18 tabs / 30 days)
rizatriptan benzoate tab 5 Tier 3
mg (generic of MAXALT)
QL (18 tabs / 30 days)
rizatriptan benzoate tab 10 Tier 3
mg (generic of MAXALT)
QL (18 tabs / 30 days)
SUMATRIPTAN NASAL
Tier 4
SPRAY 5 MG/ACT
QL (24 inhalers / 30
days)
SUMATRIPTAN NASAL
Tier 4
SPRAY 20 MG/ACT
QL (12 inhalers / 30
days)
sumatriptan succinate inj 6 Tier 4
mg/0.5ml (generic of
IMITREX)
QL (6 mL / 30 days)
QL PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
49
Drug Name
Drug Requirements/
Tier
Limits
SUMATRIPTAN
Tier 4
SUCCINATE SOLUTION
AUTO-INJECTOR 4
MG/0.5ML
QL (6 mL / 30 days)
sumatriptan succinate
Tier 4
solution auto-injector 6
mg/0.5ml (generic of
IMITREX STATDOSE
SYSTEM)
QL (6 mL / 30 days)
SUMATRIPTAN
Tier 4
SUCCINATE SOLUTION
CARTRIDGE 4 MG/0.5ML
QL (6 mL / 30 days)
SUMATRIPTAN
Tier 4
SUCCINATE SOLUTION
CARTRIDGE 6 MG/0.5ML
QL (6 mL / 30 days)
sumatriptan succinate
Tier 4
solution prefilled syringe 6
mg/0.5ml
QL (6 mL / 30 days)
sumatriptan succinate tab 25Tier 3
mg (generic of IMITREX)
QL (9 tabs / 30 days)
sumatriptan succinate tab 50Tier 3
mg (generic of IMITREX)
QL (9 tabs / 30 days)
sumatriptan succinate tab Tier 3
100 mg (generic of
IMITREX)
QL (9 tabs / 30 days)
zolmitriptan orally
Tier 4
disintegrating tab 2.5 mg
(generic of ZOMIG ZMT)
QL (12 tabs / 30 days)
zolmitriptan orally
Tier 4
disintegrating tab 5 mg
(generic of ZOMIG ZMT)
QL (12 tabs / 30 days)
zolmitriptan tab 2.5 mg
Tier 4
(generic of ZOMIG)
QL (12 tabs / 30 days)
zolmitriptan tab 5 mg
Tier 4
(generic of ZOMIG)
QL (12 tabs / 30 days)
MISCELLANEOUS
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
lithium carbonate cap 150 Tier 1
mg
lithium carbonate cap 300 Tier 1
mg
lithium carbonate cap 600 Tier 1
mg
lithium carbonate tab 300 Tier 2
mg
lithium carbonate tab cr 300 Tier 2
mg (generic of LITHOBID)
lithium carbonate tab cr 450 Tier 2
mg
LITHIUM SOL 8MEQ/5ML Tier 3
NUEDEXTA CAP 20-10MG Tier 3
PA
pyridostigmine bromide tab Tier 3
60 mg (generic of
MESTINON)
riluzole tab 50 mg (generic ofTier 4
RILUTEK)
XENAZINE TAB 12.5MG
Tier 5 QL NM LA PA
QL (240 tabs / 30
days)
XENAZINE TAB 25MG
Tier 5 QL NM LA PA
QL (120 tabs / 30
days)
MULTIPLE SCLEROSIS AGENTS
BETASERON INJ 0.3MG Tier 5
QL (14 syringes / 28
days)
COPAXONE INJ 20MG/ML Tier 5
QL (30 syringes / 30
days)
COPAXONE INJ 40MG/ML Tier 5
QL (12 syringes / 28
days)
GILENYA CAP 0.5MG
Tier 5
QL (28 caps / 28 days)
TYSABRI INJ 300/15ML
Tier 5
QL NM PA
QL NM PA
QL NM PA
QL NM PA
NM LA PA
MUSCULOSKELETAL THERAPY AGENTS
QL
QL
baclofen tab 10 mg
baclofen tab 20 mg
cyclobenzaprine hcl tab 5
mg
cyclobenzaprine hcl tab 10
mg
dantrolene sodium cap 25
mg (generic of DANTRIUM)
Tier 1
Tier 1
Tier 4
PA
Tier 4
PA
Tier 4
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
50
Drug Name
Drug Requirements/
Tier
Limits
dantrolene sodium cap 50 Tier 4
mg (generic of DANTRIUM)
dantrolene sodium cap 100 Tier 4
mg
tizanidine hcl tab 2 mg (baseTier 3
equivalent)
tizanidine hcl tab 4 mg (baseTier 3
equivalent) (generic of
ZANAFLEX)
NARCOLEPSY/CATAPLEXY
NUVIGIL TAB 50MG
Tier 4
QL (150 tabs / 30
days)
NUVIGIL TAB 150MG
Tier 4
QL (60 tabs / 30 days)
NUVIGIL TAB 200MG
Tier 4
QL (30 tabs / 30 days)
NUVIGIL TAB 250MG
Tier 4
QL (30 tabs / 30 days)
XYREM SOL 500MG/ML
Tier 5
QL (540 mL / 30 days)
QL PA
QL PA
QL PA
QL PA
QL LA PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium tab
Tier 4
delayed release 333 mg
buprenorphine hcl sl tab 2 Tier 4
mg (base equiv)
buprenorphine hcl sl tab 8 Tier 4
mg (base equiv)
buprenorphine hcl-naloxone Tier 4
hcl sl tab 2-0.5 mg (base
equiv)
QL (120 tabs / 30
days)
buprenorphine hcl-naloxone Tier 4
hcl sl tab 8-2 mg (base
equiv)
QL (120 tabs / 30
days)
buproban tab 150mg
Tier 3
(generic of ZYBAN)
CHANTIX PAK 0.5& 1MG Tier 4
CHANTIX PAK 1MG
Tier 4
CHANTIX TAB 0.5MG
Tier 4
CHANTIX TAB 1MG
Tier 4
disulfiram tab 250 mg
Tier 4
(generic of ANTABUSE)
disulfiram tab 500 mg
Tier 4
(generic of ANTABUSE)
PA
PA
QL PA
QL PA
PA
PA
PA
PA
Drug Name
Drug Requirements/
Tier
Limits
naloxone hcl inj 0.4 mg/ml Tier 3
naloxone hcl inj 1 mg/ml
Tier 3
naltrexone hcl tab 50 mg
Tier 3
(generic of REVIA)
NICOTROL INH
Tier 4
NICOTROL NS SPR
Tier 4
10MG/ML
SUBOXONE MIS 2-0.5MG Tier 4
QL (4 boxes / 30 days)
SUBOXONE MIS 4-1MG
Tier 4
QL (4 boxes / 30 days)
SUBOXONE MIS 8-2MG
Tier 4
QL (4 boxes / 30 days)
SUBOXONE MIS 12-3MG Tier 4
QL (2 boxes / 30 days)
QL PA
QL PA
QL PA
QL PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANDRODERM DIS
Tier 4
2MG/24HR
QL (30 patches / 30
days)
ANDRODERM DIS
Tier 4
4MG/24HR
QL (30 patches / 30
days)
oxandrolone tab 2.5 mg
Tier 3
(generic of OXANDRIN)
oxandrolone tab 10 mg
Tier 3
(generic of OXANDRIN)
TESTIM GEL 1%(50MG)
Tier 3
QL (300 grams / 30
days)
testosterone cypionate im injTier 3
in oil 100 mg/ml
testosterone cypionate im injTier 3
in oil 200 mg/ml (generic of
DEPO-TESTOSTERONE)
testosterone enanthate im Tier 3
inj in oil 200 mg/ml
QL PA
QL PA
PA
PA
QL PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
GAUZE PADS 2" X 2"
HUMULIN R INJ U-500
INSULIN PEN NEEDLE
INSULIN SAFETY
NEEDLES
INSULIN SYRINGE
LANTUS INJ 100/ML
Tier 3
Tier 3
Tier 5
Tier 3
Tier 3
B/D
Tier 3
Tier 3
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
51
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXTOUC
NOVOLIN INJ 70/30
RELION not covered
NOVOLIN N INJ U-100
RELION not covered
NOVOLIN R INJ U-100
RELION not covered
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ
FLEXPEN
SYMLINPEN 60 INJ
1000MCG
QL (8 pens / 30 days)
SYMLNPEN 120 INJ
1000MCG
QL (4 pens / 30 days)
TOUJEO SOLO INJ
300IU/ML
VICTOZA INJ 18MG/3ML
QL (3 pens / 30 days)
Tier 3
Tier 3
Tier 3
Tier 3
glipizide tab 10 mg (generic Tier 1
of GLUCOTROL)
QL (120 tabs / 30
days)
glipizide tab sr 24hr 2.5 mg Tier 1
(generic of GLUCOTROL
XL)
QL (240 tabs / 30
days)
glipizide tab sr 24hr 5 mg Tier 1
(generic of GLUCOTROL
XL)
QL (120 tabs / 30
days)
glipizide tab sr 24hr 10 mg Tier 1
(generic of GLUCOTROL
XL)
QL (60 tabs / 30 days)
glipizide-metformin hcl tab Tier 1
2.5-250 mg
QL (240 tabs / 30
days)
glipizide-metformin hcl tab Tier 1
2.5-500 mg
QL (120 tabs / 30
days)
glipizide-metformin hcl tab Tier 1
5-500 mg
QL (120 tabs / 30
days)
INVOKAMET TAB
Tier 3
50-500MG
QL (120 tabs / 30
days)
INVOKAMET TAB 50-1000 Tier 3
QL (60 tabs / 30 days)
INVOKAMET TAB 150-500 Tier 3
QL (60 tabs / 30 days)
INVOKAMET TAB 150-1000 Tier 3
QL (60 tabs / 30 days)
INVOKANA TAB 100MG
Tier 3
QL (90 tabs / 30 days)
INVOKANA TAB 300MG
Tier 3
QL (30 tabs / 30 days)
JANUMET TAB 50-500MG Tier 3
QL (60 tabs / 30 days)
JANUMET TAB 50-1000
Tier 3
QL (60 tabs / 30 days)
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
QL PA
Tier 4
QL PA
Tier 3
Tier 3
QL
ANTIDIABETICS, ORAL
acarbose tab 25 mg (genericTier 3
of PRECOSE)
acarbose tab 50 mg (genericTier 3
of PRECOSE)
acarbose tab 100 mg
Tier 3
(generic of PRECOSE)
glimepiride tab 1 mg
Tier 1
(generic of AMARYL)
QL (240 tabs / 30
days)
glimepiride tab 2 mg
Tier 1
(generic of AMARYL)
QL (120 tabs / 30
days)
glimepiride tab 4 mg
Tier 1
(generic of AMARYL)
QL (60 tabs / 30 days)
glipizide tab 5 mg (generic ofTier 1
GLUCOTROL)
QL (240 tabs / 30
days)
QL
QL
QL
QL
Drug Requirements/
Tier
Limits
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
52
Drug Name
Drug Requirements/
Tier
Limits
JANUMET XR TAB
Tier 3
50-500MG
QL (60 tabs / 30 days)
JANUMET XR TAB 50-1000 Tier 3
QL (60 tabs / 30 days)
JANUMET XR TAB
Tier 3
100-1000
QL (30 tabs / 30 days)
JANUVIA TAB 25MG
Tier 3
QL (30 tabs / 30 days)
JANUVIA TAB 50MG
Tier 3
QL (30 tabs / 30 days)
JANUVIA TAB 100MG
Tier 3
QL (30 tabs / 30 days)
JENTADUETO TAB 2.5-500 Tier 3
QL (60 tabs / 30 days)
JENTADUETO TAB 2.5-850 Tier 3
QL (60 tabs / 30 days)
JENTADUETO TAB
Tier 3
2.5-1000
QL (60 tabs / 30 days)
metformin hcl tab 500 mg Tier 1
(generic of GLUCOPHAGE)
QL (150 tabs / 30
days)
metformin hcl tab 850 mg Tier 1
(generic of GLUCOPHAGE)
QL (90 tabs / 30 days)
metformin hcl tab 1000 mg Tier 1
(generic of GLUCOPHAGE)
QL (75 tabs / 30 days)
metformin hcl tab sr 24hr
Tier 1
500 mg (generic of
GLUCOPHAGE XR)
QL (120 tabs / 30
days)
metformin hcl tab sr 24hr
Tier 1
750 mg (generic of
GLUCOPHAGE XR)
QL (60 tabs / 30 days)
nateglinide tab 60 mg
Tier 1
(generic of STARLIX)
QL (90 tabs / 30 days)
nateglinide tab 120 mg
Tier 1
(generic of STARLIX)
QL (90 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
pioglitazone hcl tab 15 mg Tier 1
(base equiv) (generic of
ACTOS)
QL (30 tabs / 30 days)
pioglitazone hcl tab 30 mg Tier 1
(base equiv) (generic of
ACTOS)
QL (30 tabs / 30 days)
pioglitazone hcl tab 45 mg Tier 1
(base equiv) (generic of
ACTOS)
QL (30 tabs / 30 days)
repaglinide tab 0.5 mg
Tier 1
(generic of PRANDIN)
QL (120 tabs / 30
days)
repaglinide tab 1 mg
Tier 1
(generic of PRANDIN)
QL (120 tabs / 30
days)
repaglinide tab 2 mg
Tier 1
(generic of PRANDIN)
QL (240 tabs / 30
days)
RIOMET SOL
Tier 4
QL (946 mL / 30 days)
TRADJENTA TAB 5MG
Tier 3
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
BISPHOSPHONATES
alendronate sodium tab 5 Tier 2
mg
alendronate sodium tab 10 Tier 2
mg
alendronate sodium tab 35 Tier 2
mg
QL (4 tabs / 28 days)
alendronate sodium tab 40 Tier 2
mg
alendronate sodium tab 70 Tier 2
mg (generic of FOSAMAX)
QL (4 tabs / 28 days)
ibandronate sodium tab 150 Tier 4
mg (base equivalent)
(generic of BONIVA)
QL (1 tab / 30 days)
pamidronate disodium iv
Tier 3
soln 3 mg/ml
pamidronate disodium iv
Tier 3
soln 9 mg/ml
QL
QL
B/D QL
B/D
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
53
Drug Name
Drug Requirements/
Tier
Limits
pamidronate inj 6mg/ml
Tier 3
zoledronic acid inj conc for ivTier 5
infusion 4 mg/5ml (generic of
ZOMETA)
ZOMETA INJ 4MG/100
Tier 5
B/D
B/D NM
B/D NM
CALCIUM RECEPTOR AGONISTS
SENSIPAR TAB 30MG
Tier 3
QL (120 tabs / 30
days)
SENSIPAR TAB 60MG
Tier 5
QL (60 tabs / 30 days)
SENSIPAR TAB 90MG
Tier 5
QL (120 tabs / 30
days)
QL NM
QL NM
QL NM
CHELATING AGENTS
CHEMET CAP 100MG
Tier 4
DEPEN TITRA TAB 250MG Tier 5
EXJADE TAB 125MG
Tier 5
EXJADE TAB 250MG
Tier 5
EXJADE TAB 500MG
Tier 5
sodium polystyrene
Tier 3
sulfonate oral susp 15
gm/60ml
sodium polystyrene
Tier 4
sulfonate powder (generic of
KAYEXALATE)
SYPRINE CAP 250MG
Tier 5
CONTRACEPTIVES
NM LA PA
NM LA PA
NM LA PA
Drug Name
Drug Requirements/
Tier
Limits
delyla tab 0.1-0.02
Tier 3
desogest-eth estrad & eth Tier 3
estrad tab 0.15-0.02/0.01
mg(21/5) (generic of
MIRCETTE)
drospirenone-ethinyl
Tier 3
estradiol tab 3-0.02 mg
(generic of YAZ)
DROSPIRENONE-ETHINY Tier 3
L ESTRADIOL TAB 3-0.02
MG
drospirenone-ethinyl
Tier 3
estradiol tab 3-0.03 mg
(generic of YASMIN 28)
DROSPIRENONE-ETHINY Tier 3
L ESTRADIOL TAB 3-0.03
MG
ELLA TAB 30MG
Tier 3
emoquette tab (generic of Tier 3
DESOGEN)
enpresse-28 tab
Tier 2
errin tab 0.35mg (generic of Tier 3
ORTHO MICRONOR)
falmina tab
Tier 3
gildagia tab 0.4-35 (generic Tier 3
of OVCON-35)
gildess tab 1.5/30 (generic ofTier 3
LOESTRIN 1.5/30-21)
introvale tab
Tier 3
JOLIVETTE TAB 0.35MG Tier 3
junel 1.5/30 tab (generic of Tier 3
LOESTRIN 1.5/30-21)
junel 1/20 tab (generic of
Tier 3
LOESTRIN 1/20-21)
junel fe tab 1.5/30 (generic Tier 2
of LOESTRIN FE 1.5/30)
junel fe tab 1/20 (generic of Tier 2
LOESTRIN FE 1/20)
kariva tab 28 day (generic of Tier 3
MIRCETTE)
larin fe tab 1.5/30 (generic ofTier 2
LOESTRIN FE 1.5/30)
larin fe tab 1/20 (generic of Tier 2
LOESTRIN FE 1/20)
larin tab 1.5/30 (generic of Tier 3
LOESTRIN 1.5/30-21)
larin tab 1/20 (generic of
Tier 3
LOESTRIN 1/20-21)
altavera tab
Tier 3
apri tab (generic of
Tier 3
DESOGEN)
aranelle tab (generic of
Tier 3
TRI-NORINYL 28)
aubra tab 0.1-0.02
Tier 3
aviane tab
Tier 3
balziva tab (generic of
Tier 3
OVCON-35)
briellyn tab (generic of
Tier 3
OVCON-35)
camila tab 0.35mg (generic Tier 3
of NOR-QD)
cryselle-28 tab 28 tabs
Tier 3
cyclafem tab 1/35 (generic ofTier 3
NORINYL 1+35)
cyclafem tab 7/7/7 (generic Tier 3
of ORTHO-NOVUM 7/7/7)
deblitane tab 0.35mg
Tier 3
(generic of NOR-QD)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
54
Drug Name
Drug Requirements/
Tier
Limits
lessina tab
Tier 3
levonest tab
Tier 2
levonorgestrel & ethinyl
Tier 3
estradiol (91-day) tab
0.15-0.03 mg
LEVONORGESTREL &
Tier 3
ETHINYL ESTRADIOL
(91-DAY) TAB 0.15-0.03 MG
levonorgestrel & ethinyl
Tier 3
estradiol tab 0.1 mg-20 mcg
levonorgestrel tab 0.75 mg Tier 3
levonorgestrel tab 1.5 mg Tier 3
(generic of PLAN B
ONE-STEP)
levora-28 tab 0.15/30
Tier 3
loryna tab 3-0.02mg (genericTier 3
of YAZ)
low-ogestrel tab
Tier 3
lutera tab
Tier 3
lyza tab 0.35mg (generic of Tier 3
ORTHO MICRONOR)
marlissa tab 0.15/30
Tier 3
medroxyprogesterone
Tier 2
acetate im susp 150 mg/ml
(generic of
DEPO-PROVERA
CONTRACEPTIV)
microgestin tab 1.5/30
Tier 3
(generic of LOESTRIN
1.5/30-21)
microgestin tab 1/20
Tier 3
(generic of LOESTRIN
1/20-21)
microgestin tab fe1.5/30
Tier 2
(generic of LOESTRIN FE
1.5/30)
microgestin tab fe 1/20
Tier 2
(generic of LOESTRIN FE
1/20)
MONONESSA TAB
Tier 3
my way tab 1.5mg (generic Tier 3
of PLAN B ONE-STEP)
myzilra tab
Tier 2
necon tab 0.5/35 (generic of Tier 3
BREVICON-28)
necon tab 1/35 (generic of Tier 3
NORINYL 1+35)
NECON TAB 1/50-28
Tier 3
Drug Name
Drug Requirements/
Tier
Limits
NECON TAB 7/7/7
Tier 3
necon tab 10/11-28
Tier 3
nikki tab 3-0.02mg (generic Tier 3
of YAZ)
norelgestromin-ethinyl
Tier 4
estradiol td ptwk 150-35
mcg/24hr (generic of
ORTHO EVRA)
norethindrone ace & ethinyl Tier 2
estradiol-fe tab 1 mg-20 mcg
(generic of LOESTRIN FE
1/20)
norethindrone tab 0.35 mg Tier 3
(generic of NOR-QD)
NORETHINDRONE TAB
Tier 3
0.35 MG
NORETHINDRONE-ETH Tier 3
ESTRADIOL TAB
0.5-35/1-35/0.5-35
MG-MCG
norgestimate-eth estrad tab Tier 2
0.18-35/0.215-35/0.25-35
mg-mcg (generic of ORTHO
TRI-CYCLEN)
norlyroc tab 0.35mg (genericTier 3
of NOR-QD)
nortrel tab 0.5/35 (generic of Tier 3
BREVICON-28)
nortrel tab 1/35 (generic of Tier 3
NORINYL 1+35)
nortrel tab 7/7/7 (generic of Tier 3
ORTHO-NOVUM 7/7/7)
NUVARING MIS
Tier 4
orsythia tab
Tier 3
philith tab 0.4-35 (generic of Tier 3
OVCON-35)
pimtrea tab (generic of
Tier 3
MIRCETTE)
pirmella tab 1/35 (generic of Tier 3
NORINYL 1+35)
portia-28 tab
Tier 3
previfem tab (generic of
Tier 3
ORTHO-CYCLEN)
quasense tab
Tier 3
reclipsen tab (generic of
Tier 3
DESOGEN)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
55
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
sharobel tab 0.35mg
(generic of ORTHO
MICRONOR)
SOLIA TAB
sprintec 28 tab 28 day
(generic of
ORTHO-CYCLEN)
tri-legest tab fe (generic of
ESTROSTEP FE)
tri-previfem tab (generic of
ORTHO TRI-CYCLEN)
tri-sprintec tab (generic of
ORTHO TRI-CYCLEN)
TRINESSA TAB
trivora-28 tab
velivet pak (generic of
CYCLESSA)
viorele tab (generic of
MIRCETTE)
vyfemla tab 0.4-35 (generic
of OVCON-35)
zenchent tab (generic of
OVCON-35)
Tier 3
levocarnitine oral soln 1
gm/10ml (10%) (generic of
CARNITOR)
levocarnitine tab 330 mg
(generic of CARNITOR)
LUMIZYME INJ 50MG
MYOZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ORFADIN CAP 10MG
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(generic of BUPHENYL)
ZAVESCA CAP 100MG
Tier 3
B/D
Tier 3
B/D
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
NM PA
NM PA
NM LA PA
NM PA
NM PA
NM PA
NM
Tier 5
NM LA PA
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
ESTROGENS
Tier 3
Tier 3
Tier 3
ENDOMETRIOSIS
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
SYNAREL SOL 2MG/ML
Tier 4
Tier 4
Tier 4
Tier 5
ENZYME REPLACEMENTS
ADAGEN INJ 250/ML
ALDURAZYME INJ
2.9MG/5M
CARBAGLU TAB 200MG
CERDELGA CAP 84MG
CEREZYME INJ 200UNIT
CEREZYME INJ 400UNIT
CYSTADANE POW
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
FABRAZYME INJ 5MG
FABRAZYME INJ 35MG
KUVAN POW 100MG
KUVAN TAB 100MG
levocarnitine inj 200 mg/ml
(generic of CARNITOR)
Tier 5
Tier 5
NM LA PA
NM LA PA
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
NM LA PA
NM PA
NM PA
NM PA
NM
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
B/D
COMBIPATCH DIS .05/.14 Tier 4
COMBIPATCH DIS .05/.25 Tier 4
estradiol tab 0.5 mg (genericTier 4
of ESTRACE)
estradiol tab 1 mg (generic Tier 4
of ESTRACE)
estradiol tab 2 mg (generic Tier 4
of ESTRACE)
estradiol td patch weekly 0.1 Tier 4
mg/24hr (generic of
CLIMARA)
estradiol td patch weekly
Tier 4
0.05 mg/24hr (generic of
CLIMARA)
estradiol td patch weekly
Tier 4
0.06 mg/24hr (generic of
CLIMARA)
estradiol td patch weekly
Tier 4
0.025 mg/24hr (generic of
CLIMARA)
estradiol td patch weekly
Tier 4
0.075 mg/24hr (generic of
CLIMARA)
estradiol td patch weekly
Tier 4
0.0375 mg/24hr (37.5
mcg/24hr) (generic of
CLIMARA)
ESTRADIOL VALERATE IM Tier 3
IN OIL 10 MG/ML
estradiol valerate im in oil 20Tier 3
mg/ml (generic of
DELESTROGEN)
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
56
Drug Name
Drug Requirements/
Tier
Limits
ESTRADIOL VALERATE IM Tier 3
IN OIL 40 MG/ML
PREMARIN VAG CRE
Tier 4
0.625MG
VAGIFEM TAB 10MCG
Tier 4
GLUCOCORTICOIDS
a-hydrocort inj 100mg
Tier 2
cortisone acetate tab 25 mg Tier 3
dexamethason con 1mg/ml Tier 3
dexamethasone elixir 0.5
Tier 3
mg/5ml
dexamethasone sod
Tier 2
phosphate preservative free
inj 10 mg/ml
dexamethasone sodium
Tier 2
phosphate inj 10 mg/ml
dexamethasone sodium
Tier 2
phosphate inj 20 mg/5ml
dexamethasone sodium
Tier 2
phosphate inj 100 mg/10ml
dexamethasone sodium
Tier 2
phosphate inj 120 mg/30ml
dexamethasone soln 0.5
Tier 3
mg/5ml
dexamethasone tab 0.5 mg Tier 1
dexamethasone tab 0.75 mgTier 1
dexamethasone tab 1 mg Tier 1
dexamethasone tab 1.5 mg Tier 1
dexamethasone tab 2 mg Tier 1
dexamethasone tab 4 mg Tier 1
dexamethasone tab 6 mg Tier 1
fludrocortisone acetate tab Tier 2
0.1 mg
hydrocortisone tab 5 mg
Tier 3
(generic of CORTEF)
hydrocortisone tab 10 mg Tier 3
(generic of CORTEF)
hydrocortisone tab 20 mg Tier 3
(generic of CORTEF)
methylprednisolone acetate Tier 2
inj susp 40 mg/ml (generic of
DEPO-MEDROL)
methylprednisolone acetate Tier 2
inj susp 80 mg/ml (generic of
DEPO-MEDROL)
B/D
B/D
Drug Name
Drug Requirements/
Tier
Limits
methylprednisolone sodium Tier 3
succinate for inj 40 mg
(generic of SOLU-MEDROL)
methylprednisolone sodium Tier 3
succinate for inj 125 mg
(generic of SOLU-MEDROL)
methylprednisolone sodium Tier 3
succinate for inj 1000 mg
(generic of SOLU-MEDROL)
methylprednisolone tab 4 Tier 3
mg (generic of MEDROL)
methylprednisolone tab 4 Tier 2
mg dose pack (generic of
MEDROL DOSEPAK)
methylprednisolone tab 8 Tier 3
mg (generic of MEDROL)
methylprednisolone tab 16 Tier 3
mg (generic of MEDROL)
methylprednisolone tab 32 Tier 3
mg (generic of MEDROL)
prednisolone sod phosph Tier 3
oral soln 6.7 mg/5ml (5
mg/5ml base) (generic of
PEDIAPRED)
prednisolone sod phosphate Tier 3
oral soln 15 mg/5ml (base
equiv)
prednisolone sodium
Tier 3
phosphate oral soln 25
mg/5ml (base eq)
prednisolone syrup 15
Tier 1
mg/5ml (usp solution
equivalent)
prednisone con 5mg/ml
Tier 3
prednisone oral soln 5
Tier 3
mg/5ml
prednisone tab 1 mg
Tier 1
prednisone tab 2.5 mg
Tier 1
prednisone tab 5 mg
Tier 1
prednisone tab 5 mg dose Tier 1
pack
prednisone tab 10 mg
Tier 1
prednisone tab 10 mg dose Tier 1
pack
prednisone tab 20 mg
Tier 1
prednisone tab 50 mg
Tier 1
SOLU-CORTEF INJ 250MG Tier 3
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
GLUCOSE ELEVATING AGENTS
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
57
Drug Name
Drug Requirements/
Tier
Limits
GLUCAGEN INJ HYPOKIT Tier 3
GLUCAGON KIT 1MG
Tier 3
PROGLYCEM SUS
Tier 4
50MG/ML
HUMAN GROWTH HORMONES
NORDITROPIN INJ 5/1.5MLTier 5
NORDITROPIN INJ
Tier 5
10/1.5ML
NORDITROPIN INJ
Tier 5
15/1.5ML
NORDITROPIN INJ 30/3ML Tier 5
TEV-TROPIN INJ 5MG
Tier 5
NM PA
NM PA
NM PA
NM PA
NM PA
Drug Requirements/
Tier
Limits
SANDOSTATIN KIT LAR Tier 5
30MG
SOMATULINE INJ 60/0.2MLTier 5
SOMATULINE INJ 90/0.3MLTier 5
SOMATULINE INJ 120/.5MLTier 5
SOMAVERT INJ 10MG
Tier 5
SOMAVERT INJ 15MG
Tier 5
SOMAVERT INJ 20MG
Tier 5
SOMAVERT INJ 25MG
Tier 5
SOMAVERT INJ 30MG
Tier 5
XGEVA INJ
Tier 5
NM PA
NM PA
NM PA
NM PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM PA
PARATHYROID HORMONES
FORTEO SOL 600/2.4
QL (1 pen / 28 days)
MISCELLANEOUS
cabergoline tab 0.5 mg
Tier 4
calcitonin (salmon) nasal
Tier 3
soln 200 unit/act (generic of
MIACALCIN)
FORTICAL SPR 200/ACT Tier 3
INCRELEX INJ 40MG/4ML Tier 5
methylergonovine maleate Tier 4
tab 0.2 mg (generic of
METHERGINE)
MIACALCIN INJ 200/ML
Tier 4
octreotide acetate inj 50
Tier 4
mcg/ml (0.05 mg/ml)
(generic of SANDOSTATIN)
octreotide acetate inj 100 Tier 4
mcg/ml (0.1 mg/ml) (generic
of SANDOSTATIN)
octreotide acetate inj 200 Tier 4
mcg/ml (0.2 mg/ml) (generic
of SANDOSTATIN)
octreotide acetate inj 500 Tier 5
mcg/ml (0.5 mg/ml) (generic
of SANDOSTATIN)
octreotide acetate inj 1000 Tier 5
mcg/ml (1 mg/ml) (generic of
SANDOSTATIN)
PROLIA SOL 60MG/ML
Tier 4
QL (1 syringe / 180
days)
raloxifene hcl tab 60 mg
Tier 3
(generic of EVISTA)
SANDOSTATIN KIT LAR Tier 5
10MG
SANDOSTATIN KIT LAR Tier 5
20MG
Drug Name
Tier 5 QL NM PA
PHOSPHATE BINDER AGENTS
NM LA PA
B/D
NM PA
NM PA
NM PA
NM PA
NM PA
calcium acetate (phosphate Tier 4
binder) cap 667 mg (169 mg
ca) (generic of PHOSLO)
FOSRENOL CHW 500MG Tier 5
FOSRENOL CHW 750MG Tier 5
FOSRENOL CHW 1000MG Tier 5
PHOSLYRA SOL
Tier 3
RENVELA PAK 0.8GM
Tier 5
RENVELA PAK 2.4GM
Tier 5
RENVELA TAB 800MG
Tier 3
PROGESTINS
medroxyprogesterone
Tier 1
acetate tab 2.5 mg (generic
of PROVERA)
medroxyprogesterone
Tier 1
acetate tab 5 mg (generic of
PROVERA)
medroxyprogesterone
Tier 1
acetate tab 10 mg (generic
of PROVERA)
norethindrone acetate tab 5 Tier 3
mg (generic of AYGESTIN)
QL NM
THYROID AGENTS
NM PA
levothyroxine sodium tab 25 Tier 1
mcg (generic of
SYNTHROID)
levothyroxine sodium tab 50 Tier 1
mcg (generic of
SYNTHROID)
levothyroxine sodium tab 75 Tier 1
mcg (generic of
SYNTHROID)
NM PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
58
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
levothyroxine sodium tab 88 Tier 1
propylthiouracil tab 50 mg Tier 3
mcg (generic of
SYNTHROID TAB 25MCG Tier 4
SYNTHROID)
SYNTHROID TAB 50MCG Tier 4
levothyroxine sodium tab
Tier 1
SYNTHROID TAB 75MCG Tier 4
100 mcg (generic of
SYNTHROID TAB 88MCG Tier 4
SYNTHROID)
SYNTHROID TAB 100MCG Tier 4
levothyroxine sodium tab
Tier 1
SYNTHROID TAB 112MCG Tier 4
112 mcg (generic of
SYNTHROID TAB 125MCG Tier 4
SYNTHROID)
levothyroxine sodium tab
Tier 1
SYNTHROID TAB 137MCG Tier 4
125 mcg (generic of
SYNTHROID TAB 150MCG Tier 4
SYNTHROID)
SYNTHROID TAB 175MCG Tier 4
levothyroxine sodium tab
Tier 1
SYNTHROID TAB 200MCG Tier 4
137 mcg (generic of
SYNTHROID TAB 300MCG Tier 4
SYNTHROID)
UNITHROID TAB 25MCG Tier 2
levothyroxine sodium tab
Tier 1
UNITHROID TAB 50MCG Tier 2
150 mcg (generic of
UNITHROID TAB 75MCG Tier 2
SYNTHROID)
levothyroxine sodium tab
Tier 1
UNITHROID TAB 88MCG Tier 2
175 mcg (generic of
UNITHROID TAB 100MCG Tier 2
SYNTHROID)
UNITHROID TAB 112MCG Tier 2
levothyroxine sodium tab
Tier 1
UNITHROID TAB 125MCG Tier 2
200 mcg (generic of
UNITHROID TAB 150MCG Tier 2
SYNTHROID)
UNITHROID TAB 175MCG Tier 2
levothyroxine sodium tab
Tier 1
UNITHROID TAB 200MCG Tier 2
300 mcg (generic of
UNITHROID TAB 300MCG Tier 2
SYNTHROID)
LEVOXYL TAB 25MCG
Tier 2
VASOPRESSINS
LEVOXYL TAB 50MCG
Tier 2
desmopressin acetate inj 4 Tier 4
mcg/ml (generic of DDAVP)
LEVOXYL TAB 75MCG
Tier 2
DESMOPRESSIN
Tier 4
LEVOXYL TAB 88MCG
Tier 2
ACETATE NASAL SOLN
LEVOXYL TAB 100MCG
Tier 2
0.01% (REFRIGERATED)
LEVOXYL TAB 112MCG
Tier 2
desmopressin acetate nasal Tier 4
LEVOXYL TAB 125MCG
Tier 2
spray soln 0.01% (generic of
LEVOXYL TAB 137MCG
Tier 2
DDAVP)
LEVOXYL TAB 150MCG
Tier 2
desmopressin acetate nasal Tier 4
LEVOXYL TAB 175MCG
Tier 2
spray soln 0.01%
(refrigerated)
LEVOXYL TAB 200MCG
Tier 2
desmopressin acetate tab Tier 3
liothyronine sodium tab 5
Tier 3
0.1 mg (generic of DDAVP)
mcg (generic of CYTOMEL)
desmopressin acetate tab Tier 3
liothyronine sodium tab 25 Tier 3
0.2 mg (generic of DDAVP)
mcg (generic of CYTOMEL)
GASTROINTESTINAL
liothyronine sodium tab 50 Tier 3
ANTIEMETICS
mcg (generic of CYTOMEL)
dronabinol cap 2.5 mg
Tier 4
B/D QL
methimazole tab 5 mg
Tier 1
(generic of MARINOL)
(generic of TAPAZOLE)
QL (60 caps / 30 days)
methimazole tab 10 mg
Tier 1
(generic of TAPAZOLE)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
59
Drug Name
Drug Requirements/
Tier
Limits
dronabinol cap 5 mg
Tier 4
(generic of MARINOL)
QL (60 caps / 30 days)
dronabinol cap 10 mg
Tier 5
(generic of MARINOL)
QL (60 caps / 30 days)
EMEND CAP 40MG
Tier 4
EMEND CAP 80MG
Tier 4
EMEND CAP 125MG
Tier 4
EMEND PAK 80 & 125
Tier 4
granisetron hcl inj 0.1 mg/ml Tier 4
granisetron hcl inj 1 mg/ml Tier 4
granisetron hcl inj 4 mg/4ml Tier 4
(1 mg/ml)
granisetron hcl tab 1 mg
Tier 4
meclizine hcl tab 12.5 mg Tier 2
meclizine hcl tab 25 mg
Tier 2
metoclopramide hcl inj 5
Tier 2
mg/ml
metoclopramide hcl soln 5 Tier 1
mg/5ml (10 mg/10ml)
metoclopramide hcl tab 5 mgTier 1
(generic of REGLAN)
metoclopramide hcl tab 10 Tier 1
mg (generic of REGLAN)
ondansetron hcl inj 4 mg/2mlTier 4
(2 mg/ml)
ondansetron hcl inj 40
Tier 4
mg/20ml (2 mg/ml) (generic
of ZOFRAN)
ondansetron hcl oral soln 4 Tier 4
mg/5ml (generic of
ZOFRAN)
ondansetron hcl tab 4 mg Tier 3
(generic of ZOFRAN)
ondansetron hcl tab 8 mg Tier 3
(generic of ZOFRAN)
ondansetron hcl tab 24 mg Tier 3
ondansetron orally
Tier 3
disintegrating tab 4 mg
(generic of ZOFRAN ODT)
ondansetron orally
Tier 3
disintegrating tab 8 mg
(generic of ZOFRAN ODT)
prochlorperazine edisylate Tier 3
inj 5 mg/ml
B/D QL
B/D QL
B/D
B/D
B/D
B/D
B/D
Drug Name
Drug Requirements/
Tier
Limits
prochlorperazine maleate Tier 1
tab 5 mg (base equivalent)
(generic of COMPAZINE)
prochlorperazine maleate Tier 1
tab 10 mg (base equivalent)
(generic of COMPAZINE)
prochlorperazine suppos 25 Tier 4
mg
promethazine hcl inj 25
Tier 4
mg/ml (generic of
PHENERGAN)
promethazine hcl inj 50
Tier 4
mg/ml (generic of
PHENERGAN)
TRANSDERM-SC DIS 1MG Tier 4
QL (10 patches / 30
days)
PA
PA
QL PA
ANTISPASMODICS
B/D
B/D
B/D
B/D
B/D
B/D
CUVPOSA SOL 1MG/5ML Tier 4
dicyclomine hcl cap 10 mg Tier 1
(generic of BENTYL)
dicyclomine hcl oral soln 10 Tier 3
mg/5ml
dicyclomine hcl tab 20 mg Tier 1
(generic of BENTYL)
glycopyrrolate inj 4 mg/20ml Tier 3
(0.2 mg/ml) (generic of
ROBINUL)
glycopyrrolate tab 1 mg
Tier 3
(generic of ROBINUL)
glycopyrrolate tab 2 mg
Tier 3
(generic of ROBINUL
FORTE)
H2-RECEPTOR ANTAGONISTS
famotidine for susp 40
Tier 4
mg/5ml (generic of PEPCID)
famotidine in nacl 0.9% iv Tier 2
soln 20 mg/50ml
famotidine inj 20 mg/2ml
Tier 2
famotidine inj 40 mg/4ml
Tier 2
famotidine inj 200 mg/20ml Tier 2
famotidine tab 20 mg
Tier 1
(generic of PEPCID)
famotidine tab 40 mg
Tier 1
(generic of PEPCID)
ranitidine hcl inj 50 mg/2ml Tier 2
(25 mg/ml) (generic of
ZANTAC)
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
60
Drug Name
Drug Requirements/
Tier
Limits
ranitidine hcl inj 150 mg/6ml Tier 2
(25 mg/ml) (generic of
ZANTAC)
ranitidine hcl syrup 15 mg/mlTier 3
(75 mg/5ml)
ranitidine hcl tab 150 mg
Tier 1
(generic of ZANTAC)
ranitidine hcl tab 300 mg
Tier 1
(generic of ZANTAC)
INFLAMMATORY BOWEL DISEASE
APRISO CAP 0.375GM
ASACOL HD TAB 800MG
balsalazide disodium cap
750 mg (generic of
COLAZAL)
budesonide cap sr 24hr 3
mg (generic of ENTOCORT
EC)
CANASA SUP 1000MG
DELZICOL CAP 400MG
DIPENTUM CAP 250MG
hydrocortisone enema 100
mg/60ml (generic of
CORTENEMA)
HYDROCORTISONE
ENEMA 100 MG/60ML
LIALDA TAB 1.2GM
mesalamine enema 4 gm
mesalamine rectal enema 4
gm & cleanser wipe kit
(generic of ROWASA)
PENTASA CAP 250MG CR
PENTASA CAP 500MG CR
sulfasalazine tab 500 mg
(generic of AZULFIDINE)
sulfazine ec tab 500mg
(generic of AZULFIDINE
EN-TABS)
UCERIS TAB 9MG
Tier 3
Tier 4
Tier 3
Tier 5
Tier 4
Tier 4
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Tier 3
Drug Requirements/
Tier
Limits
gavilyte-n sol flav pk
Tier 2
(generic of
NULYTELY/FLAVOR
PACKS)
generlac sol 10gm/15
Tier 2
GOLYTELY SOL
Tier 3
lactulose (encephalopathy) Tier 2
solution 10 gm/15ml
lactulose solution 10
Tier 2
gm/15ml
MOVIPREP SOL
Tier 4
NULYTELY SOL FLAV PKS Tier 3
peg 3350-kcl-na
Tier 2
bicarb-nacl-na sulfate for
soln 236 gm (generic of
GOLYTELY)
PEG 3350-KCL-NA
Tier 2
BICARB-NACL-NA
SULFATE FOR SOLN 240
GM
peg 3350-kcl-sod
Tier 2
bicarb-nacl for soln 420 gm
(generic of
NULYTELY/FLAVOR
PACKS)
polyethylene glycol 3350
Tier 3
oral packet
polyethylene glycol 3350
Tier 3
oral powder
RELISTOR INJ 8/0.4ML
Tier 4
RELISTOR INJ 12/0.6ML Tier 4
RELISTOR KIT 12/0.6ML Tier 4
SUPREP BOWEL SOL
Tier 4
PREP
trilyte sol (generic of
Tier 2
NULYTELY/FLAVOR
PACKS)
PA
PA
PA
MISCELLANEOUS
Tier 5
LAXATIVES
constulose sol 10gm/15
enulose sol 10gm/15
gavilyte-c sol (generic of
COLYTE-FLAVOR PACKS)
gavilyte-g sol (generic of
GOLYTELY)
Drug Name
Tier 2
Tier 2
Tier 2
Tier 2
AMITIZA CAP 8MCG
Tier 3
QL (60 caps / 30 days)
AMITIZA CAP 24MCG
Tier 3
QL (60 caps / 30 days)
cromolyn sodium oral conc Tier 5
100 mg/5ml (generic of
GASTROCROM)
diphenoxylate w/ atropine liq Tier 3
2.5-0.025 mg/5ml
QL
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
61
Drug Name
Drug Requirements/
Tier
Limits
diphenoxylate w/ atropine Tier 2
tab 2.5-0.025 mg (generic of
LOMOTIL)
LINZESS CAP 145MCG
Tier 3
QL (60 caps / 30 days)
LINZESS CAP 290MCG
Tier 3
QL (30 caps / 30 days)
loperamide hcl cap 2 mg
Tier 2
LOTRONEX TAB 0.5MG
Tier 5
LOTRONEX TAB 1MG
Tier 5
misoprostol tab 100 mcg
Tier 3
(generic of CYTOTEC)
misoprostol tab 200 mcg
Tier 3
(generic of CYTOTEC)
MOVANTIK TAB 12.5MG Tier 3
QL (60 tabs / 30 days)
MOVANTIK TAB 25MG
Tier 3
QL (30 tabs / 30 days)
SUCRAID SOL 8500/ML
Tier 5
sucralfate tab 1 gm (generic Tier 3
of CARAFATE)
ursodiol cap 300 mg
Tier 3
(generic of ACTIGALL)
ursodiol tab 250 mg (genericTier 4
of URSO 250)
ursodiol tab 500 mg (genericTier 4
of URSO FORTE)
XIFAXAN TAB 550MG
Tier 5
QL
QL
PA
PA
QL
QL
PA
PANCREATIC ENZYMES
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 40000UNT
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Drug Requirements/
Tier
Limits
esomeprazole sodium for Tier 4
intravenous soln 20 mg
(base equiv)
esomeprazole sodium for Tier 4
intravenous soln 40 mg
(base equiv) (generic of
NEXIUM I.V.)
NEXIUM CAP 20MG
Tier 3
QL (30 caps / 30 days)
NEXIUM CAP 40MG
Tier 3
QL (30 caps / 30 days)
NEXIUM GRA 2.5MG DR Tier 3
NEXIUM GRA 5MG DR
Tier 3
NEXIUM GRA 10MG DR
Tier 3
QL (30 packets / 30
days)
NEXIUM GRA 20MG DR
Tier 3
QL (30 packets / 30
days)
NEXIUM GRA 40MG DR
Tier 3
QL (30 packets / 30
days)
omeprazole cap delayed
Tier 2
release 10 mg (generic of
PRILOSEC)
QL (30 caps / 30 days)
omeprazole cap delayed
Tier 2
release 20 mg (generic of
PRILOSEC)
QL (60 caps / 30 days)
omeprazole cap delayed
Tier 2
release 40 mg (generic of
PRILOSEC)
QL (30 caps / 30 days)
pantoprazole sodium ec tab Tier 3
20 mg (base equiv) (generic
of PROTONIX)
QL (30 tabs / 30 days)
pantoprazole sodium ec tab Tier 3
40 mg (base equiv) (generic
of PROTONIX)
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
PROTON PUMP INHIBITORS
DEXILANT CAP 30MG DR Tier 3
QL (30 caps / 30 days)
DEXILANT CAP 60MG DR Tier 3
QL (30 caps / 30 days)
Drug Name
QL
QL
alfuzosin hcl tab sr 24hr 10 Tier 3
mg (generic of
UROXATRAL)
QL (30 tabs / 30 days)
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
62
Drug Name
Drug Requirements/
Tier
Limits
AVODART CAP 0.5MG
Tier 3
QL (30 caps / 30 days)
finasteride tab 5 mg (genericTier 2
of PROSCAR)
JALYN CAP
Tier 3
QL (30 caps / 30 days)
tamsulosin hcl cap 0.4 mg Tier 2
(generic of FLOMAX)
QL (60 caps / 30 days)
QL
QL
QL
MISCELLANEOUS
bethanechol chloride tab 5 Tier 3
mg (generic of
URECHOLINE)
bethanechol chloride tab 10 Tier 3
mg (generic of
URECHOLINE)
bethanechol chloride tab 25 Tier 3
mg (generic of
URECHOLINE)
bethanechol chloride tab 50 Tier 3
mg (generic of
URECHOLINE)
ELMIRON CAP 100MG
Tier 4
POTASSIUM CITRATE TABTier 4
CR 5 MEQ (540 MG)
POTASSIUM CITRATE TABTier 4
CR 10 MEQ (1080 MG)
Drug Requirements/
Tier
Limits
TOLTERODINE TARTRATETier 4
CAP SR 24HR 2 MG
QL (30 caps / 30 days)
TOLTERODINE TARTRATETier 4
CAP SR 24HR 4 MG
QL (30 caps / 30 days)
tolterodine tartrate tab 1 mg Tier 4
(generic of DETROL)
tolterodine tartrate tab 2 mg Tier 4
(generic of DETROL)
TOVIAZ TAB 4MG
Tier 3
QL (30 tabs / 30 days)
TOVIAZ TAB 8MG
Tier 3
QL (30 tabs / 30 days)
trospium chloride tab 20 mg Tier 4
QL (60 tabs / 30 days)
VESICARE TAB 5MG
Tier 4
QL (30 tabs / 30 days)
VESICARE TAB 10MG
Tier 4
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
VAGINAL ANTI-INFECTIVES
URINARY ANTISPASMODICS
MYRBETRIQ TAB 25MG Tier 4
QL (60 tabs / 30 days)
MYRBETRIQ TAB 50MG Tier 4
QL (30 tabs / 30 days)
oxybutynin chloride syrup 5 Tier 1
mg/5ml
oxybutynin chloride tab 5 mgTier 3
oxybutynin chloride tab sr Tier 3
24hr 5 mg (generic of
DITROPAN XL)
QL (30 tabs / 30 days)
oxybutynin chloride tab sr Tier 3
24hr 10 mg (generic of
DITROPAN XL)
QL (60 tabs / 30 days)
oxybutynin chloride tab sr Tier 3
24hr 15 mg (generic of
DITROPAN XL)
QL (60 tabs / 30 days)
Drug Name
QL
QL
QL
QL
clindamycin phosphate
vaginal cream 2% (generic
of CLEOCIN)
metronidazole vaginal gel
0.75% (generic of
METROGEL-VAGINAL)
terconazole vaginal cream
0.4% (generic of TERAZOL
7)
terconazole vaginal cream
0.8% (generic of TERAZOL
3)
terconazole vaginal suppos
80 mg
VANDAZOLE GEL 0.75%
zazole cre 0.4% (generic of
TERAZOL 7)
ZAZOLE CRE 0.8%
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN TAB 1MG
Tier 4
COUMADIN TAB 2.5MG
Tier 4
QL
COUMADIN TAB 2MG
Tier 4
COUMADIN TAB 3MG
Tier 4
COUMADIN TAB 4MG
Tier 4
COUMADIN TAB 5MG
Tier 4
COUMADIN TAB 6MG
Tier 4
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
63
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
COUMADIN TAB 7.5MG
Tier 4
HEPARIN SOD INJ
Tier 3
B/D
2500/ML
COUMADIN TAB 10MG
Tier 4
HEPARIN SODIUM
Tier 3
ELIQUIS TAB 2.5MG
Tier 3
(PORCINE) 40 UNIT/ML IN
ELIQUIS TAB 5MG
Tier 3
D5W
enoxaparin sodium inj 30
Tier 4
heparin sodium (porcine) inj Tier 3
B/D
mg/0.3ml (generic of
1000 unit/ml
LOVENOX)
heparin sodium (porcine) inj Tier 3
B/D
enoxaparin sodium inj 40
Tier 4
5000 unit/ml
mg/0.4ml (generic of
heparin sodium (porcine) inj Tier 3
B/D
LOVENOX)
10000 unit/ml
enoxaparin sodium inj 60
Tier 4
heparin sodium (porcine) inj Tier 3
B/D
mg/0.6ml (generic of
20000
unit/ml
LOVENOX)
jantoven tab 1mg (generic ofTier 1
enoxaparin sodium inj 80
Tier 4
COUMADIN)
mg/0.8ml (generic of
jantoven tab 2.5mg (generic Tier 1
LOVENOX)
of COUMADIN)
enoxaparin sodium inj 100 Tier 5
jantoven tab 2mg (generic ofTier 1
mg/ml (generic of
COUMADIN)
LOVENOX)
jantoven tab 3mg (generic ofTier 1
enoxaparin sodium inj 120 Tier 5
COUMADIN)
mg/0.8ml (generic of
jantoven tab 4mg (generic ofTier 1
LOVENOX)
COUMADIN)
enoxaparin sodium inj 150 Tier 5
jantoven tab 5mg (generic ofTier 1
mg/ml (generic of
COUMADIN)
LOVENOX)
jantoven tab 6mg (generic ofTier 1
enoxaparin sodium inj 300 Tier 4
COUMADIN)
mg/3ml (generic of
jantoven tab 7.5mg (generic Tier 1
LOVENOX)
of COUMADIN)
fondaparinux sodium
Tier 4
jantoven tab 10mg (generic Tier 1
subcutaneous inj 2.5
of COUMADIN)
mg/0.5ml (generic of
PRADAXA CAP 75MG
Tier 3
ARIXTRA)
PRADAXA
CAP
150MG
Tier 3
fondaparinux sodium
Tier 5
subcutaneous inj 5 mg/0.4ml
warfarin sodium tab 1 mg Tier 1
(generic of ARIXTRA)
(generic of COUMADIN)
fondaparinux sodium
Tier 5
warfarin sodium tab 2 mg Tier 1
subcutaneous inj 7.5
(generic of COUMADIN)
mg/0.6ml (generic of
warfarin sodium tab 2.5 mg Tier 1
ARIXTRA)
(generic of COUMADIN)
fondaparinux sodium
Tier 5
warfarin sodium tab 3 mg Tier 1
subcutaneous inj 10
(generic of COUMADIN)
mg/0.8ml (generic of
warfarin sodium tab 4 mg Tier 1
ARIXTRA)
(generic of COUMADIN)
HEP SOD/D5W INJ
Tier 3
warfarin sodium tab 5 mg Tier 1
25000UNT
(generic of COUMADIN)
HEP SOD/NACL INJ
Tier 3
warfarin sodium tab 6 mg Tier 1
25000UNT
(generic of COUMADIN)
HEPARIN SOD INJ
Tier 3
B/D
2000/ML
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
64
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
warfarin sodium tab 7.5 mg
(generic of COUMADIN)
warfarin sodium tab 10 mg
(generic of COUMADIN)
XARELTO STAR TAB
15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
Tier 1
tranexamic acid inj 100
Tier 3
mg/ml (generic of
CYKLOKAPRON)
tranexamic acid tab 650 mg Tier 4
(generic of LYSTEDA)
Tier 1
Tier 3
PLATELET AGGREGATION INHIBITORS
Tier 3
Tier 3
Tier 3
HEMATOPOIETIC GROWTH FACTORS
GRANIX INJ 300/0.5
GRANIX INJ 480/0.8
LEUKINE INJ 250MCG
MOZOBIL INJ
NEUMEGA INJ 5MG
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 40000/ML
Drug Requirements/
Tier
Limits
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 3
Tier 3
Tier 3
Tier 5
Tier 5
NM PA
NM PA
NM PA
NM PA
NM
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
MISCELLANEOUS
anagrelide hcl cap 0.5 mg Tier 4
(generic of AGRYLIN)
anagrelide hcl cap 1 mg
Tier 4
cilostazol tab 50 mg (genericTier 3
of PLETAL)
cilostazol tab 100 mg
Tier 3
(generic of PLETAL)
CINRYZE SOL 500 UNIT Tier 5 NM LA PA
FIRAZYR INJ 30MG/3ML Tier 5
NM PA
pentoxifylline tab cr 400 mg Tier 3
PROMACTA TAB 12.5MG Tier 5 QL NM LA PA
QL (360 tabs / 30
days)
PROMACTA TAB 25MG
Tier 5 QL NM LA PA
QL (180 tabs / 30
days)
PROMACTA TAB 50MG
Tier 5 QL NM LA PA
QL (90 tabs / 30 days)
PROMACTA TAB 75MG
Tier 5 QL NM LA PA
QL (60 tabs / 30 days)
AGGRENOX CAP
Tier 4
25-200MG
BRILINTA TAB 90MG
Tier 3
clopidogrel bisulfate tab 75 Tier 3
mg (base equiv) (generic of
PLAVIX)
QL (30 tabs / 30 days)
EFFIENT TAB 5MG
Tier 4
EFFIENT TAB 10MG
Tier 4
ZONTIVITY TAB 2.08MG Tier 4
QL
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDS)
CIMZIA KIT
Tier 5
CIMZIA KIT STARTER
Tier 5
CIMZIA PREFL KIT
Tier 5
200MG/ML
HUMIRA INJ 10MG/0.2
Tier 5
HUMIRA INJ 40MG/0.8
Tier 5
HUMIRA KIT 20MG/0.4
Tier 5
HUMIRA PEN INJ 40MG/0.8Tier 5
HUMIRA PEN INJ CROHNSTier 5
HUMIRA PEN INJ
Tier 5
PSORIASI
hydroxychloroquine sulfate Tier 2
tab 200 mg
leflunomide tab 10 mg
Tier 3
(generic of ARAVA)
leflunomide tab 20 mg
Tier 3
(generic of ARAVA)
methotrexate sodium tab 2.5Tier 3
mg (base equiv)
REMICADE INJ 100MG
Tier 5
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
IMMUNOGLOBULINS
BIVIGAM INJ 10%
CARIMUNE NF INJ 3GM
CARIMUNE NF INJ 6GM
CARIMUNE NF INJ 12GM
FLEBOGAMMA INJ 5%
FLEBOGAMMA INJ
10/200ML
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
65
Drug Name
Drug Requirements/
Tier
Limits
FLEBOGAMMA INJ
Tier 5
20/400ML
FLEBOGAMMA INJ DIF 5% Tier 5
FLEBOGAMMA INJ DIF
Tier 5
10%
GAMASTAN S/D INJ
Tier 3
GAMMAGARD INJ
Tier 5
1GM/10ML
GAMMAGARD INJ
Tier 5
2.5GM/25
GAMMAGARD INJ
Tier 5
5GM/50ML
GAMMAGARD INJ
Tier 5
10GM/100
GAMMAGARD INJ
Tier 5
20GM/200
GAMMAGARD INJ
Tier 5
30GM/300
GAMMAGARD SD INJ
Tier 5
2.5GM HU
GAMMAGARD SD INJ 5GM Tier 5
HU
GAMMAGARD SD INJ
Tier 5
10GM HU
GAMMAKED INJ
Tier 5
1GM/10ML
GAMMAKED INJ 2.5GM/25 Tier 5
GAMMAKED INJ
Tier 5
5GM/50ML
GAMMAKED INJ 10GM/100 Tier 5
GAMMAKED INJ 20GM/200 Tier 5
GAMMAPLEX INJ 2.5GM Tier 5
GAMMAPLEX INJ 5GM
Tier 5
GAMMAPLEX INJ 10GM
Tier 5
GAMUNEX-C INJ
Tier 5
1GM/10ML
GAMUNEX-C INJ 2.5GM/25 Tier 5
GAMUNEX-C INJ
Tier 5
5GM/50ML
GAMUNEX-C INJ
Tier 5
10GM/100
GAMUNEX-C INJ
Tier 5
20GM/200
GAMUNEX-C INJ 40/400ML Tier 5
OCTAGAM INJ 1GM
Tier 5
OCTAGAM INJ 2.5GM
Tier 5
OCTAGAM INJ 2GM/20ML Tier 5
OCTAGAM INJ 5GM
Tier 5
NM PA
NM PA
NM PA
B/D NM
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
Drug Name
Drug Requirements/
Tier
Limits
OCTAGAM INJ 10GM
OCTAGAM INJ 25GM
PRIVIGEN INJ 5 GRAMS
PRIVIGEN INJ 10GRAMS
PRIVIGEN INJ 20GRAMS
PRIVIGEN INJ 40GRAMS
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
IMMUNOMODULATORS
ACTIMMUNE INJ 2MU/0.5 Tier 5
ARCALYST INJ 220MG
Tier 5
INTRON A INJ 18MU
Tier 5
INTRON A INJ 50MU
Tier 5
INTRON-A INJ 10MU
Tier 5
INTRON-A INJ 18MU
Tier 5
INTRON-A INJ 25MU
Tier 5
PEG-INTRON KIT 50MCG Tier 5
PEG-INTRON KIT 50MCG Tier 5
RP
PEG-INTRON KIT 80MCG Tier 5
RP
PEG-INTRON KIT 120 RP Tier 5
PEG-INTRON KIT 120MCG Tier 5
PEG-INTRON KIT 150 RP Tier 5
PEGINTRON KIT 80MCG Tier 5
PEGINTRON KIT 150MCG Tier 5
REVLIMID CAP 2.5MG
Tier 5
REVLIMID CAP 5MG
Tier 5
REVLIMID CAP 10MG
Tier 5
REVLIMID CAP 15MG
Tier 5
REVLIMID CAP 20MG
Tier 5
REVLIMID CAP 25MG
Tier 5
THALOMID CAP 50MG
Tier 5
THALOMID CAP 100MG
Tier 5
THALOMID CAP 150MG
Tier 5
THALOMID CAP 200MG
Tier 5
NM LA PA
NM PA
B/D NM
B/D NM
B/D NM
B/D NM
B/D NM
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM PA
NM PA
NM PA
NM PA
IMMUNOSUPPRESSANTS
azathioprine tab 50 mg
Tier 3
B/D
(generic of IMURAN)
cyclosporine cap 25 mg
Tier 3
B/D
(generic
of
SANDIMMUNE)
NM PA
cyclosporine cap 100 mg
Tier 3
B/D
(generic of SANDIMMUNE)
NM PA
cyclosporine iv soln 50
Tier 4
B/D
mg/ml
(generic
of
NM PA
SANDIMMUNE)
NM PA
cyclosporine modified cap Tier 3
B/D
NM PA
25
mg
(generic
of
NEORAL)
NM PA
cyclosporine modified cap Tier 3
B/D
NM PA
50 mg
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
66
NM PA
NM PA
Drug Name
Drug Requirements/
Tier
Limits
cyclosporine modified cap Tier 3
100 mg (generic of
NEORAL)
cyclosporine modified oral Tier 3
soln 100 mg/ml (generic of
NEORAL)
gengraf cap 25mg (generic Tier 3
of NEORAL)
gengraf cap 100mg (generic Tier 3
of NEORAL)
gengraf sol 100mg/ml
Tier 3
(generic of NEORAL)
mycophenolate mofetil cap Tier 4
250 mg (generic of
CELLCEPT)
mycophenolate mofetil for Tier 5
oral susp 200 mg/ml
mycophenolate mofetil tab Tier 4
500 mg (generic of
CELLCEPT)
mycophenolate sodium tab Tier 4
dr 180 mg (mycophenolic
acid equiv) (generic of
MYFORTIC)
mycophenolate sodium tab Tier 5
dr 360 mg (mycophenolic
acid equiv) (generic of
MYFORTIC)
NEORAL CAP 25MG
Tier 3
NEORAL CAP 100MG
Tier 3
NEORAL SOL 100MG/ML Tier 3
NULOJIX INJ 250MG
Tier 5
PROGRAF CAP 0.5MG
Tier 4
PROGRAF CAP 1MG
Tier 4
PROGRAF CAP 5MG
Tier 5
RAPAMUNE SOL 1MG/ML Tier 5
SANDIMMUNE CAP 25MG Tier 3
SANDIMMUNE CAP 100MGTier 3
SANDIMMUNE SOL
Tier 3
100MG/ML
sirolimus tab 0.5 mg (genericTier 4
of RAPAMUNE)
SIROLIMUS TAB 1 MG
Tier 4
SIROLIMUS TAB 2 MG
Tier 5
tacrolimus cap 0.5 mg
Tier 4
(generic of PROGRAF)
tacrolimus cap 1 mg (genericTier 4
of PROGRAF)
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
Drug Name
Drug Requirements/
Tier
Limits
tacrolimus cap 5 mg (genericTier 5
of PROGRAF)
ZORTRESS TAB 0.5MG
Tier 5
ZORTRESS TAB 0.25MG Tier 4
ZORTRESS TAB 0.75MG Tier 5
B/D
B/D
B/D
B/D
VACCINES
ACTHIB INJ
Tier 3
ADACEL INJ
Tier 3
BCG VACCINE INJ
Tier 3
BOOSTRIX INJ
Tier 3
CERVARIX INJ
Tier 3
COMVAX INJ
Tier 3
DAPTACEL INJ
Tier 3
DIP/TET PED INJ 25-5LFU Tier 3
ENGERIX-B INJ 10/0.5ML Tier 3
ENGERIX-B INJ 20MCG/MLTier 3
GARDASIL 9 INJ
Tier 3
GARDASIL INJ
Tier 3
HAVRIX INJ 720UNIT
Tier 3
HAVRIX INJ 1440UNIT
Tier 3
HIBERIX SOL 10MCG
Tier 3
IMOVAX RABIE INJ 2.5/ML Tier 3
INFANRIX INJ
Tier 3
IPOL INJ INACTIVE
Tier 3
IXIARO INJ
Tier 3
M-M-R II INJ LIVE
Tier 3
MENACTRA INJ
Tier 3
MENOMUNE INJ A/C/Y/W Tier 3
MENVEO INJ
Tier 3
PEDVAX HIB INJ
Tier 3
PROQUAD INJ
Tier 3
RABAVERT INJ
Tier 3
RECOMBIVA HB INJ
Tier 3
5MCG/0.5
RECOMBIVA HB INJ
Tier 3
10MCG/ML
RECOMBIVA-HB INJ
Tier 3
40MCG/ML
ROTARIX SUS
Tier 3
ROTATEQ SOL
Tier 3
SYNAGIS INJ 50MG
Tier 5
SYNAGIS INJ 100MG/ML Tier 5
TENIVAC INJ 5-2LF
Tier 3
TET/DIP TOX INJ 2-2 LF
Tier 3
B/D
B/D
B/D
B/D
B/D
B/D
NM
NM
B/D
B/D
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
67
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
TETANUS TOX INJ 5LF
ADS
TRUMENBA INJ
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ
QL (1 vial per lifetime)
Tier 3
B/D
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
POTASSIUM CHLORIDE Tier 2
TAB CR 10 MEQ
POTASSIUM CHLORIDE Tier 2
TAB CR 20 MEQ (1500 MG)
SODIUM CHLORIDE INJ Tier 2
2.5 MEQ/ML (14.6%)
SODIUM FLUORIDE
Tier 2
CHEW; TAB; 1.1 (0.5 F)
MG/ML SOLN
TPN ELECTROL INJ
Tier 4
QL
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8 TAB 8MEQ Tier 2
ER
KLOR-CON 10 TAB 10MEQ Tier 2
ER
klor-con m15 tab 15meq er Tier 2
klor-con pow 20meq
Tier 3
MAGNESIUM SU INJ
Tier 3
40MG/ML
MAGNESIUM SU INJ
Tier 3
80MG/ML
magnesium sulfate inj 50% Tier 2
MAGNESIUM SULFATE INJTier 2
50%
MG SO4/D5W INJ
Tier 3
10MG/ML
MG SO4/D5W INJ
Tier 3
20MG/ML
potassium chloride cap cr 8 Tier 3
meq (generic of MICRO-K)
potassium chloride cap cr 10Tier 3
meq (generic of MICRO-K)
potassium chloride
Tier 2
microencapsulated crys cr
tab 10 meq
potassium chloride
Tier 2
microencapsulated crys cr
tab 20 meq
potassium chloride oral liq Tier 1
10% (20 meq/15ml)
potassium chloride oral liq Tier 1
20% (40 meq/15ml)
potassium chloride tab cr 8 Tier 2
meq (600 mg)
Drug Requirements/
Tier
Limits
B/D
IV NUTRITION
amino acid infusion 6%
Tier 2
AMINOSYN 7% INJ /LYTES Tier 4
AMINOSYN II INJ 7%
Tier 4
AMINOSYN II INJ 8.5%
Tier 4
AMINOSYN II INJ 8.5/LYTE Tier 4
AMINOSYN II INJ 10%
Tier 4
AMINOSYN INJ 8.5%
Tier 4
AMINOSYN INJ 8.5/LYTE Tier 4
AMINOSYN INJ 10%
Tier 4
AMINOSYN M INJ 3.5%
Tier 4
AMINOSYN-HBC INJ 7% Tier 4
AMINOSYN-PF INJ 7%
Tier 4
AMINOSYN-PF INJ 10%
Tier 4
AMINOSYN-RF INJ 5.2% Tier 4
CLINIMIX INJ 2.75/D5W
Tier 4
CLINIMIX INJ 4.25/D5W
Tier 4
CLINIMIX INJ 4.25/D10
Tier 4
CLINIMIX INJ 4.25/D20
Tier 4
CLINIMIX INJ 4.25/D25
Tier 4
CLINIMIX INJ 5%/D15W
Tier 4
CLINIMIX INJ 5%/D20W
Tier 4
CLINIMIX INJ 5%/D25W
Tier 4
FAT EMULSION IV SOLN Tier 3
20%
FREAMINE HBC INJ 6.9% Tier 4
FREAMINE III INJ 10%
Tier 4
HEPATAMINE SOL 8%
Tier 4
INTRALIPID INJ 20%
Tier 3
INTRALIPID INJ 30%
Tier 3
NEPHRAMINE INJ 5.4%
Tier 4
premasol sol 10%
Tier 4
PROCALAMINE INJ 3%
Tier 4
PROSOL INJ 20%
Tier 4
travasol inj 10%
Tier 4
TROPHAMINE INJ 10%
Tier 4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IV REPLACEMENT SOLUTIONS
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
68
Drug Name
Drug Requirements/
Tier
Limits
D5W/LYTES INJ #48
Tier 3
D5W/NACL INJ 0.3%
Tier 2
D10W/NACL INJ 0.2%
Tier 3
DEXTROSE 2.5% W/
Tier 2
SODIUM CHLORIDE 0.45%
DEXTROSE 5% IN
Tier 2
LACTATED RINGERS
DEXTROSE 5% W/
Tier 2
SODIUM CHLORIDE 0.2%
DEXTROSE 5% W/
Tier 2
SODIUM CHLORIDE 0.9%
DEXTROSE 5% W/
Tier 2
SODIUM CHLORIDE 0.33%
DEXTROSE 5% W/
Tier 2
SODIUM CHLORIDE 0.45%
DEXTROSE 5% W/
Tier 2
SODIUM CHLORIDE
0.225%
DEXTROSE 10% W/
Tier 2
SODIUM CHLORIDE 0.45%
DEXTROSE INJ 5%
Tier 2
DEXTROSE INJ 10%
Tier 2
DEXTROSE INJ 50%
Tier 2
dextrose inj 70%
Tier 2
IONOSOL-B/ INJ D5W
Tier 4
IONOSOL-MB INJ /D5W
Tier 4
ISOLYTE-P INJ /D5W
Tier 4
isolyte-s inj
Tier 4
KCL 10 MEQ/L (0.075%) IN Tier 2
DEXTROSE 5% & NACL
0.45% INJ
KCL 20 MEQ/L (0.15%) IN Tier 2
DEXTROSE 5% & NACL
0.2% INJ
KCL 20 MEQ/L (0.15%) IN Tier 2
DEXTROSE 5% & NACL
0.9% INJ
KCL 20 MEQ/L (0.15%) IN Tier 2
DEXTROSE 5% & NACL
0.33% INJ
KCL 20 MEQ/L (0.15%) IN Tier 2
DEXTROSE 5% & NACL
0.45% INJ
KCL 20 MEQ/L (0.15%) IN Tier 2
NACL 0.9% INJ
kcl 20 meq/l (0.15%) in nacl Tier 2
0.45% inj
Drug Name
Drug Requirements/
Tier
Limits
KCL 20 MEQ/L (0.15%) IN Tier 2
NACL 0.45% INJ
KCL 30 MEQ/L (0.224%) IN Tier 2
DEXTROSE 5% & NACL
0.45% INJ
KCL 40 MEQ/L (0.3%) IN Tier 2
DEXTROSE 5% & NACL
0.45% INJ
KCL 40 MEQ/L (0.3%) IN Tier 2
NACL 0.9% INJ
KCL/D5W/NACL INJ
Tier 2
0.3/0.9%
KCL/D5W/NACL INJ
Tier 3
0.15/0.2
LACTATED RINGER'S
Tier 2
SOLUTION
normosol -m inj /d5w
Tier 4
NORMOSOL -R INJ /D5W Tier 4
NORMOSOL-R INJ PH 7.4 Tier 4
PLASMA-LYTE INJ 56/D5W Tier 4
PLASMA-LYTE INJ -148
Tier 4
PLASMA-LYTE INJ -A
Tier 4
POTASSIUM CHLORIDE 20Tier 2
MEQ/L (0.15%) IN
DEXTROSE 5% INJ
POTASSIUM CHLORIDE 40Tier 2
MEQ/L (0.3%) IN
DEXTROSE 5% INJ
potassium chloride inj 2
Tier 2
meq/ml
potassium chloride inj 10
Tier 2
meq/50 ml
POTASSIUM CHLORIDE Tier 2
INJ 10 MEQ/100 ML
potassium chloride inj 20
Tier 2
meq/50 ml
POTASSIUM CHLORIDE Tier 2
INJ 20 MEQ/100 ML
potassium chloride inj 40
Tier 2
meq/100 ml
RINGER'S SOLUTION
Tier 2
SODIUM CHLORIDE INJ Tier 2
0.45%
SODIUM CHLORIDE INJ Tier 2
3%
SODIUM CHLORIDE INJ Tier 2
5%
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
69
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
SODIUM CHLORIDE IV
SOLN 0.9%
Tier 2
bacitracin-polymyxin-neomy Tier 3
cin-hc ophth oint 1%
blephamide oin s.o.p.
Tier 4
neomycin-polymyxin-dexam Tier 2
ethasone ophth oint 0.1%
(generic of MAXITROL)
neomycin-polymyxin-dexam Tier 2
ethasone ophth susp 0.1%
(generic of MAXITROL)
neomycin-polymyxin-hc
Tier 4
ophth susp
sulfacetamide
Tier 2
sodium-prednisolone ophth
soln 10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1% Tier 3
TOBRADEX ST SUS
Tier 3
0.3-0.05
tobramycin-dexamethasone Tier 4
ophth susp 0.3-0.1%
(generic of TOBRADEX)
ZYLET SUS 0.5-0.3%
Tier 3
ciprofloxacin hcl ophth soln Tier 2
0.3% (generic of CILOXAN)
erythromycin ophth oint 5 Tier 2
mg/gm
gatifloxacin ophth soln 0.5% Tier 3
(generic of ZYMAXID)
gentak oin 0.3% op
Tier 2
gentamicin sulfate ophth ointTier 2
0.3%
gentamicin sulfate ophth
Tier 2
soln 0.3% (generic of
GARAMYCIN)
ilotycin oin op
Tier 2
MOXEZA SOL 0.5%
Tier 3
NATACYN SUS 5% OP
Tier 4
neomycin-bacitrac
Tier 3
zn-polymyx
5(3.5)mg-400unt-10000unt
op oin
neomycin-polymy-gramicid Tier 3
op sol
1.75-10000-0.025mg-unt-m
g/ml (generic of
NEOSPORIN)
ofloxacin ophth soln 0.3% Tier 1
(generic of OCUFLOX)
polymyxin b-trimethoprim Tier 2
ophth soln 10000
unit/ml-0.1% (generic of
POLYTRIM)
sulfacetamide sodium ophth Tier 3
oint 10%
sulfacetamide sodium ophth Tier 3
soln 10% (generic of
BLEPH-10)
tobramycin ophth soln 0.3% Tier 2
(generic of TOBREX)
TOBREX OIN 0.3% OP
Tier 4
trifluridine ophth soln 1%
Tier 4
(generic of VIROPTIC)
VIGAMOX DRO 0.5%
Tier 3
ANTI-INFECTIVES
ANTI-INFLAMMATORIES
bacitracin ophth oint 500
Tier 3
unit/gm
bacitracin-polymyxin b ophthTier 2
oint
BESIVANCE SUS 0.6%
Tier 3
CILOXAN OIN 0.3% OP
Tier 3
ALREX SUS 0.2%
BROMFENAC SODIUM
OPHTH SOLN 0.09%
(BASE EQUIV)
(ONCE-DAILY)
VITAMINS
calcitriol cap 0.5 mcg
Tier 3
(generic of ROCALTROL)
calcitriol cap 0.25 mcg
Tier 3
(generic of ROCALTROL)
calcitriol inj 1 mcg/ml
Tier 4
calcitriol oral soln 1 mcg/ml Tier 4
(generic of ROCALTROL)
paricalcitol cap 1 mcg
Tier 4
(generic of ZEMPLAR)
paricalcitol cap 2 mcg
Tier 4
(generic of ZEMPLAR)
paricalcitol cap 4 mcg
Tier 4
PRENATAL
Tier 2
VITAMIN/FOLIC ACID > 0.8
MG (GENERIC)
B/D
B/D
B/D
B/D
B/D
B/D
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
Drug Requirements/
Tier
Limits
Tier 3
Tier 4
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
70
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
bromfenac sodium ophth
soln 0.09% (base
equivalent)
dexamethasone sodium
phosphate ophth soln 0.1%
diclofenac sodium ophth
soln 0.1%
DUREZOL EMU 0.05%
FLUOROMETHOLONE
OPHTH SUSP 0.1%
flurbiprofen sodium ophth
soln 0.03% (generic of
OCUFEN)
ILEVRO DRO 0.3% OP
ketorolac tromethamine
ophth soln 0.4% (generic of
ACULAR LS)
ketorolac tromethamine
ophth soln 0.5% (generic of
ACULAR)
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
LOTEMAX SUS 0.5%
MAXIDEX SUS 0.1% OP
NEVANAC SUS 0.1%
pred sod pho sol 1% op
PREDNISOLONE
ACETATE OPHTH SUSP
1%
Tier 4
brimonidine tartrate ophth Tier 2
soln 0.2%
BRIMONIDINE TARTRATE Tier 3
OPHTH SOLN 0.15%
carteolol hcl ophth soln 1% Tier 2
COMBIGAN SOL 0.2/0.5% Tier 3
dorzolamide hcl ophth soln Tier 3
2% (generic of TRUSOPT)
dorzolamide hcl-timolol
Tier 3
maleate ophth soln 22.3-6.8
mg/ml (generic of COSOPT)
ISTALOL SOL 0.5% OP
Tier 3
latanoprost ophth soln
Tier 2
0.005% (generic of
XALATAN)
levobunolol hcl ophth soln Tier 3
0.5% (generic of BETAGAN)
LEVOBUNOLOL HCL
Tier 3
OPHTH SOLN 0.25%
LUMIGAN SOL 0.01%
Tier 3
metipranolol ophth soln
Tier 3
0.3%
PHOSPHOLINE SOL
Tier 3
0.125%OP
PILOCARPINE HCL
Tier 3
OPHTH SOLN 1%
PILOCARPINE HCL
Tier 3
OPHTH SOLN 2%
PILOCARPINE HCL
Tier 3
OPHTH SOLN 4%
SIMBRINZA SUS 1-0.2% Tier 3
TIMOLOL MALEATE
Tier 3
OPHTH GEL FORMING
SOLN 0.5%
TIMOLOL MALEATE
Tier 3
OPHTH GEL FORMING
SOLN 0.25%
timolol maleate ophth soln Tier 1
0.5% (generic of TIMOPTIC)
timolol maleate ophth soln Tier 1
0.25% (generic of
TIMOPTIC)
TRAVATAN Z DRO 0.004% Tier 3
Tier 2
Tier 2
Tier 3
Tier 2
Tier 2
Tier 3
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
ANTIALLERGICS
azelastine hcl ophth soln
Tier 3
0.05%
BEPREVE DRO 1.5%
Tier 3
cromolyn sodium ophth soln Tier 1
4%
LASTACAFT SOL 0.25% Tier 4
PATADAY SOL 0.2%
Tier 3
PATANOL SOL 0.1% OP Tier 3
PAZEO DRO 0.7%
Tier 3
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
AZOPT SUS 1% OP
betaxolol hcl ophth soln
0.5%
BETOPTIC-S SUS 0.25%
OP
Tier 3
Tier 3
Tier 3
Tier 3
Drug Requirements/
Tier
Limits
MISCELLANEOUS
naphazoline hcl ophth soln Tier 1
0.1%
PROLENSA SOL 0.07%
Tier 3
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
71
Drug Name
Drug Requirements/
Tier
Limits
proparacaine hcl ophth soln Tier 2
0.5% (generic of ALCAINE)
RESTASIS EMU 0.05%
Tier 3
QL (64 vials / 30 days)
QL
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS
ANORO ELLIPT AER
Tier 3
62.5-25
QL (1 inhaler / 30
days)
COMBIVENT AER
Tier 4
RESPIMAT
QL (2 inhalers / 30
days)
ipratropium-albuterol nebu Tier 3
soln 0.5-2.5(3) mg/3ml
QL
QL
B/D
ANTICHOLINERGICS
ATROVENT HFA AER
Tier 4
17MCG
QL (2 inhalers / 30
days)
ipratropium bromide inhal Tier 2
soln 0.02%
ipratropium bromide nasal Tier 2
soln 0.03% (21 mcg/spray)
(generic of ATROVENT)
ipratropium bromide nasal Tier 2
soln 0.06% (42 mcg/spray)
(generic of ATROVENT)
SPIRIVA CAP HANDIHLR Tier 3
QL (30 caps / 30 days)
SPIRIVA SPR RESPIMAT Tier 3
QL (1 inhaler / 30
days)
TUDORZA PRES AER
Tier 3
400/ACT
QL (1 inhaler / 30
days)
TUDORZA PRES AER
Tier 3
400/ACT
QL (2 inhalers / 30
days)
QL
Drug Name
Drug Requirements/
Tier
Limits
azelastine hcl nasal spray Tier 4
0.15% (205.5 mcg/spray)
(generic of ASTEPRO)
cetirizine hcl oral soln 1
Tier 3
mg/ml (5 mg/5ml)
diphenhydramine hcl inj 50 Tier 2
mg/ml
hydroxyzine hcl im soln 25 Tier 4
mg/ml
hydroxyzine hcl im soln 50 Tier 4
mg/ml
levocetirizine
Tier 4
dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml) (generic
of XYZAL)
levocetirizine
Tier 2
dihydrochloride tab 5 mg
(generic of XYZAL)
olopatadine hcl nasal soln Tier 3
0.6% (generic of
PATANASE)
PA
PA
BETA AGONISTS
albuterol sulfate soln nebu Tier 2
B/D
0.5% (5 mg/ml)
albuterol sulfate soln nebu Tier 2
B/D
0.63 mg/3ml (base equiv)
albuterol sulfate soln nebu Tier 2
B/D
0.083% (2.5 mg/3ml)
albuterol sulfate soln nebu Tier 2
B/D
1.25 mg/3ml (base equiv)
albuterol sulfate syrup 2
Tier 2
QL
mg/5ml
albuterol sulfate tab 2 mg Tier 4
QL
albuterol sulfate tab 4 mg Tier 4
albuterol sulfate tab sr 12hr Tier 3
QL
4 mg (generic of VOSPIRE
ER)
albuterol sulfate tab sr 12hr Tier 3
8 mg (generic of VOSPIRE
QL
ER)
FORADIL CAP AEROLIZE Tier 3
QL
QL (60 caps / 30 days)
levalbuterol hcl soln nebu Tier 4
B/D
ANTIHISTAMINES
conc 1.25 mg/0.5ml (base
ASTEPRO SPR 0.15%
Tier 3
equiv) (generic of
XOPENEX
azelastine hcl nasal spray Tier 3
CONCENTRATE)
0.1% (137 mcg/spray)
PERFOROMIST NEB
Tier 4
B/D
20MCG
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
72
B/D
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
PROAIR HFA AER
QL (2 inhalers / 30
days)
SEREVENT DIS AER
50MCG
QL (1 inhaler / 30
days)
terbutaline sulfate inj 1
mg/ml
terbutaline sulfate tab 2.5
mg
terbutaline sulfate tab 5 mg
XOPENEX HFA AER
QL (2 inhalers / 30
days)
Tier 3
QL
Tier 3
QL
DALIRESP TAB 500MCG Tier 4
EPIPEN 2-PAK INJ 0.3MG Tier 3
EPIPEN-JR INJ 2-PAK
Tier 3
PROLASTIN-C INJ 1000MG Tier 5
PULMOZYME SOL 1MG/MLTier 5
XOLAIR SOL 150MG
Tier 5
ZEMAIRA INJ 1000MG
Tier 5
Tier 4
QL
LEUKOTRIENE RECEPTOR
ANTAGONISTS
montelukast sodium chew
tab 4 mg (base equiv)
(generic of SINGULAIR)
montelukast sodium chew
tab 5 mg (base equiv)
(generic of SINGULAIR)
montelukast sodium oral
granules packet 4 mg (base
equiv) (generic of
SINGULAIR)
montelukast sodium tab 10
mg (base equiv) (generic of
SINGULAIR)
zafirlukast tab 10 mg
(generic of ACCOLATE)
zafirlukast tab 20 mg
(generic of ACCOLATE)
Tier 3
Tier 4
Tier 3
Tier 3
Tier 3
MAST CELL STABILIZERS
B/D
MISCELLANEOUS
acetylcysteine inhal soln
10%
acetylcysteine inhal soln
20%
ARALAST NP INJ 400MG
ARALAST NP INJ 500MG
ARALAST NP INJ 800MG
ARALAST NP INJ 1000MG
AUVI-Q INJ 0.3MG
AUVI-Q INJ 0.15MG
Tier 3
B/D
Tier 3
B/D
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 3
flunisolide nasal soln 25
Tier 3
mcg/act (0.025%)
QL (2 bottles / 30 days)
fluticasone propionate nasal Tier 3
susp 50 mcg/act (generic of
FLONASE)
QL (1 bottle / 30 days)
NASONEX SPR 50MCG/AC Tier 3
QL (2 bottles / 30 days)
QL
QL
QL
STEROID INHALANTS
Tier 3
cromolyn sodium soln nebu Tier 3
20 mg/2ml
NM LA PA
B/D NM
NM LA PA
NM LA PA
NASAL STEROIDS
Tier 3
Tier 3
Tier 3
Drug Requirements/
Tier
Limits
NM LA PA
NM LA PA
NM LA PA
NM LA PA
ASMANEX 14 AER
220MCG
QL (2 inhalers / 30
days)
ASMANEX 30 AER
110MCG
QL (2 inhalers / 30
days)
ASMANEX 30 AER
220MCG
QL (2 inhalers / 30
days)
ASMANEX 60 AER
220MCG
QL (2 inhalers / 30
days)
ASMANEX 120 AER
220MCG
QL (2 inhalers / 30
days)
budesonide inhalation susp
0.5 mg/2ml (generic of
PULMICORT)
budesonide inhalation susp
0.25 mg/2ml (generic of
PULMICORT)
FLOVENT DISK AER
50MCG
QL (2 inhalers / 30
days)
Tier 3
QL
Tier 3
QL
Tier 3
QL
Tier 3
QL
Tier 3
QL
Tier 4
B/D
Tier 4
B/D
Tier 3
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
73
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
FLOVENT DISK AER
100MCG
QL (2 inhalers / 30
days)
FLOVENT DISK AER
250MCG
QL (4 inhalers / 30
days)
FLOVENT HFA AER
44MCG
QL (2 inhalers / 30
days)
FLOVENT HFA AER
110MCG
QL (2 inhalers / 30
days)
FLOVENT HFA AER
220MCG
QL (2 inhalers / 30
days)
QVAR AER 40MCG
QL (1 inhaler / 30
days)
QVAR AER 80MCG
QL (2 inhalers / 30
days)
Tier 3
QL
Tier 4
QL
Tier 4
QL
Tier 3
QL
DULERA AER 100-5MCG
QL (1 inhaler / 30
days)
DULERA AER 200-5MCG
QL (1 inhaler / 30
days)
SYMBICORT AER 80-4.5
QL (1 inhaler / 30
days)
SYMBICORT AER 160-4.5
QL (1 inhaler / 30
days)
Tier 3
QL
Tier 3
QL
Tier 3
Tier 3
QL
QL
Tier 3
QL
Tier 3
QL
Tier 3
QL
STEROID/BETA-AGONIST
COMBINATIONS
ADVAIR DISKU AER 100/50Tier 3
QL (1 inhaler / 30
days)
ADVAIR DISKU AER 250/50Tier 3
QL (1 inhaler / 30
days)
ADVAIR DISKU AER 500/50Tier 3
QL (1 inhaler / 30
days)
ADVAIR HFA AER 45/21
Tier 3
QL (1 inhaler / 30
days)
ADVAIR HFA AER 115/21 Tier 3
QL (1 inhaler / 30
days)
ADVAIR HFA AER 230/21 Tier 3
QL (1 inhaler / 30
days)
BREO ELLIPTA INH 100-25 Tier 3
QL (1 inhaler / 30
days)
QL
QL
QL
QL
QL
QL
XANTHINES
aminophylline inj 25 mg/ml
elixophyllin elx 80/15ml
theo-24 cap 100mg cr
theo-24 cap 200mg cr
theo-24 cap 300mg cr
theo-24 cap 400mg er
theophylline soln 80
mg/15ml
theophylline tab sr 12hr 100
mg
theophylline tab sr 12hr 200
mg
theophylline tab sr 12hr 300
mg
theophylline tab sr 12hr 450
mg
theophylline tab sr 24hr 400
mg
theophylline tab sr 24hr 600
mg
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
TOPICAL
DERMATOLOGY, ACNE
adapalene cream 0.1%
Tier 4
(generic of DIFFERIN)
adapalene gel 0.1% (genericTier 4
of DIFFERIN)
amnesteem cap 10mg
Tier 4
amnesteem cap 20mg
Tier 4
amnesteem cap 40mg
Tier 4
AVITA CRE 0.025%
Tier 3
AVITA GEL 0.025%
Tier 3
QL
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
74
Drug Name
Drug Requirements/
Tier
Limits
benzoyl
Tier 3
peroxide-erythromycin gel
5-3% (generic of
BENZAMYCIN)
claravis cap 10mg
Tier 4
claravis cap 20mg
Tier 4
claravis cap 30mg
Tier 4
claravis cap 40mg
Tier 4
clindamycin phosphate gel Tier 3
1% (generic of CLEOCIN-T)
clindamycin phosphate
Tier 3
lotion 1% (generic of
CLEOCIN-T)
clindamycin phosphate soln Tier 3
1% (generic of CLEOCIN-T)
clindamycin phosphate
Tier 3
swab 1% (generic of
CLEOCIN-T)
erythromycin gel 2%
Tier 3
(generic of ERYGEL)
erythromycin pads 2%
Tier 3
erythromycin soln 2%
Tier 3
isotretinoin cap 10 mg
Tier 4
isotretinoin cap 20 mg
Tier 4
isotretinoin cap 40 mg
Tier 4
myorisan cap 10mg
Tier 4
myorisan cap 20mg
Tier 4
myorisan cap 40mg
Tier 4
sulfacetamide sodium lotion Tier 3
10% (acne) (generic of
KLARON)
tretinoin cream 0.1%
Tier 3
(generic of RETIN-A)
tretinoin cream 0.05%
Tier 3
(generic of RETIN-A)
tretinoin cream 0.025%
Tier 3
(generic of RETIN-A)
tretinoin gel 0.01% (generic Tier 3
of RETIN-A)
tretinoin gel 0.025% (genericTier 3
of RETIN-A)
zenatane cap 30mg
Tier 4
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate cream
Tier 2
0.1%
gentamicin sulfate oint 0.1% Tier 2
Drug Name
Drug Requirements/
Tier
Limits
mupirocin oint 2% (generic
of BACTROBAN)
SILVER SULFADIAZINE
CREAM 1%
SSD CRE 1%
SULFAMYLON CRE
85MG/GM
Tier 2
Tier 2
Tier 2
Tier 4
DERMATOLOGY, ANTIFUNGALS
ciclopirox gel 0.77%
Tier 4
ciclopirox olamine cream
Tier 3
0.77% (base equiv)
ciclopirox olamine susp
Tier 3
0.77% (base equiv)
ciclopirox shampoo 1%
Tier 4
(generic of LOPROX
SHAMPOO)
clotrimazole cream 1%
Tier 3
clotrimazole soln 1%
Tier 2
econazole nitrate cream 1% Tier 3
ketoconazole cream 2%
Tier 3
nyamyc pow 100000
Tier 3
nystatin cream 100000
Tier 3
unit/gm
nystatin oint 100000 unit/gm Tier 3
nystatin topical powder
Tier 3
nystop pow 100000
Tier 3
DERMATOLOGY, ANTIPRURITIC
DOXEPIN HCL CREAM 5% Tier 4
hydrocortisone rectal cream Tier 1
2.5% (generic of
ANUSOL-HC)
procto-pak cre 1%
Tier 3
proctozone cre -hc 2.5%
Tier 1
(generic of ANUSOL-HC)
DERMATOLOGY, ANTIPSORIATICS
acitretin cap 10 mg (generic
of SORIATANE)
acitretin cap 17.5 mg
(generic of SORIATANE)
acitretin cap 25 mg (generic
of SORIATANE)
calcipotriene cream 0.005%
(generic of DOVONEX)
calcipotriene oint 0.005%
calcipotriene soln 0.005%
(50 mcg/ml)
calcitrene oin 0.005%
Tier 5
PA
Tier 5
PA
Tier 5
PA
Tier 4
Tier 4
Tier 4
Tier 4
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
75
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
8-MOP CAP 10MG
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
Tier 4
Tier 4
Tier 4
clobetasol propionate cream Tier 3
0.05% (generic of
TEMOVATE)
clobetasol propionate
Tier 3
emollient base cream 0.05%
(generic of TEMOVATE E)
clobetasol propionate gel
Tier 3
0.05% (generic of
TEMOVATE)
clobetasol propionate oint Tier 3
0.05% (generic of
TEMOVATE)
clobetasol propionate soln Tier 3
0.05% (generic of
TEMOVATE)
cormax scalp sol 0.05%
Tier 3
(generic of TEMOVATE)
DESONIDE CREAM 0.05% Tier 4
desonide lotion 0.05%
Tier 4
(generic of DESOWEN)
desonide oint 0.05%
Tier 4
(generic of DESOWEN)
desoximetasone cream
Tier 4
0.05% (generic of
TOPICORT)
desoximetasone cream
Tier 4
0.25% (generic of
TOPICORT)
desoximetasone gel 0.05% Tier 4
(generic of TOPICORT)
DESOXIMETASONE OINT Tier 4
0.05%
desoximetasone oint 0.25% Tier 4
(generic of TOPICORT)
diflorasone diacetate cream Tier 4
0.05%
diflorasone diacetate oint
Tier 4
0.05%
fluocin acet oil scalp (genericTier 4
of DERMA-SMOOTHE/FS
SCALP)
fluocinolone acetonide
Tier 3
cream 0.01%
fluocinolone acetonide
Tier 3
cream 0.025% (generic of
SYNALAR)
PA
PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo 2% Tier 2
(generic of NIZORAL)
selenium sulfide lotion 2.5% Tier 2
DERMATOLOGY, ANTIVIRALS
acyclovir oint 5% (generic of Tier 4
ZOVIRAX)
DENAVIR CRE 1%
Tier 4
DERMATOLOGY, CORTICOSTEROIDS
ala cort cre 1%
Tier 1
alclometasone dipropionate Tier 3
cream 0.05% (generic of
ACLOVATE)
alclometasone dipropionate Tier 3
oint 0.05%
amcinonide cream 0.1%
Tier 4
amcinonide lotion 0.1%
Tier 4
amcinonide oin 0.1%
Tier 4
apexicon oin 0.05%
Tier 4
betamethasone dipropionateTier 3
augmented cream 0.05%
(generic of DIPROLENE AF)
betamethasone dipropionateTier 4
augmented gel 0.05%
betamethasone dipropionateTier 4
augmented lotion 0.05%
(generic of DIPROLENE)
betamethasone dipropionateTier 4
augmented oint 0.05%
(generic of DIPROLENE)
betamethasone dipropionateTier 3
cream 0.05%
betamethasone dipropionateTier 3
lotion 0.05%
betamethasone dipropionateTier 3
oint 0.05%
betamethasone valerate
Tier 3
cream 0.1%
betamethasone valerate
Tier 3
lotion 0.1%
betamethasone valerate oint Tier 3
0.1%
Drug Requirements/
Tier
Limits
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
76
Drug Name
Drug Requirements/
Tier
Limits
fluocinolone acetonide oil Tier 4
0.01% (body oil) (generic of
DERMA-SMOOTHE/FS
BODY)
fluocinolone acetonide oint Tier 3
0.025% (generic of
SYNALAR)
fluocinolone acetonide soln Tier 4
0.01% (generic of
SYNALAR)
fluocinonide cream 0.05% Tier 3
fluocinonide emulsified base Tier 3
cream 0.05%
fluocinonide gel 0.05%
Tier 3
fluocinonide oint 0.05%
Tier 3
fluocinonide soln 0.05%
Tier 3
fluticasone propionate
Tier 2
cream 0.05% (generic of
CUTIVATE)
fluticasone propionate oint Tier 2
0.005%
halobetasol propionate
Tier 4
cream 0.05% (generic of
ULTRAVATE)
halobetasol propionate oint Tier 4
0.05% (generic of
ULTRAVATE)
hydrocortisone butyrate
Tier 3
cream 0.1% (generic of
LOCOID)
hydrocortisone butyrate oint Tier 3
0.1% (generic of LOCOID)
hydrocortisone butyrate soln Tier 2
0.1% (generic of LOCOID)
hydrocortisone cream 1% Tier 1
hydrocortisone cream 2.5% Tier 1
hydrocortisone lotion 2.5% Tier 3
hydrocortisone oint 1%
Tier 1
hydrocortisone oint 2.5%
Tier 1
hydrocortisone valerate
Tier 3
cream 0.2%
hydrocortisone valerate oint Tier 4
0.2% (generic of
WESTCORT)
LOKARA LOT 0.05%
Tier 4
mometasone furoate cream Tier 3
0.1% (generic of ELOCON)
Drug Name
Drug Requirements/
Tier
Limits
mometasone furoate oint
Tier 3
0.1% (generic of ELOCON)
mometasone furoate
Tier 3
solution 0.1% (lotion)
(generic of ELOCON)
texacort sol 2.5%
Tier 4
triamcinolone acetonide
Tier 2
cream 0.1%
triamcinolone acetonide
Tier 2
cream 0.5%
triamcinolone acetonide
Tier 2
cream 0.025%
triamcinolone acetonide
Tier 3
lotion 0.1%
triamcinolone acetonide
Tier 3
lotion 0.025%
triamcinolone acetonide oint Tier 2
0.1%
triamcinolone acetonide oint Tier 2
0.5%
triamcinolone acetonide oint Tier 2
0.025%
triderm cre 0.1%
Tier 2
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine hcl gel 2%
Tier 2
lidocaine hcl soln 4%
Tier 1
(generic of XYLOCAINE)
lidocaine oint 5%
Tier 3
lidocaine patch 5% (700 mg)Tier 4
(generic of LIDODERM)
QL (3 patches / 1 day)
lidocaine-prilocaine cream Tier 3
2.5-2.5% (generic of EMLA)
QL PA
B/D
DERMATOLOGY, MISCELLANEOUS SKIN
AND MUCOUS MEMBRANE
ELIDEL CRE 1%
Tier 4
fluorouracil cream 5%
Tier 4
(generic of EFUDEX)
fluorouracil soln 2%
Tier 3
fluorouracil soln 5%
Tier 3
imiquimod cream 5%
Tier 4
(generic of ALDARA)
lactic acid (ammonium
Tier 2
lactate) cream 12% (generic
of LAC-HYDRIN)
lactic acid (ammonium
Tier 3
lactate) lotion 12% (generic
of LAC-HYDRIN)
PA
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
77
Drug Name
Drug Requirements/
Tier
Limits
metronidazole cream 0.75% Tier 4
(generic of METROCREAM)
metronidazole gel 0.75%
Tier 4
metronidazole lotion 0.75% Tier 4
(generic of METROLOTION)
PANRETIN GEL 0.1%
Tier 5
podofilox soln 0.5% (generic Tier 3
of CONDYLOX)
TARGRETIN GEL 1%
Tier 5
VALCHLOR GEL 0.016% Tier 5
VOLTAREN GEL 1%
Tier 3
Drug Requirements/
Tier
Limits
OTIC
NM PA
NM LA PA
DERMATOLOGY, SCABICIDES AND
PEDICULIDES
EURAX CRE 10%
EURAX LOT 10%
malathion lotion 0.5%
(generic of OVIDE)
permethrin cream 5%
(generic of ELIMITE)
Drug Name
Tier 4
Tier 4
Tier 4
acetic acid 2% in aluminum Tier 3
acetate otic soln
acetic acid otic soln 2%
Tier 3
CIPRODEX SUS 0.3-0.1% Tier 3
fluocinolone acetonide (otic) Tier 4
oil 0.01% (generic of
DERMOTIC)
neomycin-polymyxin-hc otic Tier 2
soln 1% (generic of
CORTISPORIN)
neomycin-polymyxin-hc otic Tier 2
susp 3.5 mg/ml-10000
unit/ml-1%
ofloxacin otic soln 0.3%
Tier 2
Tier 3
DERMATOLOGY, WOUND CARE AGENTS
acetic acid irrigation soln
Tier 2
0.25%
REGRANEX GEL 0.01%
Tier 5
SANTYL OIN 250/GM
Tier 4
SODIUM CHLORIDE
Tier 1
IRRIGATION SOLN 0.9%
WATER FOR IRRIGATION, Tier 2
STERILE IRRIGATION
SOLN
PA
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl cap 30 mg Tier 4
(generic of EVOXAC)
chlorhexidine gluconate soln Tier 1
0.12% (generic of
PERIDEX)
clotrimazole troche 10 mg Tier 3
lidocaine hcl viscous soln Tier 1
2%
nystatin susp 100000 unit/mlTier 3
periogard sol 0.12% (genericTier 1
of PERIDEX)
pilocarpine hcl tab 5 mg
Tier 3
(generic of SALAGEN)
pilocarpine hcl tab 7.5 mg Tier 3
(generic of SALAGEN)
triamcinolone acetonide
Tier 3
dental paste 0.1%
You can find information on what symbols and abbreviations on this table mean by going to page 5.
B/D – Covered under Medicare Part B or D
QL – Quantity Limits
PA – Prior Authorization
ST – Step Therapy
LA – Limited Access
NMO – No Mail Order
00015129_v13_07/2015
78
Index
8
8-MOP CAP 10MG ...........76
A
abacavir sulfate tab 300 mg
(base equiv) ......................14
abacavir
sulfate-lamivudine-zidovudin
e tab 300-150-300 mg .......15
ABELCET INJ 5MG/ML ....13
ABILIFY
see aripiprazole tab 10 mg
......................................44
see aripiprazole tab 15 mg
......................................44
see aripiprazole tab 2 mg
......................................44
see aripiprazole tab 20 mg
......................................44
see aripiprazole tab 30 mg
......................................44
see aripiprazole tab 5 mg
......................................44
ABILIFY DISC TAB 10MG 44
ABILIFY DISC TAB 15MG 44
ABILIFY INJ 9.75MG ........44
ABILIFY MAIN INJ 300MG44
ABILIFY MAIN INJ 400MG44
ABILIFY TAB 10MG ..........44
ABILIFY TAB 15MG ..........44
ABILIFY TAB 20MG ..........44
ABILIFY TAB 2MG ............44
ABILIFY TAB 30MG ..........44
ABILIFY TAB 5MG ............44
acamprosate calcium tab
delayed release 333 mg ....51
acarbose tab 100 mg ........52
acarbose tab 25 mg ..........52
acarbose tab 50 mg ..........52
ACCOLATE
see zafirlukast tab 10 mg
......................................73
see zafirlukast tab 20 mg
......................................73
ACCUPRIL
see quinapril hcl tab 10 mg
......................................26
see quinapril hcl tab 20 mg
......................................26
see quinapril hcl tab 40 mg
...................................... 26
see quinapril hcl tab 5 mg
...................................... 26
ACCURETIC
see
quinapril-hydrochlorothiazi
de tab 10-12.5 mg ......... 25
see
quinapril-hydrochlorothiazi
de tab 20-12.5 mg ......... 25
see
quinapril-hydrochlorothiazi
de tab 20-25 mg ............ 25
acebutolol hcl cap 200 mg 30
acebutolol hcl cap 400 mg 30
ACEON
see perindopril erbumine
tab 4 mg ........................ 25
see perindopril erbumine
tab 8 mg ........................ 25
acetaminophen w/ codeine
soln 120-12 mg/5ml ............ 7
acetaminophen w/ codeine
tab 300-15 mg ..................... 8
acetaminophen w/ codeine
tab 300-30 mg ..................... 8
acetaminophen w/ codeine
tab 300-60 mg ..................... 8
acetazolamide cap sr 12hr
500 mg .............................. 33
acetazolamide tab 125 mg 33
acetazolamide tab 250 mg 33
acetic acid 2% in aluminum
acetate otic soln ................ 78
acetic acid irrigation soln
0.25%................................ 78
acetic acid otic soln 2%..... 78
acetylcysteine inhal soln 10%
.......................................... 73
acetylcysteine inhal soln 20%
.......................................... 73
acitretin cap 10 mg ........... 75
acitretin cap 17.5 mg......... 75
acitretin cap 25 mg ........... 75
ACLOVATE
see alclometasone
dipropionate cream 0.05%
...................................... 76
ACTHIB INJ ...................... 67
ACTIGALL
see ursodiol cap 300 mg
...................................... 62
ACTIMMUNE INJ 2MU/0.5
.......................................... 66
ACTIQ
see fentanyl citrate
lozenge on a handle 1200
mcg ................................. 8
see fentanyl citrate
lozenge on a handle 1600
mcg ................................. 9
see fentanyl citrate
lozenge on a handle 200
mcg ................................. 8
see fentanyl citrate
lozenge on a handle 400
mcg ................................. 8
see fentanyl citrate
lozenge on a handle 600
mcg ................................. 8
see fentanyl citrate
lozenge on a handle 800
mcg ................................. 8
ACTOS
see pioglitazone hcl tab 15
mg (base equiv) ............ 53
see pioglitazone hcl tab 30
mg (base equiv) ............ 53
see pioglitazone hcl tab 45
mg (base equiv) ............ 53
ACULAR
see ketorolac
tromethamine ophth soln
0.5% .............................. 71
ACULAR LS
see ketorolac
tromethamine ophth soln
0.4% .............................. 71
acyclovir cap 200 mg ........ 15
acyclovir oint 5% ............... 76
acyclovir sodium for inj 1000
mg..................................... 15
acyclovir sodium for inj 500
mg..................................... 15
acyclovir sodium iv soln 50
mg/ml ................................ 15
acyclovir susp 200 mg/5ml 15
acyclovir tab 400 mg ......... 15
79
acyclovir tab 800 mg .........15
ADACEL INJ .....................67
ADAGEN INJ 250/ML .......56
ADALAT CC
see afeditab tab 30mg cr
......................................31
see afeditab tab 60mg cr
......................................31
see nifedipine tab sr 24hr
30 mg ............................32
see nifedipine tab sr 24hr
60 mg ............................32
see nifedipine tab sr 24hr
90 mg ............................32
adapalene cream 0.1% .....74
adapalene gel 0.1% ..........74
ADCIRCA TAB 20MG .......34
ADDERALL
see
amphetamine-dextroamph
etamine tab 10 mg .........48
see
amphetamine-dextroamph
etamine tab 12.5 mg ......48
see
amphetamine-dextroamph
etamine tab 15 mg .........48
see
amphetamine-dextroamph
etamine tab 20 mg .........48
see
amphetamine-dextroamph
etamine tab 30 mg .........48
see
amphetamine-dextroamph
etamine tab 5 mg ...........48
see
amphetamine-dextroamph
etamine tab 7.5 mg ........48
ADDERALL XR
see
amphetamine-dextroamph
etamine cap sr 24hr 10 mg
......................................48
see
amphetamine-dextroamph
etamine cap sr 24hr 15 mg
......................................48
see
amphetamine-dextroamph
etamine cap sr 24hr 20 mg
...................................... 48
see
amphetamine-dextroamph
etamine cap sr 24hr 25 mg
...................................... 48
see
amphetamine-dextroamph
etamine cap sr 24hr 30 mg
...................................... 48
see
amphetamine-dextroamph
etamine cap sr 24hr 5 mg
...................................... 48
adefovir dipivoxil tab 10 mg
.......................................... 15
ADEMPAS TAB 0.5MG..... 34
ADEMPAS TAB 1.5MG..... 34
ADEMPAS TAB 1MG........ 34
ADEMPAS TAB 2.5MG..... 34
ADEMPAS TAB 2MG........ 35
ADOXA
see doxycycline
monohydrate tab 100 mg
...................................... 20
see doxycycline
monohydrate tab 50 mg 20
see doxycycline
monohydrate tab 75 mg 20
ADOXA PAK 1/150
see doxycycline
monohydrate tab 150 mg
...................................... 20
adriamyc inj 50mg ............. 21
adrucil inj 500/10ml ........... 21
ADVAIR DISKU AER 100/50
.......................................... 74
ADVAIR DISKU AER 250/50
.......................................... 74
ADVAIR DISKU AER 500/50
.......................................... 74
ADVAIR HFA AER 115/21 74
ADVAIR HFA AER 230/21 74
ADVAIR HFA AER 45/21 .. 74
afeditab tab 30mg cr ......... 31
afeditab tab 60mg cr ......... 31
AFINITOR DIS TAB 2MG . 22
AFINITOR DIS TAB 3MG . 22
AFINITOR DIS TAB 5MG . 22
AFINITOR TAB 10MG ...... 23
AFINITOR TAB 2.5MG ..... 23
AFINITOR TAB 5MG ........ 23
AFINITOR TAB 7.5MG ..... 23
AGGRENOX CAP
25-200MG ......................... 65
AGRYLIN
see anagrelide hcl cap 0.5
mg ................................. 65
a-hydrocort inj 100mg ....... 57
ala cort cre 1% .................. 76
ALBENZA TAB 200MG ..... 12
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml) ........ 72
albuterol sulfate soln nebu
0.5% (5 mg/ml) ................. 72
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv) . 72
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv) . 72
albuterol sulfate syrup 2
mg/5ml .............................. 72
albuterol sulfate tab 2 mg . 72
albuterol sulfate tab 4 mg . 72
albuterol sulfate tab sr 12hr 4
mg..................................... 72
albuterol sulfate tab sr 12hr 8
mg..................................... 72
ALCAINE
see proparacaine hcl ophth
soln 0.5% ...................... 72
alclometasone dipropionate
cream 0.05% .................... 76
alclometasone dipropionate
oint 0.05%......................... 76
ALCOHOL SWABS........... 51
ALDACTAZIDE
see spironolactone &
hydrochlorothiazide tab
25-25 mg ....................... 33
ALDACTONE
see spironolactone tab 100
mg ................................. 26
see spironolactone tab 25
mg ................................. 26
see spironolactone tab 50
mg ................................. 26
ALDARA
see imiquimod cream 5%
...................................... 77
ALDURAZYME INJ
2.9MG/5M ......................... 56
alendronate sodium tab 10
mg..................................... 53
80
alendronate sodium tab 35
mg .....................................53
alendronate sodium tab 40
mg .....................................53
alendronate sodium tab 5 mg
..........................................53
alendronate sodium tab 70
mg .....................................53
alfuzosin hcl tab sr 24hr 10
mg .....................................62
ALIMTA INJ 100MG ..........21
ALIMTA INJ 500MG ..........21
ALINIA SUS 100/5ML .......12
ALINIA TAB 500MG ..........12
ALKERAN
see melphalan hcl for inj 50
mg (base equiv).............21
allopurinol tab 100 mg .........7
allopurinol tab 300 mg .........7
ALPHAGAN P SOL 0.1% ..71
alprazolam con 1 mg/ml ....35
alprazolam tab 0.25 mg ....35
alprazolam tab 0.5 mg ......35
alprazolam tab 1 mg .........35
alprazolam tab 2 mg .........35
ALREX SUS 0.2%.............70
ALTACE
see ramipril cap 1.25 mg
......................................26
see ramipril cap 10 mg ..26
see ramipril cap 2.5 mg .26
see ramipril cap 5 mg ....26
altavera tab .......................54
amantadine hcl cap 100 mg
..........................................43
amantadine hcl syrup 50
mg/5ml ..............................43
amantadine hcl tab 100 mg
..........................................43
AMARYL
see glimepiride tab 1 mg
......................................52
see glimepiride tab 2 mg
......................................52
see glimepiride tab 4 mg
......................................52
AMBIEN
see zolpidem tartrate tab
10 mg ............................49
see zolpidem tartrate tab 5
mg .................................49
AMBISOME INJ 50MG ..... 13
amcinonide cream 0.1% ... 76
amcinonide lotion 0.1% ..... 76
amcinonide oin 0.1%......... 76
AMERGE
see naratriptan hcl tab 1
mg (base equiv) ............ 49
see naratriptan hcl tab 2.5
mg (base equiv) ............ 49
amifostine crystalline for inj
500 mg .............................. 24
amikacin sulfate inj 1 gm/4ml
(250 mg/ml) ....................... 11
amikacin sulfate inj 500
mg/2ml (250 mg/ml) .......... 11
amiloride &
hydrochlorothiazide tab 5-50
mg ..................................... 33
amiloride hcl tab 5 mg ....... 33
amino acid infusion 6% ..... 68
aminophylline inj 25 mg/ml 74
AMINOSYN 7% INJ /LYTES
.......................................... 68
AMINOSYN II INJ 10% ..... 68
AMINOSYN II INJ 7% ....... 68
AMINOSYN II INJ 8.5% .... 68
AMINOSYN II INJ 8.5/LYTE
.......................................... 68
AMINOSYN INJ 10% ........ 68
AMINOSYN INJ 8.5% ....... 68
AMINOSYN INJ 8.5/LYTE 68
AMINOSYN M INJ 3.5% ... 68
AMINOSYN-HBC INJ 7% . 68
AMINOSYN-PF INJ 10% .. 68
AMINOSYN-PF INJ 7% .... 68
AMINOSYN-RF INJ 5.2% . 68
amiodarone hcl inj 150
mg/3ml (50 mg/ml) ............ 27
amiodarone hcl inj 450
mg/9ml (50 mg/ml) ............ 27
amiodarone hcl inj 900
mg/18ml (50 mg/ml) .......... 27
amiodarone hcl tab 100 mg
.......................................... 27
amiodarone hcl tab 200 mg
.......................................... 28
amiodarone hcl tab 400 mg
.......................................... 28
AMITIZA CAP 24MCG ...... 61
AMITIZA CAP 8MCG ........ 61
amitriptyline hcl tab 10 mg 40
amitriptyline hcl tab 100 mg
.......................................... 40
amitriptyline hcl tab 150 mg
.......................................... 40
amitriptyline hcl tab 25 mg 40
amitriptyline hcl tab 50 mg 40
amitriptyline hcl tab 75 mg 40
amlodipine besylate tab 10
mg..................................... 31
amlodipine besylate tab 2.5
mg..................................... 31
amlodipine besylate tab 5 mg
.......................................... 31
amlodipine
besylate-benazepril hcl cap
10-20 mg .......................... 24
amlodipine
besylate-benazepril hcl cap
10-40 mg .......................... 24
amlodipine
besylate-benazepril hcl cap
2.5-10 mg ......................... 24
amlodipine
besylate-benazepril hcl cap
5-10 mg ............................ 24
amlodipine
besylate-benazepril hcl cap
5-20 mg ............................ 24
amlodipine
besylate-benazepril hcl cap
5-40 mg ............................ 24
amlodipine
besylate-valsartan tab
10-160 mg ........................ 26
amlodipine
besylate-valsartan tab
10-320 mg ........................ 26
amlodipine
besylate-valsartan tab 5-160
mg..................................... 26
amlodipine
besylate-valsartan tab 5-320
mg..................................... 26
amlodipine-valsartan-hydroc
hlorothiazide tab 10-160-12.5
mg..................................... 26
amlodipine-valsartan-hydroc
hlorothiazide tab 10-160-25
mg..................................... 26
amlodipine-valsartan-hydroc
hlorothiazide tab 10-320-25
81
mg .....................................27
amlodipine-valsartan-hydroc
hlorothiazide tab 5-160-12.5
mg .....................................26
amlodipine-valsartan-hydroc
hlorothiazide tab 5-160-25
mg .....................................26
amnesteem cap 10mg ......74
amnesteem cap 20mg ......74
amnesteem cap 40mg ......74
amoxapine tab 100 mg .....40
amoxapine tab 150 mg .....40
amoxapine tab 25 mg .......40
amoxapine tab 50 mg .......40
amoxicillin & k clavulanate
chew tab 200-28.5 mg ......19
amoxicillin & k clavulanate
chew tab 400-57 mg .........19
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml ......19
amoxicillin & k clavulanate for
susp 250-62.5 mg/5ml ......19
amoxicillin & k clavulanate for
susp 400-57 mg/5ml .........19
amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml ......19
amoxicillin & k clavulanate
tab 250-125 mg .................19
amoxicillin & k clavulanate
tab 500-125 mg .................19
amoxicillin & k clavulanate
tab 875-125 mg .................19
amoxicillin & k clavulanate
tab sr 12hr 1000-62.5 mg ..19
amoxicillin (trihydrate) cap
250 mg ..............................19
amoxicillin (trihydrate) cap
500 mg ..............................19
amoxicillin (trihydrate) chew
tab 125 mg ........................19
amoxicillin (trihydrate) chew
tab 250 mg ........................19
amoxicillin (trihydrate) for
susp 125 mg/5ml ...............19
amoxicillin (trihydrate) for
susp 200 mg/5ml ...............19
amoxicillin (trihydrate) for
susp 250 mg/5ml ...............19
amoxicillin (trihydrate) for
susp 400 mg/5ml ...............19
amoxicillin (trihydrate) tab
500 mg .............................. 19
amoxicillin (trihydrate) tab
875 mg .............................. 19
amphetamine-dextroamphet
amine cap sr 24hr 10 mg .. 48
amphetamine-dextroamphet
amine cap sr 24hr 15 mg .. 48
amphetamine-dextroamphet
amine cap sr 24hr 20 mg .. 48
amphetamine-dextroamphet
amine cap sr 24hr 25 mg .. 48
amphetamine-dextroamphet
amine cap sr 24hr 30 mg .. 48
amphetamine-dextroamphet
amine cap sr 24hr 5 mg .... 48
amphetamine-dextroamphet
amine tab 10 mg ............... 48
amphetamine-dextroamphet
amine tab 12.5 mg ............ 48
amphetamine-dextroamphet
amine tab 15 mg ............... 48
amphetamine-dextroamphet
amine tab 20 mg ............... 48
amphetamine-dextroamphet
amine tab 30 mg ............... 48
amphetamine-dextroamphet
amine tab 5 mg ................. 48
amphetamine-dextroamphet
amine tab 7.5 mg .............. 48
amphotericin b for inj 50 mg
.......................................... 13
ampicillin & sulbactam
sodium for inj 1-0.5 gm ..... 19
ampicillin & sulbactam
sodium for inj 10-5 gm ...... 19
ampicillin & sulbactam
sodium for inj 2-1 gm ........ 19
ampicillin & sulbactam
sodium for iv soln 1-0.5 gm
.......................................... 19
ampicillin & sulbactam
sodium for iv soln 10-5 gm 19
ampicillin & sulbactam
sodium for iv soln 2-1 gm .. 19
ampicillin cap 250 mg ....... 19
ampicillin cap 500 mg ....... 19
ampicillin for susp 125
mg/5ml .............................. 19
ampicillin for susp 250
mg/5ml .............................. 19
ampicillin sodium for inj 1 gm
.......................................... 19
ampicillin sodium for inj 125
mg..................................... 19
ampicillin sodium for inj 2 gm
.......................................... 19
ampicillin sodium for inj 250
mg..................................... 19
ampicillin sodium for inj 500
mg..................................... 19
ampicillin sodium for iv soln 1
gm..................................... 19
ampicillin sodium for iv soln
10 gm................................ 19
ampicillin sodium for iv soln 2
gm..................................... 19
ANAFRANIL
see clomipramine hcl cap
25 mg ............................ 40
see clomipramine hcl cap
50 mg ............................ 41
see clomipramine hcl cap
75 mg ............................ 41
anagrelide hcl cap 0.5 mg . 65
anagrelide hcl cap 1 mg .... 65
ANAPROX
see naproxen sodium tab
275 mg ............................ 7
ANAPROX DS
see naproxen sodium tab
550 mg ............................ 7
anastrozole tab 1 mg ........ 22
ANCOBON
see flucytosine cap 250 mg
...................................... 13
see flucytosine cap 500 mg
...................................... 13
ANDRODERM DIS
2MG/24HR ........................ 51
ANDRODERM DIS
4MG/24HR ........................ 51
ANORO ELLIPT AER
62.5-25 ............................. 72
ANTABUSE
see disulfiram tab 250 mg
...................................... 51
see disulfiram tab 500 mg
...................................... 51
ANUSOL-HC
see hydrocortisone rectal
cream 2.5% ................... 75
see proctozone cre -hc
82
2.5% ..............................75
apexicon oin 0.05% ...........76
APOKYN INJ 10MG/ML ....43
apri tab ..............................54
APRISO CAP 0.375GM ....61
APTIOM TAB 200MG .......35
APTIOM TAB 400MG .......35
APTIOM TAB 600MG .......35
APTIOM TAB 800MG .......35
APTIVUS CAP 250MG .....14
APTIVUS SOL ..................14
ARALAST NP INJ 1000MG
..........................................73
ARALAST NP INJ 400MG.73
ARALAST NP INJ 500MG.73
ARALAST NP INJ 800MG.73
ARALEN
see chloroquine phosphate
tab 500 mg ....................14
aranelle tab .......................54
ARAVA
see leflunomide tab 10 mg
......................................65
see leflunomide tab 20 mg
......................................65
ARCALYST INJ 220MG ....66
ARICEPT
see donepezil
hydrochloride tab 10 mg 39
see donepezil
hydrochloride tab 23 mg 39
see donepezil
hydrochloride tab 5 mg ..39
ARIMIDEX
see anastrozole tab 1 mg
......................................22
aripiprazole tab 10 mg ......44
aripiprazole tab 15 mg ......44
aripiprazole tab 2 mg ........44
aripiprazole tab 20 mg ......44
aripiprazole tab 30 mg ......44
aripiprazole tab 5 mg ........44
ARIXTRA
see fondaparinux sodium
subcutaneous inj 10
mg/0.8ml........................64
see fondaparinux sodium
subcutaneous inj 2.5
mg/0.5ml........................64
see fondaparinux sodium
subcutaneous inj 5
mg/0.4ml ....................... 64
see fondaparinux sodium
subcutaneous inj 7.5
mg/0.6ml ....................... 64
AROMASIN
see exemestane tab 25 mg
...................................... 22
ASACOL HD TAB 800MG 61
ASMANEX 120 AER
220MCG ........................... 73
ASMANEX 14 AER 220MCG
.......................................... 73
ASMANEX 30 AER 110MCG
.......................................... 73
ASMANEX 30 AER 220MCG
.......................................... 73
ASMANEX 60 AER 220MCG
.......................................... 73
ASTEPRO
see azelastine hcl nasal
spray 0.15% (205.5
mcg/spray) .................... 72
ASTEPRO SPR 0.15% ..... 72
atenolol & chlorthalidone tab
100-25 mg......................... 30
atenolol & chlorthalidone tab
50-25 mg........................... 30
atenolol tab 100 mg .......... 30
atenolol tab 25 mg ............ 30
atenolol tab 50 mg ............ 30
ATIVAN
see lorazepam inj 2 mg/ml
...................................... 35
see lorazepam inj 4 mg/ml
...................................... 35
see lorazepam tab 0.5 mg
...................................... 35
see lorazepam tab 1 mg 35
see lorazepam tab 2 mg 35
atorvastatin calcium tab 10
mg (base equivalent) ........ 28
atorvastatin calcium tab 20
mg (base equivalent) ........ 28
atorvastatin calcium tab 40
mg (base equivalent) ........ 28
atorvastatin calcium tab 80
mg (base equivalent) ........ 28
atovaquone susp 750 mg/5ml
.......................................... 12
atovaquone-proguanil hcl tab
250-100 mg....................... 14
atovaquone-proguanil hcl tab
62.5-25 mg ....................... 14
ATRIPLA TAB ................... 15
ATROVENT
see ipratropium bromide
nasal soln 0.03% (21
mcg/spray) .................... 72
see ipratropium bromide
nasal soln 0.06% (42
mcg/spray) .................... 72
ATROVENT HFA AER
17MCG ............................. 72
aubra tab 0.1-0.02 ............ 54
AUGMENTIN
see amoxicillin & k
clavulanate chew tab
200-28.5 mg .................. 19
see amoxicillin & k
clavulanate for susp
250-62.5 mg/5ml ........... 19
see amoxicillin & k
clavulanate tab 500-125
mg ................................. 19
see amoxicillin & k
clavulanate tab 875-125
mg ................................. 19
AUGMENTIN ES-600
see amoxicillin & k
clavulanate for susp
600-42.9 mg/5ml ........... 19
AUGMENTIN XR
see amoxicillin & k
clavulanate tab sr 12hr
1000-62.5 mg ................ 19
AUVI-Q INJ 0.15MG ......... 73
AUVI-Q INJ 0.3MG ........... 73
AVASTIN INJ .................... 22
AVASTIN INJ 400/16ML ... 22
aviane tab ......................... 54
AVINZA
see morphine sulfate
beads cap sr 24hr 120 mg
...................................... 10
see morphine sulfate
beads cap sr 24hr 30 mg
...................................... 10
see morphine sulfate
beads cap sr 24hr 45 mg
...................................... 10
see morphine sulfate
beads cap sr 24hr 60 mg
83
......................................10
see morphine sulfate
beads cap sr 24hr 75 mg
......................................10
see morphine sulfate
beads cap sr 24hr 90 mg
......................................10
AVITA CRE 0.025% ..........74
AVITA GEL 0.025% ..........74
AVODART CAP 0.5MG ....63
AYGESTIN
see norethindrone acetate
tab 5 mg ........................58
azacitidine for inj 100 mg ..21
AZACTAM
see aztreonam for inj 1 gm
......................................12
see aztreonam for inj 2 gm
......................................12
AZACTAM INJ 1GM ..........12
AZACTAM INJ 2GM ..........12
AZACTAM/DEX INJ 1GM .12
AZACTAM/DEX INJ 2GM .12
azathioprine tab 50 mg .....66
azelastine hcl nasal spray
0.1% (137 mcg/spray) .......72
azelastine hcl nasal spray
0.15% (205.5 mcg/spray) ..72
azelastine hcl ophth soln
0.05% ................................71
AZILECT TAB 0.5MG .......43
AZILECT TAB 1MG ..........43
azithromycin for susp 100
mg/5ml ..............................17
azithromycin for susp 200
mg/5ml ..............................17
azithromycin iv for soln 500
mg .....................................18
AZITHROMYCIN POWD
PACK FOR SUSP 1 GM ...18
azithromycin tab 250 mg ...18
azithromycin tab 500 mg ...18
azithromycin tab 600 mg ...18
AZOPT SUS 1% OP .........71
AZOR TAB 10-20MG ........27
AZOR TAB 10-40MG ........27
AZOR TAB 5-20MG ..........27
AZOR TAB 5-40MG ..........27
aztreonam for inj 1 gm ......12
aztreonam for inj 2 gm ......12
AZULFIDINE
see sulfasalazine tab 500
mg ................................. 61
AZULFIDINE EN-TABS
see sulfazine ec tab 500mg
...................................... 61
B
bacitracin ophth oint 500
unit/gm .............................. 70
bacitracin-polymyxin b ophth
oint .................................... 70
bacitracin-polymyxin-neomyc
in-hc ophth oint 1% ........... 70
baclofen tab 10 mg ........... 50
baclofen tab 20 mg ........... 50
BACTRIM
see
sulfamethoxazole-trimetho
prim tab 400-80 mg ....... 13
BACTRIM DS
see
sulfamethoxazole-trimetho
prim tab 800-160 mg ..... 13
BACTROBAN
see mupirocin oint 2% ... 75
balsalazide disodium cap 750
mg ..................................... 61
balziva tab......................... 54
BANZEL SUS 40MG/ML ... 35
BANZEL TAB 200MG ....... 35
BANZEL TAB 400MG ....... 35
BARACLUDE
see entecavir tab 0.5 mg
...................................... 16
see entecavir tab 1 mg .. 16
BARACLUDE SOL
.05MG/ML ......................... 15
BCG VACCINE INJ ........... 67
benazepril &
hydrochlorothiazide tab
10-12.5 mg........................ 24
benazepril &
hydrochlorothiazide tab
20-12.5 mg........................ 24
benazepril &
hydrochlorothiazide tab
20-25 mg........................... 24
benazepril &
hydrochlorothiazide tab
5-6.25 mg.......................... 24
benazepril hcl tab 10 mg ... 25
benazepril hcl tab 20 mg ... 25
benazepril hcl tab 40 mg ... 25
benazepril hcl tab 5 mg ..... 25
BENICAR HCT TAB 20-12.5
.......................................... 27
BENICAR HCT TAB 40-12.5
.......................................... 27
BENICAR HCT TAB
40-25MG........................... 27
BENICAR TAB 20MG ....... 27
BENICAR TAB 40MG ....... 27
BENICAR TAB 5MG ......... 27
BENTYL
see dicyclomine hcl cap 10
mg ................................. 60
see dicyclomine hcl tab 20
mg ................................. 60
BENZAMYCIN
see benzoyl
peroxide-erythromycin gel
5-3%.............................. 75
benzoyl
peroxide-erythromycin gel
5-3% ................................. 75
benztropine mesylate inj 1
mg/ml ................................ 43
benztropine mesylate tab 0.5
mg..................................... 43
benztropine mesylate tab 1
mg..................................... 43
benztropine mesylate tab 2
mg..................................... 43
BEPREVE DRO 1.5%....... 71
BESIVANCE SUS 0.6%.... 70
BETAGAN
see levobunolol hcl ophth
soln 0.5% ...................... 71
betamethasone dipropionate
augmented cream 0.05% .. 76
betamethasone dipropionate
augmented gel 0.05% ....... 76
betamethasone dipropionate
augmented lotion 0.05% ... 76
betamethasone dipropionate
augmented oint 0.05% ...... 76
betamethasone dipropionate
cream 0.05% .................... 76
betamethasone dipropionate
lotion 0.05% ...................... 76
betamethasone dipropionate
oint 0.05%......................... 76
betamethasone valerate
84
cream 0.1% .......................76
betamethasone valerate
lotion 0.1% ........................76
betamethasone valerate oint
0.1% ..................................76
BETAPACE
see sorine tab 120mg ....28
see sorine tab 160mg ....28
see sorine tab 80mg ......28
see sotalol hcl tab 120 mg
......................................28
see sotalol hcl tab 160 mg
......................................28
see sotalol hcl tab 80 mg
......................................28
BETAPACE AF
see sotalol hcl (afib/afl) tab
120 mg ..........................28
see sotalol hcl (afib/afl) tab
160 mg ..........................28
see sotalol hcl (afib/afl) tab
80 mg ............................28
BETASERON INJ 0.3MG ..50
betaxolol hcl ophth soln 0.5%
..........................................71
bethanechol chloride tab 10
mg .....................................63
bethanechol chloride tab 25
mg .....................................63
bethanechol chloride tab 5
mg .....................................63
bethanechol chloride tab 50
mg .....................................63
BETOPTIC-S SUS 0.25% OP
..........................................71
BIAXIN
see clarithromycin for susp
250 mg/5ml....................18
see clarithromycin tab 250
mg .................................18
see clarithromycin tab 500
mg .................................18
BIAXIN XL
see clarithromycin tab sr
24hr 500 mg ..................18
bicalutamide tab 50 mg .....22
BICILLIN L-A INJ 120000019
BICILLIN L-A INJ 240000019
BICILLIN L-A INJ 600000..19
BICNU INJ 100MG............20
BILTRICIDE TAB 600MG..12
bisoprolol &
hydrochlorothiazide tab
10-6.25 mg........................ 30
bisoprolol &
hydrochlorothiazide tab
2.5-6.25 mg....................... 30
bisoprolol &
hydrochlorothiazide tab
5-6.25 mg.......................... 30
bisoprolol fumarate tab 10
mg ..................................... 30
bisoprolol fumarate tab 5 mg
.......................................... 30
BIVIGAM INJ 10% ............ 65
bleomycin sulfate for inj 15
unit .................................... 21
bleomycin sulfate for inj 30
unit .................................... 21
BLEPH-10
see sulfacetamide sodium
ophth soln 10% ............. 70
blephamide oin s.o.p. ........ 70
BONIVA
see ibandronate sodium
tab 150 mg (base
equivalent)..................... 53
BOOSTRIX INJ ................. 67
BOSULIF TAB 100MG ...... 23
BOSULIF TAB 500MG ...... 23
BREO ELLIPTA INH 100-25
.......................................... 74
BREVICON-28
see necon tab 0.5/35 ..... 55
see nortrel tab 0.5/35 .... 55
briellyn tab ........................ 54
BRILINTA TAB 90MG ....... 65
BRIMONIDINE TARTRATE
OPHTH SOLN 0.15% ....... 71
brimonidine tartrate ophth
soln 0.2% .......................... 71
BRINTELLIX TAB 10MG... 40
BRINTELLIX TAB 20MG... 40
BRINTELLIX TAB 5MG..... 40
BROMFENAC SODIUM
OPHTH SOLN 0.09% (BASE
EQUIV) (ONCE-DAILY) .... 70
bromfenac sodium ophth soln
0.09% (base equivalent) ... 71
bromocriptine mesylate cap 5
mg ..................................... 43
bromocriptine mesylate tab
2.5 mg............................... 43
budesonide cap sr 24hr 3 mg
.......................................... 61
budesonide inhalation susp
0.25 mg/2ml ...................... 73
budesonide inhalation susp
0.5 mg/2ml ........................ 73
bumetanide inj 0.25 mg/ml 33
bumetanide tab 0.5 mg ..... 33
bumetanide tab 1 mg ........ 33
bumetanide tab 2 mg ........ 33
BUPHENYL
see sodium phenylbutyrate
oral powder 3
gm/teaspoonful.............. 56
buprenorphine hcl sl tab 2 mg
(base equiv) ...................... 51
buprenorphine hcl sl tab 8 mg
(base equiv) ...................... 51
buprenorphine hcl-naloxone
hcl sl tab 2-0.5 mg (base
equiv) ................................ 51
buprenorphine hcl-naloxone
hcl sl tab 8-2 mg (base equiv)
.......................................... 51
buproban tab 150mg......... 51
bupropion hcl tab 100 mg . 40
bupropion hcl tab 75 mg ... 40
bupropion hcl tab sr 12hr 100
mg..................................... 40
bupropion hcl tab sr 12hr 150
mg..................................... 40
bupropion hcl tab sr 12hr 200
mg..................................... 40
bupropion hcl tab sr 24hr 150
mg..................................... 40
bupropion hcl tab sr 24hr 300
mg..................................... 40
buspirone hcl tab 10 mg ... 35
buspirone hcl tab 15 mg ... 35
buspirone hcl tab 30 mg ... 35
buspirone hcl tab 5 mg ..... 35
buspirone hcl tab 7.5 mg .. 35
BUSULFEX INJ 6MG/ML .. 20
butorphanol tartrate inj 1
mg/ml .................................. 8
butorphanol tartrate inj 2
mg/ml .................................. 8
BYSTOLIC TAB 10MG ..... 30
BYSTOLIC TAB 2.5MG .... 30
BYSTOLIC TAB 20MG ..... 30
85
BYSTOLIC TAB 5MG .......30
C
cabergoline tab 0.5 mg .....58
cafergot tab 1-100mg ........49
CALAN
see verapamil hcl tab 120
mg .................................32
see verapamil hcl tab 80
mg .................................32
CALAN SR
see verapamil hcl tab cr
120 mg ..........................32
see verapamil hcl tab cr
180 mg ..........................32
see verapamil hcl tab cr
240 mg ..........................32
calcipotriene cream 0.005%
..........................................75
calcipotriene oint 0.005% ..75
calcipotriene soln 0.005% (50
mcg/ml) .............................75
calcitonin (salmon) nasal soln
200 unit/act .......................58
calcitrene oin 0.005% ........75
calcitriol cap 0.25 mcg ......70
calcitriol cap 0.5 mcg ........70
calcitriol inj 1 mcg/ml .........70
calcitriol oral soln 1 mcg/ml
..........................................70
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca) .....................................58
camila tab 0.35mg .............54
CAMPTOSAR
see irinotecan hcl inj 100
mg/5ml (20 mg/ml) ........24
see irinotecan hcl inj 40
mg/2ml (20 mg/ml) ........24
CANASA SUP 1000MG ....61
CANCIDAS INJ 50MG ......13
CANCIDAS INJ 70MG ......13
CAPASTAT SUL INJ 1GM 15
CAPRELSA TAB 100MG ..23
CAPRELSA TAB 300MG ..23
captopril &
hydrochlorothiazide tab
25-15 mg ...........................25
captopril &
hydrochlorothiazide tab
25-25 mg ...........................25
captopril &
hydrochlorothiazide tab
50-15 mg........................... 25
captopril &
hydrochlorothiazide tab
50-25 mg........................... 25
captopril tab 100 mg ......... 25
captopril tab 12.5 mg ........ 25
captopril tab 25 mg ........... 25
captopril tab 50 mg ........... 25
CARAFATE
see sucralfate tab 1 gm . 62
CARBAGLU TAB 200MG . 56
carbamazepine cap sr 12hr
100 mg .............................. 35
carbamazepine cap sr 12hr
200 mg .............................. 35
carbamazepine cap sr 12hr
300 mg .............................. 35
carbamazepine chew tab 100
mg ..................................... 35
carbamazepine susp 100
mg/5ml .............................. 36
carbamazepine tab 200 mg
.......................................... 36
carbamazepine tab sr 12hr
200 mg .............................. 36
carbamazepine tab sr 12hr
400 mg .............................. 36
CARBATROL
see carbamazepine cap sr
12hr 100 mg .................. 35
see carbamazepine cap sr
12hr 200 mg .................. 35
see carbamazepine cap sr
12hr 300 mg .................. 35
carbidopa & levodopa orally
disintegrating tab 10-100 mg
.......................................... 43
carbidopa & levodopa orally
disintegrating tab 25-100 mg
.......................................... 43
carbidopa & levodopa orally
disintegrating tab 25-250 mg
.......................................... 43
carbidopa & levodopa tab
10-100 mg......................... 43
carbidopa & levodopa tab
25-100 mg......................... 43
carbidopa & levodopa tab
25-250 mg......................... 43
carbidopa & levodopa tab cr
25-100 mg ........................ 43
carbidopa & levodopa tab cr
50-200 mg ........................ 43
CARBIDOPA-LEVODOPA-E
NTACAPONE TABS
12.5-50-200 MG................ 43
CARBIDOPA-LEVODOPA-E
NTACAPONE TABS
18.75-75-200 MG.............. 43
CARBIDOPA-LEVODOPA-E
NTACAPONE TABS
25-100-200 MG................. 43
CARBIDOPA-LEVODOPA-E
NTACAPONE TABS
31.25-125-200 MG............ 43
CARBIDOPA-LEVODOPA-E
NTACAPONE TABS
37.5-150-200 MG.............. 43
CARBIDOPA-LEVODOPA-E
NTACAPONE TABS
50-200-200 MG................. 43
carboplatin iv soln 150
mg/15ml ............................ 23
carboplatin iv soln 450
mg/45ml ............................ 23
carboplatin iv soln 50 mg/5ml
.......................................... 23
carboplatin iv soln 600
mg/60ml ............................ 23
CARDIZEM
see diltiazem hcl tab 120
mg ................................. 32
see diltiazem hcl tab 30 mg
...................................... 32
see diltiazem hcl tab 60 mg
...................................... 32
CARDIZEM CD
see diltiazem hcl coated
beads cap sr 24hr 120 mg
...................................... 31
see diltiazem hcl coated
beads cap sr 24hr 180 mg
...................................... 31
see diltiazem hcl coated
beads cap sr 24hr 240 mg
...................................... 31
see diltiazem hcl coated
beads cap sr 24hr 300 mg
...................................... 31
see diltiazem hcl coated
beads cap sr 24hr 360 mg
86
......................................31
CARDURA
see doxazosin mesylate
tab 1 mg ........................26
see doxazosin mesylate
tab 2 mg ........................26
see doxazosin mesylate
tab 4 mg ........................26
see doxazosin mesylate
tab 8 mg ........................26
CARIMUNE NF INJ 12GM 65
CARIMUNE NF INJ 3GM ..65
CARIMUNE NF INJ 6GM ..65
CARNITOR
see levocarnitine inj 200
mg/ml.............................56
see levocarnitine oral soln
1 gm/10ml (10%) ...........56
see levocarnitine tab 330
mg .................................56
carteolol hcl ophth soln 1%
..........................................71
carvedilol tab 12.5 mg .......30
carvedilol tab 25 mg ..........30
carvedilol tab 3.125 mg .....30
carvedilol tab 6.25 mg .......30
CASODEX
see bicalutamide tab 50
mg .................................22
CATAPRES
see clonidine hcl tab 0.1
mg .................................34
see clonidine hcl tab 0.2
mg .................................34
see clonidine hcl tab 0.3
mg .................................34
CATAPRES-TTS-1
see clonidine hcl td patch
weekly 0.1 mg/24hr .......34
CATAPRES-TTS-2
see clonidine hcl td patch
weekly 0.2 mg/24hr .......34
CATAPRES-TTS-3
see clonidine hcl td patch
weekly 0.3 mg/24hr .......34
CAYSTON INH 75MG .......12
cefaclor cap 250 mg ..........16
cefaclor cap 500 mg ..........16
cefaclor er tab 500mg .......16
cefaclor for susp 125 mg/5ml
..........................................16
cefaclor for susp 250 mg/5ml
.......................................... 16
cefaclor for susp 375 mg/5ml
.......................................... 16
cefadroxil cap 500 mg ....... 16
cefadroxil for susp 250
mg/5ml .............................. 16
cefadroxil for susp 500
mg/5ml .............................. 16
cefadroxil tab 1 gm ........... 16
cefazolin inj 1gm/50ml ...... 16
cefazolin sodium for inj 1 gm
.......................................... 16
cefazolin sodium for inj 10 gm
.......................................... 16
cefazolin sodium for inj 20 gm
.......................................... 16
cefazolin sodium for inj 500
mg ..................................... 16
cefazolin sodium for iv soln 1
gm ..................................... 16
cefdinir cap 300 mg .......... 16
cefdinir for susp 125 mg/5ml
.......................................... 16
cefdinir for susp 250 mg/5ml
.......................................... 16
cefepime hcl for inj 1 gm ... 16
cefepime hcl for inj 2 gm ... 16
cefixime for susp 100 mg/5ml
.......................................... 16
cefixime for susp 200 mg/5ml
.......................................... 16
cefotaxime sodium for inj 1
gm ..................................... 17
cefotaxime sodium for inj 2
gm ..................................... 17
cefotaxime sodium for inj 500
mg ..................................... 17
cefoxitin sodium for inj 10 gm
.......................................... 17
cefoxitin sodium for iv soln 1
gm ..................................... 17
cefoxitin sodium for iv soln 2
gm ..................................... 17
cefpodoxime proxetil for susp
100 mg/5ml ....................... 17
cefpodoxime proxetil for susp
50 mg/5ml ......................... 17
cefpodoxime proxetil tab 100
mg ..................................... 17
cefpodoxime proxetil tab 200
mg..................................... 17
cefprozil for susp 125 mg/5ml
.......................................... 17
cefprozil for susp 250 mg/5ml
.......................................... 17
cefprozil tab 250 mg ......... 17
cefprozil tab 500 mg ......... 17
ceftazidime for inj 1 gm ..... 17
ceftazidime for inj 2 gm ..... 17
ceftazidime for inj 6 gm ..... 17
CEFTAZIDIME/ SOL D5W
1GM .................................. 17
CEFTAZIDIME/ SOL D5W
2GM .................................. 17
CEFTIN
see cefuroxime axetil tab
250 mg .......................... 17
see cefuroxime axetil tab
500 mg .......................... 17
ceftriaxone sodium for inj 1
gm..................................... 17
ceftriaxone sodium for inj 10
gm..................................... 17
ceftriaxone sodium for inj 2
gm..................................... 17
ceftriaxone sodium for inj 250
mg..................................... 17
ceftriaxone sodium for inj 500
mg..................................... 17
ceftriaxone sodium for iv soln
1 gm.................................. 17
ceftriaxone sodium for iv soln
2 gm.................................. 17
cefuroxime axetil tab 250 mg
.......................................... 17
cefuroxime axetil tab 500 mg
.......................................... 17
cefuroxime inj 7.5gm......... 17
cefuroxime sodium for inj 1.5
gm..................................... 17
cefuroxime sodium for inj 7.5
gm..................................... 17
cefuroxime sodium for inj 750
mg..................................... 17
cefuroxime sodium for iv soln
1.5 gm............................... 17
CELEBREX
see celecoxib cap 100 mg
........................................ 7
see celecoxib cap 200 mg
........................................ 7
87
see celecoxib cap 400 mg
........................................7
see celecoxib cap 50 mg .7
celecoxib cap 100 mg .........7
celecoxib cap 200 mg .........7
celecoxib cap 400 mg .........7
celecoxib cap 50 mg ...........7
CELEXA
see citalopram
hydrobromide tab 10 mg
(base equiv)...................40
see citalopram
hydrobromide tab 20 mg
(base equiv)...................40
see citalopram
hydrobromide tab 40 mg
(base equiv)...................40
CELLCEPT
see mycophenolate mofetil
cap 250 mg....................67
see mycophenolate mofetil
tab 500 mg ....................67
CELONTIN CAP 300MG ...36
cephalexin cap 250 mg .....17
cephalexin cap 500 mg .....17
cephalexin for susp 125
mg/5ml ..............................17
cephalexin for susp 250
mg/5ml ..............................17
CERDELGA CAP 84MG ...56
CEREZYME INJ 200UNIT 56
CEREZYME INJ 400UNIT 56
CERVARIX INJ .................67
cetirizine hcl oral soln 1
mg/ml (5 mg/5ml) ..............72
cevimeline hcl cap 30 mg ..78
CHANTIX PAK 0.5& 1MG .51
CHANTIX PAK 1MG .........51
CHANTIX TAB 0.5MG ......51
CHANTIX TAB 1MG .........51
CHEMET CAP 100MG ......54
chlorhexidine gluconate soln
0.12% ................................78
chloroquine phosphate tab
250 mg ..............................14
chloroquine phosphate tab
500 mg ..............................14
chlorothiazide tab 250 mg .33
chlorothiazide tab 500 mg .33
chlorpromaz inj 50mg/2ml .44
chlorpromazine hcl tab 10 mg
.......................................... 44
chlorpromazine hcl tab 100
mg ..................................... 44
chlorpromazine hcl tab 200
mg ..................................... 44
chlorpromazine hcl tab 25 mg
.......................................... 44
chlorpromazine hcl tab 50 mg
.......................................... 44
chlorthalidone tab 25 mg ... 33
chlorthalidone tab 50 mg ... 33
cholestyramine light powder
packets 4 gm .................... 29
cholestyramine powder 4
gm/dose ............................ 29
cholestyramine powder
packets 4 gm .................... 29
choline fenofibrate cap dr 135
mg (fenofibric acid equiv) .. 29
choline fenofibrate cap dr 45
mg (fenofibric acid equiv) .. 29
ciclopirox gel 0.77% .......... 75
ciclopirox olamine cream
0.77% (base equiv) ........... 75
ciclopirox olamine susp
0.77% (base equiv) ........... 75
ciclopirox shampoo 1% ..... 75
cilostazol tab 100 mg ........ 65
cilostazol tab 50 mg .......... 65
CILOXAN
see ciprofloxacin hcl ophth
soln 0.3% ...................... 70
CILOXAN OIN 0.3% OP ... 70
CIMZIA KIT ....................... 65
CIMZIA KIT STARTER ..... 65
CIMZIA PREFL KIT
200MG/ML ........................ 65
CINRYZE SOL 500 UNIT.. 65
CIPRO
see ciprofloxacin for oral
susp 250 mg/5ml (5%) (5
gm/100ml) ..................... 18
see ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) ............... 18
see ciprofloxacin hcl tab
250 mg (base equiv)...... 18
see ciprofloxacin hcl tab
500 mg (base equiv)...... 18
CIPRO I.V.-IN D5W
see ciprofloxacin 200
mg/100ml in d5w ........... 18
see ciprofloxacin 400
mg/200ml in d5w ........... 18
CIPRO XR
see
ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 1000
mg(base eq) .................. 18
see
ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 500 mg
(base eq) ....................... 18
CIPRODEX SUS 0.3-0.1%78
ciprofloxacin 200 mg/100ml
in d5w ............................... 18
ciprofloxacin 400 mg/200ml
in d5w ............................... 18
ciprofloxacin for oral susp
250 mg/5ml (5%) (5
gm/100ml) ......................... 18
ciprofloxacin for oral susp
500 mg/5ml (10%) (10
gm/100ml) ......................... 18
ciprofloxacin hcl ophth soln
0.3% ................................. 70
ciprofloxacin hcl tab 100 mg
(base equiv) ...................... 18
ciprofloxacin hcl tab 250 mg
(base equiv) ...................... 18
ciprofloxacin hcl tab 500 mg
(base equiv) ...................... 18
ciprofloxacin hcl tab 750 mg
(base equiv) ...................... 18
ciprofloxacin iv soln 200
mg/20ml (1%) ................... 18
ciprofloxacin iv soln 400
mg/40ml (1%) ................... 18
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
.......................................... 18
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
.......................................... 18
cisplatin inj 100 mg/100ml (1
mg/ml) ............................... 24
cisplatin inj 200 mg/200ml (1
mg/ml) ............................... 24
cisplatin inj 50 mg/50ml (1
mg/ml) ............................... 23
citalopram hydrobromide oral
soln 10 mg/5ml ................. 40
88
citalopram hydrobromide tab
10 mg (base equiv) ...........40
citalopram hydrobromide tab
20 mg (base equiv) ...........40
citalopram hydrobromide tab
40 mg (base equiv) ...........40
cladribine inj 1 mg/ml ........21
CLAFORAN
see cefotaxime sodium for
inj 1 gm ..........................17
see cefotaxime sodium for
inj 2 gm ..........................17
see cefotaxime sodium for
inj 500 mg ......................17
claravis cap 10mg .............75
claravis cap 20mg .............75
claravis cap 30mg .............75
claravis cap 40mg .............75
clarithromycin for susp 125
mg/5ml ..............................18
clarithromycin for susp 250
mg/5ml ..............................18
clarithromycin tab 250 mg .18
clarithromycin tab 500 mg .18
clarithromycin tab sr 24hr 500
mg .....................................18
CLEOCIN
see clindamycin hcl cap
150 mg ..........................12
see clindamycin hcl cap
300 mg ..........................12
see clindamycin hcl cap 75
mg .................................12
see clindamycin phosphate
vaginal cream 2% ..........63
CLEOCIN PEDIATRIC
GRANULE
see clindamycin palmitate
hcl for soln 75 mg/5ml
(base equiv)...................12
CLEOCIN PHOSPHATE
see clindamycin phosphate
inj 300 mg/2ml ...............12
see clindamycin phosphate
inj 600 mg/4ml ...............12
see clindamycin phosphate
inj 9 gm/60ml .................12
see clindamycin phosphate
inj 900 mg/6ml ...............12
see clindamycin phosphate
iv soln 600 mg/4ml ........12
see clindamycin phosphate
iv soln 900 mg/6ml ........ 12
CLEOCIN-T
see clindamycin phosphate
gel 1% ........................... 75
see clindamycin phosphate
lotion 1% ....................... 75
see clindamycin phosphate
soln 1% ......................... 75
see clindamycin phosphate
swab 1%........................ 75
CLIMARA
see estradiol td patch
weekly 0.025 mg/24hr ... 56
see estradiol td patch
weekly 0.0375 mg/24hr
(37.5 mcg/24hr) ............. 56
see estradiol td patch
weekly 0.05 mg/24hr ..... 56
see estradiol td patch
weekly 0.06 mg/24hr ..... 56
see estradiol td patch
weekly 0.075 mg/24hr ... 56
see estradiol td patch
weekly 0.1 mg/24hr ....... 56
clindamycin hcl cap 150 mg
.......................................... 12
clindamycin hcl cap 300 mg
.......................................... 12
clindamycin hcl cap 75 mg 12
clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
.......................................... 12
clindamycin phosphate gel
1% .................................... 75
clindamycin phosphate inj
300 mg/2ml ....................... 12
clindamycin phosphate inj
600 mg/4ml ....................... 12
clindamycin phosphate inj 9
gm/60ml ............................ 12
clindamycin phosphate inj
900 mg/6ml ....................... 12
clindamycin phosphate iv
soln 300 mg/2ml ............... 12
clindamycin phosphate iv
soln 600 mg/4ml ............... 12
clindamycin phosphate iv
soln 900 mg/6ml ............... 12
clindamycin phosphate lotion
1% .................................... 75
clindamycin phosphate soln
1% .................................... 75
clindamycin phosphate swab
1% .................................... 75
clindamycin phosphate
vaginal cream 2% ............. 63
CLINIMIX INJ 2.75/D5W ... 68
CLINIMIX INJ 4.25/D10 .... 68
CLINIMIX INJ 4.25/D20 .... 68
CLINIMIX INJ 4.25/D25 .... 68
CLINIMIX INJ 4.25/D5W ... 68
CLINIMIX INJ 5%/D15W ... 68
CLINIMIX INJ 5%/D20W ... 68
CLINIMIX INJ 5%/D25W ... 68
clobetasol propionate cream
0.05% ............................... 76
clobetasol propionate
emollient base cream 0.05%
.......................................... 76
clobetasol propionate gel
0.05% ............................... 76
clobetasol propionate oint
0.05% ............................... 76
clobetasol propionate soln
0.05% ............................... 76
clomipramine hcl cap 25 mg
.......................................... 40
clomipramine hcl cap 50 mg
.......................................... 41
clomipramine hcl cap 75 mg
.......................................... 41
clonazepam orally
disintegrating tab 0.125 mg
.......................................... 36
clonazepam orally
disintegrating tab 0.25 mg 36
clonazepam orally
disintegrating tab 0.5 mg .. 36
clonazepam orally
disintegrating tab 1 mg ..... 36
clonazepam orally
disintegrating tab 2 mg ..... 36
clonazepam tab 0.5 mg .... 36
clonazepam tab 1 mg ....... 36
clonazepam tab 2 mg ....... 36
clonidine hcl tab 0.1 mg .... 34
clonidine hcl tab 0.2 mg .... 34
clonidine hcl tab 0.3 mg .... 34
clonidine hcl td patch weekly
0.1 mg/24hr ...................... 34
clonidine hcl td patch weekly
89
0.2 mg/24hr .......................34
clonidine hcl td patch weekly
0.3 mg/24hr .......................34
clopidogrel bisulfate tab 75
mg (base equiv) ................65
clorazepate dipotassium tab
15 mg ................................36
clorazepate dipotassium tab
3.75 mg .............................36
clorazepate dipotassium tab
7.5 mg ...............................36
clotrimazole cream 1% ......75
clotrimazole soln 1% .........75
clotrimazole troche 10 mg .78
CLOZAPINE ORALLY
DISINTEGRATING TAB 100
MG ....................................44
CLOZAPINE ORALLY
DISINTEGRATING TAB 12.5
MG ....................................44
CLOZAPINE ORALLY
DISINTEGRATING TAB 25
MG ....................................44
clozapine tab 100 mg ........45
clozapine tab 200 mg ........45
clozapine tab 25 mg ..........45
clozapine tab 50 mg ..........45
CLOZARIL
see clozapine tab 100 mg
......................................45
see clozapine tab 25 mg 45
COARTEM TAB 20-120MG
..........................................14
COGENTIN
see benztropine mesylate
inj 1 mg/ml .....................43
COLAZAL
see balsalazide disodium
cap 750 mg....................61
colchicine w/ probenecid tab
0.5-500 mg ..........................7
COLCRYS TAB 0.6MG .......7
COLESTID
see colestipol hcl granule
packets 5 gm .................29
see colestipol hcl granules
5 gm ..............................29
see colestipol hcl tab 1 gm
......................................29
colestipol hcl granule packets
5 gm ..................................29
colestipol hcl granules 5 gm
.......................................... 29
colestipol hcl tab 1 gm ...... 29
colistimethate sodium for inj
150 mg .............................. 12
COLY-MYCIN M
see colistimethate sodium
for inj 150 mg ................ 12
COLYTE-FLAVOR PACKS
see gavilyte-c sol ........... 61
COMBIGAN SOL 0.2/0.5%
.......................................... 71
COMBIPATCH DIS .05/.14
.......................................... 56
COMBIPATCH DIS .05/.25
.......................................... 56
COMBIVENT AER
RESPIMAT ....................... 72
COMBIVIR
see lamivudine-zidovudine
tab 150-300 mg ............. 15
COMETRIQ KIT 100MG ... 23
COMETRIQ KIT 140MG ... 23
COMETRIQ KIT 60MG ..... 23
COMPAZINE
see prochlorperazine
maleate tab 10 mg (base
equivalent)..................... 60
see prochlorperazine
maleate tab 5 mg (base
equivalent)..................... 60
COMPLERA TAB .............. 15
COMTAN
see entacapone tab 200
mg ................................. 43
COMVAX INJ .................... 67
CONDYLOX
see podofilox soln 0.5% 78
constulose sol 10gm/15 .... 61
COPAXONE INJ 20MG/ML
.......................................... 50
COPAXONE INJ 40MG/ML
.......................................... 50
COPEGUS
see ribasphere tab 200mg
...................................... 16
see ribavirin tab 200 mg 16
CORDARONE
see amiodarone hcl tab
200 mg .......................... 28
see pacerone tab 200mg
...................................... 28
COREG
see carvedilol tab 12.5 mg
...................................... 30
see carvedilol tab 25 mg 30
see carvedilol tab 3.125
mg ................................. 30
see carvedilol tab 6.25 mg
...................................... 30
CORGARD
see nadolol tab 20 mg ... 31
see nadolol tab 40 mg ... 31
see nadolol tab 80 mg ... 31
cormax scalp sol 0.05% .... 76
CORTEF
see hydrocortisone tab 10
mg ................................. 57
see hydrocortisone tab 20
mg ................................. 57
see hydrocortisone tab 5
mg ................................. 57
CORTENEMA
see hydrocortisone enema
100 mg/60ml ................. 61
cortisone acetate tab 25 mg
.......................................... 57
CORTISPORIN
see
neomycin-polymyxin-hc
otic soln 1% ................... 78
COSOPT
see dorzolamide
hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml ....... 71
COUMADIN
see jantoven tab 10mg .. 64
see jantoven tab 1mg .... 64
see jantoven tab 2.5mg . 64
see jantoven tab 2mg .... 64
see jantoven tab 3mg .... 64
see jantoven tab 4mg .... 64
see jantoven tab 5mg .... 64
see jantoven tab 6mg .... 64
see jantoven tab 7.5mg . 64
see warfarin sodium tab 1
mg ................................. 64
see warfarin sodium tab 10
mg ................................. 65
see warfarin sodium tab 2
mg ................................. 64
see warfarin sodium tab
90
2.5 mg ...........................64
see warfarin sodium tab 3
mg .................................64
see warfarin sodium tab 4
mg .................................64
see warfarin sodium tab 5
mg .................................64
see warfarin sodium tab 6
mg .................................64
see warfarin sodium tab
7.5 mg ...........................65
COUMADIN TAB 10MG ....64
COUMADIN TAB 1MG ......63
COUMADIN TAB 2.5MG ...63
COUMADIN TAB 2MG ......63
COUMADIN TAB 3MG ......63
COUMADIN TAB 4MG ......63
COUMADIN TAB 5MG ......63
COUMADIN TAB 6MG ......63
COUMADIN TAB 7.5MG ...64
COZAAR
see losartan potassium tab
100 mg ..........................27
see losartan potassium tab
25 mg ............................27
see losartan potassium tab
50 mg ............................27
CREON CAP 12000UNT ..62
CREON CAP 24000UNT ..62
CREON CAP 3000UNIT ...62
CREON CAP 36000UNT ..62
CREON CAP 6000UNIT ...62
CRESTOR TAB 10MG ......28
CRESTOR TAB 20MG ......28
CRESTOR TAB 40MG ......28
CRESTOR TAB 5MG ........28
CRIXIVAN CAP 200MG ....14
CRIXIVAN CAP 400MG ....14
cromolyn sodium ophth soln
4% .....................................71
cromolyn sodium oral conc
100 mg/5ml .......................61
cromolyn sodium soln nebu
20 mg/2ml .........................73
cryselle-28 tab 28 tabs ......54
CUBICIN SOL 500MG ......12
CUTIVATE
see fluticasone propionate
cream 0.05% .................77
CUVPOSA SOL 1MG/5ML60
cyclafem tab 1/35 ..............54
cyclafem tab 7/7/7 ............. 54
CYCLESSA
see velivet pak .............. 56
cyclobenzaprine hcl tab 10
mg ..................................... 50
cyclobenzaprine hcl tab 5 mg
.......................................... 50
CYCLOPHOSPH CAP 25MG
.......................................... 20
CYCLOPHOSPH CAP 50MG
.......................................... 20
cyclophosphamide for inj 1
gm ..................................... 20
cyclophosphamide for inj 2
gm ..................................... 20
cyclophosphamide for inj 500
mg ..................................... 20
cycloserine cap 250 mg .... 15
cyclosporine cap 100 mg .. 66
cyclosporine cap 25 mg .... 66
cyclosporine iv soln 50 mg/ml
.......................................... 66
cyclosporine modified cap
100 mg .............................. 67
cyclosporine modified cap 25
mg ..................................... 66
cyclosporine modified cap 50
mg ..................................... 66
cyclosporine modified oral
soln 100 mg/ml ................. 67
CYKLOKAPRON
see tranexamic acid inj 100
mg/ml ............................ 65
CYMBALTA
see duloxetine hcl enteric
coated pellets cap 20 mg
...................................... 41
see duloxetine hcl enteric
coated pellets cap 30 mg
...................................... 41
see duloxetine hcl enteric
coated pellets cap 60 mg
...................................... 41
CYSTADANE POW .......... 56
CYSTAGON CAP 150MG. 56
CYSTAGON CAP 50MG... 56
cytarabine inj 20 mg/ml ..... 21
CYTOMEL
see liothyronine sodium
tab 25 mcg .................... 59
see liothyronine sodium
tab 5 mcg ...................... 59
see liothyronine sodium
tab 50 mcg .................... 59
CYTOTEC
see misoprostol tab 100
mcg ............................... 62
see misoprostol tab 200
mcg ............................... 62
CYTOVENE
see ganciclovir sodium for
inj 500 mg ..................... 16
D
D.H.E. 45
see dihydroergotamine
mesylate inj 1 mg/ml ..... 49
D10W/NACL INJ 0.2%...... 69
D5W/LYTES INJ #48 ........ 69
D5W/NACL INJ 0.3%........ 69
dacarbazine for inj 200 mg 20
DALIRESP TAB 500MCG . 73
danazol cap 100 mg ......... 56
danazol cap 200 mg ......... 56
danazol cap 50 mg ........... 56
DANTRIUM
see dantrolene sodium cap
25 mg ............................ 50
see dantrolene sodium cap
50 mg ............................ 51
dantrolene sodium cap 100
mg..................................... 51
dantrolene sodium cap 25 mg
.......................................... 50
dantrolene sodium cap 50 mg
.......................................... 51
dapsone tab 100 mg ......... 12
dapsone tab 25 mg ........... 12
DAPTACEL INJ ................ 67
DARAPRIM TAB 25MG .... 12
daunorubicin hcl inj 5 mg/ml
(base equiv) ...................... 21
DDAVP
see desmopressin acetate
inj 4 mcg/ml ................... 59
see desmopressin acetate
nasal spray soln 0.01% . 59
see desmopressin acetate
tab 0.1 mg ..................... 59
see desmopressin acetate
tab 0.2 mg ..................... 59
deblitane tab 0.35mg ........ 54
DELESTROGEN
91
see estradiol valerate im in
oil 20 mg/ml ...................56
delyla tab 0.1-0.02 ............54
DELZICOL CAP 400MG ...61
DEMADEX
see torsemide tab 10 mg
......................................33
see torsemide tab 100 mg
......................................33
see torsemide tab 20 mg
......................................33
see torsemide tab 5 mg .33
DEMSER CAP 250MG .....34
DENAVIR CRE 1% ...........76
DEPACON
see valproate sodium inj
100 mg/ml......................39
DEPAKENE
see valproate sodium
syrup 250 mg/5ml (base
equiv).............................39
see valproic acid cap 250
mg .................................39
DEPAKOTE
see divalproex sodium tab
delayed release 125 mg 36
see divalproex sodium tab
delayed release 250 mg 36
see divalproex sodium tab
delayed release 500 mg 37
DEPAKOTE ER
see divalproex sodium tab
sr 24 hr 250 mg .............37
see divalproex sodium tab
sr 24 hr 500 mg .............37
DEPAKOTE SPRINKLES
see divalproex sodium cap
sprinkle 125 mg .............36
DEPEN TITRA TAB 250MG
..........................................54
DEPO-MEDROL
see methylprednisolone
acetate inj susp 40 mg/ml
......................................57
see methylprednisolone
acetate inj susp 80 mg/ml
......................................57
DEPO-PROVERA
CONTRACEPTIV
see medroxyprogesterone
acetate im susp 150 mg/ml
...................................... 55
DEPO-PROVERA INJ
400/ML .............................. 22
DEPO-TESTOSTERONE
see testosterone cypionate
im inj in oil 200 mg/ml .... 51
DERMA-SMOOTHE/FS
BODY
see fluocinolone acetonide
oil 0.01% (body oil) ........ 77
DERMA-SMOOTHE/FS
SCALP
see fluocin acet oil scalp76
DERMOTIC
see fluocinolone acetonide
(otic) oil 0.01% .............. 78
desipramine hcl tab 10 mg 41
desipramine hcl tab 100 mg
.......................................... 41
desipramine hcl tab 150 mg
.......................................... 41
desipramine hcl tab 25 mg 41
desipramine hcl tab 50 mg 41
desipramine hcl tab 75 mg 41
desmopressin acetate inj 4
mcg/ml .............................. 59
DESMOPRESSIN ACETATE
NASAL SOLN 0.01%
(REFRIGERATED) ........... 59
desmopressin acetate nasal
spray soln 0.01% .............. 59
desmopressin acetate nasal
spray soln 0.01%
(refrigerated) ..................... 59
desmopressin acetate tab 0.1
mg ..................................... 59
desmopressin acetate tab 0.2
mg ..................................... 59
DESOGEN
see apri tab ................... 54
see emoquette tab......... 54
see reclipsen tab ........... 55
desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01
mg(21/5) ........................... 54
DESONIDE CREAM 0.05%
.......................................... 76
desonide lotion 0.05%....... 76
desonide oint 0.05% ......... 76
DESOWEN
see desonide lotion 0.05%
...................................... 76
see desonide oint 0.05%
...................................... 76
desoximetasone cream
0.05% ............................... 76
desoximetasone cream
0.25% ............................... 76
desoximetasone gel 0.05%
.......................................... 76
DESOXIMETASONE OINT
0.05% ............................... 76
desoximetasone oint 0.25%
.......................................... 76
DETROL
see tolterodine tartrate tab
1 mg .............................. 63
see tolterodine tartrate tab
2 mg .............................. 63
dexamethason con 1mg/ml
.......................................... 57
dexamethasone elixir 0.5
mg/5ml .............................. 57
dexamethasone sod
phosphate preservative free
inj 10 mg/ml ...................... 57
dexamethasone sodium
phosphate inj 10 mg/ml ..... 57
dexamethasone sodium
phosphate inj 100 mg/10ml
.......................................... 57
dexamethasone sodium
phosphate inj 120 mg/30ml
.......................................... 57
dexamethasone sodium
phosphate inj 20 mg/5ml ... 57
dexamethasone sodium
phosphate ophth soln 0.1%
.......................................... 71
dexamethasone soln 0.5
mg/5ml .............................. 57
dexamethasone tab 0.5 mg
.......................................... 57
dexamethasone tab 0.75 mg
.......................................... 57
dexamethasone tab 1 mg . 57
dexamethasone tab 1.5 mg
.......................................... 57
dexamethasone tab 2 mg . 57
dexamethasone tab 4 mg . 57
dexamethasone tab 6 mg . 57
DEXILANT CAP 30MG DR
92
..........................................62
DEXILANT CAP 60MG DR
..........................................62
dexrazoxane for inj 250 mg
..........................................24
DEXTROSE 10% W/
SODIUM CHLORIDE 0.45%
..........................................69
DEXTROSE 2.5% W/
SODIUM CHLORIDE 0.45%
..........................................69
DEXTROSE 5% IN
LACTATED RINGERS ......69
DEXTROSE 5% W/ SODIUM
CHLORIDE 0.2% ..............69
DEXTROSE 5% W/ SODIUM
CHLORIDE 0.225% ..........69
DEXTROSE 5% W/ SODIUM
CHLORIDE 0.33% ............69
DEXTROSE 5% W/ SODIUM
CHLORIDE 0.45% ............69
DEXTROSE 5% W/ SODIUM
CHLORIDE 0.9% ..............69
DEXTROSE INJ 10% ........69
DEXTROSE INJ 5% ..........69
DEXTROSE INJ 50% ........69
dextrose inj 70% ...............69
DIAMOX
see acetazolamide cap sr
12hr 500 mg ..................33
diazepam con 5mg/ml .......36
diazepam inj 5 mg/ml ........36
DIAZEPAM RECTAL GEL
DELIVERY SYSTEM 10 MG
..........................................36
DIAZEPAM RECTAL GEL
DELIVERY SYSTEM 2.5 MG
..........................................36
DIAZEPAM RECTAL GEL
DELIVERY SYSTEM 20 MG
..........................................36
diazepam soln 1 mg/ml .....36
diazepam tab 10 mg .........36
diazepam tab 2 mg ...........36
diazepam tab 5 mg ...........36
diclofenac potassium tab 50
mg .......................................7
diclofenac sodium ophth soln
0.1% ..................................71
diclofenac sodium tab
delayed release 25 mg ........7
diclofenac sodium tab
delayed release 50 mg........ 7
diclofenac sodium tab
delayed release 75 mg........ 7
diclofenac sodium tab sr 24hr
100 mg ................................ 7
dicloxacillin sodium cap 250
mg ..................................... 19
dicloxacillin sodium cap 500
mg ..................................... 19
dicyclomine hcl cap 10 mg 60
dicyclomine hcl oral soln 10
mg/5ml .............................. 60
dicyclomine hcl tab 20 mg . 60
didanosine delayed release
capsule 125 mg ................ 14
didanosine delayed release
capsule 200 mg ................ 14
didanosine delayed release
capsule 250 mg ................ 14
didanosine delayed release
capsule 400 mg ................ 14
DIFFERIN
see adapalene cream
0.1% .............................. 74
see adapalene gel 0.1% 74
DIFICID TAB 200MG ........ 18
diflorasone diacetate cream
0.05%................................ 76
diflorasone diacetate oint
0.05%................................ 76
DIFLUCAN
see fluconazole for susp 10
mg/ml ............................ 13
see fluconazole for susp 40
mg/ml ............................ 13
see fluconazole tab 100
mg ................................. 13
see fluconazole tab 150
mg ................................. 13
see fluconazole tab 200
mg ................................. 13
see fluconazole tab 50 mg
...................................... 13
diflunisal tab 500 mg ........... 7
digitek tab 0.125mg .......... 32
digitek tab 0.25mg ............ 32
digoxin inj 0.25 mg/ml ....... 32
DIGOXIN ORAL SOLN 0.05
MG/ML .............................. 32
digoxin tab 125 mcg (0.125
mg) ................................... 32
digoxin tab 250 mcg (0.25
mg) ................................... 32
dihydroergotamine mesylate
inj 1 mg/ml ........................ 49
DILANTIN
see phenytoin sodium
extended cap 100 mg .... 38
dilantin cap 100mg............ 36
dilantin cap 30mg.............. 36
dilantin chw 50mg ............. 36
DILANTIN INFATABS
see phenytoin chew tab 50
mg ................................. 38
DILANTIN-125
see phenytoin susp 125
mg/5ml .......................... 38
DILANTIN-125 SUS 125/5ML
.......................................... 36
DILAUDID
see hydromorphone hcl
liqd 1 mg/ml ..................... 9
see hydromorphone hcl tab
2 mg ................................ 9
see hydromorphone hcl tab
4 mg ................................ 9
see hydromorphone hcl tab
8 mg ................................ 9
DILAUDID-HP
see hydromorphone hcl
preservative free (pf) inj 10
mg/ml .............................. 9
diltiazem hcl cap sr 12hr 120
mg..................................... 31
diltiazem hcl cap sr 12hr 60
mg..................................... 31
diltiazem hcl cap sr 12hr 90
mg..................................... 31
diltiazem hcl cap sr 24hr 120
mg..................................... 31
diltiazem hcl cap sr 24hr 180
mg..................................... 31
diltiazem hcl cap sr 24hr 240
mg..................................... 31
diltiazem hcl coated beads
cap sr 24hr 120 mg ........... 31
diltiazem hcl coated beads
cap sr 24hr 180 mg ........... 31
diltiazem hcl coated beads
cap sr 24hr 240 mg ........... 31
diltiazem hcl coated beads
93
cap sr 24hr 300 mg ...........31
diltiazem hcl coated beads
cap sr 24hr 360 mg ...........31
diltiazem hcl extended
release beads cap sr 24hr
120 mg ..............................31
diltiazem hcl extended
release beads cap sr 24hr
180 mg ..............................31
diltiazem hcl extended
release beads cap sr 24hr
240 mg ..............................31
diltiazem hcl extended
release beads cap sr 24hr
300 mg ..............................31
diltiazem hcl extended
release beads cap sr 24hr
360 mg ..............................31
diltiazem hcl extended
release beads cap sr 24hr
420 mg ..............................32
diltiazem hcl iv soln 125
mg/25ml (5 mg/ml) ............32
diltiazem hcl iv soln 25
mg/5ml (5 mg/ml) ..............32
diltiazem hcl iv soln 50
mg/10ml (5 mg/ml) ............32
diltiazem hcl tab 120 mg ...32
diltiazem hcl tab 30 mg .....32
diltiazem hcl tab 60 mg .....32
diltiazem hcl tab 90 mg .....32
DIOVAN
see valsartan tab 160 mg
......................................27
see valsartan tab 320 mg
......................................27
see valsartan tab 40 mg 27
see valsartan tab 80 mg 27
DIOVAN HCT
see
valsartan-hydrochlorothiazi
de tab 160-12.5 mg .......27
see
valsartan-hydrochlorothiazi
de tab 160-25 mg ..........27
see
valsartan-hydrochlorothiazi
de tab 320-12.5 mg .......27
see
valsartan-hydrochlorothiazi
de tab 320-25 mg ..........27
see
valsartan-hydrochlorothiazi
de tab 80-12.5 mg ......... 27
DIP/TET PED INJ 25-5LFU
.......................................... 67
DIPENTUM CAP 250MG .. 61
diphenhydramine hcl inj 50
mg/ml ................................ 72
diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml .............. 61
diphenoxylate w/ atropine tab
2.5-0.025 mg ..................... 62
DIPROLENE
see betamethasone
dipropionate augmented
lotion 0.05% .................. 76
see betamethasone
dipropionate augmented
oint 0.05% ..................... 76
DIPROLENE AF
see betamethasone
dipropionate augmented
cream 0.05% ................. 76
disopyramide phosphate cap
100 mg .............................. 28
disopyramide phosphate cap
150 mg .............................. 28
disulfiram tab 250 mg........ 51
disulfiram tab 500 mg........ 51
DITROPAN XL
see oxybutynin chloride tab
sr 24hr 10 mg ................ 63
see oxybutynin chloride tab
sr 24hr 15 mg ................ 63
see oxybutynin chloride tab
sr 24hr 5 mg .................. 63
DIURIL SUS 250/5ML ....... 33
divalproex sodium cap
sprinkle 125 mg ................ 36
divalproex sodium tab
delayed release 125 mg.... 36
divalproex sodium tab
delayed release 250 mg.... 36
divalproex sodium tab
delayed release 500 mg.... 37
divalproex sodium tab sr 24
hr 250 mg.......................... 37
divalproex sodium tab sr 24
hr 500 mg.......................... 37
DOCETAXEL FOR INJ
CONC 20 MG/ML ............. 21
DOCETAXEL FOR INJ
CONC 80 MG/4ML (20
MG/ML) ............................. 22
docetaxel inj 140/7ml ........ 22
DOCETAXEL INJ 200MG/20
.......................................... 22
DOCETAXEL INJ 80MG/8ML
.......................................... 22
DOLOPHINE
see methadone hcl tab 10
mg ................................... 9
DOLOPHINE HCL
see methadone hcl tab 5
mg ................................... 9
donepezil hydrochloride
orally disintegrating tab 10
mg..................................... 39
donepezil hydrochloride
orally disintegrating tab 5 mg
.......................................... 39
donepezil hydrochloride tab
10 mg................................ 39
donepezil hydrochloride tab
23 mg................................ 39
donepezil hydrochloride tab 5
mg..................................... 39
dorzolamide hcl ophth soln
2% .................................... 71
dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8
mg/ml ................................ 71
DOVONEX
see calcipotriene cream
0.005% .......................... 75
doxazosin mesylate tab 1 mg
.......................................... 26
doxazosin mesylate tab 2 mg
.......................................... 26
doxazosin mesylate tab 4 mg
.......................................... 26
doxazosin mesylate tab 8 mg
.......................................... 26
doxepin hcl cap 10 mg ...... 41
doxepin hcl cap 100 mg .... 41
doxepin hcl cap 150 mg .... 41
doxepin hcl cap 25 mg ...... 41
doxepin hcl cap 50 mg ...... 41
doxepin hcl cap 75 mg ...... 41
doxepin hcl conc 10 mg/ml 41
DOXEPIN HCL CREAM 5%
.......................................... 75
94
DOXIL
see doxorubicin hcl
liposomal inj (for iv
infusion) 2 mg/ml ...........21
doxorubicin hcl for inj 50 mg
..........................................21
doxorubicin hcl inj 2 mg/ml 21
doxorubicin hcl liposomal inj
(for iv infusion) 2 mg/ml .....21
doxycycline hyclate cap 100
mg .....................................20
doxycycline hyclate cap 50
mg .....................................20
doxycycline hyclate for inj
100 mg ..............................20
doxycycline hyclate tab 100
mg .....................................20
doxycycline hyclate tab 20
mg .....................................20
doxycycline monohydrate
cap 100 mg .......................20
doxycycline monohydrate
cap 50 mg .........................20
doxycycline monohydrate tab
100 mg ..............................20
doxycycline monohydrate tab
150 mg ..............................20
doxycycline monohydrate tab
50 mg ................................20
doxycycline monohydrate tab
75 mg ................................20
dronabinol cap 10 mg .......60
dronabinol cap 2.5 mg ......59
dronabinol cap 5 mg .........60
drospirenone-ethinyl
estradiol tab 3-0.02 mg .....54
DROSPIRENONE-ETHINYL
ESTRADIOL TAB 3-0.02 MG
..........................................54
drospirenone-ethinyl
estradiol tab 3-0.03 mg .....54
DROSPIRENONE-ETHINYL
ESTRADIOL TAB 3-0.03 MG
..........................................54
DROXIA CAP 200MG .......23
DROXIA CAP 300MG .......23
DROXIA CAP 400MG .......23
DULERA AER 100-5MCG.74
DULERA AER 200-5MCG.74
duloxetine hcl enteric coated
pellets cap 20 mg ..............41
duloxetine hcl enteric coated
pellets cap 30 mg .............. 41
duloxetine hcl enteric coated
pellets cap 60 mg .............. 41
DURAGESIC
see fentanyl td patch 72hr
100 mcg/hr ...................... 9
see fentanyl td patch 72hr
12 mcg/hr ........................ 9
see fentanyl td patch 72hr
25 mcg/hr ........................ 9
see fentanyl td patch 72hr
50 mcg/hr ........................ 9
see fentanyl td patch 72hr
75 mcg/hr ........................ 9
DURAMORPH INJ
0.5MG/ML ........................... 8
DURAMORPH INJ 1MG/ML
............................................ 8
DUREZOL EMU 0.05%..... 71
DYAZIDE
see triamterene &
hydrochlorothiazide cap
37.5-25 mg .................... 33
DYRENIUM CAP 100MG.. 33
DYRENIUM CAP 50MG.... 33
E
e.e.s. 400 tab 400mg ........ 18
E.E.S. GRAN SUS 200/5ML
.......................................... 18
EC-NAPROSYN
see naproxen dr tab
375mg ............................. 7
see naproxen dr tab
500mg ............................. 7
econazole nitrate cream 1%
.......................................... 75
EDECRIN TAB 25MG ....... 33
EDURANT TAB 25MG ...... 14
EFFEXOR XR
see venlafaxine hcl cap sr
24hr 150 mg (base
equivalent)..................... 43
see venlafaxine hcl cap sr
24hr 37.5 mg (base
equivalent)..................... 42
see venlafaxine hcl cap sr
24hr 75 mg (base
equivalent)..................... 42
EFFIENT TAB 10MG ........ 65
EFFIENT TAB 5MG .......... 65
EFUDEX
see fluorouracil cream 5%
...................................... 77
ELDEPRYL
see selegiline hcl cap 5 mg
...................................... 44
ELIDEL CRE 1%............... 77
ELIMITE
see permethrin cream 5%
...................................... 78
ELIQUIS TAB 2.5MG ........ 64
ELIQUIS TAB 5MG ........... 64
ELITEK INJ 1.5MG ........... 24
ELITEK INJ 7.5MG ........... 24
elixophyllin elx 80/15ml ..... 74
ELLA TAB 30MG .............. 54
ELLENCE
see epirubicin hcl iv soln
200 mg/100ml (2 mg/ml)21
see epirubicin hcl iv soln 50
mg/25ml (2 mg/ml) ........ 21
ELMIRON CAP 100MG .... 63
ELOCON
see mometasone furoate
cream 0.1% ................... 77
see mometasone furoate
oint 0.1% ....................... 77
see mometasone furoate
solution 0.1% (lotion)..... 77
EMCYT CAP 140MG ........ 20
EMEND CAP 125MG........ 60
EMEND CAP 40MG.......... 60
EMEND CAP 80MG.......... 60
EMEND PAK 80 & 125 ..... 60
EMLA
see lidocaine-prilocaine
cream 2.5-2.5% ............. 77
emoquette tab ................... 54
EMSAM DIS 12MG/24H ... 41
EMSAM DIS 6MG/24HR ... 41
EMSAM DIS 9MG/24HR ... 41
EMTRIVA CAP 200MG ..... 14
EMTRIVA SOL 10MG/ML . 14
enalapril maleate &
hydrochlorothiazide tab
10-25 mg .......................... 25
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg ......................... 25
enalapril maleate tab 10 mg
.......................................... 25
95
enalapril maleate tab 2.5 mg
..........................................25
enalapril maleate tab 20 mg
..........................................25
enalapril maleate tab 5 mg 25
endocet tab 10-325mg ........8
endocet tab 5-325mg ..........8
endocet tab 7.5-325 ............8
ENGERIX-B INJ 10/0.5ML 67
ENGERIX-B INJ 20MCG/ML
..........................................67
enoxaparin sodium inj 100
mg/ml ................................64
enoxaparin sodium inj 120
mg/0.8ml ...........................64
enoxaparin sodium inj 150
mg/ml ................................64
enoxaparin sodium inj 30
mg/0.3ml ...........................64
enoxaparin sodium inj 300
mg/3ml ..............................64
enoxaparin sodium inj 40
mg/0.4ml ...........................64
enoxaparin sodium inj 60
mg/0.6ml ...........................64
enoxaparin sodium inj 80
mg/0.8ml ...........................64
enpresse-28 tab ................54
entacapone tab 200 mg ....43
entecavir tab 0.5 mg .........16
entecavir tab 1 mg ............16
ENTOCORT EC
see budesonide cap sr
24hr 3 mg ......................61
enulose sol 10gm/15 .........61
EPIPEN 2-PAK INJ 0.3MG
..........................................73
EPIPEN-JR INJ 2-PAK .....73
epirubicin hcl iv soln 200
mg/100ml (2 mg/ml) ..........21
epirubicin hcl iv soln 50
mg/25ml (2 mg/ml) ............21
epitol tab 200mg ...............37
EPIVIR
see lamivudine oral soln 10
mg/ml.............................14
see lamivudine tab 150 mg
......................................14
see lamivudine tab 300 mg
......................................14
EPIVIR HBV
see lamivudine tab 100 mg
(hbv) .............................. 16
EPIVIR HBV SOL 5MG/ML
.......................................... 16
EPIVIR SOL 10MG/ML ..... 14
eplerenone tab 25 mg ....... 26
eplerenone tab 50 mg ....... 26
EPZICOM TAB 600-300 ... 15
ERAXIS INJ 100MG.......... 13
ERAXIS INJ 50MG ........... 13
ERIVEDGE CAP 150MG .. 22
errin tab 0.35mg ................ 54
ERYGEL
see erythromycin gel 2%
...................................... 75
ERYPED SUS 200/5ML .... 18
ERYPED SUS 400/5ML .... 18
ery-tab tab 250mg ec ........ 18
ery-tab tab 333mg ec ........ 18
ery-tab tab 500mg ec ........ 18
erythrocin inj 500mg ......... 18
erythrocin tab 250mg ........ 18
erythromycin ethylsuccinate
tab 400 mg ........................ 18
erythromycin gel 2% ......... 75
erythromycin ophth oint 5
mg/gm ............................... 70
erythromycin pads 2% ...... 75
erythromycin soln 2%........ 75
erythromycin tab 250 mg .. 18
erythromycin tab 500 mg .. 18
erythromycin w/ delayed
release particles cap 250 mg
.......................................... 18
escitalopram oxalate soln 5
mg/5ml (base equiv) ......... 41
escitalopram oxalate tab 10
mg (base equiv) ................ 41
escitalopram oxalate tab 20
mg (base equiv) ................ 41
escitalopram oxalate tab 5
mg (base equiv) ................ 41
esomeprazole sodium for
intravenous soln 20 mg (base
equiv) ................................ 62
esomeprazole sodium for
intravenous soln 40 mg (base
equiv) ................................ 62
ESTRACE
see estradiol tab 0.5 mg 56
see estradiol tab 1 mg ... 56
see estradiol tab 2 mg ... 56
estradiol tab 0.5 mg .......... 56
estradiol tab 1 mg ............. 56
estradiol tab 2 mg ............. 56
estradiol td patch weekly
0.025 mg/24hr .................. 56
estradiol td patch weekly
0.0375 mg/24hr (37.5
mcg/24hr) ......................... 56
estradiol td patch weekly 0.05
mg/24hr ............................ 56
estradiol td patch weekly 0.06
mg/24hr ............................ 56
estradiol td patch weekly
0.075 mg/24hr .................. 56
estradiol td patch weekly 0.1
mg/24hr ............................ 56
ESTRADIOL VALERATE IM
IN OIL 10 MG/ML.............. 56
estradiol valerate im in oil 20
mg/ml ................................ 56
ESTRADIOL VALERATE IM
IN OIL 40 MG/ML.............. 57
ESTROSTEP FE
see tri-legest tab fe........ 56
ethambutol hcl tab 100 mg 15
ethambutol hcl tab 400 mg 15
ethosuximide cap 250 mg . 37
ethosuximide soln 250
mg/5ml .............................. 37
ETHYOL
see amifostine crystalline
for inj 500 mg ................ 24
etodolac cap 200 mg .......... 7
etodolac cap 300 mg .......... 7
etodolac tab 400 mg ........... 7
etodolac tab 500 mg ........... 7
etodolac tab sr 24hr 400 mg
............................................ 7
etodolac tab sr 24hr 500 mg
............................................ 7
etodolac tab sr 24hr 600 mg
............................................ 7
etoposide inj 500mg/25ml (20
mg/ml) ............................... 24
EURAX CRE 10%............. 78
EURAX LOT 10% ............. 78
EVISTA
see raloxifene hcl tab 60
mg ................................. 58
EVOTAZ TAB 300-150 ..... 15
96
EVOXAC
see cevimeline hcl cap 30
mg .................................78
EXELON
see rivastigmine tartrate
cap 1.5 mg.....................40
see rivastigmine tartrate
cap 3 mg........................40
see rivastigmine tartrate
cap 4.5 mg.....................40
see rivastigmine tartrate
cap 6 mg........................40
EXELON DIS 13.3/24 .......39
EXELON DIS 4.6MG/24 ....39
EXELON DIS 9.5MG/24 ....39
exemestane tab 25 mg .....22
EXFORGE
see amlodipine
besylate-valsartan tab
10-160 mg .....................26
see amlodipine
besylate-valsartan tab
10-320 mg .....................26
see amlodipine
besylate-valsartan tab
5-160 mg .......................26
see amlodipine
besylate-valsartan tab
5-320 mg .......................26
EXFORGE HCT
see
amlodipine-valsartan-hydr
ochlorothiazide tab
10-160-12.5 mg .............26
see
amlodipine-valsartan-hydr
ochlorothiazide tab
10-160-25 mg ................26
see
amlodipine-valsartan-hydr
ochlorothiazide tab
10-320-25 mg ................27
see
amlodipine-valsartan-hydr
ochlorothiazide tab
5-160-12.5 mg ...............26
see
amlodipine-valsartan-hydr
ochlorothiazide tab
5-160-25 mg ..................26
EXJADE TAB 125MG .......54
EXJADE TAB 250MG ....... 54
EXJADE TAB 500MG ....... 54
F
FABRAZYME INJ 35MG ... 56
FABRAZYME INJ 5MG ..... 56
falmina tab ........................ 54
famciclovir tab 125 mg ...... 16
famciclovir tab 250 mg ...... 16
famciclovir tab 500 mg ...... 16
famotidine for susp 40
mg/5ml .............................. 60
famotidine in nacl 0.9% iv
soln 20 mg/50ml ............... 60
famotidine inj 20 mg/2ml ... 60
famotidine inj 200 mg/20ml
.......................................... 60
famotidine inj 40 mg/4ml ... 60
famotidine tab 20 mg ........ 60
famotidine tab 40 mg ........ 60
FAMVIR
see famciclovir tab 125 mg
...................................... 16
see famciclovir tab 250 mg
...................................... 16
see famciclovir tab 500 mg
...................................... 16
FANAPT PAK ................... 45
FANAPT TAB 10MG ......... 45
FANAPT TAB 12MG ......... 45
FANAPT TAB 1MG ........... 45
FANAPT TAB 2MG ........... 45
FANAPT TAB 4MG ........... 45
FANAPT TAB 6MG ........... 45
FANAPT TAB 8MG ........... 45
FARESTON TAB 60MG.... 22
FARYDAK CAP 10MG ...... 22
FARYDAK CAP 15MG ...... 22
FARYDAK CAP 20MG ...... 22
FASLODEX INJ 250MG.... 22
FAT EMULSION IV SOLN
20%................................... 68
FAZACLO TAB 100/ODT .. 45
FAZACLO TAB 12.5/ODT . 45
FAZACLO TAB 150MG..... 45
FAZACLO TAB 200MG..... 45
FAZACLO TAB 25MG ODT
.......................................... 45
felbamate susp 600 mg/5ml
.......................................... 37
felbamate tab 400 mg ....... 37
felbamate tab 600 mg ....... 37
FELBATOL
see felbamate susp 600
mg/5ml .......................... 37
see felbamate tab 400 mg
...................................... 37
see felbamate tab 600 mg
...................................... 37
FELDENE
see piroxicam cap 10 mg 7
see piroxicam cap 20 mg 7
felodipine tab sr 24hr 10 mg
.......................................... 32
felodipine tab sr 24hr 2.5 mg
.......................................... 32
felodipine tab sr 24hr 5 mg 32
FEMARA
see letrozole tab 2.5 mg 22
fenofibrate micronized cap
130 mg.............................. 29
fenofibrate micronized cap
134 mg.............................. 29
fenofibrate micronized cap
200 mg.............................. 29
fenofibrate micronized cap 43
mg..................................... 29
fenofibrate micronized cap 67
mg..................................... 29
fenofibrate tab 145 mg ...... 29
fenofibrate tab 160 mg ...... 29
fenofibrate tab 48 mg ........ 29
fenofibrate tab 54 mg ........ 29
fentanyl citrate lozenge on a
handle 1200 mcg ................ 8
fentanyl citrate lozenge on a
handle 1600 mcg ................ 9
fentanyl citrate lozenge on a
handle 200 mcg .................. 8
fentanyl citrate lozenge on a
handle 400 mcg .................. 8
fentanyl citrate lozenge on a
handle 600 mcg .................. 8
fentanyl citrate lozenge on a
handle 800 mcg .................. 8
fentanyl td patch 72hr 100
mcg/hr ................................. 9
fentanyl td patch 72hr 12
mcg/hr ................................. 9
fentanyl td patch 72hr 25
mcg/hr ................................. 9
fentanyl td patch 72hr 50
mcg/hr ................................. 9
97
fentanyl td patch 72hr 75
mcg/hr .................................9
FENTORA TAB 100MCG....9
FENTORA TAB 200MCG....9
FENTORA TAB 400MCG....9
FENTORA TAB 600MCG....9
FENTORA TAB 800MCG....9
FETZIMA CAP 120MG .....41
FETZIMA CAP 20MG .......41
FETZIMA CAP 40MG .......41
FETZIMA CAP 80MG .......41
FETZIMA CAP TITRATIO .41
finasteride tab 5 mg ..........63
FIRAZYR INJ 30MG/3ML..65
FLAGYL
see metronidazole tab 250
mg .................................12
see metronidazole tab 500
mg .................................12
FLEBOGAMMA INJ
10/200ML ..........................65
FLEBOGAMMA INJ
20/400ML ..........................66
FLEBOGAMMA INJ 5% ....65
FLEBOGAMMA INJ DIF 10%
..........................................66
FLEBOGAMMA INJ DIF 5%
..........................................66
flecainide acetate tab 100 mg
..........................................28
flecainide acetate tab 150 mg
..........................................28
flecainide acetate tab 50 mg
..........................................28
FLOMAX
see tamsulosin hcl cap 0.4
mg .................................63
FLONASE
see fluticasone propionate
nasal susp 50 mcg/act ...73
FLOVENT DISK AER
100MCG............................74
FLOVENT DISK AER
250MCG............................74
FLOVENT DISK AER
50MCG .............................73
FLOVENT HFA AER
110MCG............................74
FLOVENT HFA AER
220MCG............................74
FLOVENT HFA AER 44MCG
.......................................... 74
fluconazole for susp 10
mg/ml ................................ 13
fluconazole for susp 40
mg/ml ................................ 13
fluconazole in dextrose inj
200 mg/100ml ................... 13
fluconazole in dextrose inj
400 mg/200ml ................... 13
fluconazole in nacl 0.9% inj
200 mg/100ml ................... 13
fluconazole in nacl 0.9% inj
400 mg/200ml ................... 13
fluconazole tab 100 mg ..... 13
fluconazole tab 150 mg ..... 13
fluconazole tab 200 mg ..... 13
fluconazole tab 50 mg ....... 13
flucytosine cap 250 mg ..... 13
flucytosine cap 500 mg ..... 13
FLUDARA
see fludarabine phosphate
for inj 50 mg .................. 21
fludarabine phosphate for inj
50 mg ................................ 21
fludarabine phosphate inj 25
mg/ml ................................ 21
fludrocortisone acetate tab
0.1 mg ............................... 57
FLUMADINE
see rimantadine
hydrochloride tab 100 mg
...................................... 16
flunisolide nasal soln 25
mcg/act (0.025%) .............. 73
fluocin acet oil scalp .......... 76
fluocinolone acetonide (otic)
oil 0.01% ........................... 78
fluocinolone acetonide cream
0.01%................................ 76
fluocinolone acetonide cream
0.025%.............................. 76
fluocinolone acetonide oil
0.01% (body oil) ................ 77
fluocinolone acetonide oint
0.025%.............................. 77
fluocinolone acetonide soln
0.01%................................ 77
fluocinonide cream 0.05%. 77
fluocinonide emulsified base
cream 0.05%..................... 77
fluocinonide gel 0.05% ...... 77
fluocinonide oint 0.05% ..... 77
fluocinonide soln 0.05% .... 77
FLUOROMETHOLONE
OPHTH SUSP 0.1% ......... 71
fluorouracil cream 5% ....... 77
fluorouracil inj 1 gm/20ml (50
mg/ml) ............................... 21
fluorouracil inj 2.5 gm/50ml
(50 mg/ml) ........................ 21
fluorouracil inj 5 gm/100ml
(50 mg/ml) ........................ 21
fluorouracil inj 500 mg/10ml
(50 mg/ml) ........................ 21
fluorouracil soln 2% .......... 77
fluorouracil soln 5% .......... 77
fluoxetine hcl cap 10 mg ... 41
fluoxetine hcl cap 20 mg ... 41
fluoxetine hcl cap 40 mg ... 41
fluoxetine hcl solution 20
mg/5ml .............................. 41
fluoxetine hcl tab 10 mg .... 41
fluoxetine hcl tab 20 mg .... 41
fluphenazine decanoate inj
25 mg/ml ........................... 45
fluphenazine hcl elixir 2.5
mg/5ml .............................. 45
fluphenazine hcl inj 2.5 mg/ml
.......................................... 45
fluphenazine hcl oral conc 5
mg/ml ................................ 45
fluphenazine hcl tab 1 mg . 45
fluphenazine hcl tab 10 mg
.......................................... 45
fluphenazine hcl tab 2.5 mg
.......................................... 45
fluphenazine hcl tab 5 mg . 45
flurbiprofen sodium ophth
soln 0.03% ........................ 71
flurbiprofen tab 100 mg ....... 7
flurbiprofen tab 50 mg ......... 7
flutamide cap 125 mg ....... 22
fluticasone propionate cream
0.05% ............................... 77
fluticasone propionate nasal
susp 50 mcg/act................ 73
fluticasone propionate oint
0.005% ............................. 77
fluvoxamine maleate tab 100
mg..................................... 35
fluvoxamine maleate tab 25
mg..................................... 35
98
fluvoxamine maleate tab 50
mg .....................................35
fondaparinux sodium
subcutaneous inj 10
mg/0.8ml ...........................64
fondaparinux sodium
subcutaneous inj 2.5
mg/0.5ml ...........................64
fondaparinux sodium
subcutaneous inj 5 mg/0.4ml
..........................................64
fondaparinux sodium
subcutaneous inj 7.5
mg/0.6ml ...........................64
FORADIL CAP AEROLIZE
..........................................72
FORTAZ
see ceftazidime for inj 1 gm
......................................17
see ceftazidime for inj 2 gm
......................................17
see ceftazidime for inj 6 gm
......................................17
see tazicef inj 1gm .........17
see tazicef inj 2gm .........17
see tazicef inj 6gm.........17
FORTEO SOL 600/2.4 ......58
FORTICAL SPR 200/ACT .58
FOSAMAX
see alendronate sodium
tab 70 mg ......................53
foscarnet sodium inj 24
mg/ml ................................16
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg ........................25
fosinopril sodium &
hydrochlorothiazide tab
20-12.5 mg ........................25
fosinopril sodium tab 10 mg
..........................................25
fosinopril sodium tab 20 mg
..........................................25
fosinopril sodium tab 40 mg
..........................................25
FOSRENOL CHW 1000MG
..........................................58
FOSRENOL CHW 500MG 58
FOSRENOL CHW 750MG 58
FREAMINE HBC INJ 6.9%
..........................................68
FREAMINE III INJ 10% ..... 68
furosemide inj 10 mg/ml .... 33
furosemide oral soln 10
mg/ml ................................ 33
furosemide sol 8mg/ml ...... 33
furosemide tab 20 mg ....... 33
furosemide tab 40 mg ....... 33
furosemide tab 80 mg ....... 33
FUZEON INJ 90MG .......... 14
FYCOMPA TAB 10MG ..... 37
FYCOMPA TAB 12MG ..... 37
FYCOMPA TAB 2MG ....... 37
FYCOMPA TAB 4MG ....... 37
FYCOMPA TAB 6MG ....... 37
FYCOMPA TAB 8MG ....... 37
G
gabapentin cap 100 mg .... 37
gabapentin cap 300 mg .... 37
gabapentin cap 400 mg .... 37
gabapentin oral soln 250
mg/5ml .............................. 37
gabapentin tab 600 mg ..... 37
gabapentin tab 800 mg ..... 37
GABITRIL
see tiagabine hcl tab 2 mg
...................................... 39
see tiagabine hcl tab 4 mg
...................................... 39
GABITRIL TAB 12MG ....... 37
GABITRIL TAB 16MG ....... 37
galantamine hydrobromide
cap sr 24hr 16 mg ............. 39
galantamine hydrobromide
cap sr 24hr 24 mg ............. 40
galantamine hydrobromide
cap sr 24hr 8 mg ............... 39
galantamine hydrobromide
oral soln 4 mg/ml .............. 40
galantamine hydrobromide
tab 12 mg .......................... 40
galantamine hydrobromide
tab 4 mg ............................ 40
galantamine hydrobromide
tab 8 mg ............................ 40
GAMASTAN S/D INJ ........ 66
GAMMAGARD INJ
10GM/100 ......................... 66
GAMMAGARD INJ
1GM/10ML ........................ 66
GAMMAGARD INJ 2.5GM/25
.......................................... 66
GAMMAGARD INJ
20GM/200 ......................... 66
GAMMAGARD INJ
30GM/300 ......................... 66
GAMMAGARD INJ
5GM/50ML ........................ 66
GAMMAGARD SD INJ 10GM
HU .................................... 66
GAMMAGARD SD INJ
2.5GM HU ......................... 66
GAMMAGARD SD INJ 5GM
HU .................................... 66
GAMMAKED INJ 10GM/100
.......................................... 66
GAMMAKED INJ 1GM/10ML
.......................................... 66
GAMMAKED INJ 2.5GM/25
.......................................... 66
GAMMAKED INJ 20GM/200
.......................................... 66
GAMMAKED INJ 5GM/50ML
.......................................... 66
GAMMAPLEX INJ 10GM .. 66
GAMMAPLEX INJ 2.5GM . 66
GAMMAPLEX INJ 5GM .... 66
GAMUNEX-C INJ 10GM/100
.......................................... 66
GAMUNEX-C INJ 1GM/10ML
.......................................... 66
GAMUNEX-C INJ 2.5GM/25
.......................................... 66
GAMUNEX-C INJ 20GM/200
.......................................... 66
GAMUNEX-C INJ 40/400ML
.......................................... 66
GAMUNEX-C INJ 5GM/50ML
.......................................... 66
ganciclovir sodium for inj 500
mg..................................... 16
GARAMYCIN
see gentamicin sulfate
ophth soln 0.3% ............ 70
GARDASIL 9 INJ .............. 67
GARDASIL INJ ................. 67
GASTROCROM
see cromolyn sodium oral
conc 100 mg/5ml ........... 61
gatifloxacin ophth soln 0.5%
.......................................... 70
GAUZE PADS 2" X 2" ....... 51
gavilyte-c sol ..................... 61
99
gavilyte-g sol .....................61
gavilyte-n sol flav pk ..........61
gemcitabine hcl for inj 1 gm
..........................................21
gemcitabine hcl for inj 2 gm
..........................................21
gemcitabine hcl for inj 200 mg
..........................................21
GEMCITABINE INJ 1GM ..21
GEMCITABINE INJ 200MG
..........................................21
GEMCITABINE INJ 2GM ..21
gemfibrozil tab 600 mg ......29
GEMZAR
see gemcitabine hcl for inj
1 gm ..............................21
see gemcitabine hcl for inj
200 mg ..........................21
generlac sol 10gm/15 ........61
gengraf cap 100mg ...........67
gengraf cap 25mg .............67
gengraf sol 100mg/ml .......67
gentak oin 0.3% op ...........70
gentam/nacl inj 0.9mg/ml ..11
gentam/nacl inj 1.4mg/ml ..11
gentamicin in saline inj 0.8
mg/ml ................................11
gentamicin in saline inj 1
mg/ml ................................11
gentamicin in saline inj 1.2
mg/ml ................................11
gentamicin in saline inj 1.6
mg/ml ................................11
gentamicin in saline inj 2
mg/ml ................................11
gentamicin sulfate cream
0.1% ..................................75
gentamicin sulfate inj 10
mg/ml ................................11
gentamicin sulfate inj 40
mg/ml ................................11
gentamicin sulfate iv soln 10
mg/ml ................................11
gentamicin sulfate oint 0.1%
..........................................75
gentamicin sulfate ophth oint
0.3% ..................................70
gentamicin sulfate ophth soln
0.3% ..................................70
GEODON
see ziprasidone hcl cap 20
mg ................................. 47
see ziprasidone hcl cap 40
mg ................................. 47
see ziprasidone hcl cap 60
mg ................................. 48
see ziprasidone hcl cap 80
mg ................................. 48
GEODON INJ 20MG ......... 45
gildagia tab 0.4-35 ............ 54
gildess tab 1.5/30 .............. 54
GILENYA CAP 0.5MG ...... 50
GILOTRIF TAB 20MG....... 23
GILOTRIF TAB 30MG....... 23
GILOTRIF TAB 40MG....... 23
GLEEVEC TAB 100MG .... 23
GLEEVEC TAB 400MG .... 23
glimepiride tab 1 mg ......... 52
glimepiride tab 2 mg ......... 52
glimepiride tab 4 mg ......... 52
glipizide tab 10 mg ............ 52
glipizide tab 5 mg .............. 52
glipizide tab sr 24hr 10 mg 52
glipizide tab sr 24hr 2.5 mg
.......................................... 52
glipizide tab sr 24hr 5 mg .. 52
glipizide-metformin hcl tab
2.5-250 mg........................ 52
glipizide-metformin hcl tab
2.5-500 mg........................ 52
glipizide-metformin hcl tab
5-500 mg........................... 52
GLUCAGEN INJ HYPOKIT
.......................................... 58
GLUCAGON KIT 1MG ...... 58
GLUCOPHAGE
see metformin hcl tab 1000
mg ................................. 53
see metformin hcl tab 500
mg ................................. 53
see metformin hcl tab 850
mg ................................. 53
GLUCOPHAGE XR
see metformin hcl tab sr
24hr 500 mg .................. 53
see metformin hcl tab sr
24hr 750 mg .................. 53
GLUCOTROL
see glipizide tab 10 mg.. 52
see glipizide tab 5 mg.... 52
GLUCOTROL XL
see glipizide tab sr 24hr 10
mg ................................. 52
see glipizide tab sr 24hr 2.5
mg ................................. 52
see glipizide tab sr 24hr 5
mg ................................. 52
glycopyrrolate inj 4 mg/20ml
(0.2 mg/ml) ....................... 60
glycopyrrolate tab 1 mg .... 60
glycopyrrolate tab 2 mg .... 60
GOLYTELY
see gavilyte-g sol .......... 61
see peg 3350-kcl-na
bicarb-nacl-na sulfate for
soln 236 gm .................. 61
GOLYTELY SOL............... 61
granisetron hcl inj 0.1 mg/ml
.......................................... 60
granisetron hcl inj 1 mg/ml 60
granisetron hcl inj 4 mg/4ml
(1 mg/ml) .......................... 60
granisetron hcl tab 1 mg ... 60
GRANIX INJ 300/0.5......... 65
GRANIX INJ 480/0.8......... 65
GRIFULVIN V
see griseofulvin microsize
tab 500 mg .................... 13
griseofulvin microsize susp
125 mg/5ml ....................... 13
griseofulvin microsize tab
500 mg.............................. 13
griseofulvin ultramicrosize
tab 125 mg ........................ 13
griseofulvin ultramicrosize
tab 250 mg ........................ 13
GRIS-PEG
see griseofulvin
ultramicrosize tab 125 mg
...................................... 13
see griseofulvin
ultramicrosize tab 250 mg
...................................... 13
guanfacine hcl tab sr 24hr 1
mg (base equiv) ................ 48
guanfacine hcl tab sr 24hr 2
mg (base equiv) ................ 48
guanfacine hcl tab sr 24hr 3
mg (base equiv) ................ 48
guanfacine hcl tab sr 24hr 4
mg (base equiv) ................ 48
H
HALDOL
100
see haloperidol lactate inj 5
mg/ml.............................45
HALDOL DECANOATE 100
see haloperidol decanoate
im soln 100 mg/ml .........45
HALDOL DECANOATE 50
see haloperidol decanoate
im soln 50 mg/ml ...........45
halobetasol propionate
cream 0.05% .....................77
halobetasol propionate oint
0.05% ................................77
haloperidol decanoate im
soln 100 mg/ml ..................45
haloperidol decanoate im
soln 50 mg/ml....................45
haloperidol lactate inj 5
mg/ml ................................45
haloperidol lactate oral conc
2 mg/ml .............................45
haloperidol tab 0.5 mg ......45
haloperidol tab 1 mg .........45
haloperidol tab 10 mg .......45
haloperidol tab 2 mg .........45
haloperidol tab 20 mg .......45
haloperidol tab 5 mg .........45
HARVONI TAB 90-400MG 16
HAVRIX INJ 1440UNIT .....67
HAVRIX INJ 720UNIT .......67
HEP SOD/D5W INJ
25000UNT.........................64
HEP SOD/NACL INJ
25000UNT.........................64
HEPARIN SOD INJ 2000/ML
..........................................64
HEPARIN SOD INJ 2500/ML
..........................................64
HEPARIN SODIUM
(PORCINE) 40 UNIT/ML IN
D5W ..................................64
heparin sodium (porcine) inj
1000 unit/ml ......................64
heparin sodium (porcine) inj
10000 unit/ml ....................64
heparin sodium (porcine) inj
20000 unit/ml ....................64
heparin sodium (porcine) inj
5000 unit/ml ......................64
HEPATAMINE SOL 8% ....68
HEPSERA
see adefovir dipivoxil tab
10 mg ............................ 15
HERCEPTIN INJ 440MG .. 22
HEXALEN CAP 50MG ...... 20
HIBERIX SOL 10MCG ...... 67
HIPREX
see methenamine
hippurate tab 1 gm ........ 12
HUMIRA INJ 10MG/0.2..... 65
HUMIRA INJ 40MG/0.8..... 65
HUMIRA KIT 20MG/0.4 .... 65
HUMIRA PEN INJ 40MG/0.8
.......................................... 65
HUMIRA PEN INJ CROHNS
.......................................... 65
HUMIRA PEN INJ PSORIASI
.......................................... 65
HUMULIN R INJ U-500 ..... 51
HYCAMTIN
see topotecan hcl for inj 4
mg ................................. 24
HYCET
see
hydrocodone-acetaminoph
en soln 7.5-325 mg/15ml . 8
hydralazine hcl inj 20 mg/ml
.......................................... 34
hydralazine hcl tab 10 mg . 34
hydralazine hcl tab 100 mg
.......................................... 34
hydralazine hcl tab 25 mg . 34
hydralazine hcl tab 50 mg . 34
HYDREA
see hydroxyurea cap 500
mg ................................. 23
hydrochlorothiazide cap 12.5
mg ..................................... 33
hydrochlorothiazide tab 12.5
mg ..................................... 33
hydrochlorothiazide tab 25
mg ..................................... 33
hydrochlorothiazide tab 50
mg ..................................... 33
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml ......... 8
hydrocodone-acetaminophen
tab 10-325 mg ..................... 8
hydrocodone-acetaminophen
tab 5-325 mg ....................... 8
hydrocodone-acetaminophen
tab 7.5-325 mg .................... 8
hydrocodone-ibuprofen tab
7.5-200 mg ......................... 8
hydrocortisone butyrate
cream 0.1% ...................... 77
hydrocortisone butyrate oint
0.1% ................................. 77
hydrocortisone butyrate soln
0.1% ................................. 77
hydrocortisone cream 1% . 77
hydrocortisone cream 2.5%
.......................................... 77
hydrocortisone enema 100
mg/60ml ............................ 61
HYDROCORTISONE
ENEMA 100 MG/60ML ..... 61
hydrocortisone lotion 2.5% 77
hydrocortisone oint 1% ..... 77
hydrocortisone oint 2.5% .. 77
hydrocortisone rectal cream
2.5% ................................. 75
hydrocortisone tab 10 mg . 57
hydrocortisone tab 20 mg . 57
hydrocortisone tab 5 mg ... 57
hydrocortisone valerate
cream 0.2% ...................... 77
hydrocortisone valerate oint
0.2% ................................. 77
hydromorphone hcl liqd 1
mg/ml .................................. 9
hydromorphone hcl
preservative free (pf) inj 10
mg/ml .................................. 9
hydromorphone hcl tab 2 mg
............................................ 9
hydromorphone hcl tab 4 mg
............................................ 9
hydromorphone hcl tab 8 mg
............................................ 9
hydroxychloroquine sulfate
tab 200 mg ........................ 65
hydroxyurea cap 500 mg .. 23
hydroxyzine hcl im soln 25
mg/ml ................................ 72
hydroxyzine hcl im soln 50
mg/ml ................................ 72
HYZAAR
see losartan potassium &
hydrochlorothiazide tab
100-12.5 mg .................. 27
see losartan potassium &
hydrochlorothiazide tab
100-25 mg ..................... 27
101
see losartan potassium &
hydrochlorothiazide tab
50-12.5 mg ....................27
I
ibandronate sodium tab 150
mg (base equivalent) ........53
IBRANCE CAP 100MG .....22
IBRANCE CAP 125MG .....22
IBRANCE CAP 75MG .......22
ibuprofen susp 100 mg/5ml .7
ibuprofen tab 400 mg ..........7
ibuprofen tab 600 mg ..........7
ibuprofen tab 800 mg ..........7
ICLUSIG TAB 15MG .........23
ICLUSIG TAB 45MG .........23
IDAMYCIN PFS
see idarubicin hcl iv inj 10
mg/10ml (1 mg/ml) ........21
see idarubicin hcl iv inj 20
mg/20ml (1 mg/ml) ........21
see idarubicin hcl iv inj 5
mg/5ml (1 mg/ml) ..........21
idarubicin hcl iv inj 10
mg/10ml (1 mg/ml) ............21
idarubicin hcl iv inj 20
mg/20ml (1 mg/ml) ............21
idarubicin hcl iv inj 5 mg/5ml
(1 mg/ml) ...........................21
IFEX
see ifosfamide for inj 1 gm
......................................21
IFEX INJ 3GM ...................20
IFOSFAMIDE
see ifosfamide iv inj 1
gm/20ml (50 mg/ml) ......21
see ifosfamide iv inj 3
gm/60ml (50 mg/ml) ......21
ifosfamide for inj 1 gm .......21
IFOSFAMIDE INJ 3GM .....21
ifosfamide iv inj 1 gm/20ml
(50 mg/ml) .........................21
ifosfamide iv inj 3 gm/60ml
(50 mg/ml) .........................21
ILEVRO DRO 0.3% OP ....71
ilotycin oin op ....................70
IMBRUVICA CAP 140MG .23
IMDUR
see isosorbide mononitrate
tab sr 24hr 30 mg ..........34
imipenem-cilastatin
intravenous for soln 250 mg
.......................................... 12
imipenem-cilastatin
intravenous for soln 500 mg
.......................................... 12
imipramine hcl tab 10 mg .. 41
imipramine hcl tab 25 mg .. 41
imipramine hcl tab 50 mg .. 41
imiquimod cream 5% ........ 77
IMITREX
see sumatriptan succinate
inj 6 mg/0.5ml ................ 49
see sumatriptan succinate
tab 100 mg .................... 50
see sumatriptan succinate
tab 25 mg ...................... 50
see sumatriptan succinate
tab 50 mg ...................... 50
IMITREX STATDOSE
SYSTEM
see sumatriptan succinate
solution auto-injector 6
mg/0.5ml ....................... 50
IMOVAX RABIE INJ 2.5/ML
.......................................... 67
IMURAN
see azathioprine tab 50 mg
...................................... 66
INCRELEX INJ 40MG/4ML
.......................................... 58
indapamide tab 1.25 mg ... 33
indapamide tab 2.5 mg ..... 33
INDERAL LA
see propranolol hcl cap sr
24hr 120 mg .................. 31
see propranolol hcl cap sr
24hr 160 mg .................. 31
see propranolol hcl cap sr
24hr 60 mg .................... 31
see propranolol hcl cap sr
24hr 80 mg .................... 31
INFANRIX INJ ................... 67
INLYTA TAB 1MG ............ 23
INLYTA TAB 5MG ............ 23
INSPRA
see eplerenone tab 25 mg
...................................... 26
see eplerenone tab 50 mg
...................................... 26
INSULIN PEN NEEDLE .... 51
INSULIN SAFETY NEEDLES
.......................................... 51
INSULIN SYRINGE .......... 51
INTELENCE TAB 100MG . 14
INTELENCE TAB 200MG . 14
INTELENCE TAB 25MG ... 14
INTRALIPID INJ 20% ....... 68
INTRALIPID INJ 30% ....... 68
INTRON A INJ 18MU........ 66
INTRON A INJ 50MU........ 66
INTRON-A INJ 10MU ....... 66
INTRON-A INJ 18MU ....... 66
INTRON-A INJ 25MU ....... 66
introvale tab ...................... 54
INTUNIV
see guanfacine hcl tab sr
24hr 1 mg (base equiv) . 48
see guanfacine hcl tab sr
24hr 2 mg (base equiv) . 48
see guanfacine hcl tab sr
24hr 3 mg (base equiv) . 48
see guanfacine hcl tab sr
24hr 4 mg (base equiv) . 48
INVANZ INJ 1GM ............. 12
INVEGA SUST INJ 117/0.75
.......................................... 45
INVEGA SUST INJ
156MG/ML ........................ 45
INVEGA SUST INJ 234/1.5
.......................................... 45
INVEGA SUST INJ 39/0.25
.......................................... 45
INVEGA SUST INJ 78/0.5ML
.......................................... 45
INVEGA TAB 1.5MG ........ 45
INVEGA TAB 3MG ........... 45
INVEGA TAB 6MG ........... 45
INVEGA TAB 9MG ........... 45
INVIRASE CAP 200MG .... 14
INVIRASE TAB 500MG .... 14
INVOKAMET TAB 150-1000
.......................................... 52
INVOKAMET TAB 150-500
.......................................... 52
INVOKAMET TAB 50-1000
.......................................... 52
INVOKAMET TAB
50-500MG ......................... 52
INVOKANA TAB 100MG .. 52
INVOKANA TAB 300MG .. 52
IONOSOL-B/ INJ D5W ..... 69
IONOSOL-MB INJ /D5W .. 69
IPOL INJ INACTIVE.......... 67
102
ipratropium bromide inhal
soln 0.02% ........................72
ipratropium bromide nasal
soln 0.03% (21 mcg/spray)
..........................................72
ipratropium bromide nasal
soln 0.06% (42 mcg/spray)
..........................................72
ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml ......72
irinotecan hcl inj 100 mg/5ml
(20 mg/ml) .........................24
irinotecan hcl inj 40 mg/2ml
(20 mg/ml) .........................24
irinotecan hcl inj 500
mg/25ml (20 mg/ml) ..........24
ISENTRESS CHW 100MG
..........................................14
ISENTRESS CHW 25MG .14
ISENTRESS POW 100MG
..........................................14
ISENTRESS TAB 400MG .14
ISOLYTE-P INJ /D5W .......69
isolyte-s inj ........................69
isoniazid inj 100 mg/ml ......15
isoniazid syrup 50 mg/5ml.15
isoniazid tab 100 mg .........15
isoniazid tab 300 mg .........15
ISORDIL TITRADOSE
see isosorbide dinitrate tab
5 mg ..............................34
isosorbide dinitrate tab 10 mg
..........................................34
isosorbide dinitrate tab 20 mg
..........................................34
isosorbide dinitrate tab 30 mg
..........................................34
isosorbide dinitrate tab 5 mg
..........................................34
isosorbide dinitrate tab cr 40
mg .....................................34
isosorbide mononitrate tab
10 mg ................................34
isosorbide mononitrate tab
20 mg ................................34
isosorbide mononitrate tab sr
24hr 120 mg ......................34
isosorbide mononitrate tab sr
24hr 30 mg ........................34
isosorbide mononitrate tab sr
24hr 60 mg ........................34
isotretinoin cap 10 mg ....... 75
isotretinoin cap 20 mg ....... 75
isotretinoin cap 40 mg ....... 75
isradipine cap 2.5 mg ........ 32
isradipine cap 5 mg ........... 32
ISTALOL SOL 0.5% OP.... 71
ISTODAX INJ 10MG ......... 22
itraconazole cap 100 mg ... 13
ivermectin tab 3 mg .......... 12
IXIARO INJ ....................... 67
J
JAKAFI TAB 10MG ........... 23
JAKAFI TAB 15MG ........... 23
JAKAFI TAB 20MG ........... 23
JAKAFI TAB 25MG ........... 23
JAKAFI TAB 5MG ............. 23
JALYN CAP ...................... 63
jantoven tab 10mg ............ 64
jantoven tab 1mg .............. 64
jantoven tab 2.5mg ........... 64
jantoven tab 2mg .............. 64
jantoven tab 3mg .............. 64
jantoven tab 4mg .............. 64
jantoven tab 5mg .............. 64
jantoven tab 6mg .............. 64
jantoven tab 7.5mg ........... 64
JANUMET TAB 50-1000 ... 52
JANUMET TAB 50-500MG
.......................................... 52
JANUMET XR TAB 100-1000
.......................................... 53
JANUMET XR TAB 50-1000
.......................................... 53
JANUMET XR TAB
50-500MG ......................... 53
JANUVIA TAB 100MG ...... 53
JANUVIA TAB 25MG ........ 53
JANUVIA TAB 50MG ........ 53
JENTADUETO TAB
2.5-1000............................ 53
JENTADUETO TAB 2.5-500
.......................................... 53
JENTADUETO TAB 2.5-850
.......................................... 53
JOLIVETTE TAB 0.35MG . 54
junel 1.5/30 tab ................. 54
junel 1/20 tab .................... 54
junel fe tab 1.5/30 ............. 54
junel fe tab 1/20 ................ 54
K
KADCYLA INJ 100MG ...... 22
KADCYLA INJ 160MG ...... 22
KADIAN
see morphine sulfate cap
sr 24hr 10 mg ................ 10
see morphine sulfate cap
sr 24hr 100 mg .............. 10
see morphine sulfate cap
sr 24hr 20 mg ................ 10
see morphine sulfate cap
sr 24hr 30 mg ................ 10
see morphine sulfate cap
sr 24hr 50 mg ................ 10
see morphine sulfate cap
sr 24hr 60 mg ................ 10
see morphine sulfate cap
sr 24hr 80 mg ................ 10
KALETRA SOL ................. 15
KALETRA TAB 100-25MG 15
KALETRA TAB 200-50MG 15
kariva tab 28 day .............. 54
KAYEXALATE
see sodium polystyrene
sulfonate powder ........... 54
KCL 10 MEQ/L (0.075%) IN
DEXTROSE 5% & NACL
0.45% INJ ......................... 69
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.2% INJ ........................... 69
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.33% INJ ......................... 69
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.45% INJ ......................... 69
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.9% INJ ........................... 69
kcl 20 meq/l (0.15%) in nacl
0.45% inj ........................... 69
KCL 20 MEQ/L (0.15%) IN
NACL 0.45% INJ............... 69
KCL 20 MEQ/L (0.15%) IN
NACL 0.9% INJ................. 69
KCL 30 MEQ/L (0.224%) IN
DEXTROSE 5% & NACL
0.45% INJ ......................... 69
KCL 40 MEQ/L (0.3%) IN
DEXTROSE 5% & NACL
0.45% INJ ......................... 69
KCL 40 MEQ/L (0.3%) IN
103
NACL 0.9% INJ .................69
KCL/D5W/NACL INJ 0.15/0.2
..........................................69
KCL/D5W/NACL INJ
0.3/0.9% ............................69
KEFLEX
see cephalexin cap 250 mg
......................................17
see cephalexin cap 500 mg
......................................17
KEPPRA
see levetiracetam inj 500
mg/5ml (100 mg/ml) ......38
see levetiracetam oral soln
100 mg/ml......................38
see levetiracetam tab 1000
mg .................................38
see levetiracetam tab 250
mg .................................38
see levetiracetam tab 500
mg .................................38
see levetiracetam tab 750
mg .................................38
KEPPRA XR
see levetiracetam tab sr
24hr 500 mg ..................38
see levetiracetam tab sr
24hr 750 mg ..................38
ketoconazole cream 2% ....75
ketoconazole shampoo 2%
..........................................76
ketoconazole tab 200 mg ..13
ketoprofen cap 50 mg .........7
ketoprofen cap 75 mg .........7
ketorolac tromethamine
ophth soln 0.4% ................71
ketorolac tromethamine
ophth soln 0.5% ................71
KLARON
see sulfacetamide sodium
lotion 10% (acne) ..........75
KLONOPIN
see clonazepam tab 0.5
mg .................................36
see clonazepam tab 1 mg
......................................36
see clonazepam tab 2 mg
......................................36
KLOR-CON 10 TAB 10MEQ
ER .....................................68
KLOR-CON 8 TAB 8MEQ ER
.......................................... 68
klor-con m15 tab 15meq er
.......................................... 68
klor-con pow 20meq ......... 68
KUVAN POW 100MG ....... 56
KUVAN TAB 100MG ......... 56
L
labetalol hcl tab 100 mg .... 30
labetalol hcl tab 200 mg .... 30
labetalol hcl tab 300 mg .... 30
LAC-HYDRIN
see lactic acid (ammonium
lactate) cream 12% ....... 77
see lactic acid (ammonium
lactate) lotion 12% ......... 77
LACTATED RINGER'S
SOLUTION ....................... 69
lactic acid (ammonium
lactate) cream 12% ........... 77
lactic acid (ammonium
lactate) lotion 12% ............ 77
lactulose (encephalopathy)
solution 10 gm/15ml .......... 61
lactulose solution 10
gm/15ml ............................ 61
LAMICTAL
see lamotrigine tab 100 mg
...................................... 37
see lamotrigine tab 150 mg
...................................... 37
see lamotrigine tab 200 mg
...................................... 37
see lamotrigine tab 25 mg
...................................... 37
LAMICTAL CHEWABLE
DISPERS
see lamotrigine tab
chewable dispersible 25
mg ................................. 37
see lamotrigine tab
chewable dispersible 5 mg
...................................... 37
LAMICTAL XR
see lamotrigine tab sr 24hr
100 mg .......................... 37
see lamotrigine tab sr 24hr
200 mg .......................... 37
see lamotrigine tab sr 24hr
25 mg ............................ 37
see lamotrigine tab sr 24hr
250 mg .......................... 37
see lamotrigine tab sr 24hr
300 mg .......................... 37
see lamotrigine tab sr 24hr
50 mg ............................ 37
LAMISIL
see terbinafine hcl tab 250
mg ................................. 13
lamivudine oral soln 10 mg/ml
.......................................... 14
lamivudine tab 100 mg (hbv)
.......................................... 16
lamivudine tab 150 mg ...... 14
lamivudine tab 300 mg ...... 14
lamivudine-zidovudine tab
150-300 mg ...................... 15
lamotrigine tab 100 mg ..... 37
lamotrigine tab 150 mg ..... 37
lamotrigine tab 200 mg ..... 37
lamotrigine tab 25 mg ....... 37
lamotrigine tab chewable
dispersible 25 mg.............. 37
lamotrigine tab chewable
dispersible 5 mg................ 37
lamotrigine tab sr 24hr 100
mg..................................... 37
lamotrigine tab sr 24hr 200
mg..................................... 37
lamotrigine tab sr 24hr 25 mg
.......................................... 37
lamotrigine tab sr 24hr 250
mg..................................... 37
lamotrigine tab sr 24hr 300
mg..................................... 37
lamotrigine tab sr 24hr 50 mg
.......................................... 37
LANOXIN
see digitek tab 0.125mg 32
see digitek tab 0.25mg .. 32
see digoxin inj 0.25 mg/ml
...................................... 32
see digoxin tab 125 mcg
(0.125 mg) ..................... 32
see digoxin tab 250 mcg
(0.25 mg) ....................... 32
LANOXIN TAB 0.125MG .. 33
LANOXIN TAB 0.25MG .... 33
LANTUS INJ 100/ML ........ 51
LANTUS INJ SOLOSTAR . 52
larin fe tab 1.5/30 .............. 54
larin fe tab 1/20 ................. 54
larin tab 1.5/30 .................. 54
104
larin tab 1/20 .....................54
LASIX
see furosemide tab 20 mg
......................................33
see furosemide tab 40 mg
......................................33
see furosemide tab 80 mg
......................................33
LASTACAFT SOL 0.25% ..71
latanoprost ophth soln
0.005% ..............................71
LATUDA TAB 120MG .......46
LATUDA TAB 20MG .........45
LATUDA TAB 40MG .........46
LATUDA TAB 60MG .........46
LATUDA TAB 80MG .........46
LAZANDA SPR 100MCG ....9
LAZANDA SPR 400MCG ....9
leflunomide tab 10 mg .......65
leflunomide tab 20 mg .......65
LENVIMA CAP 10MG .......23
LENVIMA CAP 14MG .......23
LENVIMA CAP 20MG .......23
LENVIMA CAP 24MG .......23
lessina tab .........................55
LETAIRIS TAB 10MG .......35
LETAIRIS TAB 5MG .........35
letrozole tab 2.5 mg ..........22
leucovorin calcium for inj 100
mg .....................................24
leucovorin calcium for inj 200
mg .....................................24
leucovorin calcium for inj 350
mg .....................................24
leucovorin calcium for inj 50
mg .....................................24
leucovorin calcium tab 10 mg
..........................................24
leucovorin calcium tab 15 mg
..........................................24
leucovorin calcium tab 25 mg
..........................................24
leucovorin calcium tab 5 mg
..........................................24
leucovorin inj calcium ........24
LEUKERAN TAB 2MG ......21
LEUKINE INJ 250MCG .....65
leuprolide acetate inj kit 5
mg/ml ................................22
levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml (base
equiv) ................................ 72
LEVAQUIN
see levofloxacin in d5w iv
soln 500 mg/100ml ........ 18
see levofloxacin in d5w iv
soln 750 mg/150ml ........ 18
see levofloxacin oral soln
25 mg/ml ....................... 18
see levofloxacin tab 250
mg ................................. 18
see levofloxacin tab 500
mg ................................. 18
see levofloxacin tab 750
mg ................................. 18
LEVEMIR INJ.................... 52
LEVEMIR INJ FLEXTOUC 52
LEVETIRACETA INJ
10MG/ML .......................... 38
LEVETIRACETA INJ
15MG/ML .......................... 38
LEVETIRACETA INJ
5MG/ML ............................ 38
levetiracetam inj 500 mg/5ml
(100 mg/ml) ....................... 38
levetiracetam oral soln 100
mg/ml ................................ 38
levetiracetam tab 1000 mg 38
levetiracetam tab 250 mg .. 38
levetiracetam tab 500 mg .. 38
levetiracetam tab 750 mg .. 38
levetiracetam tab sr 24hr 500
mg ..................................... 38
levetiracetam tab sr 24hr 750
mg ..................................... 38
LEVOBUNOLOL HCL
OPHTH SOLN 0.25% ....... 71
levobunolol hcl ophth soln
0.5%.................................. 71
levocarnitine inj 200 mg/ml56
levocarnitine oral soln 1
gm/10ml (10%) ................. 56
levocarnitine tab 330 mg ... 56
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
.......................................... 72
levocetirizine dihydrochloride
tab 5 mg ............................ 72
levofloxacin in d5w iv soln
250 mg/50ml ..................... 18
levofloxacin in d5w iv soln
500 mg/100ml ................... 18
levofloxacin in d5w iv soln
750 mg/150ml ................... 18
levofloxacin iv soln 25 mg/ml
.......................................... 18
levofloxacin oral soln 25
mg/ml ................................ 18
levofloxacin tab 250 mg .... 18
levofloxacin tab 500 mg .... 18
levofloxacin tab 750 mg .... 18
levonest tab ...................... 55
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg .................... 55
LEVONORGESTREL &
ETHINYL ESTRADIOL
(91-DAY) TAB 0.15-0.03 MG
.......................................... 55
levonorgestrel & ethinyl
estradiol tab 0.1 mg-20 mcg
.......................................... 55
levonorgestrel tab 0.75 mg 55
levonorgestrel tab 1.5 mg . 55
levora-28 tab 0.15/30 ........ 55
levothyroxine sodium tab 100
mcg ................................... 59
levothyroxine sodium tab 112
mcg ................................... 59
levothyroxine sodium tab 125
mcg ................................... 59
levothyroxine sodium tab 137
mcg ................................... 59
levothyroxine sodium tab 150
mcg ................................... 59
levothyroxine sodium tab 175
mcg ................................... 59
levothyroxine sodium tab 200
mcg ................................... 59
levothyroxine sodium tab 25
mcg ................................... 58
levothyroxine sodium tab 300
mcg ................................... 59
levothyroxine sodium tab 50
mcg ................................... 58
levothyroxine sodium tab 75
mcg ................................... 58
levothyroxine sodium tab 88
mcg ................................... 59
LEVOXYL TAB 100MCG .. 59
LEVOXYL TAB 112MCG .. 59
LEVOXYL TAB 125MCG .. 59
LEVOXYL TAB 137MCG .. 59
105
LEVOXYL TAB 150MCG ..59
LEVOXYL TAB 175MCG ..59
LEVOXYL TAB 200MCG ..59
LEVOXYL TAB 25MCG ....59
LEVOXYL TAB 50MCG ....59
LEVOXYL TAB 75MCG ....59
LEVOXYL TAB 88MCG ....59
LEXAPRO
see escitalopram oxalate
soln 5 mg/5ml (base equiv)
......................................41
see escitalopram oxalate
tab 10 mg (base equiv) ..41
see escitalopram oxalate
tab 20 mg (base equiv) ..41
see escitalopram oxalate
tab 5 mg (base equiv) ....41
LEXIVA SUS 50MG/ML ....14
LEXIVA TAB 700MG .........14
LIALDA TAB 1.2GM ..........61
lidocaine hcl gel 2% ..........77
lidocaine hcl local inj 0.5% 11
lidocaine hcl local inj 1% ...11
lidocaine hcl local inj 1.5% 11
lidocaine hcl local inj 2% ...11
lidocaine hcl local
preservative free (pf) inj 0.5%
..........................................11
lidocaine hcl local
preservative free (pf) inj 1%
..........................................11
lidocaine hcl soln 4% ........77
lidocaine hcl viscous soln 2%
..........................................78
lidocaine oint 5% ...............77
lidocaine patch 5% (700 mg)
..........................................77
lidocaine-prilocaine cream
2.5-2.5%............................77
LIDODERM
see lidocaine patch 5%
(700 mg) ........................77
linezolid iv soln 2 mg/ml ....12
LINZESS CAP 145MCG ...62
LINZESS CAP 290MCG ...62
liothyronine sodium tab 25
mcg ...................................59
liothyronine sodium tab 5
mcg ...................................59
liothyronine sodium tab 50
mcg ...................................59
LIPITOR
see atorvastatin calcium
tab 10 mg (base
equivalent)..................... 28
see atorvastatin calcium
tab 20 mg (base
equivalent)..................... 28
see atorvastatin calcium
tab 40 mg (base
equivalent)..................... 28
see atorvastatin calcium
tab 80 mg (base
equivalent)..................... 28
lisinopril &
hydrochlorothiazide tab
10-12.5 mg........................ 25
lisinopril &
hydrochlorothiazide tab
20-12.5 mg........................ 25
lisinopril &
hydrochlorothiazide tab
20-25 mg........................... 25
lisinopril tab 10 mg ............ 25
lisinopril tab 2.5 mg ........... 25
lisinopril tab 20 mg ............ 25
lisinopril tab 30 mg ............ 25
lisinopril tab 40 mg ............ 25
lisinopril tab 5 mg .............. 25
lithium carbonate cap 150 mg
.......................................... 50
lithium carbonate cap 300 mg
.......................................... 50
lithium carbonate cap 600 mg
.......................................... 50
lithium carbonate tab 300 mg
.......................................... 50
lithium carbonate tab cr 300
mg ..................................... 50
lithium carbonate tab cr 450
mg ..................................... 50
LITHIUM SOL 8MEQ/5ML 50
LITHOBID
see lithium carbonate tab
cr 300 mg ...................... 50
LOCOID
see hydrocortisone
butyrate cream 0.1% ..... 77
see hydrocortisone
butyrate oint 0.1% ......... 77
see hydrocortisone
butyrate soln 0.1%......... 77
LOESTRIN 1.5/30-21
see gildess tab 1.5/30 ... 54
see junel 1.5/30 tab ....... 54
see larin tab 1.5/30........ 54
see microgestin tab 1.5/30
...................................... 55
LOESTRIN 1/20-21
see junel 1/20 tab .......... 54
see larin tab 1/20........... 54
see microgestin tab 1/20
...................................... 55
LOESTRIN FE 1.5/30
see junel fe tab 1.5/30 ... 54
see larin fe tab 1.5/30.... 54
see microgestin tab
fe1.5/30 ......................... 55
LOESTRIN FE 1/20
see junel fe tab 1/20 ...... 54
see larin fe tab 1/20....... 54
see microgestin tab fe 1/20
...................................... 55
see norethindrone ace &
ethinyl estradiol-fe tab 1
mg-20 mcg .................... 55
LOFIBRA
see fenofibrate micronized
cap 134 mg ................... 29
see fenofibrate micronized
cap 200 mg ................... 29
see fenofibrate micronized
cap 67 mg ..................... 29
see fenofibrate tab 160 mg
...................................... 29
see fenofibrate tab 54 mg
...................................... 29
LOKARA LOT 0.05% ........ 77
LOMOTIL
see diphenoxylate w/
atropine tab 2.5-0.025 mg
...................................... 62
LOMUSTINE CAP 10 MG . 21
LOMUSTINE CAP 100 MG
.......................................... 21
LOMUSTINE CAP 40 MG . 21
loperamide hcl cap 2 mg ... 62
LOPID
see gemfibrozil tab 600 mg
...................................... 29
LOPRESSOR
see metoprolol tartrate inj 1
mg/ml ............................ 30
106
see metoprolol tartrate tab
100 mg ..........................31
see metoprolol tartrate tab
50 mg ............................31
LOPRESSOR HCT
see metoprolol &
hydrochlorothiazide tab
100-25 mg .....................30
see metoprolol &
hydrochlorothiazide tab
50-25 mg .......................30
LOPROX SHAMPOO
see ciclopirox shampoo
1% .................................75
lorazepam con 2mg/ml ......35
lorazepam inj 2 mg/ml .......35
lorazepam inj 4 mg/ml .......35
lorazepam tab 0.5 mg .......35
lorazepam tab 1 mg ..........35
lorazepam tab 2 mg ..........35
loryna tab 3-0.02mg ..........55
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg ......................27
losartan potassium &
hydrochlorothiazide tab
100-25 mg .........................27
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg ........................27
losartan potassium tab 100
mg .....................................27
losartan potassium tab 25 mg
..........................................27
losartan potassium tab 50 mg
..........................................27
LOTEMAX GEL 0.5% .......71
LOTEMAX OIN 0.5% ........71
LOTEMAX SUS 0.5% .......71
LOTENSIN
see benazepril hcl tab 10
mg .................................25
see benazepril hcl tab 20
mg .................................25
see benazepril hcl tab 40
mg .................................25
LOTENSIN HCT
see benazepril &
hydrochlorothiazide tab
10-12.5 mg ....................24
see benazepril &
hydrochlorothiazide tab
20-12.5 mg .................... 24
see benazepril &
hydrochlorothiazide tab
20-25 mg ....................... 24
LOTREL
see amlodipine
besylate-benazepril hcl
cap 10-20 mg ................ 24
see amlodipine
besylate-benazepril hcl
cap 10-40 mg ................ 24
see amlodipine
besylate-benazepril hcl
cap 2.5-10 mg ............... 24
see amlodipine
besylate-benazepril hcl
cap 5-10 mg .................. 24
see amlodipine
besylate-benazepril hcl
cap 5-20 mg .................. 24
see amlodipine
besylate-benazepril hcl
cap 5-40 mg .................. 24
LOTRONEX TAB 0.5MG .. 62
LOTRONEX TAB 1MG ..... 62
lovastatin tab 10 mg .......... 29
lovastatin tab 20 mg .......... 29
lovastatin tab 40 mg .......... 29
LOVAZA
see omega-3-acid ethyl
esters cap 1 gm ............. 29
LOVENOX
see enoxaparin sodium inj
100 mg/ml ..................... 64
see enoxaparin sodium inj
120 mg/0.8ml ................ 64
see enoxaparin sodium inj
150 mg/ml ..................... 64
see enoxaparin sodium inj
30 mg/0.3ml .................. 64
see enoxaparin sodium inj
300 mg/3ml ................... 64
see enoxaparin sodium inj
40 mg/0.4ml .................. 64
see enoxaparin sodium inj
60 mg/0.6ml .................. 64
see enoxaparin sodium inj
80 mg/0.8ml .................. 64
low-ogestrel tab ................ 55
loxapine succinate cap 10 mg
.......................................... 46
loxapine succinate cap 25 mg
.......................................... 46
loxapine succinate cap 5 mg
.......................................... 46
loxapine succinate cap 50 mg
.......................................... 46
LUMIGAN SOL 0.01% ...... 71
LUMIZYME INJ 50MG ...... 56
LUPR DEP-PED INJ
11.25MG ........................... 22
LUPR DEP-PED INJ 15MG
.......................................... 22
LUPR DEP-PED INJ 30MG
.......................................... 22
LUPR DEP-PED INJ 7.5MG
.......................................... 22
LUPRON DEPOT INJ
11.25MG ........................... 22
LUPRON DEPOT INJ
3.75MG ............................. 22
lutera tab........................... 55
LYNPARZA CAP 50MG.... 22
LYRICA CAP 100MG........ 38
LYRICA CAP 150MG........ 38
LYRICA CAP 200MG........ 38
LYRICA CAP 225MG........ 38
LYRICA CAP 25MG.......... 38
LYRICA CAP 300MG........ 38
LYRICA CAP 50MG.......... 38
LYRICA CAP 75MG.......... 38
LYRICA SOL 20MG/ML .... 38
LYSODREN TAB 500MG . 22
LYSTEDA
see tranexamic acid tab
650 mg .......................... 65
lyza tab 0.35mg ................ 55
M
MACROBID
see nitrofurantoin
monohydrate
macrocrystalline cap 100
mg ................................. 12
MACRODANTIN
see nitrofurantoin
macrocrystalline cap 100
mg ................................. 12
see nitrofurantoin
macrocrystalline cap 50 mg
...................................... 12
MAGNESIUM SU INJ
107
40MG/ML ..........................68
MAGNESIUM SU INJ
80MG/ML ..........................68
magnesium sulfate inj 50%
..........................................68
MAGNESIUM SULFATE INJ
50% ...................................68
MALARONE
see atovaquone-proguanil
hcl tab 250-100 mg ........14
see atovaquone-proguanil
hcl tab 62.5-25 mg .........14
malathion lotion 0.5% ........78
maprotiline hcl tab 25 mg ..41
maprotiline hcl tab 50 mg ..41
maprotiline hcl tab 75 mg ..41
MARINOL
see dronabinol cap 10 mg
......................................60
see dronabinol cap 2.5 mg
......................................59
see dronabinol cap 5 mg
......................................60
marlissa tab 0.15/30 ..........55
MARPLAN TAB 10MG ......41
MATULANE CAP 50MG ...23
MAVIK
see trandolapril tab 1 mg
......................................26
see trandolapril tab 2 mg
......................................26
see trandolapril tab 4 mg
......................................26
MAXALT
see rizatriptan benzoate
tab 10 mg ......................49
see rizatriptan benzoate
tab 5 mg ........................49
MAXALT-MLT
see rizatriptan benzoate
orally disintegrating tab 10
mg .................................49
see rizatriptan benzoate
orally disintegrating tab 5
mg .................................49
MAXIDEX SUS 0.1% OP ..71
MAXIPIME
see cefepime hcl for inj 1
gm .................................16
see cefepime hcl for inj 2
gm .................................16
MAXITROL
see
neomycin-polymyxin-dexa
methasone ophth oint
0.1% .............................. 70
see
neomycin-polymyxin-dexa
methasone ophth susp
0.1% .............................. 70
MAXZIDE
see triamterene &
hydrochlorothiazide tab
75-50 mg ....................... 34
MAXZIDE-25
see triamterene &
hydrochlorothiazide tab
37.5-25 mg .................... 34
meclizine hcl tab 12.5 mg . 60
meclizine hcl tab 25 mg .... 60
MEDROL
see methylprednisolone
tab 16 mg ...................... 57
see methylprednisolone
tab 32 mg ...................... 57
see methylprednisolone
tab 4 mg ........................ 57
see methylprednisolone
tab 8 mg ........................ 57
MEDROL DOSEPAK
see methylprednisolone
tab 4 mg dose pack ....... 57
medroxyprogesterone
acetate im susp 150 mg/ml
.......................................... 55
medroxyprogesterone
acetate tab 10 mg ............. 58
medroxyprogesterone
acetate tab 2.5 mg ............ 58
medroxyprogesterone
acetate tab 5 mg ............... 58
mefloquine hcl tab 250 mg 14
MEGACE ES SUS 625/5ML
.......................................... 22
MEGACE ORAL
see megestrol acetate
susp 40 mg/ml ............... 22
megestrol acetate susp 40
mg/ml ................................ 22
megestrol acetate tab 20 mg
.......................................... 22
megestrol acetate tab 40 mg
.......................................... 22
MEKINIST TAB 0.5MG ..... 23
MEKINIST TAB 2MG ........ 23
MELOXICAM SUSP 7.5
MG/5ML .............................. 7
meloxicam tab 15 mg.......... 7
meloxicam tab 7.5 mg ......... 7
melphalan hcl for inj 50 mg
(base equiv) ...................... 21
MENACTRA INJ ............... 67
MENOMUNE INJ A/C/Y/W 67
MENVEO INJ .................... 67
MEPRON
see atovaquone susp 750
mg/5ml .......................... 12
mercaptopurine tab 50 mg 21
meropenem iv for soln 1 gm
.......................................... 12
meropenem iv for soln 500
mg..................................... 12
MERREM
see meropenem iv for soln
1 gm .............................. 12
see meropenem iv for soln
500 mg .......................... 12
mesalamine enema 4 gm . 61
mesalamine rectal enema 4
gm & cleanser wipe kit ...... 61
mesna inj 100 mg/ml......... 24
MESNEX
see mesna inj 100 mg/ml
...................................... 24
MESNEX TAB 400MG ...... 24
MESTINON
see pyridostigmine
bromide tab 60 mg ........ 50
metformin hcl tab 1000 mg 53
metformin hcl tab 500 mg . 53
metformin hcl tab 850 mg . 53
metformin hcl tab sr 24hr 500
mg..................................... 53
metformin hcl tab sr 24hr 750
mg..................................... 53
methadone con 10mg/ml .... 9
methadone hcl soln 10
mg/5ml ................................ 9
methadone hcl soln 5 mg/5ml
............................................ 9
methadone hcl tab 10 mg ... 9
methadone hcl tab 5 mg ..... 9
METHADOSE
108
see methadone con
10mg/ml...........................9
methazolamide tab 25 mg .33
methazolamide tab 50 mg .33
methenamine hippurate tab 1
gm .....................................12
METHERGINE
see methylergonovine
maleate tab 0.2 mg ........58
methimazole tab 10 mg .....59
methimazole tab 5 mg .......59
methotrexate sodium for inj 1
gm .....................................21
methotrexate sodium inj 25
mg/ml ................................21
methotrexate sodium inj pf 25
mg/ml ................................21
methotrexate sodium tab 2.5
mg (base equiv) ................65
methyclothiazide tab 5 mg 33
methylergonovine maleate
tab 0.2 mg .........................58
METHYLIN
see methylphenidate hcl
soln 10 mg/5ml ..............48
see methylphenidate hcl
soln 5 mg/5ml ................48
methylphenidate hcl soln 10
mg/5ml ..............................48
methylphenidate hcl soln 5
mg/5ml ..............................48
methylphenidate hcl tab 10
mg .....................................49
methylphenidate hcl tab 20
mg .....................................49
methylphenidate hcl tab 5 mg
..........................................48
methylphenidate hcl tab cr 10
mg .....................................49
methylphenidate hcl tab cr 20
mg .....................................49
methylprednisolone acetate
inj susp 40 mg/ml ..............57
methylprednisolone acetate
inj susp 80 mg/ml ..............57
methylprednisolone sodium
succinate for inj 1000 mg ..57
methylprednisolone sodium
succinate for inj 125 mg ....57
methylprednisolone sodium
succinate for inj 40 mg ......57
methylprednisolone tab 16
mg ..................................... 57
methylprednisolone tab 32
mg ..................................... 57
methylprednisolone tab 4 mg
.......................................... 57
methylprednisolone tab 4 mg
dose pack ......................... 57
methylprednisolone tab 8 mg
.......................................... 57
metipranolol ophth soln 0.3%
.......................................... 71
metoclopramide hcl inj 5
mg/ml ................................ 60
metoclopramide hcl soln 5
mg/5ml (10 mg/10ml) ........ 60
metoclopramide hcl tab 10
mg ..................................... 60
metoclopramide hcl tab 5 mg
.......................................... 60
metolazone tab 10 mg ...... 33
metolazone tab 2.5 mg ..... 33
metolazone tab 5 mg ........ 33
metoprolol &
hydrochlorothiazide tab
100-25 mg......................... 30
metoprolol &
hydrochlorothiazide tab
100-50 mg......................... 30
metoprolol &
hydrochlorothiazide tab
50-25 mg........................... 30
metoprolol succinate tab sr
24hr 100 mg...................... 30
metoprolol succinate tab sr
24hr 200 mg...................... 30
metoprolol succinate tab sr
24hr 25 mg........................ 30
metoprolol succinate tab sr
24hr 50 mg........................ 30
metoprolol tartrate inj 1 mg/ml
.......................................... 30
metoprolol tartrate tab 100
mg ..................................... 31
metoprolol tartrate tab 25 mg
.......................................... 30
metoprolol tartrate tab 50 mg
.......................................... 31
METROCREAM
see metronidazole cream
0.75% ............................ 78
METROGEL-VAGINAL
see metronidazole vaginal
gel 0.75% ...................... 63
METROLOTION
see metronidazole lotion
0.75% ............................ 78
metronidazole cream 0.75%
.......................................... 78
metronidazole gel 0.75% .. 78
metronidazole in nacl 0.79%
iv soln 500 mg/100ml ........ 12
metronidazole lotion 0.75%
.......................................... 78
metronidazole tab 250 mg 12
metronidazole tab 500 mg 12
metronidazole vaginal gel
0.75% ............................... 63
MEVACOR
see lovastatin tab 40 mg 29
mexiletine hcl cap 150 mg 28
mexiletine hcl cap 200 mg 28
mexiletine hcl cap 250 mg 28
MG SO4/D5W INJ 10MG/ML
.......................................... 68
MG SO4/D5W INJ 20MG/ML
.......................................... 68
MIACALCIN
see calcitonin (salmon)
nasal soln 200 unit/act .. 58
MIACALCIN INJ 200/ML ... 58
microgestin tab 1.5/30 ...... 55
microgestin tab 1/20 ......... 55
microgestin tab fe 1/20 ..... 55
microgestin tab fe1.5/30 ... 55
MICRO-K
see potassium chloride cap
cr 10 meq ...................... 68
see potassium chloride cap
cr 8 meq ........................ 68
MICROZIDE
see hydrochlorothiazide
cap 12.5 mg .................. 33
midodrine hcl tab 10 mg ... 34
midodrine hcl tab 2.5 mg .. 34
midodrine hcl tab 5 mg ..... 34
MINIPRESS
see prazosin hcl cap 1 mg
...................................... 26
see prazosin hcl cap 2 mg
...................................... 26
see prazosin hcl cap 5 mg
109
......................................26
minitran dis 0.1mg/hr ........34
minitran dis 0.2mg/hr ........34
minitran dis 0.4mg/hr ........34
minitran dis 0.6mg/hr ........34
MINOCIN
see minocycline hcl cap
100 mg ..........................20
see minocycline hcl cap 50
mg .................................20
see minocycline hcl cap 75
mg .................................20
minocycline hcl cap 100 mg
..........................................20
minocycline hcl cap 50 mg 20
minocycline hcl cap 75 mg 20
minoxidil tab 10 mg ...........34
minoxidil tab 2.5 mg ..........34
MIRAPEX
see pramipexole
dihydrochloride tab 0.125
mg .................................44
see pramipexole
dihydrochloride tab 0.25
mg .................................43
see pramipexole
dihydrochloride tab 0.5 mg
......................................43
see pramipexole
dihydrochloride tab 1 mg
......................................44
see pramipexole
dihydrochloride tab 1.5 mg
......................................44
MIRCETTE
see desogest-eth estrad &
eth estrad tab
0.15-0.02/0.01 mg(21/5) 54
see kariva tab 28 day ....54
see pimtrea tab..............55
see viorele tab ...............56
mirtazapine orally
disintegrating tab 15 mg ....42
mirtazapine orally
disintegrating tab 30 mg ....42
mirtazapine orally
disintegrating tab 45 mg ....42
mirtazapine tab 15 mg ......42
mirtazapine tab 30 mg ......42
mirtazapine tab 45 mg ......42
mirtazapine tab 7.5 mg .....42
misoprostol tab 100 mcg ... 62
misoprostol tab 200 mcg ... 62
mitomycin for iv soln 20 mg
.......................................... 21
mitomycin for iv soln 40 mg
.......................................... 21
mitomycin for iv soln 5 mg 21
mitoxantrone hcl inj conc 20
mg/10ml (2 mg/ml) ............ 23
mitoxantrone hcl inj conc 25
mg/12.5ml (2 mg/ml) ......... 23
mitoxantrone hcl inj conc 30
mg/15ml (2 mg/ml) ............ 23
M-M-R II INJ LIVE ............. 67
MOBIC
see meloxicam tab 15 mg7
see meloxicam tab 7.5 mg
........................................ 7
moderiba pak 1000/day .... 16
moderiba pak 1200/day .... 16
moderiba pak 600/day ...... 16
moderiba pak 800/day ...... 16
moexipril hcl tab 15 mg ..... 25
moexipril hcl tab 7.5 mg .... 25
moexipril-hydrochlorothiazid
e tab 15-12.5 mg ............... 25
moexipril-hydrochlorothiazid
e tab 15-25 mg .................. 25
moexipril-hydrochlorothiazid
e tab 7.5-12.5 mg .............. 25
mometasone furoate cream
0.1%.................................. 77
mometasone furoate oint
0.1%.................................. 77
mometasone furoate solution
0.1% (lotion)...................... 77
MONODOX
see doxycycline
monohydrate cap 100 mg
...................................... 20
MONONESSA TAB........... 55
montelukast sodium chew
tab 4 mg (base equiv) ....... 73
montelukast sodium chew
tab 5 mg (base equiv) ....... 73
montelukast sodium oral
granules packet 4 mg (base
equiv) ................................ 73
montelukast sodium tab 10
mg (base equiv) ................ 73
MORPHINE SUL INJ
2MG/ML .............................. 9
MORPHINE SUL INJ
4MG/ML .............................. 9
MORPHINE SUL INJ
8MG/ML .............................. 9
MORPHINE SULFATE
(CONCENTRATE) ORAL
SOLN 20 MG/ML ................ 9
morphine sulfate beads cap
sr 24hr 120 mg ................. 10
morphine sulfate beads cap
sr 24hr 30 mg ................... 10
morphine sulfate beads cap
sr 24hr 45 mg ................... 10
morphine sulfate beads cap
sr 24hr 60 mg ................... 10
morphine sulfate beads cap
sr 24hr 75 mg ................... 10
morphine sulfate beads cap
sr 24hr 90 mg ................... 10
morphine sulfate cap sr 24hr
10 mg................................ 10
morphine sulfate cap sr 24hr
100 mg.............................. 10
morphine sulfate cap sr 24hr
20 mg................................ 10
morphine sulfate cap sr 24hr
30 mg................................ 10
morphine sulfate cap sr 24hr
50 mg................................ 10
morphine sulfate cap sr 24hr
60 mg................................ 10
morphine sulfate cap sr 24hr
80 mg................................ 10
morphine sulfate inj pf 0.5
mg/ml ................................ 10
morphine sulfate inj pf 1
mg/ml ................................ 10
MORPHINE SULFATE IV
SOLN 1 MG/ML ................ 10
MORPHINE SULFATE IV
SOLN PF 10 MG/ML......... 10
MORPHINE SULFATE IV
SOLN PF 15 MG/ML......... 10
MORPHINE SULFATE
ORAL SOLN 10 MG/5ML . 10
MORPHINE SULFATE
ORAL SOLN 20 MG/5ML . 10
MORPHINE SULFATE TAB
15 MG ............................... 10
MORPHINE SULFATE TAB
110
30 MG ...............................10
morphine sulfate tab cr 100
mg .....................................10
morphine sulfate tab cr 15 mg
..........................................10
morphine sulfate tab cr 200
mg .....................................10
morphine sulfate tab cr 30 mg
..........................................10
morphine sulfate tab cr 60 mg
..........................................10
MOVANTIK TAB 12.5MG..62
MOVANTIK TAB 25MG ....62
MOVIPREP SOL ...............61
MOXEZA SOL 0.5% .........70
MOZOBIL INJ ...................65
MS CONTIN
see morphine sulfate tab cr
100 mg ..........................10
see morphine sulfate tab cr
15 mg ............................10
see morphine sulfate tab cr
200 mg ..........................10
see morphine sulfate tab cr
30 mg ............................10
see morphine sulfate tab cr
60 mg ............................10
MULTAQ TAB 400MG ......28
mupirocin oint 2% .............75
MUSTARGEN INJ 10MG ..21
my way tab 1.5mg .............55
MYAMBUTOL
see ethambutol hcl tab 100
mg .................................15
see ethambutol hcl tab 400
mg .................................15
MYCAMINE INJ 100MG ...13
MYCAMINE INJ 50MG .....13
MYCOBUTIN
see rifabutin cap 150 mg
......................................15
mycophenolate mofetil cap
250 mg ..............................67
mycophenolate mofetil for
oral susp 200 mg/ml ..........67
mycophenolate mofetil tab
500 mg ..............................67
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) ................................67
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) ................................ 67
MYFORTIC
see mycophenolate
sodium tab dr 180 mg
(mycophenolic acid equiv)
...................................... 67
see mycophenolate
sodium tab dr 360 mg
(mycophenolic acid equiv)
...................................... 67
myorisan cap 10mg .......... 75
myorisan cap 20mg .......... 75
myorisan cap 40mg .......... 75
MYOZYME INJ 50MG....... 56
MYRBETRIQ TAB 25MG .. 63
MYRBETRIQ TAB 50MG .. 63
MYSOLINE
see primidone tab 250 mg
...................................... 39
see primidone tab 50 mg
...................................... 39
myzilra tab ........................ 55
N
nabumetone tab 500 mg ..... 7
nabumetone tab 750 mg ..... 7
nadolol tab 20 mg ............. 31
nadolol tab 40 mg ............. 31
nadolol tab 80 mg ............. 31
nafcillin sodium for inj 1 gm
.......................................... 19
nafcillin sodium for inj 10 gm
.......................................... 19
nafcillin sodium for inj 2 gm
.......................................... 19
nafcillin sodium for iv soln 1
gm ..................................... 19
nafcillin sodium for iv soln 2
gm ..................................... 20
NAGLAZYME INJ 1MG/ML
.......................................... 56
naloxone hcl inj 0.4 mg/ml 51
naloxone hcl inj 1 mg/ml ... 51
naltrexone hcl tab 50 mg ... 51
NAMENDA SOL 10MG/5ML
.......................................... 40
NAMENDA TAB 10MG ..... 40
NAMENDA TAB 5MG ....... 40
NAMENDA XR CAP 14MG
.......................................... 40
NAMENDA XR CAP 21MG
.......................................... 40
NAMENDA XR CAP 28MG
.......................................... 40
NAMENDA XR CAP 7MG . 40
NAMENDA XR CAP
TITRATIO ......................... 40
naphazoline hcl ophth soln
0.1% ................................. 71
NAPROSYN
see naproxen tab 250 mg 7
see naproxen tab 375 mg 7
see naproxen tab 500 mg 7
naproxen dr tab 375mg ....... 7
naproxen dr tab 500mg ....... 7
naproxen sodium tab 275 mg
............................................ 7
naproxen sodium tab 550 mg
............................................ 7
naproxen susp 125 mg/5ml 7
naproxen tab 250 mg .......... 7
naproxen tab 375 mg .......... 7
naproxen tab 500 mg .......... 7
naratriptan hcl tab 1 mg (base
equiv) ................................ 49
naratriptan hcl tab 2.5 mg
(base equiv) ...................... 49
NARDIL
see phenelzine sulfate tab
15 mg ............................ 42
NASONEX SPR 50MCG/AC
.......................................... 73
NATACYN SUS 5% OP .... 70
nateglinide tab 120 mg ..... 53
nateglinide tab 60 mg ....... 53
NAVELBINE
see vinorelbine tartrate inj
10 mg/ml (base equiv)... 22
see vinorelbine tartrate inj
50 mg/5ml (10 mg/ml)
(base equiv) .................. 22
NEBUPENT INH 300MG .. 12
necon tab 0.5/35 ............... 55
necon tab 1/35 .................. 55
NECON TAB 1/50-28........ 55
necon tab 10/11-28 ........... 55
NECON TAB 7/7/7 ............ 55
nefazodone hcl tab 100 mg
.......................................... 42
nefazodone hcl tab 150 mg
.......................................... 42
nefazodone hcl tab 200 mg
111
..........................................42
nefazodone hcl tab 250 mg
..........................................42
nefazodone hcl tab 50 mg .42
neomycin sulfate tab 500 mg
..........................................11
neomycin-bacitrac
zn-polymyx
5(3.5)mg-400unt-10000unt
op oin ................................70
neomycin-polymy-gramicid
op sol
1.75-10000-0.025mg-unt-mg
/ml .....................................70
neomycin-polymyxin-dexame
thasone ophth oint 0.1% ...70
neomycin-polymyxin-dexame
thasone ophth susp 0.1% .70
neomycin-polymyxin-hc
ophth susp ........................70
neomycin-polymyxin-hc otic
soln 1% .............................78
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000
unit/ml-1% .........................78
NEORAL
see cyclosporine modified
cap 100 mg....................67
see cyclosporine modified
cap 25 mg......................66
see cyclosporine modified
oral soln 100 mg/ml .......67
see gengraf cap 100mg .67
see gengraf cap 25mg ...67
see gengraf sol 100mg/ml
......................................67
NEORAL CAP 100MG ......67
NEORAL CAP 25MG ........67
NEORAL SOL 100MG/ML 67
NEOSPORIN
see
neomycin-polymy-gramicid
op sol
1.75-10000-0.025mg-untmg/ml.............................70
NEPHRAMINE INJ 5.4%...68
NEPTAZANE
see methazolamide tab 25
mg .................................33
see methazolamide tab 50
mg .................................33
NEUMEGA INJ 5MG......... 65
NEUPOGEN INJ 300/0.5 .. 65
NEUPOGEN INJ 300MCG 65
NEUPOGEN INJ 480/0.8 .. 65
NEUPOGEN INJ 480MCG 65
NEUPRO DIS 1MG/24HR. 43
NEUPRO DIS 2MG/24HR. 43
NEUPRO DIS 3MG/24HR. 43
NEUPRO DIS 4MG/24HR. 43
NEUPRO DIS 6MG/24HR. 43
NEUPRO DIS 8MG/24HR. 43
NEURONTIN
see gabapentin cap 100
mg ................................. 37
see gabapentin cap 300
mg ................................. 37
see gabapentin cap 400
mg ................................. 37
see gabapentin oral soln
250 mg/5ml ................... 37
see gabapentin tab 600 mg
...................................... 37
see gabapentin tab 800 mg
...................................... 37
NEVANAC SUS 0.1% ....... 71
NEVIRAPINE SUSP 50
MG/5ML ............................ 14
nevirapine tab 200 mg ...... 14
nevirapine tab sr 24hr 400 mg
.......................................... 14
NEXAVAR TAB 200MG .... 23
NEXIUM CAP 20MG ......... 62
NEXIUM CAP 40MG ......... 62
NEXIUM GRA 10MG DR .. 62
NEXIUM GRA 2.5MG DR . 62
NEXIUM GRA 20MG DR .. 62
NEXIUM GRA 40MG DR .. 62
NEXIUM GRA 5MG DR .... 62
NEXIUM I.V.
see esomeprazole sodium
for intravenous soln 40 mg
(base equiv) .................. 62
niacin tab cr 1000 mg
(antihyperlipidemic) ........... 29
niacin tab cr 500 mg
(antihyperlipidemic) ........... 29
niacin tab cr 750 mg
(antihyperlipidemic) ........... 29
niacor tab 500mg .............. 29
NIASPAN
see niacin tab cr 1000 mg
(antihyperlipidemic) ....... 29
see niacin tab cr 500 mg
(antihyperlipidemic) ....... 29
see niacin tab cr 750 mg
(antihyperlipidemic) ....... 29
nicardipine hcl cap 20 mg . 32
nicardipine hcl cap 30 mg . 32
NICOTROL INH ................ 51
NICOTROL NS SPR
10MG/ML .......................... 51
nifedical xl tab 30mg ......... 32
nifedical xl tab 60mg ......... 32
nifedipine tab sr 24hr 30 mg
.......................................... 32
nifedipine tab sr 24hr 60 mg
.......................................... 32
nifedipine tab sr 24hr 90 mg
.......................................... 32
nifedipine tab sr 24hr osmotic
30 mg................................ 32
nifedipine tab sr 24hr osmotic
60 mg................................ 32
nifedipine tab sr 24hr osmotic
90 mg................................ 32
nikki tab 3-0.02mg ............ 55
NILANDRON TAB 150MG 22
nimodipine cap 30 mg....... 32
NIPENT INJ 10MG ........... 21
nitro-bid oin 2% ................. 34
NITRO-DUR
see minitran dis 0.1mg/hr
...................................... 34
see minitran dis 0.2mg/hr
...................................... 34
see minitran dis 0.4mg/hr
...................................... 34
see minitran dis 0.6mg/hr
...................................... 34
NITRO-DUR DIS 0.3MG/HR
.......................................... 34
NITRO-DUR DIS 0.8MG/HR
.......................................... 34
nitrofurantoin
macrocrystalline cap 100 mg
.......................................... 12
nitrofurantoin
macrocrystalline cap 50 mg
.......................................... 12
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
.......................................... 12
112
nitroglycerin td patch 24hr 0.1
mg/hr .................................34
nitroglycerin td patch 24hr 0.2
mg/hr .................................34
nitroglycerin td patch 24hr 0.4
mg/hr .................................34
nitroglycerin td patch 24hr 0.6
mg/hr .................................34
NITROLINGUAL SPR
PUMPSPRA ......................34
NITROSTAT SUB 0.3MG..34
NITROSTAT SUB 0.4MG..34
NITROSTAT SUB 0.6MG..34
NIZORAL
see ketoconazole
shampoo 2% .................76
NORCO
see
hydrocodone-acetaminoph
en tab 10-325 mg ............8
see
hydrocodone-acetaminoph
en tab 5-325 mg ..............8
see
hydrocodone-acetaminoph
en tab 7.5-325 mg ...........8
NORDITROPIN INJ
10/1.5ML ...........................58
NORDITROPIN INJ
15/1.5ML ...........................58
NORDITROPIN INJ 30/3ML
..........................................58
NORDITROPIN INJ 5/1.5ML
..........................................58
norelgestromin-ethinyl
estradiol td ptwk 150-35
mcg/24hr ...........................55
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
..........................................55
norethindrone acetate tab 5
mg .....................................58
norethindrone tab 0.35 mg 55
NORETHINDRONE TAB
0.35 MG ............................55
NORETHINDRONE-ETH
ESTRADIOL TAB
0.5-35/1-35/0.5-35 MG-MCG
..........................................55
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35
mg-mcg ............................. 55
NORINYL 1+35
see cyclafem tab 1/35 ... 54
see necon tab 1/35 ........ 55
see nortrel tab 1/35 ....... 55
see pirmella tab 1/35 ..... 55
norlyroc tab 0.35mg .......... 55
normosol -m inj /d5w ......... 69
NORMOSOL -R INJ /D5W 69
NORMOSOL-R INJ PH 7.4
.......................................... 69
NORPACE
see disopyramide
phosphate cap 100 mg .. 28
see disopyramide
phosphate cap 150 mg .. 28
NORPACE CAP 100MG CR
.......................................... 28
NORPACE CAP 150MG CR
.......................................... 28
NORPRAMIN
see desipramine hcl tab 10
mg ................................. 41
see desipramine hcl tab
100 mg .......................... 41
see desipramine hcl tab
150 mg .......................... 41
see desipramine hcl tab 25
mg ................................. 41
see desipramine hcl tab 50
mg ................................. 41
see desipramine hcl tab 75
mg ................................. 41
NOR-QD
see camila tab 0.35mg .. 54
see deblitane tab 0.35mg
...................................... 54
see norethindrone tab 0.35
mg ................................. 55
see norlyroc tab 0.35mg 55
nortrel tab 0.5/35 ............... 55
nortrel tab 1/35.................. 55
nortrel tab 7/7/7 ................. 55
nortriptyline hcl cap 10 mg 42
nortriptyline hcl cap 25 mg 42
nortriptyline hcl cap 50 mg 42
nortriptyline hcl cap 75 mg 42
nortriptyline hcl soln 10
mg/5ml .............................. 42
NORVASC
see amlodipine besylate
tab 10 mg ...................... 31
see amlodipine besylate
tab 2.5 mg ..................... 31
see amlodipine besylate
tab 5 mg ........................ 31
NORVIR CAP 100MG....... 14
NORVIR SOL 80MG/ML ... 14
NORVIR TAB 100MG ....... 14
NOVOLIN INJ 70/30 ......... 52
NOVOLIN N INJ U-100 ..... 52
NOVOLIN R INJ U-100 ..... 52
NOVOLOG INJ 100/ML .... 52
NOVOLOG INJ FLEXPEN 52
NOVOLOG INJ PENFILL .. 52
NOVOLOG MIX INJ 70/30 52
NOVOLOG MIX INJ
FLEXPEN ......................... 52
NOXAFIL SUS 40MG/ML . 13
NOXAFIL TAB 100MG...... 13
NUEDEXTA CAP 20-10MG
.......................................... 50
NULOJIX INJ 250MG ....... 67
NULYTELY SOL FLAV PKS
.......................................... 61
NULYTELY/FLAVOR
PACKS
see gavilyte-n sol flav pk
...................................... 61
see peg 3350-kcl-sod
bicarb-nacl for soln 420 gm
...................................... 61
see trilyte sol ................. 61
NUVARING MIS ............... 55
NUVIGIL TAB 150MG....... 51
NUVIGIL TAB 200MG....... 51
NUVIGIL TAB 250MG....... 51
NUVIGIL TAB 50MG......... 51
nyamyc pow 100000 ......... 75
NYMALIZE SOL 60/20ML . 32
nystatin cream 100000
unit/gm .............................. 75
nystatin oint 100000 unit/gm
.......................................... 75
nystatin susp 100000 unit/ml
.......................................... 78
nystatin tab 500000 unit .... 13
nystatin topical powder ..... 75
nystop pow 100000........... 75
O
OCTAGAM INJ 10GM ...... 66
OCTAGAM INJ 1GM ........ 66
113
OCTAGAM INJ 2.5GM ......66
OCTAGAM INJ 25GM .......66
OCTAGAM INJ 2GM/20ML
..........................................66
OCTAGAM INJ 5GM .........66
octreotide acetate inj 100
mcg/ml (0.1 mg/ml) ...........58
octreotide acetate inj 1000
mcg/ml (1 mg/ml) ..............58
octreotide acetate inj 200
mcg/ml (0.2 mg/ml) ...........58
octreotide acetate inj 50
mcg/ml (0.05 mg/ml) .........58
octreotide acetate inj 500
mcg/ml (0.5 mg/ml) ...........58
OCUFEN
see flurbiprofen sodium
ophth soln 0.03% ...........71
OCUFLOX
see ofloxacin ophth soln
0.3% ..............................70
ofloxacin ophth soln 0.3% .70
ofloxacin otic soln 0.3% ....78
olanzapine for im inj 10 mg
..........................................46
olanzapine orally
disintegrating tab 10 mg ....46
olanzapine orally
disintegrating tab 15 mg ....46
olanzapine orally
disintegrating tab 20 mg ....46
olanzapine orally
disintegrating tab 5 mg ......46
olanzapine tab 10 mg ........46
olanzapine tab 15 mg ........46
olanzapine tab 2.5 mg .......46
olanzapine tab 20 mg ........46
olanzapine tab 5 mg ..........46
olanzapine tab 7.5 mg .......46
olopatadine hcl nasal soln
0.6% ..................................72
OLYSIO CAP 150MG .......16
omega-3-acid ethyl esters
cap 1 gm ...........................29
omeprazole cap delayed
release 10 mg ...................62
omeprazole cap delayed
release 20 mg ...................62
omeprazole cap delayed
release 40 mg ...................62
ondansetron hcl inj 4 mg/2ml
(2 mg/ml)........................... 60
ondansetron hcl inj 40
mg/20ml (2 mg/ml) ............ 60
ondansetron hcl oral soln 4
mg/5ml .............................. 60
ondansetron hcl tab 24 mg60
ondansetron hcl tab 4 mg . 60
ondansetron hcl tab 8 mg . 60
ondansetron orally
disintegrating tab 4 mg...... 60
ondansetron orally
disintegrating tab 8 mg...... 60
ONFI SUS 2.5MG/ML ....... 38
ONFI TAB 10MG .............. 38
ONFI TAB 20MG .............. 38
ORAP TAB 1MG ............... 46
ORAP TAB 2MG ............... 46
ORFADIN CAP 10MG....... 56
ORFADIN CAP 2MG......... 56
ORFADIN CAP 5MG......... 56
orsythia tab ....................... 55
ORTHO EVRA
see norelgestromin-ethinyl
estradiol td ptwk 150-35
mcg/24hr ....................... 55
ORTHO MICRONOR
see errin tab 0.35mg ..... 54
see lyza tab 0.35mg ...... 55
see sharobel tab 0.35mg
...................................... 56
ORTHO TRI-CYCLEN
see norgestimate-eth
estrad tab
0.18-35/0.215-35/0.25-35
mg-mcg ......................... 55
see tri-previfem tab........ 56
see tri-sprintec tab ......... 56
ORTHO-CYCLEN
see previfem tab ............ 55
see sprintec 28 tab 28 day
...................................... 56
ORTHO-NOVUM 7/7/7
see cyclafem tab 7/7/7 .. 54
see nortrel tab 7/7/7 ...... 55
OVCON-35
see balziva tab .............. 54
see briellyn tab .............. 54
see gildagia tab 0.4-35 .. 54
see philith tab 0.4-35 ..... 55
see vyfemla tab 0.4-35 .. 56
see zenchent tab ........... 56
OVIDE
see malathion lotion 0.5%
...................................... 78
oxacillin sodium for inj 1 gm
.......................................... 20
oxacillin sodium for inj 10 gm
.......................................... 20
oxacillin sodium for inj 2 gm
.......................................... 20
oxaliplatin for iv inj 100 mg 24
oxaliplatin for iv inj 50 mg . 24
oxaliplatin iv soln 100
mg/20ml ............................ 24
oxaliplatin iv soln 50 mg/10ml
.......................................... 24
OXANDRIN
see oxandrolone tab 10 mg
...................................... 51
see oxandrolone tab 2.5
mg ................................. 51
oxandrolone tab 10 mg ..... 51
oxandrolone tab 2.5 mg .... 51
oxcarbazepine susp 300
mg/5ml (60 mg/ml) ............ 38
oxcarbazepine tab 150 mg 38
oxcarbazepine tab 300 mg 38
oxcarbazepine tab 600 mg 38
oxybutynin chloride syrup 5
mg/5ml .............................. 63
oxybutynin chloride tab 5 mg
.......................................... 63
oxybutynin chloride tab sr
24hr 10 mg ....................... 63
oxybutynin chloride tab sr
24hr 15 mg ....................... 63
oxybutynin chloride tab sr
24hr 5 mg ......................... 63
oxycodone hcl cap 5 mg ... 10
oxycodone hcl conc 100
mg/5ml (20 mg/ml) ............ 10
oxycodone hcl soln 5 mg/5ml
.......................................... 10
oxycodone hcl tab 10 mg .. 10
oxycodone hcl tab 15 mg .. 11
oxycodone hcl tab 20 mg .. 11
oxycodone hcl tab 30 mg .. 11
oxycodone hcl tab 5 mg .... 10
oxycodone w/
acetaminophen tab 10-325
mg..................................... 11
oxycodone w/
114
acetaminophen tab 2.5-325
mg .....................................11
oxycodone w/
acetaminophen tab 5-325 mg
..........................................11
oxycodone w/
acetaminophen tab 7.5-325
mg .....................................11
P
pacerone tab 100mg .........28
pacerone tab 200mg .........28
pacerone tab 400mg .........28
paclitaxel iv conc 100
mg/16.7ml (6 mg/ml) .........22
paclitaxel iv conc 150
mg/25ml (6 mg/ml) ............22
paclitaxel iv conc 30 mg/5ml
(6 mg/ml) ...........................22
paclitaxel iv conc 300
mg/50ml (6 mg/ml) ............22
PAMELOR
see nortriptyline hcl cap 10
mg .................................42
see nortriptyline hcl cap 25
mg .................................42
see nortriptyline hcl cap 50
mg .................................42
see nortriptyline hcl cap 75
mg .................................42
pamidronate disodium iv soln
3 mg/ml .............................53
pamidronate disodium iv soln
9 mg/ml .............................53
pamidronate inj 6mg/ml .....54
PANRETIN GEL 0.1% ......78
pantoprazole sodium ec tab
20 mg (base equiv) ...........62
pantoprazole sodium ec tab
40 mg (base equiv) ...........62
paricalcitol cap 1 mcg .......70
paricalcitol cap 2 mcg .......70
paricalcitol cap 4 mcg .......70
PARLODEL
see bromocriptine
mesylate cap 5 mg ........43
PARNATE
see tranylcypromine
sulfate tab 10 mg ...........42
paromomycin sulfate cap 250
mg .....................................11
paroxetine hcl tab 10 mg ...42
paroxetine hcl tab 20 mg ... 42
paroxetine hcl tab 30 mg ... 42
paroxetine hcl tab 40 mg ... 42
paser gra 4gm................... 15
PATADAY SOL 0.2% ........ 71
PATANASE
see olopatadine hcl nasal
soln 0.6% ...................... 72
PATANOL SOL 0.1% OP.. 71
PAXIL
see paroxetine hcl tab 10
mg ................................. 42
see paroxetine hcl tab 20
mg ................................. 42
see paroxetine hcl tab 30
mg ................................. 42
see paroxetine hcl tab 40
mg ................................. 42
PAXIL SUS 10MG/5ML..... 42
PAZEO DRO 0.7% ........... 71
PEDIAPRED
see prednisolone sod
phosph oral soln 6.7
mg/5ml (5 mg/5ml base) 57
PEDVAX HIB INJ .............. 67
peg 3350-kcl-na
bicarb-nacl-na sulfate for soln
236 gm .............................. 61
PEG 3350-KCL-NA
BICARB-NACL-NA
SULFATE FOR SOLN 240
GM .................................... 61
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm ................. 61
PEGANONE TAB 250MG . 38
PEG-INTRON KIT 120 RP 66
PEG-INTRON KIT 120MCG
.......................................... 66
PEG-INTRON KIT 150 RP 66
PEGINTRON KIT 150MCG
.......................................... 66
PEG-INTRON KIT 50MCG66
PEG-INTRON KIT 50MCG
RP ..................................... 66
PEGINTRON KIT 80MCG . 66
PEG-INTRON KIT 80MCG
RP ..................................... 66
pen g proc inj 600000 ....... 20
PENICILL GK/ INJ DEX 2MU
.......................................... 20
PENICILL GK/ INJ DEX 3MU
.......................................... 20
penicillin g potassium for inj
20000000 unit ................... 20
penicillin g potassium for inj
5000000 unit ..................... 20
penicillin g sodium for inj
5000000 unit ..................... 20
penicillin v potassium for soln
125 mg/5ml ....................... 20
penicillin v potassium for soln
250 mg/5ml ....................... 20
penicillin v potassium tab 250
mg..................................... 20
penicillin v potassium tab 500
mg..................................... 20
PENTAM 300 INJ 300MG . 13
PENTASA CAP 250MG CR
.......................................... 61
PENTASA CAP 500MG CR
.......................................... 61
pentoxifylline tab cr 400 mg
.......................................... 65
PEPCID
see famotidine for susp 40
mg/5ml .......................... 60
see famotidine tab 20 mg
...................................... 60
see famotidine tab 40 mg
...................................... 60
PERCOCET
see endocet tab 10-325mg
........................................ 8
see endocet tab 5-325mg 8
see endocet tab 7.5-325 . 8
see oxycodone w/
acetaminophen tab 10-325
mg ................................. 11
see oxycodone w/
acetaminophen tab
2.5-325 mg .................... 11
see oxycodone w/
acetaminophen tab 5-325
mg ................................. 11
see oxycodone w/
acetaminophen tab
7.5-325 mg .................... 11
see roxicet tab 5-325mg 11
PERFOROMIST NEB
20MCG ............................. 72
PERIDEX
see chlorhexidine
115
gluconate soln 0.12% ....78
see periogard sol 0.12% 78
perindopril erbumine tab 2
mg .....................................25
perindopril erbumine tab 4
mg .....................................25
perindopril erbumine tab 8
mg .....................................25
periogard sol 0.12% ..........78
permethrin cream 5% ........78
perphenazine tab 16 mg ...46
perphenazine tab 2 mg .....46
perphenazine tab 4 mg .....46
perphenazine tab 8 mg .....46
phenelzine sulfate tab 15 mg
..........................................42
PHENERGAN
see promethazine hcl inj 25
mg/ml.............................60
see promethazine hcl inj 50
mg/ml.............................60
PHENOBARB INJ 65MG/ML
..........................................38
phenobarbital elixir 20
mg/5ml ..............................38
phenobarbital sodium inj 130
mg/ml ................................38
phenobarbital tab 100 mg .38
phenobarbital tab 15 mg ...38
phenobarbital tab 16.2 mg 38
phenobarbital tab 30 mg ...38
phenobarbital tab 32.4 mg 38
phenobarbital tab 60 mg ...38
phenobarbital tab 64.8 mg 38
phenobarbital tab 97.2 mg 38
PHENYTEK
see phenytoin sodium
extended cap 200 mg ....38
see phenytoin sodium
extended cap 300 mg ....38
phenytek cap 200mg .........38
phenytek cap 300mg .........38
phenytoin chew tab 50 mg 38
phenytoin sodium extended
cap 100 mg .......................38
phenytoin sodium extended
cap 200 mg .......................38
phenytoin sodium extended
cap 300 mg .......................38
phenytoin sodium inj 50
mg/ml ................................38
phenytoin susp 125 mg/5ml
.......................................... 38
philith tab 0.4-35 ............... 55
PHOSLO
see calcium acetate
(phosphate binder) cap
667 mg (169 mg ca) ...... 58
PHOSLYRA SOL .............. 58
PHOSPHOLINE SOL
0.125%OP ........................ 71
PILOCARPINE HCL OPHTH
SOLN 1% .......................... 71
PILOCARPINE HCL OPHTH
SOLN 2% .......................... 71
PILOCARPINE HCL OPHTH
SOLN 4% .......................... 71
pilocarpine hcl tab 5 mg .... 78
pilocarpine hcl tab 7.5 mg . 78
pimtrea tab ........................ 55
pindolol tab 10 mg ............ 31
pindolol tab 5 mg .............. 31
pioglitazone hcl tab 15 mg
(base equiv) ...................... 53
pioglitazone hcl tab 30 mg
(base equiv) ...................... 53
pioglitazone hcl tab 45 mg
(base equiv) ...................... 53
piperacillin
sodium-tazobactam sodium
for inj 2-0.25 gm ................ 20
piperacillin
sodium-tazobactam sodium
for inj 3-0.375 gm .............. 20
piperacillin
sodium-tazobactam sodium
for inj 36-4.5 gm ................ 20
piperacillin
sodium-tazobactam sodium
for inj 4-0.5 gm .................. 20
pirmella tab 1/35 ............... 55
piroxicam cap 10 mg ........... 7
piroxicam cap 20 mg ........... 7
PLAN B ONE-STEP
see levonorgestrel tab 1.5
mg ................................. 55
see my way tab 1.5mg .. 55
PLASMA-LYTE INJ -148... 69
PLASMA-LYTE INJ 56/D5W
.......................................... 69
PLASMA-LYTE INJ -A ...... 69
PLAVIX
see clopidogrel bisulfate
tab 75 mg (base equiv) . 65
PLETAL
see cilostazol tab 100 mg
...................................... 65
see cilostazol tab 50 mg 65
podofilox soln 0.5%........... 78
polyethylene glycol 3350 oral
packet ............................... 61
polyethylene glycol 3350 oral
powder .............................. 61
polymyxin b-trimethoprim
ophth soln 10000
unit/ml-0.1% ...................... 70
POLYTRIM
see polymyxin
b-trimethoprim ophth soln
10000 unit/ml-0.1% ....... 70
POMALYST CAP 1MG ..... 23
POMALYST CAP 2MG ..... 23
POMALYST CAP 3MG ..... 23
POMALYST CAP 4MG ..... 23
portia-28 tab ..................... 55
POTASSIUM CHLORIDE 20
MEQ/L (0.15%) IN
DEXTROSE 5% INJ ......... 69
POTASSIUM CHLORIDE 40
MEQ/L (0.3%) IN
DEXTROSE 5% INJ ......... 69
potassium chloride cap cr 10
meq................................... 68
potassium chloride cap cr 8
meq................................... 68
POTASSIUM CHLORIDE INJ
10 MEQ/100 ML................ 69
potassium chloride inj 10
meq/50 ml ......................... 69
potassium chloride inj 2
meq/ml .............................. 69
POTASSIUM CHLORIDE INJ
20 MEQ/100 ML................ 69
potassium chloride inj 20
meq/50 ml ......................... 69
potassium chloride inj 40
meq/100 ml ....................... 69
potassium chloride
microencapsulated crys cr
tab 10 meq ........................ 68
potassium chloride
microencapsulated crys cr
tab 20 meq ........................ 68
116
potassium chloride oral liq
10% (20 meq/15ml) ...........68
potassium chloride oral liq
20% (40 meq/15ml) ...........68
POTASSIUM CHLORIDE
TAB CR 10 MEQ...............68
POTASSIUM CHLORIDE
TAB CR 20 MEQ (1500 MG)
..........................................68
potassium chloride tab cr 8
meq (600 mg)....................68
POTASSIUM CITRATE TAB
CR 10 MEQ (1080 MG) ....63
POTASSIUM CITRATE TAB
CR 5 MEQ (540 MG) ........63
POTIGA TAB 200MG ........38
POTIGA TAB 300MG ........39
POTIGA TAB 400MG ........39
POTIGA TAB 50MG ..........38
PRADAXA CAP 150MG ....64
PRADAXA CAP 75MG ......64
pramipexole dihydrochloride
tab 0.125 mg .....................44
pramipexole dihydrochloride
tab 0.25 mg .......................43
pramipexole dihydrochloride
tab 0.5 mg .........................43
pramipexole dihydrochloride
tab 0.75 mg .......................43
pramipexole dihydrochloride
tab 1 mg ............................44
pramipexole dihydrochloride
tab 1.5 mg .........................44
PRANDIN
see repaglinide tab 0.5 mg
......................................53
see repaglinide tab 1 mg
......................................53
see repaglinide tab 2 mg
......................................53
PRAVACHOL
see pravastatin sodium tab
20 mg ............................29
see pravastatin sodium tab
40 mg ............................29
see pravastatin sodium tab
80 mg ............................29
pravastatin sodium tab 10 mg
..........................................29
pravastatin sodium tab 20 mg
..........................................29
pravastatin sodium tab 40 mg
.......................................... 29
pravastatin sodium tab 80 mg
.......................................... 29
prazosin hcl cap 1 mg ....... 26
prazosin hcl cap 2 mg ....... 26
prazosin hcl cap 5 mg ....... 26
PRECOSE
see acarbose tab 100 mg
...................................... 52
see acarbose tab 25 mg 52
see acarbose tab 50 mg 52
pred sod pho sol 1% op .... 71
PREDNISOLONE ACETATE
OPHTH SUSP 1% ............ 71
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) ................................. 57
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv) ................................ 57
prednisolone sodium
phosphate oral soln 25
mg/5ml (base eq) .............. 57
prednisolone syrup 15
mg/5ml (usp solution
equivalent) ........................ 57
prednisone con 5mg/ml..... 57
prednisone oral soln 5
mg/5ml .............................. 57
prednisone tab 1 mg ......... 57
prednisone tab 10 mg ....... 57
prednisone tab 10 mg dose
pack .................................. 57
prednisone tab 2.5 mg ...... 57
prednisone tab 20 mg ....... 57
prednisone tab 5 mg ......... 57
prednisone tab 5 mg dose
pack .................................. 57
prednisone tab 50 mg ....... 57
PREMARIN VAG CRE
0.625MG ........................... 57
premasol sol 10% ............. 68
PRENATAL VITAMIN/FOLIC
ACID > 0.8 MG (GENERIC)
.......................................... 70
prevalite pow 4gm ............. 30
previfem tab ...................... 55
PREZCOBIX TAB 800-150
.......................................... 15
PREZISTA SUS 100MG/ML
.......................................... 14
PREZISTA TAB 150MG ... 14
PREZISTA TAB 600MG ... 14
PREZISTA TAB 75MG ..... 14
PREZISTA TAB 800MG ... 14
PRIFTIN TAB 150MG ....... 15
PRILOSEC
see omeprazole cap
delayed release 10 mg .. 62
see omeprazole cap
delayed release 20 mg .. 62
see omeprazole cap
delayed release 40 mg .. 62
PRIMAQUINE TAB 26.3MG
.......................................... 14
PRIMAXIN IV
see imipenem-cilastatin
intravenous for soln 250
mg ................................. 12
see imipenem-cilastatin
intravenous for soln 500
mg ................................. 12
primidone tab 250 mg ....... 39
primidone tab 50 mg ......... 39
PRINIVIL
see lisinopril tab 10 mg . 25
see lisinopril tab 20 mg . 25
see lisinopril tab 5 mg ... 25
PRISTIQ TAB 100MG....... 42
PRISTIQ TAB 25MG......... 42
PRISTIQ TAB 50MG......... 42
PRIVIGEN INJ 10GRAMS 66
PRIVIGEN INJ 20GRAMS 66
PRIVIGEN INJ 40GRAMS 66
PRIVIGEN INJ 5 GRAMS . 66
PROAIR HFA AER ........... 73
probenecid tab 500 mg ....... 7
PROCALAMINE INJ 3% ... 68
PROCARDIA XL
see nifedical xl tab 30mg
...................................... 32
see nifedical xl tab 60mg
...................................... 32
see nifedipine tab sr 24hr
osmotic 30 mg ............... 32
see nifedipine tab sr 24hr
osmotic 60 mg ............... 32
see nifedipine tab sr 24hr
osmotic 90 mg ............... 32
prochlorperazine edisylate inj
5 mg/ml ............................. 60
117
prochlorperazine maleate tab
10 mg (base equivalent) ...60
prochlorperazine maleate tab
5 mg (base equivalent) .....60
prochlorperazine suppos 25
mg .....................................60
PROCRIT INJ 10000/ML ..65
PROCRIT INJ 2000/ML ....65
PROCRIT INJ 20000/ML ..65
PROCRIT INJ 3000/ML ....65
PROCRIT INJ 4000/ML ....65
PROCRIT INJ 40000/ML ..65
procto-pak cre 1% .............75
proctozone cre -hc 2.5% ...75
PROGLYCEM SUS
50MG/ML ..........................58
PROGRAF
see tacrolimus cap 0.5 mg
......................................67
see tacrolimus cap 1 mg67
see tacrolimus cap 5 mg67
PROGRAF CAP 0.5MG ....67
PROGRAF CAP 1MG .......67
PROGRAF CAP 5MG .......67
PROLASTIN-C INJ 1000MG
..........................................73
PROLENSA SOL 0.07% ...71
PROLEUKIN INJ 22MU ....22
PROLIA SOL 60MG/ML ....58
PROMACTA TAB 12.5MG 65
PROMACTA TAB 25MG ...65
PROMACTA TAB 50MG ...65
PROMACTA TAB 75MG ...65
promethazine hcl inj 25
mg/ml ................................60
promethazine hcl inj 50
mg/ml ................................60
propafenone hcl cap sr 12hr
225 mg ..............................28
propafenone hcl cap sr 12hr
325 mg ..............................28
propafenone hcl cap sr 12hr
425 mg ..............................28
propafenone hcl tab 150 mg
..........................................28
propafenone hcl tab 225 mg
..........................................28
propafenone hcl tab 300 mg
..........................................28
proparacaine hcl ophth soln
0.5% ..................................72
propranolol &
hydrochlorothiazide tab
40-25 mg........................... 30
propranolol &
hydrochlorothiazide tab
80-25 mg........................... 30
propranolol hcl cap sr 24hr
120 mg .............................. 31
propranolol hcl cap sr 24hr
160 mg .............................. 31
propranolol hcl cap sr 24hr 60
mg ..................................... 31
propranolol hcl cap sr 24hr 80
mg ..................................... 31
propranolol hcl inj 1 mg/ml 31
propranolol hcl oral soln 20
mg/5ml .............................. 31
propranolol hcl oral soln 40
mg/5ml .............................. 31
propranolol hcl tab 10 mg . 31
propranolol hcl tab 20 mg . 31
propranolol hcl tab 40 mg . 31
propranolol hcl tab 60 mg . 31
propranolol hcl tab 80 mg . 31
propylthiouracil tab 50 mg . 59
PROQUAD INJ ................. 67
PROSCAR
see finasteride tab 5 mg 63
PROSOL INJ 20% ............ 68
PROTONIX
see pantoprazole sodium
ec tab 20 mg (base equiv)
...................................... 62
see pantoprazole sodium
ec tab 40 mg (base equiv)
...................................... 62
protriptyline hcl tab 10 mg . 42
protriptyline hcl tab 5 mg ... 42
PROVERA
see medroxyprogesterone
acetate tab 10 mg ......... 58
see medroxyprogesterone
acetate tab 2.5 mg......... 58
see medroxyprogesterone
acetate tab 5 mg ........... 58
PROZAC
see fluoxetine hcl cap 10
mg ................................. 41
see fluoxetine hcl cap 20
mg ................................. 41
see fluoxetine hcl cap 40
mg ................................. 41
PULMICORT
see budesonide inhalation
susp 0.25 mg/2ml .......... 73
see budesonide inhalation
susp 0.5 mg/2ml ............ 73
PULMOZYME SOL 1MG/ML
.......................................... 73
PURIXAN SUS 20MG/ML . 21
pyrazinamide tab 500 mg . 15
pyridostigmine bromide tab
60 mg................................ 50
Q
QUALAQUIN
see quinine sulfate cap 324
mg ................................. 14
quasense tab .................... 55
QUESTRAN
see cholestyramine
powder 4 gm/dose......... 29
see cholestyramine
powder packets 4 gm .... 29
QUESTRAN LIGHT
see prevalite pow 4gm .. 30
quetiapine fumarate tab 100
mg..................................... 46
quetiapine fumarate tab 200
mg..................................... 46
quetiapine fumarate tab 25
mg..................................... 46
quetiapine fumarate tab 300
mg..................................... 46
quetiapine fumarate tab 400
mg..................................... 46
quetiapine fumarate tab 50
mg..................................... 46
quinapril hcl tab 10 mg ...... 26
quinapril hcl tab 20 mg ...... 26
quinapril hcl tab 40 mg ...... 26
quinapril hcl tab 5 mg........ 26
quinapril-hydrochlorothiazide
tab 10-12.5 mg ................. 25
quinapril-hydrochlorothiazide
tab 20-12.5 mg ................. 25
quinapril-hydrochlorothiazide
tab 20-25 mg .................... 25
quinidine gluconate tab cr
324 mg.............................. 28
quinidine sulfate tab 200 mg
.......................................... 28
quinidine sulfate tab 300 mg
118
..........................................28
quinine sulfate cap 324 mg
..........................................14
QVAR AER 40MCG ..........74
QVAR AER 80MCG ..........74
R
RABAVERT INJ ................67
raloxifene hcl tab 60 mg ....58
ramipril cap 1.25 mg .........26
ramipril cap 10 mg ............26
ramipril cap 2.5 mg ...........26
ramipril cap 5 mg ..............26
RANEXA TAB 1000MG ....34
RANEXA TAB 500MG ......34
ranitidine hcl inj 150 mg/6ml
(25 mg/ml) .........................61
ranitidine hcl inj 50 mg/2ml
(25 mg/ml) .........................60
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml) .......................61
ranitidine hcl tab 150 mg ...61
ranitidine hcl tab 300 mg ...61
RAPAMUNE
see sirolimus tab 0.5 mg 67
RAPAMUNE SOL 1MG/ML
..........................................67
RAZADYNE
see galantamine
hydrobromide tab 12 mg 40
see galantamine
hydrobromide tab 4 mg .40
see galantamine
hydrobromide tab 8 mg .40
RAZADYNE ER
see galantamine
hydrobromide cap sr 24hr
16 mg ............................39
see galantamine
hydrobromide cap sr 24hr
24 mg ............................40
see galantamine
hydrobromide cap sr 24hr 8
mg .................................39
REBETOL
see ribasphere cap 200mg
......................................16
see ribavirin cap 200 mg
......................................16
REBETOL SOL 40MG/ML 16
reclipsen tab......................55
RECOMBIVA HB INJ
10MCG/ML ....................... 67
RECOMBIVA HB INJ
5MCG/0.5 ......................... 67
RECOMBIVA-HB INJ
40MCG/ML ....................... 67
REGLAN
see metoclopramide hcl
tab 10 mg ...................... 60
see metoclopramide hcl
tab 5 mg ........................ 60
REGRANEX GEL 0.01% .. 78
RELENZA MIS DISKHALE
.......................................... 16
RELISTOR INJ 12/0.6ML.. 61
RELISTOR INJ 8/0.4ML.... 61
RELISTOR KIT 12/0.6ML . 61
RELPAX TAB 20MG ......... 49
RELPAX TAB 40MG ......... 49
REMERON
see mirtazapine tab 15 mg
...................................... 42
see mirtazapine tab 30 mg
...................................... 42
see mirtazapine tab 45 mg
...................................... 42
REMERON SOLTAB
see mirtazapine orally
disintegrating tab 15 mg 42
see mirtazapine orally
disintegrating tab 30 mg 42
see mirtazapine orally
disintegrating tab 45 mg 42
REMICADE INJ 100MG .... 65
REMODULIN INJ 10MG/ML
.......................................... 35
REMODULIN INJ 1MG/ML
.......................................... 35
REMODULIN INJ 2.5MG/ML
.......................................... 35
REMODULIN INJ 5MG/ML
.......................................... 35
RENVELA PAK 0.8GM ..... 58
RENVELA PAK 2.4GM ..... 58
RENVELA TAB 800MG .... 58
repaglinide tab 0.5 mg ...... 53
repaglinide tab 1 mg ......... 53
repaglinide tab 2 mg ......... 53
REQUIP
see ropinirole
hydrochloride tab 0.25 mg
...................................... 44
see ropinirole
hydrochloride tab 0.5 mg
...................................... 44
see ropinirole
hydrochloride tab 1 mg .. 44
see ropinirole
hydrochloride tab 2 mg .. 44
see ropinirole
hydrochloride tab 3 mg .. 44
see ropinirole
hydrochloride tab 4 mg .. 44
see ropinirole
hydrochloride tab 5 mg .. 44
RESCRIPTOR TAB 100 MG
.......................................... 14
RESCRIPTOR TAB 200MG
.......................................... 14
RESTASIS EMU 0.05% .... 72
RESTORIL
see temazepam cap 15 mg
...................................... 49
see temazepam cap 7.5
mg ................................. 49
RETIN-A
see tretinoin cream
0.025% .......................... 75
see tretinoin cream 0.05%
...................................... 75
see tretinoin cream 0.1%
...................................... 75
see tretinoin gel 0.01% .. 75
see tretinoin gel 0.025% 75
RETROVIR
see zidovudine cap 100 mg
...................................... 15
see zidovudine syrup 10
mg/ml ............................ 15
RETROVIR INJ 10MG/ML 14
REVATIO
see sildenafil citrate tab 20
mg ................................. 35
REVATIO SUS 10MG/ML . 35
REVIA
see naltrexone hcl tab 50
mg ................................. 51
REVLIMID CAP 10MG...... 66
REVLIMID CAP 15MG...... 66
REVLIMID CAP 2.5MG..... 66
REVLIMID CAP 20MG...... 66
REVLIMID CAP 25MG...... 66
REVLIMID CAP 5MG........ 66
119
REYATAZ CAP 150MG ....14
REYATAZ CAP 200MG ....14
REYATAZ CAP 300MG ....14
REYATAZ POW 50MG .....14
ribapak pak 1000/day ........16
ribapak pak 1200/day ........16
ribapak pak 600/day ..........16
ribapak pak 800/day ..........16
ribasphere cap 200mg ......16
ribasphere tab 200mg .......16
ribasphere tab 400mg .......16
ribasphere tab 600mg .......16
ribavirin cap 200 mg ..........16
ribavirin tab 200 mg ..........16
rifabutin cap 150 mg .........15
RIFADIN
see rifampin cap 150 mg
......................................15
see rifampin cap 300 mg
......................................15
see rifampin for inj 600 mg
......................................15
rifampin cap 150 mg .........15
rifampin cap 300 mg .........15
rifampin for inj 600 mg ......15
RIFATER TAB...................15
RILUTEK
see riluzole tab 50 mg ...50
riluzole tab 50 mg ..............50
rimantadine hydrochloride
tab 100 mg ........................16
RINGER'S SOLUTION......69
RIOMET SOL ....................53
RISPERDAL
see risperidone soln 1
mg/ml.............................47
see risperidone tab 0.25
mg .................................47
see risperidone tab 0.5 mg
......................................47
see risperidone tab 1 mg
......................................47
see risperidone tab 2 mg
......................................47
see risperidone tab 3 mg
......................................47
see risperidone tab 4 mg
......................................47
RISPERDAL INJ 12.5MG..46
RISPERDAL INJ 25MG ....46
RISPERDAL INJ 37.5MG..46
RISPERDAL INJ 50MG .... 46
RISPERDAL M-TAB
see risperidone orally
disintegrating tab 0.5 mg
...................................... 47
see risperidone orally
disintegrating tab 1 mg .. 47
see risperidone orally
disintegrating tab 2 mg .. 47
see risperidone orally
disintegrating tab 3 mg .. 47
see risperidone orally
disintegrating tab 4 mg .. 47
risperidone orally
disintegrating tab 0.25 mg . 47
risperidone orally
disintegrating tab 0.5 mg ... 47
risperidone orally
disintegrating tab 1 mg...... 47
risperidone orally
disintegrating tab 2 mg...... 47
risperidone orally
disintegrating tab 3 mg...... 47
risperidone orally
disintegrating tab 4 mg...... 47
risperidone soln 1 mg/ml ... 47
risperidone tab 0.25 mg .... 47
risperidone tab 0.5 mg ...... 47
risperidone tab 1 mg ......... 47
risperidone tab 2 mg ......... 47
risperidone tab 3 mg ......... 47
risperidone tab 4 mg ......... 47
RITALIN
see methylphenidate hcl
tab 10 mg ...................... 49
see methylphenidate hcl
tab 20 mg ...................... 49
see methylphenidate hcl
tab 5 mg ........................ 48
RITUXAN INJ 500MG ....... 22
rivastigmine tartrate cap 1.5
mg ..................................... 40
rivastigmine tartrate cap 3 mg
.......................................... 40
rivastigmine tartrate cap 4.5
mg ..................................... 40
rivastigmine tartrate cap 6 mg
.......................................... 40
rizatriptan benzoate orally
disintegrating tab 10 mg.... 49
rizatriptan benzoate orally
disintegrating tab 5 mg ..... 49
rizatriptan benzoate tab 10
mg..................................... 49
rizatriptan benzoate tab 5 mg
.......................................... 49
ROBINUL
see glycopyrrolate inj 4
mg/20ml (0.2 mg/ml) ..... 60
see glycopyrrolate tab 1
mg ................................. 60
ROBINUL FORTE
see glycopyrrolate tab 2
mg ................................. 60
ROCALTROL
see calcitriol cap 0.25 mcg
...................................... 70
see calcitriol cap 0.5 mcg
...................................... 70
see calcitriol oral soln 1
mcg/ml .......................... 70
ROCEPHIN
see ceftriaxone sodium for
inj 1 gm ......................... 17
see ceftriaxone sodium for
inj 500 mg ..................... 17
ropinirole hydrochloride tab
0.25 mg ............................. 44
ropinirole hydrochloride tab
0.5 mg............................... 44
ropinirole hydrochloride tab 1
mg..................................... 44
ropinirole hydrochloride tab 2
mg..................................... 44
ropinirole hydrochloride tab 3
mg..................................... 44
ropinirole hydrochloride tab 4
mg..................................... 44
ropinirole hydrochloride tab 5
mg..................................... 44
ROTARIX SUS ................. 67
ROTATEQ SOL ................ 67
ROWASA
see mesalamine rectal
enema 4 gm & cleanser
wipe kit .......................... 61
roxicet sol 5-325/5 ............ 11
roxicet tab 5-325mg .......... 11
ROXICODONE
see oxycodone hcl tab 15
mg ................................. 11
see oxycodone hcl tab 30
120
mg .................................11
see oxycodone hcl tab 5
mg .................................10
ROZEREM TAB 8MG .......49
RYTHMOL
see propafenone hcl tab
150 mg ..........................28
see propafenone hcl tab
225 mg ..........................28
RYTHMOL SR
see propafenone hcl cap sr
12hr 225 mg ..................28
see propafenone hcl cap sr
12hr 325 mg ..................28
see propafenone hcl cap sr
12hr 425 mg ..................28
S
SABRIL POW 500MG .......39
SABRIL TAB 500MG ........39
SALAGEN
see pilocarpine hcl tab 5
mg .................................78
see pilocarpine hcl tab 7.5
mg .................................78
SANDIMMUNE
see cyclosporine cap 100
mg .................................66
see cyclosporine cap 25
mg .................................66
see cyclosporine iv soln 50
mg/ml.............................66
SANDIMMUNE CAP 100MG
..........................................67
SANDIMMUNE CAP 25MG
..........................................67
SANDIMMUNE SOL
100MG/ML ........................67
SANDOSTATIN
see octreotide acetate inj
100 mcg/ml (0.1 mg/ml) .58
see octreotide acetate inj
1000 mcg/ml (1 mg/ml) ..58
see octreotide acetate inj
200 mcg/ml (0.2 mg/ml) .58
see octreotide acetate inj
50 mcg/ml (0.05 mg/ml) .58
see octreotide acetate inj
500 mcg/ml (0.5 mg/ml) .58
SANDOSTATIN KIT LAR
10MG ................................58
SANDOSTATIN KIT LAR
20MG ................................ 58
SANDOSTATIN KIT LAR
30MG ................................ 58
SANTYL OIN 250/GM ....... 78
SAPHRIS SUB 10MG ....... 47
SAPHRIS SUB 2.5MG ...... 47
SAPHRIS SUB 5MG ......... 47
SECTRAL
see acebutolol hcl cap 200
mg ................................. 30
see acebutolol hcl cap 400
mg ................................. 30
selegiline hcl cap 5 mg...... 44
selegiline hcl tab 5 mg ...... 44
selenium sulfide lotion 2.5%
.......................................... 76
SELZENTRY TAB 150MG 14
SELZENTRY TAB 300MG 14
SENSIPAR TAB 30MG ..... 54
SENSIPAR TAB 60MG ..... 54
SENSIPAR TAB 90MG ..... 54
SEREVENT DIS AER
50MCG ............................. 73
SEROQUEL
see quetiapine fumarate
tab 100 mg .................... 46
see quetiapine fumarate
tab 200 mg .................... 46
see quetiapine fumarate
tab 25 mg ...................... 46
see quetiapine fumarate
tab 300 mg .................... 46
see quetiapine fumarate
tab 400 mg .................... 46
see quetiapine fumarate
tab 50 mg ...................... 46
SEROQUEL XR TAB 150MG
.......................................... 47
SEROQUEL XR TAB 200MG
.......................................... 47
SEROQUEL XR TAB 300MG
.......................................... 47
SEROQUEL XR TAB 400MG
.......................................... 47
SEROQUEL XR TAB 50MG
.......................................... 47
sertraline hcl oral conc 20
mg/ml ................................ 42
sertraline hcl tab 100 mg ... 42
sertraline hcl tab 25 mg..... 42
sertraline hcl tab 50 mg..... 42
sharobel tab 0.35mg ......... 56
sildenafil citrate tab 20 mg 35
SILENOR TAB 3MG ......... 49
SILENOR TAB 6MG ......... 49
SILVER SULFADIAZINE
CREAM 1% ...................... 75
SIMBRINZA SUS 1-0.2% . 71
simvastatin tab 10 mg ....... 29
simvastatin tab 20 mg ....... 29
simvastatin tab 40 mg ....... 29
simvastatin tab 5 mg ......... 29
simvastatin tab 80 mg ....... 29
SINEMET
see carbidopa & levodopa
tab 10-100 mg ............... 43
see carbidopa & levodopa
tab 25-100 mg ............... 43
see carbidopa & levodopa
tab 25-250 mg ............... 43
SINEMET CR
see carbidopa & levodopa
tab cr 25-100 mg ........... 43
see carbidopa & levodopa
tab cr 50-200 mg ........... 43
SINGULAIR
see montelukast sodium
chew tab 4 mg (base equiv)
...................................... 73
see montelukast sodium
chew tab 5 mg (base equiv)
...................................... 73
see montelukast sodium
oral granules packet 4 mg
(base equiv) .................. 73
see montelukast sodium
tab 10 mg (base equiv) . 73
sirolimus tab 0.5 mg.......... 67
SIROLIMUS TAB 1 MG .... 67
SIROLIMUS TAB 2 MG .... 67
SIRTURO TAB 100MG ..... 15
SIVEXTRO INJ 200MG .... 13
SIVEXTRO TAB 200MG ... 13
SODIUM CHLORIDE INJ
0.45% ............................... 69
SODIUM CHLORIDE INJ 2.5
MEQ/ML (14.6%) .............. 68
SODIUM CHLORIDE INJ 3%
.......................................... 69
SODIUM CHLORIDE INJ 5%
.......................................... 69
SODIUM CHLORIDE
121
IRRIGATION SOLN 0.9% .78
SODIUM CHLORIDE IV
SOLN 0.9% .......................70
SODIUM FLUORIDE CHEW;
TAB; 1.1 (0.5 F) MG/ML
SOLN ................................68
sodium phenylbutyrate oral
powder 3 gm/teaspoonful ..56
sodium polystyrene sulfonate
oral susp 15 gm/60ml ........54
sodium polystyrene sulfonate
powder ..............................54
SOLIA TAB .......................56
SOLTAMOX SOL 10MG/5ML
..........................................22
SOLU-CORTEF INJ 250MG
..........................................57
SOLU-MEDROL
see methylprednisolone
sodium succinate for inj
1000 mg ........................57
see methylprednisolone
sodium succinate for inj
125 mg ..........................57
see methylprednisolone
sodium succinate for inj 40
mg .................................57
SOMATULINE INJ 120/.5ML
..........................................58
SOMATULINE INJ 60/0.2ML
..........................................58
SOMATULINE INJ 90/0.3ML
..........................................58
SOMAVERT INJ 10MG .....58
SOMAVERT INJ 15MG .....58
SOMAVERT INJ 20MG .....58
SOMAVERT INJ 25MG .....58
SOMAVERT INJ 30MG .....58
SORIATANE
see acitretin cap 10 mg .75
see acitretin cap 17.5 mg
......................................75
see acitretin cap 25 mg .75
sorine tab 120mg ..............28
sorine tab 160mg ..............28
sorine tab 240mg ..............28
sorine tab 80mg ................28
sotalol hcl (afib/afl) tab 120
mg .....................................28
sotalol hcl (afib/afl) tab 160
mg .....................................28
sotalol hcl (afib/afl) tab 80 mg
.......................................... 28
sotalol hcl tab 120 mg ....... 28
sotalol hcl tab 160 mg ....... 28
sotalol hcl tab 240 mg ....... 28
sotalol hcl tab 80 mg ......... 28
SOVALDI TAB 400MG...... 16
SPIRIVA CAP HANDIHLR 72
SPIRIVA SPR RESPIMAT 72
spironolactone &
hydrochlorothiazide tab
25-25 mg........................... 33
spironolactone tab 100 mg 26
spironolactone tab 25 mg .. 26
spironolactone tab 50 mg .. 26
SPORANOX
see itraconazole cap 100
mg ................................. 13
sprintec 28 tab 28 day....... 56
SPRYCEL TAB 100MG .... 23
SPRYCEL TAB 140MG .... 23
SPRYCEL TAB 20MG ...... 23
SPRYCEL TAB 50MG ...... 23
SPRYCEL TAB 70MG ...... 23
SPRYCEL TAB 80MG ...... 23
SSD CRE 1%.................... 75
STARLIX
see nateglinide tab 120 mg
...................................... 53
see nateglinide tab 60 mg
...................................... 53
stavudine cap 15 mg ......... 14
stavudine cap 20 mg ......... 14
stavudine cap 30 mg ......... 14
stavudine cap 40 mg ......... 15
stavudine for oral soln 1
mg/ml ................................ 15
STIVARGA TAB 40MG ..... 23
STRATTERA CAP 100MG49
STRATTERA CAP 10MG . 49
STRATTERA CAP 18MG . 49
STRATTERA CAP 25MG . 49
STRATTERA CAP 40MG . 49
STRATTERA CAP 60MG . 49
STRATTERA CAP 80MG . 49
streptomycin sulfate for inj 1
gm ..................................... 11
STRIBILD TAB .................. 15
STROMECTOL
see ivermectin tab 3 mg 12
SUBOXONE MIS 12-3MG 51
SUBOXONE MIS 2-0.5MG
.......................................... 51
SUBOXONE MIS 4-1MG .. 51
SUBOXONE MIS 8-2MG .. 51
SUCRAID SOL 8500/ML .. 62
sucralfate tab 1 gm ........... 62
sulfacetamide sodium lotion
10% (acne) ....................... 75
sulfacetamide sodium ophth
oint 10%............................ 70
sulfacetamide sodium ophth
soln 10% ........................... 70
sulfacetamide
sodium-prednisolone ophth
soln 10-0.23(0.25)% ......... 70
sulfadiazine tab 500mg ..... 11
sulfamethoxazole-trimethopri
m iv soln 400-80 mg/5ml ... 13
sulfamethoxazole-trimethopri
m susp 200-40 mg/5ml ..... 13
sulfamethoxazole-trimethopri
m tab 400-80 mg............... 13
sulfamethoxazole-trimethopri
m tab 800-160 mg............. 13
SULFAMYLON CRE
85MG/GM ......................... 75
sulfasalazine tab 500 mg .. 61
sulfazine ec tab 500mg ..... 61
sulindac tab 150 mg............ 7
sulindac tab 200 mg............ 7
SUMATRIPTAN NASAL
SPRAY 20 MG/ACT.......... 49
SUMATRIPTAN NASAL
SPRAY 5 MG/ACT............ 49
sumatriptan succinate inj 6
mg/0.5ml ........................... 49
SUMATRIPTAN
SUCCINATE SOLUTION
AUTO-INJECTOR 4
MG/0.5ML ......................... 50
sumatriptan succinate
solution auto-injector 6
mg/0.5ml ........................... 50
SUMATRIPTAN
SUCCINATE SOLUTION
CARTRIDGE 4 MG/0.5ML 50
SUMATRIPTAN
SUCCINATE SOLUTION
CARTRIDGE 6 MG/0.5ML 50
sumatriptan succinate
solution prefilled syringe 6
122
mg/0.5ml ...........................50
sumatriptan succinate tab
100 mg ..............................50
sumatriptan succinate tab 25
mg .....................................50
sumatriptan succinate tab 50
mg .....................................50
SUPRAX
see cefixime for susp 100
mg/5ml...........................16
see cefixime for susp 200
mg/5ml...........................16
SUPRAX CAP 400MG ......17
suprax chw 100mg ............17
suprax chw 200mg ............17
suprax sus 100/5ml ...........17
suprax sus 200/5ml ...........17
SUPRAX SUS 500/5ML ....17
SUPREP BOWEL SOL
PREP ................................61
SURMONTIL CAP 100MG 42
SURMONTIL CAP 25MG ..42
SURMONTIL CAP 50MG ..42
SUSTIVA CAP 200MG .....15
SUSTIVA CAP 50MG .......15
SUSTIVA TAB 600MG ......15
SUTENT CAP 12.5MG .....23
SUTENT CAP 25MG ........23
SUTENT CAP 37.5MG .....23
SUTENT CAP 50MG ........23
SYLATRON KIT 200MCG .23
SYLATRON KIT 300MCG .23
SYLATRON KIT 600MCG .23
SYMBICORT AER 160-4.5
..........................................74
SYMBICORT AER 80-4.5 .74
SYMLINPEN 60 INJ
1000MCG..........................52
SYMLNPEN 120 INJ
1000MCG..........................52
SYNAGIS INJ 100MG/ML .67
SYNAGIS INJ 50MG .........67
SYNALAR
see fluocinolone acetonide
cream 0.025% ...............76
see fluocinolone acetonide
oint 0.025% ...................77
see fluocinolone acetonide
soln 0.01%.....................77
SYNAREL SOL 2MG/ML ..56
SYNERCID INJ 500MG ....13
SYNTHROID
see levothyroxine sodium
tab 100 mcg .................. 59
see levothyroxine sodium
tab 112 mcg .................. 59
see levothyroxine sodium
tab 125 mcg .................. 59
see levothyroxine sodium
tab 137 mcg .................. 59
see levothyroxine sodium
tab 150 mcg .................. 59
see levothyroxine sodium
tab 175 mcg .................. 59
see levothyroxine sodium
tab 200 mcg .................. 59
see levothyroxine sodium
tab 25 mcg .................... 58
see levothyroxine sodium
tab 300 mcg .................. 59
see levothyroxine sodium
tab 50 mcg .................... 58
see levothyroxine sodium
tab 75 mcg .................... 58
see levothyroxine sodium
tab 88 mcg .................... 59
SYNTHROID TAB 100MCG
.......................................... 59
SYNTHROID TAB 112MCG
.......................................... 59
SYNTHROID TAB 125MCG
.......................................... 59
SYNTHROID TAB 137MCG
.......................................... 59
SYNTHROID TAB 150MCG
.......................................... 59
SYNTHROID TAB 175MCG
.......................................... 59
SYNTHROID TAB 200MCG
.......................................... 59
SYNTHROID TAB 25MCG59
SYNTHROID TAB 300MCG
.......................................... 59
SYNTHROID TAB 50MCG59
SYNTHROID TAB 75MCG59
SYNTHROID TAB 88MCG59
SYPRINE CAP 250MG ..... 54
T
TABLOID TAB 40MG ........ 21
tacrolimus cap 0.5 mg ....... 67
tacrolimus cap 1 mg .......... 67
tacrolimus cap 5 mg .......... 67
TAFINLAR CAP 50MG ..... 23
TAFINLAR CAP 75MG ..... 23
TAMIFLU CAP 30MG ....... 16
TAMIFLU CAP 45MG ....... 16
TAMIFLU CAP 75MG ....... 16
TAMIFLU SUS 6MG/ML ... 16
tamoxifen citrate tab 10 mg
(base equivalent) .............. 22
tamoxifen citrate tab 20 mg
(base equivalent) .............. 22
tamsulosin hcl cap 0.4 mg 63
TAPAZOLE
see methimazole tab 10
mg ................................. 59
see methimazole tab 5 mg
...................................... 59
TARCEVA TAB 100MG .... 23
TARCEVA TAB 150MG .... 23
TARCEVA TAB 25MG ...... 23
TARGRETIN CAP 75MG .. 23
TARGRETIN GEL 1%....... 78
TASIGNA CAP 150MG ..... 23
TASIGNA CAP 200MG ..... 23
tazicef inj 1gm ................... 17
tazicef inj 2gm ................... 17
tazicef inj 6gm ................... 17
TAZORAC CRE 0.05% ..... 76
TAZORAC CRE 0.1% ....... 76
TEFLARO INJ 400MG ...... 17
TEFLARO INJ 600MG ...... 17
TEGRETOL
see carbamazepine susp
100 mg/5ml ................... 36
see carbamazepine tab
200 mg .......................... 36
see epitol tab 200mg ..... 37
TEGRETOL SUS 100/5ML
.......................................... 39
TEGRETOL TAB 200MG .. 39
TEGRETOL-XR
see carbamazepine tab sr
12hr 200 mg .................. 36
see carbamazepine tab sr
12hr 400 mg .................. 36
TEGRETOL-XR TAB 100MG
.......................................... 39
TEGRETOL-XR TAB 200MG
.......................................... 39
TEGRETOL-XR TAB 400MG
.......................................... 39
TEKAMLO TAB 150-10MG
123
..........................................33
TEKAMLO TAB 150-5MG .33
TEKAMLO TAB 300-10MG
..........................................33
TEKAMLO TAB 300-5MG .33
TEKTURNA HCT TAB
150-12.5 ............................33
TEKTURNA HCT TAB
150-25MG .........................33
TEKTURNA HCT TAB
300-12.5 ............................33
TEKTURNA HCT TAB
300-25MG .........................33
TEKTURNA TAB 150MG ..33
TEKTURNA TAB 300MG ..33
temazepam cap 15 mg .....49
temazepam cap 7.5 mg ....49
TEMOVATE
see clobetasol propionate
cream 0.05% .................76
see clobetasol propionate
gel 0.05% ......................76
see clobetasol propionate
oint 0.05% .....................76
see clobetasol propionate
soln 0.05%.....................76
see cormax scalp sol
0.05% ............................76
TEMOVATE E
see clobetasol propionate
emollient base cream
0.05% ............................76
TENIVAC INJ 5-2LF..........67
TENORETIC 100
see atenolol &
chlorthalidone tab 100-25
mg .................................30
TENORETIC 50
see atenolol &
chlorthalidone tab 50-25
mg .................................30
TENORMIN
see atenolol tab 100 mg 30
see atenolol tab 25 mg ..30
see atenolol tab 50 mg ..30
TERAZOL 3
see terconazole vaginal
cream 0.8% ...................63
TERAZOL 7
see terconazole vaginal
cream 0.4% ...................63
see zazole cre 0.4% ...... 63
terazosin hcl cap 1 mg ...... 26
terazosin hcl cap 10 mg .... 26
terazosin hcl cap 2 mg ...... 26
terazosin hcl cap 5 mg ...... 26
terbinafine hcl tab 250 mg . 13
terbutaline sulfate inj 1 mg/ml
.......................................... 73
terbutaline sulfate tab 2.5 mg
.......................................... 73
terbutaline sulfate tab 5 mg
.......................................... 73
terconazole vaginal cream
0.4%.................................. 63
terconazole vaginal cream
0.8%.................................. 63
terconazole vaginal suppos
80 mg ................................ 63
TESTIM GEL 1%(50MG) .. 51
testosterone cypionate im inj
in oil 100 mg/ml ................. 51
testosterone cypionate im inj
in oil 200 mg/ml ................. 51
testosterone enanthate im inj
in oil 200 mg/ml ................. 51
TET/DIP TOX INJ 2-2 LF .. 67
TETANUS TOX INJ 5LF ADS
.......................................... 68
TEV-TROPIN INJ 5MG ..... 58
texacort sol 2.5% .............. 77
THALOMID CAP 100MG .. 66
THALOMID CAP 150MG .. 66
THALOMID CAP 200MG .. 66
THALOMID CAP 50MG .... 66
theo-24 cap 100mg cr ....... 74
theo-24 cap 200mg cr ....... 74
theo-24 cap 300mg cr ....... 74
theo-24 cap 400mg er ....... 74
theophylline soln 80 mg/15ml
.......................................... 74
theophylline tab sr 12hr 100
mg ..................................... 74
theophylline tab sr 12hr 200
mg ..................................... 74
theophylline tab sr 12hr 300
mg ..................................... 74
theophylline tab sr 12hr 450
mg ..................................... 74
theophylline tab sr 24hr 400
mg ..................................... 74
theophylline tab sr 24hr 600
mg..................................... 74
thioridazine hcl tab 10 mg . 47
thioridazine hcl tab 100 mg
.......................................... 47
thioridazine hcl tab 25 mg . 47
thioridazine hcl tab 50 mg . 47
thiothixene cap 1 mg......... 47
thiothixene cap 10 mg....... 47
thiothixene cap 2 mg......... 47
thiothixene cap 5 mg......... 47
tiagabine hcl tab 2 mg....... 39
tiagabine hcl tab 4 mg....... 39
TIAZAC
see diltiazem hcl extended
release beads cap sr 24hr
120 mg .......................... 31
see diltiazem hcl extended
release beads cap sr 24hr
180 mg .......................... 31
see diltiazem hcl extended
release beads cap sr 24hr
240 mg .......................... 31
see diltiazem hcl extended
release beads cap sr 24hr
300 mg .......................... 31
see diltiazem hcl extended
release beads cap sr 24hr
360 mg .......................... 31
see diltiazem hcl extended
release beads cap sr 24hr
420 mg .......................... 32
TIKOSYN CAP 125MCG .. 28
TIKOSYN CAP 250MCG .. 28
TIKOSYN CAP 500MCG .. 28
TIMOLOL MALEATE OPHTH
GEL FORMING SOLN 0.25%
.......................................... 71
TIMOLOL MALEATE OPHTH
GEL FORMING SOLN 0.5%
.......................................... 71
timolol maleate ophth soln
0.25% ............................... 71
timolol maleate ophth soln
0.5% ................................. 71
timolol maleate tab 10 mg . 31
timolol maleate tab 20 mg . 31
timolol maleate tab 5 mg ... 31
TIMOPTIC
see timolol maleate ophth
soln 0.25% .................... 71
see timolol maleate ophth
124
soln 0.5%.......................71
TIVICAY TAB 50MG .........15
tizanidine hcl tab 2 mg (base
equivalent) ........................51
tizanidine hcl tab 4 mg (base
equivalent) ........................51
TOBI
see tobramycin nebu soln
300 mg/5ml....................11
tobra/nacl inj 80/0.9 ...........11
TOBRADEX
see
tobramycin-dexamethason
e ophth susp 0.3-0.1% ..70
TOBRADEX OIN 0.3-0.1%70
TOBRADEX ST SUS
0.3-0.05 .............................70
tobramycin nebu soln 300
mg/5ml ..............................11
tobramycin ophth soln 0.3%
..........................................70
tobramycin sulfate for inj 1.2
gm .....................................11
tobramycin sulfate inj 1.2
gm/30ml (40 mg/ml) ..........11
tobramycin sulfate inj 10
mg/ml ................................12
tobramycin sulfate inj 2
gm/50ml (40 mg/ml) ..........11
tobramycin sulfate inj 80
mg/2ml (40 mg/ml) ............12
tobramycin-dexamethasone
ophth susp 0.3-0.1% .........70
TOBREX
see tobramycin ophth soln
0.3% ..............................70
TOBREX OIN 0.3% OP ....70
TOFRANIL
see imipramine hcl tab 10
mg .................................41
see imipramine hcl tab 25
mg .................................41
see imipramine hcl tab 50
mg .................................41
TOLTERODINE TARTRATE
CAP SR 24HR 2 MG .........63
TOLTERODINE TARTRATE
CAP SR 24HR 4 MG .........63
tolterodine tartrate tab 1 mg
..........................................63
tolterodine tartrate tab 2 mg
.......................................... 63
TOPAMAX
see topiramate tab 100 mg
...................................... 39
see topiramate tab 200 mg
...................................... 39
see topiramate tab 25 mg
...................................... 39
see topiramate tab 50 mg
...................................... 39
TOPAMAX SPRINKLE
see topiramate sprinkle
cap 15 mg ..................... 39
see topiramate sprinkle
cap 25 mg ..................... 39
TOPICORT
see desoximetasone
cream 0.05% ................. 76
see desoximetasone
cream 0.25% ................. 76
see desoximetasone gel
0.05% ............................ 76
see desoximetasone oint
0.25% ............................ 76
topiramate sprinkle cap 15
mg ..................................... 39
topiramate sprinkle cap 25
mg ..................................... 39
topiramate tab 100 mg ...... 39
topiramate tab 200 mg ...... 39
topiramate tab 25 mg ........ 39
topiramate tab 50 mg ........ 39
toposar inj 1gm/50ml......... 24
topotecan hcl for inj 4 mg .. 24
TOPROL XL
see metoprolol succinate
tab sr 24hr 100 mg ........ 30
see metoprolol succinate
tab sr 24hr 200 mg ........ 30
see metoprolol succinate
tab sr 24hr 25 mg .......... 30
see metoprolol succinate
tab sr 24hr 50 mg .......... 30
torsemide inj 20mg/2ml ..... 33
torsemide inj 50mg/5ml ..... 33
torsemide tab 10 mg ......... 33
torsemide tab 100 mg ....... 33
torsemide tab 20 mg ......... 33
torsemide tab 5 mg ........... 33
TOUJEO SOLO INJ
300IU/ML .......................... 52
TOVIAZ TAB 4MG ............ 63
TOVIAZ TAB 8MG ............ 63
TPN ELECTROL INJ ........ 68
TRACLEER TAB 125MG .. 35
TRACLEER TAB 62.5MG . 35
TRADJENTA TAB 5MG .... 53
tramadol hcl tab 50 mg ....... 8
tramadol-acetaminophen tab
37.5-325 mg ....................... 8
TRANDATE
see labetalol hcl tab 100
mg ................................. 30
see labetalol hcl tab 200
mg ................................. 30
see labetalol hcl tab 300
mg ................................. 30
trandolapril tab 1 mg ......... 26
trandolapril tab 2 mg ......... 26
trandolapril tab 4 mg ......... 26
tranexamic acid inj 100 mg/ml
.......................................... 65
tranexamic acid tab 650 mg
.......................................... 65
TRANSDERM-SC DIS 1MG
.......................................... 60
TRANXENE T
see clorazepate
dipotassium tab 15 mg .. 36
see clorazepate
dipotassium tab 3.75 mg
...................................... 36
see clorazepate
dipotassium tab 7.5 mg . 36
tranylcypromine sulfate tab
10 mg................................ 42
travasol inj 10% ................ 68
TRAVATAN Z DRO 0.004%
.......................................... 71
trazodone hcl tab 100 mg . 42
trazodone hcl tab 150 mg . 42
trazodone hcl tab 50 mg ... 42
TREANDA INJ 100MG ..... 21
TREANDA INJ 180/2ML ... 21
TREANDA INJ 25MG ....... 21
TREANDA INJ 45/0.5ML .. 21
TRECATOR TAB 250MG . 15
TRELSTAR MIX INJ
11.25MG ........................... 22
TRELSTAR MIX INJ 3.75MG
.......................................... 22
tretinoin cap 10 mg ........... 23
125
tretinoin cream 0.025% .....75
tretinoin cream 0.05% .......75
tretinoin cream 0.1% .........75
tretinoin gel 0.01% ............75
tretinoin gel 0.025% ..........75
triamcinolone acetonide
cream 0.025% ...................77
triamcinolone acetonide
cream 0.1% .......................77
triamcinolone acetonide
cream 0.5% .......................77
triamcinolone acetonide
dental paste 0.1% .............78
triamcinolone acetonide
lotion 0.025% ....................77
triamcinolone acetonide
lotion 0.1% ........................77
triamcinolone acetonide oint
0.025% ..............................77
triamcinolone acetonide oint
0.1% ..................................77
triamcinolone acetonide oint
0.5% ..................................77
triamterene &
hydrochlorothiazide cap
37.5-25 mg ........................33
triamterene &
hydrochlorothiazide tab
37.5-25 mg ........................34
triamterene &
hydrochlorothiazide tab
75-50 mg ...........................34
TRIBENZOR20- TAB
5-12.5MG ..........................27
TRIBENZOR40- TAB
10-12.5 ..............................27
TRIBENZOR40- TAB
10-25MG ...........................27
TRIBENZOR40- TAB
5-12.5MG ..........................27
TRIBENZOR40- TAB
5-25MG .............................27
TRICOR
see fenofibrate tab 145 mg
......................................29
see fenofibrate tab 48 mg
......................................29
triderm cre 0.1%................77
trifluoperazine hcl tab 1 mg
..........................................47
trifluoperazine hcl tab 10 mg
.......................................... 47
trifluoperazine hcl tab 2 mg
.......................................... 47
trifluoperazine hcl tab 5 mg
.......................................... 47
trifluridine ophth soln 1%... 70
tri-legest tab fe .................. 56
TRILEPTAL
see oxcarbazepine susp
300 mg/5ml (60 mg/ml) . 38
see oxcarbazepine tab 150
mg ................................. 38
see oxcarbazepine tab 300
mg ................................. 38
see oxcarbazepine tab 600
mg ................................. 38
TRILIPIX
see choline fenofibrate cap
dr 135 mg (fenofibric acid
equiv) ............................ 29
see choline fenofibrate cap
dr 45 mg (fenofibric acid
equiv) ............................ 29
trilyte sol............................ 61
trimethoprim tab 100 mg ... 13
TRINESSA TAB ................ 56
TRI-NORINYL 28
see aranelle tab ............. 54
tri-previfem tab .................. 56
TRISENOX SOL 10MG/10M
.......................................... 23
tri-sprintec tab ................... 56
TRIUMEQ TAB ................. 15
trivora-28 tab..................... 56
TRIZIVIR
see abacavir
sulfate-lamivudine-zidovud
ine tab 300-150-300 mg 15
TROPHAMINE INJ 10% ... 68
trospium chloride tab 20 mg
.......................................... 63
TRUMENBA INJ ............... 68
TRUSOPT
see dorzolamide hcl ophth
soln 2% ......................... 71
TRUVADA TAB 200-300... 15
TUDORZA PRES AER
400/ACT............................ 72
TWINRIX INJ .................... 68
TYBOST TAB 150MG ....... 15
TYGACIL INJ 50MG ......... 13
TYKERB TAB 250MG....... 23
TYLENOL/CODEINE #3
see acetaminophen w/
codeine tab 300-30 mg ... 8
TYLENOL/CODEINE #4
see acetaminophen w/
codeine tab 300-60 mg ... 8
TYPHIM VI INJ ................. 68
TYSABRI INJ 300/15ML ... 50
TYZEKA TAB 600MG ....... 16
U
UCERIS TAB 9MG ........... 61
ULORIC TAB 40MG ........... 7
ULORIC TAB 80MG ........... 7
ULTRACET
see
tramadol-acetaminophen
tab 37.5-325 mg .............. 8
ULTRAM
see tramadol hcl tab 50 mg
........................................ 8
ULTRAVATE
see halobetasol propionate
cream 0.05% ................. 77
see halobetasol propionate
oint 0.05% ..................... 77
UNASYN
see ampicillin & sulbactam
sodium for inj 1-0.5 gm.. 19
see ampicillin & sulbactam
sodium for inj 2-1 gm..... 19
UNASYN BULK PACK
see ampicillin & sulbactam
sodium for inj 10-5 gm... 19
UNITHROID TAB 100MCG
.......................................... 59
UNITHROID TAB 112MCG
.......................................... 59
UNITHROID TAB 125MCG
.......................................... 59
UNITHROID TAB 150MCG
.......................................... 59
UNITHROID TAB 175MCG
.......................................... 59
UNITHROID TAB 200MCG
.......................................... 59
UNITHROID TAB 25MCG 59
UNITHROID TAB 300MCG
.......................................... 59
UNITHROID TAB 50MCG 59
UNITHROID TAB 75MCG 59
126
UNITHROID TAB 88MCG .59
URECHOLINE
see bethanechol chloride
tab 10 mg ......................63
see bethanechol chloride
tab 25 mg ......................63
see bethanechol chloride
tab 5 mg ........................63
see bethanechol chloride
tab 50 mg ......................63
UROXATRAL
see alfuzosin hcl tab sr
24hr 10 mg ....................62
URSO 250
see ursodiol tab 250 mg 62
URSO FORTE
see ursodiol tab 500 mg 62
ursodiol cap 300 mg ..........62
ursodiol tab 250 mg ..........62
ursodiol tab 500 mg ..........62
V
VAGIFEM TAB 10MCG ....57
valacyclovir hcl tab 1 gm ...16
valacyclovir hcl tab 500 mg
..........................................16
VALCHLOR GEL 0.016% .78
VALCYTE
see valganciclovir hcl tab
450 mg (base equivalent)
......................................16
VALCYTE SOL 50MG/ML .16
valganciclovir hcl tab 450 mg
(base equivalent) ..............16
VALIUM
see diazepam tab 10 mg
......................................36
see diazepam tab 2 mg .36
see diazepam tab 5 mg .36
valproate sodium inj 100
mg/ml ................................39
valproate sodium syrup 250
mg/5ml (base equiv) .........39
valproic acid cap 250 mg ..39
valsartan tab 160 mg ........27
valsartan tab 320 mg ........27
valsartan tab 40 mg ..........27
valsartan tab 80 mg ..........27
valsartan-hydrochlorothiazid
e tab 160-12.5 mg .............27
valsartan-hydrochlorothiazid
e tab 160-25 mg ................27
valsartan-hydrochlorothiazid
e tab 320-12.5 mg ............. 27
valsartan-hydrochlorothiazid
e tab 320-25 mg ................ 27
valsartan-hydrochlorothiazid
e tab 80-12.5 mg ............... 27
VALTREX
see valacyclovir hcl tab 1
gm ................................. 16
see valacyclovir hcl tab 500
mg ................................. 16
VANCOCIN HCL
see vancomycin hcl cap
125 mg .......................... 13
see vancomycin hcl cap
250 mg .......................... 13
vancomycin hcl cap 125 mg
.......................................... 13
vancomycin hcl cap 250 mg
.......................................... 13
vancomycin hcl for inj 10 gm
.......................................... 13
vancomycin hcl for inj 1000
mg ..................................... 13
vancomycin hcl for inj 500 mg
.......................................... 13
vancomycin hcl for inj 5000
mg ..................................... 13
vancomycin inj 750mg ...... 13
VANDAZOLE GEL 0.75% . 63
VAQTA INJ 25/0.5ML ....... 68
VAQTA INJ 50UNT/ML ..... 68
VARIVAX INJ .................... 68
VASCEPA CAP 1GM ........ 30
VASERETIC
see enalapril maleate &
hydrochlorothiazide tab
10-25 mg ....................... 25
VASOTEC
see enalapril maleate tab
10 mg ............................ 25
see enalapril maleate tab
2.5 mg ........................... 25
see enalapril maleate tab
20 mg ............................ 25
see enalapril maleate tab 5
mg ................................. 25
VELCADE INJ 3.5MG ....... 22
velivet pak ......................... 56
venlafaxine hcl cap sr 24hr
150 mg (base equivalent) . 43
venlafaxine hcl cap sr 24hr
37.5 mg (base equivalent) 42
venlafaxine hcl cap sr 24hr 75
mg (base equivalent) ........ 42
venlafaxine hcl tab 100 mg
.......................................... 43
venlafaxine hcl tab 25 mg . 43
venlafaxine hcl tab 37.5 mg
.......................................... 43
venlafaxine hcl tab 50 mg . 43
venlafaxine hcl tab 75 mg . 43
verapamil hcl cap sr 24hr 100
mg..................................... 32
verapamil hcl cap sr 24hr 120
mg..................................... 32
verapamil hcl cap sr 24hr 180
mg..................................... 32
verapamil hcl cap sr 24hr 200
mg..................................... 32
verapamil hcl cap sr 24hr 240
mg..................................... 32
verapamil hcl cap sr 24hr 300
mg..................................... 32
VERAPAMIL HCL CAP SR
24HR 360 MG ................... 32
verapamil hcl iv soln 2.5
mg/ml ................................ 32
verapamil hcl tab 120 mg .. 32
verapamil hcl tab 40 mg .... 32
verapamil hcl tab 80 mg .... 32
verapamil hcl tab cr 120 mg
.......................................... 32
verapamil hcl tab cr 180 mg
.......................................... 32
verapamil hcl tab cr 240 mg
.......................................... 32
VERELAN
see verapamil hcl cap sr
24hr 120 mg .................. 32
see verapamil hcl cap sr
24hr 180 mg .................. 32
see verapamil hcl cap sr
24hr 240 mg .................. 32
VERELAN PM
see verapamil hcl cap sr
24hr 100 mg .................. 32
see verapamil hcl cap sr
24hr 200 mg .................. 32
see verapamil hcl cap sr
24hr 300 mg .................. 32
VERSACLOZ SUS 50MG/ML
127
..........................................47
VESICARE TAB 10MG .....63
VESICARE TAB 5MG .......63
VFEND
see voriconazole for susp
40 mg/ml........................13
see voriconazole tab 200
mg .................................14
see voriconazole tab 50
mg .................................14
VFEND IV
see voriconazole for inj 200
mg .................................13
VIBRAMYCIN
see doxycycline hyclate
cap 100 mg....................20
VIBRAMYCIN SYP
50MG/5ML ........................20
VICOPROFEN
see
hydrocodone-ibuprofen tab
7.5-200 mg ......................8
VICTOZA INJ 18MG/3ML .52
VICTRELIS CAP 200MG ..16
VIDAZA
see azacitidine for inj 100
mg .................................21
VIDEX EC
see didanosine delayed
release capsule 125 mg 14
see didanosine delayed
release capsule 200 mg 14
see didanosine delayed
release capsule 250 mg 14
see didanosine delayed
release capsule 400 mg 14
VIDEX SOL 2GM ..............15
VIDEX SOL 4GM ..............15
VIGAMOX DRO 0.5% .......70
VIIBRYD KIT .....................43
VIIBRYD TAB 10MG .........43
VIIBRYD TAB 20MG .........43
VIIBRYD TAB 40MG .........43
VIMPAT INJ 200MG/20 ....39
VIMPAT SOL 10MG/ML ....39
VIMPAT TAB 100MG ........39
VIMPAT TAB 150MG ........39
VIMPAT TAB 200MG ........39
VIMPAT TAB 50MG ..........39
vinblastine inj 1mg/ml ........22
vincasar pfs inj 1mg/ml .....22
vincristine sulfate iv soln 1
mg/ml ................................ 22
vinorelbine tartrate inj 10
mg/ml (base equiv) ........... 22
vinorelbine tartrate inj 50
mg/5ml (10 mg/ml) (base
equiv) ................................ 22
viorele tab ......................... 56
VIRACEPT TAB 250MG ... 15
VIRACEPT TAB 625MG ... 15
VIRAMUNE
see nevirapine tab 200 mg
...................................... 14
VIRAMUNE XR
see nevirapine tab sr 24hr
400 mg .......................... 14
VIRAMUNE XR TAB 100MG
.......................................... 15
VIREAD POW 40MG/GM . 15
VIREAD TAB 150MG ........ 15
VIREAD TAB 200MG ........ 15
VIREAD TAB 250MG ........ 15
VIREAD TAB 300MG ........ 15
VIROPTIC
see trifluridine ophth soln
1% ................................. 70
VITEKTA TAB 150MG ...... 15
VITEKTA TAB 85MG ........ 15
VOLTAREN GEL 1% ........ 78
VOLTAREN-XR
see diclofenac sodium tab
sr 24hr 100 mg ................ 7
voriconazole for inj 200 mg
.......................................... 13
voriconazole for susp 40
mg/ml ................................ 13
voriconazole tab 200 mg ... 14
voriconazole tab 50 mg ..... 14
VOSPIRE ER
see albuterol sulfate tab sr
12hr 4 mg ...................... 72
see albuterol sulfate tab sr
12hr 8 mg ...................... 72
VOTRIENT TAB 200MG ... 23
vyfemla tab 0.4-35 ............ 56
W
warfarin sodium tab 1 mg .. 64
warfarin sodium tab 10 mg 65
warfarin sodium tab 2 mg .. 64
warfarin sodium tab 2.5 mg
.......................................... 64
warfarin sodium tab 3 mg . 64
warfarin sodium tab 4 mg . 64
warfarin sodium tab 5 mg . 64
warfarin sodium tab 6 mg . 64
warfarin sodium tab 7.5 mg
.......................................... 65
WATER FOR IRRIGATION,
STERILE IRRIGATION
SOLN ................................ 78
WELCHOL PAK 3.75GM .. 30
WELCHOL TAB 625MG ... 30
WELLBUTRIN
see bupropion hcl tab 100
mg ................................. 40
see bupropion hcl tab 75
mg ................................. 40
WELLBUTRIN SR
see bupropion hcl tab sr
12hr 100 mg .................. 40
see bupropion hcl tab sr
12hr 150 mg .................. 40
see bupropion hcl tab sr
12hr 200 mg .................. 40
WELLBUTRIN XL
see bupropion hcl tab sr
24hr 150 mg .................. 40
see bupropion hcl tab sr
24hr 300 mg .................. 40
WESTCORT
see hydrocortisone
valerate oint 0.2% ......... 77
X
XALATAN
see latanoprost ophth soln
0.005% .......................... 71
XALKORI CAP 200MG ..... 23
XALKORI CAP 250MG ..... 23
XANAX
see alprazolam tab 0.25
mg ................................. 35
see alprazolam tab 0.5 mg
...................................... 35
see alprazolam tab 1 mg
...................................... 35
see alprazolam tab 2 mg
...................................... 35
XARELTO STAR TAB
15/20MG ........................... 65
XARELTO TAB 10MG ...... 65
XARELTO TAB 15MG ...... 65
XARELTO TAB 20MG ...... 65
128
XENAZINE TAB 12.5MG ..50
XENAZINE TAB 25MG .....50
XGEVA INJ .......................58
XIFAXAN TAB 550MG ......62
XOLAIR SOL 150MG ........73
XOPENEX CONCENTRATE
see levalbuterol hcl soln
nebu conc 1.25 mg/0.5ml
(base equiv)...................72
XOPENEX HFA AER ........73
XTANDI CAP 40MG ..........22
XYLOCAINE
see lidocaine hcl local inj
0.5% ..............................11
see lidocaine hcl local inj
1% .................................11
see lidocaine hcl local inj
2% .................................11
see lidocaine hcl soln 4%
......................................77
XYLOCAINE-MPF
see lidocaine hcl local inj
1.5% ..............................11
see lidocaine hcl local
preservative free (pf) inj
0.5% ..............................11
see lidocaine hcl local
preservative free (pf) inj 1%
......................................11
XYREM SOL 500MG/ML ..51
XYZAL
see levocetirizine
dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml) .......72
see levocetirizine
dihydrochloride tab 5 mg
......................................72
Y
YASMIN 28
see drospirenone-ethinyl
estradiol tab 3-0.03 mg ..54
YAZ
see drospirenone-ethinyl
estradiol tab 3-0.02 mg ..54
see loryna tab 3-0.02mg 55
see nikki tab 3-0.02mg ..55
YF-VAX INJ.......................68
Z
zafirlukast tab 10 mg .........73
zafirlukast tab 20 mg .........73
ZANAFLEX
see tizanidine hcl tab 4 mg
(base equivalent) ........... 51
ZANTAC
see ranitidine hcl inj 150
mg/6ml (25 mg/ml) ........ 61
see ranitidine hcl inj 50
mg/2ml (25 mg/ml) ........ 60
see ranitidine hcl tab 150
mg ................................. 61
see ranitidine hcl tab 300
mg ................................. 61
ZARONTIN
see ethosuximide cap 250
mg ................................. 37
see ethosuximide soln 250
mg/5ml .......................... 37
ZAVESCA CAP 100MG .... 56
zazole cre 0.4% ................ 63
ZAZOLE CRE 0.8% .......... 63
ZEBETA
see bisoprolol fumarate tab
10 mg ............................ 30
see bisoprolol fumarate tab
5 mg .............................. 30
ZELBORAF TAB 240MG .. 23
ZEMAIRA INJ 1000MG ..... 73
ZEMPLAR
see paricalcitol cap 1 mcg
...................................... 70
see paricalcitol cap 2 mcg
...................................... 70
zenatane cap 30mg .......... 75
zenchent tab ..................... 56
ZENPEP CAP 10000UNT . 62
ZENPEP CAP 15000UNT . 62
ZENPEP CAP 20000UNT . 62
ZENPEP CAP 25000UNT . 62
ZENPEP CAP 3000UNIT .. 62
ZENPEP CAP 40000UNT . 62
ZENPEP CAP 5000UNIT .. 62
ZERIT
see stavudine cap 15 mg
...................................... 14
see stavudine cap 20 mg
...................................... 14
see stavudine cap 30 mg
...................................... 14
see stavudine cap 40 mg
...................................... 15
see stavudine for oral soln
1 mg/ml ......................... 15
ZESTORETIC
see lisinopril &
hydrochlorothiazide tab
10-12.5 mg .................... 25
see lisinopril &
hydrochlorothiazide tab
20-12.5 mg .................... 25
see lisinopril &
hydrochlorothiazide tab
20-25 mg ....................... 25
ZESTRIL
see lisinopril tab 2.5 mg 25
see lisinopril tab 30 mg . 25
see lisinopril tab 40 mg . 25
ZETIA TAB 10MG ............. 30
ZIAC
see bisoprolol &
hydrochlorothiazide tab
10-6.25 mg .................... 30
see bisoprolol &
hydrochlorothiazide tab
2.5-6.25 mg ................... 30
see bisoprolol &
hydrochlorothiazide tab
5-6.25 mg ...................... 30
ZIAGEN
see abacavir sulfate tab
300 mg (base equiv) ..... 14
ZIAGEN SOL 20MG/ML ... 15
zidovudine cap 100 mg ..... 15
zidovudine syrup 10 mg/ml
.......................................... 15
zidovudine tab 300 mg ...... 15
ZINACEF
see cefuroxime sodium for
inj 1.5 gm ...................... 17
see cefuroxime sodium for
inj 7.5 gm ...................... 17
see cefuroxime sodium for
inj 750 mg ..................... 17
see cefuroxime sodium for
iv soln 1.5 gm ................ 17
ZINECARD
see dexrazoxane for inj
250 mg .......................... 24
ziprasidone hcl cap 20 mg 47
ziprasidone hcl cap 40 mg 47
ziprasidone hcl cap 60 mg 48
ziprasidone hcl cap 80 mg 48
ZITHROMAX
see azithromycin for susp
129
100 mg/5ml....................17
see azithromycin for susp
200 mg/5ml....................17
see azithromycin iv for soln
500 mg ..........................18
see azithromycin tab 250
mg .................................18
see azithromycin tab 500
mg .................................18
see azithromycin tab 600
mg .................................18
ZMAX SUS 2GM ...............18
ZOCOR
see simvastatin tab 10 mg
......................................29
see simvastatin tab 20 mg
......................................29
see simvastatin tab 40 mg
......................................29
see simvastatin tab 5 mg
......................................29
see simvastatin tab 80 mg
......................................29
ZOFRAN
see ondansetron hcl inj 40
mg/20ml (2 mg/ml) ........60
see ondansetron hcl oral
soln 4 mg/5ml ................60
see ondansetron hcl tab 4
mg .................................60
see ondansetron hcl tab 8
mg .................................60
ZOFRAN ODT
see ondansetron orally
disintegrating tab 4 mg ..60
see ondansetron orally
disintegrating tab 8 mg ..60
zoledronic acid inj conc for iv
infusion 4 mg/5ml ..............54
ZOLINZA CAP 100MG ......22
zolmitriptan orally
disintegrating tab 2.5 mg ...50
zolmitriptan orally
disintegrating tab 5 mg ......50
zolmitriptan tab 2.5 mg ......50
zolmitriptan tab 5 mg .........50
ZOLOFT
see sertraline hcl oral conc
20 mg/ml........................42
see sertraline hcl tab 100
mg .................................42
see sertraline hcl tab 25 mg
...................................... 42
see sertraline hcl tab 50 mg
...................................... 42
zolpidem tartrate tab 10 mg
.......................................... 49
zolpidem tartrate tab 5 mg 49
ZOMETA
see zoledronic acid inj
conc for iv infusion 4
mg/5ml .......................... 54
ZOMETA INJ 4MG/100 ..... 54
ZOMIG
see zolmitriptan tab 2.5 mg
...................................... 50
see zolmitriptan tab 5 mg
...................................... 50
ZOMIG ZMT
see zolmitriptan orally
disintegrating tab 2.5 mg
...................................... 50
see zolmitriptan orally
disintegrating tab 5 mg .. 50
ZONEGRAN
see zonisamide cap 100
mg ................................. 39
see zonisamide cap 25 mg
...................................... 39
zonisamide cap 100 mg .... 39
zonisamide cap 25 mg ...... 39
zonisamide cap 50 mg ...... 39
ZONTIVITY TAB 2.08MG . 65
ZORTRESS TAB 0.25MG . 67
ZORTRESS TAB 0.5MG... 67
ZORTRESS TAB 0.75MG . 67
ZOSTAVAX INJ ................ 68
ZOSYN
see piperacillin
sodium-tazobactam
sodium for inj 2-0.25 gm 20
see piperacillin
sodium-tazobactam
sodium for inj 3-0.375 gm
...................................... 20
see piperacillin
sodium-tazobactam
sodium for inj 36-4.5 gm 20
see piperacillin
sodium-tazobactam
sodium for inj 4-0.5 gm .. 20
ZOVIRAX
see acyclovir cap 200 mg
...................................... 15
see acyclovir oint 5% .... 76
see acyclovir susp 200
mg/5ml .......................... 15
see acyclovir tab 400 mg
...................................... 15
see acyclovir tab 800 mg
...................................... 15
ZYBAN
see buproban tab 150mg
...................................... 51
ZYDELIG TAB 100MG...... 23
ZYDELIG TAB 150MG...... 23
ZYKADIA CAP 150MG ..... 23
ZYLET SUS 0.5-0.3% ....... 70
ZYLOPRIM
see allopurinol tab 100 mg
........................................ 7
see allopurinol tab 300 mg
........................................ 7
ZYMAXID
see gatifloxacin ophth soln
0.5% .............................. 70
ZYPREXA
see olanzapine for im inj 10
mg ................................. 46
see olanzapine tab 10 mg
...................................... 46
see olanzapine tab 15 mg
...................................... 46
see olanzapine tab 2.5 mg
...................................... 46
see olanzapine tab 20 mg
...................................... 46
see olanzapine tab 5 mg
...................................... 46
see olanzapine tab 7.5 mg
...................................... 46
ZYPREXA RELP INJ 210MG
.......................................... 48
ZYPREXA RELP INJ 300MG
.......................................... 48
ZYPREXA RELP INJ 405MG
.......................................... 48
ZYPREXA ZYDIS
see olanzapine orally
disintegrating tab 10 mg 46
see olanzapine orally
disintegrating tab 15 mg 46
see olanzapine orally
130
disintegrating tab 20 mg 46
see olanzapine orally
disintegrating tab 5 mg ..46
ZYTIGA TAB 250MG ........ 22
ZYVOX
see linezolid iv soln 2
mg/ml ............................ 12
ZYVOX SUS 100MG/5M .. 13
ZYVOX TAB 600MG ......... 13
131
Blue MedicareRx (PDP)
SM
P.O. Box 52429, Phoenix, AZ 85072­2429 This formulary was updated on 07/01/2015. For more recent information or other questions, please contact Blue MedicareRx Value Plus, at 1­888­543­4917 or, for TTY/TDD users, 1­866­236­1069, 24 hours a day, 7 days a week, or visit www.RxMedicarePlans.com. Blue Cross and Blue Shield of Massachusetts, Inc., is an Independent Licensee of the Blue Cross and Blue Shield Association. Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk­bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare­approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal. ® Registered Marks of the Blue Cross and Blue Shield Association. SM Service Mark of Anthem Blue Cross Blue Shield. © 2015 Blue Cross and Blue Shield of Massachusetts, Inc.