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A nonprofit independent licensee of the Blue Cross Blue Shield Association
Excellus BlueCross BlueShield
Medicare Employer Group Plans
2015 Formulary
(List of Covered Drugs)
PLEASE READ:
THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 1/1/2015. For more recent information or other questions, please
contact Excellus BlueCross BlueShield at 1-800-659-1986 or, for TTY users, 1-800-421-1220,
Monday – Friday, 8:00 a.m. – 8:00 p.m.; From October 1 to February 14, representatives are available
to assist you seven days a week from 8:00 a.m. – 8:00 p.m., or visit ExcellusMedicare.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.
Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan
with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal.
(11/2014)
H3351, H3335
Formulary ID 15378 Ver 13
M-106C Y15
8492-14 Group
When this drug list (formulary) refers to “we”, “us”, or “our,” it means Excellus BlueCross BlueShield. When it
refers to “plan” or “our plan,” it means Excellus BlueCross BlueShield.
This document includes a list of the drugs (formulary) for our plan which is current as of 1/1/2015. 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.
What is the Excellus BlueCross BlueShield Medicare Employer Group
Formulary?
A formulary is a list of covered drugs selected by
our plan 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.
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. 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 1/1/2015. To get updated information
about the drugs covered by our plan, please contact
us. Our contact information appears on the front and
back cover pages. If we make any mid-year nonmaintenance changes to our formulary, we will update
the formulary with any CMS approved changes. We
will notify you of any non-maintenance changes to
your printed formulary 60 days prior to the effective
date of the changes. The updated formulary will be
available on our Web site at ExcellusMedicare.com or
by calling Customer Service at the telephone number
that appears in the contact information on the front
and back cover pages.
If we remove drugs from our formulary, add prior
authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher costsharing tier, we must notify affected members of the
change at least 60 days before the change becomes
M-106C Y15
I
How do I use the Formulary?
Alphabetical Listing
If you are not sure what category to look under, you
should look for your drug in the Index that begins on
page 46. 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.
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 1. 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 Agents.” If you know what your
drug is used for, look for the category name in the
list that begins on page 1. Then look under the
category name for your drug.
What are generic drugs?
Our plan 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:
treat your medical condition, our plan may not cover
Drug B unless you try Drug A first. If Drug A does
not work for you, our plan will then cover Drug B.
• Prior Authorization: Our plan requires you
or your physician to get prior authorization for
certain drugs. This means that you will need to
get approval from our plan before you fill your
prescriptions. If you don’t get approval, our plan
may not cover the drug.
You can find out if your drug has any additional
requirements or limits by looking in the formulary that
begins on page 1. You can also get more information
about the restrictions applied to specific covered
drugs by visiting our Web site. We have posted online
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.
• Quantity Limits: For certain drugs, our plan
limits the amount of the drug that our plan will
cover. For example, our plan provides 30 tablets
per prescription for CRESTOR. This may be
in addition to a standard one–month or
three–month supply.
You can ask our plan 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 Excellus
BlueCross BlueShield Medicare Employer Group
Formulary?” on page III for information about how
to request an exception.
• Step Therapy: In some cases, our plan 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
II
M-106C Y15
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
Service and ask if your drug is covered.
receive the list, show it to your doctor and ask him
or her to prescribe a similar drug that is covered by
our plan.
If you learn that our plan does not cover your drug,
you have two options:
• You can ask our plan to make an exception and
cover your drug. See below for information about
how to request an exception.
• You can ask Customer Service for a list of similar
drugs that are covered by our plan. When you
How do I request an exception to the Excellus BlueCross
BlueShield Medicare Employer Group Formulary?
You can ask our plan to make an exception to our
coverage rules. There are several types of exceptions
that you can ask us to make.
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.
• 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, our plan 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
M-106C Y15
III
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.
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 98-day transition supply,
consistent with 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
31-day emergency supply of that drug (unless you
have a prescription for fewer days) while you pursue
a formulary exception.
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.
Any member experiencing a level of care change,
such as a change in their treatment setting, will
be provided a one time, up to 31-day supply of
medication. This includes emergency supplies of
non-formulary drugs and any Part D drug which
requires prior authorization or step therapy.
For more information
For more detailed information about your Excellus
BlueCross BlueShield prescription drug coverage,
please review your Evidence of Coverage and other
plan materials.
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.
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.
IV
M-106C Y15
Excellus BlueCross BlueShield’s Formulary
The formulary that begins on the next page 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 46.
and generic drugs are listed in lower-case italics
(e.g., atorvastatin).
The information in the Requirements/Limits
column tells you if our plan has any special
requirements for coverage of your drug.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., CRESTOR)
Explanation of Requirements/Limits
PRIOR
AUTHORIZATION
(PA)
Certain medications require prior authorization. This means that you need to get
approval before you fill your prescriptions. If you don’t get approval, the drug may
not be covered.
STEP THERAPY
(STEP)
In some cases, we require 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.
QUANTITY
LIMITS (QL)
For certain drugs, we limit the amount of the drug that we will cover. For example,
we provide 30 tablets per prescription for CRESTOR.
FREE FIRST
FILL for 30 days
(30 Day FFF)
This prescription drug will be provided at zero cost-sharing the first time you fill it.
EXCLUDED PART
D DRUGS (*)
VERIFICATION
FOR PART B OR
PART D (BD)
M-106C Y15
This prescription drug is not normally covered in a Medicare Prescription Drug
Plan. The amount you pay when you fill a prescription for this drug does not count
towards your total drug costs (that is, the amount you pay does not help you qualify
for catastrophic coverage). In addition, if you are receiving extra help to pay for
your prescriptions, you will not get any extra help to pay for this drug.
These medications require prior authorization only to determine whether they
qualify for payment under Part B or Part D.
V
Explanation of Tiers
Specific information on your employer or union’s prescription drug benefit should be obtained directly from your
group administrator or human resources representative.
TIER 1
Typically generic drugs.
TIER 2
Typically preferred brand-name drugs that have unique, significant clinical advantages
and offer overall greater value over the other products in the same drug class.
TIER 3
Typically non-preferred brand-name drugs.
VI
M-106C Y15
Drug Name
Drug Tier Drug Name
ANALGESICS
ABSTRAL TAB SUBL ............................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
acetaminophen-codeine solution...............................1
acetaminophen-codeine tablet ..................................1
ACTIQ LOZENGE HD ............................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
ascomp with codeine capsule....................................1
aspirin-caffeine-dihydrocodein capsule....................1
astramorph-pf vial.....................................................1
BUPRENEX AMPUL...............................................3
buprenorphine hcl syringe ........................................1
buprenorphine hcl tab subl .......................................1
butalb-acetaminoph-caff-codein capsule..................1
butalb-caff-acetaminoph-codein capsule..................1
butalbital compound-codeine capsule ......................1
butalbital-acetaminophen-caffe capsule ...................1
butalbital-acetaminophen-caffe tablet ......................1
butalbital-aspirin-caffeine capsule ...........................1
butorphanol tartrate vial...........................................1
butorphanol tartrate spray........................................1
BUTRANS PATCH TDWK.....................................3
Requirements/Limits: STEP, QL-4 unit(s) per 28 day(s)
codeine sulfate tablet ................................................1
diskets tablet sol ........................................................1
duramorph ampul......................................................1
endocet tablet ............................................................1
endodan tablet...........................................................1
EXALGO TAB ER 24H ...........................................3
Strength: 12 MG, 8 MG
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
EXALGO TAB ER 24H ...........................................3
Strength: 16 MG, 32 MG
Requirements/Limits: STEP, QL-60 unit(s) per 30 day(s)
fentanyl patch td72....................................................1
Requirements/Limits: QL-15 unit(s) per 30 day(s)
fentanyl citrate lozenge hd ........................................1
Strength: 1200 mcg, 1600 mcg, 400 mcg, 600
mcg, 800 mcg
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
fentanyl citrate lozenge hd ........................................1
Strength: 200 mcg
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
FENTORA TABLET EFF ........................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
hydrocodone bit-ibuprofen tablet..............................1
hydrocodone-acetaminophen solution ......................1
hydrocodone-acetaminophen tablet..........................1
Drug Tier
hydrocodone-ibuprofen tablet...................................1
hydromorphone er tab er 24h ...................................1
Strength: 12 mg, 16 mg, 8 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
hydromorphone er tab er 24h ...................................1
Strength: 32 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
hydromorphone hcl ampul ........................................1
hydromorphone hcl tablet .........................................1
hydromorphone hcl liquid.........................................1
hydromorphone hcl syringe ......................................1
hydromorphone hcl vial ............................................1
INFUMORPH AMPUL ............................................3
KADIAN CAP ER PEL............................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
LAZANDA SPRAY/PUMP .....................................3
Requirements/Limits: PA, QL-30 units per 30 day(s)
levorphanol tartrate tablet........................................1
methadone hcl vial ....................................................1
methadone hcl tablet .................................................1
methadone hcl solution .............................................1
methadone intensol oral conc ...................................1
methadose tablet sol..................................................1
morphine sulfate vial.................................................1
morphine sulfate pca vial..........................................1
morphine sulfate tablet .............................................1
morphine sulfate supp.rect........................................1
morphine sulfate cartridge........................................1
morphine sulfate solution..........................................1
morphine sulfate tablet er .........................................1
Requirements/Limits: QL-90 unit(s) per 30 day(s)
morphine sulfate syringe...........................................1
Strength: 2 mg/ml, 8 mg/ml
morphine sulfate oral syringe ...................................1
Strength: 20 mg/ml
morphine sulfate er cap er pel ..................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
morphine sulfate er tablet er.....................................1
Requirements/Limits: QL-90 unit(s) per 30 day(s)
morphine sulfate er cpmp 24hr .................................1
Strength: 120 mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
morphine sulfate er cpmp 24hr .................................1
Strength: 30 mg, 45 mg, 60 mg, 75 mg, 90 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
nalbuphine hcl vial....................................................1
NUCYNTA TABLET...............................................3
Requirements/Limits: QL-180 unit(s) per 30 day(s)
1
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANALGESICS (continued)
NUCYNTA ER TAB ER 12H ..................................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
OPANA ER TAB ER 12H........................................3
Requirements/Limits: STEP, QL-90 unit(s) per 30 day(s)
oxycodone hcl tablet..................................................1
oxycodone hcl capsule ..............................................1
oxycodone hcl oral conc ...........................................1
oxycodone hcl solution..............................................1
oxycodone hcl-acetaminophen tablet........................1
oxycodone hcl-aspirin tablet .....................................1
oxycodone hcl-ibuprofen tablet.................................1
oxycodone-acetaminophen tablet..............................1
OXYCONTIN TAB ER 12H....................................3
Strength: 10 MG, 15 MG, 20 MG, 30 MG, 40
MG, 60 MG
Requirements/Limits: STEP, QL-90 unit(s) per 30 day(s)
OXYCONTIN TAB ER 12H....................................3
Strength: 80 MG
Requirements/Limits: STEP, QL-120 unit(s) per 30
day(s)
oxymorphone hcl tablet.............................................1
oxymorphone hcl er tab er 12h .................................1
Requirements/Limits: QL-90 unit(s) per 30 day(s)
pentazocine-naloxone hcl tablet................................1
roxicet tablet .............................................................1
roxicet solution..........................................................1
SUBSYS SPRAY......................................................3
Requirements/Limits: PA, QL-120 units per 30 day(s)
TALWIN AMPUL....................................................3
tencon tablet ..............................................................1
tramadol hcl tablet ....................................................1
tramadol hcl er cpbp 25-75.......................................1
tramadol hcl er tab er 24h ........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
tramadol hcl-acetaminophen tablet ..........................1
XARTEMIS XR TAB IR ERO.................................3
Requirements/Limits: QL-120 unit(s) per 30 day(s)
zebutal capsule..........................................................1
ZOHYDRO ER CAP ER 12H ..................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
Drug Tier
lidocaine adh. patch..................................................1
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
lidocaine hcl jel/pf app..............................................1
lidocaine hcl ampul...................................................1
Requirements/Limits: PA
lidocaine hcl disp syrin .............................................1
lidocaine hcl jel ........................................................1
lidocaine hcl vial.......................................................1
Strength: 10 mg/ml, 20 mg/ml, 5 mg/ml
Requirements/Limits: PA
lidocaine hcl syringe .................................................1
Strength: 100 mg/5ml
lidocaine hcl vial.......................................................1
Strength: 100 mg/ml
lidocaine hcl solution ................................................1
Strength: 4 %
lidocaine hcl solution ................................................1
Strength: 40 mg/ml
lidocaine hcl viscous solution ...................................1
lidocaine-prilocaine kit .............................................1
Requirements/Limits: PA
lidocaine-prilocaine cream ......................................1
Requirements/Limits: PA
PLIAGLIS CREAM .................................................3
Requirements/Limits: PA
PONTOCAINE SOLUTION ....................................3
Requirements/Limits: PA
SYNERA M.HT PATCH..........................................3
Requirements/Limits: PA
XYLOCAINE VIAL.................................................3
Requirements/Limits: PA
XYLOCAINE-MPF AMPUL ...................................3
Requirements/Limits: PA
XYLOCAINE-MPF VIAL .......................................3
Requirements/Limits: PA
ANTI-ADDICTION, SUBSTANCE ABUSE
TREATMENTS
acamprosate calcium tablet dr..................................1
buprenorphine-naloxone tab subl .............................1
buproban tablet er.....................................................1
bupropion hcl sr tablet er .........................................1
Strength: 150 mg
CHANTIX
TAB DS PK ...........................................2
ANESTHETICS
Requirements/Limits:
QL-336 unit(s) per 365 day(s)
ALCAINE DROPS ...................................................3
EMLA CREAM .......................................................3 CHANTIX TABLET ................................................2
Requirements/Limits: QL-336 unit(s) per 365 day(s)
Requirements/Limits: PA
DEPADE
TABLET...................................................3
lidocaine oint. ...........................................................1
disulfiram
tablet ........................................................1
Requirements/Limits: PA
naloxone hcl syringe .................................................1
2
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTI-ADDICTION, SUBSTANCE ABUSE
TREATMENTS (continued)
naloxone hcl vial .......................................................1
naltrexone hcl tablet..................................................1
NICOTROL CARTRIDGE.......................................3
NICOTROL NS SPRAY ..........................................3
SUBOXONE FILM ..................................................3
VIVITROL SUS ER REC.........................................3
ANTIBACTERIALS
AKNE-MYCIN OINT. ............................................3
ALTABAX OINT. ...................................................3
Requirements/Limits: STEP
amikacin sulfate vial .................................................1
amox tr-potassium clavulanate susp recon...............1
amox tr-potassium clavulanate tab chew..................1
amox tr-potassium clavulanate tablet .......................1
amoxicillin susp recon ..............................................1
amoxicillin capsule ...................................................1
amoxicillin tab chew .................................................1
amoxicillin tablet.......................................................1
amoxicillin-clavulanate er tab er 12h.......................1
ampicillin sodium vial port .......................................1
ampicillin sodium vial...............................................1
ampicillin trihydrate capsule ....................................1
ampicillin trihydrate susp recon ...............................1
ampicillin-sulbactam vial..........................................1
ampicillin-sulbactam vial port ..................................1
AUGMENTIN SUSP RECON .................................3
AVELOX IV PIGGYBACK.....................................3
AZACTAM-ISO-OSMOTIC DEXTROSE
FROZ.PIGGY ...........................................................3
AZASITE DROPS ....................................................3
azithromycin tablet....................................................1
azithromycin susp recon............................................1
azithromycin packet ..................................................1
azithromycin vial.......................................................1
aztreonam vial...........................................................1
baciim vial.................................................................1
bacitracin vial ...........................................................1
bacitracin oint. .........................................................1
bacitracin-polymyxin oint. .......................................1
BESIVANCE DROPS SUSP....................................3
BETHKIS AMPUL-NEB .........................................3
Requirements/Limits: BD
BICILLIN C-R SYRINGE........................................3
BICILLIN L-A SYRINGE........................................3
Drug Tier
CAYSTON VIAL-NEB............................................3
cefaclor susp recon ...................................................1
cefaclor capsule ........................................................1
cefaclor er tab er 12h................................................1
cefadroxil capsule .....................................................1
cefadroxil susp recon ................................................1
cefadroxil tablet ........................................................1
cefazolin piggyback...................................................1
cefazolin sodium bulkbaginj .....................................1
cefazolin sodium vial.................................................1
cefazolin sodium vial port.........................................1
cefdinir capsule.........................................................1
cefdinir susp recon....................................................1
cefepime hcl vial .......................................................1
cefotaxime sodium vial..............................................1
cefotetan vial .............................................................1
cefotetan & dextrose piggyback................................1
cefoxitin vial..............................................................1
cefoxitin sodium piggyback.......................................1
cefpodoxime proxetil tablet.......................................1
cefpodoxime proxetil susp recon...............................1
cefprozil tablet ..........................................................1
cefprozil susp recon ..................................................1
ceftazidime vial .........................................................1
ceftazidime piggyback...............................................1
ceftibuten capsule......................................................1
ceftibuten susp recon.................................................1
CEFTIN SUSP RECON ...........................................3
CEFTRIAXONE FROZ.PIGGY ..............................3
CEFTRIAXONE VIAL PORT .................................3
ceftriaxone vial..........................................................1
CEFUROXIME PIGGYBACK ................................3
cefuroxime tablet.......................................................1
cefuroxime sodium vial .............................................1
centany oint. .............................................................1
centany at kit .............................................................1
cephalexin susp recon ...............................................1
cephalexin tablet .......................................................1
cephalexin capsule ....................................................1
CETRAXAL DROPERETTE...................................3
chloramphenicol sod succinate vial..........................1
CILOXAN OINT. ....................................................3
CIPRO SUS MC REC ..............................................3
ciprofloxacin sus mc rec ...........................................1
ciprofloxacin vial ......................................................1
ciprofloxacin er tbmp 24hr .......................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
ciprofloxacin hcl opth drops .....................................1
3
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIBACTERIALS (continued)
ciprofloxacin hcl tablet .............................................1
ciprofloxacin hcl otic droperette...............................1
ciprofloxacin-d5w piggyback ....................................1
clarithromycin tablet.................................................1
clarithromycin susp recon.........................................1
clarithromycin er tab er 24h .....................................1
CLEOCIN SUPP.VAG .............................................3
CLINDACIN ETZ KIT.............................................3
CLINDACIN P MED. SWAB ..................................3
CLINDAGEL GEL ..................................................3
clindamycin hcl capsule ............................................1
clindamycin palmitate hcl soln recon .......................1
clindamycin phosphate vial port ...............................1
clindamycin phosphate med. swab............................1
clindamycin phosphate cream/appl ..........................1
clindamycin phosphate lotion ...................................1
clindamycin phosphate gel .......................................1
clindamycin phosphate foam.....................................1
clindamycin phosphate solution................................1
clindamycin phosphate-d5w piggyback ....................1
CLINDESSE CRM ER ............................................3
colistimethate sodium vial.........................................1
CORTISPORIN CREAM ........................................3
CUBICIN VIAL........................................................3
Requirements/Limits: PA
demeclocycline hcl tablet ..........................................1
dicloxacillin sodium capsule.....................................1
DIFICID TABLET....................................................3
Requirements/Limits: QL-20 unit(s) per 10 day(s)
DORIBAX VIAL ......................................................3
doxy 100 vial .............................................................1
doxycycline hyclate capsule ......................................1
doxycycline hyclate capsule dr .................................1
doxycycline hyclate tablet .........................................1
doxycycline hyclate tablet dr.....................................1
doxycycline monohydrate capsule ............................1
doxycycline monohydrate susp recon .......................1
doxycycline monohydrate tablet................................1
doxy-lemmon capsule................................................1
doxy-lemmon tablet ...................................................1
E.E.S. 200 SUSP RECON ........................................3
e.e.s. 400 tablet .........................................................1
ery med. swab............................................................1
ERYGEL GEL .........................................................3
ERYPED 200 SUSP RECON ...................................3
ERYPED 400 SUSP RECON ...................................3
Drug Tier
ery-tab tablet dr ........................................................1
ERYTHROCIN LACTOBIONATE VIAL PORT ...3
ERYTHROCIN STEARATE TABLET ...................3
erythromycin gel ......................................................1
erythromycin med. swab ...........................................1
erythromycin oint. ....................................................1
erythromycin solution ...............................................1
erythromycin tablet ...................................................1
erythromycin capsule dr............................................1
erythromycin ethylsuccinate susp recon ...................1
erythromycin ethylsuccinate tablet ...........................1
erythromycin-sulfisoxazole susp recon .....................1
EVOCLIN FOAM.....................................................3
FACTIVE TABLET .................................................3
FLAGYL ER TABLET ER ......................................3
FLOXIN DROPERETTE .........................................3
FORTAZ VIAL.........................................................3
gatifloxacin drops .....................................................1
Requirements/Limits: QL-5 mL(s) per 25 day(s)
gentak oint. ...............................................................1
gentamicin sulfate vial ..............................................1
gentamicin sulfate drops ...........................................1
gentamicin sulfate cream .........................................1
gentamicin sulfate oint. ............................................1
Strength: 0.1 %
gentamicin sulfate in ns piggyback ...........................1
imipenem-cilastatin sodium vial ...............................1
INVANZ VIAL PORT..............................................3
INVANZ VIAL.........................................................3
kanamycin sulfate vial...............................................1
KETEK TABLET .....................................................3
lansoprazol-amoxicil-clarithro combo. pkg..............1
Requirements/Limits: QL-112 unit(s) per 30 day(s)
levofloxacin tablet .....................................................1
levofloxacin drops .....................................................1
levofloxacin solution .................................................1
levofloxacin vial ........................................................1
levofloxacin-d5w piggyback......................................1
LINCOCIN VIAL .....................................................3
MACROBID CAPSULE ..........................................3
Requirements/Limits: QL-90 unit(s) per 365 day(s)
MACRODANTIN CAPSULE..................................3
Requirements/Limits: QL-90 unit(s) per 365 day(s)
mafenide acetate packet ............................................1
MERREM VIAL.......................................................3
methenamine hippurate tablet...................................1
methenamine mandelate tablet..................................1
metronidazole capsule...............................................1
4
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIBACTERIALS (continued)
metronidazole gel .....................................................1
metronidazole gel w/appl ..........................................1
metronidazole lotion .................................................1
metronidazole tablet..................................................1
metronidazole cream ................................................1
metronidazole piggyback ..........................................1
METRYL TABLET..................................................3
minocycline hcl capsule ............................................1
minocycline hcl tablet ...............................................1
minocycline hcl tab er 24h ........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
MONUROL PACKET..............................................3
MOXATAG TBMP 24HR........................................3
MOXEZA DROPS VISC..........................................3
moxifloxacin hcl tablet ..............................................1
mupirocin cream ......................................................1
mupirocin oint. .........................................................1
NAFCILL IN DEXTROSE PIGGYBACK ..............3
nafcillin sodium vial port ..........................................1
nafcillin sodium vial..................................................1
nallpen-iso-osmotic dextrose froz.piggy ...................1
neomycin sulfate tablet..............................................1
neomycin-bacitracin-poly-hc oint. ...........................1
neomycin-bacitracin-polymyxin oint. .......................1
neomycin-polymyxin b ampul....................................1
neomycin-polymyxin-gramicidin drops.....................1
neomycin-polymyxin-hc drops susp ..........................1
Strength: 3.5-10k-10
neo-polycin oint. .......................................................1
NEO-SYNALAR CREAM ......................................3
nitrofurantoin oral susp ............................................1
Requirements/Limits: QL-1800 mL(s) per 365 day(s)
nitrofurantoin capsule...............................................1
Requirements/Limits: QL-90 unit(s) per 365 day(s)
NORITATE CREAM ..............................................3
NOROXIN TABLET................................................3
ofloxacin tablet..........................................................1
ofloxacin opth drops..................................................1
Strength: 0.3 %
ofloxacin otic drops...................................................1
Strength: 0.3 %
ORACEA CPMP 24HR ............................................3
OXACILLIN FROZ.PIGGY ....................................3
oxacillin sodium vial .................................................1
paromomycin sulfate capsule....................................1
PCE TAB PART .......................................................3
Drug Tier
penicillin g potassium vial ........................................1
penicillin g potassium in d5w piggyback ..................1
penicillin g procaine syringe ....................................1
penicillin g sodium vial.............................................1
penicillin gk-iso-osm dextrose froz.piggy .................1
penicillin v potassium tablet .....................................1
penicillin v potassium soln recon..............................1
PFIZERPEN VIAL ...................................................3
piperacillin-tazobactam vial .....................................1
polymyxin b sulfate vial ............................................1
polymyxin b sul-trimethoprim drops .........................1
PRIMAXIN I.M. VIAL ............................................3
PRIMSOL SOLUTION ............................................3
silver sulfadiazine cream .........................................1
SIVEXTRO VIAL ....................................................3
Requirements/Limits: PA, QL-6 mL(s) per 6 day(s)
SIVEXTRO TABLET ..............................................3
Requirements/Limits: PA, QL-6 unit(s) per 6 day(s)
SOLODYN TAB ER 24H ........................................3
Strength: 105 MG, 115MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
SOLODYN TAB ER 24H ........................................3
Strength: 55 MG, 65 MG, 80 MG
SPECTRACEF TABLET .........................................3
ssd cream .................................................................1
streptomycin sulfate vial ...........................................1
sulfacetamide sodium drops......................................1
sulfadiazine tablet .....................................................1
sulfamethoxazole/trimethoprim tablet ......................1
sulfamethoxazole-trimethoprim vial .........................1
sulfamethoxazole-trimethoprim tablet ......................1
sulfamethoxazole-trimethoprim oral susp.................1
SULFAMYLON CREAM .......................................3
SUPRAX TAB CHEW .............................................3
SUPRAX SUSP RECON..........................................3
SUPRAX CAPSULE ................................................3
SYNERCID VIAL ....................................................3
tazicef vial port .........................................................1
Strength: 1 g
TAZICEF VIAL PORT ............................................3
Strength: 2 G
TAZICEF VIAL........................................................3
Strength: 2 G
tazicef vial .................................................................1
Strength: 6g
tazicef in dextrose froz.piggy ....................................1
Strength: 1g/50ml
TAZICEF IN DEXTROSE FROZ.PIGGY...............3
Strength: 2G/50ML
5
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIBACTERIALS (continued)
TEFLARO VIAL ......................................................3
tetracycline hcl capsule.............................................1
thermazene cream ....................................................1
TIMENTIN VIAL.....................................................3
TOBI AMPUL-NEB .................................................3
Requirements/Limits: BD
TOBI PODHALER CAP W/DEV ............................3
tobramycin ampul-neb ..............................................1
Requirements/Limits: BD
tobramycin sulfate vial..............................................1
tobramycin sulfate drops...........................................1
tobramycin sulfate in ns piggyback...........................1
TOBREX OINT. ......................................................3
trimethoprim tablet ...................................................1
TYGACIL VIAL.......................................................3
VANCOCIN HCL CAPSULE..................................3
vancomycin hcl vial...................................................1
Requirements/Limits: PA
VANCOMYCIN HCL FROZ.PIGGY......................3
vancomycin hcl capsule ............................................1
VIBATIV VIAL........................................................3
VIBRAMYCIN SYRUP ...........................................3
VIGAMOX DROPS .................................................3
XIFAXAN TABLET ................................................3
Strength: 200 MG
XIFAXAN TABLET ................................................3
Strength: 550 MG
ZINACEF FROZ.PIGGY .........................................3
ZINACEF ISO-OSMOTIC DEXTROSE
FROZ.PIGGY ...........................................................3
ZMAX SUS ER REC................................................3
ZOSYN FROZ.PIGGY.............................................3
ZYVOX IV SOLN ....................................................3
Requirements/Limits: PA
ZYVOX TABLET ....................................................3
Requirements/Limits: PA, QL-20 unit(s) per 10 day(s)
ZYVOX SUSP RECON............................................3
Requirements/Limits: PA, QL-600 mL(s) per 10 day(s)
ANTICONVULSANTS
APTIOM TABLET ...................................................3
Strength: 200 MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
APTIOM TABLET ...................................................3
Strength: 400 MG, 800 MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
Drug Tier
APTIOM TABLET ...................................................3
Strength: 600 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
BANZEL ORAL SUSP ............................................3
Requirements/Limits: QL-2400 mL(s) per 30 day(s)
BANZEL TABLET...................................................3
Strength: 200 MG
Requirements/Limits: QL-480 unit(s) per 30 day(s)
BANZEL TABLET...................................................3
Strength: 400 MG
Requirements/Limits: QL-240 unit(s) per 30 day(s)
carbamazepine tablet ................................................1
carbamazepine tab chew...........................................1
carbamazepine oral susp ..........................................1
carbamazepine cpmp 12hr ........................................1
carbamazepine er tab er 12h ....................................1
carbamazepine xr tab er 12h ....................................1
CELONTIN CAPSULE............................................3
clonazepam tab rapdis ..............................................1
clonazepam tablet .....................................................1
clorazepate dipotassium tablet .................................1
DEPACON VIAL .....................................................3
DEPAKENE CAPSULE...........................................3
DEPAKENE SOLUTION.........................................3
DEPAKOTE TABLET DR.......................................3
DEPAKOTE ER TAB ER 24H ................................3
DEPAKOTE SPRINKLE CAP SPRINK .................3
DILANTIN TAB CHEW..........................................3
DILANTIN CAPSULE.............................................3
DILANTIN-125 ORAL SUSP..................................3
divalproex sodium cap sprink ...................................1
divalproex sodium tablet dr ......................................1
divalproex sodium er tab er 24h ...............................1
epitol tablet ...............................................................1
ethosuximide solution................................................1
ethosuximide capsule ................................................1
felbamate oral susp ...................................................1
felbamate tablet.........................................................1
Strength: 400 mg
felbamate tablet.........................................................1
Strength: 600 mg
FELBATOL TABLET..............................................3
FELBATOL ORAL SUSP........................................3
fosphenytoin sodium vial...........................................1
FYCOMPA TABLET ...............................................3
gabapentin tablet ......................................................1
gabapentin solution...................................................1
gabapentin capsule ...................................................1
6
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTICONVULSANTS (continued)
GABITRIL TABLET................................................3
GRALISE TAB ER 24H...........................................3
Strength: 300 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
GRALISE TAB ER 24H...........................................3
Strength: 300-600 MG
Requirements/Limits: PA
GRALISE TAB ER 24H...........................................3
Strength: 600 MG
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
HORIZANT TABLET ER........................................3
Strength: 300 MG
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
HORIZANT TABLET ER........................................3
Strength: 600 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
KEPPRA TABLET ...................................................3
KEPPRA SOLUTION ..............................................3
KEPPRA VIAL.........................................................3
KEPPRA XR TAB ER 24H......................................3
LAMICTAL ODT TAB RAPDIS.............................3
Requirements/Limits: STEP
LAMICTAL ODT (BLUE) TB RD DSPK...............3
Requirements/Limits: STEP
LAMICTAL ODT (GREEN) TB RD DSPK............3
Requirements/Limits: STEP
LAMICTAL ODT (ORANGE) TB RD DSPK.........3
Requirements/Limits: STEP
lamotrigine tab ds pk.................................................1
lamotrigine tb chw dsp..............................................1
lamotrigine tablet......................................................1
lamotrigine er tab er 24 ............................................1
levetiracetam vial......................................................1
levetiracetam tablet...................................................1
levetiracetam solution ...............................................1
levetiracetam er tab er 24h .......................................1
Strength: 500 mg
Requirements/Limits: QL-180 unit(s) per 30 day(s)
levetiracetam er tab er 24h .......................................1
Strength: 750 mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
levetiracetam-nacl piggyback ...................................1
LYRICA SOLUTION...............................................2
ONFI ORAL SUSP...................................................3
ONFI TABLET .........................................................3
oxcarbazepine oral susp............................................1
oxcarbazepine tablet .................................................1
Drug Tier
OXTELLAR XR TAB ER 24H................................3
PEGANONE TABLET.............................................3
phenobarbital elixir ..................................................1
Requirements/Limits: PA
phenobarbital tablet..................................................1
Requirements/Limits: PA
PHENYTEK CAPSULE...........................................3
phenytoin tab chew ...................................................1
phenytoin oral susp ...................................................1
phenytoin sodium vial ...............................................1
phenytoin sodium syringe .........................................1
phenytoin sodium extended capsule..........................1
POTIGA TABLET....................................................3
Requirements/Limits: QL-90 unit(s) per 30 day(s)
primidone tablet ........................................................1
QUDEXY XR CAP SPR 24 .....................................3
Strength: 100 MG, 25 MG, 50 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
QUDEXY XR CAP SPR 24 .....................................3
Strength: 150 MG, 200 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
SABRIL POWD PACK............................................3
Requirements/Limits: PA, QL-180 unit(s) per 30 day(s)
SABRIL TABLET ....................................................3
Requirements/Limits: PA, QL-180 unit(s) per 30 day(s)
STAVZOR CAPSULE DR.......................................3
TEGRETOL TABLET..............................................3
TEGRETOL ORAL SUSP .......................................3
TEGRETOL XR TAB ER 12H ................................3
tiagabine hcl tablet ...................................................1
TOPAMAX CAP SPRINK.......................................3
TOPAMAX TABLET ..............................................3
topiragen tablet.........................................................1
topiramate cap sprink ...............................................1
topiramate tablet.......................................................1
TOPIRAMATE ER CAP SPR 24.............................3
Strength: 100 MG, 25 MG, 50 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
TOPIRAMATE ER CAP SPR 24.............................3
Strength: 150 MG, 200 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
TRILEPTAL ORAL SUSP.......................................3
TROKENDI XR CAP ER 24H.................................3
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
valproate sodium vial................................................1
valproic acid solution ...............................................1
valproic acid capsule ................................................1
VIMPAT VIAL.........................................................3
VIMPAT SOLUTION ..............................................3
7
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTICONVULSANTS (continued)
VIMPAT TABLET ...................................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ZARONTIN CAPSULE ...........................................3
ZARONTIN SOLUTION .........................................3
zonisamide capsule ...................................................1
ANTIDEMENTIA AGENTS
donepezil hcl tablet ...................................................1
Strength: 10 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
donepezil hcl tablet ...................................................1
Strength: 23 mg, 5 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
donepezil hcl odt tab rapdis ......................................1
Strength: 10 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
donepezil hcl odt tab rapdis ......................................1
Strength: 5 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
ergoloid mesylates tab subl.......................................1
ergoloid mesylates tablet ..........................................1
EXELON PATCH TD24 ..........................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
galantamine hbr tablet ..............................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
galantamine hbr cap24h pel .....................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
galantamine hydrobromide solution .........................1
NAMENDA SOLUTION .........................................2
Requirements/Limits: QL-360 mL(s) per 30 day(s)
NAMENDA XR CAP SPR 24..................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
NAMENDA XR CAP24 DSPK................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
rivastigmine capsule .................................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ANTIDEPRESSANTS
amitriptyline hcl tablet ..............................................1
amoxapine tablet .......................................................1
APLENZIN TAB ER 24H ........................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
BRINTELLIX TABLET...........................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
bupropion hcl tablet ..................................................1
bupropion hcl sr tablet er..........................................1
Strength: 100 mg,150 mg, 200 mg
bupropion xl tab er 24h.............................................1
Drug Tier
citalopram hbr tablet ................................................1
Requirements/Limits: 30 Day FFF
citalopram hbr solution.............................................1
clomipramine hcl capsule .........................................1
desipramine hcl tablet...............................................1
desvenlafaxine er tab er 24 ......................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
DESVENLAFAXINE ER TAB ER 24H .................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
DESVENLAFAXINE FUMARATE ER TAB ER 24
3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
doxepin hcl oral conc................................................1
doxepin hcl capsule...................................................1
duloxetine hcl capsule dr ..........................................1
Strength: 20 mg, 60 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
duloxetine hcl capsule dr ..........................................1
Strength: 30 mg
Requirements/Limits: QL-90 unit(s) per 30 day(s)
EMSAM PATCH TD24 ...........................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
escitalopram oxalate solution ...................................1
escitalopram oxalate tablet.......................................1
FETZIMA CAP SA 24H ..........................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
FETZIMA CAP24HDSPK .......................................3
Requirements/Limits: QL-28 unit(s) per 28 day(s)
fluoxetine dr capsule dr.............................................1
Requirements/Limits: QL-8 unit(s) per 28 day(s)
fluoxetine hcl solution ...............................................1
fluoxetine hcl capsule................................................1
Requirements/Limits: 30 Day FFF
fluoxetine hcl tablet...................................................1
Strength: 10 mg, 20 mg
Requirements/Limits: 30 Day FFF
fluoxetine hcl tablet...................................................1
Strength: 60 mg
fluvoxamine maleate cap er 24h ...............................1
fluvoxamine maleate tablet .......................................1
imipramine hcl tablet ................................................1
IMIPRAMINE PAMOATE CAPSULE ...................3
maprotiline hcl tablet ................................................1
MARPLAN TABLET...............................................3
mirtazapine tab rapdis ..............................................1
mirtazapine tablet .....................................................1
Requirements/Limits: 30 Day FFF
nefazodone hcl tablet ................................................1
nortriptyline hcl solution...........................................1
8
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIDEPRESSANTS (continued)
nortriptyline hcl capsule ...........................................1
OLEPTRO ER TAB ER 24H....................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
paroxetine hcl tab er 24h ..........................................1
paroxetine hcl tablet..................................................1
PAXIL ORAL SUSP ................................................3
Requirements/Limits: STEP
PEXEVA TABLET...................................................3
Requirements/Limits: STEP
phenelzine sulfate tablet............................................1
PRISTIQ ER TAB ER 24H ......................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
protriptyline hcl tablet ..............................................1
SARAFEM TABLET ...............................................3
Requirements/Limits: STEP
sertraline hcl oral conc .............................................1
sertraline hcl tablet ...................................................1
SURMONTIL CAPSULE.........................................3
tranylcypromine sulfate tablet ..................................1
trazodone hcl tablet...................................................1
venlafaxine hcl tablet ................................................1
venlafaxine hcl er cap er 24h....................................1
Strength: 150 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
venlafaxine hcl er cap er 24h....................................1
Strength: 37.5 mg, 75 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
VIIBRYD TAB DS PK.............................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
VIIBRYD TABLET..................................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
ANTIEMETICS
ALOXI VIAL............................................................3
CESAMET CAPSULE .............................................3
Requirements/Limits: QL-120 unit(s) per 30 day(s)
compro supp.rect.......................................................1
dronabinol capsule....................................................1
Strength: 10 mg
dronabinol capsule....................................................1
Strength: 2.5 mg, 5 mg
EMEND CAP DS PK ...............................................3
Requirements/Limits: BD, QL-2 packs per 30 day(s)
EMEND CAPSULE..................................................3
Strength: 125 MG
Requirements/Limits: BD, QL-2 unit(s) per 30 day(s)
Drug Tier
EMEND CAPSULE..................................................3
Strength: 40 MG, 80 MG
Requirements/Limits: BD, QL-4 unit(s) per 30 day(s)
granisetron hcl vial ...................................................1
Requirements/Limits: QL-60 mL(s) per 30 day(s)
granisetron hcl tablet................................................1
Requirements/Limits: BD, QL-60 unit(s) per 30 day(s)
granisol solution .......................................................1
Requirements/Limits: BD, QL-300 mL(s) per 30 day(s)
KYTRIL VIAL .........................................................3
Requirements/Limits: STEP, QL-60 mL(s) per 30 day(s)
MARINOL CAPSULE .............................................3
meclizine hcl tablet ...................................................1
metoclopramide hcl solution.....................................1
metoclopramide hcl tablet.........................................1
metoclopramide hcl vial............................................1
METOCLOPRAMIDE HCL INTENSOL ORAL
CONC. ......................................................................3
METOZOLV ODT TAB RAPDIS ...........................3
Requirements/Limits: STEP
ondansetron hcl solution...........................................1
Requirements/Limits: BD
ondansetron hcl vial..................................................1
ondansetron hcl tablet...............................................1
Strength: 24 mg
Requirements/Limits: BD, QL-30 unit(s) per 30 day(s)
ondansetron hcl tablet...............................................1
Strength: 4 mg
Requirements/Limits: BD, QL-90 unit(s) per 30 day(s)
ondansetron hcl tablet...............................................1
Strength: 8 mg
Requirements/Limits: BD, QL-120 unit(s) per 30 day(s)
ondansetron odt tab rapdis .......................................1
Strength: 4 mg
Requirements/Limits: BD, QL-90 unit(s) per 30 day(s)
ondansetron odt tab rapdis .......................................1
Strength: 8 mg
Requirements/Limits: BD, QL-120 unit(s) per 30 day(s)
phenadoz supp.rect ...................................................1
promethazine hcl syrup .............................................1
promethazine hcl vial................................................1
promethazine hcl ampul............................................1
promethazine hcl tablet.............................................1
promethegan supp.rect..............................................1
Strength: 25 mg, 50 mg
SANCUSO PATCH TDWK.....................................3
Requirements/Limits: STEP, QL-4 unit(s) per 28 day(s)
TRANSDERM-SCOP PATCH TD72 ......................3
trimethobenzamide hcl vial .......................................1
9
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIEMETICS (continued)
trimethobenzamide hcl capsule.................................1
Requirements/Limits: BD
ZUPLENZ FILM ......................................................3
Strength: 4 MG
Requirements/Limits: BD, STEP, QL-90 unit(s) per 30
day(s)
ZUPLENZ FILM ......................................................3
Strength: 8 MG
Requirements/Limits: BD, STEP, QL-120 unit(s) per 30
day(s)
ANTIFUNGALS
ABELCET VIAL ......................................................3
Requirements/Limits: BD
AMBISOME VIAL...................................................3
Requirements/Limits: BD
amphotericin b vial ...................................................1
Requirements/Limits: BD
CANCIDAS VIAL....................................................3
CICLODAN COMBO. PKG ....................................3
Requirements/Limits: STEP
CICLODAN CREAM ..............................................3
Requirements/Limits: STEP
CICLODAN SOLUTION .........................................3
Requirements/Limits: STEP
ciclopirox cream ......................................................1
ciclopirox suspension................................................1
ciclopirox solution.....................................................1
ciclopirox shampoo ...................................................1
ciclopirox gel ............................................................1
clotrimazole troche ...................................................1
clotrimazole cream ...................................................1
clotrimazole solution.................................................1
clotrimazole-betamethasone lotion ...........................1
clotrimazole-betamethasone cream .........................1
econazole nitrate cream ...........................................1
ECOZA FOAM.........................................................3
Requirements/Limits: STEP
ERAXIS (WATER DILUENT) VIAL .....................3
ERTACZO CREAM ................................................3
Requirements/Limits: STEP
EXELDERM SOLUTION........................................3
Requirements/Limits: STEP
EXELDERM CREAM .............................................3
Requirements/Limits: STEP
EXTINA FOAM .......................................................3
Requirements/Limits: STEP
Drug Tier
fluconazole susp recon ..............................................1
fluconazole tablet ......................................................1
fluconazole in saline piggyback ................................1
flucytosine capsule ....................................................1
GRIFULVIN V TABLET.........................................3
griseofulvin tablet .....................................................1
griseofulvin oral susp................................................1
griseofulvin ultramicrosize tablet .............................1
itraconazole capsule .................................................1
JUBLIA SOL W/APPL.............................................3
Requirements/Limits: PA, QL-8 mL(s) per 30 day(s)
ketoconazole cream ..................................................1
ketoconazole tablet....................................................1
ketoconazole shampoo ..............................................1
KETODAN COMBO. PKG......................................3
Requirements/Limits: STEP
KETODAN FOAM...................................................3
Requirements/Limits: STEP
LAMISIL GRAN PACK ..........................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
LUZU CREAM ........................................................3
Requirements/Limits: STEP
MENTAX CREAM .................................................3
Requirements/Limits: STEP
miconazole 3 supp.vag ..............................................1
MYCAMINE VIAL..................................................3
NAFTIN CREAM ....................................................3
Requirements/Limits: STEP
NAFTIN GEL ..........................................................3
Requirements/Limits: STEP
NATACYN DROPS SUSP.......................................3
NOXAFIL VIAL.......................................................3
NOXAFIL TABLET DR ..........................................3
NOXAFIL ORAL SUSP...........................................3
nyamyc powder .........................................................1
nystatin cream ..........................................................1
nystatin oint. .............................................................1
nystatin oral susp ......................................................1
nystatin powder .........................................................1
nystatin tablet............................................................1
nystatin-triamcinolone oint. .....................................1
nystatin-triamcinolone cream ..................................1
nystop powder ...........................................................1
ONMEL TABLET ....................................................3
Requirements/Limits: STEP
OXISTAT CREAM .................................................3
Requirements/Limits: STEP
OXISTAT LOTION..................................................3
Requirements/Limits: STEP
10
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIFUNGALS (continued)
pedi-dri powder.........................................................1
SPORANOX CAPSULE ..........................................3
Requirements/Limits: STEP
SPORANOX SOLUTION ........................................3
Requirements/Limits: STEP
terbinafine hcl tablet .................................................1
terconazole cream/appl.............................................1
terconazole supp.vag.................................................1
VFEND SUSP RECON ............................................3
Requirements/Limits: STEP
VFEND TABLET .....................................................3
Requirements/Limits: STEP
VFEND IV VIAL......................................................3
Requirements/Limits: STEP
voriconazole susp recon............................................1
voriconazole vial .......................................................1
voriconazole tablet....................................................1
VUSION OINT. .......................................................3
XOLEGEL GEL ......................................................3
Requirements/Limits: STEP
zazole cream/appl .....................................................1
ANTIGOUT AGENTS
allopurinol tablet ......................................................1
Requirements/Limits: 30 Day FFF
allopurinol sodium vial .............................................1
COLCRYS TABLET................................................2
probenecid tablet.......................................................1
probenecid-colchicine tablet.....................................1
ULORIC TABLET ...................................................2
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
ANTI-INFLAMMATORY AGENTS
CALDOLOR VIAL ..................................................3
CELEBREX CAPSULE ...........................................3
Requirements/Limits: STEP, QL-60 unit(s) per 30 day(s)
comfort pac-ibuprofen kit..........................................1
comfort pac-meloxicam kit........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
comfort pac-naproxen kit ..........................................1
diclofenac potassium tablet.......................................1
diclofenac sodium tablet dr.......................................1
diclofenac sodium drops ...........................................1
Strength: 1.5 %
diclofenac sodium er tab er 24h................................1
diclofenac sodium-misoprostol tab ir dr...................1
diflunisal tablet .........................................................1
Drug Tier
DUEXIS TABLET....................................................3
Requirements/Limits: QL-90 unit(s) per 30 day(s)
etodolac tablet...........................................................1
etodolac capsule........................................................1
etodolac er tab er 24h ...............................................1
fenoprofen calcium tablet .........................................1
FENOPROFEN CALCIUM CAPSULE...................3
Requirements/Limits: STEP
FLECTOR PATCH TD12 ........................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
flurbiprofen tablet .....................................................1
ibuprofen oral susp ...................................................1
ibuprofen tablet.........................................................1
indomethacin capsule er ...........................................1
Requirements/Limits: PA
indomethacin capsule................................................1
Requirements/Limits: PA
ketoprofen capsule ....................................................1
ketoprofen cap24h pel...............................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
ketorolac tromethamine tablet ..................................1
Requirements/Limits: QL-20 unit(s) per 30 day(s)
meclofenamate sodium capsule.................................1
MELOXICAM ORAL SUSP ...................................3
Requirements/Limits: QL-300 mL(s) per 30 day(s)
meloxicam tablet .......................................................1
Strength: 15 mg
Requirements/Limits: 30 Day FFF, QL-30 unit(s) per 30
day(s)
meloxicam tablet .......................................................1
Strength: 7.5 mg
Requirements/Limits: 30 Day FFF, QL-60 unit(s) per 30
day(s)
nabumetone tablet .....................................................1
NALFON CAPSULE................................................3
Requirements/Limits: STEP
NAPRELAN TBMP 24HR.......................................3
Requirements/Limits: STEP
NAPRELAN TABLET ER.......................................3
Requirements/Limits: STEP
naproxen tablet dr.....................................................1
Requirements/Limits: 30 Day FFF
naproxen tablet .........................................................1
Requirements/Limits: 30 Day FFF
naproxen oral susp....................................................1
naproxen sodium tablet.............................................1
oxaprozin tablet ........................................................1
phenylbutazone tablet ...............................................1
piroxicam capsule .....................................................1
11
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTI-INFLAMMATORY AGENTS
(continued)
salsalate tablet ..........................................................1
SPRIX SPRAY .........................................................3
Requirements/Limits: STEP
sulindac tablet ...........................................................1
tolmetin sodium capsule............................................1
tolmetin sodium tablet ...............................................1
VIMOVO TAB IR DR..............................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
VOLTAREN GEL ...................................................3
ZIPSOR CAPSULE ..................................................3
Requirements/Limits: STEP
ZORVOLEX CAPSULE ..........................................3
Requirements/Limits: STEP
ANTIMIGRAINE AGENTS
ALSUMA PEN INJCTR...........................................3
Requirements/Limits: STEP, QL-6 mL(s) per 30 day(s)
AXERT TABLET .....................................................3
Strength: 12.5 MG
Requirements/Limits: STEP, QL-12 unit(s) per 1 day(s)
AXERT TABLET .....................................................3
Strength: 6.25 MG
Requirements/Limits: STEP, QL-12 unit(s) per 30 day(s)
CAFERGOT TABLET .............................................3
Requirements/Limits: QL-40 unit(s) per 1 day(s)
D.H.E.45 AMPUL ....................................................3
dihydroergotamine mesylate ampul ..........................1
dihydroergotamine mesylate spray/pump .................1
ERGOMAR TAB SUBL ..........................................3
Requirements/Limits: QL-20 unit(s) per 28 day(s)
ergotamine-caffeine tablet ........................................1
Requirements/Limits: QL-40 unit(s) per 1 day(s)
FROVA TABLET.....................................................3
Requirements/Limits: STEP, QL-18 unit(s) per 1 day(s)
INNOPRAN XL CAP ER 24H.................................3
MIGRANAL SPRAY/PUMP ...................................3
Requirements/Limits: QL-8 mL(s) per 28 day(s)
naratriptan hcl tablet ................................................1
Requirements/Limits: QL-18 unit(s) per 30 day(s)
propranolol hcl cap sa 24h .......................................1
RELPAX TABLET...................................................3
Requirements/Limits: STEP, QL-12 unit(s) per 30 day(s)
rizatriptan tab rapdis ................................................1
Requirements/Limits: QL-24 unit(s) per 30 day(s)
rizatriptan tablet .......................................................1
Requirements/Limits: QL-24 unit(s) per 30 day(s)
Drug Tier
sumatriptan spray .....................................................1
Strength: 20 mg
Requirements/Limits: QL-12 units per 30 day(s)
sumatriptan spray .....................................................1
Strength: 5 mg
Requirements/Limits: QL-18 units per 30 day(s)
sumatriptan succinate pen injctr...............................1
Requirements/Limits: QL-10 mL(s) per 30 day(s)
sumatriptan succinate vial ........................................1
Requirements/Limits: QL-10 mL(s) per 30 day(s)
sumatriptan succinate cartridge ...............................1
Requirements/Limits: QL-10 unit(s) per 30 day(s)
sumatriptan succinate tablet .....................................1
Strength: 100 mg
Requirements/Limits: QL-9 unit(s) per 30 day(s)
sumatriptan succinate tablet .....................................1
Strength: 25 mg, 50 mg
Requirements/Limits: QL-18 unit(s) per 30 day(s)
SUMAVEL DOSEPRO NDL FR INJ ......................3
Requirements/Limits: STEP, QL-5 unit(s) per 30 day(s)
timolol maleate tablet ...............................................1
TREXIMET TABLET ..............................................3
Requirements/Limits: STEP, QL-9 unit(s) per 1 day(s)
zolmitriptan tablet .....................................................1
Requirements/Limits: QL-12 unit(s) per 30 day(s)
zolmitriptan odt tab rapdis........................................1
Requirements/Limits: QL-12 unit(s) per 30 day(s)
ZOMIG SPRAY........................................................3
Requirements/Limits: STEP, QL-12 units per 30 day(s)
ANTIMYASTHENIC AGENTS
GUANIDINE HCL TABLET...................................3
MESTINON TABLET ER........................................3
MESTINON SYRUP ................................................3
pyridostigmine bromide tablet ..................................1
REGONOL AMPUL.................................................3
ANTIMYCOBACTERIALS
CAPASTAT SULFATE VIAL.................................3
cycloserine capsule ...................................................1
dapsone tablet ...........................................................1
ethambutol hcl tablet.................................................1
isoniazid solution ......................................................1
isoniazid vial .............................................................1
isoniazid tablet ..........................................................1
PASER PACKET......................................................3
PRIFTIN TABLET ...................................................3
pyrazinamide tablet...................................................1
rifabutin capsule .......................................................1
RIFAMATE CAPSULE ...........................................3
12
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIMYCOBACTERIALS (continued)
rifampin capsule........................................................1
rifampin vial..............................................................1
RIFATER TABLET..................................................3
SIRTURO TABLET .................................................3
Requirements/Limits: QL-68 unit(s) per 28 day(s)
TRECATOR TABLET .............................................3
ANTINEOPLASTICS
ABRAXANE VIAL..................................................3
ADCETRIS VIAL.....................................................3
Requirements/Limits: PA
adriamycin vial .........................................................1
adrucil vial ................................................................1
AFINITOR TABLET................................................3
Strength: 10 MG, 7.5 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
AFINITOR TABLET................................................3
Strength: 2.5 MG, 5 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
AFINITOR DISPERZ TAB SUSP ...........................3
Strength: 2 MG, 3 MG
Requirements/Limits: PA
AFINITOR DISPERZ TAB SUSP ...........................3
Strength: 5 MG
Requirements/Limits: PA, QL-112 unit(s) per 28 day(s)
ALIMTA VIAL.........................................................3
ALKERAN VIAL .....................................................3
amifostine vial ...........................................................1
anastrozole tablet......................................................1
ARRANON VIAL ....................................................3
ARZERRA VIAL .....................................................3
Requirements/Limits: PA
AVASTIN VIAL.......................................................3
Requirements/Limits: PA
azacitidine vial ..........................................................1
BICNU VIAL............................................................3
bleomycin sulfate vial................................................1
BOSULIF TABLET..................................................3
Strength: 100 MG
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
BOSULIF TABLET..................................................3
Strength: 500 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
BUSULFEX VIAL ...................................................3
CAPRELSA TABLET..............................................3
Strength: 100 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
Drug Tier
CAPRELSA TABLET..............................................3
Strength: 300 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
carboplatin vial.........................................................1
CERUBIDINE VIAL................................................3
cisplatin vial..............................................................1
cladribine vial ...........................................................1
CLOLAR VIAL ........................................................3
COMETRIQ CAPSULE...........................................3
Requirements/Limits: PA
COSMEGEN VIAL ..................................................3
cyclophosphamide tablet...........................................1
Requirements/Limits: BD
cyclophosphamide vial..............................................1
CYRAMZA VIAL ....................................................3
Requirements/Limits: PA
cytarabine vial ..........................................................1
dacarbazine vial........................................................1
DACOGEN VIAL ....................................................3
daunorubicin hcl vial ................................................1
DAUNOXOME VIAL..............................................3
decitabine vial...........................................................1
dexrazoxane vial .......................................................1
DOCEFREZ VIAL ...................................................3
docetaxel vial ............................................................1
DOXIL VIAL............................................................3
doxorubicin hcl vial ..................................................1
doxorubicin hcl liposome vial...................................1
DROXIA CAPSULE ................................................3
ELITEK VIAL ..........................................................3
ELLENCE VIAL ......................................................3
ELOXATIN VIAL....................................................3
ELSPAR VIAL .........................................................2
EMCYT CAPSULE..................................................3
epirubicin hcl vial .....................................................1
ERBITUX VIAL.......................................................3
Requirements/Limits: PA
ERIVEDGE CAPSULE............................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
ERWINAZE VIAL ...................................................3
Requirements/Limits: PA
ETOPOPHOS VIAL.................................................3
etoposide vial ............................................................1
exemestane tablet ......................................................1
FARESTON TABLET..............................................3
FASLODEX SYRINGE ...........................................3
FIRMAGON VIAL...................................................3
Strength: 120 MG
13
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTINEOPLASTICS (continued)
FIRMAGON VIAL...................................................3
Strength: 80 MG
fludarabine phosphate vial........................................1
fluorouracil vial ........................................................1
Requirements/Limits: BD
FOLOTYN VIAL .....................................................3
Requirements/Limits: PA
FUDR VIAL .............................................................3
FUSILEV VIAL........................................................3
GAZYVA VIAL .......................................................3
Requirements/Limits: PA
gemcitabine hcl vial ..................................................1
GEMZAR VIAL .......................................................3
GILOTRIF TABLET ................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
GLEEVEC TABLET ................................................3
Strength: 100 MG
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
GLEEVEC TABLET ................................................3
Strength: 400 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
HALAVEN VIAL.....................................................3
Requirements/Limits: PA
HERCEPTIN VIAL ..................................................3
Requirements/Limits: PA
HEXALEN CAPSULE .............................................3
HYCAMTIN VIAL...................................................3
hydroxyurea capsule .................................................1
ICLUSIG TABLET...................................................3
Requirements/Limits: PA
IDAMYCIN PFS VIAL ............................................3
idarubicin hcl vial .....................................................1
ifosfamide vial ...........................................................1
ifosfamide-mesna kit .................................................1
IMBRUVICA CAPSULE .........................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
INLYTA TABLET ...................................................3
Strength: 1 MG
Requirements/Limits: PA, QL-180 unit(s) per 30 day(s)
INLYTA TABLET ...................................................3
Strength: 5 MG
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
irinotecan hcl vial .....................................................1
ISTODAX VIAL.......................................................3
Requirements/Limits: PA
IXEMPRA VIAL ......................................................3
Requirements/Limits: PA
Drug Tier
JAKAFI TABLET.....................................................3
Requirements/Limits: PA
JEVTANA VIAL ......................................................3
Requirements/Limits: PA
KADCYLA VIAL.....................................................3
Requirements/Limits: PA
KYPROLIS VIAL.....................................................3
Requirements/Limits: PA
letrozole tablet ..........................................................1
leucovorin calcium tablet..........................................1
leucovorin calcium vial.............................................1
LEUKERAN TABLET.............................................2
lipodox vial................................................................1
lomustine capsule......................................................1
MARQIBO KIT ........................................................3
Requirements/Limits: PA
MATULANE CAPSULE .........................................3
MEKINIST TABLET ...............................................3
Strength: 0.5 MG
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
MEKINIST TABLET ...............................................3
Strength: 2 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
melphalan hcl vial.....................................................1
mercaptopurine tablet ...............................................1
mesna vial .................................................................1
MESNEX TABLET..................................................3
mitomycin vial ...........................................................1
mitoxantrone hcl vial ................................................1
MUSTARGEN VIAL ...............................................3
NAVELBINE VIAL .................................................3
NEXAVAR TABLET...............................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
NIPENT VIAL..........................................................3
ONCASPAR VIAL...................................................3
oxaliplatin vial ..........................................................1
paclitaxel vial............................................................1
PANRETIN GEL .....................................................3
pentostatin vial..........................................................1
PERJETA VIAL .......................................................3
Requirements/Limits: PA
PHOTOFRIN VIAL..................................................3
POMALYST CAPSULE ..........................................3
Requirements/Limits: PA, QL-21 unit(s) per 28 day(s)
PROLEUKIN VIAL .................................................3
REVLIMID CAPSULE ............................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
RITUXAN VIAL ......................................................3
Requirements/Limits: PA
14
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTINEOPLASTICS (continued)
SOLTAMOX SOLUTION .......................................3
SPRYCEL TABLET.................................................3
Strength: 100 MG, 140 MG, 80 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
SPRYCEL TABLET.................................................3
Strength: 20 MG, 50 MG, 70 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
STIVARGA TABLET ..............................................3
Requirements/Limits: PA
SUTENT CAPSULE.................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
SYLATRON 4-PACK KIT.......................................3
Requirements/Limits: PA
SYLVANT VIAL .....................................................3
Requirements/Limits: PA
SYNRIBO VIAL.......................................................3
Requirements/Limits: PA
TABLOID TABLET.................................................3
TAFINLAR CAPSULE ............................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
tamoxifen citrate tablet .............................................1
TARCEVA TABLET ...............................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
TARGRETIN GEL ..................................................3
TARGRETIN CAPSULE .........................................3
TASIGNA CAPSULE ..............................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
TAXOTERE VIAL ...................................................3
teniposide ampul .......................................................1
THALOMID CAPSULE...........................................3
Strength: 100 MG, 150 MG, 50 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
THALOMID CAPSULE...........................................3
Strength: 200 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
thiotepa vial...............................................................1
toposar vial ...............................................................1
topotecan hcl vial ......................................................1
TORISEL VIAL........................................................3
Requirements/Limits: PA
TREANDA VIAL .....................................................3
Requirements/Limits: PA
tretinoin capsule........................................................1
TRISENOX AMPUL................................................3
TYKERB TABLET ..................................................3
Requirements/Limits: PA, QL-150 unit(s) per 30 day(s)
Drug Tier
VALCHLOR GEL ...................................................3
Requirements/Limits: PA, QL-60 grams per 30 day(s)
VECTIBIX VIAL .....................................................3
VELCADE VIAL .....................................................3
Requirements/Limits: PA
VIDAZA VIAL.........................................................3
vinblastine sulfate vial ..............................................1
vincasar pfs vial ........................................................1
vincristine sulfate vial ...............................................1
vinorelbine tartrate vial ............................................1
VOTRIENT TABLET ..............................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
XALKORI CAPSULE..............................................3
Requirements/Limits: PA
YERVOY VIAL .......................................................3
Requirements/Limits: PA
ZALTRAP VIAL ......................................................3
Requirements/Limits: PA
ZANOSAR VIAL .....................................................3
ZELBORAF TABLET..............................................3
Requirements/Limits: PA
ZINECARD VIAL....................................................3
ZOLINZA CAPSULE ..............................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
ZYKADIA CAPSULE..............................................3
Requirements/Limits: PA
ZYTIGA TABLET ...................................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
ANTIPARASITICS
ALBENZA TABLET................................................3
ALINIA TABLET ....................................................3
ALINIA SUSP RECON............................................3
atovaquone oral susp ................................................1
atovaquone-proguanil hcl tablet...............................1
BILTRICIDE TABLET ............................................3
chloroquine phosphate tablet....................................1
COARTEM TABLET...............................................3
DARAPRIM TABLET .............................................3
EURAX CREAM .....................................................3
EURAX LOTION.....................................................3
hydroxychloroquine sulfate tablet.............................1
lindane lotion ............................................................1
lindane shampoo .......................................................1
malathion lotion ........................................................1
mefloquine hcl tablet.................................................1
MEPRON ORAL SUSP ...........................................3
NATROBA SUSPENSION ......................................3
15
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
Drug Tier
TASMAR TABLET..................................................3
trihexyphenidyl hcl tablet..........................................1
NEBUPENT VIAL-NEB ..........................................3 trihexyphenidyl hcl elixir ..........................................1
Requirements/Limits: BD
ZELAPAR TAB RAPDIS ........................................3
PENTAM 300 VIAL.................................................3 Requirements/Limits: STEP
permethrin cream .....................................................1 ANTIPSYCHOTICS
PRIMAQUINE TABLET .........................................3
QUALAQUIN CAPSULE........................................3 ABILIFY SOLUTION..............................................3
ABILIFY VIAL ........................................................3
Requirements/Limits: PA
quinine sulfate capsule..............................................1 ABILIFY TABLET...................................................3
ABILIFY DISCMELT TAB RAPDIS......................3
Requirements/Limits: PA
ABILIFY
MAINTENA SUSER VIAL.....................3
spinosad suspension..................................................1
STROMECTOL TABLET........................................2 ADASUVE AER POW BA ......................................3
TINDAMAX TABLET.............................................3 chlorpromazine hcl ampul ........................................1
tinidazole tablet.........................................................1 chlorpromazine hcl tablet .........................................1
ULESFIA LOTION ..................................................3 clozapine tablet .........................................................1
clozapine odt tab rapdis............................................1
ANTIPARKINSON AGENTS
FANAPT TAB DS PK..............................................3
APOKYN CARTRIDGE ..........................................3 Requirements/Limits: QL-60 unit(s) per 30 day(s)
AZILECT TABLET..................................................2 FANAPT TABLET...................................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
Strength: 1 MG, 2 MG, 4 MG
Requirements/Limits:
QL-60 unit(s) per 30 day(s)
benztropine mesylate tablet.......................................1
benztropine mesylate ampul......................................1 FANAPT TABLET...................................................3
Strength: 10 MG, 12 MG, 6 MG, 8 MG
carbidopa tablet ........................................................1
carbidopa-levodopa tab rapdis .................................1 Requirements/Limits: QL-60 unit(s) per 30 day(s)
carbidopa-levodopa tablet ........................................1 FAZACLO TAB RAPDIS ........................................3
carbidopa-levodopa er tablet er ...............................1 fluphenazine decanoate vial......................................1
carbidopa-levodopa-entacapone tablet ....................1 fluphenazine hcl elixir...............................................1
entacapone tablet ......................................................1 fluphenazine hcl oral conc ........................................1
fluphenazine hcl tablet ..............................................1
Requirements/Limits: QL-240 unit(s) per 30 day(s)
LODOSYN TABLET ...............................................3 fluphenazine hcl vial .................................................1
MIRAPEX ER TAB ER 24H....................................3 GEODON VIAL .......................................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s) haloperidol tablet......................................................1
NEUPRO PATCH TD24 ..........................................3 haloperidol decanoate vial........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
haloperidol lactate oral conc....................................1
pramipexole dihydrochloride tablet..........................1 haloperidol lactate vial .............................................1
Strength: 0.125 mg
INVEGA TAB ER 24 ...............................................3
pramipexole dihydrochloride tablet..........................1
Strength: 1.5 MG, 3 MG, 9 MG
Strength: 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
Requirements/Limits: QL-90 unit(s) per 30 day(s)
INVEGA TAB ER 24 ...............................................3
ropinirole hcl tablet ..................................................1
Strength: 6 MG
ropinirole hcl tab er 24h ...........................................1 Requirements/Limits: STEP, QL-60 unit(s) per 30 day(s)
Requirements/Limits: QL-60 unit(s) per 30 day(s)
INVEGA SUSTENNA SYRINGE ...........................3
Strength: 117MG/0.75, 156 MG/ML, 234MG/
selegiline hcl tablet ...................................................1
1.5, 78MG/0.5ML
selegiline hcl capsule ................................................1
Requirements/Limits:
STEP
SINEMET 10-100 TABLET.....................................3
INVEGA
SUSTENNA
SYRINGE ...........................3
SINEMET 25-100 TABLET.....................................3
Strength:
39MG/0.25
SINEMET 25-250 TABLET.....................................3
SINEMET CR TABLET ER.....................................3 Requirements/Limits: STEP
ANTIPARASITICS (continued)
16
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIPSYCHOTICS (continued)
LATUDA TABLET..................................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
loxapine capsule........................................................1
olanzapine vial ..........................................................1
olanzapine tablet .......................................................1
olanzapine odt tab rapdis..........................................1
olanzapine-fluoxetine hcl capsule.............................1
ORAP TABLET........................................................3
perphenazine tablet ...................................................1
perphenazine-amitriptyline tablet .............................1
prochlorperazine edisylate vial.................................1
prochlorperazine maleate tablet ...............................1
prochlorperazine maleate supp.rect .........................1
quetiapine fumarate tablet ........................................1
RISPERDAL CONSTA SYRINGE..........................3
Strength: 12.5MG/2ML, 25 MG/2 ML
RISPERDAL CONSTA SYRINGE..........................3
Strength: 37.5MG/2ML, 50 MG/2 ML
risperidone tablet ......................................................1
Requirements/Limits: 30 Day FFF
risperidone tab rapdis...............................................1
risperidone solution ..................................................1
risperidone odt tab rapdis.........................................1
SAPHRIS TAB SUBL ..............................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
SEROQUEL XR TAB ER 24H ................................2
Strength: 150 MG, 200 MG, 50 MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
SEROQUEL XR TAB ER 24H ................................2
Strength: 300 MG, 400 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
thioridazine hcl oral conc. ........................................1
thioridazine hcl tablet ...............................................1
thiothixene capsule....................................................1
trifluoperazine hcl tablet...........................................1
VERSACLOZ ORAL SUSP.....................................3
Requirements/Limits: QL-540 mL(s) per 30 day(s)
ziprasidone hcl capsule.............................................1
ZYPREXA RELPREVV VIAL ................................3
ANTISPASTICITY AGENTS
baclofen tablet...........................................................1
comfort pac-tizanidine kit .........................................1
dantrolene sodium capsule........................................1
tizanidine hcl tablet...................................................1
tizanidine hcl capsule................................................1
Drug Tier
ANTIVIRALS
abacavir tablet ..........................................................1
abacavir-lamivudine-zidovudine tablet ....................1
acyclovir oral susp....................................................1
acyclovir tablet..........................................................1
acyclovir capsule ......................................................1
acyclovir oint. ..........................................................1
Requirements/Limits: QL-30 grams per 30 day(s)
adefovir dipivoxil tablet ............................................1
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
ALFERON N VIAL..................................................3
amantadine capsule ..................................................1
amantadine syrup......................................................1
amantadine tablet......................................................1
APTIVUS SOLUTION.............................................3
APTIVUS CAPSULE...............................................3
ATRIPLA TABLET .................................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
BARACLUDE TABLET..........................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
BARACLUDE SOLUTION .....................................3
Requirements/Limits: PA, QL-600 mL(s) per 30 day(s)
cidofovir vial .............................................................1
COMBIVIR TABLET ..............................................3
COMPLERA TABLET ............................................3
COPEGUS TABLET ................................................3
Requirements/Limits: PA
CRIXIVAN CAPSULE ............................................3
DENAVIR CREAM ................................................3
Requirements/Limits: QL-5 grams per 30 day(s)
didanosine capsule dr ...............................................1
EDURANT TABLET ...............................................3
EMTRIVA SOLUTION ...........................................3
EMTRIVA CAPSULE..............................................3
EPIVIR SOLUTION.................................................3
EPIVIR HBV SOLUTION .......................................3
EPIVIR HBV TABLET............................................3
EPZICOM TABLET.................................................3
famciclovir tablet ......................................................1
Strength: 125 mg
Requirements/Limits: QL-21 unit(s) per 30 day(s)
famciclovir tablet ......................................................1
Strength: 250 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
famciclovir tablet ......................................................1
Strength: 500 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
17
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIVIRALS (continued)
foscarnet sodium infus. btl ........................................1
Requirements/Limits: BD
FUZEON VIAL ........................................................3
ganciclovir sodium vial.............................................1
HEPSERA TABLET.................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
INCIVEK TABLET..................................................3
Requirements/Limits: PA, QL-180 unit(s) per 30 day(s)
INTELENCE TABLET ............................................3
Strength: 100 MG, 200 MG
Requirements/Limits: QL-120 unit(s) per 30 day(s)
INTELENCE TABLET ............................................3
Strength: 25 MG
Requirements/Limits: QL-120 unit(s) per 30 day(s)
INTRON A VIAL .....................................................3
INTRON A PEN IJ KIT............................................3
INVIRASE TABLET................................................3
INVIRASE CAPSULE .............................................3
ISENTRESS POWD PACK .....................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ISENTRESS TABLET .............................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ISENTRESS TAB CHEW ........................................3
Strength: 100 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ISENTRESS TAB CHEW ........................................2
Strength: 25 MG
KALETRA SOLUTION ...........................................3
KALETRA TABLET................................................3
Strength: 100MG-25MG
KALETRA TABLET................................................3
Strength: 200MG-50MG
lamivudine tablet.......................................................1
lamivudine hbv tablet ................................................1
lamivudine-zidovudine tablet ....................................1
LEXIVA ORAL SUSP .............................................3
LEXIVA TABLET ...................................................3
MODERIBA TABLET .............................................3
Requirements/Limits: PA
MODERIBA TAB DS PK ........................................3
Requirements/Limits: PA
nevirapine oral susp..................................................1
nevirapine tablet .......................................................1
nevirapine er tab er 24h............................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
NORVIR CAPSULE.................................................2
NORVIR SOLUTION ..............................................2
Drug Tier
NORVIR TABLET ...................................................2
OLYSIO CAPSULE .................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
PEGASYS VIAL ......................................................3
Requirements/Limits: PA
PEGASYS SYRINGE ..............................................3
Requirements/Limits: PA, QL-2 mL(s) per 28 day(s)
PEGASYS PROCLICK PEN INJCTR .....................3
Requirements/Limits: PA
PEGINTRON KIT ....................................................3
Requirements/Limits: PA, QL-4 unit(s) per 28 day(s)
PEGINTRON REDIPEN PEN IJ KIT ......................3
Requirements/Limits: PA, QL-4 unit(s) per 28 day(s)
PREZISTA TABLET................................................3
PREZISTA ORAL SUSP .........................................3
REBETOL CAPSULE..............................................3
Requirements/Limits: PA
REBETOL SOLUTION............................................3
Requirements/Limits: PA
RELENZA BLST W/DEV........................................3
Requirements/Limits: QL-56 unit(s) per 30 day(s)
RESCRIPTOR TABLET ..........................................3
RESCRIPTOR TAB DISPER...................................3
RETROVIR VIAL ....................................................3
REYATAZ CAPSULE .............................................3
ribapak tab ds pk.......................................................1
Requirements/Limits: PA
ribasphere capsule ....................................................1
Requirements/Limits: PA
ribasphere tablet .......................................................1
Strength: 200 mg, 400 mg
Requirements/Limits: PA
ribasphere tablet .......................................................1
Strength: 600 mg
Requirements/Limits: PA
RIBATAB TAB DS PK............................................3
Requirements/Limits: PA
RIBATAB TABLET.................................................3
Requirements/Limits: PA
ribavirin tablet ..........................................................1
Requirements/Limits: PA
ribavirin capsule .......................................................1
Requirements/Limits: PA
rimantadine hcl tablet ...............................................1
SELZENTRY TABLET ...........................................3
Strength: 150 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
18
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
ANTIVIRALS (continued)
SELZENTRY TABLET ...........................................3
Strength: 300 MG
Requirements/Limits: QL-120 unit(s) per 30 day(s)
SOVALDI TABLET.................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
stavudine capsule ......................................................1
stavudine soln recon..................................................1
STRIBILD TABLET ................................................3
SUSTIVA TABLET .................................................3
SUSTIVA CAPSULE ...............................................3
TAMIFLU SUSP RECON........................................3
TAMIFLU CAPSULE ..............................................3
Strength: 30 MG, 45 MG
TAMIFLU CAPSULE ..............................................3
Strength: 75 MG
Requirements/Limits: QL-28 unit(s) per 30 day(s)
TIVICAY TABLET..................................................3
trifluridine drops .......................................................1
TRIZIVIR TABLET .................................................3
TRUVADA TABLET...............................................3
TYZEKA TABLET ..................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
valacyclovir tablet.....................................................1
VALCYTE TABLET................................................3
VALCYTE SOLN RECON ......................................3
VICTRELIS CAPSULE ...........................................3
Requirements/Limits: PA, QL-360 unit(s) per 30 day(s)
VIDEX SOLN RECON ............................................3
VIRACEPT TABLET...............................................3
VIRAMUNE ORAL SUSP.......................................3
VIRAMUNE TABLET.............................................3
VIRAMUNE XR TAB ER 24H................................3
Strength: 100 MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
VIRAMUNE XR TAB ER 24H................................3
Strength: 400 MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
VIRAZOLE VIAL-NEB...........................................3
VIREAD POWDER..................................................3
VIREAD TABLET ...................................................3
VISTIDE VIAL.........................................................3
ZIAGEN TABLET ...................................................3
ZIAGEN SOLUTION...............................................3
zidovudine capsule ....................................................1
zidovudine tablet .......................................................1
zidovudine syrup .......................................................1
ZIRGAN GEL ..........................................................3
Drug Tier
ZOVIRAX CREAM ................................................3
Requirements/Limits: QL-15 grams per 30 day(s)
ANXIOLYTICS
alprazolam tab rapdis ...............................................1
alprazolam tablet ......................................................1
alprazolam odt tab rapdis .........................................1
alprazolam xr tab er 24h...........................................1
buspirone hcl tablet...................................................1
chlordiazepoxide hcl capsule....................................1
chlordiazepoxide-amitriptyline tablet.......................1
diazepam kit ..............................................................1
diazepam oral conc ...................................................1
diazepam vial ............................................................1
diazepam tablet .........................................................1
diazepam solution .....................................................1
hydroxyzine pamoate capsule ...................................1
lorazepam tablet........................................................1
lorazepam vial...........................................................1
lorazepam syringe.....................................................1
oxazepam capsule .....................................................1
BIPOLAR AGENTS
EQUETRO CPMP 12HR..........................................3
lithium solution .........................................................1
LITHIUM CARBONATE TABLET........................3
lithium carbonate tablet er........................................1
lithium carbonate capsule.........................................1
Strength: 150 mg, 300 mg
LITHIUM CARBONATE CAPSULE .....................3
Strength: 600 MG
BLOOD GLUCOSE REGULATORS
acarbose tablet..........................................................1
ACTOPLUS MET XR TBMP 24HR .......................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
AVANDAMET TABLET ........................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
AVANDARYL TABLET.........................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
AVANDIA TABLET................................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
BYDUREON VIAL..................................................2
Requirements/Limits: QL-4 mL(s) per 28 day(s)
BYDUREON PEN PEN INJCTR.............................2
Requirements/Limits: QL-4 mL(s) per 28 day(s)
BYETTA PEN INJCTR............................................2
Strength: 10MCG/0.04
Requirements/Limits: QL-2.4 mL(s) per 30 day(s)
19
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
BLOOD GLUCOSE REGULATORS
(continued)
BYETTA PEN INJCTR............................................2
Strength: 5MCG/0.02
Requirements/Limits: QL-1.2 mL(s) per 30 day(s)
chlorpropamide tablet...............................................1
Requirements/Limits: QL-90 unit(s) per 30 day(s)
CYCLOSET TABLET..............................................3
glimepiride tablet ......................................................1
Strength: 1 mg
Requirements/Limits: QL-240 unit(s) per 30 day(s)
glimepiride tablet ......................................................1
Strength: 2 mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
glimepiride tablet ......................................................1
Strength: 4 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
glipizide tablet...........................................................1
Strength: 10 mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
glipizide tablet...........................................................1
Strength: 5 mg
Requirements/Limits: QL-240 unit(s) per 30 day(s)
glipizide er tab er 24 .................................................1
Strength: 10 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
glipizide er tab er 24 .................................................1
Strength: 2.5 mg
Requirements/Limits: QL-240 unit(s) per 30 day(s)
glipizide er tab er 24 .................................................1
Strength: 5 mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
glipizide-metformin tablet .........................................1
Strength: 2.5-250 mg
Requirements/Limits: QL-240 unit(s) per 30 day(s)
glipizide-metformin tablet .........................................1
Strength: 2.5-500 mg, 5 mg-500mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
GLUCAGEN VIAL ..................................................2
GLUCAGON EMERGENCY KIT KIT ...................2
GLUMETZA TABERGR24H ..................................3
Strength: 1000 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
GLUMETZA TABERGR24H ..................................3
Strength: 500 MG
Requirements/Limits: QL-120 unit(s) per 30 day(s)
glyburide tablet .........................................................1
Strength: 1.25 mg, 5 mg
Requirements/Limits: QL-480 unit(s) per 30 day(s)
Drug Tier
glyburide tablet .........................................................1
Strength: 2.5 mg
Requirements/Limits: QL-240 unit(s) per 30 day(s)
glyburide micronized tablet ......................................1
Strength: 1.5 mg
Requirements/Limits: QL-240 unit(s) per 30 day(s)
glyburide micronized tablet ......................................1
Strength: 3 mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
glyburide micronized tablet ......................................1
Strength: 6 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
glyburide-metformin hcl tablet..................................1
Strength: 1.25-250mg
Requirements/Limits: QL-240 unit(s) per 30 day(s)
glyburide-metformin hcl tablet..................................1
Strength: 2.5-500 mg, 5 mg-500mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
GLYSET TABLET ...................................................3
HUMALOG VIAL....................................................2
HUMALOG INSULN PEN ......................................2
HUMALOG MIX 50-50 VIAL.................................2
HUMALOG MIX 50-50 INSULN PEN...................2
HUMALOG MIX 75-25 VIAL.................................2
HUMALOG MIX 75-25 INSULN PEN...................2
HUMULIN 70/30 KWIKPEN INSULN PEN ..........2
HUMULIN 70-30 VIAL...........................................2
HUMULIN N VIAL .................................................2
HUMULIN N KWIKPEN INSULN PEN ................2
HUMULIN R VIAL..................................................2
Strength: 100/ML
HUMULIN R VIAL..................................................2
Strength: 500/ML
INVOKANA TABLET.............................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
JANUMET TABLET................................................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
JANUMET XR TBMP 24HR ...................................2
Strength: 100-1000MG, 50MG-500MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
JANUMET XR TBMP 24HR ...................................2
Strength: 50-1000 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
JANUVIA TABLET .................................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
JENTADUETO TABLET.........................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
KAZANO TABLET .................................................3
Requirements/Limits: STEP, QL-60 unit(s) per 30 day(s)
20
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
BLOOD GLUCOSE REGULATORS
(continued)
KOMBIGLYZE XR TBMP 24HR ...........................2
Strength: 2.5-1000MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
KOMBIGLYZE XR TBMP 24HR ...........................2
Strength: 5 MG-500MG, 5MG-1000MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
LANTUS VIAL ........................................................2
LANTUS SOLOSTAR INSULN PEN .....................2
LEVEMIR VIAL ......................................................2
LEVEMIR FLEXPEN INSULN PEN ......................2
metformin hcl tablet ..................................................1
Strength: 1000 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
metformin hcl tablet ..................................................1
Strength: 500 mg
Requirements/Limits: QL-150 unit(s) per 30 day(s)
metformin hcl tablet ..................................................1
Strength: 850 mg
Requirements/Limits: QL-90 unit(s) per 30 day(s)
metformin hcl er tab er 24 ........................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
metformin hcl er tab er 24h ......................................1
Strength: 500 mg
Requirements/Limits: QL-120 unit(s) per 30 day(s)
metformin hcl er tab er 24h ......................................1
Strength: 750 mg
Requirements/Limits: QL-90 unit(s) per 30 day(s)
nateglinide tablet.......................................................1
NESINA TABLET....................................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
ONGLYZA TABLET ...............................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
OSENI TABLET.......................................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
pioglitazone hcl tablet...............................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
pioglitazone-glimepiride tablet .................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
pioglitazone-metformin tablet ...................................1
Requirements/Limits: QL-90 unit(s) per 30 day(s)
PRANDIMET TABLET ...........................................3
Requirements/Limits: QL-150 unit(s) per 30 day(s)
PROGLYCEM ORAL SUSP ...................................3
repaglinide tablet ......................................................1
Requirements/Limits: QL-240 unit(s) per 30 day(s)
RIOMET SOLUTION ..............................................3
Requirements/Limits: QL-765 mL(s) per 30 day(s)
Drug Tier
SYMLINPEN 120 PEN INJCTR..............................2
Requirements/Limits: QL-12 mL(s) per 28 day(s)
SYMLINPEN 60 PEN INJCTR................................2
Requirements/Limits: QL-12 mL(s) per 28 day(s)
tolazamide tablet.......................................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
tolbutamide tablet .....................................................1
Requirements/Limits: QL-180 unit(s) per 30 day(s)
TRADJENTA TABLET ...........................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
VICTOZA 3-PAK PEN INJCTR..............................2
Requirements/Limits: QL-9 mL(s) per 30 day(s)
BLOOD PRODUCTS/MODIFIERS/
VOLUME EXPANDERS
AGGRENOX CPMP 12HR......................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
anagrelide hcl capsule ..............................................1
ARANESP VIAL......................................................3
Strength: 100 MCG/ML, 200 MCG/ML, 300
MCG/ML
Requirements/Limits: PA
ARANESP SYRINGE ..............................................3
Strength: 100MCG/0.5, 150MCG/0.3, 200MCG/
0.4, 300MCG/0.6, 500 MCG/ML
Requirements/Limits: PA
ARANESP VIAL......................................................3
Strength: 25 MCG/ML, 40 MCG/ML, 60MCG/
ML
Requirements/Limits: PA
ARANESP SYRINGE ..............................................3
Strength: 25MCG/0.42, 40 MCG/0.4, 60MCG/
0.3
Requirements/Limits: PA
ARIXTRA SYRINGE ..............................................3
BRILINTA TABLET................................................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
cilostazol tablet .........................................................1
CINRYZE VIAL.......................................................3
Requirements/Limits: PA
clopidogrel tablet ......................................................1
Strength: 300 mg
Requirements/Limits: QL-1 unit(s) per 30 day(s)
clopidogrel tablet ......................................................1
Strength: 75 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
COUMADIN TABLET ............................................2
CYKLOKAPRON AMPUL .....................................3
dipyridamole tablet ...................................................1
21
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
BLOOD PRODUCTS/MODIFIERS/
VOLUME EXPANDERS (continued)
EFFIENT TABLET ..................................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
ELIQUIS TABLET...................................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
enoxaparin sodium syringe .......................................1
enoxaparin sodium vial.............................................1
EPOGEN VIAL ........................................................3
Strength: 10000/ML, 2000/ML, 3000/ML, 4000/
ML
Requirements/Limits: PA
EPOGEN VIAL ........................................................3
Strength: 20000/ML
Requirements/Limits: PA
fondaparinux sodium syringe....................................1
FRAGMIN SYRINGE..............................................3
FRAGMIN VIAL......................................................3
GRANIX SYRINGE.................................................3
heparin flush syringe.................................................1
heparin sodium vial...................................................1
Requirements/Limits: PA
heparin sodium syringe .............................................1
Requirements/Limits: PA
heparin sodium in 5% dextrose iv soln. ....................1
heparin sodium-d5w iv soln ......................................1
heparin sodium-ns iv soln .........................................1
jantoven tablet...........................................................1
LEUKINE VIAL.......................................................3
LOVENOX VIAL.....................................................3
LOVENOX SYRINGE .............................................3
MOZOBIL VIAL ......................................................3
Requirements/Limits: PA
NEULASTA SYRINGE ...........................................3
Requirements/Limits: QL-2 mL(s) per 30 day(s)
NEUMEGA VIAL ....................................................3
NEUPOGEN SYRINGE...........................................3
NEUPOGEN VIAL...................................................3
PRADAXA CAPSULE.............................................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
PROCRIT VIAL .......................................................3
Strength: 2000/ML, 20000/2ML, 3000/ML,
4000/ML
Requirements/Limits: PA
PROCRIT VIAL .......................................................3
Strength: 20000/ML, 40000/ML
Requirements/Limits: PA
Drug Tier
PROMACTA TABLET ............................................3
Strength: 12.5 MG, 50 MG, 75 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
PROMACTA TABLET ............................................3
Strength: 25 MG
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
PROTAMINE SULFATE VIAL ..............................3
Requirements/Limits: PA
REFLUDAN VIAL...................................................3
Requirements/Limits: PA
ticlopidine hcl tablet .................................................1
tranexamic acid tablet...............................................1
tranexamic acid vial..................................................1
warfarin sodium tablet ..............................................1
XARELTO TABLET................................................2
Strength: 10 MG, 20 MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
XARELTO TABLET................................................2
Strength: 15 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
CARDIOVASCULAR AGENTS
acebutolol hcl capsule...............................................1
acetazolamide sodium vial ........................................1
ADVICOR TBMP 24HR ..........................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
afeditab cr tablet er...................................................1
ALDACTAZIDE TABLET ......................................3
ALTOPREV TAB ER 24H.......................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
amiloride hcl tablet ...................................................1
amiloride-hydrochlorothiazide tablet .......................1
amiodarone hcl tablet ...............................................1
amiodarone hcl syringe.............................................1
amiodarone hcl vial ..................................................1
amlodipine besylate tablet ........................................1
amlodipine besylate-benazepril capsule ...................1
amlodipine-atorvastatin tablet..................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
AMTURNIDE TABLET ..........................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
atenolol tablet ...........................................................1
Requirements/Limits: 30 Day FFF
atenolol-chlorthalidone tablet ..................................1
atorvastatin calcium tablet .......................................1
AZOR TABLET .......................................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
benazepril hcl tablet..................................................1
benazepril-hydrochlorothiazide tablet......................1
22
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
CARDIOVASCULAR AGENTS (continued)
BENICAR TABLET.................................................2
BENICAR HCT TABLET........................................2
betaxolol hcl tablet....................................................1
BIDIL TABLET........................................................3
Requirements/Limits: QL-180 unit(s) per 30 day(s)
bisoprolol fumarate tablet.........................................1
bisoprolol-hydrochlorothiazide tablet ......................1
bumetanide vial .........................................................1
bumetanide tablet......................................................1
BYSTOLIC TABLET...............................................3
Strength: 10 MG
Requirements/Limits: STEP, QL-120 unit(s) per 30
day(s)
BYSTOLIC TABLET...............................................3
Strength: 2.5 MG, 5 MG
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
BYSTOLIC TABLET...............................................3
Strength: 20 MG
Requirements/Limits: STEP, QL-60 unit(s) per 30 day(s)
candesartan cilexetil tablet .......................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
candesartan-hydrochlorothiazid tablet.....................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
captopril tablet..........................................................1
captopril-hydrochlorothiazide tablet ........................1
CARDENE I.V. PIGGYBACK ................................3
CARDENE SR CAPSULE ER .................................3
CARDURA XL TAB ER 24.....................................3
cartia xt cap er 24h ...................................................1
carvedilol tablet ........................................................1
Requirements/Limits: 30 Day FFF
chlorothiazide tablet .................................................1
chlorothiazide sodium vial ........................................1
chlorthalidone tablet .................................................1
cholestyramine powd pack ........................................1
CLEVIPREX VIAL ..................................................3
clonidine patch tdwk .................................................1
Requirements/Limits: QL-8 unit(s) per 28 day(s)
clonidine hcl tablet....................................................1
CLORPRES TABLET ..............................................3
colestipol hcl tablet ...................................................1
colestipol hcl packet..................................................1
COREG CR CPMP 24HR ........................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
CRESTOR TABLET ................................................2
Strength: 10 MG, 20 MG, 5 MG
Requirements/Limits: QL-45 unit(s) per 30 day(s)
Drug Tier
CRESTOR TABLET ................................................2
Strength: 40 MG
Requirements/Limits: QL-30 unit(s) per 30 day(s)
DEMSER CAPSULE................................................3
DIBENZYLINE CAPSULE .....................................3
digox tablet................................................................1
DIGOXIN SOLUTION ............................................3
digoxin syringe..........................................................1
DILATRATE-SR CAPSULE ER .............................3
diltiazem 24hr cd cap er 24h ....................................1
diltiazem 24hr er tab er 24h......................................1
diltiazem 24hr er cap er 24h.....................................1
diltiazem er capsule er ..............................................1
diltiazem er tab er 24h ..............................................1
diltiazem er cap er 12h .............................................1
diltiazem er cap er deg..............................................1
diltiazem hcl tablet....................................................1
diltiazem hcl vial port ...............................................1
diltiazem hcl vial .......................................................1
dilt-xr cap er deg.......................................................1
DIOVAN TABLET ..................................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
DYRENIUM CAPSULE ..........................................3
EDARBI TABLET ...................................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
EDARBYCLOR TABLET .......................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
EDECRIN TABLET.................................................3
enalapril maleate tablet ............................................1
enalapril-hydrochlorothiazide tablet ........................1
eplerenone tablet.......................................................1
eprosartan mesylate tablet........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
felodipine er tab er 24h.............................................1
fenofibrate capsule....................................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
fenofibrate tablet.......................................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
fenofibric acid capsule dr .........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
fenofibric acid tablet .................................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
FENOGLIDE TABLET............................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
flecainide acetate tablet ............................................1
fluvastatin sodium capsule........................................1
Strength: 20 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
23
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
CARDIOVASCULAR AGENTS (continued)
fluvastatin sodium capsule ........................................1
Strength: 40 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
fosinopril sodium tablet ............................................1
fosinopril-hydrochlorothiazide tablet .......................1
furosemide vial..........................................................1
furosemide solution ...................................................1
furosemide syringe ....................................................1
furosemide tablet.......................................................1
Requirements/Limits: 30 Day FFF
gemfibrozil tablet ......................................................1
guanfacine hcl tablet.................................................1
hctz/reserpine/hydralazine tablet..............................1
hydralazine hcl vial...................................................1
hydralazine hcl tablet................................................1
hydralazine w/hctz capsule .......................................1
hydrochlorothiazide capsule .....................................1
Requirements/Limits: 30 Day FFF
hydrochlorothiazide tablet ........................................1
Requirements/Limits: 30 Day FFF
hydrochlorothiazide/reserpine tablet........................1
indapamide tablet......................................................1
irbesartan tablet........................................................1
Strength: 150 mg, 75 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
irbesartan tablet........................................................1
Strength: 300 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
irbesartan-hydrochlorothiazide tablet ......................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
isochron tablet er ......................................................1
isoditrate tablet er.....................................................1
isosorbide dinitrate tab subl .....................................1
isosorbide dinitrate tablet .........................................1
isosorbide mononitrate tablet ...................................1
isosorbide mononitrate er tab er 24h........................1
isradipine capsule .....................................................1
JUXTAPID CAPSULE.............................................3
Strength: 10 MG, 5 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
JUXTAPID CAPSULE.............................................3
Strength: 20 MG
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
KYNAMRO SYRINGE............................................3
Requirements/Limits: PA, QL-4 mL(s) per 28 day(s)
labetalol hcl syringe..................................................1
labetalol hcl tablet ....................................................1
Drug Tier
LANOXIN AMPUL .................................................3
LANOXIN TABLET ................................................3
LANOXIN PEDIATRIC AMPUL............................3
LESCOL XL TAB ER 24H ......................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
LEVATOL TABLET................................................3
lidocaine hcl syringe .................................................1
Strength: 50 mg/5 ml
LIPTRUZET TABLET .............................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
lisinopril tablet..........................................................1
Requirements/Limits: 30 Day FFF
lisinopril-hydrochlorothiazide tablet ........................1
LIVALO TABLET ...................................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
losartan potassium tablet ..........................................1
Strength: 100 mg
Requirements/Limits: 30 Day FFF, QL-30 unit(s) per 30
day(s)
losartan potassium tablet ..........................................1
Strength: 25 mg, 50 mg
Requirements/Limits: 30 Day FFF, QL-60 unit(s) per 30
day(s)
losartan-hydrochlorothiazide tablet .........................1
Requirements/Limits: 30 Day FFF, QL-30 unit(s) per 30
day(s)
lovastatin tablet.........................................................1
Requirements/Limits: 30 Day FFF
methazolamide tablet ................................................1
methyclothiazide tablet .............................................1
methyldopa tablet......................................................1
methyldopa/hydrochlorothiazide tablet ....................1
methyldopate hcl vial ................................................1
metolazone tablet ......................................................1
metoprolol succinate tab er 24h................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
metoprolol tartrate vial.............................................1
metoprolol tartrate tablet..........................................1
Requirements/Limits: 30 Day FFF
metoprolol-hydrochlorothiazide tablet .....................1
mexiletine hcl capsule ...............................................1
midodrine hcl tablet ..................................................1
minitran patch td24...................................................1
minoxidil tablet .........................................................1
moexipril hcl tablet ...................................................1
moexipril-hydrochlorothiazide tablet .......................1
MULTAQ TABLET .................................................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
nadolol tablet ............................................................1
24
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
CARDIOVASCULAR AGENTS (continued)
nadolol-bendroflumethiazide tablet ..........................1
niacin er tab er 24h...................................................1
Strength: 1000 mg, 750 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
niacin er tab er 24h...................................................1
Strength: 500 mg
Requirements/Limits: QL-90 unit(s) per 30 day(s)
niacor tablet ..............................................................1
nicardipine hcl vial ...................................................1
nicardipine hcl capsule .............................................1
nifedical xl tab er 24 .................................................1
nifedipine er tab er 24...............................................1
nifedipine er tablet er................................................1
nimodipine capsule ...................................................1
nisoldipine tab er 24h ...............................................1
NITRO-BID OINT. ..................................................3
NITRO-DUR PATCH TD24 ....................................3
nitroglycerin vial.......................................................1
nitroglycerin spray....................................................1
nitroglycerin patch td24............................................1
NITROLINGUAL SPRAY.......................................3
NITROMIST SPRAY ...............................................3
NITROSTAT TAB SUBL ........................................2
omega-3 acid ethyl esters capsule ............................1
Requirements/Limits: QL-120 unit(s) per 30 day(s)
pacerone tablet..........................................................1
pentoxifylline tablet er ..............................................1
perindopril erbumine tablet ......................................1
pindolol tablet ...........................................................1
pravastatin sodium tablet..........................................1
Requirements/Limits: 30 Day FFF
prazosin hcl capsule..................................................1
prevalite powder .......................................................1
procainamide hcl vial................................................1
propafenone hcl cap er 12h ......................................1
propafenone hcl tablet ..............................................1
propranolol hcl solution ...........................................1
propranolol hcl vial ..................................................1
propranolol hcl tablet ...............................................1
propranolol-hydrochlorothiazid tablet .....................1
quinapril hcl tablet....................................................1
quinapril-hydrochlorothiazide tablet........................1
quinidine gluconate tablet er ....................................1
quinidine gluconate vial............................................1
quinidine sulfate tablet..............................................1
quinidine sulfate tablet er .........................................1
Drug Tier
ramipril capsule ........................................................1
Requirements/Limits: 30 Day FFF
RANEXA TAB ER 12H...........................................2
Strength: 1000 MG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
RANEXA TAB ER 12H...........................................2
Strength: 500 MG
Requirements/Limits: QL-120 unit(s) per 30 day(s)
reserpine tablet .........................................................1
SAMSCA TABLET..................................................3
Requirements/Limits: PA
SIMCOR TBMP 24HR.............................................3
Requirements/Limits: STEP, QL-60 unit(s) per 30 day(s)
simvastatin tablet ......................................................1
Requirements/Limits: 30 Day FFF
SODIUM EDECRIN VIAL......................................3
sorine tablet ..............................................................1
sotalol tablet..............................................................1
sotalol af tablet .........................................................1
spironolactone tablet ................................................1
spironolactone-hctz tablet.........................................1
TARKA TBMP 24HR ..............................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
taztia xt capsule er ....................................................1
TEKAMLO TABLET...............................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
TEKTURNA TABLET.............................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
TEKTURNA HCT TABLET....................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
telmisartan tablet ......................................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
telmisartan-amlodipine tablet ...................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
telmisartan-hydrochlorothiazid tablet ......................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
terazosin hcl capsule.................................................1
TEVETEN HCT TABLET .......................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
TIKOSYN CAPSULE ..............................................3
torsemide tablet.........................................................1
torsemide vial............................................................1
trandolapril tablet.....................................................1
triamterene-hctz tablet ..............................................1
triamterene-hctz capsule ...........................................1
triamterene-hydrochlorothiazid tablet......................1
TRIBENZOR TABLET............................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
25
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
CARDIOVASCULAR AGENTS (continued)
TRIGLIDE TABLET................................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
valsartan tablet .........................................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
valsartan-hydrochlorothiazide tablet........................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
VASCEPA CAPSULE..............................................3
VECAMYL TABLET...............................................3
verapamil er tablet er................................................1
verapamil er cap24h pel ...........................................1
verapamil er pm cap24h pct......................................1
verapamil hcl cap24h pel ..........................................1
verapamil hcl vial......................................................1
verapamil hcl tablet ..................................................1
VYTORIN TABLET ................................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
WELCHOL TABLET...............................................2
WELCHOL POWD PACK.......................................2
ZETIA TABLET.......................................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
CENTRAL NERVOUS SYSTEM AGENTS
amphetamine salt combo tablet.................................1
AMPYRA TAB ER 12H...........................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
AUBAGIO TABLET................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
AVONEX KIT ..........................................................3
Requirements/Limits: QL-4 unit(s) per 30 day(s)
AVONEX ADMINISTRATION PACK KIT...........3
Requirements/Limits: QL-4 unit(s) per 30 day(s)
BETASERON VIAL.................................................3
Requirements/Limits: PA, QL-14 mL(s) per 28 day(s)
clonidine hcl er tab er 12h ........................................1
Requirements/Limits: QL-120 unit(s) per 30 day(s)
COPAXONE SYRINGEKIT....................................3
Strength: 20 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
COPAXONE SYRINGE...........................................3
Strength: 40 MG
Requirements/Limits: PA, QL-12 mL(s) per 28 day(s)
DAYTRANA PATCH TD24....................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
dexmethylphenidate hcl tablet...................................1
dexmethylphenidate hcl er cpbp 50-50 .....................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
dextroamphetamine sulfate tablet .............................1
Drug Tier
dextroamphetamine sulfate er capsule er .................1
dextroamphetamine-amphetamine cap er 24h..........1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
EXTAVIA KIT .........................................................3
Requirements/Limits: PA, QL-15 unit(s) per 30 day(s)
GILENYA CAPSULE ..............................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
KAPVAY TAB ER 12H ...........................................3
Requirements/Limits: QL-120 unit(s) per 30 day(s)
LYRICA CAPSULE .................................................2
Requirements/Limits: QL-90 unit(s) per 30 day(s)
metadate er tablet er .................................................1
methamphetamine hcl tablet .....................................1
METHYLIN TAB CHEW ........................................3
methylphenidate er tablet er .....................................1
methylphenidate er tab er 24 ....................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
methylphenidate hcl tablet ........................................1
methylphenidate hcl cd cpbp 30-70 ..........................1
Strength: 20 mg, 40 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
methylphenidate hcl cd cpbp 30-70 ..........................1
Strength: 30 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
methylphenidate sr tablet er......................................1
NUEDEXTA CAPSULE ..........................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
phentermine hcl tablet...............................................1
Requirements/Limits: *, QL-84 unit(s) per 365 day(s)
(capped benefit)
phentermine hcl capsule............................................1
Requirements/Limits: *, QL-84 unit(s) per 365 day(s)
(capped benefit)
REBIF SYRINGE .....................................................3
Requirements/Limits: PA, QL-12 mL(s) per 28 day(s)
REBIF REBIDOSE PEN INJCTR............................3
Requirements/Limits: PA, QL-12 mL(s) per 28 day(s)
RILUTEK TABLET .................................................3
riluzole tablet ............................................................1
RITALIN LA CPBP 50-50 .......................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
SAVELLA TAB DS PK ...........................................3
Requirements/Limits: STEP
SAVELLA TABLET ................................................3
Requirements/Limits: STEP, QL-60 unit(s) per 30 day(s)
STRATTERA CAPSULE.........................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
TECFIDERA CAPSULE DR ...................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
26
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
CENTRAL NERVOUS SYSTEM AGENTS
(continued)
TYSABRI VIAL .......................................................3
Requirements/Limits: PA
VYVANSE CAPSULE.............................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
XENAZINE TABLET ..............................................3
Strength: 12.5 MG
Requirements/Limits: PA, QL-240 unit(s) per 30 day(s)
XENAZINE TABLET ..............................................3
Strength: 25 MG
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
DENTAL AND ORAL AGENTS
cevimeline hcl capsule ..............................................1
chlorhexidine gluconate mouthwash.........................1
KEPIVANCE VIAL .................................................3
periogard mouthwash ...............................................1
pilocarpine hcl tablet ................................................1
triamcinolone acetonide paste .................................1
DERMATOLOGICAL AGENTS
8-MOP CAPSULE....................................................3
ABSORICA CAPSULE............................................3
ACANYA GEL W/PUMP ........................................3
acitretin capsule........................................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ACZONE GEL .........................................................3
Requirements/Limits: STEP
adapalene gel ...........................................................1
adapalene gel w/pump ..............................................1
adapalene cream ......................................................1
ammonium lactate lotion...........................................1
ammonium lactate cream .........................................1
amnesteem capsule....................................................1
ANACAINE OINT. .................................................3
ATRALIN GEL .......................................................3
avita cream ...............................................................1
avita gel ....................................................................1
AZELEX CREAM ...................................................3
BENZAMYCINPAK GEL ......................................3
calcipotriene solution................................................1
calcipotriene cream ..................................................1
calcipotriene oint. ....................................................1
calcipotriene-betamethasone dp oint. ......................1
calcitrene oint. .........................................................1
calcitriol oint. ...........................................................1
CARAC CREAM .....................................................3
Drug Tier
claravis capsule ........................................................1
clindamycin-benzoyl peroxide gel ............................1
CONDYLOX SOLUTION .......................................3
CONDYLOX GEL ..................................................3
diclofenac sodium gel ..............................................1
DIFFERIN LOTION.................................................3
ELIDEL CREAM ....................................................3
Requirements/Limits: QL-100 grams per 30 day(s)
EPIDUO GEL ..........................................................3
erythromycin-benzoyl peroxide gel ..........................1
FINACEA GEL .......................................................3
FINACEA PLUS KIT...............................................3
FLUOROPLEX CREAM ........................................3
fluorouracil solution .................................................1
fluorouracil cream ...................................................1
imiquimod cream pack ..............................................1
methoxsalen capsule .................................................1
myorisan capsule ......................................................1
OXSORALEN LOTION ..........................................3
OXSORALEN-ULTRA CAPSULE.........................3
PICATO GEL ..........................................................2
podofilox solution......................................................1
PROTOPIC OINT. ...................................................3
Requirements/Limits: QL-100 grams per 30 day(s)
PRUDOXIN CREAM ..............................................3
REGRANEX GEL ...................................................3
RETIN-A CREAM ..................................................3
RETIN-A GEL .........................................................3
RETIN-A MICRO GEL ...........................................3
RETIN-A MICRO PUMP GEL................................3
SANTYL OINT. ......................................................3
selenium sulfide suspension ......................................1
SORIATANE CAPSULE .........................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
SORILUX FOAM.....................................................3
sotret capsule ............................................................1
sulfacetamide sodium suspension .............................1
sulfacetamide sodium lotion .....................................1
TACLONEX OINT. ................................................3
Requirements/Limits: STEP
TACLONEX SUSPENSION....................................3
Requirements/Limits: STEP
TAZORAC CREAM ...............................................3
tretinoin cream .........................................................1
tretinoin gel ..............................................................1
tretinoin microsphere gel .........................................1
UVADEX VIAL .......................................................3
VEREGEN OINT. ...................................................3
27
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
DERMATOLOGICAL AGENTS
(continued)
XERESE CREAM ...................................................3
zenatane capsule .......................................................1
ZONALON CREAM ...............................................3
ZYCLARA CRM MD PMP .....................................3
ENZYME REPLACEMENTS/ MODIFIERS
ADAGEN VIAL .......................................................3
ALDURAZYME VIAL ............................................3
Requirements/Limits: PA
BUPHENYL POWDER ...........................................3
BUPHENYL TABLET .............................................3
CARBAGLU TAB DISPER .....................................3
Requirements/Limits: PA
CEREZYME VIAL...................................................3
Requirements/Limits: PA
CREON CAPSULE DR............................................2
CYSTADANE POWDER.........................................3
CYSTAGON CAPSULE ..........................................3
ELAPRASE VIAL....................................................3
Requirements/Limits: PA
ELELYSO VIAL ......................................................3
Requirements/Limits: PA
FABRAZYME VIAL ...............................................3
Requirements/Limits: PA
KRYSTEXXA VIAL................................................3
Requirements/Limits: PA
KUVAN TABLET SOL ...........................................3
Requirements/Limits: PA
LUMIZYME VIAL...................................................3
MYOZYME VIAL ...................................................3
Requirements/Limits: PA
NAGLAZYME VIAL...............................................3
Requirements/Limits: PA
ORFADIN CAPSULE ..............................................3
Requirements/Limits: PA
PANCREAZE CAPSULE DR..................................2
RAVICTI LIQUID....................................................3
Requirements/Limits: PA
SUCRAID SOLUTION ............................................3
VIMIZIM VIAL........................................................3
Requirements/Limits: PA
VPRIV VIAL ............................................................3
Requirements/Limits: PA
ZAVESCA CAPSULE .............................................3
Requirements/Limits: PA
ZENPEP CAPSULE DR...........................................3
Drug Tier
GASTROINTESTINAL AGENTS
atropine sulfate vial ..................................................1
atropine sulfate syringe.............................................1
BENTYL AMPUL....................................................3
CANTIL TABLET....................................................3
CARAFATE TABLET .............................................3
CARAFATE ORAL SUSP .......................................3
cimetidine tablet........................................................1
cimetidine hcl solution ..............................................1
constulose solution....................................................1
CUVPOSA SOLUTION ...........................................3
DEXILANT CAP DR BP .........................................3
dicyclomine hcl tablet ...............................................1
dicyclomine hcl capsule ............................................1
dicyclomine hcl solution............................................1
diphenoxylate-atropine liquid ...................................1
diphenoxylate-atropine tablet ...................................1
enulose solution ........................................................1
esomeprazole sodium vial .........................................1
famotidine tablet .......................................................1
famotidine vial ..........................................................1
famotidine piggyback ................................................1
GASTROCROM SOLUTION..................................3
GATTEX KIT ...........................................................3
Requirements/Limits: PA, QL-1 unit(s) per 1 day(s)
gavilyte-c soln recon .................................................1
gavilyte-g soln recon.................................................1
gavilyte-n soln recon.................................................1
generlac solution.......................................................1
glycopyrrolate tablet .................................................1
glycopyrrolate vial ....................................................1
KRISTALOSE PACKET..........................................3
lactulose syrup ..........................................................1
lactulose solution ......................................................1
lansoprazole capsule dr ............................................1
Strength: 15 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
lansoprazole capsule dr ............................................1
Strength: 30 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
LINZESS CAPSULE................................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
loperamide capsule ...................................................1
LOTRONEX TABLET.............................................3
Requirements/Limits: QL-60 unit(s) per 30 day(s)
methscopolamine bromide tablet ..............................1
misoprostol tablet......................................................1
MOTOFEN TABLET ...............................................3
28
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
GASTROINTESTINAL AGENTS
(continued)
MOVIPREP POWD PACK ......................................3
NEXIUM CAPSULE DR .........................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
NEXIUM SUSPDR PKT ..........................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
NEXIUM I.V. VIAL.................................................2
nizatidine capsule......................................................1
nizatidine solution .....................................................1
omeprazole capsule dr ..............................................1
Strength: 10 mg
Requirements/Limits: 30 Day FFF, QL-30 unit(s) per 30
day(s)
omeprazole capsule dr ..............................................1
Strength: 20 mg
Requirements/Limits: 30 Day FFF, QL-120 unit(s) per 30
day(s)
omeprazole capsule dr ..............................................1
Strength: 40mg
Requirements/Limits: 30 Day FFF, QL-60 unit(s) per 30
day(s)
omeprazole-sodium bicarbonate capsule..................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
OSMOPREP TABLET .............................................3
pantoprazole sodium vial ..........................................1
pantoprazole sodium tablet dr ..................................1
Requirements/Limits: 30 Day FFF, QL-60 unit(s) per 30
day(s)
peg 3350-electrolyte soln recon................................1
peg 3350-grx powder ................................................1
peg-3350 soln recon..................................................1
peg-3350 and electrolytes soln recon .......................1
polyethylene glycol 3350 powder..............................1
PRILOSEC SUSPDR PKT .......................................3
PYLERA CAPSULE ................................................2
rabeprazole sodium tablet dr ....................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
ranitidine hcl syrup ...................................................1
ranitidine hcl vial ......................................................1
ranitidine hcl tablet...................................................1
ranitidine hcl capsule................................................1
RELISTOR SYRINGE .............................................3
Requirements/Limits: PA, QL-30 mL(s) per 30 day(s)
sucralfate oral susp...................................................1
sucralfate tablet.........................................................1
SUPREP SOLN RECON ..........................................3
trilyte with flavor packets soln recon........................1
Drug Tier
ursodiol capsule ........................................................1
ursodiol tablet ...........................................................1
GENITOURINARY AGENTS
alfuzosin hcl er tab er 24h ........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
AVODART CAPSULE ............................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
bethanechol chloride tablet.......................................1
calcium acetate tablet ...............................................1
calcium acetate capsule ............................................1
CIALIS TABLET .....................................................3
Strength: 10 MG, 20 MG
Requirements/Limits: *, QL-6 unit(s) per 30 day(s)
(capped benefit)
CIALIS TABLET .....................................................3
Strength: 2.5 MG, 5 MG
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
doxazosin mesylate tablet .........................................1
eliphos tablet.............................................................1
ELMIRON CAPSULE..............................................3
ENABLEX TAB ER 24H.........................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
finasteride tablet .......................................................1
Requirements/Limits: 30 Day FFF
flavoxate hcl tablet....................................................1
FOSRENOL TAB CHEW ........................................3
GELNIQUE GEL MD PMP .....................................3
Requirements/Limits: QL-276 grams per 30 day(s)
GELNIQUE GEL PACKET .....................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
LEVITRA TABLET .................................................3
Requirements/Limits: *, QL-6 unit(s) per 30 day(s)
(capped benefit)
LITHOSTAT TABLET ............................................3
MYRBETRIQ TAB ER 24H ....................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
oxybutynin chloride tablet.........................................1
Requirements/Limits: 30 Day FFF
oxybutynin chloride syrup.........................................1
oxybutynin chloride er tab er 24...............................1
Strength: 10 mg, 15 mg
Requirements/Limits: QL-60 unit(s) per 30 day(s)
oxybutynin chloride er tab er 24...............................1
Strength: 5 mg
Requirements/Limits: QL-30 unit(s) per 30 day(s)
OXYTROL PATCH TDSW .....................................3
Requirements/Limits: STEP, QL-8 unit(s) per 28 day(s)
PHOSLYRA SOLUTION ........................................3
RAPAFLO CAPSULE..............................................2
29
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
GENITOURINARY AGENTS (continued)
RENVELA POWD PACK........................................2
RENVELA TABLET................................................2
Requirements/Limits: QL-270 unit(s) per 30 day(s)
sevelamer carbonate tablet .......................................1
Requirements/Limits: QL-270 unit(s) per 30 day(s)
STAXYN TAB RAPDIS ..........................................3
Requirements/Limits: *, QL-6 unit(s) per 30 day(s)
(capped benefit)
STENDRA TABLET................................................3
Requirements/Limits: *, QL-6 unit(s) per 30 day(s)
(capped benefit)
tamsulosin hcl cap er 24h .........................................1
Requirements/Limits: 30 Day FFF, QL-60 unit(s) per 30
day(s)
THIOLA TABLET ...................................................3
tolterodine tartrate tablet..........................................1
tolterodine tartrate er cap er 24h .............................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
TOVIAZ TAB ER 24H.............................................3
Requirements/Limits: STEP, QL-30 unit(s) per 30 day(s)
trospium chloride tablet ............................................1
trospium chloride er cap er 24h................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
VESICARE TABLET...............................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
VIAGRA TABLET...................................................3
Requirements/Limits: *, QL-6 unit(s) per 30 day(s)
(capped benefit)
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(ADRENAL)
a-hydrocort vial.........................................................1
Requirements/Limits: BD
ala-cort cream ..........................................................1
ALA-SCALP LOTION.............................................3
Requirements/Limits: STEP
alclometasone dipropionate oint. .............................1
alclometasone dipropionate cream ..........................1
amcinonide cream ....................................................1
amcinonide lotion......................................................1
amcinonide oint. .......................................................1
a-methapred vial .......................................................1
Requirements/Limits: BD
apexicon e cream .....................................................1
ARISTOSPAN VIAL ...............................................3
Requirements/Limits: BD
Drug Tier
betamethasone dipropionate gel ..............................1
betamethasone dipropionate cream .........................1
betamethasone dipropionate lotion...........................1
betamethasone dipropionate oint. ............................1
betamethasone valerate oint. ...................................1
betamethasone valerate cream .................................1
betamethasone valerate foam....................................1
betamethasone valerate lotion ..................................1
CAPEX SHAMPOO .................................................3
Requirements/Limits: STEP
CELESTONE VIAL .................................................3
clobetasol propionate solution..................................1
clobetasol propionate foam.......................................1
clobetasol propionate gel .........................................1
clobetasol propionate lotion .....................................1
clobetasol propionate cream ....................................1
clobetasol propionate oint. ......................................1
clobetasol propionate shampoo ................................1
CLOBEX SPRAY.....................................................3
Requirements/Limits: STEP
clocortolone pivalate cream .....................................1
CORDRAN CREAM ...............................................3
Requirements/Limits: STEP
CORDRAN LOTION ...............................................3
Requirements/Limits: STEP
CORDRAN MED. TAPE .........................................3
Requirements/Limits: STEP
CORDRAN OINT. ...................................................3
Requirements/Limits: STEP
CORTIFOAM FOAM/APPL....................................3
cortisone acetate tablet .............................................1
Requirements/Limits: BD
DEPO-MEDROL VIAL ...........................................3
Requirements/Limits: BD
DESONATE GEL ....................................................3
Requirements/Limits: STEP
desonide lotion ..........................................................1
desonide cream ........................................................1
desonide oint. ...........................................................1
desoximetasone gel ..................................................1
desoximetasone oint. ................................................1
desoximetasone cream .............................................1
dexamethasone tablet................................................1
Requirements/Limits: BD
dexamethasone elixir.................................................1
Requirements/Limits: BD
dexamethasone intensol drops ..................................1
dexamethasone sodium phosphate vial .....................1
Requirements/Limits: BD
30
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(ADRENAL) (continued)
diflorasone diacetate oint. ........................................1
diflorasone diacetate cream .....................................1
fludrocortisone acetate tablet ...................................1
fluocinolone acetonide solution ................................1
fluocinolone acetonide cream ..................................1
fluocinolone acetonide oil.........................................1
fluocinolone acetonide oint. .....................................1
fluocinonide cream ...................................................1
fluocinonide solution.................................................1
fluocinonide gel ........................................................1
fluocinonide oint. .....................................................1
fluticasone propionate lotion ....................................1
fluticasone propionate cream ...................................1
fluticasone propionate oint. .....................................1
H.P. ACTHAR VIAL................................................3
Requirements/Limits: PA
halobetasol propionate oint. ....................................1
halobetasol propionate cream .................................1
HALOG CREAM ....................................................3
Requirements/Limits: STEP
HALOG OINT. ........................................................3
Requirements/Limits: STEP
hydrocortisone cream ..............................................1
hydrocortisone lotion ................................................1
hydrocortisone oint. .................................................1
hydrocortisone tablet ................................................1
Requirements/Limits: BD
hydrocortisone butyrate solution ..............................1
hydrocortisone butyrate cream ................................1
hydrocortisone butyrate oint. ...................................1
hydrocortisone plus cream........................................1
hydrocortisone valerate cream ................................1
hydrocortisone valerate oint. ...................................1
KENALOG AEROSOL............................................3
Requirements/Limits: STEP
KENALOG-10 VIAL ...............................................3
Requirements/Limits: BD
KENALOG-40 VIAL ...............................................3
Requirements/Limits: BD
LOCOID SOLUTION...............................................3
Requirements/Limits: STEP
LOCOID OINT. .......................................................3
Requirements/Limits: STEP
Drug Tier
LOCOID LOTION....................................................3
Requirements/Limits: STEP
LOCOID LIPOCREAM CREAM ...........................3
Requirements/Limits: STEP
MEDROL TABLET .................................................3
Requirements/Limits: BD
methylprednisolone tab ds pk....................................1
Requirements/Limits: BD
methylprednisolone tablet.........................................1
Strength: 16 mg, 32 mg, 8 mg
Requirements/Limits: BD
methylprednisolone acetate vial ...............................1
Requirements/Limits: BD
methylprednisolone sod succ vial .............................1
Strength: 1000 mg
Requirements/Limits: BD
methylprednisolone sod succ vial .............................1
Strength: 125 mg, 40 mg, 500mg
Requirements/Limits: BD
mometasone furoate oint. .........................................1
mometasone furoate solution ....................................1
mometasone furoate cream ......................................1
NUCORT LOTION ..................................................3
ORAPRED ODT TAB RAPDIS ..............................3
PANDEL CREAM ...................................................3
Requirements/Limits: STEP
prednicarbate oint. ...................................................1
prednicarbate cream ................................................1
prednisolone sodium phosphate solution..................1
Requirements/Limits: BD
prednisone tablet.......................................................1
Requirements/Limits: BD
prednisone tab ds pk .................................................1
prednisone solution...................................................1
Requirements/Limits: BD
prednisone intensol oral conc...................................1
Requirements/Limits: BD
procto-pak cream .....................................................1
proctosol-hc cream/appl ...........................................1
proctozone-hc cream/appl ........................................1
SOLU-CORTEF VIAL.............................................3
Requirements/Limits: BD
SOLU-MEDROL VIAL ...........................................3
Strength: 1000MG/8ML, 2 G
Requirements/Limits: BD
SOLU-MEDROL VIAL ...........................................3
Strength: 125 MG/2ML, 40 MG/ML
Requirements/Limits: BD
31
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(ADRENAL) (continued)
TOPICORT SPRAY .................................................3
Requirements/Limits: STEP
triamcinolone acetonide vial.....................................1
Requirements/Limits: BD
triamcinolone acetonide lotion .................................1
triamcinolone acetonide cream ................................1
triamcinolone acetonide oint. ..................................1
trianex oint. ..............................................................1
triderm cream ...........................................................1
u-cort cream .............................................................1
VERDESO FOAM....................................................3
Requirements/Limits: STEP
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(PITUITARY)
chorionic gonadotropin vial......................................1
DDAVP VIAL ..........................................................3
desmopressin acetate tablet ......................................1
desmopressin acetate solution ..................................1
desmopressin acetate vial .........................................1
desmopressin acetate spray/pump ............................1
EGRIFTA VIAL .......................................................3
Requirements/Limits: PA
GENOTROPIN CARTRIDGE .................................3
Requirements/Limits: PA
GENOTROPIN SYRINGE.......................................2
Strength: 0.2MG/0.25
Requirements/Limits: PA
GENOTROPIN SYRINGE.......................................3
Strength: 0.4MG/0.25, 0.6MG/0.25, 0.8MG/0.25,
1.2MG/0.25, 1.4MG/0.25, 1.6MG/0.25, 1.8MG/
0.25, 1MG/0.25ML, 2MG/0.25ML
Requirements/Limits: PA
HUMATROPE VIAL ...............................................3
Requirements/Limits: PA
HUMATROPE CARTRIDGE..................................3
Requirements/Limits: PA
INCRELEX VIAL ....................................................3
Requirements/Limits: PA
NORDITROPIN FLEXPRO PEN INJCTR..............3
Requirements/Limits: PA
NORDITROPIN NORDIFLEX PEN INJCTR.........3
Requirements/Limits: PA
novarel vial ...............................................................1
Drug Tier
NUTROPIN VIAL....................................................3
Requirements/Limits: PA
NUTROPIN AQ NUSPIN CARTRIDGE ................3
Requirements/Limits: PA
OMNITROPE VIAL.................................................3
Requirements/Limits: PA
OMNITROPE CARTRIDGE ...................................3
Requirements/Limits: PA
pregnyl vial ...............................................................1
SAIZEN VIAL..........................................................3
Requirements/Limits: PA
SAIZEN CARTRIDGE.............................................3
Requirements/Limits: PA
SEROSTIM VIAL ....................................................3
Requirements/Limits: PA
STIMATE SPRAY/PUMP .......................................3
TEV-TROPIN VIAL.................................................3
Requirements/Limits: PA
ZORBTIVE VIAL ....................................................3
Requirements/Limits: PA
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
ALORA PATCH TDSW ..........................................3
Requirements/Limits: QL-8 unit(s) per 28 day(s)
altavera tablet ...........................................................1
alyacen tablet ............................................................1
amethia tbdspk 3mo ..................................................1
amethia lo tbdspk 3mo ..............................................1
amethyst tablet ..........................................................1
ANADROL-50 TABLET .........................................3
ANDRODERM PATCH TD24 ................................2
ANDROGEL GEL MD PMP ...................................2
ANDROID CAPSULE .............................................3
androxy tablet ...........................................................1
ANGELIQ TABLET.................................................3
apri tablet..................................................................1
aranelle tablet ...........................................................1
aubra tablet ...............................................................1
aviane tablet..............................................................1
azurette tablet............................................................1
balziva tablet .............................................................1
BEYAZ TABLET .....................................................3
briellyn tablet ............................................................1
camila tablet..............................................................1
camrese tbdspk 3mo ..................................................1
camrese lo tbdspk 3mo..............................................1
CENESTIN TABLET ...............................................3
32
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS) (continued)
chateal tablet.............................................................1
CLIMARA PATCH TDWK .....................................3
Requirements/Limits: QL-4 unit(s) per 28 day(s)
CLIMARA PRO PATCH TDWK ............................3
Requirements/Limits: QL-4 unit(s) per 28 day(s)
COMBIPATCH PATCH TDSW ..............................3
Requirements/Limits: QL-8 unit(s) per 28 day(s)
cryselle tablet ............................................................1
cyclafem tablet ..........................................................1
danazol capsule.........................................................1
dasetta tablet .............................................................1
daysee tbdspk 3mo ....................................................1
DELATESTRYL SYRINGE ....................................3
DELESTROGEN VIAL ...........................................3
delyla tablet...............................................................1
DEPO-ESTRADIOL VIAL ......................................3
DEPO-SUBQ PROVERA 104 SYRINGE ...............3
desogestrel-ethinyl estradiol tablet...........................1
DIVIGEL GEL PACKET .........................................3
drospirenone-ethinyl estradiol tablet........................1
DUAVEE TABLET..................................................3
ELESTRIN GEL MD PMP.......................................3
elinest tablet ..............................................................1
ELLA TABLET ........................................................2
emoquette tablet ........................................................1
ENJUVIA TABLET .................................................3
enpresse tablet...........................................................1
enskyce tablet ............................................................1
errin tablet.................................................................1
estarylla tablet...........................................................1
ESTRACE CREAM/APPL.......................................3
estradiol tablet ..........................................................1
estradiol patch tdwk ..................................................1
Requirements/Limits: QL-4 unit(s) per 28 day(s)
estradiol valerate vial ...............................................1
estradiol-norethindrone acetat tablet .......................1
ESTRASORB EMUL PACKT .................................3
ESTRING VAG RING .............................................3
Requirements/Limits: QL-1 unit(s) per 90 day(s)
ESTROGEL GEL MD PMP .....................................3
estropipate tablet.......................................................1
EVAMIST SPRAY ...................................................3
falmina tablet ............................................................1
FEMHRT TABLET ..................................................3
Drug Tier
FEMRING VAG RING ............................................3
Requirements/Limits: QL-1 unit(s) per 90 day(s)
GENERESS FE TAB CHEW...................................3
gianvi tablet ..............................................................1
gildagia tablet ...........................................................1
gildess tablet .............................................................1
gildess fe tablet .........................................................1
heather tablet ............................................................1
introvale tbdspk 3mo.................................................1
jencycla tablet ...........................................................1
jinteli tablet ...............................................................1
jolessa tbdspk 3mo ....................................................1
jolivette tablet............................................................1
junel tablet ................................................................1
junel fe tablet.............................................................1
kariva tablet ..............................................................1
kelnor 1-35 tablet......................................................1
kurvelo tablet ............................................................1
larin tablet.................................................................1
larin fe tablet.............................................................1
leena tablet................................................................1
lessina tablet .............................................................1
levonest tablet ...........................................................1
levonorgestrel tablet .................................................1
levonorgestrel-eth estradiol tablet............................1
levonorgestrel-eth estradiol tbdspk 3mo...................1
levonorg-eth estrad eth estrad tbdspk 3mo...............1
levora-28 tablet.........................................................1
LO LOESTRIN FE TABLET...................................3
loryna tablet ..............................................................1
low-ogestrel tablet ....................................................1
lutera tablet...............................................................1
marlissa tablet...........................................................1
medroxyprogesterone acetate vial ............................1
medroxyprogesterone acetate tablet .........................1
MEGACE ES ORAL SUSP......................................3
megestrol acetate oral susp ......................................1
megestrol acetate tablet ............................................1
MENEST TABLET ..................................................3
METHITEST TABLET ............................................3
microgestin tablet......................................................1
microgestin fe tablet..................................................1
mimvey lo tablet ........................................................1
MINASTRIN 24 FE TAB CHEW............................3
mono-linyah tablet ....................................................1
mononessa tablet.......................................................1
myzilra tablet ............................................................1
NATAZIA TABLET ................................................3
33
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS) (continued)
necon tablet ...............................................................1
next choice one dose tablet .......................................1
nora-be tablet ............................................................1
norethindrone tablet..................................................1
norethindrone acetate tablet .....................................1
norethindron-ethinyl estradiol tablet ........................1
norethin-eth estra ferrous fum tablet ........................1
norgestimate-ethinyl estradiol tablet ........................1
NORINYL 1+35 TABLET .......................................3
NORINYL 1+50 TABLET .......................................3
norlyroc tablet...........................................................1
nortrel tablet .............................................................1
NUVARING VAG RING.........................................3
ocella tablet...............................................................1
orsythia tablet ...........................................................1
ORTHO TRI-CYCLEN LO TABLET .....................3
OXANDRIN TABLET .............................................3
oxandrolone tablet ....................................................1
Strength: 10 mg
oxandrolone tablet ....................................................1
Strength: 2.5 mg
philith tablet ..............................................................1
pimtrea tablet ............................................................1
pirmella tablet ...........................................................1
portia tablet...............................................................1
PREFEST TABLET..................................................3
PREMARIN TABLET..............................................2
PREMARIN CREAM/APPL....................................2
PREMARIN VIAL ...................................................2
PREMPHASE TABLET...........................................2
PREMPRO TABLET................................................2
previfem tablet...........................................................1
progesterone capsule ................................................1
QUARTETTE TBDSPK 3MO .................................3
quasense tbdspk 3mo.................................................1
raloxifene hcl tablet ..................................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
reclipsen tablet ..........................................................1
SAFYRAL TABLET ................................................3
sprintec tablet............................................................1
sronyx tablet ..............................................................1
STRIANT MUC ER 12H..........................................3
SYEDA TABLET .....................................................3
testosterone gel ........................................................1
Drug Tier
testosterone cypionate vial........................................1
testosterone enanthate vial........................................1
TESTRED CAPSULE ..............................................3
tilia fe tablet ..............................................................1
tri-estarylla tablet .....................................................1
tri-legest fe tablet ......................................................1
trinessa tablet............................................................1
tri-previfem tablet .....................................................1
tri-sprintec tablet ......................................................1
trivora-28 tablet ........................................................1
VAGIFEM TABLET ................................................3
velivet tablet ..............................................................1
vestura tablet.............................................................1
viorele tablet .............................................................1
VIVELLE-DOT PATCH TDSW..............................3
Requirements/Limits: QL-8 unit(s) per 28 day(s)
vyfemla tablet ............................................................1
wera tablet ................................................................1
wymzya fe tab chew...................................................1
zarah tablet ...............................................................1
zenchent tablet...........................................................1
zenchent fe tab chew .................................................1
zeosa tab chew ..........................................................1
zovia 1-35e tablet ......................................................1
zovia 1-50e tablet ......................................................1
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(THYROID)
CYTOMEL TABLET ...............................................3
levothyroxine sodium tablet ......................................1
levothyroxine sodium vial .........................................1
levoxyl tablet .............................................................1
liothyronine sodium tablet ........................................1
liothyronine sodium vial ...........................................1
SYNTHROID TABLET ...........................................3
THYROLAR-1 TABLET .........................................3
THYROLAR-1/2 TABLET ......................................3
THYROLAR-1/4 TABLET ......................................3
THYROLAR-2 TABLET .........................................3
THYROLAR-3 TABLET .........................................3
unithroid tablet..........................................................1
HORMONAL AGENTS, SUPPRESSANT
(ADRENAL)
LYSODREN TABLET .............................................2
34
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
HORMONAL AGENTS, SUPPRESSANT
(PARATHYROID)
SENSIPAR TABLET ...............................................2
Strength: 30 MG
SENSIPAR TABLET ...............................................3
Strength: 60 MG, 90 MG
HORMONAL AGENTS, SUPPRESSANT
(PITUITARY)
bromocriptine mesylate capsule................................1
bromocriptine mesylate tablet...................................1
cabergoline tablet .....................................................1
ELIGARD SYRINGE...............................................3
Requirements/Limits: PA
leuprolide acetate kit.................................................1
Requirements/Limits: PA
LUPRON DEPOT SYRINGEKIT............................3
Requirements/Limits: PA
LUPRON DEPOT-PED SYRINGEKIT...................3
Requirements/Limits: PA
LUPRON DEPOT-PED KIT ....................................3
Requirements/Limits: PA
octreotide acetate vial...............................................1
Strength: 100 mcg/ml, 200 mcg/ml
octreotide acetate vial...............................................1
Strength: 1000mcg/ml
octreotide acetate syringe .........................................1
Strength: 50 mcg/ml
octreotide acetate syringe .........................................1
Strength: 500 mcg/ml
SANDOSTATIN VIAL ............................................3
SANDOSTATIN AMPUL........................................3
Strength: 100 MCG/ML, 500 MCG/ML
SANDOSTATIN AMPUL........................................3
Strength: 50 MCG/ML
SANDOSTATIN LAR KIT ......................................3
SOMATULINE DEPOT SYRINGE ........................3
Requirements/Limits: PA
SOMAVERT VIAL ..................................................3
Requirements/Limits: PA
SYNAREL SPRAY ..................................................3
TRELSTAR SYRINGE ............................................3
Requirements/Limits: PA
HORMONAL AGENTS, SUPPRESSANT
(SEX HORMONES/ MODIFIERS)
bicalutamide tablet....................................................1
flutamide capsule ......................................................1
lomedia 24 fe tablet...................................................1
Drug Tier
NILANDRON TABLET ..........................................3
tri-linyah tablet .........................................................1
XTANDI CAPSULE ................................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
xulane patch tdwk .....................................................1
HORMONAL AGENTS, SUPPRESSANT
(THYROID)
methimazole tablet ....................................................1
Strength: 10 mg, 5 mg
methimazole tablet ....................................................1
Strength: 20 mg
propylthiouracil tablet ..............................................1
IMMUNOLOGICAL AGENTS
ACTEMRA SYRINGE.............................................3
Requirements/Limits: PA
ACTEMRA VIAL ....................................................3
Requirements/Limits: PA
ACTHIB VIAL .........................................................3
ACTIMMUNE VIAL ...............................................3
Requirements/Limits: PA
ADACEL TDAP VIAL ............................................3
ADACEL TDAP SYRINGE.....................................3
ARCALYST VIAL...................................................3
Requirements/Limits: PA
ASTAGRAF XL CAP ER 24H ................................3
Requirements/Limits: BD
ATGAM AMPUL.....................................................3
Requirements/Limits: PA
AZASAN TABLET ..................................................3
Requirements/Limits: BD
azathioprine tablet ....................................................1
Requirements/Limits: BD
azathioprine sodium vial...........................................1
Requirements/Limits: BD
BCG VACCINE (TICE STRAIN) VIAL .................3
BENLYSTA VIAL ...................................................3
Requirements/Limits: PA
BIOTHRAX VIAL ...................................................3
BIVIGAM VIAL ......................................................3
Requirements/Limits: PA
BOOSTRIX TDAP VIAL.........................................3
BOOSTRIX TDAP SYRINGE.................................3
CARIMUNE NF NANOFILTERED VIAL .............3
Requirements/Limits: PA
CELLCEPT CAPSULE ............................................3
Requirements/Limits: BD
CELLCEPT SUSP RECON......................................3
Requirements/Limits: BD
35
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
IMMUNOLOGICAL AGENTS (continued)
CELLCEPT TABLET...............................................3
Requirements/Limits: BD
CELLCEPT VIAL ....................................................3
Requirements/Limits: BD
CERVARIX SYRINGE............................................3
CIMZIA KIT.............................................................3
Requirements/Limits: PA, QL-6 unit(s) per 28 day(s)
CIMZIA SYRINGEKIT ...........................................3
Requirements/Limits: PA, QL-6 unit(s) per 28 day(s)
COMVAX VIAL ......................................................3
cyclosporine solution ................................................1
Requirements/Limits: BD
cyclosporine vial .......................................................1
Requirements/Limits: BD
cyclosporine capsule .................................................1
Requirements/Limits: BD
cyclosporine modified capsule ..................................1
Requirements/Limits: BD
DAPTACEL DTAP VIAL........................................3
DIPHTHERIA-TETANUS TOXOIDS-PED VIAL .3
ENBREL VIAL.........................................................3
Strength: 25 MG
Requirements/Limits: PA, QL-16 mL(s) per 28 day(s)
ENBREL SYRINGE.................................................3
Strength: 25 MG
Requirements/Limits: PA, QL-8 mL(s) per 28 day(s)
ENBREL PEN INJCTR ............................................3
Strength: 50 MG
Requirements/Limits: PA, QL-8 mL(s) per 28 day(s)
ENGERIX-B ADULT VIAL ....................................3
Requirements/Limits: BD
ENGERIX-B ADULT SYRINGE ............................3
Requirements/Limits: BD
ENGERIX-B PEDIATRIC-ADOLESCENT
SYRINGE .................................................................3
Requirements/Limits: BD
FLEBOGAMMA DIF VIAL ....................................3
Requirements/Limits: PA
GABLOFEN SYRINGE ...........................................3
Strength: 40000/20ML
GAMMAGARD LIQUID VIAL ..............................3
Requirements/Limits: PA
GAMMAKED VIAL ................................................3
Requirements/Limits: PA
GAMMAPLEX VIAL ..............................................3
Requirements/Limits: PA
GAMUNEX-C VIAL................................................3
Requirements/Limits: PA
Drug Tier
GARDASIL VIAL....................................................3
GARDASIL SYRINGE ............................................3
gengraf solution ........................................................1
Requirements/Limits: BD
gengraf capsule .........................................................1
Requirements/Limits: BD
HAVRIX SYRINGE.................................................3
HAVRIX VIAL.........................................................3
HECORIA CAPSULE ..............................................3
Requirements/Limits: BD
HIZENTRA VIAL ....................................................3
Requirements/Limits: PA
HUMIRA KIT...........................................................3
Requirements/Limits: PA, QL-6 unit(s) per 28 day(s)
HUMIRA PEN IJ KIT ..............................................3
Requirements/Limits: PA, QL-6 unit(s) per 28 day(s)
ILARIS VIAL ...........................................................3
IMOVAX RABIES VACCINE VIAL......................3
INFANRIX DTAP VIAL..........................................3
IPOL VIAL ...............................................................3
IXIARO SYRINGE ..................................................3
KINERET SYRINGE ...............................................3
Requirements/Limits: PA
KINRIX VIAL ..........................................................3
KINRIX SYRINGE ..................................................3
leflunomide tablet......................................................1
MENACTRA VIAL..................................................3
MENHIBRIX VIAL .................................................3
MENOMUNE-A-C-Y-W-135 VIAL........................3
MENVEO A-C-Y-W-135-DIP KIT..........................3
methotrexate vial.......................................................1
Requirements/Limits: BD
methotrexate tablet....................................................1
Requirements/Limits: BD
methotrexate sodium vial ..........................................1
Requirements/Limits: BD
M-M-R II VACCINE VIAL .....................................3
mycophenolate mofetil capsule .................................1
Requirements/Limits: BD
mycophenolate mofetil tablet ....................................1
Requirements/Limits: BD
mycophenolic acid tablet dr......................................1
Requirements/Limits: BD
MYFORTIC TABLET DR .......................................3
Strength: 180 MG
Requirements/Limits: BD
MYFORTIC TABLET DR .......................................3
Strength: 360 MG
Requirements/Limits: BD
36
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
IMMUNOLOGICAL AGENTS (continued)
NEORAL CAPSULE................................................3
Requirements/Limits: BD
NEORAL SOLUTION .............................................3
Requirements/Limits: BD
NULOJIX VIAL .......................................................3
Requirements/Limits: PA
OCTAGAM VIAL....................................................3
Requirements/Limits: PA
ORENCIA VIAL ......................................................3
Requirements/Limits: PA
ORENCIA SYRINGE...............................................3
Requirements/Limits: PA
PEDIARIX SYRINGE..............................................3
PEDVAXHIB VIAL .................................................3
PENTACEL KIT.......................................................3
PENTACEL ACTHIB COMPONENT VIAL..........3
PENTACEL DTAP-IPV COMPONENT VIAL.......3
PRIVIGEN VIAL .....................................................3
Requirements/Limits: PA
PROGRAF CAPSULE .............................................3
Requirements/Limits: BD
PROGRAF AMPUL .................................................3
Requirements/Limits: BD
PROLIA SYRINGE..................................................3
Requirements/Limits: PA
PROQUAD VIAL.....................................................3
RABAVERT KIT .....................................................3
RAPAMUNE SOLUTION .......................................3
Requirements/Limits: BD
RAPAMUNE TABLET............................................3
Strength: 0.5 MG
Requirements/Limits: BD
RAPAMUNE TABLET............................................3
Strength: 1 MG, 2 MG
Requirements/Limits: BD
RECOMBIVAX HB SYRINGE...............................3
Requirements/Limits: BD
RECOMBIVAX HB VIAL.......................................3
Requirements/Limits: BD
REMICADE VIAL ...................................................3
Requirements/Limits: PA
RIDAURA CAPSULE..............................................3
ROTARIX SUSP RECON........................................3
ROTATEQ ORAL SUSP..........................................3
SANDIMMUNE CAPSULE ....................................3
Requirements/Limits: BD
Drug Tier
SANDIMMUNE AMPUL ........................................3
Requirements/Limits: BD
SANDIMMUNE SOLUTION ..................................3
Requirements/Limits: BD
SIMPONI PEN INJCTR ...........................................3
Requirements/Limits: PA, QL-1 mL(s) per 28 day(s)
SIMPONI ARIA VIAL.............................................3
Requirements/Limits: PA
SIMULECT VIAL ....................................................3
sirolimus tablet..........................................................1
Requirements/Limits: BD
SOLIRIS VIAL.........................................................3
Requirements/Limits: PA
STELARA SYRINGE ..............................................3
Requirements/Limits: PA
tacrolimus capsule ....................................................1
Requirements/Limits: BD
TE ANATOXAL BERNA SYRINGE......................3
TENIVAC SYRINGE...............................................3
TETANUS DIPHTHERIA TOXOIDS VIAL ..........3
TETANUS TOXOID ADSORBED VIAL...............2
THERACYS VIAL...................................................3
THYMOGLOBULIN VIAL .....................................3
Requirements/Limits: PA
TWINRIX SYRINGE...............................................3
TWINRIX VIAL.......................................................3
TYPHIM VI VIAL ...................................................3
VAQTA SYRINGE ..................................................3
VAQTA VIAL ..........................................................3
VARIVAX VACCINE VIAL...................................3
VARIZIG VIAL........................................................3
VIVOTIF BERNA CAPSULE DR...........................3
YF-VAX VIAL.........................................................3
ZORTRESS TABLET ..............................................3
Strength: 0.25 MG
Requirements/Limits: BD
ZORTRESS TABLET ..............................................3
Strength: 0.5 MG, 0.75 MG
Requirements/Limits: BD
ZOSTAVAX VIAL ..................................................3
Requirements/Limits: PA
INFLAMMATORY BOWEL DISEASE
AGENTS
ASACOL HD TABLET DR.....................................2
balsalazide disodium capsule ...................................1
budesonide ec capdr & er .........................................1
CANASA SUPP.RECT ............................................2
colocort enema..........................................................1
37
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
INFLAMMATORY BOWEL DISEASE
AGENTS (continued)
CORTENEMA ENEMA...........................................3
DELZICOL CAPSULE DR......................................2
DIPENTUM CAPSULE ...........................................3
ENTOCORT EC CAPDR & ER...............................3
GIAZO TABLET ......................................................3
hydrocortisone enema ...............................................1
mesalamine enema kit ...............................................1
methylprednisolone tablet .........................................1
Strength: 4 mg
Requirements/Limits: BD
ROWASA ENEMA KIT ..........................................3
sulfasalazine tablet....................................................1
sulfasalazine dr tablet dr...........................................1
sulfazine tablet ..........................................................1
UCERIS TABDR & ER............................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
METABOLIC BONE DISEASE AGENTS
alendronate sodium solution.....................................1
Requirements/Limits: QL-300 mL(s) per 28 day(s)
alendronate sodium tablet.........................................1
Strength: 10 mg, 40 mg, 5 mg
Requirements/Limits: 30 Day FFF, QL-30 unit(s) per 30
day(s)
alendronate sodium tablet.........................................1
Strength: 35 mg, 70 mg
Requirements/Limits: 30 Day FFF, QL-4 unit(s) per 28
day(s)
ATELVIA TABLET DR ..........................................2
Requirements/Limits: STEP, QL-4 unit(s) per 28 day(s)
BINOSTO TABLET EFF .........................................3
Requirements/Limits: STEP, QL-4 unit(s) per 28 day(s)
BONIVA SYRINGE.................................................3
Requirements/Limits: PA
calcitonin-salmon spray/pump..................................1
calcitriol ampul .........................................................1
Requirements/Limits: PA
calcitriol capsule.......................................................1
Requirements/Limits: PA
calcitriol solution ......................................................1
Requirements/Limits: PA
doxercalciferol capsule .............................................1
Requirements/Limits: PA
doxercalciferol ampul ...............................................1
Requirements/Limits: PA
etidronate disodium tablet ........................................1
Drug Tier
FORTEO PEN INJCTR ............................................3
Requirements/Limits: PA, QL-3 mL(s) per 28 day(s)
fortical spray/pump ...................................................1
FOSAMAX PLUS D TABLET ................................3
Requirements/Limits: STEP, QL-4 unit(s) per 28 day(s)
HECTOROL CAPSULE ..........................................3
Requirements/Limits: PA
HECTOROL VIAL...................................................3
Requirements/Limits: PA
ibandronate sodium tablet ........................................1
ibandronate sodium vial ...........................................1
Requirements/Limits: PA
MIACALCIN VIAL .................................................3
Requirements/Limits: PA
pamidronate disodium vial .......................................1
Requirements/Limits: PA
paricalcitol capsule...................................................1
Requirements/Limits: PA
risedronate sodium tablet .........................................1
Requirements/Limits: QL-1 unit(s) per 28 day(s)
ROCALTROL SOLUTION......................................3
Requirements/Limits: PA
ROCALTROL CAPSULE........................................3
Requirements/Limits: PA
XGEVA VIAL ..........................................................3
Requirements/Limits: PA
ZEMPLAR VIAL .....................................................3
Requirements/Limits: PA
ZEMPLAR CAPSULE .............................................3
Requirements/Limits: PA
zoledronic acid piggyback ........................................1
Strength: 4mg/100ml
zoledronic acid vial...................................................1
Strength: 4mg/5ml
zoledronic acid infus. btl...........................................1
Strength: 5mg/100ml
ZOMETA INFUS. BTL............................................3
ZOMETA VIAL .......................................................3
MISCELLANEOUS THERAPEUTIC
AGENTS
ALCOHOL PADS MED. PAD ................................3
atropine sulfate drops ...............................................1
atropine sulfate oint. ................................................1
BOTOX VIAL ..........................................................3
Strength: 100 UNIT
Requirements/Limits: PA
BOTOX VIAL ..........................................................3
Strength: 200 UNIT
Requirements/Limits: PA
38
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
MISCELLANEOUS THERAPEUTIC
AGENTS (continued)
CARNITOR TABLET..............................................3
Requirements/Limits: PA
CARNITOR VIAL....................................................3
Requirements/Limits: PA
CARNITOR SF SOLUTION....................................3
Requirements/Limits: PA
CHENODAL TABLET ............................................3
CROFAB VIAL ........................................................3
CUROSURF VIAL ...................................................3
CYCLOGYL DROPS ...............................................3
cyclopentolate hcl drops ...........................................1
CYTOGAM VIAL....................................................3
deferoxamine mesylate vial.......................................1
Requirements/Limits: PA
DESFERAL VIAL....................................................3
Requirements/Limits: PA
dextrose in water iv soln ...........................................1
Strength: 5 %
DIGIFAB VIAL........................................................3
ECLIPSE LUER-LOK SYRINGE DISP SYRIN.....3
FIRAZYR SYRINGE ...............................................3
Requirements/Limits: PA
fomepizole vial ..........................................................1
FULYZAQ TABLET DR .........................................3
Requirements/Limits: PA
INSULIN SYRINGE DISP SYRIN..........................3
intralipid emulsion ....................................................1
Strength: 10 %, 20 %
Requirements/Limits: BD
INTRALIPID EMULSION.......................................3
Strength: 30 %
Requirements/Limits: BD
IRRIGATING SOLUTION G IRRIG SOLN ...........3
ISOPTO ATROPINE DROPS ..................................3
KORLYM TABLET .................................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
levocarnitine vial.......................................................1
Requirements/Limits: PA
levocarnitine solution................................................1
Requirements/Limits: PA
levocarnitine tablet ...................................................1
Requirements/Limits: PA
LIPOSYN II EMULSION ........................................3
Requirements/Limits: BD
LIPOSYN III EMULSION .......................................3
Strength: 30 %
Drug Tier
LIPOSYN III EMULSION .......................................3
Strength: 10 %, 20 %
Requirements/Limits: BD
methylergonovine maleate tablet ..............................1
MIFEPREX TABLET ..............................................3
MYALEPT VIAL .....................................................3
Requirements/Limits: PA
PEN NEEDLE DIS NEEDLE ..................................3
RADIOGARDASE CAPSULE ................................3
SIGNIFOR AMPUL .................................................3
Strength: 0.3 MG/ML
Requirements/Limits: PA
SIGNIFOR AMPUL .................................................3
Strength: 0.6 MG/ML, 0.9 MG/ML
SURE COMFORT DISP SYRIN .............................3
SYNAGIS VIAL.......................................................3
VERSALON SPONGE.............................................3
water irrig soln .........................................................1
XELJANZ TABLET.................................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
OPHTHALMIC AGENTS
acetazolamide capsule er..........................................1
acetazolamide tablet .................................................1
ACUVAIL DROPERETTE ......................................3
ALOCRIL DROPS ...................................................3
ALOMIDE DROPS ..................................................3
ALPHAGAN P DROPS ...........................................3
Strength: 0.1%
ALREX DROPS SUSP.............................................3
apraclonidine hcl drops ............................................1
azelastine hcl drops...................................................1
AZOPT DROPS SUSP .............................................3
Requirements/Limits: QL-15 mL(s) per 25 day(s)
BEPREVE DROPS...................................................3
betaxolol hcl drops....................................................1
BETIMOL DROPS...................................................3
BETOPTIC S DROPS SUSP....................................3
BLEPHAMIDE DROPS SUSP ................................3
BLEPHAMIDE S.O.P. OINT. .................................3
brimonidine tartrate drops........................................1
bromfenac sodium drops...........................................1
carteolol hcl drops ....................................................1
COMBIGAN DROPS...............................................3
CORTISPORIN OINT. ............................................3
COSOPT PF DROPERETTE ...................................3
Requirements/Limits: QL-60 unit(s) per 25 day(s)
cromolyn sodium drops.............................................1
CYSTARAN DROPS ...............................................3
39
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
OPHTHALMIC AGENTS (continued)
dexamethasone sodium phosphate drops ..................1
diclofenac sodium drops ...........................................1
Strength: 0.1 %
dorzolamide hcl drops...............................................1
Requirements/Limits: QL-10 mL(s) per 25 day(s)
dorzolamide-timolol drops........................................1
Requirements/Limits: QL-10 mL(s) per 25 day(s)
DUREZOL DROPS ..................................................2
EMADINE DROPS ..................................................3
epinastine hcl drops ..................................................1
FLAREX DROPS SUSP...........................................3
fluorometholone drops susp ......................................1
flurbiprofen sodium drops.........................................1
FML FORTE DROPS SUSP ....................................3
FML S.O.P. OINT. ...................................................3
gentamicin sulfate oint. ............................................1
Strength: 0.3 %
homatropaire drops...................................................1
homatropine hydrobromide drops ............................1
ILEVRO DROPS SUSP............................................2
IOPIDINE DROPERETTE.......................................3
ISTALOL DROP DAILY.........................................3
ketorolac tromethamine drops ..................................1
Requirements/Limits: QL-15 mL(s) per 25 day(s)
LACRISERT INSERT..............................................3
latanoprost drops ......................................................1
Requirements/Limits: QL-2.5 mL(s) per 25 day(s)
levobunolol hcl drops................................................1
Strength: 0.25 %
levobunolol hcl drops................................................1
Strength: 0.5 %
LOTEMAX DROPS GEL ........................................2
LOTEMAX DROPS SUSP.......................................2
LOTEMAX OINT. ...................................................2
MAXIDEX DROPS SUSP .......................................3
metipranolol drops....................................................1
MYDRIACYL DROPS.............................................3
naphazoline hcl drops ...............................................1
neomycin-polymyxin-dexameth oint. ........................1
neomycin-polymyxin-dexameth drops susp...............1
NEVANAC DROPS SUSP.......................................2
PATADAY DROPS..................................................3
PATANOL DROPS ..................................................3
PHOSPHOLINE IODIDE DROPS...........................3
pilocarpine hcl drops ................................................1
PRED MILD DROPS SUSP.....................................3
Drug Tier
PRED-G OINT. ........................................................3
PRED-G DROPS SUSP............................................3
prednisolone acetate drops susp ...............................1
prednisolone sodium phosphate drops......................1
PROCYSBI CAP DR SPR........................................3
Strength: 25 MG
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
PROCYSBI CAP DR SPR........................................3
Strength: 75 MG
Requirements/Limits: PA, QL-180 unit(s) per 30 day(s)
proparacaine hcl drops.............................................1
RESCULA DROPS ..................................................3
Requirements/Limits: QL-5 mL(s) per 25 day(s)
RESTASIS DROPERETTE......................................2
SIMBRINZA DROPS SUSP ....................................3
sulfacetamide sodium oint. .......................................1
sulfacetamide-prednisolone drops ............................1
timolol maleate drops ...............................................1
timolol maleate sol-gel..............................................1
TIMOPTIC OCUDOSE DROPERETTE .................3
TOBRADEX OINT. ................................................3
TOBRADEX ST DROPS SUSP...............................3
tobramycin-dexamethasone drops susp ....................1
TRAVATAN Z DROPS ...........................................2
Requirements/Limits: QL-5 mL(s) per 25 day(s)
travoprost drops........................................................1
Requirements/Limits: QL-5 mL(s) per 25 day(s)
tropicamide drops .....................................................1
VEXOL DROPS SUSP.............................................3
ZIOPTAN DROPERETTE .......................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
ZYLET DROPS SUSP .............................................3
OTIC AGENTS
acetasol hc drops ......................................................1
acetic acid solution ...................................................1
CIPRO HC DROPS SUSP........................................3
CIPRODEX DROPS SUSP ......................................3
COLY-MYCIN S DROPS SUSP .............................3
CORTISPORIN-TC DROPS SUSP .........................3
fluocinolone acetonide oil drops...............................1
neomycin-polymyxin-hc drops susp ..........................1
Strength: 3.5-10k-1
neomycin-polymyxin-hydrocort solution...................1
otimar solution ..........................................................1
otimar drops susp......................................................1
otomycet-hc drops .....................................................1
40
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
RESPIRATORY TRACT AGENTS
acetylcysteine vial .....................................................1
Strength: 100 mg/ml, 200 mg/ml
Requirements/Limits: BD
acetylcysteine vial .....................................................1
Strength: 200 mg/ml
Requirements/Limits: BD
ADCIRCA TABLET ................................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
ADEMPAS TABLET ...............................................3
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
ADVAIR DISKUS BLST W/DEV...........................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ADVAIR HFA HFA AER AD .................................2
Requirements/Limits: QL-60 grams per 30 day(s)
albuterol sulfate neb solution....................................1
Requirements/Limits: BD
albuterol sulfate syrup ..............................................1
albuterol sulfate tab er 12h.......................................1
albuterol sulfate tablet ..............................................1
albuterol sulfate vial-neb ..........................................1
Requirements/Limits: BD
aminophylline vial.....................................................1
ANORO ELLIPTA BLST W/DEV ..........................2
ARALAST NP VIAL................................................3
Requirements/Limits: PA
ASMANEX AER POW BA .....................................2
Requirements/Limits: QL-1 unit(s) per 30 day(s)
ATROVENT HFA HFA AER AD ...........................3
Requirements/Limits: QL-25.8 grams per 30 day(s)
azelastine hcl spray/pump.........................................1
Requirements/Limits: QL-30 mL(s) per 25 day(s)
BECONASE AQ SPRAY.........................................3
Requirements/Limits: STEP, QL-50 grams per 30 day(s)
benzonatate capsule ..................................................1
Requirements/Limits: *
BREO ELLIPTA BLST W/DEV..............................2
BROVANA VIAL-NEB ...........................................3
Requirements/Limits: BD
budesonide spray/pump.............................................1
Requirements/Limits: QL-17.2 grams per 30 day(s)
budesonide ampul-neb ..............................................1
Requirements/Limits: BD, QL-120 mL(s) per 30 day(s)
clemastine fumarate tablet ........................................1
clemastine fumarate syrup ........................................1
COMBIVENT RESPIMAT AER W/ADAP ............3
Requirements/Limits: QL-8 grams per 30 day(s)
cromolyn sodium solution .........................................1
Drug Tier
cromolyn sodium ampul-neb.....................................1
Requirements/Limits: BD
cyproheptadine hcl syrup..........................................1
cyproheptadine hcl tablet..........................................1
DALIRESP TABLET ...............................................3
Requirements/Limits: QL-30 unit(s) per 30 day(s)
desloratadine tablet ..................................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
desloratadine tab rapdis ...........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
diphenhydramine hcl vial..........................................1
diphenhydramine hcl elixir .......................................1
diphenhydramine hcl syringe....................................1
DULERA HFA AER AD..........................................3
Requirements/Limits: QL-13 grams per 30 day(s)
ELIXOPHYLLIN ELIXIR .......................................3
EPINEPHRINE AUTO INJCT.................................3
epinephrine syringe...................................................1
EPIPEN 2-PAK AUTO INJCT.................................2
Requirements/Limits: QL-2 unit(s) per 30 day(s)
EPIPEN JR 2-PAK AUTO INJCT ...........................2
Requirements/Limits: QL-2 unit(s) per 30 day(s)
epoprostenol sodium vial ..........................................1
Requirements/Limits: PA
FLOLAN VIAL ........................................................3
Requirements/Limits: PA
FLOVENT DISKUS BLST W/DEV ........................2
Strength: 100 MCG, 50 MCG
Requirements/Limits: QL-60 unit(s) per 30 day(s)
FLOVENT DISKUS BLST W/DEV ........................2
Strength: 250 MCG
Requirements/Limits: QL-240 unit(s) per 30 day(s)
FLOVENT HFA AER W/ADAP..............................2
Requirements/Limits: QL-24 grams per 30 day(s)
flunisolide spray........................................................1
Requirements/Limits: QL-50 mL(s) per 30 day(s)
fluticasone propionate spray susp ............................1
Requirements/Limits: QL-16 grams per 30 day(s)
FORADIL CAP W/DEV ..........................................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
GLASSIA VIAL .......................................................3
Requirements/Limits: PA
hydrocodone bt-homatropine mbr tablet ..................1
Requirements/Limits: *
hydrocodone-homatropine mbr syrup.......................1
Requirements/Limits: *
hydromet syrup..........................................................1
Requirements/Limits: *
hydroxyzine hcl tablet ...............................................1
41
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
RESPIRATORY TRACT AGENTS
(continued)
hydroxyzine hcl vial ..................................................1
hydroxyzine hcl syrup................................................1
ipratropium bromide spray .......................................1
ipratropium bromide neb solution ............................1
Requirements/Limits: BD
ipratropium-albuterol ampul-neb .............................1
Requirements/Limits: BD
ISUPREL AMPUL ...................................................3
KALYDECO TABLET ............................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
LETAIRIS TABLET.................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
levalbuterol hcl vial-neb ...........................................1
Requirements/Limits: BD
levocetirizine dihydrochloride tablet ........................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
levocetirizine dihydrochloride solution ....................1
Requirements/Limits: QL-300 mL(s) per 30 day(s)
LUFYLLIN TABLET...............................................3
metaproterenol sulfate tablet ....................................1
metaproterenol sulfate syrup ....................................1
montelukast sodium gran pack..................................1
montelukast sodium tab chew ...................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
montelukast sodium tablet.........................................1
Requirements/Limits: QL-30 unit(s) per 30 day(s)
NASONEX SPRAY/PUMP......................................2
Requirements/Limits: QL-34 grams per 30 day(s)
OMNARIS SPRAY/PUMP ......................................3
Requirements/Limits: STEP, QL-13 grams per 30 day(s)
OPSUMIT TABLET.................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
ORENITRAM ER TABLET ER ..............................3
Strength: 0.125 MG
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
ORENITRAM ER TABLET ER ..............................3
Strength: 0.25 MG, 1 MG
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
ORENITRAM ER TABLET ER ..............................3
Strength: 2.5 MG
Requirements/Limits: PA
PATANASE SPRAY/PUMP....................................3
Requirements/Limits: QL-31 grams per 30 day(s)
PERFOROMIST VIAL-NEB ...................................3
Requirements/Limits: BD
Drug Tier
PROAIR HFA HFA AER AD ..................................2
Requirements/Limits: QL-17 grams per 30 day(s)
promethazine hcl supp.rect .......................................1
promethazine vc syrup ..............................................1
promethegan supp.rect..............................................1
Strength: 12.5 mg
PROVENTIL HFA HFA AER AD...........................3
Requirements/Limits: QL-13.4 grams per 30 day(s)
PULMICORT AMPUL-NEB ...................................3
Requirements/Limits: BD, QL-120 mL(s) per 30 day(s)
PULMOZYME SOLUTION ....................................3
Requirements/Limits: BD
QNASL HFA AER AD.............................................3
Requirements/Limits: STEP, QL-8.7 grams per 30 day(s)
QVAR AER W/ADAP..............................................2
Requirements/Limits: QL-21.9 grams per 30 day(s)
REMODULIN VIAL ................................................3
Requirements/Limits: PA
REVATIO VIAL.......................................................3
Requirements/Limits: PA
REVATIO TABLET.................................................3
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
SEMPREX-D CAPSULE .........................................3
SEREVENT DISKUS BLST W/DEV......................2
Requirements/Limits: QL-60 unit(s) per 30 day(s)
sildenafil tablet..........................................................1
Requirements/Limits: PA, QL-90 unit(s) per 30 day(s)
SPIRIVA CAP W/DEV ............................................2
Requirements/Limits: QL-30 unit(s) per 30 day(s)
SYMBICORT HFA AER AD ..................................2
Requirements/Limits: QL-11 grams per 30 day(s)
terbutaline sulfate tablet ...........................................1
terbutaline sulfate vial ..............................................1
THEO-24 CAP ER 24H............................................3
theochron tab er 12h .................................................1
theophylline tablet er ................................................1
theophylline anhydrous tab er 12h............................1
TRACLEER TABLET..............................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
triamcinolone acetonide spray..................................1
Requirements/Limits: QL-16.5 grams per 25 day(s)
TYVASO AMPUL-NEB ..........................................3
Requirements/Limits: PA, QL-87 mL(s) per 30 day(s)
TYZINE DROPS ......................................................3
VENTAVIS AMPUL-NEB ......................................3
Requirements/Limits: PA
VENTOLIN HFA HFA AER AD.............................2
Requirements/Limits: QL-36 grams per 30 day(s)
42
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
RESPIRATORY TRACT AGENTS
(continued)
VERAMYST SPRAY SUSP ....................................3
Requirements/Limits: STEP, QL-10 grams per 30 day(s)
XOLAIR VIAL .........................................................3
Requirements/Limits: PA
XOPENEX VIAL-NEB ............................................3
Requirements/Limits: BD
XOPENEX HFA HFA AER AD ..............................3
Requirements/Limits: QL-30 grams per 30 day(s)
zafirlukast tablet........................................................1
Requirements/Limits: QL-60 unit(s) per 30 day(s)
ZEMAIRA VIAL......................................................3
Requirements/Limits: PA
ZETONNA HFA AER AD .......................................3
Requirements/Limits: STEP, QL-6.1 grams per 30 day(s)
ZYFLO TABLET .....................................................3
Requirements/Limits: STEP, QL-120 unit(s) per 30
day(s)
ZYFLO CR TBMP 12HR .........................................3
Requirements/Limits: STEP, QL-120 unit(s) per 30
day(s)
SKELETAL MUSCLE RELAXANTS
carisoprodol tablet....................................................1
Strength: 250 mg
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
carisoprodol tablet....................................................1
Strength: 350 mg
Requirements/Limits: PA
carisoprodol-aspirin tablet .......................................1
Requirements/Limits: PA
carisoprodol-aspirin-codeine tablet .........................1
Requirements/Limits: PA
chlorzoxazone tablet .................................................1
comfort pac-cyclobenzaprine kit...............................1
Requirements/Limits: PA
cyclobenzaprine hcl tablet ........................................1
Requirements/Limits: PA
metaxalone tablet ......................................................1
Requirements/Limits: PA
methocarbamol tablet ...............................................1
Requirements/Limits: PA
orphenadrine citrate ampul ......................................1
Requirements/Limits: PA
orphenadrine citrate tablet er ...................................1
Requirements/Limits: PA
orphenadrine compound forte tablet.........................1
Requirements/Limits: PA
Drug Tier
PARAFON FORTE DSC TABLET .........................3
Requirements/Limits: PA
ROBAXIN TABLET ................................................3
Requirements/Limits: PA
ROBAXIN VIAL......................................................3
Requirements/Limits: PA
ROBAXIN-750 TABLET.........................................3
Requirements/Limits: PA
SKELAXIN TABLET ..............................................3
Requirements/Limits: PA
SOMA TABLET.......................................................3
Requirements/Limits: PA, QL-120 unit(s) per 30 day(s)
SLEEP DISORDER AGENTS
AMBIEN TABLET ..................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
AMBIEN CR TAB MPHASE ..................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
EDLUAR TAB SUBL ..............................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
eszopiclone tablet......................................................1
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
HETLIOZ CAPSULE...............................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
INTERMEZZO TAB SUBL.....................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
LUNESTA TABLET ................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
modafinil tablet .........................................................1
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
NUVIGIL TABLET..................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
PROVIGIL TABLET................................................3
Requirements/Limits: PA, QL-60 unit(s) per 30 day(s)
quazepam tablet ........................................................1
ROZEREM TABLET ...............................................3
SILENOR TABLET .................................................3
SONATA CAPSULE................................................3
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
temazepam capsule ...................................................1
XYREM SOLUTION ...............................................3
Requirements/Limits: PA, QL-540 mL(s) per 30 day(s)
zaleplon capsule........................................................1
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
zolpidem tartrate tablet.............................................1
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
zolpidem tartrate er tab mphase ...............................1
Requirements/Limits: PA, QL-30 unit(s) per 30 day(s)
ZOLPIMIST SPRAY/PUMP....................................3
Requirements/Limits: PA, QL-8 mL(s) per 30 day(s)
43
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
THERAPEUTIC NUTRIENTS/
MINERALS/ ELECTROLYTES
acyclovir sodium vial ................................................1
Requirements/Limits: BD
AMINOSYN IV SOLN ............................................3
Requirements/Limits: BD
AMINOSYN II IV SOLN.........................................3
Requirements/Limits: BD
AMINOSYN M IV SOLN........................................3
Requirements/Limits: BD
AMINOSYN WITH ELECTROLYTES IV SOLN..3
Requirements/Limits: BD
AMINOSYN-HBC IV SOLN...................................3
Requirements/Limits: BD
AMINOSYN-PF IV SOLN.......................................3
Requirements/Limits: BD
AMINOSYN-RF IV SOLN ......................................3
Requirements/Limits: BD
ammonium chloride vial............................................1
calcium gluconate vial ..............................................1
Requirements/Limits: PA
CHEMET CAPSULE ...............................................3
CLINIMIX IV SOLN................................................3
Strength: 2.75%, 5 %
Requirements/Limits: BD
clinimix iv soln ..........................................................1
Strength: 4.25 %
Requirements/Limits: BD
CLINIMIX E IV SOLN ............................................3
Requirements/Limits: BD
CLINISOL IV SOLN................................................3
Requirements/Limits: BD
CUPRIMINE CAPSULE..........................................2
cyanocobalamin vial .................................................1
Requirements/Limits: *
cyanocobalamin injection vial ..................................1
Requirements/Limits: *
cytra-k solution .........................................................1
denta 5000 plus cream .............................................1
dentagel gel ..............................................................1
DEPEN TABLET .....................................................3
dextrose 10%-0.2% nacl dehp fr bg..........................1
dextrose 10%-1/4ns iv soln .......................................1
DEXTROSE 10%-1/4NS-KCL IV SOLN................3
dextrose 5%-0.2% nacl-kcl iv soln............................1
dextrose 5%-0.3% nacl-kcl iv soln............................1
dextrose 5%-0.33% nacl-kcl iv soln..........................1
dextrose 5%-0.45% nacl-kcl iv soln..........................1
Drug Tier
dextrose 5%-1/2ns-kcl iv soln ...................................1
dextrose 5%-1/4ns-kcl iv soln. ..................................1
dextrose 5%-1/4ns-kcl iv soln ...................................1
dextrose 5%-electrolyte #48 iv soln ..........................1
dextrose 5%-ns-kcl iv soln ........................................1
dextrose 5%-potassium chloride iv soln ...................1
dextrose in lactated ringers iv soln ...........................1
dextrose in ringers injection iv soln..........................1
dextrose in water syringe ..........................................1
dextrose in water iv soln. ..........................................1
dextrose in water vial................................................1
dextrose in water iv soln ...........................................1
Strength: 10 %, 2.5 %, 60 %
DEXTROSE W/ELECTROLYTE A IV SOLN. ......3
DEXTROSE W/ELECTROLYTE B IV SOLN. ......3
dextrose with sodium chloride iv soln.......................1
dextrose with sodium chloride iv soln.......................1
ed k+10 tablet sa.......................................................1
EXJADE TAB DISPER............................................3
FERRIPROX TABLET ............................................3
Requirements/Limits: PA
folic acid tablet .........................................................1
Requirements/Limits: *
FREAMINE HBC IV SOLN ....................................3
Requirements/Limits: BD
freamine iii iv soln ....................................................1
Requirements/Limits: BD
fructose iv soln ..........................................................1
fructose-electrolyte no.48 iv soln ..............................1
fructose-electrolyte no.75 iv soln ..............................1
hepatamine iv soln ....................................................1
Requirements/Limits: BD
HEPATASOL IV SOLN...........................................3
Requirements/Limits: BD
IONOSOL B WITH DEXTROSE 5% IV SOLN .....3
IONOSOL MB-DEXTROSE 5% IV SOLN.............3
IONOSOL T-DEXTROSE 5% IV SOLN ................3
ISOLYTE E IV SOLN..............................................3
ISOLYTE H W/DEXTROSE IV SOLN...................3
ISOLYTE M W/DEXTROSE IV SOLN. .................3
ISOLYTE P WITH DEXTROSE IV SOLN.............3
isolyte r w/dextrose iv soln........................................1
ISOLYTE S IV SOLN ..............................................3
ISOLYTE S WITH DEXTROSE IV SOLN.............3
kionex oral susp ........................................................1
klor-con packet..........................................................1
klor-con 10 tablet er..................................................1
klor-con 8 tablet er....................................................1
44
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Drug Name
Drug Tier Drug Name
Drug Tier
PROCALAMINE IV SOLN .....................................3
THERAPEUTIC NUTRIENTS/
Requirements/Limits: BD
MINERALS/ ELECTROLYTES (continued) PROSOL IV SOLN...................................................3
klor-con m15 tab er prt .............................................1 Requirements/Limits: BD
klor-con m20 tab er prt .............................................1 QUICK MIX WITH LYTES IV SOLN....................3
lactated ringers irrig soln .........................................1 Requirements/Limits: BD
lactated ringers iv soln..............................................1 RENACIDIN IRRIG SOLN .....................................3
MAGNESIUM CHLORIDE VIAL ..........................3 ringers injection iv soln ............................................1
magnesium sulfate vial..............................................1 ringers irrigation irrig soln ......................................1
MAGNESIUM SULFATE PIGGYBACK ...............3 sf 5000 plus cream ...................................................1
magnesium sulfate syringe ........................................1 sodium bicarbonate vial............................................1
MAGNESIUM SULFATE-D5W INFUS. BTL .......3 sodium bicarbonate iv soln. ......................................1
MEPHYTON TABLET ............................................3 sodium bicarbonate syringe......................................1
sodium chloride irrig soln.........................................1
Requirements/Limits: *
NEPHRAMINE IV SOLN........................................3 sodium chloride iv soln .............................................1
sodium chloride iv soln. ............................................1
Requirements/Limits: BD
normosol-m and dextrose iv soln ..............................1 sodium chloride vial..................................................1
Strength: 0.9 %
normosol-r and dextrose iv soln................................1
sodium
chloride vial..................................................1
NORMOSOL-R PH 7.4 IV SOLN ...........................3
Strength:
2.5 meq/ml, 4 meq/ml
NOVAMINE IV SOLN ............................................3
sodium
fluoride
solution ...........................................1
Requirements/Limits: BD
sodium
lactate
vial
....................................................1
PHOSPHA 250 NEUTRAL TABLET .....................3
physiolyte irrig soln ..................................................1 SODIUM LACTATE IV SOLN...............................3
physiosol irrig soln ...................................................1 sodium polystyrene sulfonate enema ........................1
PLASMA-LYTE 148 IV SOLN ...............................3 sps oral susp..............................................................1
PLASMA-LYTE 56 IN DEXTROSE IV SOLN ......3 SYPRINE CAPSULE ...............................................3
PLASMA-LYTE A PH 7.4 IV SOLN ......................3 TIS-U-SOL IRRIG SOLN ........................................3
PLASMA-LYTE M IN DEXTROSE IV SOLN.......3 tpn electrolytes ii vial................................................1
potassium bicarbonate tablet eff ...............................1 TRAVASOL IV SOLN.............................................3
potassium chl-normal saline iv soln..........................1 Requirements/Limits: BD
potassium chloride packet.........................................1 TRAVASOL IV SOLN.............................................3
potassium chloride vial .............................................1 Requirements/Limits: BD
potassium chloride capsule er...................................1 TRAVASOL W/DEXTROSE IV SOLN..................3
potassium chloride liquid..........................................1 Requirements/Limits: BD
potassium chloride tablet er......................................1 TRAVASOL W/ELECTROLYTES IV SOLN. .......3
Requirements/Limits: BD
potassium chloride tab er prt ....................................1
TRAVASOL WITH DEXTROSE IV SOLN ...........3
potassium chloride piggyback...................................1 Requirements/Limits: BD
POTASSIUM CHLORIDE IN D5LR IV SOLN......3 TRAVASOL WITH ELECTROLYTES IV SOLN..3
POTASSIUM CHLORIDE-NACL IV SOLN..........3 Requirements/Limits: BD
potassium citrate tablet er.........................................1 tri-vitamin with fluoride drops..................................1
potassium citrate er tablet er ....................................1 TROPHAMINE IV SOLN........................................3
potassium citrate-citric acid packet..........................1 Requirements/Limits: BD
potassium gluconate elixir ........................................1 vitamin d2 capsule ....................................................1
PREMASOL IV SOLN.............................................3 Requirements/Limits: *
Requirements/Limits: BD
PRENATAL 19 TABLET ........................................3
PRENATAL PLUS TABLET...................................3
PREVIDENT PASTE ..............................................3
45
You can find information on what the symbols and abbreviations on this table mean by going to page V.
Index of Drugs
8
8-MOP .......................................27
A
abacavir .....................................17
abacavir-lamivudinezidovudine ..................................17
ABELCET .................................10
ABILIFY....................................16
ABILIFY DISCMELT...............16
ABILIFY MAINTENA .............16
ABRAXANE .............................13
ABSORICA ...............................27
ABSTRAL ...................................1
acamprosate calcium ...................2
ACANYA ..................................27
acarbose .....................................19
acebutolol hcl .............................22
acetaminophen-codeine ...............1
acetasol hc .................................40
acetazolamide ............................39
acetazolamide sodium ................22
acetic acid ..................................40
acetylcysteine .............................41
acitretin ......................................27
ACTEMRA ................................35
ACTHIB ....................................35
ACTIMMUNE ...........................35
ACTIQ .........................................1
ACTOPLUS MET XR ...............19
ACUVAIL .................................39
acyclovir ....................................17
acyclovir sodium ........................44
ACZONE ...................................27
ADACEL TDAP ........................35
ADAGEN ..................................28
adapalene ...................................27
ADASUVE ................................16
ADCETRIS ................................13
ADCIRCA .................................41
adefovir dipivoxil .......................17
ADEMPAS ................................41
adriamycin .................................13
adrucil ........................................13
ADVAIR DISKUS ....................41
ADVAIR HFA ...........................41
ADVICOR .................................22
afeditab cr ..................................22
AFINITOR .................................13
AFINITOR DISPERZ ...............13
AGGRENOX .............................21
a-hydrocort ................................30
AKNE-MYCIN............................3
ala-cort ......................................30
ALA-SCALP .............................30
ALBENZA .................................15
albuterol sulfate .........................41
ALCAINE ....................................2
alclometasone
dipropionate ...............................30
ALCOHOL PADS .....................38
ALDACTAZIDE .......................22
ALDURAZYME .......................28
alendronate sodium ...................38
ALFERON N .............................17
alfuzosin hcl er ...........................29
ALIMTA ....................................13
ALINIA......................................15
ALKERAN ................................13
allopurinol .................................11
allopurinol sodium .....................11
ALOCRIL ..................................39
ALOMIDE .................................39
ALORA......................................32
ALOXI .........................................9
ALPHAGAN P ..........................39
alprazolam .................................19
alprazolam odt ...........................19
alprazolam xr .............................19
ALREX ......................................39
ALSUMA ..................................12
ALTABAX ..................................3
altavera ......................................32
ALTOPREV ..............................22
alyacen .......................................32
amantadine ................................17
AMBIEN....................................43
AMBIEN CR .............................43
AMBISOME ..............................10
amcinonide .................................30
a-methapred ...............................30
46
amethia ......................................32
amethia lo ..................................32
amethyst .....................................32
amifostine ...................................13
amikacin sulfate ...........................3
amiloride hcl ..............................22
amiloridehydrochlorothiazide ...................22
aminophylline ............................41
AMINOSYN ..............................44
AMINOSYN II ..........................44
AMINOSYN M .........................44
AMINOSYN WITH
ELECTROLYTES .....................44
AMINOSYN-HBC ....................44
AMINOSYN-PF ........................44
AMINOSYN-RF .......................44
amiodarone hcl ..........................22
amitriptyline hcl ...........................8
amlodipine besylate ...................22
amlodipine besylatebenazepril ..................................22
amlodipine-atorvastatin .............22
ammonium chloride ...................44
ammonium lactate ......................27
amnesteem .................................27
amox tr-potassium
clavulanate ...................................3
amoxapine ....................................8
amoxicillin ...................................3
amoxicillin-clavulanate
er ..................................................3
amphetamine salt combo ...........26
amphotericin b ...........................10
ampicillin sodium ........................3
ampicillin trihydrate ....................3
ampicillin-sulbactam ...................3
AMPYRA ..................................26
AMTURNIDE ...........................22
ANACAINE ..............................27
ANADROL-50 ..........................32
anagrelide hcl ............................21
anastrozole .................................13
ANDRODERM .........................32
ANDROGEL .............................32
Index of Drugs
ANDROID .................................32
androxy ......................................32
ANGELIQ..................................32
ANORO ELLIPTA ....................41
apexicon e ..................................30
APLENZIN ..................................8
APOKYN ...................................16
apraclonidine hcl .......................39
apri .............................................32
APTIOM ......................................6
APTIVUS ..................................17
ARALAST NP ...........................41
aranelle ......................................32
ARANESP .................................21
ARCALYST ..............................35
ARISTOSPAN ...........................30
ARIXTRA..................................21
ARRANON................................13
ARZERRA .................................13
ASACOL HD.............................37
ascomp with codeine ....................1
ASMANEX................................41
aspirin-caffeinedihydrocodein ..............................1
ASTAGRAF XL ........................35
astramorph-pf ..............................1
ATELVIA ..................................38
atenolol ......................................22
atenolol-chlorthalidone .............22
ATGAM .....................................35
atorvastatin calcium ..................22
atovaquone .................................15
atovaquone-proguanil hcl ..........15
ATRALIN ..................................27
ATRIPLA ..................................17
atropine sulfate ....................28, 38
ATROVENT HFA .....................41
AUBAGIO .................................26
aubra ..........................................32
AUGMENTIN .............................3
AVANDAMET..........................19
AVANDARYL ..........................19
AVANDIA .................................19
AVASTIN ..................................13
AVELOX IV ................................3
aviane .........................................32
avita ...........................................27
AVODART ................................29
AVONEX ..................................26
AVONEX
ADMINISTRATION
PACK.........................................26
AXERT ......................................12
azacitidine ..................................13
AZACTAM-ISOOSMOTIC DEXTROSE .............3
AZASAN ...................................35
AZASITE .....................................3
azathioprine ...............................35
azathioprine sodium ..................35
azelastine hcl .......................39, 41
AZELEX ....................................27
AZILECT ...................................16
azithromycin ................................3
AZOPT ......................................39
AZOR ........................................22
aztreonam ....................................3
azurette ......................................32
B
baciim ..........................................3
bacitracin .....................................3
bacitracin-polymyxin ...................3
baclofen .....................................17
balsalazide disodium .................37
balziva ........................................32
BANZEL .....................................6
BARACLUDE ...........................17
BCG VACCINE (TICE
STRAIN) ...................................35
BECONASE AQ .......................41
benazepril hcl ............................22
benazeprilhydrochlorothiazide ...................22
BENICAR ..................................23
BENICAR HCT .........................23
BENLYSTA ..............................35
BENTYL ...................................28
BENZAMYCINPAK .................27
benzonatate ................................41
benztropine mesylate .................16
47
BEPREVE .................................39
BESIVANCE ...............................3
betamethasone
dipropionate...............................30
betamethasone valerate .............30
BETASERON ............................26
betaxolol hcl ........................23, 39
bethanechol chloride .................29
BETHKIS ....................................3
BETIMOL .................................39
BETOPTIC S .............................39
BEYAZ ......................................32
bicalutamide ..............................35
BICILLIN C-R ............................3
BICILLIN L-A ............................3
BICNU .......................................13
BIDIL.........................................23
BILTRICIDE .............................15
BINOSTO ..................................38
BIOTHRAX...............................35
bisoprolol fumarate ...................23
bisoprololhydrochlorothiazide ...................23
BIVIGAM ..................................35
bleomycin sulfate .......................13
BLEPHAMIDE .........................39
BLEPHAMIDE S.O.P. ..............39
BONIVA ....................................38
BOOSTRIX TDAP ....................35
BOSULIF...................................13
BOTOX .....................................38
BREO ELLIPTA .......................41
briellyn .......................................32
BRILINTA.................................21
brimonidine tartrate ..................39
BRINTELLIX ..............................8
bromfenac sodium......................39
bromocriptine mesylate .............35
BROVANA ...............................41
budesonide .................................41
budesonide ec ............................37
bumetanide.................................23
BUPHENYL ..............................28
BUPRENEX ................................1
buprenorphine hcl........................1
Index of Drugs
buprenorphine-naloxone ..............2
buproban ......................................2
bupropion hcl ...............................8
bupropion hcl sr .......................2, 8
bupropion xl .................................8
buspirone hcl .............................19
BUSULFEX ...............................13
butalb-acetaminoph-caffcodein ...........................................1
butalb-caff-acetaminophcodein ...........................................1
butalbital compoundcodeine .........................................1
butalbitalacetaminophen-caffe ....................1
butalbital-aspirincaffeine .........................................1
butorphanol tartrate ....................1
BUTRANS ...................................1
BYDUREON .............................19
BYDUREON PEN.....................19
BYETTA....................................19
BYSTOLIC ................................23
C
cabergoline ................................35
CAFERGOT ..............................12
calcipotriene ..............................27
calcipotrienebetamethasone dp ......................27
calcitonin-salmon ......................38
calcitrene ...................................27
calcitriol ...............................27, 38
calcium acetate ..........................29
calcium gluconate ......................44
CALDOLOR ..............................11
camila ........................................32
camrese ......................................32
camrese lo ..................................32
CANASA ...................................37
CANCIDAS ...............................10
candesartan cilexetil ..................23
candesartanhydrochlorothiazid .....................23
CANTIL .....................................28
CAPASTAT SULFATE ............12
CAPEX SHAMPOO ..................30
CAPRELSA ...............................13
captopril .....................................23
captoprilhydrochlorothiazide ...................23
CARAC......................................27
CARAFATE ..............................28
CARBAGLU .............................28
carbamazepine .............................6
carbamazepine er.........................6
carbamazepine xr.........................6
carbidopa ...................................16
carbidopa-levodopa ...................16
carbidopa-levodopa er...............16
carbidopa-levodopaentacapone .................................16
carboplatin .................................13
CARDENE I.V. .........................23
CARDENE SR...........................23
CARDURA XL .........................23
CARIMUNE NF
NANOFILTERED .....................35
carisoprodol ...............................43
carisoprodol-aspirin ..................43
carisoprodol-aspirincodeine .......................................43
CARNITOR ...............................39
CARNITOR SF .........................39
carteolol hcl ...............................39
cartia xt ......................................23
carvedilol ...................................23
CAYSTON ..................................3
cefaclor ........................................3
cefaclor er ....................................3
cefadroxil .....................................3
cefazolin .......................................3
cefazolin sodium ..........................3
cefdinir .........................................3
cefepime hcl .................................3
cefotaxime sodium .......................3
cefotetan .......................................3
cefotetan & dextrose ....................3
cefoxitin........................................3
cefoxitin sodium ...........................3
cefpodoxime proxetil ....................3
48
cefprozil .......................................3
ceftazidime ...................................3
ceftibuten .....................................3
CEFTIN .......................................3
CEFTRIAXONE .........................3
CEFUROXIME ...........................3
cefuroxime sodium .......................3
CELEBREX ...............................11
CELESTONE ............................30
CELLCEPT ...............................35
CELONTIN .................................6
CENESTIN ................................32
centany .........................................3
centany at .....................................3
cephalexin ....................................3
CEREZYME ..............................28
CERUBIDINE ...........................13
CERVARIX ...............................36
CESAMET ...................................9
CETRAXAL ................................3
cevimeline hcl ............................27
CHANTIX ...................................2
chateal .......................................33
CHEMET ...................................44
CHENODAL .............................39
chloramphenicol sod
succinate ......................................3
chlordiazepoxide hcl ..................19
chlordiazepoxideamitriptyline ...............................19
chlorhexidine gluconate ............27
chloroquine phosphate ..............15
chlorothiazide ............................23
chlorothiazide sodium ................23
chlorpromazine hcl ....................16
chlorpropamide .........................20
chlorthalidone ............................23
chlorzoxazone ............................43
cholestyramine ...........................23
chorionic gonadotropin .............32
CIALIS ......................................29
CICLODAN ...............................10
ciclopirox ...................................10
cidofovir .....................................17
cilostazol ....................................21
Index of Drugs
CILOXAN ...................................3
cimetidine ...................................28
cimetidine hcl .............................28
CIMZIA .....................................36
CINRYZE ..................................21
CIPRO..........................................3
CIPRO HC .................................40
CIPRODEX ...............................40
ciprofloxacin ................................3
ciprofloxacin er ............................3
ciprofloxacin hcl ..........................3
ciprofloxacin-d5w ........................4
cisplatin......................................13
citalopram hbr .............................8
cladribine ...................................13
claravis ......................................27
clarithromycin..............................4
clarithromycin er .........................4
clemastine fumarate ...................41
CLEOCIN ....................................4
CLEVIPREX .............................23
CLIMARA .................................33
CLIMARA PRO ........................33
CLINDACIN ETZ .......................4
CLINDACIN P ............................4
CLINDAGEL ..............................4
clindamycin hcl ............................4
clindamycin palmitate hcl ............4
clindamycin phosphate ................4
clindamycin phosphated5w ...............................................4
clindamycin-benzoyl
peroxide .....................................27
CLINDESSE ................................4
CLINIMIX .................................44
CLINIMIX E .............................44
CLINISOL .................................44
clobetasol propionate ................30
CLOBEX ...................................30
clocortolone pivalate .................30
CLOLAR ...................................13
clomipramine hcl .........................8
clonazepam ..................................6
clonidine ....................................23
clonidine hcl...............................23
clonidine hcl er ..........................26
clopidogrel .................................21
clorazepate dipotassium ..............6
CLORPRES ...............................23
clotrimazole ...............................10
clotrimazolebetamethasone ...........................10
clozapine ....................................16
clozapine odt ..............................16
COARTEM ................................15
codeine sulfate .............................1
COLCRYS .................................11
colestipol hcl ..............................23
colistimethate sodium ..................4
colocort ......................................37
COLY-MYCIN S ......................40
COMBIGAN .............................39
COMBIPATCH .........................33
COMBIVENT
RESPIMAT ...............................41
COMBIVIR ...............................17
COMETRIQ ..............................13
comfort paccyclobenzaprine .........................43
comfort pac-ibuprofen ...............11
comfort pac-meloxicam .............11
comfort pac-naproxen ................11
comfort pac-tizanidine ...............17
COMPLERA .............................17
compro .........................................9
COMVAX .................................36
CONDYLOX .............................27
constulose ..................................28
COPAXONE .............................26
COPEGUS .................................17
CORDRAN ................................30
COREG CR ...............................23
CORTENEMA ..........................38
CORTIFOAM ............................30
cortisone acetate ........................30
CORTISPORIN .....................4, 39
CORTISPORIN-TC ...................40
COSMEGEN .............................13
COSOPT PF ..............................39
COUMADIN .............................21
49
CREON ......................................28
CRESTOR .................................23
CRIXIVAN ................................17
CROFAB ...................................39
cromolyn sodium..................39, 41
cryselle .......................................33
CUBICIN .....................................4
CUPRIMINE .............................44
CUROSURF ..............................39
CUVPOSA.................................28
cyanocobalamin .........................44
cyanocobalamin injection ..........44
cyclafem .....................................33
cyclobenzaprine hcl ...................43
CYCLOGYL .............................39
cyclopentolate hcl ......................39
cyclophosphamide .....................13
cycloserine .................................12
CYCLOSET...............................20
cyclosporine ...............................36
cyclosporine modified ................36
CYKLOKAPRON .....................21
cyproheptadine hcl ....................41
CYRAMZA ...............................13
CYSTADANE ...........................28
CYSTAGON .............................28
CYSTARAN ..............................39
cytarabine ..................................13
CYTOGAM ...............................39
CYTOMEL ................................34
cytra-k ........................................44
D
D.H.E.45 ....................................12
dacarbazine ...............................13
DACOGEN ................................13
DALIRESP ................................41
danazol.......................................33
dantrolene sodium .....................17
dapsone ......................................12
DAPTACEL DTAP ...................36
DARAPRIM ..............................15
dasetta ........................................33
daunorubicin hcl ........................13
DAUNOXOME .........................13
Index of Drugs
daysee ........................................33
DAYTRANA .............................26
DDAVP......................................32
decitabine ...................................13
deferoxamine mesylate ...............39
DELATESTRYL .......................33
DELESTROGEN .......................33
delyla..........................................33
DELZICOL ................................38
demeclocycline hcl .......................4
DEMSER ...................................23
DENAVIR .................................17
denta 5000 plus ..........................44
dentagel......................................44
DEPACON ..................................6
DEPADE......................................2
DEPAKENE ................................6
DEPAKOTE ................................6
DEPAKOTE ER ..........................6
DEPAKOTE SPRINKLE ............6
DEPEN ......................................44
DEPO-ESTRADIOL .................33
DEPO-MEDROL .......................30
DEPO-SUBQ PROVERA
104 .............................................33
DESFERAL ...............................39
desipramine hcl ............................8
desloratadine .............................41
desmopressin acetate .................32
desogestrel-ethinyl
estradiol .....................................33
DESONATE ..............................30
desonide .....................................30
desoximetasone ..........................30
desvenlafaxine er .........................8
DESVENLAFAXINE
FUMARATE ER .........................8
dexamethasone ...........................30
dexamethasone intensol .............30
dexamethasone sodium
phosphate .............................30, 40
DEXILANT ...............................28
dexmethylphenidate hcl .............26
dexmethylphenidate hcl er .........26
dexrazoxane ...............................13
dextroamphetamine
sulfate .........................................26
dextroamphetamine
sulfate er ....................................26
dextroamphetamineamphetamine ..............................26
dextrose 10%-0.2% nacl ............44
dextrose 10%-1/4ns ...................44
DEXTROSE 10%-1/4NSKCL ...........................................44
dextrose 5%-0.2% naclkcl ...............................................44
dextrose 5%-0.3% naclkcl ...............................................44
dextrose 5%-0.33% naclkcl ...............................................44
dextrose 5%-0.45% naclkcl ...............................................44
dextrose 5%-1/2ns-kcl ...............44
dextrose 5%-1/4ns-kcl ...............44
dextrose 5%-electrolyte
#48 .............................................44
dextrose 5%-ns-kcl.....................44
dextrose 5%-potassium
chloride ......................................44
dextrose in lactated
ringers ........................................44
dextrose in ringers
injection .....................................44
dextrose in water..................39, 44
DEXTROSE W/
ELECTROLYTE A ...................44
DEXTROSE W/
ELECTROLYTE B ...................44
dextrose with sodium
chloride ......................................44
diazepam ....................................19
DIBENZYLINE .........................23
diclofenac potassium .................11
diclofenac sodium ..........11, 27, 40
diclofenac sodium er ..................11
diclofenac sodiummisoprostol ................................11
dicloxacillin sodium .....................4
dicyclomine hcl ..........................28
didanosine ..................................17
DIFFERIN .................................27
50
DIFICID .......................................4
diflorasone diacetate .................31
diflunisal ....................................11
DIGIFAB ...................................39
digox ..........................................23
DIGOXIN ..................................23
dihydroergotamine
mesylate .....................................12
DILANTIN ..................................6
DILANTIN-125 ...........................6
DILATRATE-SR .......................23
diltiazem 24hr cd .......................23
diltiazem 24hr er ........................23
diltiazem er ................................23
diltiazem hcl ...............................23
dilt-xr .........................................23
DIOVAN ...................................23
DIPENTUM ...............................38
diphenhydramine hcl .................41
diphenoxylate-atropine ..............28
DIPHTHERIATETANUS TOXOIDSPED ............................................36
dipyridamole ..............................21
diskets ..........................................1
disulfiram .....................................2
divalproex sodium ........................6
divalproex sodium er ...................6
DIVIGEL ...................................33
DOCEFREZ ...............................13
docetaxel ....................................13
donepezil hcl ................................8
donepezil hcl odt ..........................8
DORIBAX ...................................4
dorzolamide hcl .........................40
dorzolamide-timolol ...................40
doxazosin mesylate ....................29
doxepin hcl ...................................8
doxercalciferol ...........................38
DOXIL .......................................13
doxorubicin hcl ..........................13
doxorubicin hcl liposome ...........13
doxy 100 .......................................4
doxycycline hyclate ......................4
doxycycline monohydrate ............4
Index of Drugs
doxy-lemmon ................................4
dronabinol....................................9
drospirenone-ethinyl
estradiol .....................................33
DROXIA ....................................13
DUAVEE ...................................33
DUEXIS .....................................11
DULERA ...................................41
duloxetine hcl ...............................8
duramorph ...................................1
DUREZOL .................................40
DYRENIUM ..............................23
E
E.E.S. 200 ....................................4
e.e.s. 400 ......................................4
ECLIPSE LUER-LOK
SYRINGE ..................................39
econazole nitrate ........................10
ECOZA ......................................10
ed k+10 ......................................44
EDARBI ....................................23
EDARBYCLOR ........................23
EDECRIN ..................................23
EDLUAR ...................................43
EDURANT ................................17
EFFIENT ...................................22
EGRIFTA ..................................32
ELAPRASE ...............................28
ELELYSO..................................28
ELESTRIN ................................33
ELIDEL .....................................27
ELIGARD ..................................35
elinest .........................................33
eliphos ........................................29
ELIQUIS ....................................22
ELITEK .....................................13
ELIXOPHYLLIN ......................41
ELLA .........................................33
ELLENCE..................................13
ELMIRON .................................29
ELOXATIN ...............................13
ELSPAR ....................................13
EMADINE .................................40
EMCYT .....................................13
EMEND .......................................9
EMLA ..........................................2
emoquette ...................................33
EMSAM .......................................8
EMTRIVA .................................17
ENABLEX .................................29
enalapril maleate .......................23
enalaprilhydrochlorothiazide ...................23
ENBREL ....................................36
endocet .........................................1
endodan .......................................1
ENGERIX-B ADULT ...............36
ENGERIX-B
PEDIATRICADOLESCENT .........................36
ENJUVIA ..................................33
enoxaparin sodium ....................22
enpresse .....................................33
enskyce .......................................33
entacapone .................................16
ENTOCORT EC ........................38
enulose .......................................28
EPIDUO .....................................27
epinastine hcl .............................40
EPINEPHRINE .........................41
EPIPEN 2-PAK .........................41
EPIPEN JR 2-PAK ....................41
epirubicin hcl .............................13
epitol ............................................6
EPIVIR ......................................17
EPIVIR HBV .............................17
eplerenone .................................23
EPOGEN ...................................22
epoprostenol sodium ..................41
eprosartan mesylate ...................23
EPZICOM ..................................17
EQUETRO .................................19
ERAXIS (WATER
DILUENT) .................................10
ERBITUX ..................................13
ergoloid mesylates .......................8
ERGOMAR ...............................12
ergotamine-caffeine ...................12
ERIVEDGE ...............................13
errin ...........................................33
51
ERTACZO .................................10
ERWINAZE ..............................13
ery ................................................4
ERYGEL .....................................4
ERYPED 200 ...............................4
ERYPED 400 ...............................4
ery-tab ..........................................4
ERYTHROCIN
LACTOBIONATE ......................4
ERYTHROCIN
STEARATE .................................4
erythromycin ................................4
erythromycin
ethylsuccinate ..............................4
erythromycin-benzoyl
peroxide .....................................27
erythromycinsulfisoxazole.................................4
escitalopram oxalate....................8
esomeprazole sodium .................28
estarylla .....................................33
ESTRACE .................................33
estradiol .....................................33
estradiol valerate .......................33
estradiol-norethindrone
acetat .........................................33
ESTRASORB ............................33
ESTRING ..................................33
ESTROGEL ...............................33
estropipate .................................33
eszopiclone.................................43
ethambutol hcl ...........................12
ethosuximide ................................6
etidronate disodium ...................38
etodolac .....................................11
etodolac er .................................11
ETOPOPHOS ............................13
etoposide ....................................13
EURAX .....................................15
EVAMIST .................................33
EVOCLIN ....................................4
EXALGO .....................................1
EXELDERM .............................10
EXELON .....................................8
exemestane .................................13
Index of Drugs
EXJADE ....................................44
EXTAVIA..................................26
EXTINA ....................................10
F
FABRAZYME ...........................28
FACTIVE ....................................4
falmina .......................................33
famciclovir .................................17
famotidine ..................................28
FANAPT ....................................16
FARESTON ...............................13
FASLODEX ..............................13
FAZACLO .................................16
felbamate......................................6
FELBATOL .................................6
felodipine er ...............................23
FEMHRT ...................................33
FEMRING .................................33
fenofibrate ..................................23
fenofibric acid ............................23
FENOGLIDE .............................23
fenoprofen calcium ....................11
fentanyl ........................................1
fentanyl citrate .............................1
FENTORA ...................................1
FERRIPROX .............................44
FETZIMA ....................................8
FINACEA ..................................27
FINACEA PLUS .......................27
finasteride ..................................29
FIRAZYR ..................................39
FIRMAGON ..............................13
FLAGYL ER ...............................4
FLAREX ....................................40
flavoxate hcl ...............................29
FLEBOGAMMA DIF ...............36
flecainide acetate .......................23
FLECTOR..................................11
FLOLAN....................................41
FLOVENT DISKUS ..................41
FLOVENT HFA ........................41
FLOXIN .......................................4
fluconazole .................................10
fluconazole in saline ..................10
flucytosine ..................................10
fludarabine phosphate ...............14
fludrocortisone acetate ..............31
flunisolide ..................................41
fluocinolone acetonide ...............31
fluocinolone acetonide oil..........40
fluocinonide ...............................31
fluorometholone .........................40
FLUOROPLEX .........................27
fluorouracil ..........................14, 27
fluoxetine dr .................................8
fluoxetine hcl ................................8
fluphenazine decanoate .............16
fluphenazine hcl .........................16
flurbiprofen ................................11
flurbiprofen sodium ...................40
flutamide ....................................35
fluticasone propionate .........31, 41
fluvastatin sodium ......................23
fluvoxamine maleate ....................8
FML FORTE .............................40
FML S.O.P. ................................40
folic acid ....................................44
FOLOTYN .................................14
fomepizole ..................................39
fondaparinux sodium .................22
FORADIL ..................................41
FORTAZ ......................................4
FORTEO ....................................38
fortical........................................38
FOSAMAX PLUS D .................38
foscarnet sodium ........................18
fosinopril sodium .......................24
fosinoprilhydrochlorothiazide ...................24
fosphenytoin sodium ....................6
FOSRENOL ...............................29
FRAGMIN .................................22
FREAMINE HBC ......................44
freamine iii .................................44
FROVA ......................................12
fructose ......................................44
fructose-electrolyte no.48 ..........44
fructose-electrolyte no.75 ..........44
FUDR .........................................14
52
FULYZAQ .................................39
furosemide .................................24
FUSILEV ...................................14
FUZEON ...................................18
FYCOMPA ..................................6
G
gabapentin ...................................6
GABITRIL ...................................7
GABLOFEN ..............................36
galantamine hbr ...........................8
galantamine
hydrobromide ...............................8
GAMMAGARD LIQUID .........36
GAMMAKED ...........................36
GAMMAPLEX .........................36
GAMUNEX-C ...........................36
ganciclovir sodium ....................18
GARDASIL ...............................36
GASTROCROM .......................28
gatifloxacin ..................................4
GATTEX ...................................28
gavilyte-c ...................................28
gavilyte-g ...................................28
gavilyte-n ...................................28
GAZYVA ..................................14
GELNIQUE ...............................29
gemcitabine hcl ..........................14
gemfibrozil .................................24
GEMZAR ..................................14
GENERESS FE .........................33
generlac .....................................28
gengraf .......................................36
GENOTROPIN ..........................32
gentak ...........................................4
gentamicin sulfate ..................4, 40
gentamicin sulfate in ns ...............4
GEODON ..................................16
gianvi .........................................33
GIAZO .......................................38
gildagia ......................................33
gildess ........................................33
gildess fe ....................................33
GILENYA .................................26
GILOTRIF .................................14
GLASSIA ..................................41
Index of Drugs
GLEEVEC .................................14
glimepiride .................................20
glipizide......................................20
glipizide er .................................20
glipizide-metformin ....................20
GLUCAGEN .............................20
GLUCAGON
EMERGENCY KIT ...................20
GLUMETZA .............................20
glyburide ....................................20
glyburide micronized .................20
glyburide-metformin hcl ............20
glycopyrrolate ............................28
GLYSET ....................................20
GRALISE ....................................7
granisetron hcl .............................9
granisol ........................................9
GRANIX ....................................22
GRIFULVIN V ..........................10
griseofulvin ................................10
griseofulvin
ultramicrosize ............................10
guanfacine hcl ............................24
GUANIDINE HCL ....................12
H
H.P. ACTHAR ...........................31
HALAVEN ................................14
halobetasol propionate ..............31
HALOG .....................................31
haloperidol .................................16
haloperidol decanoate ...............16
haloperidol lactate .....................16
HAVRIX ....................................36
hctz/reserpine/
hydralazine ................................24
heather .......................................33
HECORIA..................................36
HECTOROL ..............................38
heparin flush ..............................22
heparin sodium ..........................22
heparin sodium in 5%
dextrose ......................................22
heparin sodium-d5w ..................22
heparin sodium-ns .....................22
hepatamine .................................44
HEPATASOL ............................44
HEPSERA .................................18
HERCEPTIN .............................14
HETLIOZ ..................................43
HEXALEN ................................14
HIZENTRA ...............................36
homatropaire .............................40
homatropine
hydrobromide .............................40
HORIZANT .................................7
HUMALOG ...............................20
HUMALOG MIX 50-50 ............20
HUMALOG MIX 75-25 ............20
HUMATROPE ..........................32
HUMIRA ...................................36
HUMULIN 70/30
KWIKPEN .................................20
HUMULIN 70-30 ......................20
HUMULIN N ............................20
HUMULIN N KWIKPEN .........20
HUMULIN R .............................20
HYCAMTIN ..............................14
hydralazine hcl ..........................24
hydralazine w/hctz .....................24
hydrochlorothiazide ...................24
hydrochlorothiazide/
reserpine ....................................24
hydrocodone bitibuprofen ......................................1
hydrocodone bthomatropine mbr .......................41
hydrocodoneacetaminophen .............................1
hydrocodonehomatropine mbr .......................41
hydrocodone-ibuprofen ...............1
hydrocortisone .....................31, 38
hydrocortisone butyrate .............31
hydrocortisone plus ...................31
hydrocortisone valerate .............31
hydromet ....................................41
hydromorphone er .......................1
hydromorphone hcl ......................1
hydroxychloroquine
sulfate .........................................15
hydroxyurea ...............................14
53
hydroxyzine hcl ..........................41
hydroxyzine pamoate .................19
I
ibandronate sodium ...................38
ibuprofen ....................................11
ICLUSIG ...................................14
IDAMYCIN PFS .......................14
idarubicin hcl .............................14
ifosfamide...................................14
ifosfamide-mesna .......................14
ILARIS ......................................36
ILEVRO.....................................40
IMBRUVICA ............................14
imipenem-cilastatin
sodium ..........................................4
imipramine hcl .............................8
IMIPRAMINE
PAMOATE ..................................8
imiquimod ..................................27
IMOVAX RABIES
VACCINE .................................36
INCIVEK ...................................18
INCRELEX ...............................32
indapamide ................................24
indomethacin .............................11
INFANRIX DTAP .....................36
INFUMORPH ..............................1
INLYTA ....................................14
INNOPRAN XL ........................12
INSULIN SYRINGE .................39
INTELENCE .............................18
INTERMEZZO ..........................43
intralipid ....................................39
INTRON A ................................18
introvale .....................................33
INVANZ ......................................4
INVEGA ....................................16
INVEGA SUSTENNA ..............16
INVIRASE.................................18
INVOKANA ..............................20
IONOSOL B WITH
DEXTROSE 5% ........................44
IONOSOL MBDEXTROSE 5% ........................44
Index of Drugs
IONOSOL TDEXTROSE 5% ........................44
IOPIDINE ..................................40
IPOL ..........................................36
ipratropium bromide ..................42
ipratropium-albuterol ................42
irbesartan ...................................24
irbesartanhydrochlorothiazide ...................24
irinotecan hcl .............................14
IRRIGATING
SOLUTION G ...........................39
ISENTRESS ..............................18
isochron .....................................24
isoditrate ....................................24
ISOLYTE E ...............................44
ISOLYTE H W/
DEXTROSE ..............................44
ISOLYTE M W/
DEXTROSE ..............................44
ISOLYTE P WITH
DEXTROSE ..............................44
isolyte r w/dextrose ....................44
ISOLYTE S ...............................44
ISOLYTE S WITH
DEXTROSE ..............................44
isoniazid .....................................12
ISOPTO ATROPINE.................39
isosorbide dinitrate ....................24
isosorbide mononitrate ..............24
isosorbide mononitrate er ..........24
isradipine ...................................24
ISTALOL ...................................40
ISTODAX ..................................14
ISUPREL ...................................42
itraconazole ...............................10
IXEMPRA .................................14
IXIARO .....................................36
J
JAKAFI......................................14
jantoven ......................................22
JANUMET .................................20
JANUMET XR ..........................20
JANUVIA ..................................20
jencycla ......................................33
JENTADUETO..........................20
JEVTANA .................................14
jinteli ..........................................33
jolessa ........................................33
jolivette ......................................33
JUBLIA......................................10
junel ...........................................33
junel fe .......................................33
JUXTAPID ................................24
K
KADCYLA ................................14
KADIAN......................................1
KALETRA .................................18
KALYDECO .............................42
kanamycin sulfate ........................4
KAPVAY ...................................26
kariva .........................................33
KAZANO ..................................20
kelnor 1-35 .................................33
KENALOG ................................31
KENALOG-10 ...........................31
KENALOG-40 ...........................31
KEPIVANCE .............................27
KEPPRA ......................................7
KEPPRA XR ...............................7
KETEK ........................................4
ketoconazole ..............................10
KETODAN ................................10
ketoprofen ..................................11
ketorolac tromethamine .......11, 40
KINERET ..................................36
KINRIX .....................................36
kionex .........................................44
klor-con ......................................44
klor-con 10 .................................44
klor-con 8 ...................................44
klor-con m15 ..............................45
klor-con m20 ..............................45
KOMBIGLYZE XR ..................21
KORLYM ..................................39
KRISTALOSE ...........................28
KRYSTEXXA ...........................28
kurvelo .......................................33
KUVAN .....................................28
54
KYNAMRO ...............................24
KYPROLIS ................................14
KYTRIL .......................................9
L
labetalol hcl ...............................24
LACRISERT .............................40
lactated ringers ..........................45
lactulose .....................................28
LAMICTAL ODT .......................7
LAMICTAL ODT
(BLUE) ........................................7
LAMICTAL ODT
(GREEN) .....................................7
LAMICTAL ODT
(ORANGE) ..................................7
LAMISIL ...................................10
lamivudine .................................18
lamivudine hbv ...........................18
lamivudine-zidovudine ...............18
lamotrigine ...................................7
lamotrigine er ..............................7
LANOXIN .................................24
LANOXIN PEDIATRIC ...........24
lansoprazol-amoxicilclarithro .......................................4
lansoprazole ...............................28
LANTUS ...................................21
LANTUS SOLOSTAR ..............21
larin ...........................................33
larin fe ........................................33
latanoprost .................................40
LATUDA ...................................17
LAZANDA ..................................1
leena ...........................................33
leflunomide ................................36
LESCOL XL ..............................24
lessina ........................................33
LETAIRIS .................................42
letrozole .....................................14
leucovorin calcium ....................14
LEUKERAN ..............................14
LEUKINE ..................................22
leuprolide acetate ......................35
levalbuterol hcl ..........................42
LEVATOL .................................24
Index of Drugs
LEVEMIR..................................21
LEVEMIR FLEXPEN ...............21
levetiracetam................................7
levetiracetam er ...........................7
levetiracetam-nacl .......................7
LEVITRA ..................................29
levobunolol hcl...........................40
levocarnitine ..............................39
levocetirizine
dihydrochloride..........................42
levofloxacin ..................................4
levofloxacin-d5w ..........................4
levonest ......................................33
levonorgestrel ............................33
levonorgestrel-eth
estradiol .....................................33
levonorg-eth estrad eth
estrad .........................................33
levora-28 ....................................33
levorphanol tartrate .....................1
levothyroxine sodium .................34
levoxyl ........................................34
LEXIVA ....................................18
lidocaine ......................................2
lidocaine hcl...........................2, 24
lidocaine hcl viscous ....................2
lidocaine-prilocaine .....................2
LINCOCIN ..................................4
lindane .......................................15
LINZESS ...................................28
liothyronine sodium ...................34
lipodox .......................................14
LIPOSYN II ...............................39
LIPOSYN III .............................39
LIPTRUZET ..............................24
lisinopril .....................................24
lisinoprilhydrochlorothiazide ...................24
lithium ........................................19
LITHIUM
CARBONATE ...........................19
LITHOSTAT .............................29
LIVALO ....................................24
LO LOESTRIN FE ....................33
LOCOID ....................................31
LOCOID LIPOCREAM ............31
LODOSYN ................................16
lomedia 24 fe .............................35
lomustine ....................................14
loperamide .................................28
lorazepam ..................................19
loryna .........................................33
losartan potassium .....................24
losartanhydrochlorothiazide ...................24
LOTEMAX ................................40
LOTRONEX ..............................28
lovastatin ...................................24
LOVENOX ................................22
low-ogestrel ...............................33
loxapine .....................................17
LUFYLLIN ................................42
LUMIZYME ..............................28
LUNESTA .................................43
LUPRON DEPOT .....................35
LUPRON DEPOT-PED ............35
lutera ..........................................33
LUZU .........................................10
LYRICA ................................7, 26
LYSODREN ..............................34
M
MACROBID ................................4
MACRODANTIN .......................4
mafenide acetate ..........................4
MAGNESIUM
CHLORIDE ...............................45
magnesium sulfate .....................45
MAGNESIUM
SULFATE-D5W ........................45
malathion ...................................15
maprotiline hcl .............................8
MARINOL ...................................9
marlissa .....................................33
MARPLAN ..................................8
MARQIBO ................................14
MATULANE .............................14
MAXIDEX ................................40
meclizine hcl ................................9
meclofenamate sodium ..............11
MEDROL ..................................31
55
medroxyprogesterone
acetate ........................................33
mefloquine hcl............................15
MEGACE ES .............................33
megestrol acetate .......................33
MEKINIST ................................14
MELOXICAM...........................11
melphalan hcl ............................14
MENACTRA .............................36
MENEST ...................................33
MENHIBRIX.............................36
MENOMUNE-A-C-YW-135 ........................................36
MENTAX ..................................10
MENVEO A-C-Y-W135-DIP .....................................36
MEPHYTON .............................45
MEPRON...................................15
mercaptopurine ..........................14
MERREM ....................................4
mesalamine ................................38
mesna .........................................14
MESNEX ...................................14
MESTINON...............................12
metadate er ................................26
metaproterenol sulfate ...............42
metaxalone .................................43
metformin hcl .............................21
metformin hcl er.........................21
methadone hcl ..............................1
methadone intensol ......................1
methadose ....................................1
methamphetamine hcl ................26
methazolamide ...........................24
methenamine hippurate ...............4
methenamine mandelate ..............4
methimazole ...............................35
METHITEST .............................33
methocarbamol ..........................43
methotrexate ..............................36
methotrexate sodium ..................36
methoxsalen ...............................27
methscopolamine
bromide ......................................28
methyclothiazide ........................24
Index of Drugs
methyldopa .................................24
methyldopa/
hydrochlorothiazide ...................24
methyldopate hcl ........................24
methylergonovine
maleate .......................................39
METHYLIN ..............................26
methylphenidate er.....................26
methylphenidate hcl ...................26
methylphenidate hcl cd ..............26
methylphenidate sr .....................26
methylprednisolone ..............31, 38
methylprednisolone
acetate ........................................31
methylprednisolone sod
succ ............................................31
metipranolol ...............................40
metoclopramide hcl .....................9
METOCLOPRAMIDE
HCL INTENSOL .........................9
metolazone .................................24
metoprolol succinate ..................24
metoprolol tartrate.....................24
metoprololhydrochlorothiazide ...................24
METOZOLV ODT ......................9
metronidazole ..............................4
METRYL .....................................5
mexiletine hcl .............................24
MIACALCIN .............................38
miconazole 3 ..............................10
microgestin ................................33
microgestin fe.............................33
midodrine hcl .............................24
MIFEPREX................................39
MIGRANAL ..............................12
mimvey lo ...................................33
MINASTRIN 24 FE ..................33
minitran ......................................24
minocycline hcl ............................5
minoxidil ....................................24
MIRAPEX ER ...........................16
mirtazapine ..................................8
misoprostol ................................28
mitomycin ...................................14
mitoxantrone hcl ........................14
M-M-R II VACCINE ................36
modafinil ....................................43
MODERIBA ..............................18
moexipril hcl ..............................24
moexiprilhydrochlorothiazide ...................24
mometasone furoate ...................31
mono-linyah ...............................33
mononessa..................................33
montelukast sodium ...................42
MONUROL .................................5
morphine sulfate ..........................1
morphine sulfate er ......................1
MOTOFEN ................................28
MOVIPREP ...............................29
MOXATAG .................................5
MOXEZA ....................................5
moxifloxacin hcl ...........................5
MOZOBIL .................................22
MULTAQ ..................................24
mupirocin .....................................5
MUSTARGEN ..........................14
MYALEPT ................................39
MYCAMINE .............................10
mycophenolate mofetil ...............36
mycophenolic acid .....................36
MYDRIACYL ...........................40
MYFORTIC ...............................36
myorisan ....................................27
MYOZYME ...............................28
MYRBETRIQ ............................29
myzilra .......................................33
N
nabumetone ................................11
nadolol .......................................24
nadololbendroflumethiazide ..................25
NAFCILL IN
DEXTROSE ................................5
nafcillin sodium ...........................5
NAFTIN .....................................10
NAGLAZYME ..........................28
nalbuphine hcl .............................1
NALFON ...................................11
56
nallpen-iso-osmotic
dextrose ........................................5
naloxone hcl .................................2
naltrexone hcl ..............................3
NAMENDA .................................8
NAMENDA XR ..........................8
naphazoline hcl ..........................40
NAPRELAN ..............................11
naproxen ....................................11
naproxen sodium ........................11
naratriptan hcl ...........................12
NASONEX ................................42
NATACYN ................................10
NATAZIA .................................33
nateglinide .................................21
NATROBA ................................15
NAVELBINE ............................14
NEBUPENT ..............................16
necon ..........................................34
nefazodone hcl .............................8
neomycin sulfate ..........................5
neomycin-bacitracinpoly-hc .........................................5
neomycin-bacitracinpolymyxin .....................................5
neomycin-polymyxin b .................5
neomycin-polymyxindexameth ....................................40
neomycin-polymyxingramicidin ....................................5
neomycin-polymyxin-hc .........5, 40
neomycin-polymyxinhydrocort ...................................40
neo-polycin ..................................5
NEORAL ...................................37
NEO-SYNALAR .........................5
NEPHRAMINE .........................45
NESINA .....................................21
NEULASTA ..............................22
NEUMEGA ...............................22
NEUPOGEN ..............................22
NEUPRO ...................................16
NEVANAC ................................40
nevirapine ..................................18
nevirapine er ..............................18
Index of Drugs
NEXAVAR ................................14
NEXIUM ...................................29
NEXIUM I.V. ............................29
next choice one dose ..................34
niacin er .....................................25
niacor .........................................25
nicardipine hcl ...........................25
NICOTROL .................................3
NICOTROL NS ...........................3
nifedical xl .................................25
nifedipine er ...............................25
NILANDRON............................35
nimodipine .................................25
NIPENT .....................................14
nisoldipine..................................25
NITRO-BID ...............................25
NITRO-DUR .............................25
nitrofurantoin ...............................5
nitroglycerin ..............................25
nitroglycerin patch.....................25
NITROLINGUAL .....................25
NITROMIST..............................25
NITROSTAT .............................25
nizatidine....................................29
nora-be .......................................34
NORDITROPIN
FLEXPRO..................................32
NORDITROPIN
NORDIFLEX .............................32
norethindrone ............................34
norethindrone acetate ................34
norethindron-ethinyl
estradiol .....................................34
norethin-eth estra ferrous
fum .............................................34
norgestimate-ethinyl
estradiol .....................................34
NORINYL 1+35 ........................34
NORINYL 1+50 ........................34
NORITATE .................................5
norlyroc......................................34
normosol-m and dextrose ..........45
normosol-r and dextrose ............45
NORMOSOL-R PH 7.4 .............45
NOROXIN ...................................5
nortrel ........................................34
nortriptyline hcl ...........................8
NORVIR ....................................18
NOVAMINE .............................45
novarel .......................................32
NOXAFIL ..................................10
NUCORT ...................................31
NUCYNTA ..................................1
NUCYNTA ER ............................2
NUEDEXTA .............................26
NULOJIX ..................................37
NUTROPIN ...............................32
NUTROPIN AQ
NUSPIN .....................................32
NUVARING ..............................34
NUVIGIL ...................................43
nyamyc .......................................10
nystatin .......................................10
nystatin-triamcinolone ...............10
nystop .........................................10
O
ocella .........................................34
OCTAGAM ...............................37
octreotide acetate ......................35
ofloxacin ......................................5
olanzapine ..................................17
olanzapine odt............................17
olanzapine-fluoxetine hcl ...........17
OLEPTRO ER .............................9
OLYSIO .....................................18
omega-3 acid ethyl esters ..........25
omeprazole .................................29
omeprazole-sodium
bicarbonate ................................29
OMNARIS .................................42
OMNITROPE ............................32
ONCASPAR ..............................14
ondansetron hcl ...........................9
ondansetron odt ...........................9
ONFI ............................................7
ONGLYZA ................................21
ONMEL .....................................10
OPANA ER .................................2
OPSUMIT ..................................42
ORACEA .....................................5
57
ORAP.........................................17
ORAPRED ODT .......................31
ORENCIA .................................37
ORENITRAM ER .....................42
ORFADIN .................................28
orphenadrine citrate ..................43
orphenadrine compound
forte ............................................43
orsythia ......................................34
ORTHO TRI-CYCLEN
LO ..............................................34
OSENI .......................................21
OSMOPREP ..............................29
otimar.........................................40
otomycet-hc ................................40
OXACILLIN ...............................5
oxacillin sodium ...........................5
oxaliplatin ..................................14
OXANDRIN ..............................34
oxandrolone ...............................34
oxaprozin ...................................11
oxazepam ...................................19
oxcarbazepine ..............................7
OXISTAT ..................................10
OXSORALEN ...........................27
OXSORALEN-ULTRA ............27
OXTELLAR XR..........................7
oxybutynin chloride ...................29
oxybutynin chloride er ...............29
oxycodone hcl ..............................2
oxycodone hclacetaminophen .............................2
oxycodone hcl-aspirin..................2
oxycodone hcl-ibuprofen .............2
oxycodoneacetaminophen .............................2
OXYCONTIN .............................2
oxymorphone hcl..........................2
oxymorphone hcl er .....................2
OXYTROL ................................29
P
pacerone ....................................25
paclitaxel ...................................14
pamidronate disodium ...............38
PANCREAZE ............................28
Index of Drugs
PANDEL....................................31
PANRETIN................................14
pantoprazole sodium ..................29
PARAFON FORTE DSC ..........43
paricalcitol .................................38
paromomycin sulfate ....................5
paroxetine hcl ..............................9
PASER .......................................12
PATADAY ................................40
PATANASE ..............................42
PATANOL .................................40
PAXIL..........................................9
PCE ..............................................5
PEDIARIX .................................37
pedi-dri ......................................11
PEDVAXHIB ............................37
peg 3350-electrolyte ..................29
peg 3350-grx ..............................29
peg-3350 ....................................29
peg-3350 and electrolytes ..........29
PEGANONE ................................7
PEGASYS..................................18
PEGASYS PROCLICK .............18
PEGINTRON .............................18
PEGINTRON REDIPEN ...........18
PEN NEEDLE ...........................39
penicillin g potassium ..................5
penicillin g potassium in
d5w ...............................................5
penicillin g procaine ....................5
penicillin g sodium .......................5
penicillin gk-iso-osm
dextrose ........................................5
penicillin v potassium ..................5
PENTACEL ...............................37
PENTACEL ACTHIB
COMPONENT ..........................37
PENTACEL DTAP-IPV
COMPONENT ..........................37
PENTAM 300 ............................16
pentazocine-naloxone hcl ............2
pentostatin..................................14
pentoxifylline ..............................25
PERFOROMIST ........................42
perindopril erbumine .................25
periogard ...................................27
PERJETA ...................................14
permethrin..................................16
perphenazine ..............................17
perphenazineamitriptyline ...............................17
PEXEVA......................................9
PFIZERPEN ................................5
phenadoz ......................................9
phenelzine sulfate.........................9
phenobarbital ...............................7
phentermine hcl .........................26
phenylbutazone ..........................11
PHENYTEK ................................7
phenytoin......................................7
phenytoin sodium .........................7
phenytoin sodium
extended .......................................7
philith .........................................34
PHOSLYRA ..............................29
PHOSPHA 250
NEUTRAL .................................45
PHOSPHOLINE IODIDE .........40
PHOTOFRIN .............................14
physiolyte ...................................45
physiosol ....................................45
PICATO .....................................27
pilocarpine hcl .....................27, 40
pimtrea .......................................34
pindolol ......................................25
pioglitazone hcl ..........................21
pioglitazone-glimepiride ............21
pioglitazone-metformin ..............21
piperacillin-tazobactam ...............5
pirmella ......................................34
piroxicam ...................................11
PLASMA-LYTE 148.................45
PLASMA-LYTE 56 IN
DEXTROSE ..............................45
PLASMA-LYTE A PH
7.4 ..............................................45
PLASMA-LYTE M IN
DEXTROSE ..............................45
PLIAGLIS....................................2
podofilox ....................................27
58
polyethylene glycol 3350 ...........29
polymyxin b sulfate ......................5
polymyxin b sultrimethoprim ................................5
POMALYST ..............................14
PONTOCAINE ............................2
portia .........................................34
potassium bicarbonate ...............45
potassium chl-normal
saline ..........................................45
potassium chloride .....................45
POTASSIUM
CHLORIDE IN D5LR ...............45
POTASSIUM
CHLORIDE-NACL ...................45
potassium citrate ........................45
potassium citrate er ...................45
potassium citrate-citric
acid ............................................45
potassium gluconate ..................45
POTIGA .......................................7
PRADAXA ................................22
pramipexole
dihydrochloride .........................16
PRANDIMET ............................21
pravastatin sodium ....................25
prazosin hcl ................................25
PRED MILD ..............................40
PRED-G .....................................40
prednicarbate .............................31
prednisolone acetate ..................40
prednisolone sodium
phosphate .............................31, 40
prednisone .................................31
prednisone intensol ....................31
PREFEST ...................................34
pregnyl .......................................32
PREMARIN ...............................34
PREMASOL ..............................45
PREMPHASE ............................34
PREMPRO .................................34
PRENATAL 19 .........................45
PRENATAL PLUS ....................45
prevalite .....................................25
PREVIDENT .............................45
Index of Drugs
previfem .....................................34
PREZISTA .................................18
PRIFTIN ....................................12
PRILOSEC ................................29
PRIMAQUINE ..........................16
PRIMAXIN I.M. ..........................5
primidone .....................................7
PRIMSOL ....................................5
PRISTIQ ER ................................9
PRIVIGEN .................................37
PROAIR HFA ............................42
probenecid .................................11
probenecid-colchicine................11
procainamide hcl .......................25
PROCALAMINE ......................45
prochlorperazine
edisylate .....................................17
prochlorperazine maleate ..........17
PROCRIT ..................................22
procto-pak ..................................31
proctosol-hc ...............................31
proctozone-hc ............................31
PROCYSBI ................................40
progesterone ..............................34
PROGLYCEM ...........................21
PROGRAF .................................37
PROLEUKIN .............................14
PROLIA .....................................37
PROMACTA .............................22
promethazine hcl ....................9, 42
promethazine vc .........................42
promethegan ..........................9, 42
propafenone hcl .........................25
proparacaine hcl ........................40
propranolol hcl ....................12, 25
propranololhydrochlorothiazid .....................25
propylthiouracil .........................35
PROQUAD ................................37
PROSOL ....................................45
PROTAMINE SULFATE .........22
PROTOPIC ................................27
protriptyline hcl ...........................9
PROVENTIL HFA ....................42
PROVIGIL .................................43
PRUDOXIN ...............................27
PULMICORT ............................42
PULMOZYME ..........................42
PYLERA ....................................29
pyrazinamide .............................12
pyridostigmine bromide .............12
Q
QNASL ......................................42
QUALAQUIN ...........................16
QUARTETTE ............................34
quasense.....................................34
quazepam ...................................43
QUDEXY XR ..............................7
quetiapine fumarate ...................17
QUICK MIX WITH
LYTES .......................................45
quinapril hcl ..............................25
quinaprilhydrochlorothiazide ...................25
quinidine gluconate ...................25
quinidine sulfate ........................25
quinine sulfate ............................16
QVAR ........................................42
R
RABAVERT ..............................37
rabeprazole sodium ...................29
RADIOGARDASE ....................39
raloxifene hcl .............................34
ramipril ......................................25
RANEXA ...................................25
ranitidine hcl..............................29
RAPAFLO .................................29
RAPAMUNE .............................37
RAVICTI ...................................28
REBETOL .................................18
REBIF ........................................26
REBIF REBIDOSE ...................26
reclipsen .....................................34
RECOMBIVAX HB ..................37
REFLUDAN ..............................22
REGONOL ................................12
REGRANEX .............................27
RELENZA .................................18
RELISTOR ................................29
RELPAX ....................................12
59
REMICADE ..............................37
REMODULIN ...........................42
RENACIDIN .............................45
RENVELA.................................30
repaglinide .................................21
RESCRIPTOR ...........................18
RESCULA .................................40
reserpine ....................................25
RESTASIS .................................40
RETIN-A ...................................27
RETIN-A MICRO .....................27
RETIN-A MICRO PUMP .........27
RETROVIR ...............................18
REVATIO ..................................42
REVLIMID ................................14
REYATAZ.................................18
ribapak .......................................18
ribasphere ..................................18
RIBATAB ..................................18
ribavirin .....................................18
RIDAURA .................................37
rifabutin .....................................12
RIFAMATE ...............................12
rifampin .....................................13
RIFATER...................................13
RILUTEK ..................................26
riluzole .......................................26
rimantadine hcl ..........................18
ringers injection .........................45
ringers irrigation .......................45
RIOMET ....................................21
risedronate sodium ....................38
RISPERDAL CONSTA ............17
risperidone .................................17
risperidone odt ...........................17
RITALIN LA .............................26
RITUXAN .................................14
rivastigmine .................................8
rizatriptan ..................................12
ROBAXIN .................................43
ROBAXIN-750 ..........................43
ROCALTROL ...........................38
ropinirole hcl .............................16
ROTARIX .................................37
Index of Drugs
ROTATEQ .................................37
ROWASA ..................................38
roxicet ..........................................2
ROZEREM ................................43
S
SABRIL .......................................7
SAFYRAL .................................34
SAIZEN .....................................32
salsalate .....................................12
SAMSCA ...................................25
SANCUSO ...................................9
SANDIMMUNE ........................37
SANDOSTATIN .......................35
SANDOSTATIN LAR ..............35
SANTYL....................................27
SAPHRIS ...................................17
SARAFEM ..................................9
SAVELLA .................................26
selegiline hcl ..............................16
selenium sulfide .........................27
SELZENTRY ............................18
SEMPREX-D .............................42
SENSIPAR ................................35
SEREVENT DISKUS ...............42
SEROQUEL XR ........................17
SEROSTIM................................32
sertraline hcl ................................9
sevelamer carbonate ..................30
sf 5000 plus ................................45
SIGNIFOR .................................39
sildenafil ....................................42
SILENOR ..................................43
silver sulfadiazine ........................5
SIMBRINZA .............................40
SIMCOR ....................................25
SIMPONI ...................................37
SIMPONI ARIA ........................37
SIMULECT ...............................37
simvastatin .................................25
SINEMET 10-100 ......................16
SINEMET 25-100 ......................16
SINEMET 25-250 ......................16
SINEMET CR ............................16
sirolimus ....................................37
SIRTURO ..................................13
SIVEXTRO..................................5
SKELAXIN ...............................43
sodium bicarbonate ...................45
sodium chloride .........................45
SODIUM EDECRIN .................25
sodium fluoride ..........................45
sodium lactate ............................45
sodium polystyrene
sulfonate .....................................45
SOLIRIS ....................................37
SOLODYN ..................................5
SOLTAMOX .............................15
SOLU-CORTEF ........................31
SOLU-MEDROL .......................31
SOMA ........................................43
SOMATULINE DEPOT ...........35
SOMAVERT .............................35
SONATA ...................................43
SORIATANE .............................27
SORILUX ..................................27
sorine .........................................25
sotalol ........................................25
sotalol af ....................................25
sotret ..........................................27
SOVALDI ..................................19
SPECTRACEF ............................5
spinosad .....................................16
SPIRIVA ....................................42
spironolactone ...........................25
spironolactone-hctz....................25
SPORANOX ..............................11
sprintec ......................................34
SPRIX ........................................12
SPRYCEL ..................................15
sps ..............................................45
sronyx .........................................34
ssd ................................................5
stavudine ....................................19
STAVZOR ...................................7
STAXYN ...................................30
STELARA .................................37
STENDRA .................................30
STIMATE ..................................32
STIVARGA ...............................15
60
STRATTERA ............................26
streptomycin sulfate .....................5
STRIANT ..................................34
STRIBILD .................................19
STROMECTOL .........................16
SUBOXONE ...............................3
SUBSYS ......................................2
SUCRAID ..................................28
sucralfate ...................................29
sulfacetamide sodium ......5, 27, 40
sulfacetamideprednisolone ..............................40
sulfadiazine ..................................5
sulfamethoxazole/
trimethoprim ................................5
sulfamethoxazoletrimethoprim ................................5
SULFAMYLON ..........................5
sulfasalazine ..............................38
sulfasalazine dr ..........................38
sulfazine .....................................38
sulindac ......................................12
sumatriptan ................................12
sumatriptan succinate ................12
SUMAVEL DOSEPRO .............12
SUPRAX .....................................5
SUPREP .....................................29
SURE COMFORT .....................39
SURMONTIL ..............................9
SUSTIVA ..................................19
SUTENT ....................................15
SYEDA ......................................34
SYLATRON 4-PACK ...............15
SYLVANT .................................15
SYMBICORT ............................42
SYMLINPEN 120 .....................21
SYMLINPEN 60 .......................21
SYNAGIS ..................................39
SYNAREL .................................35
SYNERA .....................................2
SYNERCID .................................5
SYNRIBO ..................................15
SYNTHROID ............................34
SYPRINE ...................................45
Index of Drugs
T
TABLOID ..................................15
TACLONEX ..............................27
tacrolimus ..................................37
TAFINLAR................................15
TALWIN......................................2
TAMIFLU..................................19
tamoxifen citrate ........................15
tamsulosin hcl ............................30
TARCEVA ................................15
TARGRETIN .............................15
TARKA......................................25
TASIGNA ..................................15
TASMAR ...................................16
TAXOTERE ..............................15
tazicef ...........................................5
tazicef in dextrose ........................5
TAZORAC ................................27
taztia xt.......................................25
TE ANATOXAL
BERNA ......................................37
TECFIDERA .............................26
TEFLARO ...................................6
TEGRETOL .................................7
TEGRETOL XR ..........................7
TEKAMLO ................................25
TEKTURNA ..............................25
TEKTURNA HCT .....................25
telmisartan .................................25
telmisartan-amlodipine ..............25
telmisartanhydrochlorothiazid .....................25
temazepam .................................43
tencon ...........................................2
teniposide ...................................15
TENIVAC ..................................37
terazosin hcl ...............................25
terbinafine hcl ............................11
terbutaline sulfate ......................42
terconazole .................................11
testosterone ................................34
testosterone cypionate ...............34
testosterone enanthate ...............34
TESTRED ..................................34
TETANUS
DIPHTHERIA
TOXOIDS ..................................37
TETANUS TOXOID
ADSORBED ..............................37
tetracycline hcl ............................6
TEVETEN HCT ........................25
TEV-TROPIN ............................32
THALOMID ..............................15
THEO-24 ...................................42
theochron ...................................42
theophylline ...............................42
theophylline anhydrous..............42
THERACYS ..............................37
thermazene ...................................6
THIOLA ....................................30
thioridazine hcl ..........................17
thiotepa ......................................15
thiothixene .................................17
THYMOGLOBULIN ................37
THYROLAR-1 ..........................34
THYROLAR-1/2 .......................34
THYROLAR-1/4 .......................34
THYROLAR-2 ..........................34
THYROLAR-3 ..........................34
tiagabine hcl ................................7
ticlopidine hcl ............................22
TIKOSYN ..................................25
tilia fe .........................................34
TIMENTIN ..................................6
timolol maleate ....................12, 40
TIMOPTIC OCUDOSE ............40
TINDAMAX .............................16
tinidazole ...................................16
TIS-U-SOL ................................45
TIVICAY ...................................19
tizanidine hcl ..............................17
TOBI ............................................6
TOBI PODHALER ......................6
TOBRADEX .............................40
TOBRADEX ST ........................40
tobramycin ...................................6
tobramycin sulfate .......................6
tobramycin sulfate in ns ...............6
61
tobramycindexamethasone...........................40
TOBREX .....................................6
tolazamide ..................................21
tolbutamide ................................21
tolmetin sodium..........................12
tolterodine tartrate ....................30
tolterodine tartrate er ................30
TOPAMAX .................................7
TOPICORT ................................32
topiragen ......................................7
topiramate ....................................7
TOPIRAMATE ER .....................7
toposar .......................................15
topotecan hcl..............................15
TORISEL ...................................15
torsemide ...................................25
TOVIAZ ....................................30
tpn electrolytes ii .......................45
TRACLEER...............................42
TRADJENTA ............................21
tramadol hcl .................................2
tramadol hcl er ............................2
tramadol hclacetaminophen .............................2
trandolapril ................................25
tranexamic acid .........................22
TRANSDERM-SCOP .................9
tranylcypromine sulfate ...............9
TRAVASOL ..............................45
TRAVASOL W/
DEXTROSE ..............................45
TRAVASOL W/
ELECTROLYTES .....................45
TRAVASOL WITH
DEXTROSE ..............................45
TRAVASOL WITH
ELECTROLYTES .....................45
TRAVATAN Z ..........................40
travoprost...................................40
trazodone hcl ...............................9
TREANDA ................................15
TRECATOR ..............................13
TRELSTAR ...............................35
tretinoin ...............................15, 27
Index of Drugs
tretinoin microsphere.................27
TREXIMET ...............................12
triamcinolone acetonide 27, 32, 42
triamterene-hctz .........................25
triamterenehydrochlorothiazid .....................25
trianex ........................................32
TRIBENZOR .............................25
triderm .......................................32
tri-estarylla ................................34
trifluoperazine hcl ......................17
trifluridine ..................................19
TRIGLIDE .................................26
trihexyphenidyl hcl.....................16
tri-legest fe .................................34
TRILEPTAL ................................7
tri-linyah ....................................35
trilyte with flavor packets ..........29
trimethobenzamide hcl .................9
trimethoprim ................................6
trinessa .......................................34
tri-previfem ................................34
TRISENOX................................15
tri-sprintec .................................34
tri-vitamin with fluoride .............45
trivora-28 ...................................34
TRIZIVIR ..................................19
TROKENDI XR ..........................7
TROPHAMINE .........................45
tropicamide ................................40
trospium chloride .......................30
trospium chloride er ..................30
TRUVADA ................................19
TWINRIX ..................................37
TYGACIL ....................................6
TYKERB ...................................15
TYPHIM VI ...............................37
TYSABRI ..................................27
TYVASO ...................................42
TYZEKA ...................................19
TYZINE .....................................42
U
UCERIS .....................................38
u-cort ..........................................32
ULESFIA ...................................16
ULORIC ....................................11
unithroid ....................................34
ursodiol ......................................29
UVADEX ..................................27
V
VAGIFEM .................................34
valacyclovir................................19
VALCHLOR..............................15
VALCYTE .................................19
valproate sodium .........................7
valproic acid ................................7
valsartan ....................................26
valsartanhydrochlorothiazide ...................26
VANCOCIN HCL .......................6
vancomycin hcl ............................6
VAQTA .....................................37
VARIVAX VACCINE ..............37
VARIZIG ...................................37
VASCEPA .................................26
VECAMYL................................26
VECTIBIX .................................15
VELCADE .................................15
velivet .........................................34
venlafaxine hcl .............................9
venlafaxine hcl er .........................9
VENTAVIS ...............................42
VENTOLIN HFA ......................42
VERAMYST .............................43
verapamil er ...............................26
verapamil er pm .........................26
verapamil hcl .............................26
VERDESO .................................32
VEREGEN .................................27
VERSACLOZ ............................17
VERSALON ..............................39
VESICARE ................................30
vestura........................................34
VEXOL ......................................40
VFEND ......................................11
VFEND IV .................................11
VIAGRA ....................................30
VIBATIV .....................................6
VIBRAMYCIN............................6
VICTOZA 3-PAK .....................21
62
VICTRELIS ...............................19
VIDAZA ....................................15
VIDEX .......................................19
VIGAMOX ..................................6
VIIBRYD .....................................9
VIMIZIM ...................................28
VIMOVO ...................................12
VIMPAT ......................................7
vinblastine sulfate ......................15
vincasar pfs ................................15
vincristine sulfate .......................15
vinorelbine tartrate ....................15
viorele ........................................34
VIRACEPT ................................19
VIRAMUNE ..............................19
VIRAMUNE XR .......................19
VIRAZOLE ...............................19
VIREAD ....................................19
VISTIDE ....................................19
vitamin d2 ..................................45
VIVELLE-DOT .........................34
VIVITROL ..................................3
VIVOTIF BERNA .....................37
VOLTAREN ..............................12
voriconazole ...............................11
VOTRIENT ...............................15
VPRIV .......................................28
VUSION ....................................11
vyfemla .......................................34
VYTORIN .................................26
VYVANSE ................................27
W
warfarin sodium .........................22
water ..........................................39
WELCHOL ................................26
wera ...........................................34
wymzya fe ...................................34
X
XALKORI .................................15
XARELTO .................................22
XARTEMIS XR ..........................2
XELJANZ ..................................39
XENAZINE ...............................27
XERESE ....................................28
Index of Drugs
XGEVA .....................................38
XIFAXAN ...................................6
XOLAIR ....................................43
XOLEGEL .................................11
XOPENEX .................................43
XOPENEX HFA ........................43
XTANDI ....................................35
xulane .........................................35
XYLOCAINE ..............................2
XYLOCAINE-MPF .....................2
XYREM .....................................43
Y
YERVOY ...................................15
YF-VAX ....................................37
Z
zafirlukast ..................................43
zaleplon ......................................43
ZALTRAP .................................15
ZANOSAR ................................15
zarah ..........................................34
ZARONTIN .................................8
ZAVESCA .................................28
zazole .........................................11
zebutal ..........................................2
ZELAPAR .................................16
ZELBORAF ...............................15
ZEMAIRA .................................43
ZEMPLAR .................................38
zenatane .....................................28
zenchent .....................................34
zenchent fe .................................34
ZENPEP .....................................28
zeosa ..........................................34
ZETIA ........................................26
ZETONNA ................................43
ZIAGEN ....................................19
zidovudine ..................................19
ZINACEF ....................................6
ZINACEF ISOOSMOTIC DEXTROSE .............6
ZINECARD ...............................15
ZIOPTAN ..................................40
ziprasidone hcl ...........................17
ZIPSOR......................................12
ZIRGAN ....................................19
ZMAX .........................................6
ZOHYDRO ER ............................2
zoledronic acid ..........................38
ZOLINZA ..................................15
zolmitriptan ................................12
zolmitriptan odt..........................12
zolpidem tartrate........................43
zolpidem tartrate er ...................43
ZOLPIMIST ..............................43
ZOMETA ...................................38
ZOMIG ......................................12
ZONALON ................................28
zonisamide ...................................8
ZORBTIVE ...............................32
ZORTRESS ...............................37
ZORVOLEX ..............................12
ZOSTAVAX ..............................37
ZOSYN ........................................6
zovia 1-35e .................................34
zovia 1-50e .................................34
ZOVIRAX .................................19
ZUPLENZ .................................10
ZYCLARA ................................28
ZYFLO ......................................43
ZYFLO CR ................................43
ZYKADIA .................................15
ZYLET .......................................40
ZYPREXA RELPREVV ...........17
ZYTIGA ....................................15
ZYVOX .......................................6
63
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Rochester, NY 14647
Important Plan Information
This formulary was updated on 1/1/2015. For more recent information or other questions, please contact Excellus
BlueCross BlueShield at 1-800-659-1986 or, for TTY users, 1-800-421-1220, Monday – Friday, 8:00 a.m. – 8:00 p.m.;
From October 1 to February 14, representatives are available to assist you seven days a week from 8:00 a.m. –
8:00 p.m., or visit ExcellusMedicare.com.