1. No category

SilverScript
2015 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS
INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary File 15301, Version 6
This formulary was updated on November 1, 2014. For more recent information or other questions, please
contact SilverScript at 1-866-235-5660 or, for TTY users, 1-866-236-1069, 24 hours a day, 7 days a week,
or visit www.silverscript.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 SilverScript® Insurance Company.
When it refers to “plan” or “our plan,” it means SilverScript Choice (PDP).
This document includes a list of the drugs (formulary) for our plan which is current as of
January 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.
Y0080_62001_FORM_COMP_2015 Accepted
15-FORMCM-CHC
1
What is the SilverScript Formulary?
A formulary is a list of covered drugs selected by
SilverScript Choice (PDP) 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.
Our plan will generally cover the drugs listed in
our formulary as long as the drug is medically
necessary, the prescription is filled at a plan
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 cost-sharing
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 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 January 1,
2015. To get updated information about the drugs
covered by SilverScript Choice (PDP), please
contact us. Our contact information appears on the
front and back cover pages.
If we have a mid-year non-maintenance formulary
change (i.e. remove drugs from our formulary,
add prior authorization requirements, quantity
limits and/or step therapy restrictions on a drug, or
move a drug to a higher cost-sharing tier), we will
notify you by mail. We will also update our
formulary with the new information. The updated
formulary may be obtained from our Web site or
by calling us. Our contact information appears on
the front and back cover pages.
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 7. Then look under the category
name for your drug.
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
cost-sharing 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 60-day supply of
the drug.
2
Alphabetical Listing
Step Therapy (ST)
If you are not sure what category to look under,
you should look for your drug in the Index that
begins on page 50. 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.
In some cases, SilverScript Choice (PDP) 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, we 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.
What are generic drugs?
SilverScript Choice (PDP) 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 (PA)
SilverScript Choice (PDP) requires you or your
physician to get prior authorization for certain
drugs. This means that you will need to get
approval from us before you fill your
prescriptions. If you don’t get approval, we may
not cover the drug.
Quantity Limits (QL)
For certain drugs, SilverScript Choice (PDP)
limits the amount of the drug that we will cover.
For example, our plan provides up to nine tablets
per prescription for sumatriptan tab 50mg. This
may be in addition to a standard one-month or
three-month supply.
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 us 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
SilverScript Choice (PDP) 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 SilverScript Choice (PDP) does
not cover your drug, you have two options:
You can ask Customer Care for a list of
similar drugs that are covered by our plan.
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 us to make an exception and
cover your drug. See below for information
about how to request an exception.
3
How do I request an exception to the
SilverScript 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 pre-determined
cost-sharing level, and you would not be
able to ask us to provide the drug at a lower
cost-sharing level.
You can ask us to cover a formulary drug at
a lower cost-sharing 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, our plan 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, SilverScript Choice (PDP) will only
approve your request for an exception if the
alternative drugs included on the plan’s
formulary, the lower cost-sharing drug or
additional utilization restrictions would not be as
effective in treating your condition and/or would
cause you to have adverse medical effects.
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 30-day supply
(unless you have a prescription written for fewer
days) when you go to a network pharmacy.
After your first 30-day 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 long-term care facility,
we will allow you to refill your prescription until
we have provided you with a 102-day 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 34-day
emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a
formulary exception.
4
If you experience a change in your level of care,
such as a move from a hospital to a home setting,
and need a drug that is not on our formulary (or if
your ability to get your drugs is limited), we may
cover a one-time temporary supply from a
network pharmacy for up to 34 days unless you
have a prescription for fewer days. You should
use the plan's exception process if you wish to
have continued coverage of the drug after the
temporary supply is finished.
For more information
For more detailed information about your
SilverScript Choice (PDP) prescription drug
coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about our plan, 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 1-800-MEDICARE (1-800-633-4227), 24 hours
a day, 7 days a week. TTY users should call
1-877-486-2048. Or, visit
http://www.medicare.gov.
The information in the Requirements/Limits
column tells you if our plan has any special
requirements for coverage of your drug.
PA – Prior authorization.
QL – Drug has quantity limit.
ST – Step therapy required.
NM - Not available at our mail-order pharmacies.
LA – Limited Access. This prescription may be
available only at certain pharmacies. For more
information consult your Pharmacy Directory or
call Customer Care at 1-866-235-5660, 24 hours a
day, 7 days a week. TTY users should call
1-866-236-1069.
HR – High Risk Drug. According to medical
experts, these drugs may cause more side effects
if you are 65 years of age or older. If you are
taking one of these drugs, ask your doctor if there
are safer options available.
B/D – This drug may be covered under Medicare
Part B or D depending upon the circumstances.
Information may need to be submitted describing
the use and setting of the drug to make the
determination.
SilverScript Choice (PDP)’s Formulary
The formulary that begins on page 7 provides
coverage information about the drugs covered by
our plan. If you have trouble finding your drug in
the list, turn to the Index that begins on page 50.
The first column of the chart lists the drug name.
Brand name drugs are capitalized (e.g.,
SYNTHROID) and generic drugs are listed in
lower-case italics (e.g., levothyroxine).
5
The Tier column of the drug list that begins on page 7 tells you which tier your drug is in. The table
below tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay
during the initial coverage period) for up to a one month supply of drugs in each tier.
Initial Coverage Period Copayment / Coinsurance Levels
Standard retail cost-sharing (in-network) (Up to a 30-day supply)
Tier 1
(Generic)
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Tier 2
(Preferred Brand)
Tier 3
(Non-Preferred
Brand)
Tier 4
(Specialty Tier)
(includes preferred
(includes
brand drugs
non-preferred brand
(includes generic
and some
drugs and some
(includes high cost
and some preferred non-preferred
non-preferred generic generic and brand
brand drugs)
generic drugs)
drugs)
drugs)
$7.00
$33.00
47%
33%
$2.00
17%
37%
25%
$9.00
$35.00
46%
33%
$7.00
$33.00
44%
33%
$8.00
$41.00
43%
33%
$8.00
$40.00
45%
33%
$8.00
$27.00
33%
45%
$7.00
$40.00
33%
46%
$7.00
$40.00
33%
46%
$8.00
$40.00
33%
42%
$7.00
$35.00
46%
33%
$10.00
$36.00
45%
33%
$8.00
$33.00
42%
33%
$8.00
$37.00
43%
33%
$7.00
$34.00
33%
45%
$9.00
$22.00
33%
43%
$7.00
$36.00
33%
42%
$7.00
$34.00
33%
45%
$8.00
$29.00
33%
45%
$7.00
$38.00
43%
33%
$7.00
$40.00
46%
33%
$8.00
$27.00
45%
33%
$7.00
$40.00
43%
33%
$9.00
$22.00
33%
43%
$7.00
$37.00
33%
47%
$7.00
$31.00
33%
43%
$9.00
$22.00
33%
43%
$9.00
$22.00
33%
43%
$8.00
$35.00
45%
33%
$7.00
$38.00
43%
33%
$8.00
$34.00
47%
33%
$8.00
$40.00
44%
33%
$7.00
$34.00
33%
47%
$7.00
$37.00
33%
47%
$9.00
$22.00
33%
43%
5
Tier 1
(Generic)
State
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Tier 2
(Preferred Brand)
Tier 3
(Non-Preferred
Brand)
Tier 4
(Specialty Tier)
(includes preferred
(includes
brand drugs
non-preferred brand
(includes generic
and some
drugs and some
(includes high cost
and some preferred non-preferred
non-preferred generic generic and brand
brand drugs)
generic drugs)
drugs)
drugs)
$8.00
$27.00
46%
33%
$7.00
$33.00
33%
46%
$7.00
$37.00
33%
43%
$7.00
$32.00
33%
47%
$8.00
$27.00
45%
33%
$8.00
$34.00
46%
33%
$9.00
$22.00
33%
43%
$7.00
$33.00
33%
47%
$8.00
$37.00
47%
33%
$8.00
$33.00
42%
33%
$8.00
$27.00
45%
33%
$8.00
$36.00
33%
45%
$7.00
$37.00
33%
43%
$7.00
$32.00
47%
33%
$8.00
$26.00
43%
33%
$9.00
$22.00
33%
43%
You can find complete cost-sharing information, including costs for long-term supplies and mail order
pharmacy pricing, in your Evidence of Coverage.
6
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
ANALGESICS
GOUT
allopurinol tab (generic of
ZYLOPRIM)
colchicine w/ probenecid
COLCRYS
QL (120 tabs / 30 days)
probenecid
ULORIC
Drug Requirements/
Tier
Limits
piroxicam (generic of
FELDENE) CAPS
sulindac TABS
1
2
1
OPIOID ANALGESICS
2
2
QL
2
2
ST
3
QL
3
QL
3
QL
3
QL
NSAIDS
CELEBREX CAP 50MG
QL (60 caps / 30 days)
CELEBREX CAP 100MG
QL (60 caps / 30 days)
CELEBREX CAP 200MG
QL (60 caps / 30 days)
CELEBREX CAP 400MG
QL (60 caps / 30 days)
diclofenac potassium (generic
of CATAFLAM)
diclofenac sodium (generic of
VOLTAREN-XR) TB24
diclofenac sodium TBEC
diflunisal
etodolac CAPS; TABS
etodolac TB24
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg,
600mg, 800mg
ketoprofen CAPS
MELOXICAM SUSP
meloxicam (generic of
MOBIC) TABS
nabumetone TABS
naproxen (generic of
NAPROSYN) SUSP
naproxen (generic of
NAPROSYN) TABS
naproxen (generic of
EC-NAPROSYN) TBEC
naproxen sodium (generic of
ANAPROX) TABS 275mg
naproxen sodium (generic of
ANAPROX DS) TABS
550mg
Drug Name
1
2
1
2
2
3
1
2
1
1
3
1
1
2
1
1
1
1
acetaminophen w/ codeine
SOLN
QL (5000 mL / 30 days)
acetaminophen w/ codeine
TABS
QL (400 tabs / 30 days)
acetaminophen w/ codeine
(generic of
TYLENOL/CODEINE #3)
TABS
QL (400 tabs / 30 days)
acetaminophen w/ codeine
(generic of
TYLENOL/CODEINE #4)
TABS
QL (400 tabs / 30 days)
butorphanol tartrate SOLN
1mg/ml, 2mg/ml
BUTRANS 5mcg/hr
QL (16 patches / 28
days)
BUTRANS 10mcg/hr
QL (8 patches / 28 days)
BUTRANS 15mcg/hr,
20mcg/hr
QL (4 patches / 28 days)
hydroco/apap tab 5-325mg
(generic of NORCO)
QL (360 tabs / 30 days)
hydroco/apap tab 7.5-325mg
(generic of NORCO)
QL (360 tabs / 30 days)
hydroco/apap tab 10-325mg
(generic of NORCO)
QL (360 tabs / 30 days)
hydrocodone-acetaminophen
7.5-325 mg/15ml (generic of
HYCET)
QL (5400 mL / 30 days)
hydrocodone-ibuprofen
7.5-200mg (generic of
VICOPROFEN)
QL (150 tabs / 30 days)
1
QL
1
QL
1
QL
1
QL
2
2
QL
2
QL
2
QL
1
QL
1
QL
1
QL
3
QL
2
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
7
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
tramadol hcl (generic of
ULTRAM) TABS
QL (240 tabs / 30 days)
tramadol-acetaminophen
(generic of ULTRACET)
QL (240 tabs / 30 days)
1
QL
2
QL
OPIOID ANALGESICS, CII
DURAMORPH
endocet (generic of
PERCOCET)
QL (360 tabs / 30 days)
fentanyl citrate (generic of
ACTIQ) LPOP
QL (120 lozenges / 30
days)
fentanyl patch (generic of
DURAGESIC)
QL (10 patches / 30
days)
hydromorphon inj 10mg/ml
(generic of DILAUDID-HP)
hydromorphone hcl (generic
of DILAUDID) LIQD
hydromorphone hcl (generic
of DILAUDID) TABS
QL (270 tabs / 30 days)
LAZANDA
QL (30 bottles / 30 days)
methadone hcl (generic of
METHADOSE) CONC
QL (120 mL / 30 days)
methadone hcl SOLN
5mg/5ml, 10mg/5ml
QL (600 mL / 30 days)
methadone hcl (generic of
DOLOPHINE HCL) TABS
5mg
QL (240 tabs / 30 days)
methadone hcl (generic of
DOLOPHINE) TABS 10mg
QL (240 tabs / 30 days)
morphine ext-rel tab (generic
of MS CONTIN) 15mg,
30mg, 60mg, 100mg
QL (90 tabs / 30 days)
morphine ext-rel tab (generic
of MS CONTIN) 200mg
QL (60 tabs / 30 days)
1
2
B/D
QL
4 QL NM PA
3
3
QL
B/D
2
2
QL
4 QL NM PA
2
QL
2
QL
1
QL
1
QL
2
QL
2
QL
Drug Name
Drug Requirements/
Tier
Limits
MORPHINE SUL INJ
1mg/ml, 10mg/ml, 15mg/ml
morphine sul inj .5mg/ml,
1mg/ml
MORPHINE SUL INJ
2MG/ML
MORPHINE SUL INJ
4MG/ML
MORPHINE SULFATE
SOLN 8mg/ml
MORPHINE SULFATE
TABS
QL (180 tabs / 30 days)
MORPHINE SULFATE ORAL
SOL
NUCYNTA ER 50mg,
100mg
QL (120 tabs / 30 days)
NUCYNTA ER 150mg,
200mg, 250mg
QL (60 tabs / 30 days)
OPANA ER (CRUSH
RESISTANT
QL (120 tabs / 30 days)
oxycodone hcl CAPS
QL (180 caps / 30 days)
oxycodone hcl CONC
oxycodone hcl SOLN
oxycodone hcl TABS 10mg,
20mg
QL (180 tabs / 30 days)
oxycodone hcl (generic of
ROXICODONE) TABS
15mg, 30mg
QL (180 tabs / 30 days)
oxycodone hcl tab 5 mg
(generic of ROXICODONE)
QL (180 tabs / 30 days)
oxycodone w/ acetaminophen
2.5-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen
5-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
1
B/D
1
B/D
2
B/D
2
B/D
2
B/D
1
QL
2
2
QL
2
QL
2
QL
2
QL
3
3
2
QL
2
QL
2
QL
2
QL
2
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
8
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
oxycodone w/ acetaminophen
7.5-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen
10-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
OXYCONTIN
QL (120 tabs / 30 days)
roxicet soln
QL (1800 mL / 30 days)
roxicet tab 5-325mg (generic
of PERCOCET)
QL (360 tabs / 30 days)
2
2
QL
QL
2
QL
2
QL
2
QL
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl (local anesth.)
(generic of XYLOCAINE)
lidocaine inj 0.5% (generic of
XYLOCAINE-MPF)
lidocaine inj 1% (generic of
XYLOCAINE) 1%
lidocaine inj 1% (generic of
XYLOCAINE-MPF) 1%
lidocaine inj 1.5% (generic of
XYLOCAINE-MPF)
lidocaine inj 2% (generic of
XYLOCAINE)
1
B/D
1
B/D
1
B/D
1
B/D
1
B/D
1
B/D
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
gentamicin in saline
gentamicin sulfate SOLN
neomycin sulfate TABS
paromomycin sulfate CAPS
streptomycin sulfate SOLR
sulfadiazine TABS
tobramycin (generic of TOBI)
NEBU
tobramycin inj 1.2/30ml
tobramycin inj 1.2gm
tobramycin inj 10mg/ml
tobramycin inj 40mg/ml
tobramycin inj 80mg/2ml
tobramycin sulfate in saline
3
1
1
2
3
3
3
4
2
3
2
2
2
2
B/D NM
Drug Name
Drug Requirements/
Tier
Limits
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA
ALINIA
atovaquone (generic of
MEPRON) SUSP
AZACTAM
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam (generic of
AZACTAM)
BILTRICIDE
CAYSTON
clindamycin cap 75mg
(generic of CLEOCIN)
clindamycin cap 300mg
(generic of CLEOCIN)
clindamycin hcl cap 150 mg
(generic of CLEOCIN)
clindamycin phosphate inj
150mg/ml
clindamycin phosphate inj
(generic of CLEOCIN
PHOSPHATE) 150mg/ml,
300mg/2ml, 600mg/4ml,
900mg/6ml, 9000mg/60ml
clindamycin sol 75mg/5ml
(generic of CLEOCIN
PEDIATRIC GRANULE)
colistimethate sodium
(generic of COLY-MYCIN M)
SOLR
CUBICIN
dapsone TABS
DARAPRIM
e.s.p.
ees/sulfisox sus 200-600
imipenem-cilastatin (generic
of PRIMAXIN IV)
INVANZ
meropenem (generic of
MERREM)
methenamine hippurate
(generic of HIPREX)
metronidazole (generic of
FLAGYL) TABS
metronidazole in nacl
3
3
4
NM
3
3
4
2
2
4
1
NM
NM LA PA
1
1
2
2
3
3
4
2
3
2
2
3
B/D NM
3
3
2
1
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
9
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
NEBUPENT
nitrofurantoin macrocrystal
(generic of MACRODANTIN)
HR: 90 day limit if > 64 yr
nitrofurantoin monohyd macro
(generic of MACROBID)
HR: 90 day limit if > 64 yr
PENTAM 300
sulfamethoxazole-trimethopri
m inj
sulfamethoxazole-trimethopri
m susp
sulfamethoxazole-trimethopri
m tab (generic of BACTRIM)
sulfamethoxazole-trimethopri
m tab (generic of BACTRIM
DS)
SYNERCID
trimethoprim TABS
TYGACIL
vancomycin hcl (generic of
VANCOCIN HCL) CAPS
vancomycin hcl SOLR
ZYVOX
3
3
B/D
PA
3
PA
3
2
1
Drug Requirements/
Tier
Limits
ketoconazole TABS
MYCAMINE
NOXAFIL SUSP; TBEC
nystatin TABS
terbinafine hcl (generic of
LAMISIL) TABS
QL (90 tabs / 365 days)
voriconazole (generic of
VFEND IV) SOLR
voriconazole (generic of
VFEND) SUSR; TABS
1
4
4
2
1
PA
NM
NM
QL
3
4
NM
ANTIMALARIALS
1
1
4
1
4
4
NM
2
4
B/D
NM
4
4
3
4
4
2
B/D NM
B/D NM
B/D
NM
NM
NM
NM
ANTIFUNGALS
ABELCET
AMBISOME
amphotericin b SOLR
CANCIDAS
ERAXIS
fluconazole (generic of
DIFLUCAN) SUSR
fluconazole (generic of
DIFLUCAN) TABS
fluconazole in dextrose
fluconazole inj nacl 200
fluconazole inj nacl 400
flucytosine (generic of
ANCOBON) CAPS
griseofulvin microsize SUSP
griseofulvin microsize (generic
of GRIFULVIN V) TABS
griseofulvin ultramicrosize
(generic of GRIS-PEG)
itraconazole (generic of
SPORANOX) CAPS
Drug Name
1
2
2
2
4
NM
3
3
3
3
PA
atovaquone-proguanil hcl
(generic of MALARONE)
chloroquine phosphate
TABS 250mg
chloroquine phosphate
(generic of ARALEN) TABS
500mg
COARTEM
mefloquine hcl
PRIMAQUINE PHOSPHATE
quinine sulfate (generic of
QUALAQUIN) CAPS
3
2
2
2
2
2
3
PA
ANTIRETROVIRAL AGENTS
abacavir sulfate (generic of
ZIAGEN)
APTIVUS
CRIXIVAN
didanosine (generic of VIDEX
EC)
EDURANT
EMTRIVA
EPIVIR SOLN
FUZEON
INTELENCE 25mg
INTELENCE 100mg, 200mg
INVIRASE CAPS
INVIRASE TABS
ISENTRESS CHEW 25mg
ISENTRESS CHEW 100mg
ISENTRESS PACK
ISENTRESS TABS
lamivudine (generic of
EPIVIR) 150mg, 300mg
LEXIVA
3
4
3
3
NM
4
2
2
4
3
4
3
4
2
4
2
4
2
NM
NM
NM
NM
NM
NM
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
10
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
NEVIRAPINE SUSP 50
MG/5ML
nevirapine tab 200mg
(generic of VIRAMUNE)
nevirapine tb24 (generic of
VIRAMUNE XR)
NORVIR
PREZISTA SUSP
PREZISTA TABS 75mg,
150mg
PREZISTA TABS 600mg,
800mg
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY
stavudine (generic of ZERIT)
CAPS
stavudine (generic of ZERIT)
SOLR
SUSTIVA CAPS
SUSTIVA TABS
TIVICAY
VIDEX PEDIATRIC
VIRACEPT
VIRAMUNE XR 100mg
VIREAD
ZIAGEN SOLN
zidovudine (generic of
RETROVIR) CAPS; SYRP
zidovudine TABS
Drug Requirements/
Tier
Limits
3
TRUVADA
QL (30 tabs / 30 days)
2
ANTITUBERCULAR AGENTS
3
2
4
2
NM
4
NM
3
2
4
4
2
NM
NM
3
2
4
4
3
4
3
4
3
2
NM
NM
NM
NM
2
ANTIRETROVIRAL COMBINATION
AGENTS
abacavir
sulfate-lamivudine-zidovudine
(generic of TRIZIVIR)
ATRIPLA
COMPLERA
EPZICOM
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
(generic of COMBIVIR)
STRIBILD
Drug Name
4
NM
4
4
4
4
2
4
4
NM
NM
NM
NM
4
NM
NM
NM
CAPASTAT SULFATE
ethambutol hcl (generic of
MYAMBUTOL) TABS
isoniazid TABS
isoniazid inj 100 mg/ml
isoniazid syp 50mg/5ml
paser d/r
PRIFTIN
pyrazinamide
rifabutin (generic of
MYCOBUTIN)
rifampin (generic of RIFADIN)
CAPS
rifampin (generic of RIFADIN)
SOLR
RIFATER
SIRTURO
TRECATOR
4
QL NM
4
2
NM
1
2
3
2
3
3
3
2
3
3
4
3
NM LA PA
ANTIVIRALS
acyclovir (generic of
ZOVIRAX) CAPS; TABS
acyclovir (generic of
ZOVIRAX) SUSP
acyclovir sodium SOLN
acyclovir sodium SOLR
1000mg
adefovir dipivoxil (generic of
HEPSERA)
BARACLUDE SOLN
BARACLUDE TABS
EPIVIR HBV SOLN
famciclovir (generic of
FAMVIR) TABS
foscarnet sodium
ganciclovir inj 500mg (generic
of CYTOVENE)
lamivudine (generic of EPIVIR
HBV) 100mg
moderiba 800 dose pack
moderiba pak 600/day
moderiba pak 1000/day
moderiba pak 1200/day
1
2
3
3
B/D
B/D
4
NM
2
4
3
2
3
2
NM
B/D
3
4
4
4
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
NM PA
NM PA
NM PA
NM PA
11
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
moderiba tab 200mg (generic
of COPEGUS)
OLYSIO
REBETOL SOL 40MG/ML
RELENZA DISKHALER
ribapak mis 600/day
ribasphere (generic of
REBETOL) CAPS
ribasphere (generic of
COPEGUS) TABS 200mg
ribasphere TABS 400mg
ribasphere TABS 600mg
ribasphere ribapak 800
ribasphere ribapak 1000
ribasphere ribapak 1200
ribavirin cap 200mg (generic
of REBETOL)
ribavirin tab 200mg (generic
of COPEGUS)
rimantadine hydrochloride
(generic of FLUMADINE)
SOVALDI
TAMIFLU
TYZEKA
valacyclovir hcl (generic of
VALTREX) TABS
VALCYTE
VICTRELIS CAP 200MG
2
NM PA
4
4
2
4
2
NM PA
NM PA
2
NM PA
3
4
4
4
4
2
NM PA
NM PA
NM PA
NM PA
NM PA
NM PA
2
NM PA
2
4
2
3
2
NM PA
4
4
NM
NM PA
CEPHALOSPORINS
cefaclor CAPS
cefaclor SUSR
cefaclor er tab 500mg
cefadroxil CAPS
cefadroxil SUSR
cefadroxil TABS
cefazolin in d5w
cefazolin inj
cefazolin sodium 1gm, 20gm
cefdinir CAPS
cefdinir SUSR
cefepime hcl (generic of
MAXIPIME)
cefotaxime sodium (generic of
CLAFORAN)
cefoxitin sodium
NM PA
NM PA
2
3
2
1
2
3
2
2
2
2
3
3
2
3
Drug Name
Drug Requirements/
Tier
Limits
cefpodoxime proxetil
cefprozil
ceftazidime (generic of
FORTAZ) 1gm, 2gm, 6gm
CEFTAZIDIME/DEXTROSE
ceftriaxone sodium SOLR
1gm, 2gm, 10gm, 250mg
ceftriaxone sodium (generic of
ROCEPHIN) SOLR 1gm,
500mg
cefuroxime axetil (generic of
CEFTIN) TABS
cefuroxime sodium (generic of
ZINACEF) 1.5gm, 7.5gm,
750mg
cefuroxime sodium 7.5gm
cephalexin (generic of
KEFLEX) CAPS 250mg,
500mg
cephalexin SUSR
SUPRAX CAPS
suprax CHEW
suprax SUSR 100mg/5ml,
200mg/5ml
SUPRAX SUSR 500mg/5ml
suprax TABS
tazicef (generic of FORTAZ)
SOLR
tazicef vial (generic of
FORTAZ)
TEFLARO
3
2
2
3
2
2
1
2
2
1
1
2
3
2
2
2
2
2
3
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACK
azithromycin (generic of
ZITHROMAX) SOLR 500mg
azithromycin (generic of
ZITHROMAX) SUSR
azithromycin (generic of
ZITHROMAX) TABS
clarithromycin (generic of
BIAXIN) TABS
clarithromycin er (generic of
BIAXIN XL)
clarithromycin for susp
125mg/5ml
1
2
2
1
2
2
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
12
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
clarithromycin for susp
(generic of BIAXIN)
250mg/5ml
DIFICID
e.e.s. 400mg tab
E.E.S. GRANULES
ery-tab
ERYPED 200
ERYPED 400
erythrocin lactobionate
500mg
erythrocin stearate
erythromycin base
erythromycin cap 250mg ec
erythromycin ethylsuccinate
ZMAX
3
4
3
3
3
3
3
3
3
3
3
3
2
FLUOROQUINOLONES
ciprofloxacin (generic of
CIPRO) SUSR
ciprofloxacin er (generic of
CIPRO XR)
ciprofloxacin hcl tab 100mg,
750mg
ciprofloxacin hcl tab (generic
of CIPRO) 250mg, 500mg
ciprofloxacin in d5w (generic
of CIPRO I.V.-IN D5W)
ciprofloxacin inj
levofloxacin (generic of
LEVAQUIN) TABS
levofloxacin in d5w (generic of
LEVAQUIN)
levofloxacin inj 25mg/ml
levofloxacin oral soln 25
mg/ml (generic of LEVAQUIN)
3
2
1
1
2
2
1
2
3
3
PENICILLINS
amoxicillin
amoxicillin & pot clavulanate
CHEW
amoxicillin & pot clavulanate
(generic of AUGMENTIN)
CHEW
amoxicillin & pot clavulanate
SUSR
1
2
2
2
NM
Drug Name
Drug Requirements/
Tier
Limits
amoxicillin & pot clavulanate
(generic of AUGMENTIN)
SUSR
amoxicillin & pot clavulanate
(generic of AUGMENTIN
ES-600) SUSR
amoxicillin & pot clavulanate
TABS
amoxicillin & pot clavulanate
(generic of AUGMENTIN)
TABS
amoxicillin & pot clavulanate
(generic of AUGMENTIN XR)
TB12
ampicillin & sulbactam sodium
ampicillin & sulbactam sodium
(generic of UNASYN)
ampicillin & sulbactam sodium
(generic of UNASYN BULK
PACK)
ampicillin cap
ampicillin inj
ampicillin sodium
ampicillin susp
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium 1gm
nafcillin sodium 2gm, 10gm
oxacillin sodium 1gm, 2gm
oxacillin sodium 10gm
PENICILLIN G POT IN
DEXTROSE
penicillin g potassium
penicillin g procaine
penicillin g sodium
penicillin v potassium
penicilln gk inj 5mu
piperacillin
sodium-tazobactam sodium
(generic of ZOSYN)
TIMENTIN SOLR
TIMENTIN INJ 3.1GM
2
2
1
1
3
2
2
2
1
3
3
1
3
1
3
4
3
4
3
NM
NM
3
3
3
1
3
3
3
3
TETRACYCLINES
doxycycline (monohydrate)
CAPS 50mg
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
13
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
doxycycline (monohydrate)
(generic of MONODOX)
CAPS 100mg
doxycycline (monohydrate)
(generic of ADOXA) TABS
50mg, 75mg, 100mg
doxycycline (monohydrate)
(generic of ADOXA PAK
1/150) TABS 150mg
doxycycline hyclate CAPS
50mg
doxycycline hyclate (generic
of VIBRAMYCIN) CAPS
100mg
doxycycline hyclate SOLR
doxycycline hyclate TABS
minocycline hcl (generic of
MINOCIN) CAPS
VIBRAMYCIN SYRP
2
2
2
2
ANTIBIOTICS
2
bleomycin sulfate
mitomycin SOLR
2
3
2
4
B/D
B/D
B/D
B/D NM
3
B/D
4
B/D NM
3
3
B/D
B/D
2
4
4
B/D
B/D NM
B/D NM
4
2
2
3
B/D NM
B/D
B/D
B/D
3
B/D
2
4
4
B/D
B/D NM
B/D NM
4
2
B/D NM
1
3
B/D
4
B/D NM
4
B/D NM
4
4
B/D NM
B/D NM
3
4
B/D
B/D NM
ANTIMETABOLITES
3
2
1
3
3
3
3
B/D
B/D
B/D
3
3
4
3
3
B/D
NM
B/D
B/D
2
B/D
3
2
B/D
B/D
adrucil
ALIMTA
azacitidine (generic of
VIDAZA)
cladribine
cytarabine SOLN 20mg/ml
cytarabine SOLR 100mg
fludarabine phosphate
SOLN
fludarabine phosphate
(generic of FLUDARA)
SOLR
fluorouracil SOLN
GEMCITABINE HCL SOLN
gemcitabine hcl (generic of
GEMZAR) SOLR 1gm,
200mg
gemcitabine hcl SOLR 2gm
mercaptopurine (generic of
PURINETHOL) TABS
methotrexate sodium inj
TABLOID
ANTIMITOTIC, TAXOIDS
3
2
4
B/D NM
3
4
B/D
B/D NM
3
3
2
B/D
B/D
B/D
ANTHRACYCLINES
adriamycin 50mg
adriamycin inj 20mg
daunorubicin hcl
Drug Requirements/
Tier
Limits
daunorubicin hcl for inj 20 mg
doxorubicin hcl for inj 50 mg
doxorubicin hcl inj 2 mg/ml
doxorubicin hcl liposomal
(generic of DOXIL)
epirubicin hcl (generic of
ELLENCE) SOLN
idarubicin hcl (generic of
IDAMYCIN PFS)
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BICNU
BUSULFEX
cyclophosphamide SOLR;
TABS
dacarbazine 200mg
EMCYT
HEXALEN
IFEX 3gm
ifosfamide inj 1gm (generic of
IFEX)
ifosfamide inj 1gm/20ml
(generic of IFOSFAMIDE)
IFOSFAMIDE INJ 3GM
ifosfamide inj 3gm/60ml
(generic of IFOSFAMIDE)
LEUKERAN
LOMUSTINE
melphalan hcl (generic of
ALKERAN)
MUSTARGEN
TREANDA
Drug Name
DOCETAXEL CONC
20mg/0.5ml
DOCETAXEL CONC
20mg/ml, 80mg/4ml
docetaxel CONC 140mg/7ml
DOCETAXEL SOLN
80mg/8ml
paclitaxel
TAXOTERE 80mg/2ml
ANTIMITOTIC, VINCA ALKALOIDS
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
14
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
vinblastine sulfate SOLN
vincasar
vincristine sulfate
vinorelbine tartrate (generic of
NAVELBINE)
3
1
1
3
B/D
B/D
B/D
B/D
4
4
4
4
4
4
4
4
4
B/D NM
NM LA PA
B/D NM
B/D NM
B/D NM
B/D NM
NM PA
B/D NM
NM PA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole (generic of
ARIMIDEX) TABS
bicalutamide (generic of
CASODEX)
DEPO-PROVERA INJ 400/ML
exemestane (generic of
AROMASIN)
FARESTON
FASLODEX
flutamide
letrozole (generic of
FEMARA) TABS
leuprolide inj 1mg/0.2
LUPR DEP-PED INJ 30MG
(3-MONTH)
LUPRON DEPO INJ 11.25MG
(3-MONTH)
LUPRON DEPOT 3.75mg
LUPRON DEPOT-PED
LYSODREN
MEGACE ES
HR
megestrol acetate (generic of
MEGACE ORAL) SUSP
HR
megestrol acetate TABS
HR
NILANDRON
SOLTAMOX
tamoxifen citrate TABS
Drug Requirements/
Tier
Limits
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
XTANDI
ZYTIGA
4
4
4
4
NM PA
NM PA
NM LA PA
NM PA
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
NM PA
NM PA
NM PA
NM LA PA
NM PA
NM LA PA
NM LA PA
NM LA PA
NM PA
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM PA
NM LA PA
NM PA
NM LA PA
NM PA
NM PA
NM PA
NM PA
NM LA PA
NM PA
NM LA PA
NM LA PA
NM LA PA
KINASE INHIBITORS
BIOLOGIC RESPONSE MODIFIERS
AVASTIN
ERIVEDGE
HERCEPTIN
ISTODAX
KADCYLA
PROLEUKIN
RITUXAN
VELCADE
ZOLINZA
Drug Name
2
2
3
3
B/D
4
4
2
2
NM
B/D NM
2
4
NM PA
NM PA
4
NM PA
4
4
2
4
NM PA
NM PA
3
PA
3
PA
4
3
1
NM
NM PA
AFINITOR
AFINITOR DISPERZ
BOSULIF
CAPRELSA
COMETRIQ
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC
ICLUSIG
IMBRUVICA CAP 140MG
INLYTA
JAKAFI
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
MISCELLANEOUS
DROXIA
hydroxyurea (generic of
HYDREA) CAPS
MATULANE
mitoxantrone hcl
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
TARGRETIN CAPS
tretinoin (chemotherapy)
2
2
4
2
4
4
4
4
4
4
4
4
4
NM
B/D NM
NM LA PA
NM LA PA
NM LA PA
NM LA PA
NM PA
NM PA
NM PA
NM PA
NM
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
15
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
TRISENOX
4
B/D NM
PLATINUM-BASED AGENTS
carboplatin SOLN
cisplatin
oxaliplatin
2
2
4
B/D
B/D
B/D NM
4
B/D NM
4
B/D NM
4
3
2
3
B/D NM
B/D
3
B/D
3
4
B/D
NM
PROTECTIVE AGENTS
amifostine crystalline (generic
of ETHYOL)
dexrazoxane (generic of
ZINECARD) 250mg
ELITEK
leucovorin calcium SOLR
leucovorin calcium TABS
leucovorin calcium for inj 500
mg
leucovorin calcium inj 10
mg/ml
mesna (generic of MESNEX)
MESNEX TABS
B/D
TOPOISOMERASE INHIBITORS
etoposide SOLN
500mg/25ml
irinotecan hcl (generic of
CAMPTOSAR) 40mg/2ml,
100mg/5ml
irinotecan hcl 500mg/25ml
toposar 1gm/50ml
topotecan hcl (generic of
HYCAMTIN) SOLR
2
B/D
4
B/D NM
4
2
4
B/D NM
B/D
B/D NM
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine
besylate-benazepril hcl cap
2.5-10 mg (generic of
LOTREL)
QL (30 caps / 30 days)
amlodipine
besylate-benazepril hcl cap
5-10 mg (generic of LOTREL)
QL (30 caps / 30 days)
amlodipine
besylate-benazepril hcl cap
5-20 mg (generic of LOTREL)
QL (30 caps / 30 days)
1
QL
Drug Name
Drug Requirements/
Tier
Limits
amlodipine
besylate-benazepril hcl cap
5-40 mg (generic of LOTREL)
QL (30 caps / 30 days)
amlodipine
besylate-benazepril hcl cap
10-20 mg (generic of
LOTREL)
QL (30 caps / 30 days)
amlodipine
besylate-benazepril hcl cap
10-40 mg (generic of
LOTREL)
benazepril &
hydrochlorothiazide
benazepril &
hydrochlorothiazide (generic
of LOTENSIN HCT)
captopril &
hydrochlorothiazide
enalapril maleate &
hydrochlorothiazide
enalapril maleate &
hydrochlorothiazide (generic
of VASERETIC)
fosinopril sodium &
hydrochlorothiazide
lisinopril &
hydrochlorothiazide (generic
of ZESTORETIC)
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
(generic of ACCURETIC)
1
QL
1
QL
1
1
1
1
1
1
1
1
1
1
ACE INHIBITORS
1
1
QL
QL
benazepril hcl TABS 5mg
benazepril hcl (generic of
LOTENSIN) TABS 10mg,
20mg, 40mg
captopril TABS
enalapril maleate (generic of
VASOTEC) TABS
fosinopril sodium
lisinopril (generic of ZESTRIL)
TABS 2.5mg, 30mg, 40mg
lisinopril (generic of PRINIVIL)
TABS 5mg, 10mg, 20mg
1
1
1
1
1
1
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
16
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
moexipril hcl (generic of
UNIVASC)
perindopril erbumine 2mg
perindopril erbumine (generic
of ACEON) 4mg, 8mg
quinapril hcl (generic of
ACCUPRIL)
ramipril (generic of ALTACE)
trandolapril (generic of
MAVIK)
1
1
1
1
1
1
ALDOSTERONE RECEPTOR
ANTAGONISTS
eplerenone (generic of
INSPRA)
spironolactone (generic of
ALDACTONE) TABS
3
1
ALPHA BLOCKERS
doxazosin mesylate (generic
of CARDURA) 1mg, 2mg,
4mg
QL (30 tabs / 30 days)
doxazosin mesylate (generic
of CARDURA) 8mg
prazosin hcl (generic of
MINIPRESS)
terazosin hcl
2
QL
2
1
1
ANGIOTENSIN II RECEPTOR
ANTAGONIST COMBINATIONS
AZOR TAB 5-20MG
QL (30 tabs / 30 days)
AZOR TAB 5-40MG
QL (30 tabs / 30 days)
AZOR TAB 10-20MG
QL (30 tabs / 30 days)
AZOR TAB 10-40MG
BENICAR HCT 40-25MG
BENICAR HCT TAB
20-12.5MG
QL (30 tabs / 30 days)
BENICAR HCT TAB
40-12.5MG
QL (30 tabs / 30 days)
EXFORGE HCT TAB
5-160-12.5
QL (30 tabs / 30 days)
2
QL
2
QL
2
QL
2
2
2
2
2
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
EXFORGE HCT TAB
5-160-25
QL (60 tabs / 30 days)
EXFORGE HCT TAB
10-160-12.5
QL (30 tabs / 30 days)
EXFORGE HCT TAB
10-160-25
QL (30 tabs / 30 days)
EXFORGE HCT TAB
10-320-25
EXFORGE TAB 5-160MG
QL (30 tabs / 30 days)
EXFORGE TAB 5-320MG
QL (30 tabs / 30 days)
EXFORGE TAB 10-160MG
QL (30 tabs / 30 days)
EXFORGE TAB 10-320MG
losartan potassium & hctz tab
50-12.5 mg (generic of
HYZAAR)
QL (30 tabs / 30 days)
losartan potassium & hctz tab
100-12.5 mg (generic of
HYZAAR)
QL (30 tabs / 30 days)
losartan potassium & hctz tab
100-25 mg (generic of
HYZAAR)
TRIBENZOR TAB
20-5-12.5MG
QL (30 tabs / 30 days)
TRIBENZOR TAB
40-5-12.5MG
QL (30 tabs / 30 days)
TRIBENZOR TAB 40-5-25MG
QL (30 tabs / 30 days)
TRIBENZOR TAB 40-10-12.5
QL (30 tabs / 30 days)
TRIBENZOR TAB
40-10-25MG
valsartan & hctz tab
80-12.5mg (generic of
DIOVAN HCT)
QL (30 tabs / 30 days)
2
QL
2
QL
2
QL
2
2
QL
2
QL
2
QL
2
1
QL
1
QL
1
2
QL
2
QL
2
QL
2
QL
2
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
QL
17
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
valsartan & hctz tab
160-12.5mg (generic of
DIOVAN HCT)
QL (30 tabs / 30 days)
valsartan & hctz tab
160-25mg (generic of
DIOVAN HCT)
QL (30 tabs / 30 days)
valsartan & hctz tab
320-12.5mg (generic of
DIOVAN HCT)
valsartan & hctz tab
320-25mg (generic of
DIOVAN HCT)
1
1
QL
QL
1
1
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
BENICAR 5mg
QL (60 tabs / 30 days)
BENICAR 20mg
QL (30 tabs / 30 days)
BENICAR 40mg
DIOVAN 40mg, 80mg,
160mg
QL (60 tabs / 30 days)
DIOVAN 320mg
losartan potassium (generic of
COZAAR) 25mg, 50mg
QL (60 tabs / 30 days)
losartan potassium (generic of
COZAAR) 100mg
valsartan (generic of
DIOVAN) 40mg, 80mg,
160mg
QL (60 tabs / 30 days)
valsartan (generic of
DIOVAN) 320mg
2
QL
2
QL
2
3
QL
3
1
QL
1
1
QL
1
ANTIARRHYTHMICS
amiodarone hcl soln
amiodarone tab 100mg
amiodarone tab 200mg
(generic of CORDARONE)
amiodarone tab 400mg
disopyramide phosphate
(generic of NORPACE)
HR
flecainide acetate
mexiletine hcl
1
3
1
3
3
PA
Drug Name
Drug Requirements/
Tier
Limits
MULTAQ
NORPACE CR
HR
pacerone 100mg, 400mg
pacerone (generic of
CORDARONE) 200mg
propafenone hcl (generic of
RYTHMOL SR) CP12
propafenone hcl (generic of
RYTHMOL) TABS 150mg,
225mg
propafenone hcl TABS
300mg
quinidine gluconate TBCR
quinidine sulfate TABS
sorine (generic of
BETAPACE) 80mg, 120mg,
160mg
sorine 240mg
sotalol hcl (generic of
BETAPACE) 80mg, 120mg,
160mg
sotalol hcl 240mg
sotalol hcl (afib/afl) (generic of
BETAPACE AF)
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
3
3
PA
3
1
3
2
2
3
1
1
1
1
1
2
3
3
3
NM
NM
NM
ANTILIPEMICS, HMG-CoA REDUCTASE
INHIBITORS
atorvastatin calcium (generic
of LIPITOR)
QL (30 tabs / 30 days)
CRESTOR
QL (30 tabs / 30 days)
lovastatin 10mg
QL (30 tabs / 30 days)
lovastatin (generic of
MEVACOR) 20mg
QL (120 tabs / 30 days)
lovastatin (generic of
MEVACOR) 40mg
QL (60 tabs / 30 days)
pravastatin sodium 10mg
QL (30 tabs / 30 days)
1
QL
2
QL
1
QL
1
QL
1
QL
1
QL
2
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
18
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
pravastatin sodium (generic of 1
PRAVACHOL) 20mg, 40mg,
80mg
QL (30 tabs / 30 days)
simvastatin (generic of
1
ZOCOR) TABS
QL (30 tabs / 30 days)
QL
QL
ANTILIPEMICS, MISCELLANEOUS
ANTARA
cholestyramine (generic of
QUESTRAN)
cholestyramine light
choline fenofibrate cap dr 45
mg (generic of TRILIPIX)
choline fenofibrate cap dr 135
mg (generic of TRILIPIX)
colestipol hcl (generic of
COLESTID)
fenofibrate (generic of
TRICOR) TABS 48mg,
145mg
fenofibrate (generic of
LOFIBRA) TABS 54mg,
160mg
fenofibrate micronized
(generic of LOFIBRA) 67mg,
134mg, 200mg
gemfibrozil (generic of LOPID)
TABS
niacin (antihyperlipidemic)
(generic of NIASPAN)
500mg
QL (90 tabs / 30 days)
niacin (antihyperlipidemic)
(generic of NIASPAN)
750mg, 1000mg
niacor
omega-3-acid ethyl esters
prevalite (generic of
QUESTRAN LIGHT)
VASCEPA
WELCHOL
ZETIA
BETA-BLOCKER/DIURETIC
COMBINATIONS
2
3
3
3
2
3
2
2
2
3
2
3
3
3
2
3
Drug Requirements/
Tier
Limits
atenolol & chlorthalidone
(generic of TENORETIC 100)
bisoprolol &
hydrochlorothiazide (generic
of ZIAC)
metoprolol &
hydrochlorothiazide
metoprolol &
hydrochlorothiazide (generic
of LOPRESSOR HCT)
propranolol &
hydrochlorothiazide
1
1
2
2
2
BETA-BLOCKERS
3
3
Drug Name
QL
acebutolol hcl (generic of
SECTRAL) CAPS
atenolol (generic of
TENORMIN) TABS
bisoprolol fumarate (generic
of ZEBETA)
BYSTOLIC
carvedilol (generic of
COREG)
labetalol hcl (generic of
TRANDATE) TABS
metoprolol succinate (generic
of TOPROL XL) 25mg,
50mg
QL (60 tabs / 30 days)
metoprolol succinate (generic
of TOPROL XL) 100mg
QL (45 tabs / 30 days)
metoprolol succinate (generic
of TOPROL XL) 200mg
metoprolol tartrate (generic of
LOPRESSOR) SOLN
metoprolol tartrate TABS
25mg
metoprolol tartrate (generic of
LOPRESSOR) TABS 50mg,
100mg
nadolol (generic of
CORGARD) TABS
pindolol
propranolol cap er (generic of
INDERAL LA)
propranolol hcl SOLN
propranolol hcl TABS
1
1
2
3
1
2
1
QL
1
QL
1
2
1
1
3
2
2
2
atenolol & chlorthalidone
1
1
(generic of TENORETIC 50)
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
19
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
propranolol tab
timolol maleate TABS
1
2
CALCIUM CHANNEL BLOCKERS
afeditab cr (generic of
ADALAT CC) 30mg
QL (60 tabs / 30 days)
afeditab cr (generic of
ADALAT CC) 60mg
amlodipine besylate (generic
of NORVASC) TABS
cartia xt (generic of
CARDIZEM CD)
dilt-cd cap (generic of
CARDIZEM CD)
dilt-xr cap
diltiazem cap (generic of
TIAZAC)
diltiazem cap 120mg/24hr
diltiazem cap er/12hr
diltiazem hcl SOLN
diltiazem hcl (generic of
CARDIZEM) TABS 30mg,
60mg, 120mg
diltiazem hcl TABS 90mg
diltiazem hcl coated beads
(generic of CARDIZEM CD)
CP24 120mg, 180mg, 240mg,
300mg
diltiazem hcl coated beads
(generic of CARDIZEM CD)
CP24 360mg
diltzac cap 120mg/24 (generic
of TIAZAC)
diltzac cap 180mg/24 (generic
of TIAZAC)
diltzac cap 240mg/24 (generic
of TIAZAC)
diltzac cap 300mg/24 (generic
of TIAZAC)
felodipine 2.5mg
QL (30 tabs / 30 days)
felodipine 5mg
QL (60 tabs / 30 days)
felodipine 10mg
isradipine
nicardipine hcl CAPS
2
QL
2
1
2
2
2
2
2
2
1
1
1
2
3
2
2
Drug Requirements/
Tier
Limits
nifedical (generic of
PROCARDIA XL) 30mg
QL (30 tabs / 30 days)
nifedical (generic of
PROCARDIA XL) 60mg
nifedipine (generic of ADALAT
CC) TB24 30mg
QL (60 tabs / 30 days)
nifedipine (generic of ADALAT
CC) TB24 60mg, 90mg
nifedipine er (generic of
PROCARDIA XL) 30mg
QL (30 tabs / 30 days)
nifedipine er (generic of
PROCARDIA XL) 60mg,
90mg
nimodipine CAPS
NYMALIZE
taztia (generic of TIAZAC)
verapamil cap er (generic of
VERELAN PM) 100mg,
200mg, 300mg
verapamil cap er (generic of
VERELAN) 120mg, 180mg,
240mg
VERAPAMIL CAP ER
360mg
verapamil hcl SOLN
verapamil hcl TABS 40mg
verapamil hcl (generic of
CALAN) TABS 80mg,
120mg
verapamil tab er (generic of
CALAN SR)
2
QL
2
2
QL
2
2
QL
2
3
4
2
2
NM
2
2
2
1
1
1
DIGITALIS GLYCOSIDES
2
2
2
QL
2
QL
2
3
2
Drug Name
digoxin (generic of LANOXIN)
SOLN
HR (doses > 0.125 mg/day)
digoxin (generic of LANOXIN)
TABS
HR (doses > 0.125 mg/day)
DIGOXIN SOL 50MCG/ML
HR (doses > 0.125 mg/day)
LANOXIN TABS 125mcg,
250mcg
HR (doses > 0.125 mg/day)
2
1
2
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
20
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
DIRECT RENIN
INHIBITORS/COMBINATIONS
AMTURNIDE TAB 150-5-12.5
QL (30 tabs / 30 days)
AMTURNIDE TAB 300-5-12.5
QL (30 tabs / 30 days)
AMTURNIDE TAB
300-5-25MG
QL (30 tabs / 30 days)
AMTURNIDE TAB
300-10-12.5
QL (30 tabs / 30 days)
AMTURNIDE TAB
300-10-25MG
TEKAMLO TAB 150-5MG
QL (30 tabs / 30 days)
TEKAMLO TAB 150-10MG
QL (30 tabs / 30 days)
TEKAMLO TAB 300-5MG
QL (30 tabs / 30 days)
TEKAMLO TAB 300-10MG
TEKTURNA 150mg
QL (30 tabs / 30 days)
TEKTURNA 300mg
TEKTURNA HCT TAB
150-12.5MG
QL (30 tabs / 30 days)
TEKTURNA HCT TAB
150-25MG
QL (60 tabs / 30 days)
TEKTURNA HCT TAB
300-12.5MG
QL (30 tabs / 30 days)
TEKTURNA HCT TAB
300-25MG
2
QL
2
QL
2
QL
2
QL
2
2
QL
2
QL
2
QL
2
2
QL
2
2
QL
2
QL
2
QL
2
Drug Requirements/
Tier
Limits
DIURIL SUS 250/5ML
DYRENIUM
EDECRIN
furosemide SOLN
furosemide (generic of LASIX)
TABS
furosemide inj
hydrochlorothiazide (generic
of MICROZIDE) CAPS
hydrochlorothiazide TABS
indapamide
methazolamide (generic of
NEPTAZANE) TABS
methyclothiazide
metolazone (generic of
ZAROXOLYN) 2.5mg, 5mg
metolazone 10mg
spironolactone &
hydrochlorothiazide (generic
of ALDACTAZIDE)
torsemide inj
torsemide tabs (generic of
DEMADEX)
triamterene &
hydrochlorothiazide (generic
of MAXZIDE) TABS
triamterene &
hydrochlorothiazide (generic
of MAXZIDE-25) TABS
triamterene &
hydrochlorothiazide cap
37.5-25 mg (generic of
DYAZIDE)
2
3
3
1
1
1
1
1
1
3
2
1
1
1
1
1
1
1
1
MISCELLANEOUS
DIURETICS
acetazolamide (generic of
DIAMOX) CP12
acetazolamide TABS
amiloride &
hydrochlorothiazide
amiloride hcl
bumetanide SOLN
bumetanide TABS
chlorothiazide
chlorthalidone 25mg, 50mg
Drug Name
3
2
1
2
2
1
1
1
BIDIL
clonidine hcl (generic of
CATAPRES-TTS-1) PTWK
.1mg/24hr
clonidine hcl (generic of
CATAPRES-TTS-2) PTWK
.2mg/24hr
clonidine hcl (generic of
CATAPRES-TTS-3) PTWK
.3mg/24hr
clonidine hcl (generic of
CATAPRES) TABS
2
3
3
3
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
21
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
DEMSER
hydralazine hcl SOLN
hydralazine hcl TABS
midodrine hcl
minoxidil TABS
RANEXA
4
3
2
3
2
3
NM
NITRATES
isosorb mononitrate tab
isosorbide dinitrate (generic of
ISORDIL TITRADOSE)
TABS 5mg
isosorbide dinitrate TABS
10mg, 20mg, 30mg
isosorbide dinitrate TBCR
isosorbide mononitrate
(generic of IMDUR)
minitran (generic of
NITRO-DUR)
nitro-bid
NITRO-DUR DIS 0.3MG/HR
NITRO-DUR DIS 0.8MG/HR
nitroglycerin td patch 24hr 0.1
mg/hr
nitroglycerin td patch 24hr 0.2
mg/hr
nitroglycerin td patch 24hr 0.4
mg/hr
nitroglycerin td patch 24hr 0.6
mg/hr
NITROLINGUAL
PUMPSPRAY
NITROSTAT
1
2
2
2
1
2
2
3
3
2
2
2
2
3
2
PULMONARY ARTERIAL
HYPERTENSION
ADCIRCA
QL (60 tabs / 30 days)
ADEMPAS
QL (90 tabs / 30 days)
LETAIRIS
QL (30 tabs / 30 days)
REMODULIN
sildenafil citrate (pulmonary
hypertension) (generic of
REVATIO)
QL (90 tabs / 30 days)
4 QL NM PA
4 QL NM PA
4 QL NM LA PA
4 B/D NM LA
4 QL NM PA
Drug Name
Drug Requirements/
Tier
Limits
TRACLEER 62.5mg
QL (120 tabs / 30 days)
TRACLEER 125mg
QL (60 tabs / 30 days)
4 QL NM LA PA
4 QL NM LA PA
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam CONC
QL (300 mL / 30 days)
alprazolam tab 0.5mg
(generic of XANAX)
QL (240 tabs / 30 days)
alprazolam tab 0.25mg
(generic of XANAX)
QL (480 tabs / 30 days)
alprazolam tab 1mg (generic
of XANAX)
QL (120 tabs / 30 days)
alprazolam tab 2 mg (generic
of XANAX)
QL (150 tabs / 30 days)
buspirone hcl TABS 5mg,
7.5mg, 10mg, 15mg
buspirone hcl TABS 30mg
fluvoxamine maleate TABS
25mg, 50mg
QL (45 tabs / 30 days)
fluvoxamine maleate TABS
100mg
lorazepam CONC
QL (150 mL / 30 days)
lorazepam (generic of
ATIVAN) SOLN
lorazepam (generic of
ATIVAN) TABS
QL (150 tabs / 30 days)
2
QL
1
QL
1
QL
1
QL
1
QL
2
3
2
QL
2
2
QL
2
1
QL
3
QL
3
QL
3
QL
3
QL
3
3
3
PA
PA
PA
ANTICONVULSANTS
APTIOM 200mg
QL (180 tabs / 30 days)
APTIOM 400mg
QL (90 tabs / 30 days)
APTIOM 600mg
QL (60 tabs / 30 days)
APTIOM 800mg
QL (30 tabs / 30 days)
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
22
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
carbamazepine CHEW
1
DIAZEPAM GEL
3
(ANTICONVULSANT)
carbamazepine (generic of
3
diazepam inj
2
CARBATROL) CP12
carbamazepine (generic of
2
dilantin
3
TEGRETOL) SUSP
DILANTIN-125 SUS 125/5ML 3
carbamazepine (generic of
1
divalproex sodium (generic of 2
TEGRETOL) TABS
DEPAKOTE SPRINKLES)
carbamazepine (generic of
3
CPSP
TEGRETOL-XR) TB12
divalproex sodium (generic of 3
CELONTIN
3
DEPAKOTE ER) TB24
clonazepam (generic of
1
QL
divalproex sodium (generic of 2
KLONOPIN) TABS 1mg
DEPAKOTE) TBEC
QL (600 tabs / 30 days)
epitol (generic of TEGRETOL) 1
clonazepam (generic of
1
QL
ethosuximide (generic of
3
KLONOPIN) TABS 2mg
ZARONTIN) CAPS; SOLN
QL (300 tabs / 30 days)
felbamate (generic of
4
NM
clonazepam (generic of
1
QL
FELBATOL) SUSP
KLONOPIN) TABS .5mg
felbamate (generic of
3
QL (1200 tabs / 30
FELBATOL) TABS 400mg
days)
felbamate (generic of
4
NM
clonazepam TBDP 1mg
2
QL
FELBATOL) TABS 600mg
QL (600 tabs / 30 days)
FYCOMPA 2mg
3
QL PA
clonazepam TBDP 2mg
2
QL
QL (180 tabs / 30 days)
QL (300 tabs / 30 days)
FYCOMPA 4mg
3
QL PA
clonazepam TBDP .5mg
2
QL
QL (90 tabs / 30 days)
QL (1200 tabs / 30
FYCOMPA 6mg
3
QL PA
days)
QL (60 tabs / 30 days)
clonazepam TBDP .25mg
2
QL
FYCOMPA 8mg, 10mg,
3
QL PA
QL (2400 tabs / 30
12mg
days)
QL (30 tabs / 30 days)
clonazepam TBDP .125mg
2
QL
gabapentin (generic of
1
QL
QL (4800 tabs / 30
NEURONTIN) CAPS 100mg
days)
QL (1080 caps / 30
clorazepate dipotassium
2
QL PA
days)
(generic of TRANXENE T)
gabapentin (generic of
1
QL
3.75mg, 7.5mg
NEURONTIN) CAPS 300mg
QL (120 tabs / 30 days)
QL (360 caps / 30 days)
clorazepate dipotassium
2
QL PA
gabapentin (generic of
1
QL
(generic of TRANXENE T)
NEURONTIN) CAPS 400mg
15mg
QL (270 caps / 30 days)
QL (180 tabs / 30 days)
gabapentin (generic of
2
QL
diazepam CONC
2
QL PA
NEURONTIN) SOLN
QL (240 mL / 30 days)
QL (2160 mL / 30 days)
diazepam SOLN
2
QL PA
gabapentin (generic of
1
QL
QL (1200 mL / 30 days)
NEURONTIN) TABS 600mg
diazepam (generic of
1
QL PA
QL (180 tabs / 30 days)
VALIUM) TABS
QL (120 tabs / 30 days)
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
23
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
gabapentin (generic of
NEURONTIN) TABS 800mg
QL (120 tabs / 30 days)
GABITRIL 12mg, 16mg
lamotrigine (generic of
LAMICTAL CHEWABLE
DISPERS) CHEW
lamotrigine (generic of
LAMICTAL) TABS
lamotrigine (generic of
LAMICTAL XR) TB24
levetiraceta sol 100mg/ml
(generic of KEPPRA)
levetiracetam (generic of
KEPPRA) TABS
levetiracetam (generic of
KEPPRA XR) TB24
levetiracetam inj (generic of
KEPPRA)
LYRICA CAPS 25mg, 50mg,
75mg, 100mg, 150mg
QL (120 caps / 30 days)
LYRICA CAPS 200mg
QL (90 caps / 30 days)
LYRICA CAPS 225mg,
300mg
QL (60 caps / 30 days)
LYRICA SOLN
QL (946 mL / 30 days)
ONFI SOLN
ONFI TAB
oxcarbazepine (generic of
TRILEPTAL) SUSP
oxcarbazepine (generic of
TRILEPTAL) TABS
PEGANONE
phenobarbital ELIX; TABS
HR
PHENOBARBITAL SODIUM
65mg/ml
HR
phenobarbital sodium
130mg/ml
HR
phenytek
1
QL
3
2
1
3
2
2
3
3
2
QL
2
QL
2
QL
2
QL
3
3
3
PA
PA
2
3
3
PA
3
PA
3
3
PA
Drug Name
Drug Requirements/
Tier
Limits
phenytoin (generic of
DILANTIN INFATABS)
CHEW
phenytoin (generic of
DILANTIN) SUSP
phenytoin sodium SOLN
phenytoin sodium extended
(generic of DILANTIN)
100mg
phenytoin sodium extended
(generic of PHENYTEK)
200mg, 300mg
POTIGA 50mg
POTIGA 200mg
QL (180 tabs / 30 days)
POTIGA 300mg, 400mg
QL (90 tabs / 30 days)
primidone (generic of
MYSOLINE) TABS
SABRIL PACK
QL (180 packets / 30
days)
SABRIL TABS
QL (180 tabs / 30 days)
TEGRETOL
TEGRETOL-XR
tiagabine hcl (generic of
GABITRIL)
topiramate (generic of
TOPAMAX SPRINKLE)
CPSP
topiramate (generic of
TOPAMAX) TABS
valproate sodium (generic of
DEPACON) SOLN
valproate sodium (generic of
DEPAKENE) SYRP
valproic acid (generic of
DEPAKENE) CAPS
VIMPAT SOLN 10mg/ml
QL (1200 mL / 30 days)
VIMPAT SOLN 200mg/20ml
VIMPAT TABS 50mg
QL (180 tabs / 30 days)
VIMPAT TABS 100mg,
150mg, 200mg
QL (60 tabs / 30 days)
2
2
2
1
1
3
3
QL
3
QL
2
4 QL NM LA PA
4 QL NM LA PA
3
3
3
3
2
3
1
2
3
QL
3
3
QL
3
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
24
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
zonisamide (generic of
ZONEGRAN) 25mg, 100mg
zonisamide 50mg
2
2
ANTIDEMENTIA
donepezil hydrochloride
(generic of ARICEPT) TABS
5mg
QL (30 tabs / 30 days)
donepezil hydrochloride
(generic of ARICEPT) TABS
10mg
donepezil hydrochloride
(generic of ARICEPT) TABS
23mg
donepezil hydrochloride
TBDP 5mg
QL (30 tabs / 30 days)
donepezil hydrochloride
(generic of ARICEPT ODT)
TBDP 10mg
EXELON PATCHES
QL (30 patches / 30
days)
galantamine hydrobromide
(generic of RAZADYNE ER)
CP24 8mg, 16mg
QL (30 caps / 30 days)
galantamine hydrobromide
(generic of RAZADYNE ER)
CP24 24mg
galantamine hydrobromide
(generic of RAZADYNE)
SOLN
galantamine hydrobromide
(generic of RAZADYNE)
TABS 4mg
QL (180 tabs / 30 days)
galantamine hydrobromide
(generic of RAZADYNE)
TABS 8mg
QL (90 tabs / 30 days)
galantamine hydrobromide
(generic of RAZADYNE)
TABS 12mg
NAMENDA SOL 10MG/5ML
PA if <30yr
2
QL
2
Drug Name
Drug Requirements/
Tier
Limits
NAMENDA XR 7mg, 14mg
QL (30 caps / 30 days)
PA if <30yr
NAMENDA XR 21mg, 28mg
PA if <30yr
NAMENDA XR TITRATION
PACK
PA if <30yr
rivastigmine tartrate (generic
of EXELON)
3
QL PA
3
PA
3
PA
3
ANTIDEPRESSANTS
3
3
QL
3
3
QL
3
QL
3
3
3
3
QL
QL
3
2
PA
amitriptyline hcl TABS
HR
amoxapine
BRINTELLIX 5mg
QL (120 tabs / 30 days)
BRINTELLIX 10mg
QL (60 tabs / 30 days)
BRINTELLIX 20mg
QL (30 tabs / 30 days)
bupropion hcl (generic of
WELLBUTRIN) TABS
bupropion hcl (generic of
WELLBUTRIN SR) TB12
bupropion hcl (generic of
WELLBUTRIN XL) TB24
150mg
QL (90 tabs / 30 days)
bupropion hcl (generic of
WELLBUTRIN XL) TB24
300mg
QL (30 tabs / 30 days)
citalopram hydrobromide
SOLN
citalopram hydrobromide
(generic of CELEXA) TABS
10mg, 20mg
QL (45 tabs / 30 days)
citalopram hydrobromide
(generic of CELEXA) TABS
40mg
QL (30 tabs / 30 days)
clomipramine hcl (generic of
ANAFRANIL) CAPS
HR
desipramine hcl (generic of
NORPRAMIN) TABS
3
PA
2
3
QL
3
QL
3
QL
2
2
2
QL
2
QL
2
1
QL
1
QL
3
PA
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
25
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
doxepin hcl CAPS; CONC
HR
duloxetine hcl (generic of
CYMBALTA) CPEP
QL (60 caps / 30 days)
EMSAM
QL (30 patches / 30
days)
escitalopram oxalate (generic
of LEXAPRO) SOLN
QL (600 mL / 30 days)
escitalopram oxalate (generic
of LEXAPRO) TABS 5mg,
10mg
QL (45 tabs / 30 days)
escitalopram oxalate (generic
of LEXAPRO) TABS 20mg
QL (60 tabs / 30 days)
FETZIMA 20mg
QL (180 caps / 30 days)
FETZIMA 40mg
QL (90 caps / 30 days)
FETZIMA 80mg, 120mg
QL (30 caps / 30 days)
FETZIMA TITRATION PACK
fluoxetine hcl (generic of
PROZAC) CAPS 10mg
QL (30 caps / 30 days)
fluoxetine hcl (generic of
PROZAC) CAPS 20mg
QL (120 caps / 30 days)
fluoxetine hcl (generic of
PROZAC) CAPS 40mg
fluoxetine hcl SOLN
fluoxetine hcl TABS 10mg
QL (45 tabs / 30 days)
fluoxetine hcl TABS 20mg
imipramine hcl (generic of
TOFRANIL) TABS
HR
maprotiline hcl
MARPLAN TAB 10MG
QL (180 tabs / 30 days)
mirtazapine TABS 7.5mg
QL (45 tabs / 30 days)
3
PA
3
QL
4 QL NM PA
3
2
2
QL
QL
QL
3
QL
3
QL
3
QL
3
1
QL
1
QL
1
2
1
QL
1
3
PA
2
3
QL
1
QL
Drug Name
Drug Requirements/
Tier
Limits
mirtazapine (generic of
REMERON) TABS 15mg
QL (45 tabs / 30 days)
mirtazapine (generic of
REMERON) TABS 30mg,
45mg
mirtazapine (generic of
REMERON SOLTAB) TBDP
15mg
QL (30 tabs / 30 days)
mirtazapine (generic of
REMERON SOLTAB) TBDP
30mg, 45mg
nefazodone hcl
nortriptyline hcl (generic of
PAMELOR) CAPS
nortriptyline hcl SOLN
paroxetine hcl (generic of
PAXIL) TABS 10mg, 20mg,
40mg
QL (45 tabs / 30 days)
paroxetine hcl (generic of
PAXIL) TABS 30mg
QL (60 tabs / 30 days)
PAXIL SUSP
QL (900 mL / 30 days)
phenelzine sulfate (generic of
NARDIL) TABS
PRISTIQ
QL (30 tabs / 30 days)
protriptyline hcl (generic of
VIVACTIL)
sertraline hcl (generic of
ZOLOFT) CONC
sertraline hcl (generic of
ZOLOFT) TABS 25mg,
50mg
QL (45 tabs / 30 days)
sertraline hcl (generic of
ZOLOFT) TABS 100mg
SURMONTIL CAP 25MG
QL (240 caps / 30 days)
HR
SURMONTIL CAP 50MG
QL (120 caps / 30 days)
HR
1
QL
1
2
QL
2
2
1
3
1
QL
1
QL
3
QL
2
2
QL
3
2
1
QL
1
3
QL PA
3
QL PA
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
26
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
SURMONTIL CAP 100MG
QL (60 caps / 30 days)
HR
tranylcypromine sulfate
(generic of PARNATE)
trazodone hcl TABS 50mg,
100mg, 150mg
venlafaxine hcl (generic of
EFFEXOR XR) CP24
37.5mg, 75mg
QL (30 caps / 30 days)
venlafaxine hcl (generic of
EFFEXOR XR) CP24 150mg
QL (60 caps / 30 days)
venlafaxine hcl TABS
VIIBRYD KIT
VIIBRYD TABS
QL (30 tabs / 30 days)
3
QL PA
3
1
2
2
2
3
3
QL
QL
QL
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS
amantadine hcl SYRP
amantadine hcl TABS
APOKYN
AZILECT
benztropine mesylate (generic
of COGENTIN) SOLN
benztropine mesylate TABS
HR
bromocriptine mesylate
(generic of PARLODEL)
CAPS
bromocriptine mesylate
TABS
carbidopa-levodopa (generic
of SINEMET) TABS
carbidopa-levodopa (generic
of SINEMET CR) TBCR
carbidopa-levodopa TBDP
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
2
1
3
4
2
3
3
3
3
2
2
3
3
3
3
3
Drug Name
Drug Requirements/
Tier
Limits
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
entacapone (generic of
COMTAN)
NEUPRO
pramipexole dihydrochloride
.75mg
pramipexole dihydrochloride
(generic of MIRAPEX)
.125mg, .25mg, .5mg, 1mg,
1.5mg
ropinirole hydrochloride
(generic of REQUIP) TABS
selegiline hcl (generic of
ELDEPRYL) CAPS
selegiline hcl TABS
trihexyphenidyl hcl
HR
3
3
3
3
2
2
2
3
2
3
PA
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
ANTIPSYCHOTICS
NM LA PA
PA
ABILIFY DISC TAB 10MG
QL (60 tabs / 30 days)
ABILIFY DISC TAB 15MG
QL (60 tabs / 30 days)
ABILIFY INJ
QL (4 mL / 1 day)
ABILIFY MAIN INJ 300MG
QL (1 vial / 28 days)
ABILIFY MAIN INJ 400MG
QL (1 vial / 28 days)
ABILIFY SOL 1MG/ML
QL (900 mL / 30 days)
ABILIFY TAB 2MG
QL (30 tabs / 30 days)
ABILIFY TAB 5MG
QL (30 tabs / 30 days)
ABILIFY TAB 10MG
QL (30 tabs / 30 days)
ABILIFY TAB 15MG
QL (30 tabs / 30 days)
ABILIFY TAB 20MG
QL (30 tabs / 30 days)
ABILIFY TAB 30MG
QL (30 tabs / 30 days)
chlorpromazine hcl SOLN;
TABS
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
27
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
clozapine (generic of
CLOZARIL) TABS 100mg
QL (270 tabs / 30 days)
clozapine TABS 200mg
QL (135 tabs / 30 days)
CLOZAPINE TBDP 12.5mg,
25mg
CLOZAPINE TBDP 100mg
QL (270 tabs / 30 days)
clozapine tab 25mg (generic
of CLOZARIL)
clozapine tab 50mg
FANAPT
QL (60 tabs / 30 days)
FANAPT TITRATION PACK
FAZACLO 12.5mg, 25mg
FAZACLO 100mg
QL (270 tabs / 30 days)
FAZACLO 150mg
QL (180 tabs / 30 days)
FAZACLO 200mg
QL (135 tabs / 30 days)
fluphenazine decanoate
SOLN
fluphenazine hcl CONC;
ELIX; SOLN
fluphenazine hcl TABS
GEODON SOLR
QL (6 mL / 3 days)
haloperidol TABS
haloperidol decanoate
(generic of HALDOL
DECANOATE 50) SOLN
50mg/ml
haloperidol decanoate
(generic of HALDOL
DECANOATE 100) SOLN
100mg/ml
haloperidol lactate (generic of
HALDOL)
haloperidol lactate conc
INVEGA 1.5mg, 3mg, 9mg
QL (30 tabs / 30 days)
INVEGA 6mg
QL (60 tabs / 30 days)
3
QL
3
QL
3
PA
3
QL PA
2
2
3
QL ST
3
3
3
ST
PA
QL PA
3
QL PA
3
QL PA
3
3
1
3
QL
2
2
2
2
2
3
QL
3
QL
Drug Name
Drug Requirements/
Tier
Limits
INVEGA SUST INJ
39MG/0.25ML
QL (1 injection / 28
days)
INVEGA SUST INJ
78MG/0.5ML
QL (1 injection / 28
days)
INVEGA SUST INJ
117MG/0.75ML
QL (1 injection / 28
days)
INVEGA SUST INJ
156MG/ML
QL (1 injection / 28
days)
INVEGA SUST INJ
234MG/1.5ML
QL (1 injection / 28
days)
LATUDA 20mg
QL (240 tabs / 30 days)
LATUDA 40mg, 120mg
QL (30 tabs / 30 days)
LATUDA 60mg, 80mg
QL (60 tabs / 30 days)
loxapine succinate
olanzapine (generic of
ZYPREXA) SOLR
QL (3 vials / 1 day)
olanzapine (generic of
ZYPREXA) TABS 2.5mg,
5mg, 7.5mg
QL (30 tabs / 30 days)
olanzapine (generic of
ZYPREXA) TABS 10mg,
15mg, 20mg
QL (60 tabs / 30 days)
olanzapine (generic of
ZYPREXA ZYDIS) TBDP
5mg
QL (30 tabs / 30 days)
olanzapine (generic of
ZYPREXA ZYDIS) TBDP
10mg, 15mg
QL (60 tabs / 30 days)
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
2
3
QL
3
QL
3
QL
3
QL
3
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
28
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
olanzapine (generic of
ZYPREXA ZYDIS) TBDP
20mg
QL (60 tabs / 30 days)
ORAP
perphenazine TABS
quetiapine fumarate (generic
of SEROQUEL)
QL (90 tabs / 30 days)
RISPERDAL INJ 12.5MG
QL (2 injections / 28
days)
RISPERDAL INJ 25MG
QL (2 injections / 28
days)
RISPERDAL INJ 37.5MG
QL (2 injections / 28
days)
RISPERDAL INJ 50MG
QL (2 injections / 28
days)
risperidone (generic of
RISPERDAL) SOLN
QL (240 mL / 30 days)
risperidone (generic of
RISPERDAL) TABS 1mg,
2mg, 3mg
QL (60 tabs / 30 days)
risperidone (generic of
RISPERDAL) TABS 4mg
QL (120 tabs / 30 days)
risperidone (generic of
RISPERDAL) TABS .25mg,
.5mg
QL (90 tabs / 30 days)
risperidone (generic of
RISPERDAL M-TAB) TBDP
1mg, 2mg, 3mg
QL (60 tabs / 30 days)
risperidone (generic of
RISPERDAL M-TAB) TBDP
4mg
QL (120 tabs / 30 days)
risperidone (generic of
RISPERDAL M-TAB) TBDP
.5mg
QL (90 tabs / 30 days)
4
3
2
3
QL NM
QL
3
QL
3
QL
3
QL
3
QL
3
QL
2
QL
2
QL
Drug Name
Drug Requirements/
Tier
Limits
risperidone TBDP .25mg
QL (90 tabs / 30 days)
SAPHRIS 5mg
QL (120 tabs / 30 days)
SAPHRIS 10mg
QL (60 tabs / 30 days)
SEROQUEL XR 50mg
QL (120 tabs / 30 days)
SEROQUEL XR 150mg,
200mg
QL (30 tabs / 30 days)
SEROQUEL XR 300mg,
400mg
QL (60 tabs / 30 days)
thioridazine hcl TABS
HR
thiothixene
trifluoperazine hcl
VERSACLOZ
QL (600 mL / 30 days)
ziprasidone hcl (generic of
GEODON) 20mg, 40mg
QL (60 caps / 30 days)
ziprasidone hcl (generic of
GEODON) 60mg, 80mg
QL (90 caps / 30 days)
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
PA
2
2
4 QL NM PA
3
QL
3
QL
ATTENTION DEFICIT HYPERACTIVITY
DISORDER
amphetamine-dextroampheta 3
mine cap sr 24hr 5 mg
(generic of ADDERALL XR)
2
QL
QL (90 caps / 30 days)
amphetamine-dextroampheta 3
mine cap sr 24hr 10 mg
(generic of ADDERALL XR)
3
QL
QL (90 caps / 30 days)
amphetamine-dextroampheta 3
mine cap sr 24hr 15 mg
(generic of ADDERALL XR)
3
QL
QL (30 caps / 30 days)
amphetamine-dextroampheta 3
mine cap sr 24hr 20 mg
(generic of ADDERALL XR)
3
QL
QL (30 caps / 30 days)
amphetamine-dextroampheta 3
mine cap sr 24hr 25 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
QL
QL
QL
QL
QL
29
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
amphetamine-dextroampheta
mine cap sr 24hr 30 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroampheta
mine tab 5 mg (generic of
ADDERALL)
QL (360 tabs / 30 days)
amphetamine-dextroampheta
mine tab 7.5 mg (generic of
ADDERALL)
QL (240 tabs / 30 days)
amphetamine-dextroampheta
mine tab 10 mg (generic of
ADDERALL)
QL (180 tabs / 30 days)
amphetamine-dextroampheta
mine tab 12.5 mg (generic of
ADDERALL)
QL (144 tabs / 30 days)
amphetamine-dextroampheta
mine tab 15 mg (generic of
ADDERALL)
QL (120 tabs / 30 days)
amphetamine-dextroampheta
mine tab 20 mg (generic of
ADDERALL)
QL (90 tabs / 30 days)
amphetamine-dextroampheta
mine tab 30 mg (generic of
ADDERALL)
QL (60 tabs / 30 days)
INTUNIV
HR
metadate tab 20mg er
(generic of RITALIN SR)
QL (90 tabs / 30 days)
methylphenidate hcl (generic
of RITALIN) TABS 5mg,
10mg
QL (180 tabs / 30 days)
methylphenidate hcl (generic
of RITALIN) TABS 20mg
QL (90 tabs / 30 days)
methylphenidate hcl TBCR
10mg
QL (90 tabs / 30 days)
3
QL
2
QL
2
QL
2
QL
2
QL
2
QL
Drug Name
Drug Requirements/
Tier
Limits
methylphenidate hcl (generic
of RITALIN SR) TBCR 20mg
QL (90 tabs / 30 days)
methylphenidate hcl oral soln
(generic of METHYLIN)
5mg/5ml
QL (1800 mL / 30 days)
methylphenidate hcl oral soln
(generic of METHYLIN)
10mg/5ml
QL (900 mL / 30 days)
STRATTERA 10mg, 18mg,
25mg
QL (120 caps / 30 days)
STRATTERA 40mg
QL (60 caps / 30 days)
STRATTERA 60mg, 80mg,
100mg
QL (30 caps / 30 days)
2
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
1
QL PA
1
QL PA
3
QL PA
HYPNOTICS
2
2
QL
QL
3
2
QL
2
QL
2
QL
2
QL
ROZEREM
QL (30 tabs / 30 days)
SILENOR 3mg
QL (60 tabs / 30 days)
HR
SILENOR 6mg
QL (30 tabs / 30 days)
HR
temazepam (generic of
RESTORIL) 7.5mg
QL (30 caps / 30 days)
90 day limit if >64 yr
temazepam (generic of
RESTORIL) 15mg
QL (60 caps / 30 days)
90 day limit if >64 yr
zolpidem tartrate (generic of
AMBIEN) TABS
QL (30 tabs / 30 days)
HR:90 day limit if >64 yr
MIGRAINE
cafergot
dihydroergotamine mesylate
(generic of D.H.E. 45)
naratriptan hcl (generic of
AMERGE)
QL (9 tabs / 30 days)
3
2
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
QL
30
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
RELPAX
QL (12 tabs / 30 days)
rizatriptan benzoate (generic
of MAXALT) TABS
QL (18 tabs / 30 days)
rizatriptan benzoate (generic
of MAXALT-MLT) TBDP
QL (18 tabs / 30 days)
SUMATRIPTAN SOLN
5mg/act
QL (24 inhalers / 30
days)
SUMATRIPTAN SOLN
20mg/act
QL (12 inhalers / 30
days)
SUMATRIPTAN SUCCINATE
SOAJ
QL (6 mL / 30 days)
SUMATRIPTAN SUCCINATE
SOCT
QL (6 mL / 30 days)
sumatriptan succinate SOSY
QL (6 mL / 30 days)
sumatriptan succinate
(generic of IMITREX) TABS
QL (9 tabs / 30 days)
sumatriptan succinate inj
(generic of IMITREX
STATDOSE SYSTEM)
SOAJ
QL (6 mL / 30 days)
SUMATRIPTAN SUCCINATE
INJ SOCT
QL (6 mL / 30 days)
sumatriptan succinate inj
(generic of IMITREX) SOLN
QL (6 mL / 30 days)
zolmitriptan (generic of
ZOMIG) TABS
QL (12 tabs / 30 days)
zolmitriptan odt (generic of
ZOMIG ZMT)
QL (12 tabs / 30 days)
2
QL
2
QL
3
QL
3
3
QL
QL
3
QL
3
QL
3
QL
2
3
QL
QL
Drug Requirements/
Tier
Limits
GRALISE 600mg
QL (90 tabs / 30 days)
GRALISE STARTER
LITHIUM
lithium carbonate CAPS;
TABS
lithium carbonate er (generic
of LITHOBID) 300mg
lithium carbonate er 450mg
NUEDEXTA
pyridostigmine bromide
(generic of MESTINON)
TABS
riluzole (generic of RILUTEK)
XENAZINE 12.5mg
QL (240 tabs / 30 days)
XENAZINE 25mg
QL (120 tabs / 30 days)
2
QL
2
2
1
1
1
2
2
PA
3
4 QL NM LA PA
4 QL NM LA PA
MULTIPLE SCLEROSIS AGENTS
BETASERON
QL (14 syringes / 28
days)
COPAXONE INJ 40MG/ML
QL (12 syringes / 28
days)
COPAXONE KIT 20MG/ML
QL (1 kit / 30 days)
GILENYA CAP 0.5MG
QL (28 caps / 28 days)
TYSABRI
4 QL NM PA
4 QL NM PA
4 QL NM PA
4 QL NM PA
4
NM LA PA
MUSCULOSKELETAL THERAPY AGENTS
3
3
3
QL
QL
QL
3
QL
2
QL
MISCELLANEOUS
GRALISE 300mg
QL (180 tabs / 30 days)
Drug Name
baclofen TABS
cyclobenzaprine hcl TABS
5mg, 10mg
HR
dantrolene sodium (generic of
DANTRIUM) CAPS 25mg,
50mg
dantrolene sodium CAPS
100mg
tizanidine hcl TABS 2mg
tizanidine hcl (generic of
ZANAFLEX) TABS 4mg
1
3
PA
3
3
2
2
NARCOLEPSY/CATAPLEXY
NUVIGIL 50mg
QL (150 tabs / 30 days)
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
QL PA
31
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
NUVIGIL 150mg
QL (60 tabs / 30 days)
NUVIGIL 200mg, 250mg
QL (30 tabs / 30 days)
XYREM
QL (540 mL / 30 days)
3
QL PA
3
QL PA
4 QL NM LA PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium (generic
of CAMPRAL)
buprenorphine hcl SUBL
buprenorphine hcl-naloxone
hcl sl
QL (120 tabs / 30 days)
buproban (generic of ZYBAN)
CHANTIX PAK 0.5& 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
disulfiram (generic of
ANTABUSE) TABS
naloxone inj 0.4mg/ml
naloxone inj 1mg/ml
naltrexone hcl (generic of
REVIA) TABS
NICOTROL INHALER
NICOTROL NS
SUBOXONE MIS 2-0.5MG
QL (4 boxes / 30 days)
SUBOXONE MIS 4-1MG
QL (4 boxes / 30 days)
SUBOXONE MIS 8-2MG
QL (4 boxes / 30 days)
SUBOXONE MIS 12-3MG
QL (2 boxes / 30 days)
3
Drug Requirements/
Tier
Limits
testosterone cypionate
SOLN 100mg/ml
testosterone cypionate
(generic of
DEPO-TESTOSTERONE)
SOLN 200mg/ml
testosterone enanthate
SOLN
2
2
2
ANTIDIABETICS, INJECTABLE
3
3
2
3
3
3
3
PA
QL PA
PA
PA
PA
2
2
2
3
3
3
QL PA
3
QL PA
3
QL PA
3
QL PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANDRODERM
QL (30 patches / 30
days)
androxy
oxandrolone tab 2.5mg
(generic of OXANDRIN)
oxandrolone tab 10mg
(generic of OXANDRIN)
TESTIM
QL (300 grams / 30
days)
Drug Name
3
QL PA
ALCOHOL SWABS
GAUZE PADS 2" X 2"
HUMULIN R INJ U-500
INSULIN PEN NEEDLE
INSULIN SYRINGE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
NOVOLIN 70/30
RELION not covered
NOVOLIN N
RELION not covered
NOVOLIN R
RELION not covered
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
QL (8 pens / 30 days)
SYMLINPEN 120
QL (4 pens / 30 days)
VICTOZA
QL (3 pens / 30 days)
2
2
4
2
2
2
2
2
2
2
B/D NM
2
2
2
2
2
2
2
3
QL PA
3
QL PA
2
QL
ANTIDIABETICS, ORAL
3
2
PA
PA
2
PA
2
QL PA
acarbose (generic of
PRECOSE)
glimepiride (generic of
AMARYL) 1mg
QL (240 tabs / 30 days)
glimepiride (generic of
AMARYL) 2mg
QL (120 tabs / 30 days)
2
1
QL
1
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
32
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
glimepiride (generic of
AMARYL) 4mg
QL (60 tabs / 30 days)
glip/metform tab 2.5-250mg
QL (240 tabs / 30 days)
glip/metform tab 2.5-500mg
QL (120 tabs / 30 days)
glip/metform tab 5-500mg
QL (120 tabs / 30 days)
glipizide (generic of
GLUCOTROL) TABS 5mg
QL (240 tabs / 30 days)
glipizide (generic of
GLUCOTROL) TABS 10mg
QL (120 tabs / 30 days)
glipizide (generic of
GLUCOTROL XL) TB24
2.5mg
QL (240 tabs / 30 days)
glipizide (generic of
GLUCOTROL XL) TB24
5mg
QL (120 tabs / 30 days)
glipizide (generic of
GLUCOTROL XL) TB24
10mg
QL (60 tabs / 30 days)
INVOKANA 100mg
QL (90 tabs / 30 days)
INVOKANA 300mg
QL (30 tabs / 30 days)
JANUMET
QL (60 tabs / 30 days)
JANUMET XR TAB
50-500MG
QL (60 tabs / 30 days)
JANUMET XR TAB 50-1000
QL (60 tabs / 30 days)
JANUMET XR TAB 100-1000
QL (30 tabs / 30 days)
JANUVIA
QL (30 tabs / 30 days)
JENTADUETO
QL (60 tabs / 30 days)
metformin hcl (generic of
GLUCOPHAGE) TABS
500mg
QL (150 tabs / 30 days)
1
QL
1
QL
1
QL
1
QL
1
QL
1
QL
1
QL
1
QL
1
QL
2
QL
2
QL
2
QL
Drug Name
Drug Requirements/
Tier
Limits
metformin hcl (generic of
GLUCOPHAGE) TABS
850mg
QL (90 tabs / 30 days)
metformin hcl (generic of
GLUCOPHAGE) TABS
1000mg
QL (75 tabs / 30 days)
metformin hcl (generic of
GLUCOPHAGE XR) TB24
500mg
QL (120 tabs / 30 days)
metformin hcl (generic of
GLUCOPHAGE XR) TB24
750mg
QL (60 tabs / 30 days)
nateglinide (generic of
STARLIX)
QL (90 tabs / 30 days)
pioglitazone hcl (generic of
ACTOS)
QL (30 tabs / 30 days)
repaglinide (generic of
PRANDIN) 2mg
QL (240 tabs / 30 days)
repaglinide (generic of
PRANDIN) .5mg, 1mg
QL (120 tabs / 30 days)
RIOMET
QL (946 mL / 30 days)
TRADJENTA
QL (30 tabs / 30 days)
1
QL
1
QL
1
QL
1
QL
1
QL
1
QL
1
QL
1
QL
3
QL
2
QL
BISPHOSPHONATES
2
QL
2
QL
2
QL
2
QL
2
QL
1
QL
alendronate sodium TABS
5mg, 10mg, 40mg
alendronate sodium TABS
35mg
QL (4 tabs / 28 days)
alendronate sodium (generic
of FOSAMAX) TABS 70mg
QL (4 tabs / 28 days)
BINOSTO
QL (1 box / 28 days)
ibandronate sodium (generic
of BONIVA) TABS
QL (1 tab / 30 days)
pamidronate disodium SOLN
1
1
QL
1
QL
3
QL
3
B/D QL
2
B/D
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
33
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
zoledronic inj 4mg/5ml
(generic of ZOMETA)
ZOMETA SOLN
4
B/D NM
4
B/D NM
CALCIUM RECEPTOR AGONISTS
SENSIPAR 30mg
QL (120 tabs / 30 days)
SENSIPAR 60mg
QL (60 tabs / 30 days)
SENSIPAR 90mg
QL (120 tabs / 30 days)
2
QL NM
4
QL NM
4
QL NM
CHELATING AGENTS
CHEMET
DEPEN TITRATABS
EXJADE
kionex powder (generic of
KAYEXALATE)
kionex susp 15gm/60ml
sodium polystyrene sulfonate
sps susp 15gm/60ml
SYPRINE
3
4
4
3
2
2
2
4
CONTRACEPTIVES
altavera
apri 28 day (generic of
DESOGEN)
aranelle 28 (generic of
TRI-NORINYL 28)
aviane 28
balziva 28 day (generic of
OVCON-35)
briellyn 28 day (generic of
OVCON-35)
camila 28 day (generic of
NOR-QD)
cryselle 28
cyclafem 1/35 28 day (generic
of NORINYL 1+35)
cyclafem 7/7/7 28 day
(generic of ORTHO-NOVUM
7/7/7)
drospirenone-ethinyl estradiol
(generic of YASMIN 28)
ELLA
emoquette (generic of
DESOGEN)
enpresse 28 day
2
2
2
2
2
2
2
2
2
2
2
2
2
NM
NM LA PA
NM
Drug Name
Drug Requirements/
Tier
Limits
errin 28 day (generic of
ORTHO MICRONOR)
GIANVI TAB 3-0.02MG
gildagia (generic of
OVCON-35)
heather (generic of NOR-QD)
introvale 91 day
JOLIVETTE
junel 1.5/30 21 day (generic of
LOESTRIN 1.5/30-21)
junel 1/20 21 day (generic of
LOESTRIN 1/20-21)
junel fe 1.5/30 28 day (generic
of LOESTRIN FE 1.5/30)
junel fe 1/20 28 day (generic
of LOESTRIN FE 1/20)
kariva 28 day (generic of
MIRCETTE)
larin 1/20 (generic of
LOESTRIN 1/20-21)
larin fe 1.5/30 (generic of
LOESTRIN FE 1.5/30)
larin fe 1/20 (generic of
LOESTRIN FE 1/20)
LEENA TAB
lessina 28 day
levonest 28 day
levonorgestrel (emergency
oc) (generic of PLAN B
ONE-STEP) 1.5mg
levonorgestrel (emergency
oc) (generic of PLAN B)
.75mg
levonorgestrel-ethinyl
estradiol (91-day)
levora 0.15/30 28 day
loryna 28 day (generic of
YAZ)
low-ogestrel 28 day
lutera 28 day
lyza (generic of ORTHO
MICRONOR)
marlissa 28 day
2
2
2
2
2
2
2
2
1
1
2
2
1
1
2
2
1
2
2
2
2
2
2
2
2
2
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
34
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
Drug Name
Drug Requirements/
Tier
Limits
medroxyprogesterone acetate 1
pimtrea pack (generic of
2
150 mg/ml (generic of
MIRCETTE)
DEPO-PROVERA
pirmella 1/35 28 day (generic 2
CONTRACEPTIV)
of NORINYL 1+35)
microgestin 1.5/30 21 day
2
portia 28 day
2
(generic of LOESTRIN
previfem 28 day (generic of
2
1.5/30-21)
ORTHO-CYCLEN)
microgestin 1/20 21 day
2
quasense 91 day
2
(generic of LOESTRIN
reclipsen 28 day (generic of
2
1/20-21)
DESOGEN)
microgestin fe 1.5/30 28 day
1
SOLIA
2
(generic of LOESTRIN FE
sprintec 28 day (generic of
2
1.5/30)
ORTHO-CYCLEN)
microgestin fe 1/20 28 day
1
sronyx 28 day
2
(generic of LOESTRIN FE
syeda (generic of YASMIN
2
1/20)
28)
MONONESSA
2
tri-legest 28 day (generic of
2
my way (generic of PLAN B
2
ESTROSTEP FE)
ONE-STEP)
tri-previfem 28 day (generic of 1
myzilra
1
ORTHO TRI-CYCLEN)
necon 0.5/35 28 day (generic 2
tri-sprintec 28 day (generic of 1
of BREVICON-28)
ORTHO TRI-CYCLEN)
necon 1/35 28 day (generic of 2
TRINESSA
1
NORINYL 1+35)
trivora 28 day
1
NECON 1/50-28
2
velivet 28 day (generic of
2
NECON 7/7/7
2
CYCLESSA)
necon 10/11 28 day
2
vestura (generic of YAZ)
2
next choice one dose (generic 2
viorele (generic of
2
of PLAN B ONE-STEP)
MIRCETTE)
NORA-BE TAB 0.35MG
2
vyfemia 28 day (generic of
2
norethindrone (contraceptive) 2
OVCON-35)
(generic of NOR-QD)
xulane dis 150-35 (generic of 3
norgestimate-ethinyl estradiol 1
ORTHO EVRA)
(triphasic) (generic of ORTHO
zarah (generic of YASMIN 28) 2
TRI-CYCLEN)
zenchent 28 day (generic of
2
nortrel 0.5/35 28 day (generic 2
OVCON-35)
of BREVICON-28)
ENDOMETRIOSIS
nortrel 1/35 21 day (generic of 2
danazol CAPS
3
NORINYL 1+35)
SYNAREL
4
NM
nortrel 1/35 28 day (generic of 2
ENZYME
REPLACEMENTS
NORINYL 1+35)
ADAGEN
4 NM LA PA
nortrel 7/7/7 28 day (generic
2
ALDURAZYME
4 NM LA PA
of ORTHO-NOVUM 7/7/7)
CARBAGLU
4 NM LA PA
NUVARING
3
CEREZYME
4
NM PA
OCELLA TAB 3-0.03MG
2
CYSTADANE
POW
4
NM
orsythia 28 day
2
CYSTAGON
3
NM
PA
philith (generic of OVCON-35) 2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
35
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
FABRAZYME
KUVAN
levocarnitine (metabolic
modifiers) (generic of
CARNITOR)
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
sodium phenylbutyrate
(generic of BUPHENYL)
ZAVESCA
4
4
2
NM PA
NM PA
B/D
4
4
4
4
4
NM PA
NM PA
NM LA PA
NM PA
NM
4
NM LA PA
3
PA
ESTROGENS
COMBIPATCH
HR
ESTRAD VAL INJ 10MG/ML
estrad val inj 20mg/ml
(generic of DELESTROGEN)
ESTRAD VAL INJ 40MG/ML
estradiol (generic of
CLIMARA) PTWK
HR
estradiol (generic of
ESTRACE) TABS
HR
PREMARIN TABS 1.25mg
HR
PREMARIN TABS .3mg,
.45mg
QL (60 tabs / 30 days)
HR
PREMARIN TABS .625mg,
.9mg
QL (30 tabs / 30 days)
HR
PREMARIN CREAM
PREMPHASE TAB
QL (28 tabs / 28 days)
HR
PREMPRO TAB 0.3-1.5
QL (28 tabs / 28 days)
HR
PREMPRO TAB 0.45-1.5
QL (28 tabs / 28 days)
HR
2
2
2
3
PA
3
PA
3
PA
3
QL PA
3
3
3
QL PA
QL PA
3
QL PA
3
QL PA
Drug Name
Drug Requirements/
Tier
Limits
PREMPRO TAB 0.625-5
QL (28 tabs / 28 days)
HR
PREMPRO TAB .625-2.5
QL (28 tabs / 28 days)
HR
VAGIFEM
3
QL PA
3
QL PA
3
GLUCOCORTICOIDS
a-hydrocort
cortisone acetate TABS
dexamethasone CONC;
ELIX; SOLN
dexamethasone TABS
dexamethasone sodium
phosphate
fludrocortisone acetate
TABS
hydrocortisone (generic of
CORTEF) TABS
methylpr ace inj 40mg/ml
(generic of DEPO-MEDROL)
methylpr ace inj 80mg/ml
(generic of DEPO-MEDROL)
methylpr ss inj 1gm (generic
of SOLU-MEDROL)
methylpr ss inj 40mg (generic
of SOLU-MEDROL)
methylpr ss inj 125mg
(generic of SOLU-MEDROL)
methylpr ss inj 500mg
(generic of SOLU-MEDROL)
methylpred pak 4mg (generic
of MEDROL DOSEPAK)
methylpred tab 4mg (generic
of MEDROL)
methylpred tab 8mg (generic
of MEDROL)
methylpred tab 16mg (generic
of MEDROL)
methylpred tab 32mg (generic
of MEDROL)
pred sod pho sol 5mg/5ml
(generic of PEDIAPRED)
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone syrup 15 mg/5ml
(generic of PRELONE)
1
2
2
1
1
1
2
1
B/D
1
B/D
2
B/D
2
B/D
2
B/D
2
B/D
1
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
2
1
B/D
B/D
B/D
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
36
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
prednisone con 5mg/ml
prednisone pak 5mg
prednisone pak 10mg
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
SOLU-CORTEF 250mg
2
1
1
2
1
1
1
1
1
1
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
2
GLUCAGON EMERGENCY
2
KIT
PROGLYCEM SUS 50MG/ML 3
4
4
NM PA
NM PA
4
NM PA
MISCELLANEOUS
cabergoline
calcitonin (salmon) (generic of
MIACALCIN)
FORTICAL
INCRELEX
methylergonovine maleate
(generic of METHERGINE)
TABS
MIACALCIN 200unit/ml
octreotide acetate (generic of
SANDOSTATIN) 50mcg/ml,
100mcg/ml, 200mcg/ml
octreotide acetate (generic of
SANDOSTATIN)
500mcg/ml, 1000mcg/ml
PROLIA
QL (1 syringe / 180
days)
raloxifene tab 60mg (generic
of EVISTA)
SANDOSTATIN LAR DEPOT
SOMATULINE DEPOT
SOMAVERT 10mg, 15mg,
20mg
3
2
2
4
3
3
3
4
3
NM LA PA
XGEVA
4
NM PA
PARATHYROID HORMONES
FORTEO
QL (1 pen / 28 days)
4 QL NM PA
PHOSPHATE BINDER AGENTS
calcium acetate (phosphate
binder) (generic of PHOSLO)
FOSRENOL
PHOSLYRA
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
3
3
2
4
4
2
NM
NM
medroxyprogesterone acetate
tab (generic of PROVERA)
norethindrone acetate
(generic of AYGESTIN)
TABS
1
2
THYROID AGENTS
levothyroxine sodium (generic
of SYNTHROID) TABS
liothyronine sodium (generic
of CYTOMEL) TABS
methimazole (generic of
TAPAZOLE) TABS
propylthiouracil TABS
SYNTHROID
1
2
1
2
2
VASOPRESSINS
B/D
NM PA
NM PA
QL NM
2
4
4
4
Drug Requirements/
Tier
Limits
PROGESTINS
HUMAN GROWTH HORMONES
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
PEN
TEV-TROPIN
Drug Name
NM PA
NM PA
NM LA PA
desmopressin acetate spray
(generic of DDAVP)
desmopressin acetate spray
refrigerated
desmopressin acetate tabs
(generic of DDAVP)
desmopressin inj 4mcg/ml
(generic of DDAVP)
DESMOPRESSIN SOL 0.01%
3
3
2
3
3
GASTROINTESTINAL
ANTIEMETICS
compro
dronabinol (generic of
MARINOL) 2.5mg, 5mg
QL (60 caps / 30 days)
dronabinol (generic of
MARINOL) 10mg
QL (60 caps / 30 days)
3
3
B/D QL
4 B/D QL NM
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
37
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
granisetron hcl SOLN
granisetron hcl TABS
meclizine hcl TABS
metoclopramide hcl SOLN
metoclopramide hcl (generic
of REGLAN) TABS
metoclopramide hcl inj
ondansetron hcl (generic of
ZOFRAN) SOLN
ondansetron hcl (generic of
ZOFRAN) TABS 4mg, 8mg
ondansetron hcl TABS 24mg
ondansetron hcl inj
ondansetron hcl oral soln
(generic of ZOFRAN)
ondansetron odt (generic of
ZOFRAN ODT)
phenadoz
HR
prochlorperazine inj
prochlorperazine maleate
(generic of COMPAZINE)
TABS
prochlorperazine supp
promethazine hcl (generic of
PHENERGAN) SOLN
HR
promethazine hcl SUPP;
SYRP; TABS
HR
promethegan
HR
TRANSDERM-SCOP
QL (10 patches / 30
days)
HR
3
3
3
3
3
3
1
1
1
B/D
2
B/D
2
3
3
B/D
2
B/D
3
PA
B/D
2
1
3
3
PA
PA
3
PA
3
QL PA
2
glycopyrrolate (generic of
ROBINUL) SOLN 4mg/20ml
glycopyrrolate (generic of
ROBINUL) TABS 1mg
glycopyrrolate (generic of
ROBINUL FORTE) TABS
2mg
2
2
2
famotidine SOLN 40mg/4ml,
200mg/20ml
famotidine in nacl
famotidine inj
famotidine oral sus 40mg/5ml
(generic of PEPCID)
famotidine tab (generic of
PEPCID)
ranitidine hcl (generic of
ZANTAC) SOLN
ranitidine hcl (generic of
ZANTAC) TABS 150mg,
300mg
ranitidine hcl inj (generic of
ZANTAC)
ranitidine syrup
1
1
1
3
1
1
1
1
2
INFLAMMATORY BOWEL DISEASE
3
3
1
Drug Requirements/
Tier
Limits
H2-RECEPTOR ANTAGONISTS
1
3
ANTISPASMODICS
CUVPOSA
dicyclomine hcl (generic of
BENTYL) CAPS; TABS
dicyclomine hcl SOLN
B/D
B/D
B/D
B/D
Drug Name
APRISO
ASACOL HD
balsalazide disodium (generic
of COLAZAL)
budesonide ec (generic of
ENTOCORT EC)
CANASA
colocort (generic of
CORTENEMA)
DELZICOL
DIPENTUM
HYDROCORTISONE
(INTRARECTAL)
LIALDA
mesalamine enema
mesalamine w/ cleanser
(generic of ROWASA)
PENTASA
sulfasalazine (generic of
AZULFIDINE) TABS
3
3
2
4
NM
3
3
3
4
3
NM
3
3
3
3
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
38
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
sulfasalazine ec (generic of
AZULFIDINE EN-TABS)
UCERIS
2
3
1
1
1
1
1
1
2
1
1
3
2
1
CREON
ZENPEP
4
2
PA
NM
2
3
3
4
NM PA
2
3
PROTON PUMP INHIBITORS
1
1
PA
MISCELLANEOUS
AMITIZA
QL (60 caps / 30 days)
cromolyn sodium
(mastocytosis) (generic of
GASTROCROM)
diphenoxylate w/ atropine
LIQD
diphenoxylate w/ atropine
(generic of LOMOTIL) TABS
LINZESS CAP 145MCG
QL (60 caps / 30 days)
LINZESS CAP 290MCG
QL (30 caps / 30 days)
1
3
2
PANCREATIC ENZYMES
1
3
3
1
Drug Requirements/
Tier
Limits
loperamide hcl CAPS
LOTRONEX
misoprostol (generic of
CYTOTEC) TABS
SUCRAID
sucralfate (generic of
CARAFATE) TABS
ursodiol (generic of
ACTIGALL) CAPS
ursodiol (generic of URSO
250) TABS 250mg
ursodiol (generic of URSO
FORTE) TABS 500mg
XIFAXAN 550mg
LAXATIVES
constulose
enulose
gaviltye-g (generic of
GOLYTELY)
gavilyte-c (generic of
COLYTE-FLAVOR PACKS)
gavilyte-n (generic of
NULYTELY/FLAVOR PACKS)
generlac
GOLYTELY
lactulose
lactulose (encephalopathy)
MOVIPREP
NULYTELY/FLAVOR PACKS
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate (generic
of GOLYTELY)
peg 3350-potassium
chloride-sod bicarbonate-sod
chloride (generic of
NULYTELY/FLAVOR PACKS)
PEG 3350/ELECTROLYTES
polyethylene glycol 3350
PACK; POWD
RELISTOR
SUPREP BOWEL PREP
trilyte (generic of
NULYTELY/FLAVOR PACKS)
Drug Name
2
QL
4
NM
DEXILANT CAP 30MG DR
DEXILANT CAP 60MG DR
esomeprazole sodium 20mg
esomeprazole sodium
(generic of NEXIUM I.V.)
40mg
NEXIUM CAP 20MG
NEXIUM CAP 40MG
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
NEXIUM GRA 20MG DR
NEXIUM GRA 40MG DR
omeprazole (generic of
PRILOSEC) CPDR 10mg
QL (30 caps / 30 days)
omeprazole cap 20mg
(generic of PRILOSEC)
2
2
3
3
2
2
2
2
2
2
2
1
QL
1
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
2
1
2
QL
2
QL
alfuzosin hcl (generic of
UROXATRAL)
QL (30 tabs / 30 days)
AVODART
QL (30 caps / 30 days)
finasteride (generic of
PROSCAR) TABS 5mg
2
QL
3
QL
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
39
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
JALYN
QL (30 caps / 30 days)
RAPAFLO 4mg
QL (60 caps / 30 days)
RAPAFLO 8mg
QL (30 caps / 30 days)
tamsulosin hcl (generic of
FLOMAX)
QL (60 caps / 30 days)
3
QL
2
QL
2
QL
1
QL
MISCELLANEOUS
bethanechol chloride (generic
of URECHOLINE) TABS
ELMIRON
POTASSIUM CITRATE
(ALKALINIZER) 540mg
POTASSIUM CITRATE
(ALKALINIZER) 1080mg
2
3
3
3
3
QL
3
QL
1
2
2
QL
2
QL
3
QL
3
2
QL
3
QL
3
QL
VAGINAL ANTI-INFECTIVES
clindamycin phosphate
vaginal (generic of CLEOCIN)
2
Drug Requirements/
Tier
Limits
metronidazole vaginal
(generic of
METROGEL-VAGINAL)
terconazole vaginal (generic
of TERAZOL 7) CREA .4%
terconazole vaginal (generic
of TERAZOL 3) CREA .8%
terconazole vaginal SUPP
VANDAZOLE
zazole (generic of TERAZOL
7) .4%
ZAZOLE .8%
2
2
2
2
2
2
2
HEMATOLOGIC
ANTICOAGULANTS
URINARY ANTISPASMODICS
MYRBETRIQ TAB 25MG
QL (60 tabs / 30 days)
MYRBETRIQ TAB 50MG
QL (30 tabs / 30 days)
oxybutynin chloride SYRP
oxybutynin chloride TABS
oxybutynin chloride (generic
of DITROPAN XL) TB24
5mg
QL (30 tabs / 30 days)
oxybutynin chloride (generic
of DITROPAN XL) TB24
10mg, 15mg
QL (60 tabs / 30 days)
TOLTERODINE TARTRATE
CAP ER
QL (30 caps / 30 days)
tolterodine tartrate tabs
(generic of DETROL)
TOVIAZ
QL (30 tabs / 30 days)
trospium chloride TABS
QL (60 tabs / 30 days)
VESICARE
QL (30 tabs / 30 days)
Drug Name
COUMADIN
ELIQUIS
enoxaparin sodium (generic of
LOVENOX) 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml, 300mg/3ml
enoxaparin sodium (generic of
LOVENOX) 100mg/ml,
120mg/0.8ml, 150mg/ml
fondaparinux sodium (generic
of ARIXTRA) 2.5mg/0.5ml
fondaparinux sodium (generic
of ARIXTRA) 5mg/0.4ml,
7.5mg/0.6ml, 10mg/0.8ml
heparin sod inj 1000/ml
HEPARIN SOD INJ 2000/ML
HEPARIN SOD INJ 2500/ML
heparin sod inj 5000/ml
heparin sod inj 10000/ml
heparin sod inj 20000/ml
HEPARIN SODIUM/D5W
HEPARIN SODIUM/NACL
0.45%
HEPARIN SODIUM/SODIUM
CHL
jantoven (generic of
COUMADIN)
PRADAXA
warfarin sodium (generic of
COUMADIN)
XARELTO
3
2
3
4
NM
3
4
NM
2
2
2
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
2
1
2
1
2
HEMATOPOIETIC GROWTH FACTORS
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
40
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
GRANIX
LEUKINE
MOZOBIL
NEUMEGA
NEUPOGEN
PROCRIT 2000unit/ml,
3000unit/ml, 4000unit/ml,
10000unit/ml
PROCRIT 20000unit/ml,
40000unit/ml
4
4
4
4
4
2
NM PA
NM PA
NM PA
NM
NM PA
NM PA
4
NM PA
MISCELLANEOUS
anagrelide hcl 1mg
anagrelide hcl (generic of
AGRYLIN) .5mg
cilostazol (generic of PLETAL)
CINRYZE
FIRAZYR
pentoxifylline TBCR
PROMACTA 12.5mg
QL (240 tabs / 30 days)
PROMACTA 25mg
QL (120 tabs / 30 days)
PROMACTA 50mg
QL (60 tabs / 30 days)
PROMACTA 75mg
QL (30 tabs / 30 days)
tranexamic acid (generic of
CYKLOKAPRON) SOLN
tranexamic acid (generic of
LYSTEDA) TABS
2
4 NM LA PA
4
NM PA
2
4 QL NM LA PA
4 QL NM LA PA
4 QL NM LA PA
4 QL NM LA PA
2
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASE
HUMIRA PEN-PSORIASIS
STAR
hydroxychloroquine sulfate
(generic of PLAQUENIL)
leflunomide (generic of
ARAVA) TABS
methotrexate sodium tabs
REMICADE INJ 100MG
4
4
NM PA
NM PA
4
NM PA
1
2
2
4
NM PA
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D
GAMMAKED
GAMMAPLEX 2.5gm/50ml,
5gm/100ml, 10gm/200ml
GAMUNEX-C
OCTAGAM 1gm/20ml,
2.5gm/50ml, 5gm/100ml,
10gm/200ml, 25gm/500ml
PRIVIGEN
4
4
4
4
2
4
4
4
4
NM PA
NM PA
NM PA
NM PA
B/D NM
NM PA
NM PA
NM PA
NM PA
4
4
NM PA
NM PA
4
NM PA
4
4
4
4
4
4
4
4
4
NM LA PA
NM PA
B/D NM
B/D NM
B/D NM
B/D NM
NM PA
NM PA
NM PA
4
NM PA
4
4
4
4
NM PA
NM PA
NM LA PA
NM PA
IMMUNOMODULATORS
3
3
3
1
QL
3
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDS)
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT
200MG/ML
HUMIRA
HUMIRA KIT 40MG/0.8
Drug Requirements/
Tier
Limits
IMMUNOGLOBULINS
3
3
PLATELET AGGREGATION INHIBITORS
AGGRENOX
BRILINTA
clopidogrel bisulfate (generic
of PLAVIX) 75mg
QL (30 tabs / 30 days)
EFFIENT
Drug Name
4
4
4
NM PA
NM PA
NM PA
4
4
NM PA
NM PA
ACTIMMUNE
ARCALYST
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
PEG-INTRON
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 50MCG
RP
PEG-INTRON KIT 80MCG
RP
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 150 RP
REVLIMID
THALOMID
IMMUNOSUPPRESSANTS
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
41
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
azathioprine (generic of
IMURAN) TABS
CELLCEPT SUSR
cyclosporine (generic of
SANDIMMUNE) CAPS
cyclosporine (generic of
SANDIMMUNE) SOLN
cyclosporine modified (for
microemulsion) (generic of
NEORAL) CAPS 25mg,
100mg
cyclosporine modified (for
microemulsion) CAPS 50mg
cyclosporine modified (for
microemulsion) (generic of
NEORAL) SOLN
gengraf (generic of NEORAL)
mycophenolate mofetil
(generic of CELLCEPT)
mycophenolate sodium
(generic of MYFORTIC)
180mg
mycophenolate sodium
(generic of MYFORTIC)
360mg
NEORAL
NULOJIX
PROGRAF CAPS 5mg
PROGRAF CAPS .5mg,
1mg
RAPAMUNE SOLN
RAPAMUNE TABS 1mg,
2mg
SANDIMMUNE CAPS
SANDIMMUNE SOLN
100mg/ml
sirolimus (generic of
RAPAMUNE) TABS
tacrolimus (generic of
PROGRAF) CAPS 5mg
tacrolimus (generic of
PROGRAF) CAPS .5mg,
1mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
VACCINES
2
B/D
4
2
B/D NM
B/D
3
B/D
2
B/D
2
B/D
2
B/D
2
3
B/D
B/D
3
B/D
4
B/D NM
2
4
4
3
B/D
B/D NM
B/D NM
B/D
4
4
B/D NM
B/D NM
2
2
B/D
B/D
3
B/D
4
B/D NM
3
B/D
4
3
4
B/D NM
B/D
B/D NM
Drug Name
ACTHIB
ADACEL
BCG VACCINE
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
DIPHTHERIA/TETANUS
TOXOID
ENGERIX-B SUSP
GARDASIL
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
M-M-R II W/DILUENT 10
DOS
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
PEDVAX HIB
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SYNAGIS
TENIVAC
TETANUS TOXOID
ADSORBED
TETANUS/DIPHTHERIA
TOXOID
TWINRIX INJ
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
QL (1 vial per lifetime)
Drug Requirements/
Tier
Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
2
2
B/D
B/D
B/D
NM
B/D
B/D
2
B/D
2
2
2
2
2
2
QL
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
klor-con
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
42
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
KLOR-CON 8
KLOR-CON 10
klor-con pow 20meq
MAGNESIUM SULFATE
SOLN
MAGNESIUM SULFATE IN
D5W
magnesium sulfate inj 50%
potassium chloride (generic of
MICRO-K) CPCR
potassium chloride LIQD
POTASSIUM CHLORIDE
TBCR
POTASSIUM CHLORIDE ER
potassium chloride
microencapsulated crystals cr
SODIUM CHLORIDE SOLN
2.5meq/ml
SODIUM FLUORIDE CHEW;
TAB; 1.1 (0.5 F) MG/ML
SOLN
TPN ELECTROLYTES
1
1
2
2
2
1
1
1
1
1
1
1
Drug Name
CLINIMIX 5%/DEXTROSE
25%
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 4.25/D20
FREAMINE HBC 6.9%
FREAMINE III
HEPATAMINE
hepatasol 8
INTRALIPID INJ 20%
INTRALIPID INJ 30%
NEPHRAMINE
premasol 6%
premasol 10%
PROCALAMINE
PROSOL
travasol 10
TROPHAMINE INJ 10%
Drug Requirements/
Tier
Limits
3
B/D
3
3
3
3
3
3
2
2
3
1
3
3
3
3
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
IV REPLACEMENT SOLUTIONS
DEXTROSE 2.5%/NACL
1
0.45%
DEXTROSE 5%
1
DEXTROSE 5%
2
3
B/D
/ELECTROLYTE
IV NUTRITION
DEXTROSE 5%/LACTATED
1
AMINOSYN
3
B/D
RING
AMINOSYN
3
B/D
DEXTROSE 5%/NACL 0.2%
1
7%/ELECTROLYTES
DEXTROSE 5%/NACL 0.3%
1
AMINOSYN
3
B/D
8.5%/ELECTROLYTE
DEXTROSE 5%/NACL 0.9%
1
AMINOSYN II
3
B/D
DEXTROSE 5%/NACL 0.33% 1
AMINOSYN II
3
B/D
DEXTROSE 5%/NACL 0.45% 1
8.5%/ELECTROL
DEXTROSE 5%/NACL
1
AMINOSYN M
3
B/D
0.225%
AMINOSYN-HBC
3
B/D
DEXTROSE 5%/POTASSIUM 1
AMINOSYN-PF
3
B/D
CHL
AMINOSYN-PF 7%
3
B/D
DEXTROSE 10% FLEX
1
AMINOSYN-RF
3
B/D
CONTAIN
CLINIMIX 2.75%/DEXTROSE 3
B/D
DEXTROSE 10%/NACL 0.2% 2
5%
DEXTROSE 10%/NACL
1
CLINIMIX 4.25%/DEXTROSE 3
B/D
0.45%
5%
DEXTROSE 50%
1
CLINIMIX 4.25%/DEXTROSE 3
B/D
dextrose inj 70%
1
25%
IONOSOL-B/DEXTROSE 5% 3
CLINIMIX 5%/DEXTROSE
3
B/D
IONOSOL-MB/DEXTROSE
3
15%
5%
CLINIMIX 5%/DEXTROSE
3
B/D
ISOLYTE P
3
20%
isolyte s
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
1
43
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
KCL0.15%/D5W/NACL0.2%
KCL0.15%/D5W/NACL0.225
%
KCL 0.3%/D5W/NACL 0.9%
KCL 0.3%/D5W/NACL 0.45%
KCL 0.15%/D5W/NACL 0.9%
KCL 0.075%/D5W/NACL
0.45%
KCL/D5W INJ 0.3%
KCL/NACL INJ 0.3-0.9
LACTATED RINGER'S INJ
normosol-m
NORMOSOL-R
NORMOSOL-R IN D5W
PLASMA-LYTE A
PLASMA-LYTE-56/D5W
PLASMA-LYTE-148
POTASSIUM CHLORIDE
SOLN 10meq/100ml,
20meq/100ml
potassium chloride SOLN
.4meq/ml, 2meq/ml,
10meq/50ml, 40meq/100ml
POTASSIUM CHLORIDE
0.15%
POTASSIUM CHLORIDE
0.22%
potassium chloride in nacl
RINGER'S
SOD CHLORIDE INJ 0.9%
SODIUM CHLORIDE SOLN
3%, 5%
SODIUM CHLORIDE 0.45%
VIA
bacitracin-poly-neomycin-hc
blephamide OINT
neomycin-polymy-dexameth
(generic of MAXITROL)
neomycin-polymyxin-hc
(ophth)
sulfacetamide
sod-prednisolone
TOBRADEX OINT
TOBRADEX ST
tobramycin-dexamethasone
(generic of TOBRADEX)
ZYLET
1
1
1
1
1
1
1
3
3
3
3
3
3
1
OPHTHALMIC
2
3
1
3
1
3
3
3
2
ANTI-INFECTIVES
1
1
1
1
1
1
1
1
2
B/D
3
3
B/D
B/D
3
B/D
1
Drug Requirements/
Tier
Limits
ANTI-INFECTIVE/ANTI-INFLAMMATORY
1
2
VITAMINS
calcitriol (generic of
ROCALTROL) CAPS
calcitriol inj
calcitriol oral soln 1 mcg/ml
(generic of ROCALTROL)
paricalcitol (generic of
ZEMPLAR)
PRENATAL VITAMIN/FOLIC
ACID > 0.8 MG (GENERIC)
Drug Name
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
BESIVANCE
CILOXAN OINT
ciprofloxacin hcl (ophth)
(generic of CILOXAN)
erythromycin (ophth)
gatifloxacin (ophth) (generic of
ZYMAXID)
gentak
gentamicin sulfate (ophth)
OINT
gentamicin sulfate (ophth)
(generic of GARAMYCIN)
SOLN
MOXEZA
NATACYN
neomycin-bacitracin
zn-polymyxin
neomycin-polymy-gramicid
(generic of NEOSPORIN)
ofloxacin (ophth) (generic of
OCUFLOX)
polymyxin b-trimethoprim
(generic of POLYTRIM)
sulfacetamide sodium (ophth)
OINT
sulfacetamide sodium (ophth)
(generic of BLEPH-10)
SOLN
2
1
2
2
1
1
2
1
1
1
3
3
2
2
1
1
2
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
44
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
tobramycin sulfate (ophth)
(generic of TOBREX)
TOBREX OINT
trifluridine (generic of
VIROPTIC) SOLN
VIGAMOX
ZIRGAN
1
3
3
3
3
ANTI-INFLAMMATORIES
ALREX
BROMFENAC SODIUM
(OPHTH)(ONCE-DAILY)
dexamethasone sodium
phosphate (ophth)
diclofenac sodium (ophth)
DUREZOL
FLUOROMETHOLONE
flurbiprofen sodium (generic
of OCUFEN)
ILEVRO
ketorolac tromethamine
(ophth) (generic of ACULAR
LS) .4%
ketorolac tromethamine
(ophth) (generic of ACULAR)
.5%
LOTEMAX
MAXIDEX
NEVANAC
PREDNISOLONE ACETATE
(OPHTH)
prednisolone sodium
phosphate (ophth)
2
3
1
1
3
1
1
3
1
1
2
2
3
2
2
2
2
1
3
2
3
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
ALPHAGAN P SOL 0.15%
AZOPT
betaxolol hcl (ophth)
Drug Requirements/
Tier
Limits
BETOPTIC-S
brimonidine sol 0.2%
carteolol hcl (ophth)
COMBIGAN
dorzolamide hcl (generic of
TRUSOPT)
dorzolamide hcl-timolol
maleate (generic of COSOPT)
ISTALOL
latanoprost (generic of
XALATAN)
levobunolol hcl (generic of
BETAGAN) .5%
LEVOBUNOLOL HCL .25%
LUMIGAN
metipranolol
PHOSPHOLINE IODIDE
PILOCARPINE HCL SOLN
SIMBRINZA
timolol maleate (ophth)
(generic of TIMOPTIC)
TIMOLOL MALEATE GEL
TRAVATAN Z
3
1
1
2
2
2
2
1
2
2
2
2
2
2
3
1
2
2
MISCELLANEOUS
ANTIALLERGICS
azelastine hcl (ophth) (generic
of OPTIVAR)
BEPREVE
cromolyn sodium (ophth)
LASTACAFT
PATADAY
PATANOL
Drug Name
2
2
3
2
naphazoline 0.1%
PROLENSA
proparacaine hcl (generic of
ALCAINE) SOLN
RESTASIS
QL (64 vials / 30 days)
1
2
1
2
QL
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS
ANORO ELLIPTA
2
QL (1 inhaler / 30 days)
COMBIVENT RESPIMAT
3
QL (2 inhalers / 30 days)
ipratropium-albuterol nebu
2
QL
QL
B/D
ANTICHOLINERGICS
ATROVENT HFA
3
QL (2 inhalers / 30 days)
ipratropium bromide SOLN
1
ipratropium bromide (nasal)
1
(generic of ATROVENT)
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
QL
B/D
45
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
SPIRIVA CAP HANDIHLR
QL (30 caps / 30 days)
TUDORZA PRESSAIR
QL (1 inhaler / 30 days)
3
QL
2
QL
ANTIHISTAMINES
ASTEPRO
azelastine spr 0.1%
azelastine spr 0.15% (generic
of ASTEPRO)
cetirizine syrup
diphenhydramine hcl inj
hydroxyz hcl inj
HR
hydroxyzine hcl SOLN;
TABS
HR
levocetirizine dihydrochloride
(generic of XYZAL) SOLN
levocetirizine dihydrochloride
(generic of XYZAL) TABS
PATANASE
Drug Requirements/
Tier
Limits
montelukast sodium (generic
of SINGULAIR) TABS
zafirlukast (generic of
ACCOLATE)
1
2
MAST CELL STABILIZERS
2
2
3
cromolyn sod neb 20mg/2ml
2
B/D
2
B/D
4
2
3
2
2
4
4
4
4
NM LA PA
2
QL
1
QL
3
QL
MISCELLANEOUS
2
1
3
PA
3
PA
3
1
acetylcysteine SOLN 10%,
20%
ARALAST NP
AUVI-Q
DALIRESP
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
PROLASTIN-C
PULMOZYME
XOLAIR
ZEMAIRA
NM LA PA
B/D NM
NM LA PA
NM LA PA
NASAL STEROIDS
3
BETA AGONISTS
albuterol sulfate NEBU
albuterol sulfate SYRP
albuterol sulfate TABS
albuterol sulfate (generic of
VOSPIRE ER) TB12
FORADIL AEROLIZER
QL (60 caps / 30 days)
levalbuterol conc
1.25mg/0.5ml
PERFOROMIST
PROAIR HFA
QL (2 inhalers / 30 days)
SEREVENT DISKUS
QL (1 inhaler / 30 days)
terbutaline sulfate SOLN
terbutaline sulfate TABS
XOPENEX HFA
QL (2 inhalers / 30 days)
Drug Name
1
1
3
2
B/D
2
QL
flunisolide (nasal)
QL (2 bottles / 30 days)
fluticasone propionate (nasal)
(generic of FLONASE)
QL (1 bottle / 30 days)
NASONEX
QL (2 bottles / 30 days)
STEROID INHALANTS
ASMANEX 14 METERED
2
QL
DOSES
QL (2 inhalers / 30 days)
3
B/D
ASMANEX 30 METERED
2
QL
DOSES
3
B/D
QL (2 inhalers / 30 days)
2
QL
ASMANEX 60 METERED
2
QL
DOSES
2
QL
QL (2 inhalers / 30 days)
ASMANEX
120 METERED
2
QL
3
DOSES
2
QL (2 inhalers / 30 days)
2
QL
ASMANEX TWISTHALER 30 2
QL
ME
LEUKOTRIENE RECEPTOR
QL (2 inhalers / 30 days)
ANTAGONISTS
budesonide (inhalation)
3
B/D
montelukast sodium (generic
2
(generic of PULMICORT)
of SINGULAIR) CHEW
FLOVENT DISKUS
3
QL
montelukast sodium (generic
3
50mcg/blist, 100mcg/blist
of SINGULAIR) PACK
QL (2 inhalers / 30 days)
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
46
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
FLOVENT DISKUS
250mcg/blist
QL (4 inhalers / 30 days)
FLOVENT HFA
QL (2 inhalers / 30 days)
QVAR 40mcg/act
QL (1 inhaler / 30 days)
QVAR 80mcg/act
QL (2 inhalers / 30 days)
3
QL
3
QL
2
QL
2
QL
STEROID/BETA-AGONIST
COMBINATIONS
ADVAIR DISKUS
QL (1 inhaler / 30 days)
ADVAIR HFA
QL (1 inhaler / 30 days)
BREO ELLIPTA
QL (1 inhaler / 30 days)
DULERA
QL (1 inhaler / 30 days)
SYMBICORT
QL (1 inhaler / 30 days)
QL
3
QL
3
QL
3
QL
2
QL
erythromycin (acne aid)
(generic of ERYGEL) GEL
erythromycin (acne aid)
SOLN
myorisan
sulfacetamide sodium (acne)
(generic of KLARON)
tretinoin (generic of RETIN-A)
CREA; GEL
zenatane
2
2
3
2
2
3
gentamicin sulfate (topical)
mafenide acetate (generic of
SULFAMYLON) PACK
mupirocin (generic of
BACTROBAN) OINT
SILVER SULFADIAZINE
CREA
SSD
SULFAMYLON CREA
1
3
1
1
1
3
DERMATOLOGY, ANTIFUNGALS
1
3
3
3
1
2
TOPICAL
DERMATOLOGY, ACNE
adapalene (generic of
DIFFERIN) CREA
adapalene (generic of
DIFFERIN) GEL .1%
amnesteem
AVITA CREA
AVITA GEL
benzoyl
peroxide-erythromycin
(generic of BENZAMYCIN)
claravis
clindamycin phosphate
(topical) (generic of
CLEOCIN-T) GEL; LOTN;
SOLN; SWAB
ery pad 2%
Drug Requirements/
Tier
Limits
DERMATOLOGY, ANTIBIOTICS
3
XANTHINES
aminophylline inj
elixophyllin
theo-24
theophylline SOLN
theophylline TB12
theophylline TB24
Drug Name
3
3
3
2
2
2
3
2
2
ciclopirox CREA; SUSP
ciclopirox GEL
ciclopirox shampoo 1%
(generic of LOPROX
SHAMPOO)
clotrimazole (topical) CREA
clotrimazole (topical) SOLN
econazole nitrate CREA
ketoconazole cream
nyamyc
nystatin (topical)
nystop
pedi-dri
2
3
3
2
1
2
2
2
2
2
2
DERMATOLOGY, ANTIPRURITIC
procto-pak
proctozone hc (generic of
ANUSOL-HC)
PRUDOXIN CRE 5%
2
1
3
DERMATOLOGY, ANTIPSORIATICS
acitretin (generic of
SORIATANE)
calcipotriene (generic of
DOVONEX) CREA
calcipotriene OINT; SOLN
4
NM PA
3
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
47
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
calcitrene oin 0.005%
8-MOP
TAZORAC CREA
3
3
3
PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo
(generic of NIZORAL)
selenium sulfide LOTN
1
1
DERMATOLOGY, ANTIVIRALS
acyclovir topical (generic of
ZOVIRAX)
DENAVIR
3
3
DERMATOLOGY, CORTICOSTEROIDS
ala-cort
alclometasone dipropionate
(generic of ACLOVATE)
CREA
alclometasone dipropionate
OINT
amcinonide
betamethasone dipropionate
(topical)
betamethasone dipropionate
augmented (generic of
DIPROLENE AF) CREA
betamethasone dipropionate
augmented GEL
betamethasone dipropionate
augmented (generic of
DIPROLENE) LOTN; OINT
betamethasone valerate
CREA; LOTN; OINT
clobetasol propionate (generic
of TEMOVATE) CREA
clobetasol propionate (generic
of TEMOVATE) GEL
clobetasol propionate (generic
of TEMOVATE) OINT
clobetasol propionate (generic
of TEMOVATE) SOLN
clobetasol propionate e
(generic of TEMOVATE E)
DESONIDE CREA
desonide (generic of
DESOWEN) LOTN; OINT
desoximetasone (generic of
TOPICORT) CREA
1
2
2
3
2
2
3
3
2
2
2
2
2
2
3
3
3
Drug Name
Drug Requirements/
Tier
Limits
desoximetasone (generic of
TOPICORT) GEL
DESOXIMETASONE OINT
.05%
desoximetasone (generic of
TOPICORT) OINT .25%
diflorasone diacetate
fluocinolone acetonide
CREA .01%
fluocinolone acetonide
(generic of SYNALAR)
CREA .025%
fluocinolone acetonide
(generic of
DERMA-SMOOTHE/FS
BODY) OIL
fluocinolone acetonide
(generic of SYNALAR) OINT
fluocinolone acetonide
(generic of SYNALAR)
SOLN
fluocinonide CREA .05%
fluocinonide GEL
fluocinonide OINT
fluocinonide SOLN
fluocinonide emulsified base
fluticasone propionate
(generic of CUTIVATE)
CREA
fluticasone propionate
(generic of CUTIVATE)
OINT
halobetasol propionate
(generic of ULTRAVATE)
hydrocortisone (topical)
CREA; OINT
hydrocortisone (topical)
LOTN
hydrocortisone butyrate
(generic of LOCOID) CREA;
OINT
hydrocortisone butyrate
(generic of LOCOID) SOLN
hydrocortisone valerate
CREA
3
3
3
3
2
2
3
2
3
2
2
2
2
2
1
1
3
1
2
2
1
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
48
2015 SSI Choice 15301 v6 eff 01/01/2015
Drug Name
Drug Requirements/
Tier
Limits
hydrocortisone valerate
(generic of WESTCORT)
OINT
LOKARA LOTN 0.05%
mometasone furoate (generic
of ELOCON) CREA; OINT;
SOLN
texacort soln 2.5%
triamcinolone acetonide
(topical) CREA; OINT
triamcinolone acetonide
(topical) LOTN
triderm
3
3
2
3
1
EURAX
malathion (generic of OVIDE)
permethrin (generic of
ELIMITE) CREA
2
1
1
2
2
B/D
2
QL PA
1
2
PA
2
3
NM PA
NM LA PA
3
3
2
acetic acid .25%
REGRANEX
SANTYL
SODIUM CHLORIDE 0.9%
STERILE WATER
IRRIGATION
1
4
3
1
1
NM PA
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl (generic of
EVOXAC)
chlorhexidine gluconate
(mouth-throat) (generic of
PERIDEX)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
periogard (generic of
PERIDEX)
pilocarpine hcl (oral) (generic
of SALAGEN)
triamcinolone acetonide
(mouth)
3
1
2
1
2
1
2
2
OTIC
2
3
3
3
4
2
4
4
2
DERMATOLOGY, WOUND CARE AGENTS
1
3
3
3
DERMATOLOGY, SCABICIDES AND
PEDICULIDES
DERMATOLOGY, MISCELLANEOUS SKIN
AND MUCOUS MEMBRANE
ammonium lactate (generic of
LAC-HYDRIN) CREA
ammonium lactate (generic of
LAC-HYDRIN) LOTN
ELIDEL CRE 1%
fluorouracil (topical) (generic
of EFUDEX) CREA
fluorouracil (topical) SOLN
imiquimod (generic of
ALDARA) CREA
laclotion 12% (generic of
LAC-HYDRIN)
metronidazole (topical)
(generic of METROCREAM)
CREA
metronidazole (topical)
(generic of METROLOTION)
LOTN
metronidazole gel 0.75%
PANRETIN
podofilox (generic of
CONDYLOX) SOLN
Drug Requirements/
Tier
Limits
rosadan cre 0.75% (generic of
METROCREAM)
TARGRETIN GEL
VALCHLOR
VOLTAREN
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine hcl GEL
lidocaine hcl (generic of
XYLOCAINE) SOLN 4%
lidocaine oint 5%
lidocaine-prilocaine (generic
of EMLA)
LIDODERM DIS 5%
QL (3 patches / 1 day)
Drug Name
NM
acetic acid (otic)
acetic acid-aluminum acetate
CIPRODEX
fluocinolone acetonide (otic)
(generic of DERMOTIC)
neomycin-polymyxin-hc (otic)
(generic of CORTISPORIN)
SOLN
neomycin-polymyxin-hc (otic)
SUSP
ofloxacin (otic)
2
2
3
3
1
1
1
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
HR - High Risk
Medication
49
2015 SSI Choice 15301 v6 eff 01/01/2015
Index
8
8-MOP ..............................48
A
abacavir sulfate .................10
abacavir
sulfate-lamivudine-zidovudin
e ........................................11
ABELCET..........................10
ABILIFY DISC TAB 10MG 27
ABILIFY DISC TAB 15MG 27
ABILIFY INJ ......................27
ABILIFY MAIN INJ 300MG27
ABILIFY MAIN INJ 400MG27
ABILIFY SOL 1MG/ML ......27
ABILIFY TAB 10MG ..........27
ABILIFY TAB 15MG ..........27
ABILIFY TAB 20MG ..........27
ABILIFY TAB 2MG ............27
ABILIFY TAB 30MG ..........27
ABILIFY TAB 5MG ............27
acamprosate calcium ........32
acarbose ...........................32
ACCOLATE
see zafirlukast ...............46
ACCUPRIL
see quinapril hcl ............17
ACCURETIC
see
quinapril-hydrochlorothiazi
de ..................................16
acebutolol hcl ....................19
ACEON
see perindopril erbumine
......................................17
acetaminophen w/ codeine .7
acetazolamide ...................21
acetic acid .........................49
acetic acid (otic) ................49
acetic acid-aluminum acetate
..........................................49
acetylcysteine ...................46
acitretin .............................47
ACLOVATE
see alclometasone
dipropionate...................48
ACTHIB .............................42
ACTIGALL
see ursodiol ................... 39
ACTIMMUNE .................... 41
ACTIQ
see fentanyl citrate .......... 8
ACTOS
see pioglitazone hcl ....... 33
ACULAR
see ketorolac
tromethamine (ophth) .... 45
ACULAR LS
see ketorolac
tromethamine (ophth) .... 45
acyclovir ............................ 11
acyclovir sodium ............... 11
acyclovir topical ................ 48
ADACEL ........................... 42
ADAGEN........................... 35
ADALAT CC
see afeditab cr ............... 20
see nifedipine ................ 20
adapalene ......................... 47
ADCIRCA.......................... 22
ADDERALL
see
amphetamine-dextroamph
etamine tab 10 mg......... 30
see
amphetamine-dextroamph
etamine tab 12.5 mg...... 30
see
amphetamine-dextroamph
etamine tab 15 mg......... 30
see
amphetamine-dextroamph
etamine tab 20 mg......... 30
see
amphetamine-dextroamph
etamine tab 30 mg......... 30
see
amphetamine-dextroamph
etamine tab 5 mg .......... 30
see
amphetamine-dextroamph
etamine tab 7.5 mg........ 30
ADDERALL XR
see
amphetamine-dextroamph
etamine cap sr 24hr 10 mg
...................................... 29
see
amphetamine-dextroamph
etamine cap sr 24hr 15 mg
...................................... 29
see
amphetamine-dextroamph
etamine cap sr 24hr 20 mg
...................................... 29
see
amphetamine-dextroamph
etamine cap sr 24hr 25 mg
...................................... 29
see
amphetamine-dextroamph
etamine cap sr 24hr 30 mg
...................................... 30
see
amphetamine-dextroamph
etamine cap sr 24hr 5 mg
...................................... 29
adefovir dipivoxil ............... 11
ADEMPAS ........................ 22
ADOXA
see doxycycline
(monohydrate) ............... 14
ADOXA PAK 1/150
see doxycycline
(monohydrate) ............... 14
adriamycin ........................ 14
adriamycin inj 20mg .......... 14
adrucil ............................... 14
ADVAIR DISKUS .............. 47
ADVAIR HFA .................... 47
afeditab cr ......................... 20
AFINITOR ......................... 15
AFINITOR DISPERZ ........ 15
AGGRENOX ..................... 41
AGRYLIN
see anagrelide hcl ......... 41
a-hydrocort ....................... 36
ala-cort.............................. 48
ALBENZA ........................... 9
albuterol sulfate ................ 46
ALCAINE
see proparacaine hcl ..... 45
50
2015 SSI Choice 15301 v6 eff 01/01/2015
alclometasone dipropionate
..........................................48
ALCOHOL SWABS ...........32
ALDACTAZIDE
see spironolactone &
hydrochlorothiazide .......21
ALDACTONE
see spironolactone ........17
ALDARA
see imiquimod ...............49
ALDURAZYME .................35
alendronate sodium ..........33
alfuzosin hcl ......................39
ALIMTA .............................14
ALINIA ................................9
ALKERAN
see melphalan hcl .........14
allopurinol tab......................7
ALPHAGAN P SOL 0.1% ..45
ALPHAGAN P SOL 0.15% 45
alprazolam ........................22
alprazolam tab 0.25mg .....22
alprazolam tab 0.5mg .......22
alprazolam tab 1mg ..........22
alprazolam tab 2 mg .........22
ALREX ..............................45
ALTACE
see ramipril ....................17
altavera .............................34
amantadine hcl..................27
AMARYL
see glimepiride ........32, 33
AMBIEN
see zolpidem tartrate .....30
AMBISOME.......................10
amcinonide........................48
AMERGE
see naratriptan hcl .........30
amifostine crystalline .........16
amikacin sulfate ..................9
amiloride &
hydrochlorothiazide ...........21
amiloride hcl ......................21
aminophylline inj ...............47
AMINOSYN .......................43
AMINOSYN
7%/ELECTROLYTES .......43
AMINOSYN
8.5%/ELECTROLYTE ....... 43
AMINOSYN II .................... 43
AMINOSYN II
8.5%/ELECTROL .............. 43
AMINOSYN M ................... 43
AMINOSYN-HBC .............. 43
AMINOSYN-PF ................. 43
AMINOSYN-PF 7% ........... 43
AMINOSYN-RF ................. 43
amiodarone hcl soln .......... 18
amiodarone tab 100mg ..... 18
amiodarone tab 200mg ..... 18
amiodarone tab 400mg ..... 18
AMITIZA............................ 39
amitriptyline hcl ................. 25
amlodipine besylate .......... 20
amlodipine
besylate-benazepril hcl cap
10-20 mg........................... 16
amlodipine
besylate-benazepril hcl cap
10-40 mg........................... 16
amlodipine
besylate-benazepril hcl cap
2.5-10 mg.......................... 16
amlodipine
besylate-benazepril hcl cap
5-10 mg............................. 16
amlodipine
besylate-benazepril hcl cap
5-20 mg............................. 16
amlodipine
besylate-benazepril hcl cap
5-40 mg............................. 16
ammonium lactate ............ 49
amnesteem ....................... 47
amoxapine ........................ 25
amoxicillin ......................... 13
amoxicillin & pot clavulanate
.......................................... 13
amphetamine-dextroamphet
amine cap sr 24hr 10 mg .. 29
amphetamine-dextroamphet
amine cap sr 24hr 15 mg .. 29
amphetamine-dextroamphet
amine cap sr 24hr 20 mg .. 29
amphetamine-dextroamphet
amine cap sr 24hr 25 mg .. 29
amphetamine-dextroamphet
amine cap sr 24hr 30 mg .. 30
amphetamine-dextroamphet
amine cap sr 24hr 5 mg .... 29
amphetamine-dextroamphet
amine tab 10 mg ............... 30
amphetamine-dextroamphet
amine tab 12.5 mg ............ 30
amphetamine-dextroamphet
amine tab 15 mg ............... 30
amphetamine-dextroamphet
amine tab 20 mg ............... 30
amphetamine-dextroamphet
amine tab 30 mg ............... 30
amphetamine-dextroamphet
amine tab 5 mg ................. 30
amphetamine-dextroamphet
amine tab 7.5 mg .............. 30
amphotericin b .................. 10
ampicillin & sulbactam
sodium .............................. 13
ampicillin cap .................... 13
ampicillin inj ...................... 13
ampicillin sodium .............. 13
ampicillin susp .................. 13
AMTURNIDE TAB
150-5-12.5 ........................ 21
AMTURNIDE TAB
300-10-12.5 ...................... 21
AMTURNIDE TAB
300-10-25MG ................... 21
AMTURNIDE TAB
300-5-12.5 ........................ 21
AMTURNIDE TAB
300-5-25MG ..................... 21
ANAFRANIL
see clomipramine hcl .... 25
anagrelide hcl ................... 41
ANAPROX
see naproxen sodium ...... 7
ANAPROX DS
see naproxen sodium ...... 7
anastrozole ....................... 15
ANCOBON
see flucytosine .............. 10
ANDRODERM .................. 32
androxy ............................. 32
ANORO ELLIPTA ............. 45
51
2015 SSI Choice 15301 v6 eff 01/01/2015
ANTABUSE
see disulfiram ................32
ANTARA ...........................19
ANUSOL-HC
see proctozone hc .........47
APOKYN ...........................27
apri 28 day ........................34
APRISO ............................38
APTIOM ............................22
APTIVUS...........................10
ARALAST NP....................46
ARALEN
see chloroquine
phosphate......................10
aranelle 28 ........................34
ARAVA
see leflunomide .............41
ARCALYST .......................41
ARICEPT
see donepezil
hydrochloride .................25
ARICEPT ODT
see donepezil
hydrochloride .................25
ARIMIDEX
see anastrozole .............15
ARIXTRA
see fondaparinux sodium
......................................40
AROMASIN
see exemestane ............15
ASACOL HD .....................38
ASMANEX 120 METERED
DOSES .............................46
ASMANEX 14 METERED
DOSES .............................46
ASMANEX 30 METERED
DOSES .............................46
ASMANEX 60 METERED
DOSES .............................46
ASMANEX TWISTHALER
30 ME ...............................46
ASTEPRO .........................46
see azelastine spr 0.15%
......................................46
atenolol .............................19
atenolol & chlorthalidone ...19
ATIVAN
see lorazepam ............... 22
atorvastatin calcium .......... 18
atovaquone ......................... 9
atovaquone-proguanil hcl.. 10
ATRIPLA ........................... 11
ATROVENT
see ipratropium bromide
(nasal) ........................... 45
ATROVENT HFA .............. 45
AUGMENTIN
see amoxicillin & pot
clavulanate .................... 13
AUGMENTIN ES-600
see amoxicillin & pot
clavulanate .................... 13
AUGMENTIN XR
see amoxicillin & pot
clavulanate .................... 13
AUVI-Q ............................. 46
AVASTIN .......................... 15
aviane 28 .......................... 34
AVITA ............................... 47
AVODART ........................ 39
AYGESTIN
see norethindrone acetate
...................................... 37
azacitidine ......................... 14
AZACTAM........................... 9
see aztreonam ................ 9
AZACTAM/DEX INJ 1GM ... 9
AZACTAM/DEX INJ 2GM ... 9
azathioprine ...................... 42
azelastine hcl (ophth) ........ 45
azelastine spr 0.1% .......... 46
azelastine spr 0.15%......... 46
AZILECT ........................... 27
azithromycin ...................... 12
AZITHROMYCIN .............. 12
AZOPT .............................. 45
AZOR TAB 10-20MG ........ 17
AZOR TAB 10-40MG ........ 17
AZOR TAB 5-20MG .......... 17
AZOR TAB 5-40MG .......... 17
aztreonam ........................... 9
AZULFIDINE
see sulfasalazine ........... 38
AZULFIDINE EN-TABS
see sulfasalazine ec ...... 39
B
bacitracin (ophthalmic) ...... 44
bacitracin-polymyxin b
(ophth) .............................. 44
bacitracin-poly-neomycin-hc
.......................................... 44
baclofen ............................ 31
BACTRIM
see
sulfamethoxazole-trimetho
prim tab ......................... 10
BACTRIM DS
see
sulfamethoxazole-trimetho
prim tab ......................... 10
BACTROBAN
see mupirocin ................ 47
balsalazide disodium ........ 38
balziva 28 day ................... 34
BANZEL SUS 40MG/ML ... 22
BANZEL TAB 200MG ....... 22
BANZEL TAB 400MG ....... 22
BARACLUDE .................... 11
BCG VACCINE ................. 42
benazepril &
hydrochlorothiazide........... 16
benazepril hcl ................... 16
BENICAR .......................... 18
BENICAR HCT 40-25MG . 17
BENICAR HCT TAB
20-12.5MG ........................ 17
BENICAR HCT TAB
40-12.5MG ........................ 17
BENTYL
see dicyclomine hcl ....... 38
BENZAMYCIN
see benzoyl
peroxide-erythromycin ... 47
benzoyl
peroxide-erythromycin ...... 47
benztropine mesylate........ 27
BEPREVE ......................... 45
BESIVANCE ..................... 44
BETAGAN
see levobunolol hcl........ 45
betamethasone dipropionate
(topical) ............................. 48
betamethasone dipropionate
52
2015 SSI Choice 15301 v6 eff 01/01/2015
augmented ........................48
betamethasone valerate ...48
BETAPACE
see sorine ......................18
see sotalol hcl................18
BETAPACE AF
see sotalol hcl (afib/afl) ..18
BETASERON ....................31
betaxolol hcl (ophth) ..........45
bethanechol chloride .........40
BETOPTIC-S ....................45
BIAXIN
see clarithromycin .........12
see clarithromycin for susp
......................................13
BIAXIN XL
see clarithromycin er .....12
bicalutamide ......................15
BICILLIN L-A .....................13
BICNU ...............................14
BIDIL .................................21
BILTRICIDE ........................9
BINOSTO ..........................33
bisoprolol &
hydrochlorothiazide ...........19
bisoprolol fumarate ...........19
BIVIGAM ...........................41
bleomycin sulfate ..............14
BLEPH-10
see sulfacetamide sodium
(ophth) ...........................44
blephamide .......................44
BONIVA
see ibandronate sodium 33
BOOSTRIX .......................42
BOSULIF...........................15
BREO ELLIPTA ................47
BREVICON-28
see necon 0.5/35 28 day
......................................35
see nortrel 0.5/35 28 day
......................................35
briellyn 28 day ...................34
BRILINTA ..........................41
brimonidine sol 0.2% .........45
BRINTELLIX .....................25
BROMFENAC SODIUM
(OPHTH)(ONCE-DAILY) ...45
bromocriptine mesylate ..... 27
budesonide (inhalation)..... 46
budesonide ec .................. 38
bumetanide ....................... 21
BUPHENYL
see sodium phenylbutyrate
...................................... 36
buprenorphine hcl ............. 32
buprenorphine hcl-naloxone
hcl sl.................................. 32
buproban........................... 32
bupropion hcl .................... 25
buspirone hcl .................... 22
BUSULFEX ....................... 14
butorphanol tartrate ............ 7
BUTRANS........................... 7
BYSTOLIC ........................ 19
C
cabergoline ....................... 37
cafergot ............................. 30
CALAN
see verapamil hcl .......... 20
CALAN SR
see verapamil tab er ...... 20
calcipotriene...................... 47
calcitonin (salmon) ............ 37
calcitrene oin 0.005%........ 48
calcitriol ............................. 44
calcitriol inj ........................ 44
calcitriol oral soln 1 mcg/ml
.......................................... 44
calcium acetate (phosphate
binder)............................... 37
camila 28 day.................... 34
CAMPRAL
see acamprosate calcium
...................................... 32
CAMPTOSAR
see irinotecan hcl .......... 16
CANASA ........................... 38
CANCIDAS ....................... 10
CAPASTAT SULFATE ...... 11
CAPRELSA....................... 15
captopril ............................ 16
captopril &
hydrochlorothiazide ........... 16
CARAFATE
see sucralfate ................ 39
CARBAGLU ...................... 35
carbamazepine ................. 23
CARBATROL
see carbamazepine ....... 23
CARBIDOPA/LEVODOPA/E
NTACAPONE ................... 27
carbidopa-levodopa .......... 27
carboplatin ........................ 16
CARDIZEM
see diltiazem hcl............ 20
CARDIZEM CD
see cartia xt ................... 20
see dilt-cd cap ............... 20
see diltiazem hcl coated
beads ............................ 20
CARDURA
see doxazosin mesylate 17
CARIMUNE
NANOFILTERED .............. 41
CARNITOR
see levocarnitine
(metabolic modifiers) ..... 36
carteolol hcl (ophth) .......... 45
cartia xt ............................. 20
carvedilol .......................... 19
CASODEX
see bicalutamide ........... 15
CATAFLAM
see diclofenac potassium 7
CATAPRES
see clonidine hcl............ 21
CATAPRES-TTS-1
see clonidine hcl............ 21
CATAPRES-TTS-2
see clonidine hcl............ 21
CATAPRES-TTS-3
see clonidine hcl............ 21
CAYSTON .......................... 9
cefaclor ............................. 12
cefaclor er tab 500mg ....... 12
cefadroxil .......................... 12
cefazolin in d5w ................ 12
cefazolin inj ....................... 12
cefazolin sodium ............... 12
cefdinir .............................. 12
cefepime hcl ..................... 12
cefotaxime sodium ............ 12
cefoxitin sodium ................ 12
53
2015 SSI Choice 15301 v6 eff 01/01/2015
cefpodoxime proxetil .........12
cefprozil.............................12
ceftazidime ........................12
CEFTAZIDIME/DEXTROSE
..........................................12
CEFTIN
see cefuroxime axetil .....12
ceftriaxone sodium ............12
cefuroxime axetil ...............12
cefuroxime sodium ............12
CELEBREX CAP 100MG ....7
CELEBREX CAP 200MG ....7
CELEBREX CAP 400MG ....7
CELEBREX CAP 50MG ......7
CELEXA
see citalopram
hydrobromide ................25
CELLCEPT .......................42
see mycophenolate mofetil
......................................42
CELONTIN ........................23
cephalexin .........................12
CEREZYME ......................35
CERVARIX........................42
cetirizine syrup ..................46
cevimeline hcl ...................49
CHANTIX PAK 0.5& 1MG .32
CHANTIX TAB 0.5MG ......32
CHANTIX TAB 1MG .........32
CHEMET ...........................34
chlorhexidine gluconate
(mouth-throat) ...................49
chloroquine phosphate ......10
chlorothiazide ....................21
chlorpromazine hcl ............27
chlorthalidone....................21
cholestyramine ..................19
cholestyramine light ..........19
choline fenofibrate cap dr
135 mg ..............................19
choline fenofibrate cap dr 45
mg .....................................19
ciclopirox ...........................47
ciclopirox shampoo 1% .....47
cilostazol ...........................41
CILOXAN ..........................44
see ciprofloxacin hcl
(ophth) ...........................44
CIMZIA KIT ....................... 41
CIMZIA KIT STARTER ..... 41
CIMZIA PREFL KIT
200MG/ML ........................ 41
CINRYZE .......................... 41
CIPRO
see ciprofloxacin ........... 13
see ciprofloxacin hcl tab 13
CIPRO I.V.-IN D5W
see ciprofloxacin in d5w 13
CIPRO XR
see ciprofloxacin er ....... 13
CIPRODEX ....................... 49
ciprofloxacin ...................... 13
ciprofloxacin er .................. 13
ciprofloxacin hcl (ophth) .... 44
ciprofloxacin hcl tab .......... 13
ciprofloxacin in d5w .......... 13
ciprofloxacin inj ................. 13
cisplatin ............................. 16
citalopram hydrobromide .. 25
cladribine .......................... 14
CLAFORAN
see cefotaxime sodium.. 12
claravis.............................. 47
clarithromycin .................... 12
clarithromycin er ............... 12
clarithromycin for susp 12, 13
CLEOCIN
see clindamycin cap
300mg ............................. 9
see clindamycin cap 75mg
........................................ 9
see clindamycin hcl cap
150 mg ............................ 9
see clindamycin
phosphate vaginal ......... 40
CLEOCIN PEDIATRIC
GRANULE
see clindamycin sol
75mg/5ml ........................ 9
CLEOCIN PHOSPHATE
see clindamycin
phosphate inj ................... 9
CLEOCIN-T
see clindamycin
phosphate (topical) ........ 47
CLIMARA
see estradiol .................. 36
clindamycin cap 300mg ...... 9
clindamycin cap 75mg ........ 9
clindamycin hcl cap 150 mg 9
clindamycin phosphate
(topical) ............................. 47
clindamycin phosphate inj ... 9
clindamycin phosphate
vaginal .............................. 40
clindamycin sol 75mg/5ml ... 9
CLINIMIX
2.75%/DEXTROSE 5%..... 43
CLINIMIX
4.25%/DEXTROSE 25%... 43
CLINIMIX
4.25%/DEXTROSE 5%..... 43
CLINIMIX 5%/DEXTROSE
15% .................................. 43
CLINIMIX 5%/DEXTROSE
20% .................................. 43
CLINIMIX 5%/DEXTROSE
25% .................................. 43
CLINIMIX INJ 4.25/D10 .... 43
CLINIMIX INJ 4.25/D20 .... 43
clobetasol propionate........ 48
clobetasol propionate e..... 48
clomipramine hcl ............... 25
clonazepam ...................... 23
clonidine hcl ...................... 21
clopidogrel bisulfate .......... 41
clorazepate dipotassium ... 23
clotrimazole ...................... 49
clotrimazole (topical) ......... 47
clozapine .......................... 28
CLOZAPINE ..................... 28
clozapine tab 25mg........... 28
clozapine tab 50mg........... 28
CLOZARIL
see clozapine ................ 28
see clozapine tab 25mg 28
COARTEM ........................ 10
COGENTIN
see benztropine mesylate
...................................... 27
COLAZAL
see balsalazide disodium
...................................... 38
colchicine w/ probenecid ..... 7
54
2015 SSI Choice 15301 v6 eff 01/01/2015
COLCRYS...........................7
COLESTID
see colestipol hcl ...........19
colestipol hcl .....................19
colistimethate sodium .........9
colocort .............................38
COLY-MYCIN M
see colistimethate sodium
........................................9
COLYTE-FLAVOR PACKS
see gavilyte-c ................39
COMBIGAN ......................45
COMBIPATCH ..................36
COMBIVENT RESPIMAT .45
COMBIVIR
see lamivudine-zidovudine
......................................11
COMETRIQ.......................15
COMPAZINE
see prochlorperazine
maleate..........................38
COMPLERA ......................11
compro ..............................37
COMTAN
see entacapone .............27
COMVAX ..........................42
CONDYLOX
see podofilox .................49
constulose .........................39
COPAXONE INJ 40MG/ML
..........................................31
COPAXONE KIT 20MG/ML
..........................................31
COPEGUS
see moderiba tab 200mg
......................................12
see ribasphere...............12
see ribavirin tab 200mg .12
CORDARONE
see amiodarone tab
200mg ...........................18
see pacerone.................18
COREG
see carvedilol ................19
CORGARD
see nadolol ....................19
CORTEF
see hydrocortisone ........36
CORTENEMA
see colocort ................... 38
cortisone acetate .............. 36
CORTISPORIN
see
neomycin-polymyxin-hc
(otic) .............................. 49
COSOPT
see dorzolamide
hcl-timolol maleate ........ 45
COUMADIN ...................... 40
see jantoven .................. 40
see warfarin sodium ...... 40
COZAAR
see losartan potassium . 18
CREON ............................. 39
CRESTOR ........................ 18
CRIXIVAN ......................... 10
cromolyn sod neb 20mg/2ml
.......................................... 46
cromolyn sodium
(mastocytosis)................... 39
cromolyn sodium (ophth) .. 45
cryselle 28......................... 34
CUBICIN ............................. 9
CUTIVATE
see fluticasone propionate
...................................... 48
CUVPOSA ........................ 38
cyclafem 1/35 28 day ........ 34
cyclafem 7/7/7 28 day ....... 34
CYCLESSA
see velivet 28 day ......... 35
cyclobenzaprine hcl .......... 31
cyclophosphamide ............ 14
cyclosporine ...................... 42
cyclosporine modified (for
microemulsion) ................. 42
CYKLOKAPRON
see tranexamic acid ...... 41
CYMBALTA
see duloxetine hcl ......... 26
CYSTADANE POW .......... 35
CYSTAGON...................... 35
cytarabine ......................... 14
CYTOMEL
see liothyronine sodium. 37
CYTOTEC
see misoprostol ............. 39
CYTOVENE
see ganciclovir inj 500mg
...................................... 11
D
D.H.E. 45
see dihydroergotamine
mesylate ........................ 30
dacarbazine ...................... 14
DALIRESP ........................ 46
danazol ............................. 35
DANTRIUM
see dantrolene sodium .. 31
dantrolene sodium ............ 31
dapsone .............................. 9
DAPTACEL ....................... 42
DARAPRIM ......................... 9
daunorubicin hcl................ 14
daunorubicin hcl for inj 20
mg..................................... 14
DDAVP
see desmopressin acetate
spray ............................. 37
see desmopressin acetate
tabs ............................... 37
see desmopressin inj
4mcg/ml ........................ 37
DELESTROGEN
see estrad val inj 20mg/ml
...................................... 36
DELZICOL ........................ 38
DEMADEX
see torsemide tabs ........ 21
DEMSER .......................... 22
DENAVIR .......................... 48
DEPACON
see valproate sodium .... 24
DEPAKENE
see valproate sodium .... 24
see valproic acid ........... 24
DEPAKOTE
see divalproex sodium .. 23
DEPAKOTE ER
see divalproex sodium .. 23
DEPAKOTE SPRINKLES
see divalproex sodium .. 23
DEPEN TITRATABS......... 34
DEPO-MEDROL
55
2015 SSI Choice 15301 v6 eff 01/01/2015
see methylpr ace inj
40mg/ml.........................36
see methylpr ace inj
80mg/ml.........................36
DEPO-PROVERA
CONTRACEPTIV
see medroxyprogesterone
acetate 150 mg/ml .........35
DEPO-PROVERA INJ
400/ML ..............................15
DEPO-TESTOSTERONE
see testosterone cypionate
......................................32
DERMA-SMOOTHE/FS
BODY
see fluocinolone acetonide
......................................48
DERMOTIC
see fluocinolone acetonide
(otic) ..............................49
desipramine hcl .................25
desmopressin acetate spray
..........................................37
desmopressin acetate spray
refrigerated........................37
desmopressin acetate tabs
..........................................37
desmopressin inj 4mcg/ml.37
DESMOPRESSIN SOL
0.01% ................................37
DESOGEN
see apri 28 day ..............34
see emoquette...............34
see reclipsen 28 day .....35
desonide ...........................48
DESONIDE .......................48
DESOWEN
see desonide .................48
desoximetasone ................48
DESOXIMETASONE ........48
DETROL
see tolterodine tartrate
tabs ...............................40
dexamethasone ................36
dexamethasone sodium
phosphate .........................36
dexamethasone sodium
phosphate (ophth) .............45
DEXILANT CAP 30MG DR
.......................................... 39
DEXILANT CAP 60MG DR
.......................................... 39
dexrazoxane ..................... 16
DEXTROSE 10% FLEX
CONTAIN.......................... 43
DEXTROSE 10%/NACL
0.2%.................................. 43
DEXTROSE 10%/NACL
0.45%................................ 43
DEXTROSE 2.5%/NACL
0.45%................................ 43
DEXTROSE 5% ................ 43
DEXTROSE 5%
/ELECTROLYTE ............... 43
DEXTROSE 5%/LACTATED
RING ................................. 43
DEXTROSE 5%/NACL 0.2%
.......................................... 43
DEXTROSE 5%/NACL
0.225%.............................. 43
DEXTROSE 5%/NACL 0.3%
.......................................... 43
DEXTROSE 5%/NACL
0.33%................................ 43
DEXTROSE 5%/NACL
0.45%................................ 43
DEXTROSE 5%/NACL 0.9%
.......................................... 43
DEXTROSE
5%/POTASSIUM CHL ...... 43
DEXTROSE 50% .............. 43
dextrose inj 70% ............... 43
DIAMOX
see acetazolamide ........ 21
diazepam .......................... 23
DIAZEPAM GEL
(ANTICONVULSANT) ....... 23
diazepam inj ...................... 23
diclofenac potassium .......... 7
diclofenac sodium ............... 7
diclofenac sodium (ophth) . 45
dicloxacillin sodium ........... 13
dicyclomine hcl ................. 38
didanosine ........................ 10
DIFFERIN
see adapalene ............... 47
DIFICID ............................. 13
diflorasone diacetate......... 48
DIFLUCAN
see fluconazole ............. 10
diflunisal.............................. 7
digoxin .............................. 20
DIGOXIN SOL 50MCG/ML
.......................................... 20
dihydroergotamine mesylate
.......................................... 30
dilantin .............................. 23
DILANTIN
see phenytoin ................ 24
see phenytoin sodium
extended ....................... 24
DILANTIN INFATABS
see phenytoin ................ 24
DILANTIN-125 SUS
125/5ML ............................ 23
DILAUDID
see hydromorphone hcl ... 8
DILAUDID-HP
see hydromorphon inj
10mg/ml .......................... 8
dilt-cd cap ......................... 20
diltiazem cap ..................... 20
diltiazem cap 120mg/24hr . 20
diltiazem cap er/12hr ........ 20
diltiazem hcl ...................... 20
diltiazem hcl coated beads 20
dilt-xr cap .......................... 20
diltzac cap 120mg/24 ........ 20
diltzac cap 180mg/24 ........ 20
diltzac cap 240mg/24 ........ 20
diltzac cap 300mg/24 ........ 20
DIOVAN ............................ 18
see valsartan ................. 18
DIOVAN HCT
see valsartan & hctz tab
160-12.5mg ................... 18
see valsartan & hctz tab
160-25mg ...................... 18
see valsartan & hctz tab
320-12.5mg ................... 18
see valsartan & hctz tab
320-25mg ...................... 18
see valsartan & hctz tab
80-12.5mg ..................... 17
56
2015 SSI Choice 15301 v6 eff 01/01/2015
DIPENTUM .......................38
diphenhydramine hcl inj ....46
diphenoxylate w/ atropine .39
DIPHTHERIA/TETANUS
TOXOID ............................42
DIPROLENE
see betamethasone
dipropionate augmented 48
DIPROLENE AF
see betamethasone
dipropionate augmented 48
disopyramide phosphate ...18
disulfiram...........................32
DITROPAN XL
see oxybutynin chloride .40
DIURIL SUS 250/5ML .......21
divalproex sodium .............23
docetaxel...........................14
DOCETAXEL ....................14
DOLOPHINE
see methadone hcl ..........8
DOLOPHINE HCL
see methadone hcl ..........8
donepezil hydrochloride ....25
dorzolamide hcl .................45
dorzolamide hcl-timolol
maleate .............................45
DOVONEX
see calcipotriene ...........47
doxazosin mesylate ..........17
doxepin hcl ........................26
DOXIL
see doxorubicin hcl
liposomal .......................14
doxorubicin hcl for inj 50 mg
..........................................14
doxorubicin hcl inj 2 mg/ml 14
doxorubicin hcl liposomal ..14
doxycycline (monohydrate)
....................................13, 14
doxycycline hyclate ...........14
dronabinol .........................37
drospirenone-ethinyl
estradiol ............................34
DROXIA ............................15
DULERA ...........................47
duloxetine hcl ....................26
DURAGESIC
see fentanyl patch ........... 8
DURAMORPH .................... 8
DUREZOL......................... 45
DYAZIDE
see triamterene &
hydrochlorothiazide cap
37.5-25 mg .................... 21
DYRENIUM ....................... 21
E
e.e.s. 400mg tab ............... 13
E.E.S. GRANULES ........... 13
e.s.p. ................................... 9
EC-NAPROSYN
see naproxen .................. 7
econazole nitrate .............. 47
EDECRIN.......................... 21
EDURANT ........................ 10
ees/sulfisox sus 200-600 .... 9
EFFEXOR XR
see venlafaxine hcl ........ 27
EFFIENT ........................... 41
EFUDEX
see fluorouracil (topical) 49
ELDEPRYL
see selegiline hcl ........... 27
ELIDEL CRE 1% ............... 49
ELIMITE
see permethrin .............. 49
ELIQUIS............................ 40
ELITEK ............................. 16
elixophyllin ........................ 47
ELLA ................................. 34
ELLENCE
see epirubicin hcl .......... 14
ELMIRON ......................... 40
ELOCON
see mometasone furoate
...................................... 49
EMCYT ............................. 14
EMEND CAP 125MG ........ 38
EMEND CAP 40MG .......... 38
EMEND CAP 80MG .......... 38
EMEND PAK 80 & 125 ..... 38
EMLA
see lidocaine-prilocaine . 49
emoquette ......................... 34
EMSAM............................. 26
EMTRIVA .......................... 10
enalapril maleate .............. 16
enalapril maleate &
hydrochlorothiazide........... 16
endocet ............................... 8
ENGERIX-B ...................... 42
enoxaparin sodium ........... 40
enpresse 28 day ............... 34
entacapone ....................... 27
ENTOCORT EC
see budesonide ec ........ 38
enulose ............................. 39
EPIPEN 2-PAK ................. 46
EPIPEN-JR 2-PAK............ 46
epirubicin hcl ..................... 14
epitol ................................. 23
EPIVIR .............................. 10
see lamivudine .............. 10
EPIVIR HBV ..................... 11
see lamivudine .............. 11
eplerenone ........................ 17
EPZICOM ......................... 11
ERAXIS ............................ 10
ERIVEDGE ....................... 15
errin 28 day ....................... 34
ery pad 2% ....................... 47
ERYGEL
see erythromycin (acne
aid) ................................ 47
ERYPED 200 .................... 13
ERYPED 400 .................... 13
ery-tab .............................. 13
erythrocin lactobionate...... 13
erythrocin stearate ............ 13
erythromycin (acne aid) .... 47
erythromycin (ophth) ......... 44
erythromycin base ............ 13
erythromycin cap 250mg ec
.......................................... 13
erythromycin ethylsuccinate
.......................................... 13
escitalopram oxalate ......... 26
esomeprazole sodium....... 39
ESTRACE
see estradiol .................. 36
ESTRAD VAL INJ 10MG/ML
.......................................... 36
estrad val inj 20mg/ml ....... 36
ESTRAD VAL INJ 40MG/ML
57
2015 SSI Choice 15301 v6 eff 01/01/2015
..........................................36
estradiol ............................36
ESTROSTEP FE
see tri-legest 28 day ......35
ethambutol hcl...................11
ethosuximide .....................23
ETHYOL
see amifostine crystalline
......................................16
etodolac ..............................7
etoposide ..........................16
EURAX .............................49
EVISTA
see raloxifene tab 60mg 37
EVOXAC
see cevimeline hcl .........49
EXELON
see rivastigmine tartrate 25
EXELON PATCHES .........25
exemestane ......................15
EXFORGE HCT TAB
10-160-12.5.......................17
EXFORGE HCT TAB
10-160-25..........................17
EXFORGE HCT TAB
10-320-25..........................17
EXFORGE HCT TAB
5-160-12.5.........................17
EXFORGE HCT TAB
5-160-25............................17
EXFORGE TAB 10-160MG
..........................................17
EXFORGE TAB 10-320MG
..........................................17
EXFORGE TAB 5-160MG.17
EXFORGE TAB 5-320MG.17
EXJADE ............................34
F
FABRAZYME ....................36
famciclovir .........................11
famotidine .........................38
famotidine in nacl ..............38
famotidine inj .....................38
famotidine oral sus
40mg/5ml ..........................38
famotidine tab ...................38
FAMVIR
see famciclovir ...............11
FANAPT............................ 28
FANAPT TITRATION PACK
.......................................... 28
FARESTON ...................... 15
FASLODEX....................... 15
FAZACLO ......................... 28
felbamate .......................... 23
FELBATOL
see felbamate ................ 23
FELDENE
see piroxicam .................. 7
felodipine .......................... 20
FEMARA
see letrozole .................. 15
fenofibrate ......................... 19
fenofibrate micronized....... 19
fentanyl citrate .................... 8
fentanyl patch ..................... 8
FETZIMA .......................... 26
FETZIMA TITRATION PACK
.......................................... 26
finasteride ......................... 39
FIRAZYR .......................... 41
FLAGYL
see metronidazole ........... 9
FLEBOGAMMA ................ 41
FLEBOGAMMA DIF .......... 41
flecainide acetate .............. 18
FLOMAX
see tamsulosin hcl ......... 40
FLONASE
see fluticasone propionate
(nasal) ........................... 46
FLOVENT DISKUS ..... 46, 47
FLOVENT HFA ................. 47
fluconazole ........................ 10
fluconazole in dextrose ..... 10
fluconazole inj nacl 200..... 10
fluconazole inj nacl 400..... 10
flucytosine ......................... 10
FLUDARA
see fludarabine phosphate
...................................... 14
fludarabine phosphate ...... 14
fludrocortisone acetate...... 36
FLUMADINE
see rimantadine
hydrochloride ................. 12
flunisolide (nasal) .............. 46
fluocinolone acetonide ...... 48
fluocinolone acetonide (otic)
.......................................... 49
fluocinonide ...................... 48
fluocinonide emulsified base
.......................................... 48
FLUOROMETHOLONE .... 45
fluorouracil ........................ 14
fluorouracil (topical) .......... 49
fluoxetine hcl ..................... 26
fluphenazine decanoate .... 28
fluphenazine hcl ................ 28
flurbiprofen .......................... 7
flurbiprofen sodium ........... 45
flutamide ........................... 15
fluticasone propionate....... 48
fluticasone propionate
(nasal)............................... 46
fluvoxamine maleate ......... 22
fondaparinux sodium ........ 40
FORADIL AEROLIZER ..... 46
FORTAZ
see ceftazidime ............. 12
see tazicef ..................... 12
see tazicef vial............... 12
FORTEO........................... 37
FORTICAL ........................ 37
FOSAMAX
see alendronate sodium 33
foscarnet sodium .............. 11
fosinopril sodium ............... 16
fosinopril sodium &
hydrochlorothiazide........... 16
FOSRENOL ...................... 37
FREAMINE HBC 6.9% ..... 43
FREAMINE III ................... 43
furosemide ........................ 21
furosemide inj ................... 21
FUZEON ........................... 10
FYCOMPA ........................ 23
G
gabapentin .................. 23, 24
GABITRIL ......................... 24
see tiagabine hcl ........... 24
galantamine hydrobromide25
GAMASTAN S/D............... 41
GAMMAGARD LIQUID ..... 41
58
2015 SSI Choice 15301 v6 eff 01/01/2015
GAMMAGARD S/D ...........41
GAMMAKED .....................41
GAMMAPLEX ...................41
GAMUNEX-C ....................41
ganciclovir inj 500mg ........11
GARAMYCIN
see gentamicin sulfate
(ophth) ...........................44
GARDASIL ........................42
GASTROCROM
see cromolyn sodium
(mastocytosis) ...............39
gatifloxacin (ophth)............44
GAUZE PADS 2" X 2" .......32
gaviltye-g...........................39
gavilyte-c ...........................39
gavilyte-n...........................39
gemcitabine hcl .................14
GEMCITABINE HCL .........14
gemfibrozil.........................19
GEMZAR
see gemcitabine hcl .......14
generlac ............................39
gengraf ..............................42
gentak ...............................44
gentamicin in saline ............9
gentamicin sulfate ...............9
gentamicin sulfate (ophth) .44
gentamicin sulfate (topical)
..........................................47
GEODON ..........................28
see ziprasidone hcl ........29
GIANVI TAB 3-0.02MG .....34
gildagia .............................34
GILENYA CAP 0.5MG ......31
GILOTRIF TAB 20MG .......15
GILOTRIF TAB 30MG .......15
GILOTRIF TAB 40MG .......15
GLEEVEC .........................15
glimepiride...................32, 33
glip/metform tab 2.5-250mg
..........................................33
glip/metform tab 2.5-500mg
..........................................33
glip/metform tab 5-500mg .33
glipizide .............................33
GLUCAGEN HYPOKIT .....37
GLUCAGON EMERGENCY
KIT .................................... 37
GLUCOPHAGE
see metformin hcl .......... 33
GLUCOPHAGE XR
see metformin hcl .......... 33
GLUCOTROL
see glipizide .................. 33
GLUCOTROL XL
see glipizide .................. 33
glycopyrrolate ................... 38
GOLYTELY ....................... 39
see gaviltye-g ................ 39
see peg 3350-kcl-sod
bicarb-sod chloride-sod
sulfate............................ 39
GRALISE .......................... 31
GRALISE STARTER......... 31
granisetron hcl .................. 38
GRANIX ............................ 41
GRIFULVIN V
see griseofulvin microsize
...................................... 10
griseofulvin microsize........ 10
griseofulvin ultramicrosize . 10
GRIS-PEG
see griseofulvin
ultramicrosize ................ 10
H
HALDOL
see haloperidol lactate .. 28
HALDOL DECANOATE 100
see haloperidol decanoate
...................................... 28
HALDOL DECANOATE 50
see haloperidol decanoate
...................................... 28
halobetasol propionate...... 48
haloperidol ........................ 28
haloperidol decanoate....... 28
haloperidol lactate ............. 28
haloperidol lactate conc .... 28
HAVRIX ............................ 42
heather.............................. 34
heparin sod inj 1000/ml ..... 40
heparin sod inj 10000/ml ... 40
HEPARIN SOD INJ 2000/ML
.......................................... 40
heparin sod inj 20000/ml ... 40
HEPARIN SOD INJ 2500/ML
.......................................... 40
heparin sod inj 5000/ml..... 40
HEPARIN SODIUM/D5W . 40
HEPARIN SODIUM/NACL
0.45% ............................... 40
HEPARIN
SODIUM/SODIUM CHL .... 40
HEPATAMINE .................. 43
hepatasol 8 ....................... 43
HEPSERA
see adefovir dipivoxil ..... 11
HERCEPTIN ..................... 15
HEXALEN ......................... 14
HIBERIX ........................... 42
HIPREX
see methenamine
hippurate ......................... 9
HUMIRA ........................... 41
HUMIRA KIT 40MG/0.8 .... 41
HUMIRA PEN ................... 41
HUMIRA PEN-CROHNS
DISEASE .......................... 41
HUMIRA PEN-PSORIASIS
STAR ................................ 41
HUMULIN R INJ U-500..... 32
HYCAMTIN
see topotecan hcl .......... 16
HYCET
see
hydrocodone-acetaminoph
en 7.5-325 mg/15ml ........ 7
hydralazine hcl .................. 22
HYDREA
see hydroxyurea............ 15
hydrochlorothiazide........... 21
hydroco/apap tab 10-325mg
............................................ 7
hydroco/apap tab 5-325mg . 7
hydroco/apap tab 7.5-325mg
............................................ 7
hydrocodone-acetaminophen
7.5-325 mg/15ml ................. 7
hydrocodone-ibuprofen
7.5-200mg .......................... 7
hydrocortisone .................. 36
HYDROCORTISONE
(INTRARECTAL) .............. 38
59
2015 SSI Choice 15301 v6 eff 01/01/2015
hydrocortisone (topical) .....48
hydrocortisone butyrate ....48
hydrocortisone valerate ....48,
49
hydromorphon inj 10mg/ml..8
hydromorphone hcl .............8
hydroxychloroquine sulfate
..........................................41
hydroxyurea ......................15
hydroxyz hcl inj .................46
hydroxyzine hcl .................46
HYZAAR
see losartan potassium &
hctz tab 100-12.5 mg .....17
see losartan potassium &
hctz tab 100-25 mg ........17
see losartan potassium &
hctz tab 50-12.5 mg .......17
I
ibandronate sodium ..........33
ibuprofen .............................7
ICLUSIG............................15
IDAMYCIN PFS
see idarubicin hcl ...........14
idarubicin hcl .....................14
IFEX ..................................14
see ifosfamide inj 1gm ...14
IFOSFAMIDE
see ifosfamide inj
1gm/20ml.......................14
see ifosfamide inj
3gm/60ml.......................14
ifosfamide inj 1gm .............14
ifosfamide inj 1gm/20ml ....14
IFOSFAMIDE INJ 3GM .....14
ifosfamide inj 3gm/60ml ....14
ILEVRO .............................45
IMBRUVICA CAP 140MG .15
IMDUR
see isosorbide
mononitrate ...................22
imipenem-cilastatin .............9
imipramine hcl ...................26
imiquimod..........................49
IMITREX
see sumatriptan succinate
......................................31
see sumatriptan succinate
inj................................... 31
IMITREX STATDOSE
SYSTEM
see sumatriptan succinate
inj................................... 31
IMOVAX RABIES (H.D.C.V.)
.......................................... 42
IMURAN
see azathioprine ............ 42
INCRELEX ........................ 37
indapamide ....................... 21
INDERAL LA
see propranolol cap er... 19
INFANRIX ......................... 42
INLYTA ............................. 15
INSPRA
see eplerenone ............. 17
INSULIN PEN NEEDLE .... 32
INSULIN SYRINGE........... 32
INTELENCE...................... 10
INTRALIPID INJ 20%........ 43
INTRALIPID INJ 30%........ 43
INTRON-A INJ 10MU........ 41
INTRON-A INJ 18MU........ 41
INTRON-A INJ 25MU........ 41
INTRON-A INJ 50MU........ 41
introvale 91 day ................ 34
INTUNIV ........................... 30
INVANZ............................... 9
INVEGA ............................ 28
INVEGA SUST INJ
117MG/0.75ML ................. 28
INVEGA SUST INJ
156MG/ML ........................ 28
INVEGA SUST INJ
234MG/1.5ML ................... 28
INVEGA SUST INJ
39MG/0.25ML ................... 28
INVEGA SUST INJ
78MG/0.5ML ..................... 28
INVIRASE ......................... 10
INVOKANA ....................... 33
IONOSOL-B/DEXTROSE
5% .................................... 43
IONOSOL-MB/DEXTROSE
5% .................................... 43
IPOL INACTIVATED IPV .. 42
ipratropium bromide .......... 45
ipratropium bromide (nasal)
.......................................... 45
ipratropium-albuterol nebu 45
irinotecan hcl .................... 16
ISENTRESS ..................... 10
ISOLYTE P ....................... 43
isolyte s............................. 43
isoniazid ............................ 11
isoniazid inj 100 mg/ml ..... 11
isoniazid syp 50mg/5ml .... 11
ISORDIL TITRADOSE
see isosorbide dinitrate . 22
isosorb mononitrate tab .... 22
isosorbide dinitrate............ 22
isosorbide mononitrate ..... 22
isradipine .......................... 20
ISTALOL ........................... 45
ISTODAX .......................... 15
itraconazole ...................... 10
IXIARO ............................. 42
J
JAKAFI ............................. 15
JALYN .............................. 40
jantoven ............................ 40
JANUMET ......................... 33
JANUMET XR TAB
100-1000 .......................... 33
JANUMET XR TAB 50-1000
.......................................... 33
JANUMET XR TAB
50-500MG ......................... 33
JANUVIA .......................... 33
JENTADUETO .................. 33
JOLIVETTE ...................... 34
junel 1.5/30 21 day ........... 34
junel 1/20 21 day .............. 34
junel fe 1.5/30 28 day ....... 34
junel fe 1/20 28 day .......... 34
K
KADCYLA ......................... 15
KALETRA SOL ................. 11
KALETRA TAB 100-25MG 11
KALETRA TAB 200-50MG 11
kariva 28 day .................... 34
KAYEXALATE
see kionex powder ........ 34
KCL 0.075%/D5W/NACL
0.45% ............................... 44
60
2015 SSI Choice 15301 v6 eff 01/01/2015
KCL 0.15%/D5W/NACL
0.9% ..................................44
KCL 0.3%/D5W/NACL
0.45% ................................44
KCL 0.3%/D5W/NACL 0.9%
..........................................44
KCL/D5W INJ 0.3% ..........44
KCL/NACL INJ 0.3-0.9 ......44
KCL0.15%/D5W/NACL0.2%
..........................................44
KCL0.15%/D5W/NACL0.225
% .......................................44
KEFLEX
see cephalexin ..............12
KEPPRA
see levetiraceta sol
100mg/ml.......................24
see levetiracetam ..........24
see levetiracetam inj ......24
KEPPRA XR
see levetiracetam ..........24
ketoconazole .....................10
ketoconazole cream ..........47
ketoconazole shampoo .....48
ketoprofen ...........................7
ketorolac tromethamine
(ophth) ..............................45
kionex powder ...................34
kionex susp 15gm/60ml ....34
KLARON
see sulfacetamide sodium
(acne) ............................47
KLONOPIN
see clonazepam ............23
klor-con .............................42
KLOR-CON 10 ..................43
KLOR-CON 8 ....................43
klor-con pow 20meq ..........43
KUVAN .............................36
L
labetalol hcl .......................19
LAC-HYDRIN
see ammonium lactate ..49
see laclotion 12% ..........49
laclotion 12%.....................49
LACTATED RINGER'S INJ
..........................................44
lactulose ............................39
lactulose (encephalopathy)
.......................................... 39
LAMICTAL
see lamotrigine .............. 24
LAMICTAL CHEWABLE
DISPERS
see lamotrigine .............. 24
LAMICTAL XR
see lamotrigine .............. 24
LAMISIL
see terbinafine hcl ......... 10
lamivudine................... 10, 11
lamivudine-zidovudine ...... 11
lamotrigine ........................ 24
LANOXIN .......................... 20
see digoxin .................... 20
LANTUS............................ 32
LANTUS SOLOSTAR ....... 32
larin 1/20 ........................... 34
larin fe 1.5/30 .................... 34
larin fe 1/20 ....................... 34
LASIX
see furosemide .............. 21
LASTACAFT ..................... 45
latanoprost ........................ 45
LATUDA............................ 28
LAZANDA ........................... 8
LEENA TAB ...................... 34
leflunomide ....................... 41
lessina 28 day ................... 34
LETAIRIS .......................... 22
letrozole ............................ 15
leucovorin calcium ............ 16
leucovorin calcium for inj 500
mg ..................................... 16
leucovorin calcium inj 10
mg/ml ................................ 16
LEUKERAN ...................... 14
LEUKINE .......................... 41
leuprolide inj 1mg/0.2 ........ 15
levalbuterol conc
1.25mg/0.5ml .................... 46
LEVAQUIN
see levofloxacin ............. 13
see levofloxacin in d5w . 13
see levofloxacin oral soln
25 mg/ml ....................... 13
LEVEMIR .......................... 32
LEVEMIR FLEXPEN......... 32
levetiraceta sol 100mg/ml . 24
levetiracetam .................... 24
levetiracetam inj ................ 24
levobunolol hcl .................. 45
LEVOBUNOLOL HCL ....... 45
levocarnitine (metabolic
modifiers) .......................... 36
levocetirizine dihydrochloride
.......................................... 46
levofloxacin ....................... 13
levofloxacin in d5w............ 13
levofloxacin inj 25mg/ml .... 13
levofloxacin oral soln 25
mg/ml ................................ 13
levonest 28 day ................ 34
levonorgestrel (emergency
oc)..................................... 34
levonorgestrel-ethinyl
estradiol (91-day) .............. 34
levora 0.15/30 28 day ....... 34
levothyroxine sodium ........ 37
LEXAPRO
see escitalopram oxalate
...................................... 26
LEXIVA ............................. 10
LIALDA ............................. 38
lidocaine hcl ...................... 49
lidocaine hcl (local anesth.) 9
lidocaine hcl (mouth-throat)
.......................................... 49
lidocaine inj 0.5% ................ 9
lidocaine inj 1% ................... 9
lidocaine inj 1.5% ................ 9
lidocaine inj 2% ................... 9
lidocaine oint 5%............... 49
lidocaine-prilocaine ........... 49
LIDODERM DIS 5%.......... 49
LINZESS CAP 145MCG ... 39
LINZESS CAP 290MCG ... 39
liothyronine sodium ........... 37
LIPITOR
see atorvastatin calcium 18
lisinopril ............................. 16
lisinopril &
hydrochlorothiazide........... 16
LITHIUM ........................... 31
lithium carbonate .............. 31
61
2015 SSI Choice 15301 v6 eff 01/01/2015
lithium carbonate er ..........31
LITHOBID
see lithium carbonate er 31
LOCOID
see hydrocortisone
butyrate .........................48
LOESTRIN 1.5/30-21
see junel 1.5/30 21 day .34
see microgestin 1.5/30 21
day ................................35
LOESTRIN 1/20-21
see junel 1/20 21 day ....34
see larin 1/20 .................34
see microgestin 1/20 21
day ................................35
LOESTRIN FE 1.5/30
see junel fe 1.5/30 28 day
......................................34
see larin fe 1.5/30 ..........34
see microgestin fe 1.5/30
28 day............................35
LOESTRIN FE 1/20
see junel fe 1/20 28 day 34
see larin fe 1/20 .............34
see microgestin fe 1/20 28
day ................................35
LOFIBRA
see fenofibrate...............19
see fenofibrate micronized
......................................19
LOKARA LOTN 0.05% ......49
LOMOTIL
see diphenoxylate w/
atropine .........................39
LOMUSTINE .....................14
loperamide hcl...................39
LOPID
see gemfibrozil ..............19
LOPRESSOR
see metoprolol tartrate ..19
LOPRESSOR HCT
see metoprolol &
hydrochlorothiazide .......19
LOPROX SHAMPOO
see ciclopirox shampoo
1% .................................47
lorazepam .........................22
loryna 28 day ....................34
losartan potassium ............ 18
losartan potassium & hctz
tab 100-12.5 mg ................ 17
losartan potassium & hctz
tab 100-25 mg ................... 17
losartan potassium & hctz
tab 50-12.5 mg .................. 17
LOTEMAX......................... 45
LOTENSIN
see benazepril hcl ......... 16
LOTENSIN HCT
see benazepril &
hydrochlorothiazide ....... 16
LOTREL
see amlodipine
besylate-benazepril hcl
cap 10-20 mg ................ 16
see amlodipine
besylate-benazepril hcl
cap 10-40 mg ................ 16
see amlodipine
besylate-benazepril hcl
cap 2.5-10 mg ............... 16
see amlodipine
besylate-benazepril hcl
cap 5-10 mg .................. 16
see amlodipine
besylate-benazepril hcl
cap 5-20 mg .................. 16
see amlodipine
besylate-benazepril hcl
cap 5-40 mg .................. 16
LOTRONEX ...................... 39
lovastatin........................... 18
LOVENOX
see enoxaparin sodium . 40
low-ogestrel 28 day ........... 34
loxapine succinate ............ 28
LUMIGAN ......................... 45
LUMIZYME ....................... 36
LUPR DEP-PED INJ 30MG
(3-MONTH) ....................... 15
LUPRON DEPO INJ
11.25MG (3-MONTH) ....... 15
LUPRON DEPOT ............. 15
LUPRON DEPOT-PED ..... 15
lutera 28 day ..................... 34
LYRICA ............................. 24
LYSODREN ...................... 15
LYSTEDA
see tranexamic acid ...... 41
lyza ................................... 34
M
MACROBID
see nitrofurantoin
monohyd macro ............ 10
MACRODANTIN
see nitrofurantoin
macrocrystal .................. 10
mafenide acetate .............. 47
MAGNESIUM SULFATE .. 43
MAGNESIUM SULFATE IN
D5W .................................. 43
magnesium sulfate inj 50%
.......................................... 43
MALARONE
see atovaquone-proguanil
hcl ................................. 10
malathion .......................... 49
maprotiline hcl .................. 26
MARINOL
see dronabinol............... 37
marlissa 28 day................. 34
MARPLAN TAB 10MG...... 26
MATULANE ...................... 15
MAVIK
see trandolapril.............. 17
MAXALT
see rizatriptan benzoate 31
MAXALT-MLT
see rizatriptan benzoate 31
MAXIDEX ......................... 45
MAXIPIME
see cefepime hcl ........... 12
MAXITROL
see
neomycin-polymy-dexamet
h .................................... 44
MAXZIDE
see triamterene &
hydrochlorothiazide ....... 21
MAXZIDE-25
see triamterene &
hydrochlorothiazide ....... 21
meclizine hcl ..................... 38
MEDROL
62
2015 SSI Choice 15301 v6 eff 01/01/2015
see methylpred tab 16mg
......................................36
see methylpred tab 32mg
......................................36
see methylpred tab 4mg 36
see methylpred tab 8mg 36
MEDROL DOSEPAK
see methylpred pak 4mg
......................................36
medroxyprogesterone
acetate 150 mg/ml ............35
medroxyprogesterone
acetate tab ........................37
mefloquine hcl ...................10
MEGACE ES.....................15
MEGACE ORAL
see megestrol acetate ...15
megestrol acetate .............15
MEKINIST .........................15
meloxicam ...........................7
MELOXICAM ......................7
melphalan hcl ....................14
MENACTRA ......................42
MENOMUNE-A/C/Y/W-135
..........................................42
MENVEO ..........................42
MEPRON
see atovaquone ...............9
mercaptopurine .................14
meropenem .........................9
MERREM
see meropenem ..............9
mesalamine enema ...........38
mesalamine w/ cleanser ...38
mesna ...............................16
MESNEX ...........................16
see mesna .....................16
MESTINON
see pyridostigmine
bromide .........................31
metadate tab 20mg er .......30
metformin hcl ....................33
methadone hcl ....................8
METHADOSE
see methadone hcl ..........8
methazolamide ..................21
methenamine hippurate ......9
METHERGINE
see methylergonovine
maleate ......................... 37
methimazole ..................... 37
methotrexate sodium inj .... 14
methotrexate sodium tabs. 41
methyclothiazide ............... 21
methylergonovine maleate 37
METHYLIN
see methylphenidate hcl
oral soln......................... 30
methylphenidate hcl .......... 30
methylphenidate hcl oral soln
.......................................... 30
methylpr ace inj 40mg/ml .. 36
methylpr ace inj 80mg/ml .. 36
methylpr ss inj 125mg ....... 36
methylpr ss inj 1gm ........... 36
methylpr ss inj 40mg ......... 36
methylpr ss inj 500mg ....... 36
methylpred pak 4mg ......... 36
methylpred tab 16mg ........ 36
methylpred tab 32mg ........ 36
methylpred tab 4mg .......... 36
methylpred tab 8mg .......... 36
metipranolol ...................... 45
metoclopramide hcl ........... 38
metoclopramide hcl inj ...... 38
metolazone ....................... 21
metoprolol &
hydrochlorothiazide ........... 19
metoprolol succinate ......... 19
metoprolol tartrate ............. 19
METROCREAM
see metronidazole
(topical) ......................... 49
see rosadan cre 0.75% . 49
METROGEL-VAGINAL
see metronidazole vaginal
...................................... 40
METROLOTION
see metronidazole
(topical) ......................... 49
metronidazole ..................... 9
metronidazole (topical)...... 49
metronidazole gel 0.75% .. 49
metronidazole in nacl .......... 9
metronidazole vaginal ....... 40
MEVACOR
see lovastatin ................ 18
mexiletine hcl .................... 18
MIACALCIN ...................... 37
see calcitonin (salmon) . 37
microgestin 1.5/30 21 day . 35
microgestin 1/20 21 day .... 35
microgestin fe 1.5/30 28 day
.......................................... 35
microgestin fe 1/20 28 day 35
MICRO-K
see potassium chloride . 43
MICROZIDE
see hydrochlorothiazide 21
midodrine hcl .................... 22
MINIPRESS
see prazosin hcl ............ 17
minitran ............................. 22
MINOCIN
see minocycline hcl ....... 14
minocycline hcl ................. 14
minoxidil ............................ 22
MIRAPEX
see pramipexole
dihydrochloride .............. 27
MIRCETTE
see kariva 28 day .......... 34
see pimtrea pack ........... 35
see viorele ..................... 35
mirtazapine ....................... 26
misoprostol ....................... 39
mitomycin ......................... 14
mitoxantrone hcl ............... 15
M-M-R II W/DILUENT 10
DOS .................................. 42
MOBIC
see meloxicam ................ 7
moderiba 800 dose pack .. 11
moderiba pak 1000/day .... 11
moderiba pak 1200/day .... 11
moderiba pak 600/day ...... 11
moderiba tab 200mg ......... 12
moexipril hcl ...................... 17
moexipril-hydrochlorothiazid
e........................................ 16
mometasone furoate ......... 49
MONODOX
see doxycycline
(monohydrate) ............... 14
63
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MONONESSA...................35
montelukast sodium ..........46
morphine ext-rel tab ............8
morphine sul inj ...................8
MORPHINE SUL INJ ..........8
MORPHINE SUL INJ
2MG/ML ..............................8
MORPHINE SUL INJ
4MG/ML ..............................8
MORPHINE SULFATE .......8
MORPHINE SULFATE
ORAL SOL ..........................8
MOVIPREP .......................39
MOXEZA ...........................44
MOZOBIL ..........................41
MS CONTIN
see morphine ext-rel tab ..8
MULTAQ ...........................18
mupirocin ..........................47
MUSTARGEN ...................14
my way ..............................35
MYAMBUTOL
see ethambutol hcl ........11
MYCAMINE.......................10
MYCOBUTIN
see rifabutin ...................11
mycophenolate mofetil ......42
mycophenolate sodium .....42
MYFORTIC
see mycophenolate
sodium ...........................42
myorisan ...........................47
MYOZYME ........................36
MYRBETRIQ TAB 25MG ..40
MYRBETRIQ TAB 50MG ..40
MYSOLINE
see primidone ................24
myzilra ..............................35
N
nabumetone ........................7
nadolol ..............................19
nafcillin sodium .................13
NAGLAZYME ....................36
naloxone inj 0.4mg/ml .......32
naloxone inj 1mg/ml ..........32
naltrexone hcl....................32
NAMENDA SOL 10MG/5ML
..........................................25
NAMENDA XR .................. 25
NAMENDA XR TITRATION
PACK ................................ 25
naphazoline 0.1% ............. 45
NAPROSYN
see naproxen .................. 7
naproxen ............................. 7
naproxen sodium ................ 7
naratriptan hcl ................... 30
NARDIL
see phenelzine sulfate... 26
NASONEX ........................ 46
NATACYN......................... 44
nateglinide ........................ 33
NAVELBINE
see vinorelbine tartrate .. 15
NEBUPENT ...................... 10
necon 0.5/35 28 day ......... 35
necon 1/35 28 day ............ 35
NECON 1/50-28 ................ 35
necon 10/11 28 day .......... 35
NECON 7/7/7 .................... 35
nefazodone hcl ................. 26
neomycin sulfate ................. 9
neomycin-bacitracin
zn-polymyxin ..................... 44
neomycin-polymy-dexameth
.......................................... 44
neomycin-polymy-gramicid
.......................................... 44
neomycin-polymyxin-hc
(ophth) .............................. 44
neomycin-polymyxin-hc (otic)
.......................................... 49
NEORAL ........................... 42
see cyclosporine modified
(for microemulsion)........ 42
see gengraf ................... 42
NEOSPORIN
see
neomycin-polymy-gramicid
...................................... 44
NEPHRAMINE .................. 43
NEPTAZANE
see methazolamide ....... 21
NEUMEGA........................ 41
NEUPOGEN ..................... 41
NEUPRO .......................... 27
NEURONTIN
see gabapentin........ 23, 24
NEVANAC ........................ 45
NEVIRAPINE SUSP 50
MG/5ML ............................ 11
nevirapine tab 200mg ....... 11
nevirapine tb24 ................. 11
NEXAVAR ........................ 15
NEXIUM CAP 20MG......... 39
NEXIUM CAP 40MG......... 39
NEXIUM GRA 10MG DR .. 39
NEXIUM GRA 2.5MG DR . 39
NEXIUM GRA 20MG DR .. 39
NEXIUM GRA 40MG DR .. 39
NEXIUM GRA 5MG DR .... 39
NEXIUM I.V.
see esomeprazole sodium
...................................... 39
next choice one dose ........ 35
niacin (antihyperlipidemic) 19
niacor ................................ 19
NIASPAN
see niacin
(antihyperlipidemic) ....... 19
nicardipine hcl ................... 20
NICOTROL INHALER....... 32
NICOTROL NS ................. 32
nifedical ............................ 20
nifedipine .......................... 20
nifedipine er ...................... 20
NILANDRON .................... 15
nimodipine ........................ 20
nitro-bid............................. 22
NITRO-DUR
see minitran .................. 22
NITRO-DUR DIS 0.3MG/HR
.......................................... 22
NITRO-DUR DIS 0.8MG/HR
.......................................... 22
nitrofurantoin macrocrystal 10
nitrofurantoin monohyd
macro ................................ 10
nitroglycerin td patch 24hr
0.1 mg/hr .......................... 22
nitroglycerin td patch 24hr
0.2 mg/hr .......................... 22
nitroglycerin td patch 24hr
0.4 mg/hr .......................... 22
64
2015 SSI Choice 15301 v6 eff 01/01/2015
nitroglycerin td patch 24hr
0.6 mg/hr ...........................22
NITROLINGUAL
PUMPSPRAY ...................22
NITROSTAT......................22
NIZORAL
see ketoconazole
shampoo........................48
NORA-BE TAB 0.35MG ....35
NORCO
see hydroco/apap tab
10-325mg ........................7
see hydroco/apap tab
5-325mg ..........................7
see hydroco/apap tab
7.5-325mg .......................7
NORDITROPIN FLEXPRO
..........................................37
NORDITROPIN
NORDIFLEX PEN .............37
norethindrone
(contraceptive) ..................35
norethindrone acetate .......37
norgestimate-ethinyl
estradiol (triphasic) ............35
NORINYL 1+35
see cyclafem 1/35 28 day
......................................34
see necon 1/35 28 day ..35
see nortrel 1/35 21 day ..35
see nortrel 1/35 28 day ..35
see pirmella 1/35 28 day
......................................35
normosol-m .......................44
NORMOSOL-R .................44
NORMOSOL-R IN D5W ....44
NORPACE
see disopyramide
phosphate......................18
NORPACE CR ..................18
NORPRAMIN
see desipramine hcl ......25
NOR-QD
see camila 28 day .........34
see heather ...................34
see norethindrone
(contraceptive)...............35
nortrel 0.5/35 28 day .........35
nortrel 1/35 21 day ............ 35
nortrel 1/35 28 day ............ 35
nortrel 7/7/7 28 day ........... 35
nortriptyline hcl .................. 26
NORVASC
see amlodipine besylate 20
NORVIR ............................ 11
NOVOLIN 70/30 ................ 32
NOVOLIN N ...................... 32
NOVOLIN R ...................... 32
NOVOLOG........................ 32
NOVOLOG FLEXPEN ...... 32
NOVOLOG MIX 70/30 ...... 32
NOVOLOG MIX 70/30
PREFILL ........................... 32
NOVOLOG PENFILL ........ 32
NOXAFIL .......................... 10
NUCYNTA ER .................... 8
NUEDEXTA ...................... 31
NULOJIX........................... 42
NULYTELY/FLAVOR
PACKS.............................. 39
see gavilyte-n ................ 39
see peg 3350-potassium
chloride-sod
bicarbonate-sod chloride
...................................... 39
see trilyte ....................... 39
NUVARING ....................... 35
NUVIGIL ..................... 31, 32
nyamyc ............................. 47
NYMALIZE ........................ 20
nystatin ............................. 10
nystatin (mouth-throat) ...... 49
nystatin (topical) ................ 47
nystop ............................... 47
O
OCELLA TAB 3-0.03MG ... 35
OCTAGAM........................ 41
octreotide acetate ............. 37
OCUFEN
see flurbiprofen sodium . 45
OCUFLOX
see ofloxacin (ophth) ..... 44
ofloxacin (ophth) ............... 44
ofloxacin (otic)................... 49
olanzapine .................. 28, 29
OLYSIO ............................ 12
omega-3-acid ethyl esters 19
omeprazole ....................... 39
omeprazole cap 20mg ...... 39
ondansetron hcl ................ 38
ondansetron hcl inj............ 38
ondansetron hcl oral soln .. 38
ondansetron odt ................ 38
ONFI SOLN ...................... 24
ONFI TAB ......................... 24
OPANA ER (CRUSH
RESISTANT ....................... 8
OPTIVAR
see azelastine hcl (ophth)
...................................... 45
ORAP ............................... 29
ORFADIN ......................... 36
orsythia 28 day ................. 35
ORTHO EVRA
see xulane dis 150-35 ... 35
ORTHO MICRONOR
see errin 28 day ............ 34
see lyza ......................... 34
ORTHO TRI-CYCLEN
see norgestimate-ethinyl
estradiol (triphasic) ........ 35
see tri-previfem 28 day.. 35
see tri-sprintec 28 day ... 35
ORTHO-CYCLEN
see previfem 28 day ...... 35
see sprintec 28 day ....... 35
ORTHO-NOVUM 7/7/7
see cyclafem 7/7/7 28 day
...................................... 34
see nortrel 7/7/7 28 day 35
OVCON-35
see balziva 28 day ........ 34
see briellyn 28 day ........ 34
see gildagia ................... 34
see philith ...................... 35
see vyfemia 28 day ....... 35
see zenchent 28 day ..... 35
OVIDE
see malathion ................ 49
oxacillin sodium ................ 13
oxaliplatin.......................... 16
OXANDRIN
see oxandrolone tab 10mg
...................................... 32
65
2015 SSI Choice 15301 v6 eff 01/01/2015
see oxandrolone tab
2.5mg ............................32
oxandrolone tab 10mg ......32
oxandrolone tab 2.5mg .....32
oxcarbazepine...................24
oxybutynin chloride ...........40
oxycodone hcl .....................8
oxycodone hcl tab 5 mg ......8
oxycodone w/
acetaminophen 10-325mg ..9
oxycodone w/
acetaminophen 2.5-325mg .8
oxycodone w/
acetaminophen 5-325mg ....8
oxycodone w/
acetaminophen 7.5-325mg .9
OXYCONTIN.......................9
P
pacerone ...........................18
paclitaxel ...........................14
PAMELOR
see nortriptyline hcl .......26
pamidronate disodium .......33
PANRETIN ........................49
paricalcitol .........................44
PARLODEL
see bromocriptine
mesylate ........................27
PARNATE
see tranylcypromine
sulfate ............................27
paromomycin sulfate ...........9
paroxetine hcl....................26
paser d/r ............................11
PATADAY .........................45
PATANASE .......................46
PATANOL .........................45
PAXIL ................................26
see paroxetine hcl .........26
PEDIAPRED
see pred sod pho sol
5mg/5ml.........................36
pedi-dri ..............................47
PEDVAX HIB ....................42
PEG 3350/ELECTROLYTES
..........................................39
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate ...........39
peg 3350-potassium
chloride-sod bicarbonate-sod
chloride ............................. 39
PEGANONE ..................... 24
PEG-INTRON ................... 41
PEG-INTRON KIT 120 RP 41
PEG-INTRON KIT 150 RP 41
PEG-INTRON KIT 50MCG41
PEG-INTRON KIT 50MCG
RP ..................................... 41
PEG-INTRON KIT 80MCG
RP ..................................... 41
PENICILLIN G POT IN
DEXTROSE ...................... 13
penicillin g potassium ........ 13
penicillin g procaine .......... 13
penicillin g sodium ............ 13
penicillin v potassium ........ 13
penicilln gk inj 5mu ........... 13
PENTAM 300 .................... 10
PENTASA ......................... 38
pentoxifylline ..................... 41
PEPCID
see famotidine oral sus
40mg/5ml ...................... 38
see famotidine tab ......... 38
PERCOCET
see endocet..................... 8
see oxycodone w/
acetaminophen 10-325mg
........................................ 9
see oxycodone w/
acetaminophen 2.5-325mg
........................................ 8
see oxycodone w/
acetaminophen 5-325mg . 8
see oxycodone w/
acetaminophen 7.5-325mg
........................................ 9
see roxicet tab 5-325mg .. 9
PERFOROMIST ............... 46
PERIDEX
see chlorhexidine
gluconate (mouth-throat)
...................................... 49
see periogard ................ 49
perindopril erbumine ......... 17
periogard........................... 49
permethrin ........................ 49
perphenazine .................... 29
phenadoz .......................... 38
phenelzine sulfate ............. 26
PHENERGAN
see promethazine hcl .... 38
phenobarbital .................... 24
phenobarbital sodium ....... 24
PHENOBARBITAL SODIUM
.......................................... 24
phenytek ........................... 24
PHENYTEK
see phenytoin sodium
extended ....................... 24
phenytoin .......................... 24
phenytoin sodium.............. 24
phenytoin sodium extended
.......................................... 24
philith ................................ 35
PHOSLO
see calcium acetate
(phosphate binder) ........ 37
PHOSLYRA ...................... 37
PHOSPHOLINE IODIDE .. 45
PILOCARPINE HCL ......... 45
pilocarpine hcl (oral) ......... 49
pimtrea pack ..................... 35
pindolol ............................. 19
pioglitazone hcl ................. 33
piperacillin
sodium-tazobactam sodium
.......................................... 13
pirmella 1/35 28 day ......... 35
piroxicam ............................ 7
PLAN B
see levonorgestrel
(emergency oc) ............. 34
PLAN B ONE-STEP
see levonorgestrel
(emergency oc) ............. 34
see my way ................... 35
see next choice one dose
...................................... 35
PLAQUENIL
see hydroxychloroquine
sulfate ........................... 41
PLASMA-LYTE A.............. 44
PLASMA-LYTE-148 .......... 44
66
2015 SSI Choice 15301 v6 eff 01/01/2015
PLASMA-LYTE-56/D5W ...44
PLAVIX
see clopidogrel bisulfate 41
PLETAL
see cilostazol .................41
podofilox............................49
polyethylene glycol 3350 ...39
polymyxin b-trimethoprim ..44
POLYTRIM
see polymyxin
b-trimethoprim ...............44
POMALYST CAP 1MG .....15
POMALYST CAP 2MG .....15
POMALYST CAP 3MG .....15
POMALYST CAP 4MG .....15
portia 28 day .....................35
potassium chloride ......43, 44
POTASSIUM CHLORIDE 43,
44
POTASSIUM CHLORIDE
0.15% ................................44
POTASSIUM CHLORIDE
0.22% ................................44
POTASSIUM CHLORIDE
ER .....................................43
potassium chloride in nacl .44
potassium chloride
microencapsulated crystals
cr .......................................43
POTASSIUM CITRATE
(ALKALINIZER).................40
POTIGA ............................24
PRADAXA .........................40
pramipexole dihydrochloride
..........................................27
PRANDIN
see repaglinide ..............33
PRAVACHOL
see pravastatin sodium..19
pravastatin sodium ......18, 19
prazosin hcl .......................17
PRECOSE
see acarbose .................32
pred sod pho sol 5mg/5ml .36
PREDNISOLONE ACETATE
(OPHTH) ...........................45
prednisolone sodium
phosphate (ophth) .............45
prednisolone sol 15mg/5ml
.......................................... 36
prednisolone sol 25mg/5ml
.......................................... 36
prednisolone syrup 15
mg/5ml .............................. 36
prednisone con 5mg/ml..... 37
prednisone pak 10mg ....... 37
prednisone pak 5mg ......... 37
prednisone sol 5mg/5ml .... 37
prednisone tab 10mg ........ 37
prednisone tab 1mg .......... 37
prednisone tab 2.5mg ....... 37
prednisone tab 20mg ........ 37
prednisone tab 50mg ........ 37
prednisone tab 5mg .......... 37
PRELONE
see prednisolone syrup 15
mg/5ml .......................... 36
PREMARIN ....................... 36
PREMARIN CREAM ......... 36
premasol 10% ................... 43
premasol 6% ..................... 43
PREMPHASE TAB ........... 36
PREMPRO TAB .625-2.5.. 36
PREMPRO TAB 0.3-1.5.... 36
PREMPRO TAB 0.45-1.5.. 36
PREMPRO TAB 0.625-5... 36
PRENATAL VITAMIN/FOLIC
ACID > 0.8 MG (GENERIC)
.......................................... 44
prevalite ............................ 19
previfem 28 day ................ 35
PREZISTA ........................ 11
PRIFTIN ............................ 11
PRILOSEC
see omeprazole ............. 39
see omeprazole cap 20mg
...................................... 39
PRIMAQUINE PHOSPHATE
.......................................... 10
PRIMAXIN IV
see imipenem-cilastatin ... 9
primidone .......................... 24
PRINIVIL
see lisinopril .................. 16
PRISTIQ ........................... 26
PRIVIGEN......................... 41
PROAIR HFA .................... 46
probenecid .......................... 7
PROCALAMINE................ 43
PROCARDIA XL
see nifedical .................. 20
see nifedipine er ............ 20
prochlorperazine inj .......... 38
prochlorperazine maleate . 38
prochlorperazine supp ...... 38
PROCRIT ......................... 41
procto-pak ......................... 47
proctozone hc ................... 47
PROGLYCEM SUS
50MG/ML .......................... 37
PROGRAF ........................ 42
see tacrolimus ............... 42
PROLASTIN-C.................. 46
PROLENSA ...................... 45
PROLEUKIN ..................... 15
PROLIA ............................ 37
PROMACTA ..................... 41
promethazine hcl .............. 38
promethegan .................... 38
propafenone hcl ................ 18
proparacaine hcl ............... 45
propranolol &
hydrochlorothiazide........... 19
propranolol cap er ............. 19
propranolol hcl .................. 19
propranolol tab .................. 20
propylthiouracil ................. 37
PROQUAD ....................... 42
PROSCAR
see finasteride ............... 39
PROSOL ........................... 43
protriptyline hcl ................. 26
PROVERA
see medroxyprogesterone
acetate tab .................... 37
PROZAC
see fluoxetine hcl .......... 26
PRUDOXIN CRE 5% ........ 47
PULMICORT
see budesonide
(inhalation) .................... 46
PULMOZYME ................... 46
PURINETHOL
see mercaptopurine ...... 14
67
2015 SSI Choice 15301 v6 eff 01/01/2015
pyrazinamide.....................11
pyridostigmine bromide .....31
Q
QUALAQUIN
see quinine sulfate ........10
quasense 91 day...............35
QUESTRAN
see cholestyramine .......19
QUESTRAN LIGHT
see prevalite ..................19
quetiapine fumarate ..........29
quinapril hcl .......................17
quinapril-hydrochlorothiazide
..........................................16
quinidine gluconate ...........18
quinidine sulfate ................18
quinine sulfate ...................10
QVAR ................................47
R
RABAVERT.......................42
raloxifene tab 60mg ..........37
ramipril ..............................17
RANEXA ...........................22
ranitidine hcl ......................38
ranitidine hcl inj .................38
ranitidine syrup..................38
RAPAFLO .........................40
RAPAMUNE......................42
see sirolimus .................42
RAZADYNE
see galantamine
hydrobromide ................25
RAZADYNE ER
see galantamine
hydrobromide ................25
REBETOL
see ribasphere...............12
see ribavirin cap 200mg 12
REBETOL SOL 40MG/ML 12
reclipsen 28 day ................35
RECOMBIVAX HB ............42
REGLAN
see metoclopramide hcl.38
REGRANEX ......................49
RELENZA DISKHALER ....12
RELISTOR ........................39
RELPAX ............................31
REMERON
see mirtazapine ............. 26
REMERON SOLTAB
see mirtazapine ............. 26
REMICADE INJ 100MG .... 41
REMODULIN .................... 22
RENVELA PAK 0.8GM ..... 37
RENVELA PAK 2.4GM ..... 37
RENVELA TAB 800MG .... 37
repaglinide ........................ 33
REQUIP
see ropinirole
hydrochloride ................. 27
RESCRIPTOR .................. 11
RESTASIS ........................ 45
RESTORIL
see temazepam ............. 30
RETIN-A
see tretinoin................... 47
RETROVIR
see zidovudine .............. 11
RETROVIR IV INFUSION . 11
REVATIO
see sildenafil citrate
(pulmonary hypertension)
...................................... 22
REVIA
see naltrexone hcl ......... 32
REVLIMID ......................... 41
REYATAZ ......................... 11
ribapak mis 600/day .......... 12
ribasphere ......................... 12
ribasphere ribapak 1000 ... 12
ribasphere ribapak 1200 ... 12
ribasphere ribapak 800 ..... 12
ribavirin cap 200mg .......... 12
ribavirin tab 200mg ........... 12
rifabutin ............................. 11
RIFADIN
see rifampin ................... 11
rifampin ............................. 11
RIFATER .......................... 11
RILUTEK
see riluzole .................... 31
riluzole .............................. 31
rimantadine hydrochloride. 12
RINGER'S ......................... 44
RIOMET ............................ 33
RISPERDAL
see risperidone.............. 29
RISPERDAL INJ 12.5MG . 29
RISPERDAL INJ 25MG .... 29
RISPERDAL INJ 37.5MG . 29
RISPERDAL INJ 50MG .... 29
RISPERDAL M-TAB
see risperidone.............. 29
risperidone ........................ 29
RITALIN
see methylphenidate hcl 30
RITALIN SR
see metadate tab 20mg er
...................................... 30
see methylphenidate hcl 30
RITUXAN .......................... 15
rivastigmine tartrate .......... 25
rizatriptan benzoate .......... 31
ROBINUL
see glycopyrrolate ......... 38
ROBINUL FORTE
see glycopyrrolate ......... 38
ROCALTROL
see calcitriol .................. 44
see calcitriol oral soln 1
mcg/ml .......................... 44
ROCEPHIN
see ceftriaxone sodium . 12
ropinirole hydrochloride .... 27
rosadan cre 0.75%............ 49
ROTARIX.......................... 42
ROTATEQ ........................ 42
ROWASA
see mesalamine w/
cleanser ........................ 38
roxicet soln ......................... 9
roxicet tab 5-325mg ............ 9
ROXICODONE
see oxycodone hcl .......... 8
see oxycodone hcl tab 5
mg ................................... 8
ROZEREM ........................ 30
RYTHMOL
see propafenone hcl...... 18
RYTHMOL SR
see propafenone hcl...... 18
S
SABRIL ............................. 24
SALAGEN
68
2015 SSI Choice 15301 v6 eff 01/01/2015
see pilocarpine hcl (oral)
......................................49
SANDIMMUNE .................42
see cyclosporine............42
SANDOSTATIN
see octreotide acetate ...37
SANDOSTATIN LAR
DEPOT .............................37
SANTYL ............................49
SAPHRIS ..........................29
SECTRAL
see acebutolol hcl ..........19
selegiline hcl .....................27
selenium sulfide ................48
SELZENTRY .....................11
SENSIPAR ........................34
SEREVENT DISKUS ........46
SEROQUEL
see quetiapine fumarate 29
SEROQUEL XR ................29
sertraline hcl......................26
sildenafil citrate (pulmonary
hypertension) ....................22
SILENOR ..........................30
SILVER SULFADIAZINE...47
SIMBRINZA ......................45
simvastatin ........................19
SINEMET
see carbidopa-levodopa 27
SINEMET CR
see carbidopa-levodopa 27
SINGULAIR
see montelukast sodium 46
sirolimus ............................42
SIRTURO ..........................11
SOD CHLORIDE INJ 0.9%
..........................................44
SODIUM CHLORIDE ..43, 44
SODIUM CHLORIDE 0.45%
VIA ....................................44
SODIUM CHLORIDE 0.9%
..........................................49
SODIUM FLUORIDE CHEW;
TAB; 1.1 (0.5 F) MG/ML
SOLN ................................43
sodium phenylbutyrate ......36
sodium polystyrene sulfonate
..........................................34
SOLIA ............................... 35
SOLTAMOX ...................... 15
SOLU-CORTEF ................ 37
SOLU-MEDROL
see methylpr ss inj 125mg
...................................... 36
see methylpr ss inj 1gm. 36
see methylpr ss inj 40mg
...................................... 36
see methylpr ss inj 500mg
...................................... 36
SOMATULINE DEPOT ..... 37
SOMAVERT ...................... 37
SORIATANE
see acitretin ................... 47
sorine ................................ 18
sotalol hcl .......................... 18
sotalol hcl (afib/afl) ............ 18
SOVALDI .......................... 12
SPIRIVA CAP HANDIHLR 46
spironolactone .................. 17
spironolactone &
hydrochlorothiazide ........... 21
SPORANOX
see itraconazole ............ 10
sprintec 28 day ................. 35
SPRYCEL ......................... 15
sps susp 15gm/60ml ......... 34
sronyx 28 day ................... 35
SSD .................................. 47
STARLIX
see nateglinide .............. 33
stavudine .......................... 11
STERILE WATER
IRRIGATION ..................... 49
STIVARGA........................ 15
STRATTERA .................... 30
streptomycin sulfate ............ 9
STRIBILD.......................... 11
SUBOXONE MIS 12-3MG 32
SUBOXONE MIS 2-0.5MG
.......................................... 32
SUBOXONE MIS 4-1MG .. 32
SUBOXONE MIS 8-2MG .. 32
SUCRAID.......................... 39
sucralfate .......................... 39
sulfacetamide sodium (acne)
.......................................... 47
sulfacetamide sodium
(ophth) .............................. 44
sulfacetamide
sod-prednisolone .............. 44
sulfadiazine ......................... 9
sulfamethoxazole-trimethopri
m inj .................................. 10
sulfamethoxazole-trimethopri
m susp .............................. 10
sulfamethoxazole-trimethopri
m tab................................. 10
SULFAMYLON ................. 47
see mafenide acetate .... 47
sulfasalazine ..................... 38
sulfasalazine ec ................ 39
sulindac .............................. 7
SUMATRIPTAN ................ 31
sumatriptan succinate ....... 31
SUMATRIPTAN
SUCCINATE ..................... 31
sumatriptan succinate inj .. 31
SUMATRIPTAN
SUCCINATE INJ............... 31
suprax ............................... 12
SUPRAX ........................... 12
SUPREP BOWEL PREP .. 39
SURMONTIL CAP 100MG 27
SURMONTIL CAP 25MG . 26
SURMONTIL CAP 50MG . 26
SUSTIVA .......................... 11
SUTENT ........................... 15
syeda ................................ 35
SYLATRON KIT 296MCG 15
SYLATRON KIT 444MCG 15
SYLATRON KIT 888MCG 15
SYMBICORT .................... 47
SYMLINPEN 120 .............. 32
SYMLINPEN 60 ................ 32
SYNAGIS .......................... 42
SYNALAR
see fluocinolone acetonide
...................................... 48
SYNAREL ......................... 35
SYNERCID ....................... 10
SYNTHROID .................... 37
see levothyroxine sodium
...................................... 37
SYPRINE .......................... 34
69
2015 SSI Choice 15301 v6 eff 01/01/2015
T
TABLOID...........................14
tacrolimus..........................42
TAFINLAR.........................15
TAMIFLU...........................12
tamoxifen citrate................15
tamsulosin hcl ...................40
TAPAZOLE
see methimazole ...........37
TARCEVA .........................15
TARGRETIN ...............15, 49
TASIGNA ..........................15
TAXOTERE.......................14
tazicef ...............................12
tazicef vial .........................12
TAZORAC .........................48
taztia .................................20
TEFLARO .........................12
TEGRETOL.......................24
see carbamazepine .......23
see epitol .......................23
TEGRETOL-XR ................24
see carbamazepine .......23
TEKAMLO TAB 150-10MG
..........................................21
TEKAMLO TAB 150-5MG .21
TEKAMLO TAB 300-10MG
..........................................21
TEKAMLO TAB 300-5MG .21
TEKTURNA.......................21
TEKTURNA HCT TAB
150-12.5MG ......................21
TEKTURNA HCT TAB
150-25MG .........................21
TEKTURNA HCT TAB
300-12.5MG ......................21
TEKTURNA HCT TAB
300-25MG .........................21
temazepam .......................30
TEMOVATE
see clobetasol propionate
......................................48
TEMOVATE E
see clobetasol propionate
e ....................................48
TENIVAC ..........................42
TENORETIC 100
see atenolol &
chlorthalidone ................ 19
TENORETIC 50
see atenolol &
chlorthalidone ................ 19
TENORMIN
see atenolol ................... 19
TERAZOL 3
see terconazole vaginal. 40
TERAZOL 7
see terconazole vaginal. 40
see zazole ..................... 40
terazosin hcl ...................... 17
terbinafine hcl ................... 10
terbutaline sulfate ............. 46
terconazole vaginal ........... 40
TESTIM............................. 32
testosterone cypionate ...... 32
testosterone enanthate ..... 32
TETANUS TOXOID
ADSORBED...................... 42
TETANUS/DIPHTHERIA
TOXOID ............................ 42
TEV-TROPIN .................... 37
texacort soln 2.5% ............ 49
THALOMID ....................... 41
theo-24.............................. 47
theophylline....................... 47
thioridazine hcl .................. 29
thiothixene ........................ 29
tiagabine hcl...................... 24
TIAZAC
see diltiazem cap .......... 20
see diltzac cap 120mg/24
...................................... 20
see diltzac cap 180mg/24
...................................... 20
see diltzac cap 240mg/24
...................................... 20
see diltzac cap 300mg/24
...................................... 20
see taztia ....................... 20
TIKOSYN CAP 125MCG .. 18
TIKOSYN CAP 250MCG .. 18
TIKOSYN CAP 500MCG .. 18
TIMENTIN ......................... 13
TIMENTIN INJ 3.1GM ....... 13
timolol maleate .................. 20
timolol maleate (ophth) ..... 45
TIMOLOL MALEATE GEL 45
TIMOPTIC
see timolol maleate
(ophth)........................... 45
TIVICAY............................ 11
tizanidine hcl ..................... 31
TOBI
see tobramycin ................ 9
TOBRADEX ...................... 44
see
tobramycin-dexamethason
e .................................... 44
TOBRADEX ST ................ 44
tobramycin .......................... 9
tobramycin inj 1.2/30ml ....... 9
tobramycin inj 1.2gm........... 9
tobramycin inj 10mg/ml ....... 9
tobramycin inj 40mg/ml ....... 9
tobramycin inj 80mg/2ml ..... 9
tobramycin sulfate (ophth) 45
tobramycin sulfate in saline 9
tobramycin-dexamethasone
.......................................... 44
TOBREX ........................... 45
see tobramycin sulfate
(ophth)........................... 45
TOFRANIL
see imipramine hcl ........ 26
TOLTERODINE TARTRATE
CAP ER ............................ 40
tolterodine tartrate tabs ..... 40
TOPAMAX
see topiramate .............. 24
TOPAMAX SPRINKLE
see topiramate .............. 24
TOPICORT
see desoximetasone ..... 48
topiramate ......................... 24
toposar.............................. 16
topotecan hcl .................... 16
TOPROL XL
see metoprolol succinate
...................................... 19
torsemide inj ..................... 21
torsemide tabs .................. 21
TOVIAZ............................. 40
TPN ELECTROLYTES ..... 43
TRACLEER ...................... 22
70
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TRADJENTA .....................33
tramadol hcl ........................8
tramadol-acetaminophen ....8
TRANDATE
see labetalol hcl.............19
trandolapril ........................17
tranexamic acid .................41
TRANSDERM-SCOP ........38
TRANXENE T
see clorazepate
dipotassium ...................23
tranylcypromine sulfate .....27
travasol 10 ........................43
TRAVATAN Z....................45
trazodone hcl ....................27
TREANDA .........................14
TRECATOR ......................11
TRELSTAR DEP INJ
3.75MG .............................15
TRELSTAR LA INJ 11.25MG
..........................................15
tretinoin .............................47
tretinoin (chemotherapy) ...15
triamcinolone acetonide
(mouth) .............................49
triamcinolone acetonide
(topical) .............................49
triamterene &
hydrochlorothiazide ...........21
triamterene &
hydrochlorothiazide cap
37.5-25 mg ........................21
TRIBENZOR TAB
20-5-12.5MG .....................17
TRIBENZOR TAB
40-10-12.5.........................17
TRIBENZOR TAB
40-10-25MG ......................17
TRIBENZOR TAB
40-5-12.5MG .....................17
TRIBENZOR TAB
40-5-25MG ........................17
TRICOR
see fenofibrate...............19
triderm ...............................49
trifluoperazine hcl ..............29
trifluridine ..........................45
trihexyphenidyl hcl ............27
tri-legest 28 day ................ 35
TRILEPTAL
see oxcarbazepine ........ 24
TRILIPIX
see choline fenofibrate cap
dr 135 mg ...................... 19
see choline fenofibrate cap
dr 45 mg ........................ 19
trilyte ................................. 39
trimethoprim ...................... 10
TRINESSA ........................ 35
TRI-NORINYL 28
see aranelle 28 .............. 34
tri-previfem 28 day ............ 35
TRISENOX ....................... 16
tri-sprintec 28 day ............. 35
trivora 28 day .................... 35
TRIZIVIR
see abacavir
sulfate-lamivudine-zidovud
ine ................................. 11
TROPHAMINE INJ 10% ... 43
trospium chloride .............. 40
TRUSOPT
see dorzolamide hcl ...... 45
TRUVADA......................... 11
TUDORZA PRESSAIR ..... 46
TWINRIX INJ .................... 42
TYGACIL .......................... 10
TYKERB ........................... 15
TYLENOL/CODEINE #3
see acetaminophen w/
codeine............................ 7
TYLENOL/CODEINE #4
see acetaminophen w/
codeine............................ 7
TYPHIM VI ........................ 42
TYSABRI .......................... 31
TYZEKA ............................ 12
U
UCERIS ............................ 39
ULORIC .............................. 7
ULTRACET
see
tramadol-acetaminophen. 8
ULTRAM
see tramadol hcl .............. 8
ULTRAVATE
see halobetasol
propionate ..................... 48
UNASYN
see ampicillin & sulbactam
sodium .......................... 13
UNASYN BULK PACK
see ampicillin & sulbactam
sodium .......................... 13
UNIVASC
see moexipril hcl ........... 17
URECHOLINE
see bethanechol chloride
...................................... 40
UROXATRAL
see alfuzosin hcl............ 39
URSO 250
see ursodiol ................... 39
URSO FORTE
see ursodiol ................... 39
ursodiol ............................. 39
V
VAGIFEM ......................... 36
valacyclovir hcl.................. 12
VALCHLOR ...................... 49
VALCYTE ......................... 12
VALIUM
see diazepam ................ 23
valproate sodium .............. 24
valproic acid ...................... 24
valsartan ........................... 18
valsartan & hctz tab
160-12.5mg ...................... 18
valsartan & hctz tab
160-25mg ......................... 18
valsartan & hctz tab
320-12.5mg ...................... 18
valsartan & hctz tab
320-25mg ......................... 18
valsartan & hctz tab
80-12.5mg ........................ 17
VALTREX
see valacyclovir hcl ....... 12
VANCOCIN HCL
see vancomycin hcl ....... 10
vancomycin hcl ................. 10
VANDAZOLE .................... 40
VAQTA ............................. 42
VARIVAX .......................... 42
71
2015 SSI Choice 15301 v6 eff 01/01/2015
VASCEPA .........................19
VASERETIC
see enalapril maleate &
hydrochlorothiazide .......16
VASOTEC
see enalapril maleate ....16
VELCADE .........................15
velivet 28 day ....................35
venlafaxine hcl ..................27
verapamil cap er ...............20
VERAPAMIL CAP ER .......20
verapamil hcl .....................20
verapamil tab er ................20
VERELAN
see verapamil cap er .....20
VERELAN PM
see verapamil cap er .....20
VERSACLOZ ....................29
VESICARE ........................40
vestura ..............................35
VFEND
see voriconazole ...........10
VFEND IV
see voriconazole ...........10
VIBRAMYCIN....................14
see doxycycline hyclate .14
VICOPROFEN
see
hydrocodone-ibuprofen
7.5-200mg .......................7
VICTOZA ..........................32
VICTRELIS CAP 200MG ..12
VIDAZA
see azacitidine...............14
VIDEX EC
see didanosine ..............10
VIDEX PEDIATRIC ...........11
VIGAMOX .........................45
VIIBRYD............................27
VIMPAT.............................24
vinblastine sulfate .............15
vincasar.............................15
vincristine sulfate ..............15
vinorelbine tartrate ............15
viorele ...............................35
VIRACEPT ........................11
VIRAMUNE
see nevirapine tab 200mg
...................................... 11
VIRAMUNE XR ................. 11
see nevirapine tb24 ....... 11
VIREAD ............................ 11
VIROPTIC
see trifluridine ................ 45
VIVACTIL
see protriptyline hcl ....... 26
VOLTAREN ...................... 49
VOLTAREN-XR
see diclofenac sodium ..... 7
voriconazole ...................... 10
VOSPIRE ER
see albuterol sulfate ...... 46
VOTRIENT........................ 15
vyfemia 28 day.................. 35
W
warfarin sodium ................ 40
WELCHOL ........................ 19
WELLBUTRIN
see bupropion hcl .......... 25
WELLBUTRIN SR
see bupropion hcl .......... 25
WELLBUTRIN XL
see bupropion hcl .......... 25
WESTCORT
see hydrocortisone
valerate ......................... 49
X
XALATAN
see latanoprost .............. 45
XALKORI .......................... 15
XANAX
see alprazolam tab
0.25mg .......................... 22
see alprazolam tab 0.5mg
...................................... 22
see alprazolam tab 1mg 22
see alprazolam tab 2 mg
...................................... 22
XARELTO ......................... 40
XENAZINE ........................ 31
XGEVA ............................. 37
XIFAXAN .......................... 39
XOLAIR............................. 46
XOPENEX HFA ................ 46
XTANDI............................. 15
xulane dis 150-35 ............. 35
XYLOCAINE
see lidocaine hcl............ 49
see lidocaine hcl (local
anesth.) ........................... 9
see lidocaine inj 1% ........ 9
see lidocaine inj 2% ........ 9
XYLOCAINE-MPF
see lidocaine inj 0.5% ..... 9
see lidocaine inj 1% ........ 9
see lidocaine inj 1.5% ..... 9
XYREM ............................. 32
XYZAL
see levocetirizine
dihydrochloride .............. 46
Y
YASMIN 28
see drospirenone-ethinyl
estradiol ........................ 34
see syeda ...................... 35
see zarah ...................... 35
YAZ
see loryna 28 day .......... 34
see vestura ................... 35
YF-VAX ............................. 42
Z
zafirlukast ......................... 46
ZANAFLEX
see tizanidine hcl........... 31
ZANTAC
see ranitidine hcl ........... 38
see ranitidine hcl inj....... 38
zarah................................. 35
ZARONTIN
see ethosuximide .......... 23
ZAROXOLYN
see metolazone ............. 21
ZAVESCA ......................... 36
zazole ............................... 40
ZAZOLE............................ 40
ZEBETA
see bisoprolol fumarate . 19
ZELBORAF ....................... 15
ZEMAIRA .......................... 46
ZEMPLAR
see paricalcitol .............. 44
zenatane ........................... 47
zenchent 28 day ............... 35
ZENPEP ........................... 39
72
2015 SSI Choice 15301 v6 eff 01/01/2015
ZERIT
see stavudine ................11
ZESTORETIC
see lisinopril &
hydrochlorothiazide .......16
ZESTRIL
see lisinopril...................16
ZETIA ................................19
ZIAC
see bisoprolol &
hydrochlorothiazide .......19
ZIAGEN.............................11
see abacavir sulfate ......10
zidovudine .........................11
ZINACEF
see cefuroxime sodium..12
ZINECARD
see dexrazoxane ...........16
ziprasidone hcl ..................29
ZIRGAN ............................45
ZITHROMAX
see azithromycin ...........12
ZMAX ................................13
ZOCOR
see simvastatin..............19
ZOFRAN
see ondansetron hcl ...... 38
see ondansetron hcl oral
soln................................ 38
ZOFRAN ODT
see ondansetron odt...... 38
zoledronic inj 4mg/5ml ...... 34
ZOLINZA........................... 15
zolmitriptan ....................... 31
zolmitriptan odt ................. 31
ZOLOFT
see sertraline hcl ........... 26
zolpidem tartrate ............... 30
ZOMETA ........................... 34
see zoledronic inj 4mg/5ml
...................................... 34
ZOMIG
see zolmitriptan ............. 31
ZOMIG ZMT
see zolmitriptan odt ....... 31
ZONEGRAN
see zonisamide ............. 25
zonisamide........................ 25
ZORTRESS TAB 0.25MG. 42
ZORTRESS TAB 0.5MG... 42
ZORTRESS TAB 0.75MG 42
ZOSTAVAX ...................... 42
ZOSYN
see piperacillin
sodium-tazobactam
sodium .......................... 13
ZOVIRAX
see acyclovir ................. 11
see acyclovir topical ...... 48
ZYBAN
see buproban ................ 32
ZYKADIA .......................... 15
ZYLET .............................. 44
ZYLOPRIM
see allopurinol tab ........... 7
ZYMAXID
see gatifloxacin (ophth) . 44
ZYPREXA
see olanzapine .............. 28
ZYPREXA ZYDIS
see olanzapine ........ 28, 29
ZYTIGA............................. 15
ZYVOX ............................. 10
73
P.O. Box 52424 Phoenix, AZ 85072-2424
This formulary was updated on November 1, 2014. For more recent information or other questions, please
contact SilverScript at 1-866-235-5660 or, for TTY users, 1-866-236-1069, 24 hours a day, 7 days a week, or
visit www.silverscript.com.
This information is available for free in other languages. Please call our Customer Care number at
1-866-235-5660 (TTY: 1-866-236-1069), 24 hours a day, 7 days a week. Esta información está disponible
gratuitamente en otros idiomas. Llame a nuestro Servicio al Miembro, al 1-866-235-5660 (teléfono de texto
(TTY): 1-866-236-1069), las 24 horas del día, los 7 días de la semana.
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Enrollment in SilverScript depends on contract renewal.