ICS Community Care Plus FIDA-MMP

Transcripción

LISTA DE
MEDICAMENTOS
CUBIERTOS
Community Care Plus
FIDA-MMP 2016
1.877.ICS.2525
1.877.ICS.2525
www.icsny.org
www.icsny.org
H4465_ListofCoveredDrugsSpan_2016_92315_Approved
H4465_ListofCoveredDrugsSpan_2016_92315
ICS Community Care Plus FIDA-MMP | 2016
Lista de medicamentos cubiertos (Formulario)
Ésta es una lista de medicamentos que los participantes pueden obtener en ICS Community
Care Plus FIDA-MMP.
 ICS Community Care Plus FIDA-MMP es un plan de salud administrado que tiene un
contrato con Medicare y el Departamento de salud del estado de New York
(Medicaid) proporcionar los beneficios de los dos programas a los participantes a
través de un programa FIDA (Fully Integrated Duals Advantage o Organización
integral para personas elegibles para ambos programas).
 Los beneficios, la Lista de medicamentos cubiertos y las redes de proveedores
pueden cambiar durante el año y el 1º de enero de cada año.
 Usted siempre puede revisar la Lista de medicamentos cubiertos actualizada de ICS
Community Care Plus FIDA-MMP en internet en www.icsny.org/care-plus o llamar a
Servicios al participante de ICS Community Care Plus FIDA-MMP al
1.877.ICS.2525.
 Se pueden aplicar limitaciones y restricciones. Para obtener más información, llame
a Servicios al participante de ICS Community Care Plus FIDA-MMP o lea el Manual
del participante de ICS Community Care Plus FIDA-MMP.
 No hay copagos para los medicamentos cubiertos.
 Usted puede pedir esta información en otros formatos, como Braille o letra grande,
de manera gratuita. Llame al 1.877.ICS.2525. La llamada es gratuita.
 You can get this information for free in other languages. Call 1.877.ICS.2525 and
TTY: 711 during 8 a.m. to 8 p.m., Monday through Friday. The call is free.
 Usted puede obtener esta información en otros idiomas, de manera gratuita. Llame
al 1.877.ICS.2525 y TTY: 711 de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es
gratuita.
 Вы можете бесплатно получить всю эту информацию на других языках.
Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу 711 с понедельника по
пятницу с 8:00 до 20:00. Звонок бесплатный.
Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al
1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para
obtener más información, vaya a www.icsny.org/care-plus.
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 您可免费获得所有这些信息的其他语言版本。请在周一至周五上午 8 点至晚上 8 点致
电 ICS，电话号码为 1.877.ICS.2525，听障专线 (TTY) 为 711。此为免费电话。
 Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan
1.877.ICS.2525 ak TTY 711, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis.
 이 모든 정보는 타 언어로 무료로 제공됩니다. 월요일~금요일, 오전 8시~오후 8시
사이에 1.877.ICS.2525 및 TTY(청각 장애인용 전화) 711로 ICS에 전화해 주십시오.
이 전화는 무료입니다.
 Le informazioni in questione sono disponibili gratuitamente anche in altre lingue.
Chiamare ICS ai numeri 1.877.ICS.2525 e TTY 711 tra le 8:00 e le 20.00 dal lunedì
al venerdì. La chiamata è gratuita.
 El estado de New York creó un Programa Ombudsman para los participantes para
proporcionarle a los Participantes asistencia gratuita, confidencial para los servicios
que ofrece ICS Community Care Plus FIDA-MMP. Para comunicarse con el
Ombudsman para el participante llame al 1.844.614.8800 o vaya a www.icannys.org.
Preguntas frecuentes (FAQ)
Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de
medicamentos cubiertos. Usted puede leer todas las Preguntas frecuentes para saber más o
buscar preguntas y respuestas.
1. ¿Qué medicamentos de receta se encuentran en la Lista de
medicamentos cubiertos? (Llamamos “Lista de medicamentos”
a la Lista de medicamentos cubiertos, para abrebiar.)
Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 13 son
los medicamentos cubiertos por ICS Community Care Plus FIDA-MMP. Los medicamentos
están disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si
tenemos un acuerdo con ellos, para trabajar con nosotros y proporcionarle servicios a usted.
Nos referimos a estas farmacias como “farmacias de la red”.
ICS Community Care Plus FIDA-MMP cubrirá todos los medicamentos de la Lista, si:
 Su médico u otro proveedor de la red dice que usted los necesita para mejorar o
para seguir sano,
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 El medicamento es médicamente necesario para su enfermedad, y
 Usted surte la receta en una farmacia de la red de ICS Community Care Plus
FIDA-MMP.
 ICS Community Care Plus FIDA-MMP podría tener pasos adicionales para tener
acceso a ciertos tipos de medicamentos (lea en el pregunta #5 de abajo). En
algunos casos es probable que usted tenga que hacer algo antes de obtener un
medicamento, por ejemplo: primero probar otros medicamentos.
Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro
sitio web en www.icsny.org/care-plus o llame a Servicios al participante al 1.877.ICS.2525.
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2. ¿La Lista de medicamentos cambia alguna vez?
Sí. ICS Community Care Plus FIDA-MMP podría agregar o quitar medicamentos de la Lista de
medicamentos durante el año. De manera general, la Lista de medicamentos sólo cambiará si:
 Aparece un nuevo medicamento, que funcione tan bien como algún medicamento
que se encuentre actualmente en la Lista de medicamentos o
 Nos enteramos que algún medicamento no es seguro.
También podemos cambiar nuestras reglas sobre sobre algunos medicamentos. Por ejemplo,
podríamos:
 Decidir si exigir o no aprobación previa para algún medicamento. (Aprobación
previa es el permiso de ICS Community Care Plus FIDA-MMP o su Equipo
interdisciplinario (IDT) antes que usted puede obtener un medicamento.)
 Aumentar o cambiar la cantidad de un medicamento que usted puede obtener
(llamado "límite de cantidad”).
 Agregar o cambiar restricciones de tratamiento progresivo de un medicamento.
(Terapia progresiva significa que usted podría tener que probar un medicamento
antes que cubramos otro medicamento.)
(Para obtener más información acerca de estas reglas para los medicamentos, lea la página 5.)
Le avisaremos cuando quitemos de la Lista de Medicamento algún medicamento que usted
esté tomando. También le diremos cuando cambiemos nuestras reglas para cubrir algún
medicamento. Las preguntas 3, 4 y 7 de abajo tienen más información sobre lo que sucederá
cuando cambie la Lista de medicamentos.
 Usted siempre puede leer la Lista de medicamentos actualizada de ICS
Community Care Plus FIDA-MMP en internet, en www.icsny.org/care-plus.
También puede llamar a Servicios al participante para revisar la Lista de
medicamentos actual, al 1.877.ICS.2525.
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3. ¿Qué sucederá cuando aparezca un medicamento más barato
que funcione tan bien como algún medicamento que se
encuentre actualmente en la Lista de medicamentos?
Si aparece un medicamento más barato que funcione tan bien como algún medicamento que
se encuentre actualmente en la Lista de medicamentos:
 Es probable que su farmacéutico le dé un medicamento más barato la próxima
vez que surta su receta. Si usted y su proveedor deciden que el medicamento
más barato no es el correcto para usted, su proveedor puede indicarle al
farmacéutico que continúe surtiéndole el medicamento que toma ahora.
 Es probable que ICS Community Care Plus FIDA-MMP decida quitar el
medicamento más caro de la Lista de medicamentos. Si usted está tomando un
medicamento que quitamos de la Lista de medicamentos, porque aparece un
medicamento más barato que funcione tan bien, le avisaremos con 60 días de
anticipación antes de quitarlo de la Lista de medicamentos o cuando pida que
surtamos nuevamente el medicamento. En ese momento, usted podrá obtener un
suministro de 60 días del medicamento antes de que se haga el cambio en la
Lista de medicamentos.
 El plan Community Care Plus FIDA-MMP de ICS informará estos cambios a los
miembros por correo e incluirá información sobre cómo presentar una queja,
apelación o solicitud de excepción. El plan Community Care Plus FIDA-MMP de
ICS también publicará esta información en nuestro sitio web, el cual puede
encontrarse en www.icsny.org/care-plus y notificará a los miembros todos los años
sobre nuestro formulario actualizado. Esta información puede proporcionarse en
formatos alternativos.
4. ¿Qué sucederá cuándo averigüemos que algún medicamento no
es seguro?
Si la Administración de alimentos y medicamentos (FDA) dice que algún medicamento no es
seguro, lo quitaremos inmediatamente de la Lista de medicamentos. También le enviaremos
una carta y lo llamaremos para avistarle que el medicamento que no es seguro fue quitado de
la Lista de medicamentos. Se le indicará que se comunique con el médico que emite sus
recetas lo antes posible para recibir instrucciones a fin de reemplazar el medicamento
discontinuado. También puede ponerse en contacto con su gerente de atención para obtener
ayuda.
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5. ¿La cobertura de medicamentos tiene alguna restricción o
límite? ¿O hay que hacer algo en particular para poder obtener
ciertos medicamentos?
Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted
puede obtener. En algunos casos, tendrá que hacer algo antes de poder obtener el
medicamento. Por ejemplo:
 Aprobación previa (o autorización previa): Para algunos medicamentos, usted
o su médico deben obtener una aprobación de ICS Community Care Plus FIDAMMP o su Equipo interdisciplinario (IDT) antes de surtir su receta. Y si usted no
consigue la aprobación, ICS Community Care Plus FIDA-MMP podría no cubrir el
medicamento.
 Límites de cantidad: A veces ICS Community Care Plus FIDA-MMP limita la
cantidad de un medicamento que usted puede obtener.
 Tratamiento progresivo: A veces ICS Community Care Plus FIDA-MMP exige
que usted siga un tratamiento progresivo. Esto significa que usted tendrá que
probar los medicamentos en un cierto orden para su enfermedad. Usted podría
tener que probar un medicamento antes de que cubramos otro medicamento. Si a
su médico le parece que el primer medicamento no funciona para usted, entonces
cubriremos el segundo.
Usted puede averiguar si su medicamento tiene algún requisito o límite adicional, leyendo los
cuadros de las página 14. Usted también puede obtener más información en nuestro sitio web
en www.icsny.org/care-plus. Hemos publicado documentos en línea que explican nuestra
autorización previa y las restricciones de la terapia escalonada. Usted puede pedirnos que le
enviemos una copia.
Usted también puede pedir una "excepción" a esos límites. Por favor lea en la pregunta 11 más
información sobre las excepciones.

Si usted está en un hogar para personas de la tercera edad u otra institución de
cuidados a largo plazo y necesita algún medicamento que no esté en la Lista de
medicamentos o si no puede obtener el medicamento que necesite fácilmente,
podemos ayudarle. Cubriremos un suministro de emergencia de 31 días del
medicamento que usted necesite (a menos que tenga una receta para menos
días), sin importar que usted sea o no un participante nuevo de ICS Community
Care Plus FIDA-MMP. Esto le dará tiempo para hablar con su médico u otro
proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro
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medicamento similar en la Lista de medicamentos que usted pueda tomar en su
lugar o si tiene que pedir una excepción. Por favor lea en la pregunta 11 más
6. ¿Cómo sabrá si el medicamento que usted quiere tiene
limitaciones o si tiene que hacer algo para obtenerlo?
La Lista de medicamentos cubiertos de la página 14 tiene una columna llamada "Medidas
necesarias, restricciones o límites de uso".
7. ¿Qué sucederá si cambiamos nuestras reglas sobre cómo
cubrimos algunos medicamentos? Por ejemplo, si agregamos
requisitos de autorización (aprobación) previa, límites de
cantidad y/o restricciones de tratamiento progresivo a algún
medicamento.
Le avisaremos si agregamos requisitos de aprobación previa, límites de cantidad y/o
restricciones de tratamiento progresivo a un medicamento. Le avisaremos por lo menos 60 días
antes de agregar la restricción o cuando pida su siguiente resurtido. En ese momento, usted
podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en la
Lista de medicamentos. Esto le dará tiempo para hablar con su médico u otra persona que
prescribe sobre qué hacer después.
8. ¿Cómo puede encontrar un medicamento en la Lista de
medicamentos?
Hay dos maneras de encontrar un medicamento:
 Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del
medicamento), o
 Puede buscar por enfermedad.
Para buscar por orden alfabético, vaya a la sección alfabética de la lista en la página I-1.
Luego busque el nombre en la Lista de medicamentos.
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Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por
enfermedad” de la página 14. Luego, busque su enfermedad. Por ejemplo, si usted tiene una
enfermedad del corazón, usted debe buscar en esa categoría. Ahí encontrará los
medicamentos que traten enfermedades del corazón.
9. ¿Qué pasará si el medicamento que usted quiere tomar no está
en la Lista de medicamentos?
Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicios al
participante al 1.877.ICS.2525 y pregunte por él. Si se entera que ICS Community Care Plus
FIDA-MMP no cubrirá el medicamento, usted puede hacer algo de lo siguiente:
 Pida a Servicios al participante una lista de medicamentos similar al que quiera
tomar. Luego, muestre la lista a su médico u otro proveedor médico. Éste podrá
recetarle un medicamento similar al de la Lista de medicamentos que usted quiere
tomar. O,
 Usted también puede pedir al plan o a su Equipo interdisciplinario (IDT) que haga
una excepción para cubrir su medicamento. Por favor lea en la pregunta 11 más
10. ¿Qué pasará si usted es un participante nuevo de ICS Community
Care Plus FIDA-MMP y no puede encontrar su medicamento en la
Lista o tiene problemas para obtener su medicamento?
Podemos ayudarle. Debemos cubrir un suministro temporario de hasta 90 días de su
medicamento, cuando sea necesario, durante los primeros 90 días que usted sea participante
de ICS Community Care Plus FIDA-MMP. Esto le dará tiempo para hablar con su médico u otro
proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la
Lista de medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción.
Cubriremos un suministro de hasta 90 días de su medicamento si:
 Usted está tomando algún medicamento que no esté en nuestra Lista de
medicamentos o
 Las reglas del plan de salud no le permiten obtener la cantidad recetada por su
proveedor médico o
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 El medicamento requiere aprobación previa de ICS Community Care Plus FIDAMMP o de su Equipo interdisciplinario (IDT) o
 Usted toma algún medicamento que forme parte de una restricción de tratamiento
progresivo.
Si usted vive en un hogar para personas de la tercera edad u otra institución de cuidados a
largo plazo, usted puede resurtir su receta hasta por días por tanto tiempo como 98 días. Usted
podrá resurtir el medicamento varias veces durante los 98 días. Esto le dará tiempo a su
proveedor médico para cambiar su medicamento por alguno que esté en la Lista de
medicamentos o para pedir una excepción.
Si es un participante actual que experimenta un cambio en el nivel de atención de un
tratamiento por otro, es probable que reúna los requisitos para obtener el suministro para 90
días de un medicamento que no se encuentre en la Lista de medicamentos, a fin de darle
tiempo a su médico o a la persona que le emite las recetas para que localice un medicamento
en la lista o para que presente una excepción. Es probable que usted reúna los requisitos para
obtener el suministro de transición de nivel de atención si:






ingresa a un centro de atención a largo plazo (Long-Term Care, LTC) de un
hospital u otro establecimiento
abandona un centro de LTC y regresa a la comunidad
le dan de alta de un hospital y regresa a un hogar
finalizó su internación en un centro de enfermería especializada cubierto por la
Parte A de Medicare (incluidos los cargos de farmacia) y regresa a la cobertura
de la Parte D
vuelve del estado de cuidados paliativos a los beneficios estándar de la Parte A
y B de Medicare o
le dan de alta de un hospital psiquiátrico con regímenes de medicamentos que
son altamente individualizados.
11. ¿Puede pedir al plan que haga una excepción para cubrir su
medicamento?
Sí. Usted puede pedirle a ICS Community Care Plus FIDA-MMP o a su Equipo interdisciplinario
(IDT) que haga una excepción para cubrir su medicamento si éste no está en la Lista de
medicamentos.
Usted también puede pedirle a ICS Community Care Plus FIDA-MMP o a su IDT un cambio a
las reglas de su medicamento.
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 Por ejemplo, ICS Community Care Plus FIDA-MMP podría limitar la cantidad que
cubriremos de un medicamento. Si su medicamento tiene un límite, usted puede
pedirnos a nosotros o a su IDT que cambiemos el límite y que cubramos más.
 Otros ejemplos: Usted puede pedirnos a nosotros o a su IDT que quitemos las
restricciones de tratamiento progresivo o los requisitos de aprobación previa.
12. ¿Cuánto tiempo toma obtener una excepción?
Primero, ICS Community Care Plus FIDA-MMP o su Equipo interdisciplinario (IDT) recibir
una declaración de su proveedor médico apoyando su pedido de una excepción. Después
de recibir la declaración, le daremos una decisión sobre su pedido de excepción a más
tardar en 72 horas.
Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar
72 horas para obtener una decisión, entonces usted puede pedir una excepción acelerada.
Ésta es una decisión más rápida. Si su proveedor médico apoya su pedido, le daremos una
decisión dentro de las 24 horas después de recibir la declaración de apoyo de su proveedor
médico.
13. ¿Cómo puede pedir una excepción?
Para pedir una excepción, llame a su Administrador de cuidados. Su Administrador de cuidados
trabajará con usted y su proveedor para ayudarle a pedir una excepción.
14. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos están hechos con los mismos ingredientes que los medicamentos
de marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas
tan conocidas. Los medicamentos genéricos son aprobados por la Administración de alimentos
y medicamentos (FDA).
ICS Community Care Plus FIDA-MMP cubre tanto medicamentos de marca como
medicamentos genéricos.
15. ¿Qué son los medicamentos de venta libre (OTC)?
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OTC quiere decir "medicamentos que se venden sin receta". ICS Community Care Plus FIDAMMP cubre algunos medicamentos de venta libre cuando su proveedor escribe una receta para
ellos.
Usted puede leer la Lista de medicamentos de ICS Community Care Plus FIDA-MMP para ver
qué medicamentos de venta libre están cubiertos.
16. ¿ICS Community Care Plus FIDA-MMP cubre algún producto de
venta libre que no sea un medicamento?
ICS Community Care Plus FIDA-MMP cubre algunos productos de venta libre cuando su
proveedor escribe una receta para ellos. Entre los ejemplos se incluyen vendas de gasa,
algodones/almohadillas con alcohol, agujas y jeringas para la insulina, etc.
Usted puede leer la Lista de medicamentos de ICS Community Care Plus FIDA-MMP para ver
qué productos de venta libre, que no son medicamentos, están cubiertos.
17. ¿Cuánto es su copago?
A usted no le cobrarán un copago por los medicamentos de la Lista de medicamentos.
18. ¿Qué son los niveles de medicamentos? Los niveles son grupos
de medicamentos. Todo medicamento de la Lista de
medicamentos del plan se encuentra en uno de los 4 niveles.
Usted no tiene que pagar nada por los medicamentos de
cualquiera de los niveles.
 Nivel 1: Medicamentos genéricos cubiertos por Medicare
 Nivel 2: Medicamentos de marca y especialidad cubiertos por Medicare
 Nivel 3: Medicamentos genéricos y de marca no pertenecientes a la Parte D cubiertos
por Medicaid
 Nivel 4: Medicamentos de venta libre (over-the-counter, OTC) cubiertos por Medicaid
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Lista de medicamentos cubiertos
La lista de medicamentos cubiertos que comienza en la página siguiente le da información
sobre los medicamentos cubiertos por ICS Community Care Plus FIDA-MMP. Si usted tiene
problemas para encontrar su medicamento en la lista, lea el Índice que comienza en la página
I-1.
La primera columna del cuadro contiene el nombre del medicamento. Los medicamentos de
marca están escritos en mayúsculas (p.ej.: AVONEX) y los medicamentos genéricos están
escritos en cursivas minúsculas (p.ej.: amoxicillin).
La información de la columna titulada "Medidas necesarias, restricciones o límites de uso", le
indica si ICS Community Care Plus FIDA-MMP tiene alguna regla para cubrir su medicamento.
Abreviaturas y símbolos
Dentro del cuerpo de este documento, encontrará las siguientes abreviaturas
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Restricción de administración de uso
PA
PA BvD
Restricción de la
autorización previa
Restricción de la
para determinar la
Parte B frente a la
Parte D
Usted (o su médico) debe recibir la
autorización previa de parte del plan
Community Care Plus FIDA-MMP de ICS
para surtir su receta a fin de obtener este
medicamento. Sin la autorización previa,
es probable que el plan Community Care
Plus FIDA-MMP de ICS no cubra este
medicamento.
Este medicamento puede ser elegible
para ser pagado por la Parte B o Parte D
de Medicare. Usted (o su médico) debe
obtener la autorización previa de parte
del plan Community Care Plus FIDAMMP de ICS para determinar que este
medicamento está cubierto por la Parte
D de Medicare, a fin de surtir su receta
para obtener este medicamento. Sin la
autorización previa, es probable que
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ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
FIDA Care Complete no cubra este
medicamento.
PA NSO
QL
ST
LA
Restricción de
solo para nuevos
miembros
Si es miembro nuevo o no ha tomado
antes este medicamento, usted (o su
médico) debe recibir la autorización
previa de parte del plan Community
Care Plus FIDA-MMP de ICS para
surtir su receta a fin de obtener este
medicamento. Sin la autorización
previa, es probable que FIDA Care
Complete no cubra este
medicamento.
Restricción de límite
de cantidad
El plan Community Care Plus FIDAMMP de ICS limita la cantidad de este
medicamento que está cubierto por la
receta o dentro de un período
específico.
Restricción de la
terapia escalonada
Antes de que el plan Community Care
Plus FIDA-MMP de ICS brinde
cobertura para este medicamento,
usted debe probar primero otros
medicamentos para tratar su afección
médica. Este medicamento solo
puede cubrirse si otro(s)
medicamento(s) no le funciona(n) a
usted.
Otras abreviaturas de la cobertura
Medicamento con
Es posible que este medicamento se
acceso limitado
encuentre disponible solamente en
ciertas farmacias. Para obtener más
información, consulte su Directorio de
farmacias o llame al plan Community
Care Plus FIDA-MMP de ICS al
1.877.ICS.2525, de lunes a viernes, de 8
a. m. a 8 p. m o TTY al 711.
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ABREVIATURA
NM
*
DESCRIPCIÓN
EXPLICACIÓN
Medicamentos
pedidos por correo:
Es posible que usted pueda recibir
suministro de más de un 1 mes de la
mayoría de los medicamentos en su
formulario a través de pedidos por correo
a una cuota de costo reducido. Los
medicamentos que no están disponibles
a través de su beneficio de pedidos por
correo se indican con " NM " en la
columna Requisitos / límites de su
formulario.
Medicamento que no
pertenece a la Parte
D
Este medicamento es un medicamento
que no pertenece a la Parte D cubierto
por Medicaid.
Nota: El símbolo (*) junto a un medicamento significa que el medicamento no es un
“medicamento Parte D”. Estos medicamentos tienen reglas diferentes para las apelaciones.
Una apelación es una manera formal de pedirnos que revisemos alguna decisión de cobertura
y que la cambiemos, si le parece que hemos cometido un error. Por ejemplo, ICS Community
Care Plus FIDA-MMP o su Equipo interdisciplinario (IDT) podría decidir que un medicamento
que usted quiere ya no está cubierto por Medicare o Medicaid. Si usted o su médico no están
de acuerdo con nuestra decisión, usted puede apelar. Para pedir instrucciones sobre cómo
apelar, llame a Servicios al participante, al 1.877.ICS.2525 o al Ombudsman para el
participante de FIDA al 1.877.ICS.2525. Usted también puede enterarse de cómo apelar una
decisión leyendo el Manual del participante.
16
Estos son los significados de los códigos usados en la columna “Pasos necesarios,
restricciones o límites de uso”:
(g) = Sólo se cubre la version genérica de este medicamento. La versión de marca no está
cubierta.
M = La versión de marca de este medicamento está en Nivel 3. La versión genérica está en
el Nivel 1.
PA = Autorización previa (aprobación): usted debe tener aprobación del plan o de su Equipo
interdisciplinario (IDT) antes de poder obtener este medicamento.
ST = Terapia progresiva: usted debe probar otro medicamento antes de poder obtener éste.
17
Tier level
What the
drug will
cost you
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen
with Codeine)
1
$0
1
$0
1
$0
4
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Analgesics
Analgesics, Miscellaneous
acephen * rectal suppository 120
mg
acephen * rectal suppository 325
mg, 650 mg
acetaminophen * oral
drops,suspension
acetaminophen * oral elixir
acetaminophen * oral
tablet,disintegrating
acetaminophen * rectal suppository
120 mg, 650 mg
acetaminophen-codeine oral
solution 120-12 mg/5 ml, 300 mg30 mg /12.5 ml
acetaminophen-codeine oral tablet
300-15 mg, 300-30 mg
acetaminophen-codeine oral tablet
300-60 mg
arthritis pain relief (acetam) *
QL (360 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Acetaminophen)
(Fiorinal with
ascomp with codeine
Codeine #3)
(Buprenorphine
buprenorphine hcl injection syringe
HCl)
(Fiorinal with
butalbital compound w/codeine
Codeine #3)
(Fioricet with
butalbital-acetaminop-caf-cod
Codeine)
butalbital-acetaminophen
(Tencon)
1
$0
butalbital-acetaminophen-caff oral
tablet 50-325-40 mg
(Esgic)
1
$0
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener
más información, vaya a www.icsny.org/care-plus.
18
Name of Drug
butalbital-aspirin-caffeine oral
capsule
BUTRANS
(Fiorinal)
Tier level
What the
drug will
cost you
1
$0
2
$0
capacet
(Esgic)
1
$0
children's mapap *
children's non-aspirin * oral elixir
children's non-aspirin * oral
tablet,chewable
children's pain & fever relief * oral
suspension
children's pain reliever * oral
tablet,chewable
(Acetaminophen)
(Acetaminophen)
4
4
$0
$0
(Acetaminophen)
4
$0
(Infants' Tylenol)
4
$0
(Acetaminophen)
4
$0
4
$0
1
$0
(Xolox)
1
$0
(Percodan)
1
$0
fentanyl
(Duragesic)
1
$0
fentanyl citrate
(Actiq)
1
$0
(Acetaminophen)
4
$0
(Hycet)
1
$0
children's silapap *
codeine sulfate oral tablet
endocet oral tablet 10-325 mg, 2.5325 mg, 5-325 mg, 7.5-325 mg
endodan
feverall * rectal suppository 120
mg, 325 mg, 650 mg
hydrocodone-acetaminophen oral
solution 10-325 mg/15 ml(15 ml),
2.5-167 mg/5 ml, 7.5-325 mg/15 ml
tablet 10-300 mg, 5-300 mg, 7.5300 mg
(Tylenol Sore
Throat)
(Codeine Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (180 per
30 days)
QL (4 per 28 days)
PA-HRM; QL (180 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (10 per 30
days)
PA; QL (120 per 30
days)
QL (30 per 30 days)
(Norco)
1
$0
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
19
Name of Drug
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
hydrocodone-ibuprofen
hydromorphone (pf) injection
solution 10 mg/ml
hydromorphone (pf) injection
solution 4 mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2
mg/ml
hydromorphone oral liquid
hydromorphone oral tablet 2 mg, 4
mg
hydromorphone oral tablet 8 mg
junior mapap *
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
(Norco)
1
$0
(Ibudone)
(Hydromorphone
HCl/PF)
1
$0
1
$0
(Dilaudid)
1
$0
1
$0
1
$0
1
$0
(Dilaudid)
1
$0
(Dilaudid)
(Acetaminophen)
1
4
$0
$0
2
$0
(Hydromorphone
HCl)
(Hydromorphone
HCl)
(Dilaudid)
LAZANDA
QL (30 per 30 days)
PA; QL (30 per 30
days)
lorcet (hydrocodone)
(Norco)
1
$0
lorcet hd
(Norco)
1
$0
lorcet plus oral tablet 7.5-325 mg
(Norco)
1
$0
mapap (acetaminophen) * oral
(Acetaminophen)
4
$0
capsule
(Acetaminophen)
4
$0
elixir
(Tylenol Sore
4
$0
liquid 500 mg/15 ml
Throat)
(Infants' Tylenol)
4
$0
suspension
(Tylenol)
4
$0
tablet
QL (30 per 30 days)
(Acetaminophen)
4
$0
tablet,chewable
20
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (180 per
30 days)
mapap arthritis pain *
mapap extra strength *
(Acetaminophen)
(Tylenol)
4
4
$0
$0
margesic
(Esgic)
1
$0
methadone injection
methadone oral solution
methadone oral tablet
methadose oral tablet,soluble
morphine concentrate oral solution
morphine concentrate oral syringe
morphine injection solution 10
mg/ml, 15 mg/ml, 8 mg/ml
morphine injection syringe 2 mg/ml
morphine intramuscular
morphine intravenous cartridge
morphine intravenous solution 25
mg/ml, 50 mg/ml
morphine intravenous syringe
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml
MORPHINE ORAL TABLET
morphine oral tablet extended
release 100 mg, 30 mg, 60 mg
morphine oral tablet extended
release 15 mg, 200 mg
morphine rectal
non-aspirin extra strength * oral
capsule
non-aspirin extra strength * oral
liquid
non-aspirin jr strength *
nortemp * oral drops
NUCYNTA
(Methadone HCl)
(Methadone HCl)
(Diskets)
(Diskets)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
$0
$0
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
2
$0
$0
$0
$0
(MS Contin)
1
$0
(MS Contin)
1
$0
(Morphine Sulfate)
1
$0
(Acetaminophen)
4
$0
4
$0
4
4
2
$0
$0
$0
(Tylenol Sore
Throat)
(Acetaminophen)
(Acetaminophen)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
21
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
(Oxycodone HCl)
(Oxycodone HCl)
(Roxicodone)
2
1
1
1
$0
$0
$0
$0
QL (60 per 30 days)
(Xolox)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
1
$0
2
$0
Name of Drug
NUCYNTA ER
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet
oxycodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
tablet 10-650 mg
tablet 7.5-500 mg
oxycodone-aspirin
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG,
15 MG, 20 MG, 30 MG, 40 MG, 60
MG
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet
oxymorphone oral tablet extended
release 12 hr 10 mg, 15 mg, 20 mg,
5 mg, 7.5 mg
oxymorphone oral tablet extended
release 12 hr 30 mg, 40 mg
pain relief adult *
pain relief * oral capsule
pain relief * oral tablet extended
release
pain reliever extra strength *
pain reliever jr strength *
pharbetol * oral tablet 325 mg
QL (60 per 30 days)
2
$0
(Opana)
1
$0
(Opana ER)
1
$0
(Opana ER)
1
$0
4
$0
4
$0
(Acetaminophen)
4
$0
(Tylenol)
(Acetaminophen)
(Tylenol)
4
4
4
$0
$0
$0
(Tylenol Sore
Throat)
(Acetaminophen)
QL (60 per 30 days)
QL (30 per 30 days)
22
Tier level
What the
drug will
cost you
4
4
4
$0
$0
$0
4
$0
4
1
$0
$0
1
$0
silapap *
tactinal *
tactinal extra strength *
(Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol Sore
Throat)
(Tylenol)
(Ibudone)
(Oxycodone
HCl/Acetaminophe
n)
(Acetaminophen)
(Tylenol)
(Tylenol)
4
4
4
$0
$0
$0
tencon oral tablet 50-325 mg
(Tencon)
1
$0
tramadol oral tablet
tramadol-acetaminophen
(Ultram)
(Ultracet)
1
1
$0
$0
vicodin es oral tablet 7.5-300 mg
(Norco)
1
$0
vicodin hp oral tablet 10-300 mg
(Norco)
1
$0
vicodin oral tablet 5-300 mg
(Norco)
1
$0
xylon 10
(Ibudone)
1
$0
zebutal oral capsule 50-325-40 mg
(Esgic)
1
$0
Name of Drug
pharbetol * oral tablet 500 mg
q-pap extra strength *
q-pap * oral drops
q-pap * oral liquid
q-pap * oral tablet 325 mg
reprexain
roxicet oral solution
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
(includes Vicodin,
Vicodin ES and
per 30 days)
PA-HRM; QL (180 per
30 days)
Nonsteroidal Anti-Inflammatory Agents
advil * oral tablet
(Motrin Ib)
4
$0
23
Name of Drug
advil * oral tablet,chewable
aspirin * oral tablet 325 mg
aspirin * oral tablet,chewable
(Ibuprofen)
(Ecotrin)
(Bayer Chewable
Aspirin)
aspirin * oral tablet,delayed release
(Ecotrin)
(dr/ec) 325 mg, 500 mg, 81 mg
aspirin * rectal
(Aspirin)
(Aspirin/Calcium
aspirin, buffered *
Carbonate/Mag)
aspir-low *
(Ecotrin)
(Aspirin/Calcium
bufferin * oral tablet 325 mg
Carbonate/Mag)
CALDOLOR INTRAVENOUS
RECON SOLN 400 MG/4 ML (100
MG/ML)
celecoxib
(Celebrex)
(Children'S
children's advil *
Motrin)
(Choline Sal/Mag
choline,magnesium salicylate
Salicylate)
(Diclofenac
diclofenac potassium
Potassium)
diclofenac sodium oral tablet
(Voltaren-XR)
extended release 24 hr
diclofenac sodium oral
(Diclofenac
tablet,delayed release (dr/ec)
Sodium)
diclofenac sodium topical gel
(Solaraze)
diclofenac-misoprostol
(Arthrotec 50)
diflunisal
(Diflunisal)
e.c. prin *
(Ecotrin)
etodolac
(Etodolac)
(Fenoprofen
fenoprofen oral tablet
Calcium)
Tier level
What the
drug will
cost you
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
1
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
4
1
$0
$0
$0
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
24
Tier level
What the
drug will
cost you
2
1
$0
$0
4
$0
4
4
$0
$0
(Ibuprofen)
1
$0
(Motrin Ib)
4
$0
(Ibuprofen)
1
$0
indomethacin oral capsule 25 mg
(Indomethacin)
1
$0
indomethacin oral capsule 50 mg
(Indomethacin)
1
$0
indomethacin oral capsule,
extended release
(Indomethacin)
1
$0
1
$0
(Ketoprofen)
4
3
1
$0
$0
$0
(Ketoprofen)
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
Name of Drug
FLECTOR
flurbiprofen
ibuprofen * 100 mg/5 ml susp
children's (otc)
ibuprofen jr strength *
ibuprofen * oral capsule
ibuprofen oral suspension 100 mg/5
ml
ibuprofen * oral tablet 100 mg, 200
mg
ibuprofen oral tablet 400 mg, 600
mg, 800 mg
indomethacin sodium
infant's ibuprofen *
INFANT'S MOTRIN *
ketoprofen oral capsule
ketoprofen oral capsule,ext rel.
pellets 24 hr 200 mg
ketorolac oral
mefenamic acid
meloxicam
nabumetone
naproxen oral suspension
naproxen oral tablet
(Flurbiprofen)
(Children'S
Motrin)
(Ibuprofen)
(Advil)
(Indomethacin
Sodium)
(Infants' Motrin)
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per
30 days)
PA-HRM
QL (20 per 30 days)
25
Tier level
What the
drug will
cost you
(Ec-Naprosyn)
1
$0
(Anaprox)
1
$0
(Feldene)
(Salsalate)
(Bayer Chewable
Aspirin)
(Ecotrin)
(Sulindac)
(Tolmetin Sodium)
(Aspirin/Calcium
Carbonate/Mag)
1
1
$0
$0
4
$0
4
1
1
$0
$0
$0
4
$0
(Advil)
2
4
$0
$0
(Lidocaine HCl)
1
$0
Name of Drug
naproxen oral tablet,delayed
release (dr/ec)
naproxen sodium oral tablet 275
mg, 550 mg
piroxicam
salsalate
st joseph aspirin *
st. joseph aspirin *
sulindac oral
tolmetin
tri-buffered aspirin *
VOLTAREN TOPICAL
wal-profen * oral capsule
Necessary Actions,
Restrictions, or
Limits on Use
Anesthetics
Local Anesthetics
glydo
lidocaine (pf) injection solution 15
mg/ml (1.5 %), 40 mg/ml (4 %), 5
mg/ml (0.5 %)
lidocaine hcl injection solution 10
mg/ml (1 %), 20 mg/ml (2 %)
lidocaine hcl laryngotracheal
lidocaine hcl mucous membrane gel
lidocaine hcl mucous membrane
jelly in applicator
lidocaine hcl mucous membrane
solution
lidocaine hcl urethral
lidocaine topical adhesive
patch,medicated
(Xylocaine-MPF)
1
$0
(Xylocaine)
1
$0
(Xylocaine)
(Lidocaine HCl)
1
1
$0
$0
(Lidocaine HCl)
1
$0
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Lidoderm)
1
$0
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA
26
Name of Drug
Tier level
What the
drug will
cost you
lidocaine topical ointment
(Lidocaine)
1
$0
lidocaine viscous
(Xylocaine)
1
$0
lidocaine-prilocaine topical cream
(EMLA)
1
$0
lidocaine-prilocaine topical kit
(Lidocaine/Prilocai
ne)
1
$0
1
$0
1
$0
1
$0
1
2
$0
$0
2
$0
2
$0
2
$0
1
1
1
1
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD
Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
(Acamprosate
acamprosate
Calcium)
buprenorphine hcl sublingual
buprenorphine-naloxone
bupropion hcl sr 150 mg tablet f/c
CHANTIX
CHANTIX CONTINUING
MONTH BOX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
BOX
depade
disulfiram
naloxone
naltrexone oral
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 14 MG/24 HR, 21 MG/24
HR
(Subutex)
(Buprenorphine
HCl/Naloxone
HCl)
(Zyban)
(Revia)
(Antabuse)
(Naloxone HCl)
(Revia)
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
QL (56 per 28 days)
QL (56 per 28 days)
QL (53 per 28 days)
4
$0
27
Tier level
What the
drug will
cost you
4
$0
(Nicorette)
(Nicorette)
(Nicorette)
4
4
4
$0
$0
$0
(Nicoderm Cq)
4
$0
(Nicoderm Cq)
4
$0
2
$0
2
$0
(Xanax)
(Chlordiazepoxide
HCl)
1
$0
1
$0
(Klonopin)
1
$0
(Klonopin)
1
$0
(Clonazepam)
1
$0
(Clonazepam)
1
$0
(Tranxene T-Tab)
1
$0
(Tranxene T-Tab)
1
$0
(Diazepam)
(Diazepam)
(Diazepam)
1
1
1
$0
$0
$0
Name of Drug
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 7 MG/24 HR
nicorelief * buccal gum
nicorette * buccal gum 2 mg
nicotine (polacrilex) *
nicotine * transdermal patch 24
hour 14 mg/24 hr, 7 mg/24 hr
nicotine * transdermal patch 24
hour 21 mg/24 hr, 22 mg/24 hr
NICOTROL
ZUBSOLV
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
chlordiazepoxide hcl
clonazepam oral tablet 0.5 mg, 1
mg
clonazepam oral tablet 2 mg
clonazepam oral
tablet,disintegrating 0.125 mg, 0.25
mg, 0.5 mg, 1 mg
clonazepam oral
tablet,disintegrating 2 mg
clorazepate dipotassium oral tablet
15 mg
clorazepate dipotassium oral tablet
3.75 mg, 7.5 mg
diazepam injection solution
diazepam intensol
diazepam oral solution 5 mg/5 ml
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (10 per 28 days)
28
Name of Drug
diazepam oral tablet
diazepam rectal
lorazepam oral tablet
(Valium)
(Diastat)
(Ativan)
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
1
1
$0
$0
$0
2
$0
PA BvD
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
QL (90 per 30 days)
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl (iso-osm)
intravenous piggyback 100 mg/100
ml, 100 mg/50 ml, 60 mg/50 ml, 70
mg/50 ml, 80 mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
gentamicin injection solution 40
mg/ml
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin
streptomycin intramuscular
(Gentamicin In
Nacl, Iso-Osm)
(Gentamicin
Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE
tobramycin in 0.225 % nacl
(Tobi)
(Tobramycin/Sodiu
tobramycin in 0.9 % nacl
m Chloride)
tobramycin sulfate injection
(Tobramycin
solution
Sulfate)
Antibacterials, Miscellaneous
bacitracin intramuscular
(Bacitracin)
(Chloramphenicol
chloramphenicol sod succinate
Sod Succ)
clindamycin hcl
(Cleocin HCl)
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
PA BvD
29
Tier level
What the
drug will
cost you
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
2
1
1
$0
$0
$0
1
$0
1
$0
1
$0
(Macrodantin)
1
$0
(Macrodantin)
1
$0
Name of Drug
clindamycin in 5 % dextrose
clindamycin palmitate hcl
clindamycin pediatric
clindamycin phosphate injection
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na)
CUBICIN
linezolid
methenamine hippurate
methenamine mandelate
metronidazole in nacl (iso-os)
metronidazole oral
nitrofurantoin macrocrystal oral
capsule 100 mg
nitrofurantoin macrocrystal oral
capsule 50 mg
(Cleocin Phosphate
In D5w)
(Cleocin Palmitate)
(Cleocin Palmitate)
(Cleocin
Phosphate)
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
(Metronidazole/So
dium Chloride)
(Flagyl)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (120 per
30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
30
Name of Drug
Tier level
What the
drug will
cost you
nitrofurantoin monohyd/m-cryst
(Macrobid)
1
$0
polymyxin b sulfate
(Polymyxin B
Sulfate)
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
SYNERCID
trimethoprim
vancomycin in d5w intravenous
piggyback 1 gram/200 ml
vancomycin intravenous recon soln
1,000 mg, 10 gram, 750 mg
vancomycin intravenous recon soln
500 mg
vancomycin oral capsule
XIFAXAN ORAL TABLET 200
MG
ZYVOX ORAL SUSPENSION
FOR RECONSTITUTION
Cephalosporins
cefaclor oral capsule
cefaclor oral suspension for
reconstitution 125 mg/5 ml, 250
mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500
mg/5 ml
cefadroxil oral tablet
(Trimethoprim)
(Vancomycin
HCl/D5W)
(Vancomycin HCl)
(Vancomycin
HCl/D5W)
(Vancocin HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use of
nitrofurantoin drugs);
PA; QL (9 per 30 days)
31
Tier level
What the
drug will
cost you
(Cefazolin
Sodium/Dextrose,
Iso)
1
$0
(Cefazolin Sodium)
1
$0
(Cefdinir)
(Spectracef)
(Maxipime)
1
1
1
2
$0
$0
$0
$0
2
$0
1
1
$0
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
(Rocephin)
1
$0
(Ceftriaxone
Na/Dextrose, Iso)
1
$0
Name of Drug
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/50
ml, 2 gram/50 ml
cefazolin injection recon soln 1
gram, 10 gram, 100 gram, 300 g,
500 mg
cefdinir
cefditoren pivoxil
cefepime
CEFEPIME IN DEXTROSE 5 %
CEFEPIME IN DEXTROSE,ISOOSM INTRAVENOUS
PIGGYBACK 2 GRAM/100 ML
cefotaxime
cefoxitin
cefoxitin in dextrose, iso-osm
ml
cefpodoxime
cefprozil
ceftazidime
ceftibuten
ceftriaxone in dextrose,iso-os
ml
CEFTRIAXONE IN
DEXTROSE,ISO-OS
INTRAVENOUS PIGGYBACK 2
GRAM/50 ML
ceftriaxone injection recon soln 1
gram, 10 gram, 250 mg, 500 mg
ceftriaxone intravenous recon soln
1 gram
(Claforan)
(Cefoxitin Sodium)
(Cefoxitin
Sodium/Dextrose,
Iso)
(Cefpodoxime
Proxetil)
(Cefprozil)
(Fortaz)
(Cedax)
(Ceftriaxone
Na/Dextrose, Iso)
Necessary Actions,
Restrictions, or
Limits on Use
32
Name of Drug
CEFTRIAXONE INTRAVENOUS
RECON SOLN 2 GRAM
cefuroxime axetil oral tablet
(Ceftin)
cefuroxime sodium injection recon
(Zinacef)
soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
(Zinacef)
(Cefuroxime
cefuroxime-dextrose (iso-osm)
Sodium/Dextrose,
Iso)
cephalexin oral capsule
(Keflex)
cephalexin oral suspension for
(Cephalexin)
reconstitution
cephalexin oral tablet
(Cephalexin)
MEFOXIN IN DEXTROSE (ISOOSM)
SUPRAX ORAL
TABLET,CHEWABLE
tazicef injection recon soln 2 gram,
(Fortaz)
6 gram
tazicef intravenous
(Ceftazidime)
TEFLARO
Macrolides
azithromycin
(Zithromax)
clarithromycin oral suspension for
(Biaxin)
reconstitution
clarithromycin oral tablet
(Biaxin)
clarithromycin oral tablet extended
(Clarithromycin)
release 24 hr
DIFICID
(Erythromycin
e.e.s. 400 oral tablet
Ethylsuccinate)
e.e.s. granules
(Eryped 200)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
1
$0
1
2
$0
$0
1
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 10 days)
33
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
(Erythromycin
Stearate)
1
$0
(Eryped 200)
1
$0
Name of Drug
ery-tab oral tablet,delayed release
(dr/ec) 250 mg, 500 mg
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
ERYTHROCIN
erythrocin (as stearate) oral tablet
250 mg
erythromycin ethylsuccinate oral
suspension for reconstitution
erythromycin ethylsuccinate oral
tablet
erythromycin oral capsule,delayed
release(dr/ec)
(Erythromycin
Base)
Necessary Actions,
Restrictions, or
Limits on Use
(Erythromycin
1
$0
Ethylsuccinate)
(Erythromycin
1
$0
Base)
(Erythromycin
erythromycin oral tablet
1
$0
Base)
Miscellaneous B-Lactam Antibiotics
aztreonam injection recon soln 1
(Azactam)
1
$0
gram
CAYSTON
2
$0
LA
imipenem-cilastatin
(Primaxin)
1
$0
INVANZ
2
$0
meropenem
(Merrem)
1
$0
Penicillins
amoxicillin oral capsule
(Amoxicillin)
1
$0
amoxicillin oral suspension for
(Amoxicillin)
1
$0
reconstitution
amoxicillin oral tablet
(Amoxicillin)
1
$0
amoxicillin oral tablet,chewable
(Amoxicillin)
1
$0
125 mg, 250 mg
amoxicillin-pot clavulanate oral
(Augmentin)
1
$0
(Augmentin)
1
$0
tablet
34
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
(Ampicillin
Sodium)
1
$0
(Ampicillin
Sodium)
1
$0
(Unasyn)
1
$0
(Unasyn)
1
2
2
$0
$0
$0
1
$0
1
$0
(Nafcillin Sodium)
1
$0
(Oxacillin
Sodium/Dextrose,
Iso)
1
$0
(Oxacillin Sodium)
1
$0
(Oxacillin Sodium)
(Pen G
Pot/DextroseWater)
(Penicillin G
Potassium)
(Penicillin G
Procaine)
1
$0
1
$0
1
$0
1
$0
Name of Drug
tablet extended release 12 hr
tablet,chewable
ampicillin
ampicillin sodium injection recon
soln 1 gram, 10 gram, 125 mg, 2
gram
ampicillin sodium intravenous
recon soln 2 gram
ampicillin-sulbactam injection
recon soln 15 gram, 3 gram
ampicillin-sulbactam intravenous
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin injection
nafcillin intravenous recon soln 2
gram
oxacillin in dextrose(iso-osm)
oxacillin injection recon soln 10
gram
oxacillin intravenous
penicillin g pot in dextrose
penicillin g potassium
penicillin g procaine
(Augmentin XR)
(Amoxicillin/Potas
sium Clav)
(Ampicillin
Trihydrate)
(Dicloxacillin
Sodium)
(Nafcillin Sodium)
Necessary Actions,
Restrictions, or
Limits on Use
35
Tier level
What the
drug will
cost you
1
$0
1
$0
(Zosyn)
1
$0
(Cipro)
(Cipro)
(Cipro I.V.)
(Ciprofloxacin
Lactate)
1
1
1
$0
$0
$0
1
$0
(Levaquin)
1
$0
(Levofloxacin)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
1
1
$0
$0
$0
$0
(Sulfadiazine)
(Sulfamethoxazole/
Trimethoprim)
(Sulfamethoxazole/
Trimethoprim)
1
$0
1
$0
1
$0
(Bactrim)
1
$0
(Azulfidine)
(Sulfamethoxazole/
Trimethoprim)
(Azulfidine)
(Azulfidine)
1
$0
1
$0
1
1
$0
$0
Name of Drug
penicillin v potassium
pfizerpen-g injection recon soln 20
million unit
piperacillin-tazobactam intravenous
recon soln 3.375 gram, 4.5 gram,
40.5 gram
Quinolones
ciprofloxacin
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate
levofloxacin in d5w intravenous
piggyback 500 mg/100 ml, 750
mg/150 ml
levofloxacin intravenous
levofloxacin oral
moxifloxacin
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
sulfamethoxazole-trimethoprim oral
suspension
sulfamethoxazole-trimethoprim oral
tablet
sulfasalazine
sulfatrim
sulfazine
sulfazine ec
(Penicillin V
Potassium)
(Penicillin G
Potassium)
Necessary Actions,
Restrictions, or
Limits on Use
36
Tier level
What the
drug will
cost you
1
$0
1
1
$0
$0
1
$0
(Adoxa)
1
$0
(Morgidox)
1
$0
(Avidoxy)
1
$0
(Doryx)
1
$0
(Adoxa)
1
$0
(Vibramycin)
1
$0
(Avidoxy)
1
$0
(Minocin)
(Minocycline HCl)
(Tetracycline HCl)
1
1
1
2
$0
$0
$0
$0
Anticancer Agents
ABRAXANE
2
$0
ADCETRIS
2
$0
1
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Tetracyclines
doxy-100
doxycycline hyclate 100 mg cap
doxycycline hyclate 100 mg tab f/c
doxycycline hyclate intravenous
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate oral capsule 50
mg
doxycycline hyclate oral tablet 100
mg, 50 mg
doxycycline hyclate oral tablet 20
mg
doxycycline monohydrate oral
capsule
tablet
minocycline oral capsule
minocycline oral tablet
tetracycline
TYGACIL
(Doxycycline
Hyclate)
(Morgidox)
(Doryx)
(Doxycycline
Hyclate)
Anticancer Agents
adriamycin intravenous recon soln
10 mg
(Doxorubicin HCl)
PA NSO; QL (4 per 21
days)
PA BvD
37
Name of Drug
adrucil intravenous solution 2.5
gram/50 ml, 500 mg/10 ml
(Fluorouracil)
AFINITOR DISPERZ
AFINITOR ORAL TABLET 10
MG
AFINITOR ORAL TABLET 2.5
MG, 5 MG, 7.5 MG
ALIMTA INTRAVENOUS
RECON SOLN 500 MG
anastrozole
AVASTIN
azacitidine
BELEODAQ
bicalutamide
bleomycin
(Arimidex)
(Vidaza)
(Casodex)
(Bleomycin
Sulfate)
BLINCYTO
BOSULIF ORAL TABLET 100
MG
BOSULIF ORAL TABLET 500
MG
CAPRELSA ORAL TABLET 100
MG
CAPRELSA ORAL TABLET 300
MG
COMETRIQ
cyclophosphamide intravenous
recon soln 2 gram
CYCLOPHOSPHAMIDE ORAL
CAPSULE
(Cyclophosphamid
e)
Tier level
What the
drug will
cost you
1
$0
2
$0
2
$0
2
$0
2
$0
1
2
1
2
1
$0
$0
$0
$0
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
PA NSO
PA NSO
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
PA BvD
PA BvD; ST
38
Tier level
What the
drug will
cost you
(Cyclophosphamid
e)
1
$0
(Dactinomycin)
(Dacogen)
(Doxil)
2
1
1
1
2
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
ERIVEDGE
2
$0
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
FARYDAK
FASLODEX
floxuridine
fluorouracil intravenous solution
2.5 gram/50 ml, 5 gram/100 ml
flutamide
GAZYVA
(Floxuridine)
2
1
1
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
(Fluorouracil)
1
$0
(Flutamide)
1
2
$0
$0
GILOTRIF
2
$0
GLEEVEC ORAL TABLET 100
MG
2
$0
Name of Drug
cyclophosphamide oral tablet
CYRAMZA
dactinomycin
decitabine
doxorubicin, peg-liposomal
DROXIA
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG (3 MONTH)
SYRINGE 30 MG (4 MONTH)
SYRINGE 45 MG (6 MONTH)
SYRINGE 7.5 MG (1 MONTH)
EMCYT
(Etoposide)
(Aromasin)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; ST
PA NSO
PA BvD
QL (1 per 84 days)
QL (1 per 112 days)
QL (1 per 168 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA BvD
PA BvD
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (90 per
30 days)
39
Tier level
What the
drug will
cost you
2
$0
2
2
1
$0
$0
$0
IBRANCE
2
$0
ICLUSIG ORAL TABLET 15 MG
2
$0
ICLUSIG ORAL TABLET 45 MG
2
$0
1
$0
1
$0
1
$0
2
$0
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
IXEMPRA
2
$0
JAKAFI
2
$0
KEYTRUDA
2
$0
KYPROLIS
2
$0
LENVIMA
letrozole
LEUKERAN
(Femara)
2
1
2
$0
$0
$0
leuprolide
(Leuprolide
Acetate)
1
$0
Name of Drug
GLEEVEC ORAL TABLET 400
MG
HERCEPTIN
HEXALEN
hydroxyurea
(Hydrea)
ifosfamide intravenous recon soln 1
(Ifex)
gram
ifosfamide intravenous solution 1
(Ifex)
gram/20 ml
(Ifosfamide/Mesna
ifosfamide-mesna
)
IMBRUVICA
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA NSO
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
days)
PA NSO
40
Tier level
What the
drug will
cost you
1
1
2
2
2
2
$0
$0
$0
$0
$0
$0
LYNPARZA
2
$0
LYSODREN
MATULANE
2
2
$0
$0
1
$0
MEKINIST ORAL TABLET 0.5
MG
2
$0
MEKINIST ORAL TABLET 2 MG
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
NEXAVAR
2
$0
NILANDRON
ONCASPAR
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
2
2
$0
$0
2
$0
Name of Drug
lipodox
lomustine
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
megestrol oral tablet
mercaptopurine
methotrexate sodium (pf) injection
recon soln
methotrexate sodium (pf) injection
solution
methotrexate sodium injection
methotrexate sodium oral
mitoxantrone
(Doxil)
(Gleostine)
(Megestrol
Acetate)
(Mercaptopurine)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitoxantrone
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
PA NSO; QL (480 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
41
Tier level
What the
drug will
cost you
POMALYST
2
$0
PROLEUKIN
PURIXAN
REVLIMID
RITUXAN
SOLTAMOX
SPRYCEL ORAL TABLET 100
MG, 140 MG, 50 MG, 70 MG, 80
MG
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
SPRYCEL ORAL TABLET 20 MG
2
$0
STIVARGA
2
$0
SUTENT
2
$0
SYLVANT
2
$0
SYNRIBO
2
$0
TABLOID
2
$0
TAFINLAR
2
$0
1
$0
Name of Drug
tamoxifen
(Tamoxifen
Citrate)
TARCEVA ORAL TABLET 100
MG, 25 MG
TARCEVA ORAL TABLET 150
MG
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (21 per
28 days)
PA NSO; LA
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (28 per
28 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (90 per
2
$0
30 days)
PA NSO; QL (420 per
TARGRETIN ORAL
2
$0
30 days)
PA NSO; QL (60 per
TARGRETIN TOPICAL
2
$0
28 days)
PA NSO; QL (112 per
TASIGNA
2
$0
28 days)
2
$0
42
Tier level
What the
drug will
cost you
TEMODAR INTRAVENOUS
toposar
(Etoposide)
TREANDA
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
SYRINGE 11.25 MG/2 ML
tretinoin (chemotherapy)
(Tretinoin)
TREXALL
TYKERB
VALSTAR
VELCADE
vinorelbine intravenous solution 50
(Navelbine)
mg/5 ml
2
1
2
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
1
2
2
2
2
$0
$0
$0
$0
$0
1
$0
VOTRIENT
2
$0
XALKORI
2
$0
XTANDI
2
$0
YERVOY INTRAVENOUS
SOLUTION 50 MG/10 ML (5
MG/ML)
2
$0
ZELBORAF
2
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; (vial only)
QL (1 per 168 days)
QL (1 per 84 days)
QL (1 per 168 days)
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
ZOLADEX SUBCUTANEOUS
2
$0
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
QL (1 per 28 days)
2
$0
IMPLANT 3.6 MG
43
Tier level
What the
drug will
cost you
ZOLINZA
2
$0
ZYDELIG
2
$0
ZYKADIA
2
$0
ZYTIGA
2
$0
1
$0
1
$0
1
$0
2
2
$0
$0
(Carbatrol)
1
$0
(Tegretol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
2
$0
1
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (60 per
30 days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05
(Atropine Sulfate)
mg/ml, 0.1 mg/ml
(Propantheline
propantheline
Bromide)
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension 100
mg/5 ml
carbamazepine oral tablet
carbamazepine oral tablet extended
release 12 hr
carbamazepine oral tablet,chewable
CELONTIN ORAL CAPSULE 300
MG
DILANTIN
divalproex oral capsule, sprinkle
(Depakote
Sprinkle)
ST
ST
44
Tier level
What the
drug will
cost you
(Depakote ER)
1
$0
(Depakote)
1
$0
(Tegretol)
(Zarontin)
(Felbatol)
(Cerebyx)
(Neurontin)
1
1
1
1
2
1
$0
$0
$0
$0
$0
$0
(Neurontin)
1
$0
(Neurontin)
1
$0
2
$0
2
$0
(Lamictal)
1
$0
(Lamictal XR)
1
$0
(Lamictal)
1
$0
(Lamictal (Blue))
1
$0
(Keppra)
1
$0
(Keppra)
1
$0
(Keppra)
1
$0
(Keppra XR)
1
$0
2
$0
Name of Drug
divalproex oral tablet extended
release 24 hr
divalproex oral tablet,delayed
release (dr/ec)
epitol
ethosuximide
felbamate
fosphenytoin
FYCOMPA
gabapentin oral capsule
gabapentin oral solution 250 mg/5
ml
gabapentin oral tablet 600 mg, 800
mg
GABITRIL ORAL TABLET 12
MG, 16 MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2
MG
lamotrigine oral tablet
lamotrigine oral tablet extended
release 24hr
lamotrigine oral tablet, chewable
dispersible
lamotrigine oral tablets,dose pack
25 mg (35)
levetiracetam intravenous
levetiracetam oral solution 100
mg/ml
levetiracetam oral tablet
levetiracetam oral tablet extended
release 24 hr
LYRICA ORAL CAPSULE
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (90 per 30 days)
45
Tier level
What the
drug will
cost you
(Phenobarbital)
2
1
2
2
1
$0
$0
$0
$0
$0
(Phenobarbital)
1
$0
(Phenobarbital)
(Phenobarbital
Sodium)
1
$0
1
$0
(Dilantin-125)
1
$0
(Dilantin)
(Phenytoin
Sodium)
(Dilantin)
1
$0
1
$0
1
$0
2
$0
2
$0
(Gabitril)
(Topamax)
(Topamax)
1
2
1
1
1
$0
$0
$0
$0
$0
(Qudexy XR)
1
$0
(Topamax)
1
2
1
1
$0
$0
$0
$0
Name of Drug
LYRICA ORAL SOLUTION
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital oral elixir
phenobarbital oral tablet 100 mg,
15 mg, 16.2 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection
solution
phenytoin oral suspension 125 mg/5
ml
phenytoin oral tablet,chewable
phenytoin sodium
phenytoin sodium extended
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
(Trileptal)
POTIGA ORAL TABLET 50 MG
primidone
SABRIL
tiagabine
topiragen
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er
24hr
topiramate oral tablet
TROKENDI XR
valproate sodium
valproic acid
(Mysoline)
(Depacon)
(Depakene)
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (90 per 30 days)
QL (2 per 30 days)
ST; QL (90 per 30
days)
ST; QL (270 per 30
days)
ST
46
Tier level
What the
drug will
cost you
1
$0
VIMPAT INTRAVENOUS
2
$0
VIMPAT ORAL SOLUTION
2
$0
VIMPAT ORAL TABLET
2
$0
(Zonegran)
1
$0
(Aricept)
(Donepezil HCl)
1
1
$0
$0
(Razadyne ER)
1
$0
(Galantamine Hbr)
(Razadyne)
1
1
$0
$0
2
$0
2
$0
2
1
$0
$0
1
$0
1
2
1
1
$0
$0
$0
$0
Name of Drug
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
zonisamide
(Depakene)
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (200 per 5
days)
ST; QL (1200 per 30
days)
ST; QL (60 per 30
days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet
donepezil oral tablet,disintegrating
galantamine oral capsule,ext rel.
pellets 24 hr
galantamine oral solution
galantamine oral tablet
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
NAMZARIC
rivastigmine tartrate
(Exelon)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (28 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
Antidepressants
Antidepressants
amitriptyline
amoxapine
BRINTELLIX
buproban
bupropion hcl oral tablet
(Amitriptyline
HCl)
(Amoxapine)
(Wellbutrin SR)
(Wellbutrin)
PA NSO-HRM
ST
47
Tier level
What the
drug will
cost you
(Wellbutrin SR)
1
$0
(Wellbutrin XL)
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Irenka)
1
$0
(Irenka)
1
$0
(Prozac)
2
1
2
1
$0
$0
$0
$0
(Prozac Weekly)
1
$0
(Fluoxetine HCl)
(Fluoxetine HCl)
(Fluvoxamine
Maleate)
(Tofranil)
(Tofranil-Pm)
(Maprotiline HCl)
1
1
$0
$0
1
$0
1
1
1
2
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
bupropion hcl oral tablet extended
release
bupropion hcl oral tablet extended
release 24 hr
citalopram oral solution
citalopram oral tablet
clomipramine
desipramine oral
doxepin oral
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
duloxetine oral capsule,delayed
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine oral capsule
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
fluvoxamine
imipramine hcl
imipramine pamoate
maprotiline
MARPLAN
mirtazapine
nefazodone
nortriptyline oral capsule
nortriptyline oral solution
olanzapine-fluoxetine
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Lexapro)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Nortriptyline HCl)
(Symbyax)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
ST
PA NSO-HRM
PA NSO-HRM
48
Tier level
What the
drug will
cost you
(Paxil)
1
$0
(Paxil CR)
1
$0
2
$0
1
$0
1
$0
2
$0
ST; QL (30 per 30
days)
$0
$0
$0
$0
$0
$0
QL (30 per 30 days)
PA NSO-HRM
(Parnate)
(Trazodone HCl)
1
1
2
2
1
1
(Effexor XR)
1
$0
(Venlafaxine HCl)
1
$0
(Venlafaxine HCl)
1
$0
2
$0
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
CYCLOSET
1
2
$0
$0
GLYXAMBI
2
$0
2
$0
2
$0
Name of Drug
paroxetine hcl oral tablet
paroxetine hcl oral tablet extended
release 24 hr
PAXIL ORAL SUSPENSION
perphenazine-amitriptyline
phenelzine
(Perphenazine/Ami
triptyline HCl)
(Nardil)
PRISTIQ
protriptyline
sertraline
SILENOR
SURMONTIL
tranylcypromine
trazodone
venlafaxine oral capsule,extended
release 24hr
venlafaxine oral tablet
venlafaxine oral tablet extended
release 24hr 150 mg, 37.5 mg, 75
mg
VIIBRYD
(Protriptyline HCl)
(Zoloft)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
Antidiabetic Agents
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 501,000 MG
INVOKAMET ORAL TABLET
50-500 MG
QL (90 per 30 days)
ST; QL (30 per 30
days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
49
Name of Drug
INVOKANA ORAL TABLET 100
MG
INVOKANA ORAL TABLET 300
MG
JANUMET
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1001,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 501,000 MG
JANUVIA
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
ST; QL (60 per 30
days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
2
$0
2
$0
JARDIANCE
2
$0
JENTADUETO
2
$0
KORLYM
2
$0
(Glucophage)
(Glucophage)
(Glucophage)
1
1
1
$0
$0
$0
(Glucophage XR)
1
$0
(Glucophage XR)
1
$0
(Fortamet)
1
$0
(Starlix)
(Actos)
(Duetact)
(Actoplus Met)
1
1
1
1
2
1
$0
$0
$0
$0
$0
$0
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended
release 24 hr 500 mg
release 24 hr 750 mg
release 24hr 1,000 mg
nateglinide
pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
PRANDIMET
repaglinide
Necessary Actions,
Restrictions, or
Limits on Use
(Prandin)
QL (30 per 30 days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
50
Tier level
What the
drug will
cost you
SYMLINPEN 120
2
$0
SYMLINPEN 60
TRADJENTA
TRULICITY
VICTOZA 3-PAK
Insulins
HUMULIN R U-500
"CONCENTRATED"
LANTUS
LANTUS SOLOSTAR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG PENFILL
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended
release 24hr 10 mg
glipizide oral tablet extended
release 24hr 2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (30 per 28 days)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
1
1
1
1
$0
$0
$0
$0
(Glucotrol XL)
1
$0
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
1
$0
1
$0
1
$0
Name of Drug
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (10.8 per 28
days)
QL (30 per 30 days)
ST; QL (4 per 28 days)
QL (40 per 28 days)
QL (30 per 30 days)
51
Name of Drug
glyburide micronized oral tablet 1.5
(Glynase)
mg
glyburide micronized oral tablet 3
(Glynase)
mg
glyburide micronized oral tablet 6
(Glynase)
mg
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
glyburide oral tablet 1.25 mg
(Glyburide)
1
$0
glyburide oral tablet 2.5 mg
(Glyburide)
1
$0
glyburide oral tablet 5 mg
(Glyburide)
1
$0
(Glucovance)
1
$0
(Glucovance)
1
$0
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
$0
$0
$0
(Miconazole
Nitrate)
4
$0
2
4
$0
$0
4
$0
(Amphotericin B)
2
1
$0
$0
(Tolnaftate)
4
$0
(Tolnaftate)
4
$0
glyburide-metformin oral tablet
1.25-250 mg
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
QL (60 per 30 days)
Antifungals
Antifungals
3 day vaginal *
ABELCET
af *
aloe vesta * topical ointment 2 %
AMBISOME
amphotericin b
antifungal (tolnaftate) * topical
aerosol,spray
antifungal (tolnaftate) * topical
powder
(Tinactin)
(Miconazole
Nitrate)
PA BvD
PA BvD
PA BvD
52
Name of Drug
antifungal * topical solution
baza antifungal *
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
(Undecylenic Acid)
(Nuzole)
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox
Olamine)
(Ciclodan)
(Lotrimin AF)
(Clotrimazole)
(Gyne-Lotrimin)
(Clotrimazole)
(Clotrimazole)
(Lotrimin)
(Gyne-Lotrimin)
(Clotrimazole)
(Gyne-Lotrimin)
ciclopirox-ure-camph-menth-euc
clotrimazole * 1% cream (otc)
clotrimazole * 1% solution (otc)
clotrimazole 3 day *
clotrimazole mucous membrane
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole * vaginal cream
clotrimazole * vaginal tablet
clotrimazole-7 *
clotrimazole-betamethasone topical
(Lotrisone)
cream
clotrimazole-betamethasone topical (Clotrimazole/Beta
lotion
methasone Dip)
(Miconazole
critic-aid clear af *
Nitrate)
(Miconazole
dermafungal *
Nitrate)
econazole topical
(Econazole Nitrate)
elon dual defense *
(Undecylenic Acid)
fluconazole
(Diflucan)
fluconazole in dextrose(iso-o)
(Fluconazole In
Nacl,Iso-Osm)
ml
Tier level
What the
drug will
cost you
4
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
1
$0
1
4
4
4
1
1
1
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
4
$0
4
$0
1
4
1
$0
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
53
Tier level
What the
drug will
cost you
(Fluconazole In
Nacl,Iso-Osm)
1
$0
(Ancobon)
(Clotrimazole)
1
4
$0
$0
4
$0
4
1
4
1
1
1
1
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
1
$0
$0
4
$0
4
$0
Name of Drug
fluconazole in nacl (iso-osm)
ml
flucytosine
fungi cure *
FUNGI-NAIL * TOPICAL
TINCTURE
fungoid-d *
griseofulvin microsize oral tablet
inzo antifungal *
itraconazole
ketoconazole oral
ketoconazole topical cream
ketoconazole topical shampoo
LAMISIL (AEROSOL) *
lamisil af * topical aerosol powder
lamisil af * topical powder
LAMISIL AT * TOPICAL GEL
micatin *
miconazole 7 * vaginal suppository
miconazole nitrate * topical cream
miconazole nitrate * vaginal comb
pack,prefill appl & cream
miconazole nitrate * vaginal cream
miconazole-3 * vaginal kit
miconazole-3 vaginal suppository
MONISTAT 3 * VAGINAL
COMB PACK,PREFILL APPL &
CREAM
MONISTAT 3 * VAGINAL KIT
(Tinactin)
(Grifulvin V)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tinactin)
(Tolnaftate)
(Nuzole)
(Miconazole
Nitrate)
(Nuzole)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Monistat 3)
(Monistat 3)
Necessary Actions,
Restrictions, or
Limits on Use
54
Name of Drug
monistat 7 * vaginal cream
myco nail a *
NOXAFIL ORAL
nyamyc
NYSTATIN (BULK) POWDER 1
BILLION UNIT, 10 BILLION
UNIT
nystatin oral suspension
nystatin oral tablet
nystatin topical
nystatin-triamcinolone
nystop
terbinafine hcl oral
terbinafine hcl * topical
tolnaftate * topical cream
tolnaftate * topical solution
triple paste af *
voriconazole intravenous
voriconazole oral
(Miconazole
Nitrate)
(Undecylenic Acid)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin/Triamcin
)
(Nystatin)
(Lamisil)
(Desenex)
(Tinactin)
(Tolnaftate)
(Miconazole
Nitrate)
(Vfend IV)
(Vfend)
Tier level
What the
drug will
cost you
4
$0
4
2
1
$0
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
1
4
4
4
$0
$0
$0
$0
$0
4
$0
1
1
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
Antihistamines
Antihistamines
alavert d-12 allergy-sinus *
allegra allergy *
aller-chlor * oral syrup
aller-chlor * oral tablet
allerclear d-12hr *
(Claritin-D 12
Hour)
(Fexofenadine
HCl)
(Chlorpheniramine
Maleate)
(Chlor-Trimeton)
(Claritin-D 12
Hour)
55
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(Zyrtec)
4
$0
(Claritin)
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
4
$0
$0
(Zyrtec)
4
$0
(Zyrtec-D)
4
$0
(Zyrtec)
4
$0
(Dimetapp)
(Dimetapp)
(Fexofenadine
HCl)
4
4
$0
$0
4
$0
Name of Drug
allerclear d-24hr *
allergy (chlorpheniramine) *
allergy (diphenhydramine) * oral
tablet
allergy relief (cetirizine) * oral
capsule
allergy relief (loratadine) * oral
allerhist-1 *
aller-tec d *
ambi 60pse-4cpm *
aprodine *
banophen allergy *
banophen * oral capsule 25 mg
banophen * oral tablet
benadryl allergy * oral tablet
cetirizine * oral solution 1 mg/ml
cetirizine * oral tablet 10 mg
cetirizine * oral tablet,chewable 5
mg
cetirizine-pseudoephedrine *
child allergy relf(cetirizine) * oral
tablet,chewable 10 mg
child triaminic cold & allergy *
child wal-tap cold-allergy *
children's allegra allergy * oral
suspension
(Claritin-D 24
Hour)
(Chlor-Trimeton)
(Diphenhydramine
HCl)
(Clemastine
Fumarate)
(Zyrtec-D)
(Pseudoephed/Chlo
rpheniramine)
(Pseudoephedrine/
Triprolidine)
(Zzzquil)
(Benadryl)
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Children'S Zyrtec)
(Zyrtec)
Necessary Actions,
Restrictions, or
Limits on Use
56
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
(Zzzquil)
4
$0
(Zyrtec)
4
$0
4
$0
4
4
4
$0
$0
$0
Name of Drug
children's allegra allergy * oral
tablet
children's aller-tec *
CHILDREN'S CLARITIN *
children's wal-dryl allergy * oral
liquid
children's wal-zyr * oral
tablet,chewable
CHILDREN'S ZYRTEC
ALLERGY *
CLARITIN LIQUI-GEL *
CLARITIN * ORAL TABLET
CLARITIN REDITABS *
(Fexofenadine
HCl)
(Children'S Zyrtec)
Necessary Actions,
Restrictions, or
Limits on Use
(Clemastine
4
$0
Fumarate)
(Triaminic
cold & cough * oral liquid 6.25-2.5
Nighttime Cold4
$0
mg/5 ml
Cough)
(Diphenhydramine
compoz *
4
$0
HCl)
(Cyproheptadine
PA-HRM
cyproheptadine
1
$0
HCl)
(Clemastine
dailyhist-1 *
4
$0
Fumarate)
(Clemastine
dayhist allergy *
4
$0
Fumarate)
dimaphen (pe) *
(Dimetapp)
4
$0
(Triaminic
dimetapp cold-congestion *
Nighttime Cold4
$0
Cough)
diphenhist * oral capsule
(Benadryl)
4
$0
diphenhist * oral liquid
(Zzzquil)
4
$0
(Diphenhydramine
diphenhist * oral tablet 25 mg
4
$0
HCl)
clemastine * oral tablet 1.34 mg
57
Name of Drug
diphenhydramine hcl injection
solution 50 mg/ml
diphenhydramine hcl * oral capsule
diphenhydramine hcl * oral tablet
50 mg
ed a-hist * oral tablet
ed chlorped jr *
fexofenadine * oral suspension
fexofenadine * oral tablet 180 mg,
60 mg
levocetirizine
loradamed *
loratadine * oral solution
loratadine * oral tablet
loratadine-d * oral tablet extended
release 12 hr
loratadine-d * oral tablet extended
release 24 hr
promethazine oral syrup
q-dryl * oral liquid
siladryl sa *
simply sleep *
sinus & allergy (pseudoephed) *
sleep aid (diphenhydramine) * oral
liquid
(Diphenhydramine
HCl)
(Benadryl)
(Diphenhydramine
HCl)
(Phenylephrine/Chl
orpheniramine)
(Chlorpheniramine
Maleate)
(Fexofenadine
HCl)
(Fexofenadine
HCl)
(Xyzal)
(Claritin)
(Children'S
Claritin)
(Claritin)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Promethazine
HCl)
(Zzzquil)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
(Zzzquil)
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
4
$0
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
4
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
(Doxylamine
4
$0
Succinate)
sleep aid (doxylamine) *
58
Name of Drug
sudogest sinus & allergy *
TRIAMINIC COLD & COUGH
NT (PE) *
unisom sleepgels *
wal-act d cold & allergy *
wal-dryl allergy * oral capsule
wal-dryl allergy * oral tablet
wal-fex allergy *
wal-finate *
wal-finate-d *
wal-itin d *
wal-itin d 12 hour *
wal-itin * oral solution
wal-itin * oral tablet
wal-itin * oral tablet,disintegrating
wal-phed * oral tablet 4-60 mg
wal-phed pe sinus & allergy *
(Pseudoephed/Chlo
rpheniramine)
(Benadryl)
(Pseudoephedrine/
Triprolidine)
(Benadryl)
(Diphenhydramine
HCl)
(Fexofenadine
HCl)
(Chlor-Trimeton)
(Pseudoephed/Chlo
rpheniramine)
(Claritin-D 24
Hour)
(Claritin-D 12
Hour)
(Children'S
Claritin)
(Claritin)
(Claritin)
(Pseudoephed/Chlo
rpheniramine)
(Phenylephrine/Chl
orpheniramine)
(Benadryl)
(Zzzquil)
(Unisom
Sleepmelts)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
wal-sleep z * oral capsule
4
$0
wal-sleep z * oral liquid
4
$0
wal-sleep z * oral
4
$0
wal-som (diphenhydramine) * oral
(Benadryl)
4
$0
capsule
wal-tap *
(Dimetapp)
4
$0
59
Tier level
What the
drug will
cost you
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
4
$0
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
(Amerge)
(Maxalt)
1
1
2
1
1
$0
$0
$0
$0
$0
(Maxalt Mlt)
1
$0
(Imitrex)
(Imitrex)
1
1
$0
$0
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
Name of Drug
wal-zyr (cetirizine) * oral solution
wal-zyr (cetirizine) * oral tablet
wal-zyr d *
z-sleep * oral capsule
z-sleep * oral liquid
ZYRTEC * ORAL CAPSULE
ZYRTEC * ORAL TABLET
ZYRTEC * ORAL
TABLET,DISINTEGRATING
(Children'S Zyrtec)
(Zyrtec)
(Zyrtec-D)
(Benadryl)
(Zzzquil)
Necessary Actions,
Restrictions, or
Limits on Use
Anti-Infectives (Skin And Mucous Membrane)
Anti-Infectives (Skin And Mucous Membrane)
ABREVA *
AVC VAGINAL
clindamycin phosphate vaginal
(Cleocin)
metronidazole vaginal
(Metrogel-Vaginal)
terconazole vaginal cream
(Terazol 7)
terconazole vaginal suppository
(Terconazole)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
dihydroergotamine nasal
ERGOMAR
naratriptan
rizatriptan oral tablet
rizatriptan oral
sumatriptan
sumatriptan succinate oral
sumatriptan succinate subcutaneous
cartridge 6 mg/0.5 ml
pen injector 4 mg/0.5 ml
(D.H.E.45)
(Migranal)
QL (30 per 28 days)
QL (8 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (12 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
60
Tier level
What the
drug will
cost you
(Imitrex)
1
$0
(Imitrex)
1
$0
(Zomig)
1
$0
(Zomig Zmt)
1
$0
2
1
1
1
2
2
1
1
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
SIRTURO
2
$0
TRECATOR
2
$0
1
1
4
4
4
1
2
$0
$0
$0
$0
$0
$0
$0
Name of Drug
pen injector 6 mg/0.5 ml
solution
zolmitriptan oral tablet
zolmitriptan oral
Necessary Actions,
Restrictions, or
Limits on Use
QL (4 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin intravenous
rifampin oral
RIFATER
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
PA; QL (188 per 168
days)
Antinausea Agents
Antinausea Agents
compro
dimenhydrinate injection solution
dimenhydrinate * oral
dramamine * oral tablet
driminate *
dronabinol
EMEND INTRAVENOUS
(Compazine)
(Dimenhydrinate)
(Dimenhydrinate)
(Dimenhydrinate)
(Dimenhydrinate)
(Marinol)
QL (2 per 28 days)
61
Tier level
What the
drug will
cost you
2
$0
(Granisetron
HCl/PF)
1
$0
(Granisetron HCl)
1
$0
(Granisetron HCl)
1
$0
(Meclizine HCl)
4
$0
(Meclizine HCl)
4
$0
(Antivert)
1
$0
(Zofran Odt)
(Ondansetron
HCl/PF)
(Zofran)
(Phenergan)
(Compazine)
(Prochlorperazine
Edisylate)
(Compazine)
(Promethazine
HCl)
(Phenergan)
(Phenergan)
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
(Bonine)
(Dimenhydrinate)
1
1
2
4
4
$0
$0
$0
$0
$0
(Mepron)
(Malarone)
2
2
1
1
$0
$0
$0
$0
Name of Drug
EMEND ORAL
granisetron (pf) intravenous
solution 100 mcg/ml
granisetron hcl intravenous solution
1 mg/ml (1 ml)
granisetron hcl oral
meclizine * 12.5 mg caplet caplet
(otc)
meclizine * 25 mg tablet (otc)
meclizine oral tablet 12.5 mg, 25
mg
ondansetron
ondansetron hcl (pf) injection
solution
ondansetron hcl oral
phenadoz
prochlorperazine
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral
promethazine oral tablet
promethazine rectal
promethegan
TRANSDERM-SCOP
travel sickness (meclizine) *
wal-dram *
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
atovaquone-proguanil
62
Tier level
What the
drug will
cost you
1
$0
2
2
1
1
1
2
$0
$0
$0
$0
$0
$0
1
$0
2
2
1
$0
$0
$0
1
2
2
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Sinemet CR)
1
$0
(Stalevo 50)
(Comtan)
1
1
$0
$0
2
$0
1
1
$0
$0
Name of Drug
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
NEBUPENT
paromomycin
PENTAM
PRIMAQUINE
quinine sulfate
(Chloroquine
Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin
Sulfate)
(Qualaquin)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral
APOKYN
AZILECT
benztropine oral
bromocriptine
cabergoline
carbidopa
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet
extended release
carbidopa-levodopa-entacapone
entacapone
(Amantadine HCl)
(Benztropine
Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
NEUPRO
pramipexole oral tablet
ropinirole oral tablet
(Mirapex)
(Requip)
QL (60 per 30 days)
PA-HRM
ST; QL (30 per 30
days)
63
Tier level
What the
drug will
cost you
(Requip XL)
1
$0
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
HCl)
1
1
$0
$0
1
$0
2
$0
2
$0
Name of Drug
ropinirole oral tablet extended
release 24 hr
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10
MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING
aripiprazole oral tablet 10 mg, 15
mg, 20 mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
QL (90 per 30 days)
QL (1 per 28 days)
2
$0
(Abilify)
1
$0
(Abilify)
(Chlorpromazine
HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
FANAPT ORAL TABLET
2
$0
FANAPT ORAL TABLETS,DOSE
PACK
2
$0
chlorpromazine
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
ST
ST; QL (60 per 30
days)
(Fluphenazine
1
$0
Decanoate)
fluphenazine decanoate
64
Name of Drug
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate
intramuscular solution 100 mg/ml
haloperidol decanoate
intramuscular solution 50 mg/ml
haloperidol lactate
(Fluphenazine
HCl)
(Haloperidol)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
(Haloperidol
Lactate)
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 1.5
MG, 3 MG, 9 MG
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 6
MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE
117 MG/0.75 ML
INVEGA SUSTENNA
156 MG/ML
INVEGA SUSTENNA
234 MG/1.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 39
MG/0.25 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 78
MG/0.5 ML
INVEGA TRINZA
273 MG/0.875 ML
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
2
$0
ST; QL (30 per 30
days)
2
$0
ST; QL (60 per 30
days)
QL (6 per 28 days)
QL (0.75 per 28 days)
2
$0
2
$0
2
$0
QL (1 per 28 days)
2
$0
2
$0
2
$0
65
Name of Drug
Tier level
INVEGA TRINZA
410 MG/1.315 ML
INVEGA TRINZA
546 MG/1.75 ML
INVEGA TRINZA
819 MG/2.625 ML
LATUDA ORAL TABLET 120
MG, 20 MG, 40 MG, 60 MG
olanzapine intramuscular
olanzapine oral tablet
olanzapine oral
tablet,disintegrating 10 mg, 15 mg,
5 mg
olanzapine oral
tablet,disintegrating 20 mg
ORAP
perphenazine
quetiapine
RISPERDAL CONSTA
risperidone oral solution
risperidone oral tablet
risperidone oral
tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg
risperidone oral
tablet,disintegrating 3 mg, 4 mg
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
1
$0
$0
(Zyprexa Zydis)
1
$0
(Zyprexa Zydis)
1
$0
(Risperdal)
(Risperdal)
2
1
1
2
1
1
$0
$0
$0
$0
$0
$0
(Risperdal M-Tab)
1
$0
(Risperdal M-Tab)
1
$0
LATUDA ORAL TABLET 80 MG
loxapine succinate
What the
drug will
cost you
(Loxapine
Succinate)
(Zyprexa)
(Zyprexa)
(Perphenazine)
(Seroquel)
ST; QL (30 per 30
days)
ST; QL (60 per 30
days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (31 per 30 days)
QL (90 per 30 days)
QL (4 per 28 days)
QL (60 per 30 days)
QL (60 per 30 days)
66
Name of Drug
SAPHRIS (BLACK CHERRY)
thioridazine
thiothixene
trifluoperazine
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine
HCl)
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 210 MG, 405
MG
(Geodon)
Tier level
What the
drug will
cost you
2
$0
1
1
$0
$0
1
$0
2
$0
1
$0
2
$0
1
1
2
2
2
$0
$0
$0
$0
$0
2
$0
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
2
2
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
PA NSO-HRM
ST; QL (540 per 30
days)
QL (60 per 30 days)
Antivirals (Systemic)
Antiretrovirals
abacavir
(Ziagen)
abacavir-lamivudine-zidovudine
(Trizivir)
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
didanosine
(Videx EC)
EDURANT
EMTRIVA
EPIVIR HBV ORAL SOLUTION
EPZICOM
EVOTAZ
FUZEON SUBCUTANEOUS
RECON SOLN
INTELENCE
INVIRASE
67
Tier level
What the
drug will
cost you
(Viramune)
(Viramune)
2
2
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
(Viramune XR)
1
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
2
1
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
2
$0
$0
Name of Drug
ISENTRESS
KALETRA
lamivudine
lamivudine-zidovudine
LEXIVA
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended
release 24 hr
NORVIR
PREZCOBIX
PREZISTA
RESCRIPTOR
RETROVIR INTRAVENOUS
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET
SELZENTRY
stavudine
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX 2 GRAM PEDIATRIC
VIRACEPT ORAL TABLET
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR
100 MG
VIREAD
VITEKTA
(Epivir)
(Combivir)
(Zerit)
Necessary Actions,
Restrictions, or
Limits on Use
68
Tier level
What the
drug will
cost you
2
1
1
1
$0
$0
$0
$0
1
2
1
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
HARVONI
2
$0
OLYSIO
2
$0
SOVALDI
2
$0
Interferons
INTRON A INJECTION
PEGASYS
PEGASYS PROCLICK
PEGINTRON
2
2
2
2
$0
$0
$0
$0
SYLATRON
2
$0
Nucleosides And Nucleotides
acyclovir oral capsule
(Zovirax)
1
$0
Name of Drug
ZIAGEN ORAL SOLUTION
zidovudine oral capsule
zidovudine oral syrup
zidovudine oral tablet
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
SYNAGIS
TAMIFLU ORAL CAPSULE 30
MG
MG
MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION
Hcv Antivirals
(Retrovir)
(Retrovir)
(Zidovudine)
(Foscavir)
(Flumadine)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA NSO
PA
PA
PA
days)
69
Tier level
What the
drug will
cost you
(Zovirax)
1
$0
(Zovirax)
(Acyclovir
Sodium)
(Hepsera)
(Baraclude)
(Famvir)
(Cytovene)
(Rebetol)
(Copegus)
1
$0
1
$0
1
1
1
1
1
1
2
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Lovenox)
2
2
1
$0
$0
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
Name of Drug
acyclovir oral suspension 200 mg/5
ml
acyclovir oral tablet
acyclovir sodium intravenous
solution
adefovir
entecavir
famciclovir
ganciclovir sodium
ribasphere oral capsule
ribasphere oral tablet
TYZEKA
valacyclovir
valganciclovir
VIRAZOLE
(Valtrex)
(Valcyte)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
Blood Products/Modifiers/Volume Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
ELIQUIS
enoxaparin subcutaneous solution
enoxaparin subcutaneous syringe
100 mg/ml
120 mg/0.8 ml, 80 mg/0.8 ml
150 mg/ml
30 mg/0.3 ml
40 mg/0.4 ml
60 mg/0.6 ml
QL (36 per 30 days)
QL (36 per 30 days)
QL (34 per 30 days)
QL (18 per 30 days)
70
Tier level
What the
drug will
cost you
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Heparin
Sodium,Porcine/D5
W)
1
$0
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
(Heparin
Sodium,Porcine/Ns
/PF)
1
$0
Name of Drug
fondaparinux subcutaneous syringe
10 mg/0.8 ml
2.5 mg/0.5 ml
5 mg/0.4 ml
7.5 mg/0.6 ml
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml, 20,000 unit/500
ml (40 unit/ml), 25,000 unit/500 ml
(50 unit/ml)
heparin (porcine) in 5 % dex
25,000 unit/250 ml(100 unit/ml)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml
heparin (porcine) injection solution
1,000 unit/ml, 20,000 unit/ml, 5,000
unit/ml
heparin (porcine) injection solution
10,000 unit/ml
heparin lockflush(porcine)(pf)
intravenous syringe 10 unit/ml
heparin, porcine (pf) injection
syringe
heparin, porcine (pf) intravenous
syringe
heparin-0.45% nacl 25,000
units/250 ml (100 units/ml) bag
latex-free, inner
(Heparin
Sodium,Porcine)
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (24 per 30 days)
QL (15 per 30 days)
QL (12 per 30 days)
QL (18 per 30 days)
PA BvD; (PA for
ESRD Only)
PA BvD
PA BvD; (PA for
ESRD Only)
71
Tier level
What the
drug will
cost you
1
$0
2
$0
1
$0
PRADAXA
2
$0
warfarin
(Coumadin)
XARELTO
Blood Formation Modifiers
CINRYZE
EPOGEN INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
GRANIX
LEUKINE INJECTION RECON
SOLN
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 50 MCG/0.3
ML, 75 MCG/0.3 ML
MOZOBIL
NEULASTA SUBCUTANEOUS
SYRINGE
NEUMEGA
NEUPOGEN
PROCRIT INJECTION
SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/2
ML, 20,000 UNIT/ML, 3,000
UNIT/ML, 4,000 UNIT/ML
1
2
$0
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
heparin-d5w 25,000 units/250 ml
(100 units/ml) bag excel container
(Heparin
Sodium,Porcine/D5
W)
IPRIVASK
jantoven
(Coumadin)
2
$0
2
$0
2
$0
2
2
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (24 per 28
days)
ST; QL (60 per 30
days)
PA
PA; QL (12 per 28
days)
PA; QL (0.6 per 28
days)
PA; QL (12 per 28
days)
2
$0
72
Tier level
What the
drug will
cost you
PROCRIT INJECTION
SOLUTION 40,000 UNIT/ML
2
$0
PROMACTA
2
$0
1
$0
1
1
$0
$0
1
$0
Name of Drug
Hematologic Agents, Miscellaneous
(Aminocaproic
aminocaproic acid oral solution
Acid)
aminocaproic acid oral tablet
(Amicar)
anagrelide
(Agrylin)
protamine
(Protamine Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (30 per 30
days)
PA BvD; (PA for
ESRD Only)
tranexamic acid intravenous
(Tranexamic Acid)
1
$0
tranexamic acid oral
(Lysteda)
1
$0
QL (30 per 30 days)
Platelet-Aggregation Inhibitors
AGGRENOX
2
$0
QL (60 per 30 days)
BRILINTA
2
$0
cilostazol
(Pletal)
1
$0
clopidogrel
(Plavix)
1
$0
EFFIENT
2
$0
QL (30 per 30 days)
pentoxifylline
(Pentoxifylline)
1
$0
Volume Expanders
ALBUKED-25
2
$0
ALBUKED-5
2
$0
ALBUMIN, HUMAN 25 %
2
$0
ALBUMIN, HUMAN 5 %
2
$0
ALBUMINAR 25 %
2
$0
ALBUMINAR 5 %
2
$0
ALBURX (HUMAN) 5 %
2
$0
ALBUTEIN 25 %
2
$0
ALBUTEIN 5 %
2
$0
BUMINATE 25 %
2
$0
BUMINATE 5 %
2
$0
FLEXBUMIN 25 %
2
$0
73
Name of Drug
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
Tier level
What the
drug will
cost you
2
2
2
2
$0
$0
$0
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
AMINOSYN 10 %
AMINOSYN 3.5 %
AMINOSYN 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
AMINOSYN 8.5 %
AMINOSYN 8.5 %ELECTROLYTES
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
AMINOSYN M 3.5 %
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 % (SULFITEFREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE
CLINIMIX 5%/D25W SULFITEFREE
CLINIMIX 2.75%/D5W SULFIT
FREE
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
74
Name of Drug
CLINIMIX 4.25%/D10W SULF
FREE
CLINIMIX 4.25%/D5W SULFIT
FREE
CLINIMIX 4.25%-D20W SULFFREE
CLINIMIX 4.25%-D25W SULFFREE
CLINIMIX 5%-D20W(SULFITEFREE)
CLINIMIX E 2.75%/D10W SUL
FREE
CLINIMIX E 2.75%/D5W SULF
FREE
FREE
FREE
CLINIMIX E 4.25%/D5W SULF
FREE
CLINIMIX E 5%/D15W SULFIT
FREE
FREE
FREE
CLINISOL SF 15 %
cysteine (l-cysteine) intravenous
solution
(Cysteine HCl)
(Dextrose 10 %
and 0.9 % NaCl)
dex4 glucose * oral tablet,chewable (Dextrose)
dextrose 10 % in water (d10w)
(Dextrose 10 % in
Water)
d10 %-0.9 % sodium chloride
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
75
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Dextrose)
(Dextrose)
2
2
4
4
$0
$0
$0
$0
(Dextrose)
4
$0
(Dextrose)
4
2
2
$0
$0
$0
4
$0
2
$0
2
2
2
2
$0
$0
$0
$0
Name of Drug
dextrose 2.5 % in water(d2.5w)
dextrose 5 % in ringers
FREAMINE HBC 6.9 %
FREAMINE III 10 %
gluco burst *
glucose gel *
glucose * oral tablet,chewable 4
gram
glutose 15 *
HEPATAMINE 8%
HEPATASOL 8 %
insta-glucose *
(Dextrose 2.5 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5% In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
(Dextrose/Dextrin/
Maltose)
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN
LIPOSYN II
LIPOSYN III
NEPHRAMINE 5.4 %
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
76
Name of Drug
NUTRILIPID
PERIKABIVEN
PREMASOL 10 %
PREMASOL 6 %
PROCALAMINE 3%
PROSOL 20 %
TRAVASOL 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
PA-HRM
2
$0
PA; QL (180 per 30
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet
(Catapres)
clonidine transdermal patch weekly
(Catapres-Tts 1)
0.1 mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly
(Catapres-Tts 1)
0.3 mg/24 hr
(Clonidine
clorpres
HCl/Chlorthalidon
e)
doxazosin
(Cardura)
guanfacine oral tablet
(Tenex)
midodrine
(Midodrine HCl)
NORTHERA
QL (4 per 28 days)
QL (8 per 28 days)
phenylephrine hcl injection
(Vazculep)
1
$0
prazosin oral
(Minipress)
1
$0
Angiotensin Ii Receptor Antagonists
BENICAR
2
$0
ST
BENICAR HCT
2
$0
ST
candesartan
(Atacand)
1
$0
candesartan-hydrochlorothiazid
(Atacand HCT)
1
$0
irbesartan
(Avapro)
1
$0
irbesartan-hydrochlorothiazide
(Avalide)
1
$0
77
Name of Drug
Tier level
What the
drug will
cost you
losartan
(Cozaar)
losartan-hydrochlorothiazide
(Hyzaar)
telmisartan
(Micardis)
telmisartan-hydrochlorothiazid
(Micardis HCT)
TRIBENZOR
valsartan
(Diovan)
valsartan-hydrochlorothiazide
(Diovan HCT)
Angiotensin-Converting Enzyme Inhibitors
benazepril
(Lotensin)
benazepril-hydrochlorothiazide
(Lotensin HCT)
captopril
(Captopril)
(Captopril/Hydroch
captopril-hydrochlorothiazide
lorothiazide)
enalapril maleate
(Vasotec)
(Enalaprilat
enalaprilat intravenous injectable
Dihydrate)
enalapril-hydrochlorothiazide
(Vaseretic)
(Fosinopril
fosinopril
Sodium)
(Fosinopril/Hydroc
fosinopril-hydrochlorothiazide
hlorothiazide)
lisinopril
(Zestril)
lisinopril-hydrochlorothiazide
(Zestoretic)
moexipril
(Moexipril HCl)
(Moexipril/Hydroc
moexipril-hydrochlorothiazide
hlorothiazide)
perindopril erbumine
(Aceon)
quinapril
(Accupril)
quinapril-hydrochlorothiazide
(Accuretic)
ramipril
(Altace)
trandolapril
(Mavik)
Antiarrhythmic Agents
amiodarone oral
(Cordarone)
1
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
78
Tier level
What the
drug will
cost you
(Norpace)
1
$0
(Tambocor)
(Lidocaine
HCl/PF)
1
$0
1
$0
1
$0
(Mexiletine HCl)
1
2
$0
$0
(Cordarone)
1
$0
(Procainamide
HCl)
1
$0
(Rythmol SR)
1
$0
(Rythmol)
(Quinidine
Gluconate)
(Quinidine Sulfate)
1
$0
1
$0
1
2
$0
$0
1
1
1
1
1
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
disopyramide phosphate oral
capsule
flecainide
lidocaine (pf) intravenous syringe
50 mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8
mg/ml (0.8 %)
mexiletine
MULTAQ
pacerone oral tablet 100 mg, 200
mg, 400 mg
procainamide injection
propafenone oral capsule,extended
release 12 hr
propafenone oral tablet
quinidine gluconate oral
(Lidocaine
HCl/D5w/PF)
quinidine sulfate
TIKOSYN
Beta-Adrenergic Blocking Agents
acebutolol oral
(Sectral)
atenolol
(Tenormin)
atenolol-chlorthalidone
(Tenoretic 50)
betaxolol oral
(Kerlone)
bisoprolol fumarate
(Zebeta)
bisoprolol-hydrochlorothiazide
(Ziac)
BYSTOLIC
carvedilol
(Coreg)
esmolol intravenous solution
(Esmolol HCl)
labetalol intravenous solution
(Labetalol HCl)
labetalol oral
(Trandate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
79
Tier level
What the
drug will
cost you
(Toprol XL)
(Lopressor HCT)
1
1
$0
$0
(Lopressor)
1
$0
(Lopressor)
(Corgard)
(Pindolol)
(Propranolol HCl)
1
1
1
1
$0
$0
$0
$0
(Inderal LA)
1
$0
1
1
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
Name of Drug
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous
solution
metoprolol tartrate oral
nadolol
pindolol
propranolol intravenous
propranolol oral capsule,extended
release 24 hr
propranolol oral solution
propranolol oral tablet
(Propranolol HCl)
(Propranolol HCl)
(Propranolol/Hydro
propranolol-hydrochlorothiazid
chlorothiazid)
sorine
(Betapace)
sotalol af oral tablet 120 mg
(Betapace)
sotalol oral
(Betapace)
timolol maleate oral
(Timolol Maleate)
Calcium-Channel Blocking Agents
cartia xt
(Cardizem CD)
diltiazem hcl intravenous
(Cardizem CD)
diltiazem hcl oral capsule, extended
(Cardizem CD)
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 12 hr
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 24hr
diltiazem hcl oral tablet
(Cardizem CD)
diltiazem hcl oral tablet extended
(Cardizem LA)
release 24 hr
dilt-xr
(Cardizem CD)
matzim la
(Cardizem CD)
taztia xt
(Cardizem CD)
Necessary Actions,
Restrictions, or
Limits on Use
80
Name of Drug
verapamil intravenous syringe
(Verapamil HCl)
verapamil oral capsule, 24 hr er
(Verelan Pm)
pellet ct
verapamil oral capsule,ext rel.
(Verelan)
pellets 24 hr
verapamil oral tablet
(Calan)
verapamil oral tablet extended
(Calan SR)
release
Cardiovascular Agents, Miscellaneous
DEMSER
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
digitek oral tablet 125 mcg
(Lanoxin)
1
$0
digitek oral tablet 250 mcg
(Lanoxin)
1
$0
digox
(Lanoxin)
1
$0
digoxin injection
DIGOXIN ORAL SOLUTION 50
MCG/ML
(Digoxin)
1
$0
2
$0
digoxin oral tablet
(Lanoxin)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
PA-HRM; QL (30 per
30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA-HRM
PA-HRM; QL (300 per
30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
81
Name of Drug
dobutamine in d5w intravenous
parenteral solution 1,000 mg/250
ml (4,000 mcg/ml), 250 mg/250 ml
(1 mg/ml), 500 mg/250 ml (2,000
mcg/ml)
dobutamine intravenous solution
250 mg/20 ml (12.5 mg/ml)
dopamine in 5 % dextrose
intravenous solution 200 mg/250 ml
(800 mcg/ml), 400 mg/250 ml
(1,600 mcg/ml), 800 mg/250 ml
(3,200 mcg/ml)
dopamine intravenous solution 200
mg/5 ml (40 mg/ml), 800 mg/10 ml
(80 mg/ml), 800 mg/5 ml (160
mg/ml)
ephedrine sulfate injection solution
epinephrine injection auto-injector
epinephrine injection solution 1
mg/ml (1:1,000) (1ml)
epinephrine injection syringe 0.1
mg/ml (1:10,000)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
Tier level
FIRAZYR
hydralazine
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
(Dobutamine
HCl/D5W)
1
$0
(Dobutamine HCl)
1
$0
PA BvD
PA BvD
(Dopamine
HCl/D5W)
1
$0
PA BvD
(Dopamine HCl)
1
$0
(Ephedrine Sulfate)
(Adrenaclick)
1
1
$0
$0
(Epinephrine)
1
$0
(Epinephrine)
1
$0
2
2
$0
$0
1
$0
2
1
$0
$0
(Ethanolamine
Oleate)
ethamolin
What the
drug will
cost you
(Hydralazine HCl)
LANOXIN ORAL TABLET 187.5
MCG, 62.5 MCG
2
$0
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
82
Tier level
What the
drug will
cost you
(Milrinone Lactate)
1
$0
(Milrinone
Lactate/D5W)
1
$0
1
$0
1
1
2
$0
$0
$0
1
1
1
1
1
2
$0
$0
$0
$0
$0
$0
2
$0
(Felodipine)
(Isradipine)
(Nicardipine HCl)
(Procardia XL)
1
1
1
1
$0
$0
$0
$0
(Adalat CC)
1
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
(Midamor)
(Amiloride/Hydroc
hlorothiazide)
(Bumetanide)
1
$0
1
$0
1
$0
Name of Drug
milrinone
milrinone in 5 % dextrose
ml (200 mcg/ml)
norepinephrine bitartrate
papaverine injection solution
papaverine oral
RANEXA
Dihydropyridines
afeditab cr
amlodipine
amlodipine-benazepril
amlodipine-valsartan
amlodipine-valsartan-hcthiazid
AZOR
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine
isradipine
nicardipine oral
nifedical xl
nifedipine oral tablet extended
release 24hr 30 mg
release 24hr 60 mg, 90 mg
release 30 mg
Diuretics
amiloride oral
amiloride-hydrochlorothiazide
bumetanide
(Levophed
Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
(Adalat CC)
(Norvasc)
(Lotrel)
(Exforge)
(Exforge HCT)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA
PA
ST
83
Tier level
What the
drug will
cost you
(Chlorothiazide)
(Sodium Diuril)
1
1
$0
$0
(Chlorthalidone)
1
$0
(Furosemide)
2
1
$0
$0
(Furosemide)
1
$0
(Lasix)
(Microzide)
(Hydrochlorothiazi
de)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
1
1
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Dyazide)
1
$0
(Maxzide)
1
$0
(Caduet)
(Lipitor)
1
1
$0
$0
(Questran)
1
$0
(Questran)
1
$0
(Colestid)
1
2
$0
$0
(Slo-Niacin)
4
$0
(Lofibra)
(Tricor)
1
1
$0
$0
Name of Drug
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25 mg, 50
mg
DYRENIUM
furosemide injection
furosemide oral solution 10 mg/ml,
40 mg/5 ml
furosemide oral tablet
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
capsule
triamterene-hydrochlorothiazid oral
tablet
Dyslipidemics
amlodipine-atorvastatin
atorvastatin
cholestyramine (with sugar) oral
powder in packet
cholestyramine light oral powder in
packet
colestipol
CRESTOR
endur-acin * oral tablet extended
release 500 mg
fenofibrate micronized
fenofibrate nanocrystallized
Necessary Actions,
Restrictions, or
Limits on Use
84
Tier level
What the
drug will
cost you
(Mevacor)
1
1
1
1
2
2
1
$0
$0
$0
$0
$0
$0
$0
(Niacin)
4
$0
(Slo-Niacin)
4
$0
(Niaspan)
1
$0
(Slo-Niacin)
4
$0
(Niacinamide)
(Niacin)
(Lovaza)
(Pravachol)
(Cholestyramine/A
spartame)
(Zocor)
4
1
1
1
$0
$0
$0
$0
1
$0
1
2
2
$0
$0
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
Name of Drug
fenofibrate oral tablet
fenofibric acid
fenofibric acid (choline)
gemfibrozil oral
JUXTAPID
KYNAMRO
lovastatin
niacin * oral capsule, extended
release 500 mg
niacin * oral tablet 50 mg, 500 mg
niacin oral tablet extended release
24 hr
niacin * oral tablet extended
release 500 mg
niacinamide * oral tablet 500 mg
niacor
omega-3 acid ethyl esters
pravastatin
prevalite
(Lofibra)
(Fibricor)
(Trilipix)
(Lopid)
simvastatin
VASCEPA
ZETIA
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
spironolactone
(Aldactone)
spironolacton-hydrochlorothiaz
(Aldactazide)
Vasodilators
isosorbide dinitrate oral
(Isochron)
(Isosorbide
isosorbide dinitrate sublingual
Dinitrate)
(Isosorbide
isosorbide mononitrate oral tablet
Mononitrate)
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (30 per 30 days)
85
Tier level
What the
drug will
cost you
(Imdur)
1
$0
(Nitro-Dur)
1
$0
(Nitro-Dur)
1
$0
(Minoxidil)
1
2
$0
$0
(Nitroglycerin/D5
W)
1
$0
(Nitroglycerin)
1
$0
(Nitro-Dur)
1
$0
(Nitro-Dur)
1
$0
2
2
$0
$0
Central Nervous System Agents
amphetamine salt combo
(Adderall)
1
$0
AMPYRA
2
$0
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
1
1
$0
$0
1
$0
(Kapvay)
1
$0
(Focalin)
1
$0
Name of Drug
isosorbide mononitrate oral tablet
minitran transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour
0.4 mg/hr
minoxidil oral
NITRO-BID
nitroglycerin in 5 % dextrose
intravenous solution 100 mg/250 ml
(400 mcg/ml), 25 mg/250 ml (100
mcg/ml), 50 mg/250 ml (200
mcg/ml)
nitroglycerin intravenous
nitroglycerin transdermal patch 24
hour 0.1 mg/hr, 0.2 mg/hr, 0.6
mg/hr
nitroglycerin transdermal patch 24
hour 0.4 mg/hr
NITROSTAT
PROGLYCEM
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
Central Nervous System Agents
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
clonidine hcl oral tablet extended
release 12 hr
dexmethylphenidate oral tablet
QL (60 per 30 days)
PA; QL (60 per 30
days)
QL (60 per 30 days)
86
Tier level
What the
drug will
cost you
(Dexedrine)
1
$0
(Dexedrine)
1
$0
(Adderall XR)
1
$0
(Adderall XR)
1
$0
(Romazicon)
1
$0
(Intuniv)
1
$0
1
$0
1
$0
(Lithobid)
1
$0
(Lithium Citrate)
1
$0
Name of Drug
dextroamphetamine oral capsule,
extended release
dextroamphetamine oral tablet
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
10 mg, 15 mg, 5 mg
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
20 mg, 25 mg, 30 mg
flumazenil
guanfacine oral tablet extended
release 24 hr
lithium carbonate oral capsule
lithium carbonate oral tablet
lithium carbonate oral tablet
extended release
lithium citrate oral solution 8 meq/5
ml
methylphenidate oral capsule, er
biphasic 30-70 10 mg, 20 mg, 40
mg, 50 mg, 60 mg
methylphenidate oral capsule, er
biphasic 30-70 30 mg
methylphenidate oral capsule,er
biphasic 50-50 20 mg, 40 mg
methylphenidate oral capsule,er
biphasic 50-50 30 mg
methylphenidate oral solution
methylphenidate oral tablet
extended release
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
(Lithium
Carbonate)
(Lithobid)
QL (30 per 30 days)
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Methylin)
(Ritalin)
(Methylphenidate
HCl)
1
1
$0
$0
1
$0
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
87
Name of Drug
extended release 24hr 18 mg, 27
mg, 54 mg
extended release 24hr 36 mg
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
(Concerta)
1
$0
(Concerta)
1
$0
(Rilutek)
2
2
1
2
2
$0
$0
$0
$0
$0
2
$0
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
XENAZINE
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
AFTERA *
altavera (28)
alyacen 1/35 (28)
alyacen 7/7/7 (28)
amethia
amethia lo
apri
aranelle (28)
ashlyna
aubra
aviane
azurette (28)
balziva (28)
briellyn
camila
camrese
camrese lo
caziant (28)
(Amethyst)
(Modicon)
(Modicon)
(Seasonique)
(Seasonique)
(Desogen)
(Modicon)
(Seasonique)
(Amethyst)
(Amethyst)
(Mircette)
(Modicon)
(Modicon)
(Nor-Q-D)
(Seasonique)
(Seasonique)
(Desogen)
QL (6 per 365 days)
QL (91 per 84 days)
QL (91 per 84 days)
QL (91 per 84 days)
QL (91 per 84 days)
88
Name of Drug
cryselle (28)
cyclafem 1/35 (28)
cyclafem 7/7/7 (28)
dasetta 1/35 (28)
dasetta 7/7/7 (28)
daysee
deblitane
delyla (28)
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
drospirenone-ethinyl estradiol
econtra ez *
elinest
(Norgestrel-Ethinyl
Estradiol)
(Modicon)
(Modicon)
(Modicon)
(Modicon)
(Seasonique)
(Nor-Q-D)
(Amethyst)
(Mircette)
(Desogen)
(Yaz)
(Aftera)
(Norgestrel-Ethinyl
Estradiol)
ELLA
emoquette
enpresse
enskyce
errin
estarylla
falmina (28)
gianvi (28)
gildagia
gildess
gildess 24 fe
gildess fe
heather
Tier level
What the
drug will
cost you
1
$0
1
1
1
1
1
1
1
1
1
1
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
2
1
1
1
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
(Desogen)
(Amethyst)
(Desogen)
(Nor-Q-D)
(Ortho-Cyclen)
(Amethyst)
(Yaz)
(Modicon)
(Loestrin)
(Loestrin Fe)
(Loestrin Fe)
(Nor-Q-D)
(LevonorgestrelQL (91 per 84 days)
introvale
1
$0
Ethin Estradiol)
jencycla
(Nor-Q-D)
1
$0
jolessa
1
$0
Ethin Estradiol)
89
Tier level
What the
drug will
cost you
(Nor-Q-D)
(Loestrin)
(Loestrin)
(Loestrin Fe)
(Loestrin Fe)
(Loestrin Fe)
(Mircette)
(Ethynodiol DEthinyl Estradiol)
(Amethyst)
(Seasonique)
(Loestrin)
(Loestrin)
(Loestrin Fe)
(Loestrin Fe)
(Modicon)
(Amethyst)
(Amethyst)
(Plan B One-Step)
(Plan B One-Step)
(Aftera)
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
1
$0
1
1
1
1
1
1
1
1
1
1
1
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
(Amethyst)
(Loestrin Fe)
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
(Amethyst)
1
1
1
$0
$0
$0
1
$0
1
$0
Name of Drug
jolivette
junel 1.5/30 (21)
junel 1/20 (21)
junel fe 1.5/30 (28)
junel fe 1/20 (28)
junel fe 24
kariva (28)
kelnor 1/35 (28)
kurvelo
l norgest/e.estradiol-e.estrad
larin 1.5/30 (21)
larin 1/20 (21)
larin 24 fe
larin fe
leena 28
lessina
levonest (28)
levonorgestrel 1.5 mg tablet (rx)
levonorgestrel oral tablet 0.75 mg
levonorgestrel * oral tablet 1.5 mg
levonorgestrel-ethinyl estrad oral
tablet 0.1-20 mg-mcg
tablet 0.15-0.03 mg
tablets,dose pack,3 month
levora-28
lomedia 24 fe
loryna (28)
low-ogestrel (28)
lutera (28)
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
QL (91 per 84 days)
90
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
lyza
(Nor-Q-D)
1
$0
marlissa
(Amethyst)
1
$0
microgestin 1.5/30 (21)
(Loestrin)
1
$0
microgestin 1/20 (21)
(Loestrin)
1
$0
microgestin fe 1.5/30 (28)
(Loestrin Fe)
1
$0
microgestin fe 1/20 (28)
(Loestrin Fe)
1
$0
mono-linyah
(Ortho-Cyclen)
1
$0
mononessa (28)
(Ortho-Cyclen)
1
$0
my way *
(Aftera)
4
$0
QL (6 per 365 days)
myzilra
(Amethyst)
1
$0
necon 0.5/35 (28)
(Modicon)
1
$0
necon 1/35 (28)
(Modicon)
1
$0
necon 1/50 (28)
(Norinyl 1+50)
1
$0
necon 10/11 (28)
(Modicon)
1
$0
necon 7/7/7 (28)
(Modicon)
1
$0
next choice one dose 1.5 mg tb (rx) (Plan B One-Step)
1
$0
QL (6 per 365 days)
next choice one dose * oral tablet
QL (6 per 365 days)
(Aftera)
4
$0
1.5 mg
nikki (28)
(Yaz)
1
$0
nora-be
(Nor-Q-D)
1
$0
norethindrone (contraceptive)
(Nor-Q-D)
1
$0
norethindrone ac-eth estradiol oral
(Loestrin)
1
$0
tablet 1-20 mg-mcg
norethindrone-e.estradiol-iron oral
(Loestrin Fe)
1
$0
tablet 1 mg-20 mcg (24)/75 mg (4)
norgestimate-ethinyl estradiol
(Ortho-Cyclen)
1
$0
norlyroc
(Nor-Q-D)
1
$0
nortrel 0.5/35 (28)
(Modicon)
1
$0
nortrel 1/35 (21)
(Modicon)
1
$0
nortrel 1/35 (28)
(Modicon)
1
$0
nortrel 7/7/7 (28)
(Modicon)
1
$0
NUVARING
2
$0
ocella
(Yaz)
1
$0
91
Name of Drug
ogestrel (28)
opcicon one-step *
orsythia
philith
pimtrea (28)
pirmella
PLAN B ONE-STEP *
portia
previfem
(Norgestrel-Ethinyl
Estradiol)
(Aftera)
(Amethyst)
(Modicon)
(Mircette)
(Modicon)
Tier level
What the
drug will
cost you
1
$0
4
1
1
1
1
3
1
1
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (6 per 365 days)
(Amethyst)
(Ortho-Cyclen)
quasense
1
$0
Ethin Estradiol)
reclipsen (28)
(Desogen)
1
$0
sharobel
(Nor-Q-D)
1
$0
sprintec (28)
(Ortho-Cyclen)
1
$0
sronyx
(Amethyst)
1
$0
syeda
(Yaz)
1
$0
tarina fe
(Loestrin Fe)
1
$0
tilia fe
(Loestrin Fe)
1
$0
tri-estarylla
(Ortho-Cyclen)
1
$0
tri-legest fe
(Loestrin Fe)
1
$0
tri-linyah
(Ortho-Cyclen)
1
$0
trinessa (28)
(Ortho-Cyclen)
1
$0
tri-previfem (28)
(Ortho-Cyclen)
1
$0
tri-sprintec (28)
(Ortho-Cyclen)
1
$0
trivora (28)
(Amethyst)
1
$0
velivet triphasic regimen (28)
(Desogen)
1
$0
vestura (28)
(Yaz)
1
$0
viorele (28)
(Mircette)
1
$0
vyfemla (28)
(Modicon)
1
$0
wera (28)
(Modicon)
1
$0
xulane
(Ortho Evra)
1
$0
QL (3 per 28 days)
zarah
(Yaz)
1
$0
92
Name of Drug
zenchent (28)
zovia 1/35e (28)
zovia 1/50e (28)
(Modicon)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
Cough And Cold Products
Cough And Cold Products
30pse-150gfn-15dm *
(Trispec Pse)
adt robitussin peak cld dm max *
(G-Zyncof)
(Pseudoephedrine
adult nasal decongestant *
HCl)
(Dextromethorphan
adult robitussin lingering cld *
Hbr)
adult robitussin peak cold dm *
(G-Zyncof)
(Robitussin
adult wal-tussin *
Mucus-Chest
Congest)
adult wal-tussin dm max *
(G-Zyncof)
(Guaifenesin/Dextr
alka-seltzer plus mucus-conges *
omethorphan)
(Dm/Phenyleph/Ch
ambi 10peh-4cpm-20dm *
lorpheniramine)
ambi 20dm-4cpm *
(Coricidin Hbp)
(Guaifenesin/Dm/P
ambi 40pse-400gfn-20dm *
seudoephedrine)
(D-Methorphan
ambi 60pse-4cpm-20dm *
Hb/P-Ephed
HCl/Cp)
benzonatate *
(Zonatuss)
(D-Methorphan
bio-dtuss dmx *
Hb/P-Epd
HCl/Bpm)
bionel pediatric *
(Trispec Pse)
93
Name of Drug
biospec dmx *
bromfed dm *
bromphenex dm *
brompheniramine-pseudoeph-dm *
centergy dm *
cheratussin dac *
chest congestion relief + dm *
chest congestion relief d *
chest congestion relief pe *
child cough & sore throat *
child mucinex chest congestion *
child plus cough & runny nose *
child triaminic cough-congest *
child wal-tussin cough relief *
children's chest congestion *
children's mucinex cough *
childrens plus cold * oral
suspension 1-2.5-5-160 mg/5 ml
(G-Zyncof)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Dm/Phenyleph/Ch
lorpheniramine)
(Tusnel C)
(Allfen Dm)
(Poly-Vent Ir)
(Maxiphen)
(D-Methorphan
Hb/Acetaminophen
)
(Robitussin
Mucus-Chest
Congest)
(Dextromethorphn/
Acetaminoph/Cp)
(Cough Formula
Dm)
(Dextromethorphan
Hbr)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Childrens Tylenol
Plus Cold)
Tier level
What the
drug will
cost you
4
$0
3
$0
4
$0
4
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
94
Name of Drug
(Pseudoephedrine
HCl)
(Pseudoephedrine
children's sudafed *
HCl)
(Dextromethorphan
children's sudafed pe cough *
/Phenylephrine)
(Chlophedianol
chlophedianol-guaifenesin *
HCl/Guaifenesin)
(Dm/Phenyleph/Ch
chlorpheniramine-phenyleph-dm *
lorpheniramine)
(Pyrilamine/Pe/De
codituss dm *
xtromethorphan)
(Dm
cold multi-symptom day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dm
cold relief m/s day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dcold-flu relief * oral liquid 12.5-30Methorphan/Aceta
1,000 mg/30 ml
min/Doxylamn)
(Vicks Dayquilcold-flu relief, day/night *
Nyquil)
congestac *
(Poly-Vent Ir)
(Dcoricidin hbp cold-multi sympt *
Methorphan/Aceta
min/Doxylamn)
(Guaifenesin/Dextr
coricidin hbp * oral capsule
omethorphan)
cough & cold * oral tablet
(Coricidin Hbp)
cough & runny nose * oral liquid 1- (Vicks Children'S
5 mg/5 ml
Nyquil)
daytime cold & cough *
(Triaminic)
children's silfedrine *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
95
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
(Dm/Phenyleph/Ch
lorpheniramine)
(Despec)
(Trispec Pse)
(G-Zyncof)
(Dextromethorphan
/Pseudoephed)
(Robitussin
Mucus-Chest
Congest)
(Dm/Pe/Acetamino
ph/Diphenhydram)
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
Name of Drug
daytime cold-flu *
day-time cough *
daytime-nighttime *
daytime-nighttime cold-flu *
daytime-nighttime cough *
decongestant cough *
delsym cough+chest congest dm *
despec-dm (pseudoeph-dm-guaif) *
oral tablet 30-10-200 mg
dextromethorphan polistirex *
diabetic siltussin das-na *
diabetic tussin dm * oral liquid 10100 mg/5 ml
diabetic tussin max st *
ed a-hist dm * oral liquid
ed bron gp *
entre-cough *
expectorant dm * oral liquid
expectorant max strength *
expectorant * oral liquid
flu formula daytime-nighttime *
(DMethorphan/Pe/Ac
etaminophen)
(Dextromethorphan
Hbr)
(Vicks DayquilNyquil)
(Dm/Pe/Acetamino
phen/Doxylamine)
(Dextromethorphan
Hb/Doxylamine)
(Trispec Pse)
(G-Zyncof)
(Guaifenesin/Dm/P
seudoephedrine)
(Delsym)
(Robitussin
Mucus-Chest
Congest)
Necessary Actions,
Restrictions, or
Limits on Use
96
Name of Drug
flu severe cold-congestion *
flu-severe cold-cough daytime *
guaifenesin dac *
guaifenesin * oral tablet 200 mg
guaifenesin * oral tablet extended
release 12hr
head congestion day-night *
hydrocodone-chlorpheniramine *
hydrocodone-homatropine * oral
tablet
hydromet *
infants' non-aspirin cold *
liquibid d-r *
lohist-dm *
lortuss ex * oral syrup
mar-cof bp *
mar-cof cg *
maximum strength flu *
medi-brom *
mesehist dm *
mucinex fast-max nite (doxyl) *
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Theraflu)
(Tusnel C)
(Allfen)
(Mucinex)
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(Tussionex)
(Tussigon)
(Hydrocodone
Bit/Homatrop MeBr)
(Dm/Pseudoephed/
Acetaminophen)
(Maxiphen)
(Ala-Hist Dm)
(Tusnel C)
(Bromphenira/Pseu
doephed/Codein)
(M-Clear Wc)
(Coricidin Hbp)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Alka-Seltzer Plus
Night)
Tier level
What the
drug will
cost you
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
$0
4
3
4
$0
$0
$0
3
$0
3
4
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
97
Name of Drug
mucinex fast-max sev cld-sinus *
mucus dm *
mucus dm max *
mucus relief cough *
mucus relief * oral tablet 400 mg
multi-symptom cold night time *
multi-symptom cold-cough *
nasal & sinus decongestant *
neo-tuss *
NEXAFED *
night time cold-flu * oral capsule
night time cold-flu relief * oral
liquid 7.5-60-30-1,000 mg/30 ml
night time * oral capsule 6.25-3015-325 mg
nighttime cough *
(DMethorphan/Pe/Ac
etaminophen)
(Mucinex Dm)
(Mucinex Dm)
(G-Zyncof)
(Allfen)
(Theraflu)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Sudafed 12-Hour)
(G-Zyncof)
(Dm/PEphed/Acetaminop
h/Doxylam)
h/Doxylam)
h/Doxylam)
(Dextromethorphan
Hb/Doxylamine)
NITE TIME COLD-FLU RELIEF *
ORAL CAPSULE
nite time-d cold-flu relief *
nohist-dm *
h/Doxylam)
(Dm/Phenyleph/Ch
lorpheniramine)
Tier level
What the
drug will
cost you
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
98
Name of Drug
non-aspirin cold *
non-aspirin flu * oral tablet 30-15500 mg
pecgen dmx * oral liquid 15-125
mg/5 ml
pedia relief *
pedia relief cough-cold *
pedia relief infant *
pediacare multi-symptom cold *
phenylhistine dh *
poly-tussin *
promethazine vc-codeine *
promethazine-codeine *
promethazine-dm *
pseudoephedrine hcl * oral liquid
pseudoephedrine hcl * oral tablet
q-tapp dm *
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Dm/Pseudoephed/
Acetaminophen)
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Pseudoephed)
(Dextromethorphan
/Phenylephrine)
(P-Ephed
HCl/Cod/Chlorphe
nir)
(Chlorcyclizine/Co
deine)
(Promethazine/Phe
nyleph/Codeine)
(Promethazine
HCl/Codeine)
(Promethazine/Dex
tromethorphan)
(Pseudoephedrine
HCl)
(Sudafed 12-Hour)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
99
Name of Drug
q-tussin *
q-tussin dm *
refenesen * oral tablet 200 mg
refenesen pe *
relcof c *
REZIRA *
robafen *
robafen cough *
robafen dm *
robitussin cough-chest-cong dm *
(Robitussin
Mucus-Chest
Congest)
(Cough Formula
Dm)
(Allfen)
(Maxiphen)
(M-Clear Wc)
(Robitussin
Mucus-Chest
Congest)
(Dextromethorphan
Hbr)
(Cough Formula
Dm)
(Guaifenesin/Dextr
omethorphan)
ROBITUSSIN LONG-ACTING *
robitussin pediatric *
rydex *
rynex dm *
safe tussin dm *
scot-tussin dm *
scot-tussin expectorant *
siltussin sa *
(Dextromethorphan
Hbr)
(Bromphenira/Pseu
doephed/Codein)
(Brompheniram/Ph
enylephrine/Dm)
(G-Zyncof)
(Vicks Children'S
Nyquil)
(Robitussin
Mucus-Chest
Congest)
(Robitussin
Mucus-Chest
Congest)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
4
3
3
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
100
Name of Drug
siltussin-dm *
sudogest *
suphedrin * oral liquid
suphedrine pe day-night *
suphedrine severe cold max str *
(Cough Formula
Dm)
(Sudafed 12-Hour)
(Pseudoephedrine
HCl)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dm/Pseudoephed/
Acetaminophen)
THERAFLU DAYTIME COLDCOUGH *
THERAFLU MULTI-SYMPTOM
COLD *
triacting m-sym cold/cough *
triaminic cold & cough (pe) *
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Phenylephrine)
TRIAMINIC COUGH-SORE
THROAT *
tri-dex pe *
trymine cg *
tusnel diabetic *
TUSNEL NEW FORMULA *
ORAL SOLUTION
TUSNEL PEDIATRIC * ORAL
LIQUID
TUSSI PRES-B * ORAL LIQUID
4-10-30 MG/5 ML
tussin cf cough-cold *
tussin cf * oral syrup
(Dm/Phenyleph/Ch
lorpheniramine)
(M-Clear Wc)
(G-Zyncof)
(Giltuss)
(Guaifenesin/Dm/P
seudoephedrine)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
101
Name of Drug
tussin cold-congestion *
tussin cough (dm only) * oral
capsule
tussin dm cough & chest * oral
liquid 10-200 mg/5 ml
tussin dm * oral syrup
tussin maximum strength *
tussin pe * oral liquid
valu-tapp dm *
(Guaifenesin/Dm/P
seudoephedrine)
(Dextromethorphan
Hbr)
(G-Zyncof)
(Cough Formula
Dm)
(Dextromethorphan
Hbr)
(Despec)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
VANACOF *
vicks dayquil cold&flu relief * oral
capsule
(DMethorphan/Pe/Ac
etaminophen)
vicks dayquil cough *
vicks nature fusion cough *
vicks nyquil severe cold-flu * oral
liquid
virdec dm *
virtussin ac *
wal-phed * oral tablet 30 mg
wal-phed pe day-night *
wal-tussin cough *
wal-tussin cough & cold cf *
wal-tussin dm *
(Dextromethorphan
Hbr)
(Dm/Pe/Acetamino
phen/Doxylamine)
(Dm/Phenyleph/Ch
lorpheniramine)
(M-Clear Wc)
(Sudafed 12-Hour)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dextromethorphan
Hbr)
(Giltuss)
(Cough Formula
Dm)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
102
Tier level
What the
drug will
cost you
(G-Zyncof)
4
3
4
$0
$0
$0
(Evoxac)
1
$0
(Peridex)
1
$0
1
$0
1
1
3
$0
$0
$0
(Sodium Fluoride)
3
$0
(Triamcinolone
Acetonide)
1
$0
2
1
$0
$0
4
$0
4
$0
4
1
1
1
$0
$0
$0
$0
4
$0
Name of Drug
zephrex-d *
ZONATUSS *
zyncof * oral liquid
(Sudafed 12-Hour)
Necessary Actions,
Restrictions, or
Limits on Use
Dental And Oral Agents
Dental And Oral Agents
cevimeline
chlorhexidine gluconate mucous
membrane
oralone
periogard
pilocarpine hcl oral
PREVIDENT 5000 SENSITIVE *
sodium fluoride * oral
tablet,chewable 0.25 mg fluorid
(0.55 mg)
triamcinolone acetonide dental
(Triamcinolone
Acetonide)
(Peridex)
(Salagen)
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
(Soriatane)
acne medication * topical lotion 10
(Benzoyl Peroxide)
%
ACNE MEDICATION * TOPICAL
LOTION 5 %
acne-clear *
(Benzoyl Peroxide)
acyclovir topical
(Zovirax)
ALCOHOL PADS
ALCOHOL PREP PADS
(Ammonium
amlactin * topical lotion
Lactate)
QL (30 per 30 days)
103
Tier level
What the
drug will
cost you
4
$0
4
$0
(Lac-Hydrin)
1
$0
(Lac-Hydrin)
1
$0
2
$0
(Benzoyl Peroxide)
4
$0
(Dovonex)
(Calcipotriene)
(Calcipotriene)
(Calcipotriene)
(Vectical)
4
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
2
2
2
2
2
1
1
$0
$0
$0
$0
$0
$0
$0
4
$0
(Aldara)
1
$0
(Mineral Oil)
(Oxsoralen-Ultra)
4
4
1
$0
$0
$0
Name of Drug
ammonium lactate * 12% cream
fragrance free (otc)
ammonium lactate * 12% lotion
(otc)
ammonium lactate topical cream 12
%
ammonium lactate topical lotion 12
%
ANACAINE
benzoyl peroxide * topical gel 10
%, 5 %
BETADINE SPRAY *
calcipotriene topical cream
calcipotriene topical ointment
calcipotriene topical solution
calcitrene
calcitriol topical
CASTELLANI PAINT MODIFIED
*
CONDYLOX TOPICAL GEL
COSENTYX (2 SYRINGES)
COSENTYX PEN
COSENTYX PEN (2 PENS)
FLUOROPLEX
fluorouracil topical cream
fluorouracil topical solution
geri-hydrolac * topical lotion
imiquimod
LACTINOL HX *
lobana bath *
methoxsalen rapid
(Ammonium
Lactate)
(Ammonium
Lactate)
(Carac)
(Fluorouracil)
(Ammonium
Lactate)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
PA NSO; QL (24 per
30 days)
104
Name of Drug
PANRETIN
persa-gel *
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podocon
podofilox
potassium hydroxide
(Benzoyl Peroxide)
(Podophyllum
Resin)
(Condylox)
(Potassium
Hydroxide)
SANTYL
skin treatment *
(Ammonium
Lactate)
VALCHLOR
zenatane
(Isotretinoin)
zinc oxide * topical ointment 20 % (Boudreauxs)
ZOVIRAX TOPICAL CREAM
Dermatological Antibacterials
bacitracin * topical ointment
(Bacitracin)
bacitraycin plus * topical ointment
(Bacitracin)
500 unit/gram
clindamycin phosphate topical gel
(Cleocin T)
clindamycin phosphate topical
(Cleocin T)
lotion
clindamycin phosphate topical
(Cleocin T)
solution
clindamycin phosphate topical swab (Cleocin T)
(Erythromycin
ery pads
Base/Ethanol)
erythromycin with ethanol topical
(Emgel)
gel
(Erythromycin
solution
Base/Ethanol)
Tier level
What the
drug will
cost you
2
4
2
2
$0
$0
$0
$0
1
$0
1
$0
1
$0
2
$0
4
$0
2
1
4
2
$0
$0
$0
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (3 per 56 days)
QL (2 per 56 days)
QL (15 per 30 days)
105
Name of Drug
swab
(Erythromycin
Base/Ethanol)
(Gentamicin
gentamicin topical
Sulfate)
metronidazole topical cream
(Metrocream)
metronidazole topical gel
(Rosadan)
metronidazole topical lotion
(Metrolotion)
mupirocin
(Centany)
mupirocin calcium
(Bactroban)
(Neosporin G.U.
neomycin-polymyxin b gu
Irrigant)
(Neomycin
neosporin (neo-bac-polym) *
Su/Bacitrac
topical ointment
Zn/Poly)
rosadan topical cream
(Metrocream)
selenium sulfide
(Selenium Sulfide)
(Silver Nitrate
silver nitrate applicators
Applicator)
silver nitrate topical
(Silver Nitrate)
silver sulfadiazine
(Silvadene)
ssd
(Silvadene)
sulfacetamide sodium (acne)
(Klaron)
(Neomycin
triple antibiotic * topical ointment Su/Bacitrac
Zn/Poly)
Dermatological Anti-Inflammatory Agents
ala-cort topical cream
(Anusol-HC)
ala-scalp
(Scalacort)
(Alclometasone
alclometasone
Dipropionate)
aquanil hc *
(Cortizone-10)
beta-hc *
(Cortizone-10)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
1
$0
4
$0
1
1
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
4
$0
1
1
$0
$0
1
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
106
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
(Diprolene AF)
1
$0
(Betamethasone
Dipropionate)
1
$0
(Diprolene)
1
$0
(Diprolene)
1
$0
(Temovate)
(Olux)
(Clobetasol
Propionate)
(Clobex)
(Temovate)
(Clobex)
(Clobetasol
Propionate)
(Temovate)
(Cloderm)
(Cortenema)
(Clobetasol
Propionate)
(Hydrocortisone)
1
1
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
4
$0
Name of Drug
betamethasone dipropionate
betamethasone valerate topical
cream
foam
lotion
ointment
betamethasone, augmented topical
cream
gel
lotion
ointment
clobetasol topical cream
clobetasol topical foam
clobetasol topical gel
clobetasol topical lotion
clobetasol topical ointment
clobetasol topical shampoo
clobetasol topical solution
clobetasol-emollient topical cream
clocortolone pivalate
colocort
cormax topical solution
cortizone-10 * topical cream
(Betamethasone
Dipropionate)
(Betamethasone
Valerate)
(Luxiq)
(Betamethasone
Valerate)
(Betamethasone
Valerate)
Necessary Actions,
Restrictions, or
Limits on Use
107
Tier level
What the
drug will
cost you
4
$0
4
4
1
1
1
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
4
$0
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
4
$0
1
$0
4
$0
1
$0
(Locoid)
1
$0
(Locoid)
1
$0
Name of Drug
CORTIZONE-10 * TOPICAL
LOTION
cortizone-10 * topical ointment
dermarest eczema (hydrocort) *
desonide topical cream
desonide topical ointment
desoximetasone
ELIDEL
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-e
fluticasone topical cream
fluticasone topical ointment
halobetasol propionate
hydro skin * topical lotion
hydrocortisone * 1% cream
maximum strength (otc)
hydrocortisone * 1% ointment
carton (otc)
hydrocortisone acet-aloe vera
topical gel
hydrocortisone acetate * topical
cream 1 %
hydrocortisone butyrate topical
cream
ointment
solution
(Hydrocortisone)
(Cortizone-10)
(Desowen)
(Desonide)
(Topicort)
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
(Cortizone-10)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Acetate)
(Hydrocortisone
Butyrate)
Necessary Actions,
Restrictions, or
Limits on Use
108
Tier level
What the
drug will
cost you
1
$0
1
$0
(Hydrocortisone)
4
$0
(Anusol-HC)
1
$0
(Cortizone-10)
3
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
1
$0
(Hydrocortisone
Valerate)
1
$0
(Westcort)
1
$0
(Elocon)
(Hydrocortisone)
1
4
$0
$0
2
$0
2
$0
1
4
1
1
1
4
1
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
Name of Drug
hydrocortisone butyr-emollient
hydrocortisone rectal enema
hydrocortisone * topical cream 0.5
%
hydrocortisone topical cream 1 %,
2.5 %
hydrocortisone * topical lotion 1 %
hydrocortisone * topical ointment
0.5 %
hydrocortisone topical ointment 1
%, 2.5 %
hydrocortisone valerate topical
cream
hydrocortisone valerate topical
ointment
mometasone
neosporin anti-itch *
(Hydrocortisone
Butyrate)
(Cortenema)
ONFI ORAL SUSPENSION
ONFI ORAL TABLET 10 MG, 20
MG
prednicarbate
preparation h hydrocortisone *
procto-pak
proctosol hc
proctozone-hc
recort plus *
tacrolimus topical
triamcinolone acetonide topical
cream
lotion
(Dermatop)
(Hydrocortisone)
(Anusol-HC)
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
(Protopic)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (480 per
30 days)
PA NSO; QL (60 per
30 days)
109
Name of Drug
ointment 0.025 %, 0.1 %, 0.5 %
trianex
u-cort
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Hydrocortisone
Acetate/Urea)
Dermatological Retinoids
adapalene topical cream
(Differin)
adapalene topical gel 0.1 %
(Differin)
TAZORAC TOPICAL CREAM
tretinoin microspheres
(Retin-A Micro)
tretinoin topical
(Retin-A)
Scabicides And Pediculicides
lice cream rinse *
(Nix)
(Piperonyl
lice killing *
Butoxide/Pyrethrin
s)
lice treatment * topical liquid 1 %
(Nix)
malathion
(Ovide)
permethrin topical cream
(Elimite)
permethrin * topical liquid
(Nix)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
1
2
1
1
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
1
4
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 X 1/2"
BD ECLIPSE LUER-LOK
SYRINGE 1 ML 27 X 1/2"
BD INSULIN PEN NEEDLE UF
SHORT
BD INSULIN SYRINGE ULTRAFINE SYRINGE 0.3 ML 31 X
5/16", 1 ML 31 X 5/16", 1/2 ML 31
X 5/16"
110
Name of Drug
INSULIN PEN NEEDLE NEEDLE
29 GAUGE X 1/2 "
INSULIN SYRINGE-NEEDLE U100 SYRINGE 0.3 ML 29, 1 ML
29 X 1/2", 1/2 ML 28
VGO 40
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
$0
2
2
$0
$0
2
$0
2
2
$0
$0
2
$0
2
$0
2
$0
2
$0
2
2
2
1
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
Disinfectants (For Non-Dermatologic Use)
Disinfectants (For Non-Dermatologic Use)
iodine *
(Iodine)
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CREON
ELAPRASE
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
KRYSTEXXA
KUVAN ORAL
TABLET,SOLUBLE
MYOZYME
NAGLAZYME
ORFADIN
pancrelipase 5000
(Zenpep)
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
PA BvD
PA
QL (90 per 30 days)
111
Name of Drug
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000
-55,000 UNIT, 15,000-51,000 82,000 UNIT, 20,000-68,000 109,000 UNIT, 25,000-85,000136,000 UNIT, 3,000-10,00016,000 UNIT, 40,000-136,000218,000 UNIT
Tier level
What the
drug will
cost you
2
$0
2
1
1
4
1
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
1
4
4
1
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN (PF)
alcaine
(Proparacaine HCl)
altacaine
(Tetcaine)
altamist *
(Little Remedies)
apraclonidine
(Iopidine)
artificial tears (petro/min) *
(Genteal Pm)
(Dextran
artificial tears (pf) * ophthalmic
70/Hypromellose/P
dropperette 0.1-0.3 %
F)
(Polyvinyl
artificial tears (polyvin alc) *
Alcohol)
artificial tears * ophthalmic drops
(Tears Naturale)
0.1-0.3 %
(Glycerin/Propylen
artificial tears(glycerin-peg) *
e Glycol)
(Genteal Mild To
artificial tears(hypromellose) *
Moderate)
atropine ophthalmic drops
(Isopto Atropine)
atropine ophthalmic ointment
(Atropine Sulfate)
ayr saline * nasal aerosol,spray
(Little Remedies)
ayr saline * nasal drops
(Sodium Chloride)
azelastine nasal aerosol,spray
(Astepro)
QL (30 per 25 days)
112
Tier level
What the
drug will
cost you
1
$0
4
$0
1
$0
1
$0
2
$0
1
2
4
$0
$0
$0
4
$0
1
$0
4
$0
1
$0
4
$0
4
4
4
$0
$0
$0
1
$0
1
$0
(Atrovent)
1
$0
(Atrovent)
1
$0
Name of Drug
azelastine ophthalmic
bion tears (pf) *
carteolol
cromolyn ophthalmic
CYCLOGYL OPHTHALMIC
DROPS 0.5 %
cyclopentolate
CYSTARAN
deep sea nasal *
dristan long lasting *
epinastine
eq gentle *
flucaine
(Azelastine HCl)
(Dextran
70/Hypromellose/P
F)
(Carteolol HCl)
(Cromolyn
Sodium)
(Cyclogyl)
(Little Remedies)
(Oxymetazoline
HCl)
(Elestat)
(Genteal Mild To
Moderate)
(Proparacaine/Fluo
rescein Sod)
GENTEAL MILD TO
MODERATE *
GENTEAL GEL *
GENTEAL MILD *
GENTEAL SEVERE *
homatropaire
homatropine hbr
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
(Isopto
Homatropine)
(Isopto
Homatropine)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 28 days)
QL (15 per 10 days)
(Genteal Mild To
4
$0
Moderate)
isopto tears *
113
Name of Drug
LACRISERT
lubricant dry eye relief *
lubricant eye (cmc-glycer)(pf) *
lubricant eye (cmc-glycerin) *
lubricant eye (pg-peg 400) *
lubricant eye (polyv alcohol) *
lubricant eye (propyl glycol) *
lubricant eye drops * ophthalmic
dropperette
lubricant eye drops * ophthalmic
drops
lubricant gel *
lubricating drops *
lubrifresh pm *
muro 128 *
naphazoline
nasal decongestant (oxymetazl) *
natural balance *
natural tears (pf) *
nature's tears *
neo-synephrine 12 h spr (oxym) *
nighttime relief eye *
ocean nasal *
(Carboxymethylcel
lulose Sodium)
(Carboxymethylcel
l/Glycerin/PF)
(Refresh Optive)
(Systane)
(Polyvinyl
Alcohol)
(Propylene Glycol)
(Carboxymethylcel
lulose Sodium)
(Refresh Tears)
(Carboxymethylcel
l/Hypromellose)
(Refresh Optive)
(Genteal Pm)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
(Dextran
70/Hypromellose/P
F)
(Genteal Mild To
Moderate)
(Oxymetazoline
HCl)
(Petrolat,Wht/Min
Oil/Sod Chl)
(Little Remedies)
Tier level
What the
drug will
cost you
2
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
1
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
114
Name of Drug
phenylephrine hcl ophthalmic
proparacaine
pure & gentle eye *
(Mydfrin)
(Proparacaine HCl)
(Genteal Mild To
Moderate)
REFRESH CELLUVISC *
REFRESH CLASSIC (PF) *
REFRESH LACRI-LUBE *
REFRESH OPTIVE *
retaine cmc *
saline mist *
sea soft nasal mist *
sodium chloride * ophthalmic
SYSTANE *
SYSTANE GEL * OPHTHALMIC
DROPS,GEL
(Carboxymethylcel
lulose Sodium)
(Little Remedies)
(Little Remedies)
(Sodium Chloride)
(Polyvinyl
Alcohol)
(Lanolin/Min
tears again * ophthalmic ointment
Oil/Petrolat, Wht)
(Dextran
tears naturale free (pf) *
70/Hypromellose/P
F)
(Tetracaine
tetracaine hcl (pf) ophthalmic
HCl/PF)
(Lanolin/Min
ultra fresh pm *
Oil/Petrolat, Wht)
(Oxymetazoline
vicks qlearquil(oxymetazoline) *
HCl)
vicks sinex 12-hour *
(Afrin)
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid otic
(Acetic Acid)
bacitracin ophthalmic
(Bacitracin)
tears again * ophthalmic drops
Tier level
What the
drug will
cost you
1
1
$0
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
1
1
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
115
Name of Drug
bacitracin-polymyxin b ophthalmic
bleph-10
CIPRODEX
ciprofloxacin hcl ophthalmic
ciprofloxacin hcl otic
COLY-MYCIN S
erythromycin ophthalmic
gatifloxacin
gentak ophthalmic ointment
gentamicin ophthalmic
levofloxacin ophthalmic
MOXEZA
NATACYN
(Bacitracin/Polymy
xin B Sulfate)
(Sulfacetamide
Sodium)
(Ciloxan)
(Cetraxal)
(Ilotycin)
(Zymaxid)
(Garamycin)
(Garamycin)
(Levofloxacin)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
neomycin-bacitracin-polymyxin
Su/Bacitra/Polymy
xin)
neomycin-polymyxin b-dexameth
(Maxitrol)
neomycin-polymyxin-gramicidin
(Neosporin)
(Neomycin/Polymy
neomycin-polymyxin-hc ophthalmic
xin B Sulf/HC)
neomycin-polymyxin-hc otic
(Neomycin/Polymy
drops,suspension
xin B Sulf/HC)
neomycin-polymyxin-hc otic
(Cortisporin)
solution
(Neomycin
neo-polycin
Su/Bacitra/Polymy
xin)
(Neomycin Su/Baci
neo-polycin hc
Zn/Poly/HC)
neomycin-bacitracin-poly-hc
Tier level
What the
drug will
cost you
1
$0
1
$0
2
1
1
2
1
1
1
1
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
116
Name of Drug
ofloxacin ophthalmic
ofloxacin otic
polymyxin b sulf-trimethoprim
REFRESH OPTIVE ADVANCED
*
sulfacetamide sodium ophthalmic
sulfacetamide-prednisolone
Tier level
What the
drug will
cost you
1
1
1
$0
$0
$0
4
$0
1
$0
1
$0
2
1
1
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
2
$0
1
$0
1
1
$0
$0
1
$0
2
1
2
$0
$0
$0
(Ocuflox)
(Ocuflox)
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
TOBRADEX ST
tobramycin
(Tobrex)
trifluridine
(Viroptic)
VIGAMOX
ZIRGAN
ZYLET
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
ALREX
(Bromfenac
bromfenac
Sodium)
dexamethasone sodium phosphate
(Dexasol)
ophthalmic
(Diclofenac
diclofenac sodium ophthalmic
Sodium)
DUREZOL
flunisolide nasal spray,non-aerosol
(Flunisolide)
25 mcg (0.025 %)
fluorometholone
(FML)
flurbiprofen sodium
(Ocufen)
(Fluticasone
fluticasone nasal
Propionate)
ILEVRO
ketorolac ophthalmic
(Acular)
LOTEMAX
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (50 per 25 days)
QL (16 per 30 days)
117
Name of Drug
NEVANAC
prednisolone acetate
prednisolone sodium phosphate
ophthalmic
PROLENSA
RESTASIS
(Omnipred)
(Prednisolone Sod
Phosphate)
Tier level
What the
drug will
cost you
2
1
$0
$0
1
$0
2
2
$0
$0
4
4
$0
$0
4
$0
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
4
$0
4
4
1
2
1
$0
$0
$0
$0
$0
1
$0
4
1
1
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
anti-gas maximum strength *
(Phazyme)
bicarsim forte *
(Simethicone)
gas relief extra strength * oral
(Gas-X)
tablet,chewable
gas relief * oral capsule 125 mg
(Phazyme)
gas relief * oral tablet,chewable
(Gas-X)
gas-x ultra-strength *
(Phazyme)
mi-acid gas relief *
(Gas-X)
mytab gas *
(Gas-X)
mytab gas maximum strength *
(Gas-X)
simethicone * oral capsule 180 mg (Phazyme)
simethicone * oral
(Simethicone)
drops,suspension
Antiulcer Agents And Acid Suppressants
acid reducer (famotidine) *
(Pepcid Ac)
acid relief (cimetidine) *
(Tagamet Hb)
amoxicil-clarithromy-lansopraz
(Prevpac)
CARAFATE ORAL SUSPENSION
cimetidine hcl oral
(Cimetidine HCl)
cimetidine oral tablet 200 mg, 300
(Cimetidine)
mg, 400 mg, 800 mg
cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb)
esomeprazole sodium
(Nexium I.V.)
famotidine (pf)
(Famotidine)
(Rx Product Only)
118
Name of Drug
(Famotidine In
Nacl,Iso-Osm/PF)
famotidine intravenous
(Famotidine)
famotidine oral tablet 20 mg, 40 mg (Pepcid)
lansoprazole * dr 15 mg capsule
(Prevacid 24hr)
na/f (otc)
lansoprazole oral capsule,delayed
(Prevacid)
misoprostol
(Cytotec)
(Omeprazole
omeprazole magnesium *
Magnesium)
omeprazole oral capsule,delayed
(Prilosec)
release(dr/ec)
omeprazole * oral tablet,delayed
(Omeprazole)
release (dr/ec)
omeprazole-sodium bicarbonate
(Zegerid)
oral capsule 20-1.1 mg-gram
pantoprazole oral
(Protonix)
PRILOSEC OTC *
pub famotidine * 20 mg tablet max
(Pepcid Ac)
strength (otc)
ra omepraz-bicarb 20-1,100 cap
(Zegerid Otc)
3x14 day course (otc)
ranitidine 150 mg tablet maximum
(Zantac)
strength (otc)
ranitidine hcl injection
(Zantac)
ranitidine hcl oral syrup
(Ranitidine HCl)
ranitidine hcl oral tablet 150 mg,
(Zantac)
300 mg
ranitidine hcl * oral tablet 75 mg
(Zantac)
sucralfate oral suspension
(Sucralfate)
sucralfate oral tablet
(Carafate)
wal-zan 75 *
(Zantac)
famotidine (pf)-nacl (iso-os)
Tier level
What the
drug will
cost you
1
$0
1
1
$0
$0
4
$0
1
$0
1
$0
4
$0
1
$0
4
$0
3
$0
1
4
$0
$0
4
$0
4
$0
4
$0
1
1
$0
$0
1
$0
4
1
1
4
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
119
Name of Drug
Tier level
What the
drug will
cost you
ZANTAC 75 *
ZANTAC * ORAL TABLET 150
MG
Gastrointestinal Agents, Other
acid gone antacid *
(Gaviscon)
(Maalox Maximum
almacone * oral suspension
Strength)
(Maalox Maximum
almacone-2 *
Strength)
aluminum hydroxide gel * oral
(Aluminum
suspension 320 mg/5 ml
Hydroxide)
AMITIZA
antacid anti-gas * oral suspension (Maalox Maximum
200-200-20 mg/5 ml
Strength)
(Calcium
antacid anti-gas * oral
Carbonate/Simethi
tablet,chewable
cone)
anti-diarrheal *
(Pepto-Bismol)
anti-diarrheal (loperamide) * oral
(Loperamide HCl)
capsule
anti-diarrheal (loperamide) * oral
(Loperamide HCl)
tablet
bismatrol * oral suspension 262
(Pepto-Bismol)
mg/15 ml
BUPHENYL ORAL TABLET
calci-chew *
(Tums)
calcium antacid * oral
tablet,chewable 200 mg calcium
(Tums)
(500 mg), 300 mg (750 mg)
calcium carbonate * oral
tablet,chewable 500 mg calcium
(Tums)
(1,250 mg)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
4
$0
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
120
Tier level
What the
drug will
cost you
4
$0
4
2
4
4
$0
$0
$0
$0
4
$0
1
1
4
1
1
1
$0
$0
$0
$0
$0
$0
1
$0
1
1
$0
$0
4
$0
4
2
2
$0
$0
$0
(Maalox Maximum
Strength)
4
$0
(Almacone)
4
$0
(Lactulose)
(Robinul)
(Robinul)
(Loperamide HCl)
(Pepto-Bismol)
1
1
1
4
4
$0
$0
$0
$0
$0
Name of Drug
calcium carbonate-vitamin d3 *
oral tablet,chewable 500-100 mgunit
cal-gest antacid *
CARBAGLU
children's pepto *
children's soothe *
comfort gel extra strength *
constulose
cromolyn oral
diamode *
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
enulose
flanax antacid *
foaming antacid *
GATTEX 30-VIAL
GATTEX ONE-VIAL
gelusil antacid & anti-gas * oral
suspension
gelusil antacid & anti-gas * oral
tablet,chewable
generlac
glycopyrrolate injection
glycopyrrolate oral
imodium a-d * oral liquid
kaopectate (bismuth subsalicy) *
(Calcium
Carbonate/Vitamin
D3)
(Tums)
(Tums)
(Tums)
(Maalox Maximum
Strength)
(Lactulose)
(Gastrocrom)
(Loperamide HCl)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Lactulose)
(Maalox Maximum
Strength)
(Gaviscon)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
121
Tier level
What the
drug will
cost you
(Sodium
Polystyrene
Sulfonate)
1
$0
(Lactulose)
1
$0
(Loperamide HCl)
(Loperamide HCl)
2
1
4
2
$0
$0
$0
$0
(Maalox Maximum
Strength)
4
$0
4
$0
(Uromag)
4
$0
(Magox 400)
4
$0
Name of Drug
kionex
lactulose oral solution 10 gram/15
ml
LINZESS
loperamide oral capsule
loperamide * oral liquid
LOTRONEX
maalox advanced * oral suspension
MAGNEBIND 300 *
magnesium oxide * oral capsule
500 mg
magnesium oxide * oral tablet 250
mg, 400 mg, 500 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
(Maalox Maximum
4
$0
Strength)
(Methscopolamine
methscopolamine oral
1
$0
Bromide)
metoclopramide hcl injection
(Metoclopramide
1
$0
solution
HCl)
(Metoclopramide
metoclopramide hcl oral solution
1
$0
HCl)
metoclopramide hcl oral tablet
(Reglan)
1
$0
mgo *
(Magox 400)
4
$0
(Maalox Maximum
mi-acid * oral suspension
4
$0
Strength)
mi-acid * oral tablet,chewable
(Rolaids)
4
$0
(Maalox Maximum
mintox *
4
$0
Strength)
(Maalox Maximum
mintox maximum strength *
4
$0
Strength)
mintox plus *
(Almacone)
4
$0
masanti double strength *
122
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
MOVANTIK
2
$0
QL (30 per 30 days)
NUTRESTORE
2
$0
pep-t-med *
(Pepto-Bismol)
4
$0
phillips *
(Magox 400)
4
$0
pink bismuth * oral tablet,chewable (Pepto-Bismol)
4
$0
RAVICTI
2
$0
PA
RELISTOR SUBCUTANEOUS
PA; QL (28 per 28
2
$0
SOLUTION
days)
RELISTOR SUBCUTANEOUS
PA; QL (28 per 28
2
$0
SYRINGE 8 MG/0.4 ML
days)
(Maalox Maximum
ri-gel ii *
4
$0
Strength)
(Maalox Maximum
ri-mox *
4
$0
Strength)
sodium bicarbonate * oral tablet
(Sodium
4
$0
650 mg
Bicarbonate)
(Sodium
sodium polystyrene (sorb free)
Polystyrene
1
$0
Sulfonate)
(Sodium
sodium polystyrene sulfonate rectal
Polystyrene
1
$0
enema 30 gram/120 ml
Sulfonate)
soothe (bismuth subsalicylate) *
(Bismuth
4
$0
oral tablet
Subsalicylate)
soothe regular strength *
(Pepto-Bismol)
4
$0
(Sodium
sps oral
Polystyrene
1
$0
Sulfonate)
(Bismuth
stomach relief * oral tablet
4
$0
Subsalicylate)
ultra strength antacid *
(Tums)
4
$0
ursodiol oral capsule
(Actigall)
1
$0
ursodiol oral tablet
(Urso)
1
$0
Laxatives
123
Tier level
What the
drug will
cost you
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Gavilax)
(Sof-Lax)
(Sof-Lax)
(Docusate Sodium)
(Surfak)
(Docusate Sodium)
(Docusate Sodium)
(Sof-Lax)
(Docusate Sodium)
(Sof-Lax)
(Enema)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Enema)
4
$0
(Docusate Sodium)
(Docusol Plus)
(Calcium
Polycarbophil)
(Fibercon)
(Citrucel)
(Psyllium Seed)
(Psyllium Seed
(With Sugar))
4
4
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
Name of Drug
alophen *
bisac-evac *
bisacodyl * oral
bisacodyl * rectal
biscolax *
clearlax * oral powder
colace * oral capsule 100 mg
doc-q-lace * oral capsule
docu *
docusate calcium *
docusate sodium * oral tablet
docusol *
dok * oral capsule 100 mg
dok * oral tablet
dulcolax stool softener (dss) *
enema disposable *
enema * rectal enema * 19-7
gram/118 ml
enemeez *
enemeez plus *
equalactin *
fiber (calcium polycarbophil) *
fiber laxative (methylcellulo) *
fiber smooth *
fiber therapy (psyllium/sugar) *
Necessary Actions,
Restrictions, or
Limits on Use
fiber therapy * oral powder 2
(Citrucel)
4
$0
gram/19 gram
fiber therapy * oral tablet
(Citrucel)
4
$0
fiber-lax *
(Fibercon)
4
$0
FLEET BISACODYL *
4
$0
gavilyte-c
(Golytely)
1
$0
124
Name of Drug
gavilyte-g
gavilyte-n
gentlelax *
glycolax * oral powder
healthylax *
hydrocil instant *
konsyl (sugar) * oral powder in
packet
konsyl fiber *
KONSYL SUGAR-FREE * ORAL
POWDER IN PACKET
laxative peg 3350 * oral powder
milk of magnesia *
mineral oil laxative *
MOVIPREP
natural fiber laxative therapy *
oral saline laxative * oral liquid
peg 3350-electrolytes
peg-electrolyte soln
peri-colace *
phillips liqui-gels *
phosphate laxative * oral liquid
polyethylene glycol 3350 oral
powder
polyethylene glycol 3350 * oral
powder in packet
(Golytely)
(Nulytely with
Flavor Packs)
(Gavilax)
(Gavilax)
(Miralax)
(Psyllium Seed)
(Psyllium Husk
(With Sugar))
(Fibercon)
(Gavilax)
(Milk Of
Magnesia)
(Mineral Oil)
(Psyllium Seed
(With Sugar))
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
(Nulytely with
Flavor Packs)
(Sennosides/Docus
ate Sodium)
(Sof-Lax)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene
Glycol 3350)
(Miralax)
Tier level
What the
drug will
cost you
1
$0
1
$0
4
3
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
2
$0
$0
4
$0
4
$0
1
$0
1
$0
4
$0
4
$0
4
$0
1
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
125
Tier level
What the
drug will
cost you
(Docusate Sodium)
(Gavilax)
(Miralax)
(Psyllium Seed
(With Sugar))
(Sennosides)
(Senokot)
(Senokot)
(Sennosides)
(Sennosides)
(Senokot)
(Sennosides/Docus
ate Sodium)
(Sennosides/Docus
ate Sodium)
(Docusate Sodium)
(Miralax)
(Dulcolax)
(Nulytely with
Flavor Packs)
4
4
4
$0
$0
$0
4
$0
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
4
4
$0
$0
$0
1
$0
(Phoslo)
(Calcium Acetate)
(Calcium Acetate)
(Calcium Acetate)
(Calcium
Carbonate/Mag
Carb/Fa)
1
1
4
1
$0
$0
$0
$0
1
$0
2
2
2
$0
$0
$0
Name of Drug
promolaxin *
purelax * oral powder
purelax * oral powder in packet
reguloid * oral powder
senexon * oral syrup
senexon * oral tablet
senna lax *
senna * oral capsule
senna * oral syrup 8.8 mg/5 ml
senna * oral tablet
senna with docusate sodium *
senokot-s *
silace *
smoothlax * oral powder in packet
the magic bullet *
trilyte with flavor packets
Phosphate Binders
calcium acetate oral capsule
calcium acetate oral tablet 667 mg
calphron *
eliphos
magnebind 400
PHOSLYRA
RENAGEL
RENVELA
Necessary Actions,
Restrictions, or
Limits on Use
Genitourinary Agents
Antispasmodics, Urinary
126
Tier level
What the
drug will
cost you
2
$0
(Oxybutynin
Chloride)
1
$0
(Ditropan XL)
1
$0
(Detrol LA)
1
$0
(Detrol)
1
2
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
2
2
2
$0
$0
$0
1
$0
2
$0
Name of Drug
MYRBETRIQ
oxybutynin chloride oral tablet
oxybutynin chloride oral tablet
extended release 24hr
tolterodine oral capsule,extended
release 24hr
tolterodine oral tablet
TOVIAZ
(Trospium
Chloride)
Genitourinary Agents, Miscellaneous
alfuzosin
(Uroxatral)
tamsulosin
(Flomax)
terazosin
(Terazosin HCl)
trospium
Necessary Actions,
Restrictions, or
Limits on Use
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2
(Desferal)
gram
DEPEN TITRATABS
EXJADE
FERRIPROX
sodium thiosulfate intravenous
(Sodium
solution 1 gram/10 ml (100 mg/ml),
Thiosulfate)
12.5 gram/50 ml (250 mg/ml)
SYPRINE
PA BvD
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
ANDRODERM
2
$0
ANDROGEL TRANSDERMAL
GEL IN METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62 %)
2
$0
PA; QL (30 per 30
days)
PA; QL (150 per 30
days)
127
Name of Drug
ANDROGEL TRANSDERMAL
GEL IN PACKET 1.62 % (20.25
MG/1.25 GRAM), 1.62 % (40.5
MG/2.5 GRAM)
androxy
danazol oral
oxandrolone
Tier level
What the
drug will
cost you
2
$0
1
1
1
$0
$0
$0
1
$0
testosterone enanthate
testosterone transdermal gel in
(Androgel)
packet 1 % (25 mg/2.5gram)
Estrogens And Antiestrogens
1
$0
1
$0
COMBIPATCH
2
$0
DUAVEE
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch
semiweekly
(Estrace)
2
2
1
$0
$0
$0
(Vivelle-Dot)
1
$0
estradiol transdermal patch weekly
(Climara)
1
$0
estradiol valerate
estradiol-norethindrone acet
estropipate
FEMRING
MENEST
mimvey
mimvey lo
PREMARIN INJECTION
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
(Delestrogen)
(Activella)
(Estropipate)
1
1
1
2
2
1
1
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
testosterone cypionate
(Fluoxymesterone)
(Danazol)
(Oxandrin)
(DepoTestosterone)
(Delatestryl)
(Activella)
(Activella)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (150 per 30
days)
PA
PA; QL (300 per 30
days)
PA-HRM; QL (8 per 28
days)
PA-HRM
PA-HRM
days)
days)
PA-HRM
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
128
Name of Drug
Tier level
What the
drug will
cost you
PREMPRO
raloxifene
(Evista)
VAGIFEM
Glucocorticoids/Mineralocorticoids
(Hydrocortisone
a-hydrocort
Sod Succinate)
betamethasone acet,sod phos
(Celestone)
cortisone
(Cortisone Acetate)
dexamethasone oral elixir
(Dexamethasone)
dexamethasone oral tablet
(Dexamethasone)
dexamethasone sodium phosphate
(Dexamethasone
injection
Sod Phosphate)
(Fludrocortisone
fludrocortisone
Acetate)
hydrocortisone oral
(Cortef)
methylprednisolone
(Medrol)
methylprednisolone acetate
(Depo-Medrol)
methylprednisolone sodium succ
(A-Methapred)
injection recon soln 125 mg, 40 mg
(A-Methapred)
intravenous
oral solution 15 mg/5 ml, 25 mg/5
(Pediapred)
ml (5 mg/ml), 5 mg base/5 ml (6.7
mg/5 ml)
prednisone oral
(Prednisone)
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
(Triamcinolone
triamcinolone acetonide injection
Acetonide)
Pituitary
(Desmopressin
desmopressin injection
Acetate)
2
1
2
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
QL (18 per 28 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
$0
1
$0
2
$0
1
$0
1
$0
PA BvD
PA BvD
129
Name of Drug
desmopressin nasal solution
desmopressin nasal spray,nonaerosol
desmopressin oral
GENOTROPIN
GENOTROPIN MINIQUICK
INCRELEX
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3
MONTH) INTRAMUSCULAR
SYRINGE KIT 30 MG
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
mcg/ml, 500 mcg/ml
octreotide acetate injection solution
50 mcg/ml
octreotide acetate injection syringe
50 mcg/ml (1 ml)
SAIZEN
SAIZEN CLICK.EASY
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6
MG
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION
(DDAVP)
(Desmopressin
Acetate)
(DDAVP)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
2
2
2
2
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (15 per 30 days)
QL (15 per 30 days)
PA
PA
QL (1 per 84 days)
(Sandostatin)
(Octreotide
Acetate)
(Octreotide
Acetate)
2
$0
2
2
$0
$0
1
$0
1
$0
1
$0
2
2
$0
$0
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
PA
PA
PA
PA
PA
QL (1 per 28 days)
QL (1 per 360 days)
QL (10 per 28 days)
130
Tier level
What the
drug will
cost you
1
$0
1
2
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
1
$0
$0
1
$0
1
$0
Immunological Agents
ARCALYST
ASTAGRAF XL
2
2
$0
$0
AUBAGIO
2
$0
1
$0
1
$0
Name of Drug
medroxyprogesterone
(Depo-Provera)
intramuscular
medroxyprogesterone oral
(Provera)
MEGACE ES
megestrol oral suspension 400
(Megace Es)
mg/10 ml (40 mg/ml)
norethindrone acetate
(Aygestin)
progesterone in oil
(Progesterone)
progesterone micronized
(Prometrium)
Thyroid And Antithyroid Agents
(Levothyroxine
levothyroxine intravenous
Sodium)
levothyroxine oral
(Levoxyl)
liothyronine oral
(Cytomel)
methimazole oral tablet 10 mg, 5
(Tapazole)
mg
propylthiouracil
(Propylthiouracil)
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 84 days)
Immunological Agents
azathioprine
azathioprine sodium
(Imuran)
(Azathioprine
Sodium)
CARIMUNE NF
NANOFILTERED
INTRAVENOUS RECON SOLN 6
GRAM
CELLCEPT INTRAVENOUS
CIMZIA
PA BvD
PA; QL (28 per 28
days)
PA BvD
PA BvD
PA BvD
2
$0
2
2
$0
$0
PA BvD
PA
131
Name of Drug
CIMZIA POWDER FOR
RECONST
cyclosporine intravenous
cyclosporine modified
cyclosporine oral capsule
ENBREL
ENBREL SURECLICK
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAPLEX
gengraf
HUMIRA
HUMIRA CROHN'S DIS START
PCK
HUMIRA PEN
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
(Sandimmune)
(Neoral)
(Sandimmune)
(Neoral)
KINERET
Tier level
What the
drug will
cost you
2
$0
1
1
1
2
2
2
2
2
2
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA
PA; QL (18.76 per 28
days)
leflunomide
(Arava)
1
$0
mycophenolate mofetil
(Cellcept)
1
$0
PA BvD
mycophenolate sodium
(Myfortic)
1
$0
PA BvD
NULOJIX
2
$0
PA BvD
OCTAGAM
2
$0
PA BvD
ORENCIA
2
$0
PA
ORENCIA (WITH MALTOSE)
2
$0
PA
PRIVIGEN
2
$0
PA BvD
PROGRAF INTRAVENOUS
2
$0
PA BvD
RAPAMUNE ORAL SOLUTION
2
$0
PA BvD
RIDAURA
2
$0
sirolimus
(Rapamune)
1
$0
PA BvD
132
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
TYSABRI
2
$0
ZORTRESS
2
$0
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
2
$0
2
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
ENGERIX-B (PF)
2
$0
ENGERIX-B PEDIATRIC (PF)
2
$0
Name of Drug
tacrolimus oral
(Hecoria)
Vaccines
ACTHIB (PF)
ADACEL(TDAP
ADOLESN/ADULT)(PF)
BCG VACCINE, LIVE (PF)
BEXSERO (PF)
BOOSTRIX TDAP
CERVARIX VACCINE (PF)
COMVAX (PF)
DAPTACEL (DTAP PEDIATRIC)
(PF)
PA BvD
PA BvD; QL (3 per 365
days)
days)
GARDASIL (PF)
2
$0
GARDASIL 9 (PF)
2
$0
HAVRIX (PF)
INTRAMUSCULAR
2
$0
SUSPENSION 1,440 ELISA
UNIT/ML
HAVRIX (PF)
2
$0
IMOVAX RABIES VACCINE
PA BvD
2
$0
(PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
2
$0
SUSPENSION
IPOL
2
$0
133
Name of Drug
IXIARO (PF)
KINRIX (PF)
MENACTRA (PF)
INTRAMUSCULAR SOLUTION
MENHIBRIX (PF)
MENOMUNE - A/C/Y/W-135 (PF)
MENVEO A-C-Y-W-135-DIP (PF)
MENVEO MENA COMPONENT
(PF)
MENVEO MENCYW-135
COMPNT (PF)
M-M-R II (PF)
PEDIARIX (PF)
PEDVAX HIB (PF)
PENTACEL (PF)
PENTACEL ACTHIB
COMPONENT (PF)
PENTACEL DTAP-IPV COMPNT
(PF)
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40
MCG/ML
RECOMBIVAX HB (PF)
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF)
Tier level
What the
drug will
cost you
2
2
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
2
$0
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 365 days)
QL (2 per 365 days)
PA BvD
days)
days)
134
Name of Drug
TETANUS TOXOID,ADSORBED
(PF)
TETANUS,DIPHTHERIA TOX
PED(PF)
TETANUS-DIPHTHERIA
TOXOIDS-TD
TICE BCG
TRUMENBA
TWINRIX (PF)
TYPHIM VI INTRAMUSCULAR
SOLUTION
VAQTA (PF)
VARIVAX (PF)
YF-VAX (PF)
ZOSTAVAX (PF)
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
2
1
1
2
2
$0
$0
$0
$0
$0
$0
1
$0
2
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
QL (2 per 365 days)
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
ASACOL HD
balsalazide
(Colazal)
budesonide oral
(Entocort EC)
DELZICOL
DIPENTUM
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
LACTATED RINGERS
IRRIGATION
ringers irrigation
sodium chloride irrigation
sorbitol irrigation
(Acetic Acid)
(Ringers Solution)
(Sodium Chloride
Irrig Solution)
(Sorbitol Solution)
135
Name of Drug
sorbitol-mannitol
water for irrigation, sterile
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
(Alendronate
alendronate oral solution
Sodium)
alendronate oral tablet 10 mg, 40
(Fosamax)
mg, 5 mg
alendronate oral tablet 35 mg, 70
(Fosamax)
mg
calcitonin (salmon)
(Miacalcin)
calcitriol intravenous solution 1
(Calcitriol)
mcg/ml
calcitriol oral
(Rocaltrol)
1
$0
doxercalciferol intravenous
(Doxercalciferol)
1
$0
doxercalciferol oral
(Hectorol)
1
$0
FORTEO
2
$0
FORTICAL
2
$0
ibandronate intravenous solution
(Ibandronate
Sodium)
1
$0
ibandronate oral
(Boniva)
1
$0
MIACALCIN INJECTION
2
$0
NATPARA
2
$0
1
$0
paricalcitol oral
(Zemplar)
QL (4 per 28 days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (2.4 per 28
days)
PA BvD; (PA for
ESRD Only); QL (3 per
84 days)
QL (1 per 28 days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
136
Name of Drug
PROLIA
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
(Actonel)
(Actonel)
ZEMPLAR INTRAVENOUS
zoledronic acid intravenous
solution
(Zometa)
(Zoledronic
zoledronic acid-mannitol-water
Acid/Mannitol and
intravenous piggyback 4 mg/100 ml
Water)
(Reclast)
intravenous solution
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Tier level
What the
drug will
cost you
2
1
1
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
2
1
1
$0
$0
$0
$0
1
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 28 days)
PA BvD; (PA for
ESRD Only)
PA BvD
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
SOLUTION 200 MG/10 ML (20
MG/ML)
ACTEMRA SUBCUTANEOUS
ACTIMMUNE
allopurinol
(Zyloprim)
amifostine crystalline
(Ethyol)
(Citrate Phosphate
anticoag citrate phos dextrose
Dextros Soln)
AVONEX (WITH ALBUMIN)
AVONEX INTRAMUSCULAR
PEN INJECTOR KIT
AVONEX INTRAMUSCULAR
SYRINGE KIT
BENLYSTA INTRAVENOUS
RECON SOLN 120 MG
PA
PA
ST
ST
ST
PA
137
Tier level
What the
drug will
cost you
2
$0
1
1
2
1
$0
$0
$0
$0
1
$0
2
$0
(Acetic Acid)
(Droperidol)
2
4
1
2
$0
$0
$0
$0
(Ergoloid
Mesylates)
1
$0
2
$0
4
4
1
1
2
$0
$0
$0
$0
$0
1
$0
GILENYA
2
$0
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
guanidine
hydroxyzine hcl intramuscular
2
$0
2
$0
1
1
$0
$0
Name of Drug
BETASERON SUBCUTANEOUS
KIT
bethanechol chloride
buspirone
CERDELGA
colchicine oral tablet
colchicine-probenecid
COPAXONE SUBCUTANEOUS
SYRINGE
CYSTADANE
douche vinegar & water extra *
droperidol injection solution
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS
KIT
extra cleansing douche *
feminine care douche *
finasteride oral tablet 5 mg
fomepizole
FUSILEV
GAUZE PAD TOPICAL
BANDAGE 2 X 2 "
(Urecholine)
(Buspirone HCl)
(Colcrys)
(Colchicine/Proben
ecid)
(Acetic Acid)
(Acetic Acid)
(Proscar)
(Fomepizole)
(Guanidine HCl)
(Hydroxyzine HCl)
Necessary Actions,
Restrictions, or
Limits on Use
ST
PA
ST
PA; QL (28 per 28
days)
PA-HRM
138
Tier level
What the
drug will
cost you
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
(Vistaril)
1
1
2
2
$0
$0
$0
$0
1
$0
1
$0
1
$0
Name of Drug
hydroxyzine hcl oral solution 10
mg/5 ml
hydroxyzine hcl oral tablet
hydroxyzine pamoate
JALYN
LEMTRADA
leucovorin calcium injection recon
soln 100 mg, 200 mg, 350 mg
leucovorin calcium oral
levocarnitine (with sugar)
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
levocarnitine oral tablet
(Carnitor)
1
$0
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
MESTINON TIMESPAN
MINERAL OIL *
mineral oil * topical
(Mesnex)
1
2
2
2
4
4
$0
$0
$0
$0
$0
$0
1
$0
OTEZLA
2
$0
OTEZLA STARTER
2
$0
OTREXUP (PF)
PLEGRIDY
probenecid
PROCYSBI
pyridostigmine bromide oral tablet
RASUVO (PF)
REBIF (WITH ALBUMIN)
2
2
1
2
1
2
2
$0
$0
$0
$0
$0
$0
$0
morrhuate sodium
(Mineral Oil)
(Sodium
Morrhuate)
(Probenecid)
(Mestinon)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
QL (30 per 30 days)
PA
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
ST
139
Tier level
What the
drug will
cost you
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
2
$0
1
$0
(Acetic Acid)
4
$0
(Acetic Acid)
4
2
$0
$0
2
$0
Name of Drug
REBIF REBIDOSE
REBIF TITRATION PACK
REMICADE
SENSIPAR
SIGNIFOR
SIMPONI ARIA
SIMPONI SUBCUTANEOUS
SYRINGE
STELARA SUBCUTANEOUS
SYRINGE
STERILE PADS TOPICAL
BANDAGE 2 X 2 "
summer's eve disposable douche *
vaginal solution
summers eve extra cleansing *
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)240 MG (46), 240 MG
2
$0
THALOMID
2
$0
TYBOST
2
$0
ULORIC
2
$0
XELJANZ
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (60 per 30 days)
PA
PA
PA
PA; QL (14 per 30
days)
PA; QL (60 per 30
days)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
ST; QL (30 per 30
days)
PA; QL (60 per 30
days)
Ophthalmic Agents
Antiglaucoma Agents
140
Tier level
What the
drug will
cost you
(Diamox Sequels)
1
$0
(Acetazolamide)
(Acetazolamide
Sodium)
1
$0
1
$0
2
$0
2
1
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
(Neptazane)
(Metipranolol)
1
1
2
$0
$0
$0
(Isopto Carpine)
1
$0
(Timolol Maleate)
2
1
$0
$0
(Timoptic-Xe)
1
$0
2
$0
1
$0
Name of Drug
acetazolamide oral capsule,
extended release
acetazolamide oral tablet
acetazolamide sodium
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT
betaxolol ophthalmic
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
latanoprost
levobunolol
LUMIGAN OPHTHALMIC
DROPS 0.01 %
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1
%, 2 %, 4 %
SIMBRINZA
timolol maleate ophthalmic drops
timolol maleate ophthalmic gel
forming solution
TRAVATAN Z
travoprost (benzalkonium)
(Betaxolol HCl)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Travoprost
(Benzalkonium))
Necessary Actions,
Restrictions, or
Limits on Use
(drops: 0.15%, 0.20%)
Replacement Preparations
Replacement Preparations
141
Name of Drug
(Ca/D3/Mag
ca-d3-mag ox-zinc-cop-mang-bor *
Ox/Zinc/Cop/Mang
oral tablet,chewable
/Bor)
calcitrate *
(Calcium Citrate)
calcium 500 + d (d3) *
(Caltrate 600 + D)
calcium 500 + d * oral tablet 500
(Caltrate 600 + D)
mg(1,250mg) -400 unit
calcium 500 with d *
(Caltrate 600 + D)
(Calcium
calcium 600 *
Carbonate)
(Calcium
calcium 600 + d(3) * oral capsule
Carbonate/Vitamin
D3)
calcium 600 + d(3) * oral tablet
600 mg(1,500mg) -200 unit, 600(Caltrate 600 + D)
125 mg-unit
(Calcium
calcium 600 with vitamin d3 * oral
Carbonate/Vitamin
capsule
D3)
calcium carbonate * oral
(Calcium
suspension
Carbonate)
calcium carbonate * oral tablet 260 (Calcium
mg calcium (648 mg)
Carbonate)
(Calcium
Carbonate/Vitamin
D2)
(Calcium
oral capsule 600 mg(1,500mg) -100
Carbonate/Vitamin
unit, 600 mg(1,500mg) -400 unit,
D3)
600 mg(1,500mg) -500 unit
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
142
Tier level
What the
drug will
cost you
(Caltrate 600 + D)
4
$0
(Calcium 600 + Vit
D)
4
$0
(Calcium Chloride)
(Citracal-Vitamin
D)
(Calcium
Gluconate)
(Calcium
Gluconate)
1
$0
4
$0
1
$0
4
$0
(Calcium Lactate)
4
$0
(Caltrate 600 + D)
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
Name of Drug
oral tablet 1,000 mg(2,500 mg)-800
unit, 500mg (1,250mg) -600 unit,
600 mg(1,500mg) -400 unit, 600
mg(1,500mg) -800 unit
oral tablet,chewable 500
mg(1,250mg) -400 unit
calcium chloride intravenous
calcium citrate-vitamin d3 * oral
tablet 315-200 mg-unit
calcium gluconate intravenous
calcium gluconate * oral tablet 45
mg (500 mg)
calcium lactate * oral tablet 84 mg
(650 mg)
calcium+d * oral tablet 400-133.3
mg-unit
CALTRATE 600 + D *
CALTRATE-600 + D VIT D3
(800) *
(Citracal-Vitamin
D)
citrus calcium * oral tablet 315-250 (Citracal-Vitamin
mg-unit
D)
(Citric
cytra-2
Acid/Sodium
Citrate)
(Sod/Pot/K Cit/Sod
cytra-3
Cit/Cit Acid)
(Dextrose 10 %
d10 % & 0.45 % sodium chloride
and 0.45 % NaCl)
citracal + d maximum *
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
143
Name of Drug
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
dextrose 10 % and 0.2 % nacl
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
effer-k oral tablet, effervescent 25
meq
electrolyte-48 in d5w
hi-cal plus vit d *
HYPERLYTE CR
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE M IN 5 % DEXTROSE
ISOLYTE-H IN 5 % DEXTROSE
ISOLYTE-P IN 5 % DEXTROSE
ISOLYTE-S
k-effervescent
KELP (IODINE) *
klor-con 10
(Dextrose 2.5 %
and 0.45 % NaCl)
(Dextrose 5 % and
0.9 % NaCl)
(Dextrose 5 %-0.45
% NaCl)
(Dextrose 10 %
and 0.2 % NaCl)
(Dextrose 5%Lactated Ringers)
(Dextrose 5 %-0.2
% NaCl)
(Dextrose 5 % and
0.3 % NaCl)
(Dextrose 5 %-0.2
% NaCl)
(Klor-Con-Ef)
(Electrolyte-48
Solution/D5W)
(Caltrate 600 + D)
(Klor-Con-Ef)
(Potassium
Chloride)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
2
2
2
2
2
2
2
1
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
144
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
(Magonate)
4
$0
(Magnesium)
4
$0
(Magnesium
Sulfate/D5W)
1
$0
(Magnesium
Sulfate in Water)
1
$0
1
$0
4
$0
2
$0
Name of Drug
klor-con m10
klor-con m15
klor-con m20
liquid calcium with vitamin d *
mag 64 *
mag-delay *
mag-g *
magnesium (oxide/aa chelate) *
magnesium chloride injection
magnesium gluconate * oral tablet
27 mg (500 mg)
magnesium * oral tablet 250 mg
magnesium sulfate in d5w
ml
magnesium sulfate in water
ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection
natural calcium *
(Potassium
Chloride)
(Potassium
Chloride)
(Potassium
Chloride)
(Calcium
Carbonate/Vitamin
D3)
(Magnesium
Chloride)
(Magnesium
Chloride)
(Magonate)
(Magnesium
Oxide/Mag Aa
Chelate)
(Magnesium
Chloride)
(Magnesium
Sulfate)
(Calcium
Carbonate)
NORMOSOL-M IN 5 %
DEXTROSE
Necessary Actions,
Restrictions, or
Limits on Use
145
Name of Drug
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
oysco 500/d * oral tablet
oysco d *
oysco-500 *
oyster shell calcium 500 *
oyster shell calcium with d *
oyster shell calcium-vit d3 *
oystercal-d *
pediatric electrolyte * oral solution
pediatric freezer pops *
PHOS-NAK *
phospha 250 neutral
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
potassium bicarb-citric acid
potassium chlorid-d5-0.45%nacl
potassium chloride in 0.9%nacl
meq/l, 40 meq/l
(Caltrate 600 + D)
(Caltrate 600 + D)
(Calcium
Carbonate)
(Calcium
Carbonate)
(Calcium
Carbonate/Vitamin
D2)
(Caltrate 600 + D)
(Caltrate 600 + D)
(Pedialyte)
(Pedialyte)
(K-Phos Neutral)
(Potassium
Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
Tier level
What the
drug will
cost you
2
2
2
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
4
4
4
4
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
146
Tier level
What the
drug will
cost you
(Potassium
Chloride In D5w)
1
$0
(Potassium
Chloride In Lr-D5)
1
$0
potassium chloride intravenous
(Potassium
Chloride)
1
$0
potassium chloride oral capsule,
extended release
(Micro-K)
1
$0
1
$0
1
$0
(K-Tab ER)
1
$0
(K-Tab ER)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
potassium chloride in 5 % dex
meq/l, 30 meq/l, 40 meq/l
potassium chloride in lr-d5
meq/l
potassium chloride oral liquid
potassium chloride oral packet
potassium chloride oral tablet
extended release 10 meq, 8 meq
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
potassium chloride-0.45 % nacl
potassium chloride-d5-0.2%nacl
meq/l
potassium citrate
potassium citrate-citric acid oral
packet
(Potassium
Chloride)
(Klor-Con)
(Potassium
Chloride)
(Potassium
Chloride-0.45%
NaCl)
(Potassium
Chloride/D50.2%NaCl)
(Potassium
(Potassium
(Urocit-K)
(Potassium
Citrate/Citric Acid)
Necessary Actions,
Restrictions, or
Limits on Use
147
Name of Drug
(Potassium
potassium phosphate dibasic
Phos,M-Basic-DBasic)
ringers intravenous
(Ringers Solution)
sodium acetate intravenous
(Sodium Acetate)
sodium bicarbonate intravenous
(Sodium
solution 1 meq/ml (8.4 %)
Bicarbonate)
sodium bicarbonate intravenous
(Sodium
syringe
Bicarbonate)
sodium chloride 0.45 % intravenous (Sodium Chloride
parenteral solution
0.45 %)
sodium chloride 0.9 % injection
(0.9 % Sodium
solution
Chloride)
sodium chloride 0.9 % intravenous (0.9 % Sodium
parenteral solution
Chloride)
(Sodium Chloride
sodium chloride 3 %
3 %)
(Sodium Chloride
sodium chloride 5 %
5 %)
sodium chloride intravenous
(Sodium Chloride)
(Citric
sodium citrate-citric acid
Acid/Sodium
Citrate)
sodium lactate intravenous
(Sodium Lactate)
(Sodium Phos,Msodium phosphate
Basic-D-Basic)
TPN ELECTROLYTES
TPN ELECTROLYTES II
(Sod/Pot/K Cit/Sod
tricitrates
Cit/Cit Acid)
virt-phos 250 neutral
(K-Phos Neutral)
Tier level
What the
drug will
cost you
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
2
$0
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
148
Name of Drug
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE
DULERA
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 100 MCG/ACTUATION,
50 MCG/ACTUATION
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 250 MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 110
MCG/ACTUATION
MCG/ACTUATION
MCG/ACTUATION
QVAR
Antileukotrienes
montelukast
zafirlukast
Bronchodilators
albuterol sulfate inhalation solution
for nebulization 0.63 mg/3 ml, 1.25
mg/3 ml, 2.5 mg /3 ml (0.083 %), 5
mg/ml
albuterol sulfate oral syrup
albuterol sulfate oral tablet
Tier level
What the
drug will
cost you
2
2
$0
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (12 per 28 days)
QL (60 per 30 days)
QL (13 per 28 days)
QL (60 per 30 days)
2
$0
QL (12 per 28 days)
2
$0
2
$0
2
$0
2
$0
1
1
$0
$0
QL (24 per 28 days)
(Singulair)
(Accolate)
PA BvD
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
(Albuterol Sulfate)
1
1
$0
$0
149
Name of Drug
albuterol sulfate oral tablet
ATROVENT HFA
COMBIVENT RESPIMAT
metaproterenol oral
(Vospire ER)
(Metaproterenol
Sulfate)
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA WITH HANDIHALER
STRIVERDI RESPIMAT
terbutaline oral
terbutaline subcutaneous
theochron
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
(Theophylline
Anhydrous)
theophylline in dextrose 5 %
(Theophylline/D5
mg/100 ml, 200 mg/50 ml, 400
W)
mg/250 ml, 400 mg/500 ml, 800
mg/250 ml
(Theophylline
theophylline oral solution
Anhydrous)
theophylline oral tablet extended
(Theophylline
release
Anhydrous)
theophylline oral tablet extended
(Theophylline
release 12 hr
Anhydrous)
TUDORZA PRESSAIR
Respiratory Tract Agents, Other
acetylcysteine intravenous
(Acetadote)
acetylcysteine solution
(Acetadote)
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
2
2
$0
$0
1
$0
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
QL (1 per 28 days)
1
1
$0
$0
PA BvD
PA BvD
QL (8 per 30 days)
QL (17 per 25 days)
QL (2 per 30 days)
QL (60 per 30 days)
QL (4 per 30 days)
QL (30 per 30 days)
150
Tier level
What the
drug will
cost you
1
$0
4
2
$0
$0
ESBRIET
2
$0
KALYDECO
2
$0
OFEV
PROLASTIN-C
sodium chloride * inhalation
solution for nebulization 0.9 %
XOLAIR
2
2
$0
$0
3
$0
2
$0
Name of Drug
cromolyn inhalation
cromolyn * nasal
DALIRESP
(Cromolyn
Sodium)
(Nasalcrom)
(Pulmosal)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (30 per 30 days)
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
1
$0
carisoprodol
(Soma)
1
$0
chlorzoxazone
(Parafon Forte
DSC)
1
$0
(Fexmid)
1
$0
(Dantrium)
(Skelaxin)
(Robaxin)
(Dantrium)
(Zanaflex)
1
1
1
1
1
$0
$0
$0
$0
$0
cyclobenzaprine oral tablet 10 mg,
5 mg
dantrolene
metaxalone
methocarbamol oral
revonto
tizanidine
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
HETLIOZ
2
$0
PA
NUVIGIL
2
$0
PA
ROZEREM
2
$0
XYREM
2
$0
LA
151
Name of Drug
Tier level
What the
drug will
cost you
zaleplon
(Sonata)
1
$0
zolpidem oral tablet
(Ambien)
1
$0
zolpidem oral tablet,ext release
multiphase
(Ambien CR)
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
Vasodilating Agents
Vasodilating Agents
ADCIRCA
PA; QL (60 per 30
days)
152
Tier level
What the
drug will
cost you
2
$0
1
$0
LETAIRIS
2
$0
OPSUMIT
2
$0
ORENITRAM
REMODULIN
2
2
$0
$0
Name of Drug
ADEMPAS
epoprostenol (glycine)
(Flolan)
sildenafil intravenous
(Revatio)
1
$0
sildenafil oral
(Revatio)
1
$0
TRACLEER
2
$0
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
2
2
2
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
PA BvD
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
PA BvD
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
PA; LA; QL (60 per 30
days)
PA BvD
PA BvD
PA BvD
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula *
a thru z high potency * oral tablet
a thru z select 50+ formula *
a thru z select * oral tablet
a thru z select * oral tablet 300600-300 mcg, 500-300-250 mcg
a thru z select women's *
abc plus *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin WMinerals/Lutein)
(Biocel)
(Biocel)
(Multivits WFe,Other Min/Lut)
(Biocel)
153
Name of Drug
adult one daily gummies *
adults 50+ daily formula *
adults' daily formula *
airshield * oral tablet, effervescent
5,000-1000-30 unit-mg-unit
animal chews *
animal shape vitamins *
animal shapes plus iron *
antioxidant *
antioxidant vitamins * oral tablet
1,000 unit-200 mg-60 unit-2 mg
apatate forte *
(One-A-Day
Vitacraves)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Vit A,C, and
E/Dietary Supp
No.12)
(Multivitamin)
(Multivitamin)
(Multivitamins
with Iron)
(Beta-Carotene(A)
W-C and E/Min)
(Vit A,C and
E/Lutein/Minerals)
(Multivitamin with
Minerals)
ascorbic acid * oral tablet extended
(Ascorbic Acid)
release 1,500 mg
ascorbic acid * oral
(Ascorbic Acid)
tablet,chewable
(Vitamin B
b complete *
Complex)
(Vitamin B
b complex 1 *
Complex)
(Vitamin B
b complex 100 * oral
Complex/Folic
Acid)
(Vitamin B
b complex-vitamin b12 *
Complex)
b complex-vitamin c-folic acid *
(Dialyvite 800)
(Vitamin B
b-100 complex * oral tablet
Complex)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
154
Name of Drug
Tier level
What the
drug will
cost you
(B-12)
(Vitamin B
b-50 complex * oral tablet
Complex)
(Vitamin B
bal b-100 *
Complex)
(Vitamin B
bal b-50 *
Complex)
(Vitamin B
balance b-100 *
Complex)
(Vitamin B
balance b-50 *
Complex)
(Vitamin B
balanced b-100 * oral tablet
Complex)
(Vitamin B
balanced b-100 * oral tablet 0.4 mg Complex/Folic
Acid)
(Vit B Complex
balanced b-100 * oral tablet 100
100 Cmb
mg
#3/Herbs)
(Vitamin B
balanced b-150 *
Complex)
(Vitamin B
balanced b-50 complex *
Complex)
(Vitamin B
balanced b-50 * oral tablet
Complex)
(Vitamin B
b-complex * oral tablet
Complex)
b-complex with vitamin c * oral
(B Complex with
capsule
Vitamin C)
(Vita-Bee with C)
tablet
(Fa/Vit B Complex
tablet 400-500 mcg-mg
and C/Rice Bran)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
b-12 dots *
Necessary Actions,
Restrictions, or
Limits on Use
155
Name of Drug
biosupp *
biotin * oral tablet 300 mcg
biovol *
c complex *
calcidol *
centamin *
central vite with lutein *
central-vite for seniors *
central-vite * oral tablet 18-400
mg-mcg
central-vite select * oral tablet
central-vite senior *
centram-care *
centravites 50 plus *
centrum complete *
centrum * oral liquid
centrum silver * oral tablet
century adults 50+ *
century mature * oral tablet
(Multivitamin with
Minerals)
(Biotin)
(Multivitamin with
Minerals)
(Ascorbic Acid)
(Drisdol)
(Multivits WMin/Ferrous Gluc)
(Biocel)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Biocel)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
century mature * oral tablet 0.4300-250 mg-mcg-mcg, 500-300-250 (Biocel)
4
$0
mcg
century * oral tablet 18-400 mg(Multivitamin/Iron/
4
$0
mcg
Folic Acid)
156
Name of Drug
century ultimate women's * oral
tablet 18-400 mg-mcg
(Multivitamin/Iron/
Folic Acid)
(Multivits Wcerovite *
Min/Ferrous Gluc)
(Multivitamin/Iron/
cerovite advanced formula *
Folic Acid)
certavite senior-antioxidant *
(Biocel)
certavite-antioxid (iron gluc) * oral (Multivits Wliquid 9 mg iron/15 ml
Min/Ferrous Gluc)
(Multivitamin/Iron/
certavite-antioxidant *
Folic Acid)
chewable multi vitamin *
(Multivitamin)
(Pedi Mv
child complete multivitamin *
No.58/Ferrous
Fumarate)
(Multivitamin
child vitamin with minerals *
W/Iron, Minerals)
children's chewable *
(Multivitamin)
children's chewable complete * oral
(Multivitamin)
tablet,chewable
children's chewable vitamin *
(Multivitamin)
(Multivitamin
children's chewable w/minerals *
W/Iron, Minerals)
(Pedi Mv
children's complete vitamin *
No.67/Ferrous
Fumarate)
children's multivit w/extra c *
(Multivitamin)
childs chew vite *
(Multivitamin)
(Multivitamins
child's vitamin with iron *
with Iron)
child's vitamin with vitamin c *
(Multivitamin)
(Multivitamins
childs/iron *
with Iron)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
157
Tier level
What the
drug will
cost you
(D3-50)
4
$0
(Just D)
4
$0
(Cholecalciferol
(Vitamin D3))
4
$0
(Vitamin D3)
4
$0
(Biocel)
(Biocel)
(Multivits,Th WFe,Other Min)
4
4
$0
$0
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
cholecalciferol (vitamin d3) * oral
capsule 1,000 unit, 10,000 unit,
5,000 unit
drops 5,000 unit/ml
liquid
tablet,chewable 400 unit
complete 50+ *
complete multi 50+ *
complete multivitamin * oral tablet
complete multivitamin * oral tablet
0.4-300-250 mg-mcg-mcg
complete multivitamin-mineral *
oral tablet
complete senior * oral tablet
complete senior * oral tablet 0.4300-250 mg-mcg-mcg
cyanocobalamin (vitamin b-12) *
injection
daily gummies *
daily multiple * oral tablet
daily multiple * oral tablet 18-400
mg-mcg
daily multi-vitamin *
daily multivitamin with iron *
daily multi-vitamins/iron *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin
W/Iron, Minerals)
(Biocel)
(Cyanocobalamin
(Vitamin B-12))
(One-A-Day
Vitacraves)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamins
with Iron)
Necessary Actions,
Restrictions, or
Limits on Use
158
Name of Drug
daily teen multi-vitamin *
daily value *
daily vitamin *
daily vitamin formula *
daily vitamin formula + iron *
daily vitamin formula-minerals *
daily vitamin with iron *
daily vites/iron *
daily-vite *
dino-life *
dino-life with extra c *
dino-life with iron-zinc *
eldertonic *
ellis tonic *
ergocalciferol (vitamin d2) * oral
drops
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamins
with Iron)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
(B1,B2,B3,B6,B12
/Dexpan/Zn/Mang)
(Multivitamin with
Minerals)
(Drisdol)
Tier level
What the
drug will
cost you
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Multivitamin/Iron/
4
$0
Folic Acid)
(Multivits Wessential balance with lutein *
4
$0
Fe,Other Min/Lut)
essential daily *
(Tab A Vite)
4
$0
(Fe Fumarate/Vit
ferocon *
3
$0
C/B12-If/Fa)
(Fe Fumarate/Vit
ferotrinsic *
3
$0
C/B12-If/Fa)
ferretts *
(Ferrous Fumarate)
4
$0
essentia *
159
Tier level
What the
drug will
cost you
(Pic 200)
(Iron Aspgly and
Ps Cmplx/C/Sucac)
(Ferrous Fumarate)
4
$0
4
$0
4
$0
(Ferrous Fumarate)
4
$0
(Fergon)
4
$0
(Fer-In-Sol)
(Ferrous Sulfate)
(Ferrous Sulfate)
4
4
4
$0
$0
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Multivitamin
W/Iron, Minerals)
4
$0
(Multivitamin)
4
$0
(Pedi Mv
No.79/Ferrous
Fumarate)
4
$0
(Multivitamin)
4
$0
(Folic Acid)
3
$0
4
$0
(Folic Acid)
4
$0
(Calcium/Multivita
mins W-Iron)
4
$0
Name of Drug
ferrex 150 *
ferrex 150 plus *
ferrocite *
ferrous fumarate * oral tablet 324
mg (106 mg iron)
ferrous gluconate * oral tablet 236
mg (27 mg iron), 240 mg (27 mg
iron), 256 mg (28 mg iron), 324 mg
(36 mg iron), 324 mg (38 mg iron),
325 mg (36 mg iron)
ferrous sulfate * oral drops
ferrous sulfate * oral liquid
ferrous sulfate * oral solution
ferrous sulfate * oral tablet 325 mg
(65 mg iron)
ferrous sulfate * oral tablet,delayed
release (dr/ec) 324 mg (65 mg iron)
flintstones complete (iron) * oral
tablet,chewable
flintstones multivitamin * oral
tablet,chewable
flintstones with iron *
flintstones/extra c * oral
tablet,chewable
folic acid * 1 mg tablet (rx)
FOLIC ACID * ORAL CAPSULE
20 MG
folic acid * oral tablet 1 mg, 400
mcg
fosfree *
Necessary Actions,
Restrictions, or
Limits on Use
160
Tier level
What the
drug will
cost you
(Pediavit)
(Pediavit)
(Multivitamin)
(Multivitamin)
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Mv,Ca,Min/Iron
Gluc/Fa/Biotin)
(Vit A,C and
E/Lutein/Minerals)
(Ferrous Fumarate)
(Vitamin B
Complex)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
(Multivitamin with
Minerals)
(Pic 200)
(Fergon)
(Multivitamin)
(Ped Multivit
#17/Iron Fumarate)
(Multivitamins
with Iron)
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
kid's vitamins * oral
tablet,chewable
(Multivitamin)
4
$0
life-pack women's *
(Multivitamin
W/Iron, Minerals)
4
$0
Name of Drug
geravim *
geriaton *
gummi bear multivitamin *
gummy swirls *
hair vitamins *
hair,skin & nails * oral tablet
hair,skin & nails * oral tablet 1 mg
iron-66.7 mcg-1,000 mcg
healthy eyes *
hemocyte *
hi-b complex *
high potency multivit-multimin *
honey bears *
honey bears with iron-zinc *
icaps plus *
iferex 150 *
iron high potency *
kid's vitamins + extra c *
kids vitamins + iron *
kid's vitamins + iron *
Necessary Actions,
Restrictions, or
Limits on Use
161
Name of Drug
LIQUI-E *
little animals *
little animals-iron * oral
tablet,chewable
lysiplex plus * oral liquid
MACUVITE *
MACUVITE EYE CARE *
maximum daily multivitamin *
mega multiple/chelated mineral *
mega multivitamin with mineral *
oral tablet
men's multi-vitamin *
men's one daily * oral tablet
(Multivitamin)
(Multivitamins
with Iron)
(Pediavit)
(Tab A Vite)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamin with
Minerals)
MEPHYTON *
milltrium senior *
multi complete with iron *
multi-day with iron *
multi-delyn with iron *
multiple vitamin-minerals *
multiple vitamins *
multiple vitamins with iron *
multivital platinum * oral tablet
multivital platinum * oral tablet
500-300-250 mcg
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Ferr
ous Gluconate)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamins
with Iron)
(Biocel)
Tier level
What the
drug will
cost you
4
4
$0
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
162
Name of Drug
multivitamin 50 plus *
multi-vitamin hp/minerals *
multivitamin with fluoride
multivitamin with iron *
multivitamin with minerals * oral
liquid
multivitamin with minerals * oral
tablet
multi-vite *
multi-vite 50 & over *
my favorite multiple *
my-vitalife *
(Multivitamins,The
r W-Minerals)
(Pedi M.Vit No.17
with Fluoride)
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin with
Minerals)
NASCOBAL *
natural b-100 *
natural b-100 complex *
nephplex rx *
nephron fa *
nephro-vite rx *
(Vitamin B
Complex)
(Vit B Complex
100 Cmb
#2/Herbs)
(Vit B Cmplx
No3/Fa/C/Biot/Zin
c)
(Fe
Fumarate/Doss/Fa/
Bcomp and C)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
Tier level
What the
drug will
cost you
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
3
$0
3
$0
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
163
Tier level
What the
drug will
cost you
(Niacinamide)
4
$0
(Pic 200)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamins,The
rapeutic)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Tab A Vite)
(Multivitamins
with Iron)
(Multivitamin)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
(Quintabs)
4
$0
Name of Drug
niacinamide * oral tablet extended
release
nu-iron *
ocutabs *
oncovite *
one daily 50 plus *
one daily complete * oral tablet
one daily energy * oral tablet
one daily essential * oral tablet
one daily maximum (with ca) *
one daily multi-vit w-mineral *
one daily multivitamin * oral tablet
one daily multivitamin * oral tablet
400 mcg
Necessary Actions,
Restrictions, or
Limits on Use
(Multivitamin/Iron/
4
$0
Folic Acid)
one daily * oral tablet
(Multivitamin)
4
$0
(Multivitamins
one daily plus iron * oral tablet
4
$0
with Iron)
one daily plus iron * oral tablet 18- (Multivitamin/Iron/
4
$0
400 mg-mcg
Folic Acid)
(Multivitamin with
one daily plus minerals *
4
$0
Minerals)
(Multivitamins
one daily with iron *
4
$0
with Iron)
one-a-day essential *
(Multivitamin)
4
$0
(Multivitamin with
one-a-day maximum formula *
4
$0
Minerals)
one daily multivitamin-iron *
164
Name of Drug
one-a-day teen advantage * oral
one-a-day teen advantage * oral
tablet 9 mg iron-400 mcg
opti-vitamins * oral tablet
opti-vitamins * oral tablet 1,000
unit-200 mg-60 unit-2 mg
pediatric multivitamin *
pharmacist favorite multi-vit *
poly-iron *
poly-vita *
poly-vita (iron) *
poly-vitamin *
poly-vitamin with iron * oral drops
1,500 unit-400 unit-10 mg/ml
poly-vitamins *
prenatal formula * oral tablet 280.8 mg
prenatal * oral tablet 28-0.8 mg
(Multivitamin/Iron/
Folic Acid)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Beta-Carotene(A)
W-C and E/Min)
(Vit A,C and
E/Lutein/Minerals)
(Multivitamin)
(Multivitamin)
(Pic 200)
(Pediatric Multivit
Comb No.20)
(Ped Multivit
#46/Iron Sulfate)
(Pediatric Multivit
Comb No.20)
(Ped Multivit
#46/Iron Sulfate)
(Multivitamin)
(Classic Prenatal)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Classic Prenatal)
4
$0
(Pnv with
(All Rx Prenatal
prenatal plus (calcium carb)
2
$0
Ca,No.72/Iron/Fa)
Vitamins Covered)
(Prenatal
prenatal vit#96-ferrous fum-fa *
Vit#96/Ferrous
4
$0
Fum/Fa)
prenatal vitamin with minerals *
(Classic Prenatal)
4
$0
(Pnv with
(All Rx Prenatal
prenatal vitamins low iron
2
$0
Ca,No.72/Iron/Fa)
Vitamins Covered)
prenatal vit-iron fumarate-fa *
(Classic Prenatal)
4
$0
(A/C/E/Zinc/Sod
prosight *
4
$0
Selenate/Copper)
165
Name of Drug
pyridoxine * injection
(Pyridoxine HCl)
(Multivitamin
ra central-vite select * tab p/f
W/Iron, Minerals)
(Vit B Cmplx
rena-vite rx *
3/Fa/Vit C/Biotin)
(Multivitamin
scooby-doo one a day *
W/Iron, Minerals)
(Multivitamin/Iron/
sentry * oral tablet 18-400 mg-mcg
Folic Acid)
sentry senior *
(Biocel)
(Pedi M.Vit No.17
sodium fluoride oral tablet
with Fluoride)
spectravite adult 50+ * oral tablet (Biocel)
spectravite advanced formula * oral (Multivitamin/Iron/
Folic Acid)
spectravite * oral liquid
(Pediavit)
(Multivitamins
spectravite * oral tablet,chewable
with Iron)
(Multivitamin
spectravite senior * oral tablet
W/Iron, Minerals)
spectravite senior * oral tablet 500(Biocel)
300-250 mcg
(Multivitamin Wspectravite senior w-lycopene *
Minerals/Lutein)
(Multivitamin/Iron/
spectravite ultra women *
Folic Acid)
(Multivits,Stress
stress 500 plus zinc *
Formula/Zinc)
(Multivits,Stress
stress b with zinc *
Formula/Zinc)
(Vitamin B
stress b-biotin *
Complex)
(Multivits,Stress
stress formula *
Formula)
Tier level
What the
drug will
cost you
3
$0
4
$0
3
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
166
Name of Drug
stress formula plus iron *
stress formula with iron *
stress formula with zinc *
sunvite *
super b complex-vitamin c *
super b/c *
super b-50 complex *
super b-50 complex plus *
super multiple * oral tablet
super multivitamin *
super quints *
super quints b-50 *
super thera vite m *
superior 35 *
superplex-t *
support *
support-500 *
(Iron/Multivits,Stre
ss Formula)
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivits,Stress
Formula/Zinc)
(Mv-Min/Iron
Fum/Fa/K/Lyco/Lu
tn)
(Vita-Bee with C)
(B Complex with
Vitamin C)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
(Vitamin B
Complex/Folic
Acid)
(Vitamin B
Complex)
(Multivitamins,The
r W-Minerals)
(Multivitamin
W/Iron, Minerals)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(B Complex with
Vitamin C)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
167
Name of Drug
Tier level
What the
drug will
cost you
(Multivitamin)
(Multivitamins
tab-a-vite/iron *
with Iron)
(Multivitamin with
tab-a-vite-minerals *
Minerals)
(Multivits,Ca,Mine
thera m plus (ferrous fumarat) *
rals/Iron/Fa)
(Multivitamins,The
thera vitamin *
rapeutic)
(Multivit,Ther
theradex m *
Iron,Ca,Fa and
Min)
(Multivit,Ther
thera-m * oral tablet 27-0.4 mg
Iron,Ca,Fa and
Min)
thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine
mcg
rals/Iron/Fa)
(Multivitamins,The
therapeutic liquid *
rapeutic)
therapeutic m + beta-carotene *
(Tab A Vite)
(Multivitamins
therapeutic vitamins/minerals *
with Min No.7/Fa)
therapeutic-m * oral tablet 9 mg
(Multivits,Ca,Mine
iron-400 mcg
rals/Iron/Fa)
(Multivit,Ther
therapeutic-m vitamin/minerals *
Iron,Ca,Fa and
oral tablet 27-0.4 mg
Min)
(Multivitamins,The
thera-tabs *
rapeutic)
(Multivitamin
theratrum complete 50 plus *
W/Iron, Minerals)
(Multivitamin Wtheratrum complete 50 plus/lut *
Minerals/Lutein)
thiamine hcl * injection
(Thiamine HCl)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
tab-a-vite *
Necessary Actions,
Restrictions, or
Limits on Use
168
Tier level
What the
drug will
cost you
(Thiamine HCl)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(Vit A
Palmitate/Vit C/Vit
D3)
(Pedi Multivits
A,C, and D3
No.21)
(Pedi Multivits
A,C, and D3
No.21)
(Vitamin B
Complex)
(Multivitamins
with Min No.7/Fa)
(Multivitamins
with Min No.7/Fa)
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
(Vit A,C and
E/Lutein/Minerals)
(Vitamin B
Complex/Folic
Acid)
(Multivitamins
with Iron)
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Vitamin A)
4
$0
Name of Drug
thiamine hcl * oral tablet 500 mg
total b/c *
totalday multiple *
tri-vi-sol *
tri-vita *
tri-vitamin *
ultra b-100 complex * oral tablet
v-c forte *
vic-forte *
vision *
vision formula *
vision formula (with lutein) *
vision plus lutein *
vit b complex-folic acid * oral
tablet
vitalets * oral tablet,chewable
vitamin a * oral capsule 10,000
unit, 25,000 unit
Necessary Actions,
Restrictions, or
Limits on Use
169
Name of Drug
vitamin b complex *
vitamin b-100 complex *
vitamin b-12 * oral drops
(Vitamin B
Complex)
(Vitamin B
Complex)
(Cyanocobalamin
(Vitamin B-12))
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
vitamin b-12 * oral tablet 1,000
mcg, 100 mcg, 250 mcg, 500 mcg
(B-12)
4
$0
vitamin b12-folic acid * oral
(Cyanocobalamin/
Folic Acid)
4
$0
(Pyridoxine HCl)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Drisdol)
3
$0
(D3-50)
4
$0
(Vitamin D3)
4
$0
(Phytonadione)
(Multivitamins,The
r W-Minerals)
(Vitamin B
Complex)
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivitamin)
4
$0
4
$0
4
$0
4
$0
4
$0
vitamin b-6 * oral tablet 250 mg, 50
mg
vitamin c * oral syrup
vitamin c * oral tablet 1,000 mg,
250 mg
vitamin c * oral tablet extended
release
vitamin c * oral tablet,chewable
250 mg, 500 mg
vitamin d2 *
vitamin d3 * oral capsule 1,000
unit, 2,000 unit, 4,000 unit
vitamin d3 * oral tablet 1,000 unit,
2,000 unit, 400 unit
vitamin k * oral
vitamins & minerals *
vitamins b complex * oral tablet
vitamins b complex * oral tablet
500 mg-400 mcg- 18 mg iron
vitamins for hair * oral tablet
Necessary Actions,
Restrictions, or
Limits on Use
170
Name of Drug
vitrum senior * oral tablet
vitrum senior * oral tablet 500-300(Biocel)
250 mcg
(One-A-Day
womens daily gummies *
Vitacraves)
women's daily multivitamin *
(Tab A Vite)
(Multivitamin/Iron/
yelets *
Folic Acid)
zoo chews *
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
171
INDEX
3
3 day vaginal .......................... 52
30pse-150gfn-15dm ............... 93
8
8-MOP.................................. 103
A
a thru z advanced formula .... 153
a thru z high potency ............ 153
a thru z select ....................... 153
a thru z select 50+ formula... 153
a thru z select women's ........ 153
abacavir .................................. 67
abacavir-lamivudine-zidovudine
............................................ 67
abc plus ................................ 153
ABELCET.............................. 52
ABILIFY DISCMELT ........... 64
ABILIFY MAINTENA ......... 64
ABRAXANE ......................... 37
ABREVA ............................... 60
acamprosate............................ 27
acarbose.................................. 49
acebutolol ............................... 79
acephen .................................. 18
acetaminophen ....................... 18
acetaminophen-codeine.......... 18
acetazolamide ............... 140, 141
acetazolamide sodium .......... 141
acetic acid..................... 115, 135
acetylcysteine ....................... 150
acid gone antacid.................. 120
acid reducer (famotidine) ..... 118
acid relief (cimetidine) ......... 118
acitretin ................................ 103
acne medication ................... 103
ACNE MEDICATION ........ 103
acne-clear ............................. 103
ACTEMRA .......................... 137
ACTHIB (PF) ....................... 133
ACTIMMUNE ..................... 137
acyclovir ................... 69, 70, 103
acyclovir sodium .................... 70
ADACEL(TDAP
ADOLESN/ADULT)(PF) 133
ADAGEN ............................. 111
adapalene .............................. 110
ADCETRIS ............................ 37
ADCIRCA ............................ 152
adefovir .................................. 70
ADEMPAS........................... 153
adriamycin .............................. 37
adrucil..................................... 38
adt robitussin peak cld dm max
............................................ 93
adult nasal decongestant......... 93
adult one daily gummies ...... 154
adult robitussin lingering cld.. 93
adult robitussin peak cold dm 93
adult wal-tussin ...................... 93
adult wal-tussin dm max ........ 93
adults 50+ daily formula ...... 154
adults' daily formula ............. 154
ADVAIR DISKUS ....... 148, 149
ADVAIR HFA ..................... 149
advil .................................. 23, 24
af 52
afeditab cr ............................... 83
AFINITOR ............................. 38
AFINITOR DISPERZ ............ 38
AFTERA ................................ 88
AGGRENOX ......................... 73
a-hydrocort ........................... 129
airshield ................................ 154
AKTEN (PF) ........................ 112
I-1
Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de
ventaja doble completamente integrado (Fully Integrated Duals Advantage
Medicare-Medicaid Plan, FIDA MMP) de ICS
Identificación del formulario:16508.000, Versión: 7
ala-cort.................................. 106
ala-scalp................................ 106
alavert d-12 allergy-sinus ....... 55
ALBENZA ............................. 62
ALBUKED-25 ....................... 73
ALBUKED-5 ......................... 73
ALBUMIN, HUMAN 25 % ... 73
ALBUMIN, HUMAN 5 % ..... 73
ALBUMINAR 25 % .............. 73
ALBUMINAR 5 % ................ 73
ALBURX (HUMAN) 5 % ..... 73
ALBUTEIN 25 % .................. 73
ALBUTEIN 5 % .................... 73
albuterol sulfate ............ 149, 150
alcaine .................................. 112
alclometasone ....................... 106
ALCOHOL PADS ............... 103
ALCOHOL PREP PADS ..... 103
ALDURAZYME .................. 111
alendronate ........................... 136
alfuzosin ............................... 127
ALIMTA ................................ 38
ALINIA .................................. 62
alka-seltzer plus mucus-conges
............................................ 93
allegra allergy ......................... 55
aller-chlor ............................... 55
allerclear d-12hr ..................... 55
allerclear d-24hr ..................... 56
allergy (chlorpheniramine) ..... 56
allergy (diphenhydramine) ..... 56
allergy relief (cetirizine) ......... 56
allergy relief (loratadine)........ 56
allerhist-1................................ 56
aller-tec d ................................ 56
allopurinol ............................ 137
almacone .............................. 120
Fecha de entrada en vigencia:
01 de enero 2016
almacone-2 ........................... 120
aloe vesta ................................ 52
alophen ......................... 123, 124
ALPHAGAN P .................... 141
alprazolam .............................. 28
ALREX ................................ 117
altacaine ............................... 112
altamist ................................. 112
altavera (28) ........................... 88
aluminum hydroxide gel ...... 120
alyacen 1/35 (28).................... 88
alyacen 7/7/7 (28) .................. 88
amantadine hcl ....................... 63
ambi 10peh-4cpm-20dm ........ 93
ambi 20dm-4cpm ................... 93
ambi 40pse-400gfn-20dm ...... 93
ambi 60pse-4cpm ................... 56
ambi 60pse-4cpm-20dm......... 93
AMBISOME .......................... 52
amethia ................................... 88
amethia lo ............................... 88
amifostine crystalline ........... 137
amiloride ................................ 83
amiloride-hydrochlorothiazide83
AMINO ACIDS 15 % ............ 74
aminocaproic acid .................. 73
AMINOSYN 10 % ................. 74
AMINOSYN 3.5 % ................ 74
AMINOSYN 7 % ................... 74
AMINOSYN 7 % WITH
ELECTROLYTES ............. 74
AMINOSYN 8.5 % ................ 74
AMINOSYN 8.5 %ELECTROLYTES ............. 74
AMINOSYN II 10 % ............. 74
AMINOSYN II 15 % ............. 74
AMINOSYN II 7 % ............... 74
AMINOSYN II 8.5 % ............ 74
AMINOSYN II 8.5 %ELECTROLYTES ............. 74
AMINOSYN M 3.5 % ........... 74
AMINOSYN-HBC 7% .......... 74
AMINOSYN-PF 10 % ........... 74
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 74
AMINOSYN-RF 5.2 %.......... 74
amiodarone ............................. 78
AMITIZA ............................. 120
amitriptyline ........................... 47
amlactin ................................ 103
amlodipine.............................. 83
amlodipine-atorvastatin .......... 84
amlodipine-benazepril ............ 83
amlodipine-valsartan .............. 83
amlodipine-valsartan-hcthiazid
............................................ 83
ammonium lactate ................ 104
amoxapine .............................. 47
amoxicil-clarithromy-lansopraz
.......................................... 118
amoxicillin ............................. 34
amoxicillin-pot clavulanate ... 34,
35
amphetamine salt combo ........ 86
amphotericin b........................ 52
ampicillin ............................... 35
ampicillin sodium................... 35
ampicillin-sulbactam .............. 35
AMPYRA............................... 86
ANACAINE ......................... 104
anagrelide ............................... 73
anastrozole ............................. 38
ANDRODERM .................... 127
ANDROGEL ................ 127, 128
androxy................................. 128
animal chews ........................ 154
animal shape vitamins .......... 154
animal shapes plus iron ........ 154
antacid anti-gas .................... 120
anticoag citrate phos dextrose
.......................................... 137
anti-diarrheal ........................ 120
anti-diarrheal (loperamide) .. 120
antifungal ............................... 53
I-2
antifungal (tolnaftate) ............. 52
anti-gas maximum strength .. 118
antioxidant ............................ 154
antioxidant vitamins ............. 154
apatate forte .......................... 154
APOKYN ............................... 63
apraclonidine ........................ 112
apri.......................................... 88
APRISO................................ 135
aprodine .................................. 56
APTIOM ................................ 44
APTIVUS ............................... 67
aquanil hc ............................. 106
aranelle (28) ........................... 88
ARCALYST ......................... 131
aripiprazole ............................. 64
arthritis pain relief (acetam) ... 18
artificial tears ........................ 112
artificial tears (petro/min) .... 112
artificial tears (pf) ................. 112
artificial tears (polyvin alc) .. 112
artificial tears(glycerin-peg) . 112
artificial tears(hypromellose) 112
ASACOL HD ....................... 135
ascomp with codeine .............. 18
ascorbic acid ......................... 154
ashlyna.................................... 88
aspirin ..................................... 24
aspirin, buffered ..................... 24
aspir-low ................................. 24
ASSURE ID INSULIN
SAFETY ........................... 110
ASTAGRAF XL .................. 131
atenolol ................................... 79
atenolol-chlorthalidone .......... 79
atorvastatin ............................. 84
atovaquone ............................. 62
atovaquone-proguanil ............. 62
ATRIPLA ............................... 67
atropine ........................... 44, 112
ATROVENT HFA ............... 150
AUBAGIO ........................... 131
01 de enero 2016
aubra ....................................... 88
AVASTIN .............................. 38
AVC VAGINAL .................... 60
aviane ..................................... 88
AVONEX ............................. 137
AVONEX (WITH ALBUMIN)
.......................................... 137
ayr saline .............................. 112
azacitidine .............................. 38
azathioprine .......................... 131
azathioprine sodium ............. 131
azelastine ...................... 112, 113
AZILECT ............................... 63
azithromycin .......................... 33
AZOPT ................................. 141
AZOR ..................................... 83
aztreonam ............................... 34
azurette (28) ........................... 88
B
b complete ............................ 154
b complex 1 .......................... 154
b complex 100 ...................... 154
b complex-vitamin b12 ........ 154
b complex-vitamin c-folic acid
.......................................... 154
b-100 complex ..................... 154
b-12 dots............................... 155
b-50 complex ....................... 155
bacitracin ................ 29, 105, 115
bacitracin-polymyxin b ........ 116
bacitraycin plus .................... 105
baclofen ................................ 151
bal b-100 .............................. 155
bal b-50 ................................ 155
balance b-100 ....................... 155
balance b-50 ......................... 155
balanced b-100 ..................... 155
balanced b-150 ..................... 155
balanced b-50 ....................... 155
balanced b-50 complex ........ 155
balsalazide ............................ 135
balziva (28) ............................ 88
banophen ................................ 56
banophen allergy .................... 56
BANZEL ................................ 44
baza antifungal ....................... 53
BCG VACCINE, LIVE (PF) 133
b-complex............................. 155
b-complex with vitamin c .... 155
BD ECLIPSE LUER-LOK .. 110
BD INSULIN PEN NEEDLE
UF SHORT ...................... 110
BD INSULIN SYRINGE
ULTRA-FINE .................. 110
BELEODAQ .......................... 38
benadryl allergy...................... 56
benazepril ............................... 78
benazepril-hydrochlorothiazide
............................................ 78
BENICAR .............................. 77
BENICAR HCT ..................... 77
BENLYSTA ......................... 137
benzonatate............................. 93
benzoyl peroxide .................. 104
benztropine ............................. 63
BETADINE SPRAY ............ 104
beta-hc .................................. 106
betamethasone acet,sod phos 129
betamethasone dipropionate . 107
betamethasone valerate ........ 107
betamethasone, augmented .. 107
BETASERON ...................... 138
betaxolol ......................... 79, 141
bethanechol chloride ............ 138
BETHKIS ............................... 29
BEXSERO (PF) ................... 133
bicalutamide ........................... 38
bicarsim forte ....................... 118
BICILLIN C-R ....................... 35
BICILLIN L-A ....................... 35
bio-dtuss dmx ......................... 93
bion tears (pf) ....................... 113
bionel pediatric ....................... 93
biospec dmx ........................... 94
I-3
biosupp ................................. 156
biotin .................................... 156
biovol.................................... 156
bisac-evac ............................. 124
bisacodyl .............................. 124
biscolax ................................ 124
bismatrol ............................... 120
bisoprolol fumarate ................ 79
bisoprolol-hydrochlorothiazide
............................................ 79
bleomycin ............................... 38
bleph-10................................ 116
BLINCYTO............................ 38
BOOSTRIX TDAP .............. 133
BOSULIF ............................... 38
BREO ELLIPTA .................. 149
briellyn ................................... 88
BRILINTA ............................. 73
brimonidine .......................... 141
BRINTELLIX ........................ 47
bromfed dm ............................ 94
bromfenac ............................. 117
bromocriptine ......................... 63
bromphenex dm ...................... 94
brompheniramine-pseudoephdm ....................................... 94
budesonide............................ 135
bufferin ................................... 24
bumetanide ............................. 83
BUMINATE 25 % ................. 73
BUMINATE 5 % ................... 73
BUPHENYL ........................ 120
buprenorphine hcl............. 18, 27
buprenorphine-naloxone ........ 27
buproban ................................. 47
bupropion hcl ............. 27, 47, 48
buspirone .............................. 138
butalbital compound w/codeine
............................................ 18
butalbital-acetaminop-caf-cod 18
butalbital-acetaminophen ....... 18
butalbital-acetaminophen-caff 18
01 de enero 2016
butalbital-aspirin-caffeine ...... 19
BUTRANS ............................. 19
BYSTOLIC ............................ 79
C
c complex ............................. 156
cabergoline ............................. 63
ca-d3-mag ox-zinc-cop-mangbor ............................ 141, 142
caffeine citrated ...................... 86
caffeine-sodium benzoate ...... 86
calci-chew ............................ 120
calcidol ................................. 156
calcipotriene ......................... 104
calcitonin (salmon)............... 136
calcitrate ............................... 142
calcitrene .............................. 104
calcitriol ....................... 104, 136
calcium 500 + d.................... 142
calcium 500 + d (d3) ............ 142
calcium 500 with d ............... 142
calcium 600 .......................... 142
calcium 600 + d(3) ............... 142
calcium 600 with vitamin d3 142
calcium acetate ..................... 126
calcium antacid .................... 120
calcium carbonate ........ 120, 142
calcium carbonate-vitamin d2
.......................................... 142
calcium carbonate-vitamin d3
.......................... 121, 142, 143
calcium chloride ................... 143
calcium citrate-vitamin d3 ... 143
calcium gluconate ................ 143
calcium lactate ..................... 143
calcium+d............................. 143
CALDOLOR .......................... 24
cal-gest antacid..................... 121
calphron................................ 126
CALTRATE 600 + D .......... 143
CALTRATE-600 + D VIT D3
(800) ................................. 143
camila ..................................... 88
camrese................................... 88
camrese lo .............................. 88
CANCIDAS ........................... 53
candesartan ............................. 77
candesartan-hydrochlorothiazid
............................................ 77
capacet .................................... 19
CAPASTAT ........................... 61
CAPRELSA ........................... 38
captopril ................................. 78
captopril-hydrochlorothiazide 78
CARAFATE......................... 118
CARBAGLU ........................ 121
carbamazepine ........................ 44
carbidopa ................................ 63
carbidopa-levodopa ................ 63
carbidopa-levodopa-entacapone
............................................ 63
CARIMUNE NF
NANOFILTERED ........... 131
carisoprodol .......................... 151
carteolol ................................ 113
cartia xt ................................... 80
carvedilol ................................ 79
CASTELLANI PAINT
MODIFIED ...................... 104
CAYSTON ............................. 34
caziant (28) ............................. 88
cefaclor ................................... 31
cefadroxil ............................... 31
cefazolin ................................. 32
cefazolin in dextrose (iso-os) . 32
cefdinir ................................... 32
cefditoren pivoxil ................... 32
cefepime ................................. 32
CEFEPIME IN DEXTROSE 5
% ........................................ 32
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 32
cefotaxime .............................. 32
cefoxitin ................................. 32
cefoxitin in dextrose, iso-osm 32
I-4
cefpodoxime ........................... 32
cefprozil.................................. 32
ceftazidime ............................. 32
ceftibuten ................................ 32
ceftriaxone .............................. 32
CEFTRIAXONE .................... 33
ceftriaxone in dextrose,iso-os. 32
CEFTRIAXONE IN
DEXTROSE,ISO-OS ......... 32
cefuroxime axetil .................... 33
cefuroxime sodium ................. 33
cefuroxime-dextrose (iso-osm)
............................................ 33
celecoxib ................................ 24
CELLCEPT INTRAVENOUS
.......................................... 131
CELONTIN ............................ 44
centamin ............................... 156
centergy dm ............................ 94
central vite with lutein .......... 156
central-vite............................ 156
central-vite for seniors.......... 156
central-vite select ......... 156, 166
central-vite senior ................. 156
centram-care ......................... 156
centravites 50 plus ................ 156
centrum ................................. 156
centrum complete ................. 156
centrum silver ....................... 156
century .................................. 156
century adults 50+ ................ 156
century mature ...................... 156
century ultimate women's..... 157
cephalexin .............................. 33
CEPROTIN (BLUE BAR) ..... 70
CERDELGA ........................ 138
CEREZYME ........................ 111
cerovite ................................. 157
cerovite advanced formula ... 157
certavite senior-antioxidant .. 157
certavite-antioxid (iron gluc) 157
certavite-antioxidant ............. 157
01 de enero 2016
CERVARIX VACCINE (PF)
.......................................... 133
cetirizine ................................. 56
cetirizine-pseudoephedrine .... 56
cevimeline ............................ 103
CHANTIX.............................. 27
CHANTIX CONTINUING
MONTH BOX ................... 27
CHANTIX CONTINUING
MONTH PAK .................... 27
CHANTIX STARTING
MONTH BOX ................... 27
cheratussin dac ....................... 94
chest congestion relief + dm .. 94
chest congestion relief d......... 94
chest congestion relief pe ....... 94
chewable multi vitamin ........ 157
child allergy relf(cetirizine) ... 56
child complete multivitamin 157
child cough & sore throat ....... 94
child mucinex chest congestion
............................................ 94
child plus cough & runny nose
............................................ 94
child triaminic cold & allergy 56
child triaminic cough-congest 94
child vitamin with minerals . 157
child wal-tap cold-allergy ...... 56
child wal-tussin cough relief .. 94
children's advil ....................... 24
children's allegra allergy .. 56, 57
children's aller-tec .................. 57
children's chest congestion..... 94
children's chewable .............. 157
children's chewable complete
.......................................... 157
children's chewable vitamin . 157
children's chewable w/minerals
.......................................... 157
CHILDREN'S CLARITIN ..... 57
children's complete vitamin . 157
children's mapap .................... 19
children's mucinex cough ....... 94
children's multivit w/extra c . 157
children's non-aspirin ............. 19
children's pain & fever relief.. 19
children's pain reliever ........... 19
children's pepto .................... 121
childrens plus cold ................. 94
children's silapap .................... 19
children's silfedrine ................ 95
children's soothe ................... 121
children's sudafed ................... 95
children's sudafed pe cough ... 95
children's wal-dryl allergy...... 57
children's wal-zyr ................... 57
CHILDREN'S ZYRTEC
ALLERGY ......................... 57
childs chew vite .................... 157
child's vitamin with iron....... 157
child's vitamin with vitamin c
.......................................... 157
childs/iron............................. 157
chlophedianol-guaifenesin ..... 95
chloramphenicol sod succinate
............................................ 29
chlordiazepoxide hcl .............. 28
chlorhexidine gluconate ....... 103
chloroquine phosphate ........... 63
chlorothiazide ......................... 84
chlorothiazide sodium ............ 84
chlorpheniramine-phenyleph-dm
............................................ 95
chlorpromazine....................... 64
chlorthalidone......................... 84
chlorzoxazone ...................... 151
cholecalciferol (vitamin d3) . 158
cholestyramine (with sugar) ... 84
cholestyramine light ............... 84
choline,magnesium salicylate 24
ciclopirox ............................... 53
ciclopirox-ure-camph-menth-euc
............................................ 53
cilostazol ................................ 73
I-5
cimetidine ............................. 118
cimetidine hcl ....................... 118
CIMZIA................................ 131
CIMZIA POWDER FOR
RECONST........................ 132
CINRYZE .............................. 72
CIPRODEX .......................... 116
ciprofloxacin .......................... 36
ciprofloxacin hcl............. 36, 116
ciprofloxacin in 5 % dextrose 36
ciprofloxacin lactate ............... 36
citalopram ............................... 48
citracal + d maximum........... 143
citrus calcium ....................... 143
clarithromycin ........................ 33
CLARITIN ............................. 57
CLARITIN LIQUI-GEL ........ 57
CLARITIN REDITABS......... 57
clearlax ................................. 124
clemastine ............................... 57
CLEVIPREX .......................... 83
clindamycin hcl ...................... 29
clindamycin in 5 % dextrose .. 30
clindamycin palmitate hcl ...... 30
clindamycin pediatric ............. 30
clindamycin phosphate .... 30, 60,
105
CLINIMIX 5%/D15W
SULFITE FREE ................. 74
CLINIMIX 5%/D25W
SULFITE-FREE ................. 74
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 74
CLINIMIX 4.25%/D10W SULF
FREE .................................. 75
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 75
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 75
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 75
01 de enero 2016
CLINIMIX 5%D20W(SULFITE-FREE) ... 75
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 75
SULF FREE ....................... 75
SUL FREE ......................... 75
SUL FREE ......................... 75
SULF FREE ....................... 75
CLINIMIX E 5%/D15W
SULFIT FREE ................... 75
CLINIMIX E 5%/D20W
SULFIT FREE ................... 75
CLINIMIX E 5%/D25W
SULFIT FREE ................... 75
CLINISOL SF 15 %............... 75
clobetasol ............................. 107
clobetasol-emollient ............. 107
clocortolone pivalate ............ 107
clomipramine ......................... 48
clonazepam ............................ 28
clonidine ................................. 77
clonidine hcl ..................... 77, 86
clopidogrel ............................. 73
clorazepate dipotassium ......... 28
clorpres ................................... 77
clotrimazole............................ 53
clotrimazole 3 day .................. 53
clotrimazole-7 ........................ 53
clotrimazole-betamethasone .. 53
clozapine ................................ 64
COARTEM ............................ 63
codeine sulfate ....................... 19
codituss dm ............................ 95
colace ................................... 124
colchicine ............................. 138
colchicine-probenecid .......... 138
cold & cough .......................... 57
cold multi-symptom day/night95
cold relief m/s day/night ........ 95
cold-flu relief.......................... 95
cold-flu relief, day/night ........ 95
colestipol ................................ 84
colistin (colistimethate na) ..... 30
colocort................................. 107
COLY-MYCIN S ................. 116
COMBIGAN ........................ 141
COMBIPATCH ................... 128
COMBIVENT RESPIMAT . 150
COMETRIQ ........................... 38
comfort gel extra strength .... 121
COMPLERA .......................... 67
complete 50+ ........................ 158
complete multi 50+ .............. 158
complete multivitamin ......... 158
complete multivitamin-mineral
.......................................... 158
complete senior .................... 158
compoz ................................... 57
compro ................................... 61
COMVAX (PF) .................... 133
CONDYLOX ....................... 104
congestac ................................ 95
constulose ............................. 121
COPAXONE ........................ 138
coricidin hbp .......................... 95
coricidin hbp cold-multi sympt
............................................ 95
cormax .................................. 107
cortisone ............................... 129
cortizone-10 ................. 107, 108
CORTIZONE-10 .................. 108
COSENTYX (2 SYRINGES)
.......................................... 104
COSENTYX PEN ................ 104
COSENTYX PEN (2 PENS) 104
cough & cold .......................... 95
cough & runny nose ............... 95
CREON ................................ 111
CRESTOR.............................. 84
critic-aid clear af .................... 53
I-6
CRIXIVAN ............................ 67
cromolyn .............. 113, 121, 151
cryselle (28) ............................ 89
CUBICIN ............................... 30
cyanocobalamin (vitamin b-12)
.......................................... 158
cyclafem 1/35 (28) ................. 89
cyclafem 7/7/7 (28) ................ 89
cyclobenzaprine.................... 151
CYCLOGYL ........................ 113
cyclopentolate ...................... 113
cyclophosphamide ............ 38, 39
CYCLOPHOSPHAMIDE ...... 38
CYCLOSET ........................... 49
cyclosporine ......................... 132
cyclosporine modified .......... 132
cyproheptadine ....................... 57
CYRAMZA ............................ 39
CYSTADANE...................... 138
CYSTARAN ........................ 113
cysteine (l-cysteine) ............... 75
cytra-2 .................................. 143
cytra-3 .................................. 143
D
d10 % & 0.45 % sodium
chloride ............................. 143
d10 %-0.9 % sodium chloride 75
d2.5 %-0.45 % sodium chloride
.......................................... 144
d5 % and 0.9 % sodium chloride
.......................................... 144
.......................................... 144
dactinomycin .......................... 39
daily gummies ...................... 158
daily multiple ....................... 158
daily multi-vitamin ............... 158
daily multivitamin with iron. 158
daily multi-vitamins/iron ...... 158
daily teen multi-vitamin ....... 159
daily value ............................ 159
daily vitamin......................... 159
01 de enero 2016
daily vitamin formula ........... 159
daily vitamin formula + iron 159
daily vitamin formula-minerals
.......................................... 159
daily vitamin with iron ......... 159
daily vites/iron ..................... 159
dailyhist-1 .............................. 57
daily-vite .............................. 159
DALIRESP .......................... 151
danazol ................................. 128
dantrolene ............................. 151
dapsone .................................. 61
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 133
DARAPRIM .......................... 63
dasetta 1/35 (28) ..................... 89
dasetta 7/7/7 (28).................... 89
dayhist allergy ........................ 57
daysee ..................................... 89
daytime cold & cough ............ 95
daytime cold-flu ..................... 96
day-time cough....................... 96
daytime-nighttime .................. 96
daytime-nighttime cold-flu .... 96
daytime-nighttime cough ....... 96
deblitane ................................. 89
decitabine ............................... 39
decongestant cough ................ 96
deep sea nasal ....................... 113
deferoxamine........................ 127
delsym cough+chest congest dm
............................................ 96
delyla (28) .............................. 89
DELZICOL .......................... 135
DEMSER ............................... 81
depade .................................... 27
DEPEN TITRATABS .......... 127
DEPO-PROVERA ............... 130
dermafungal ........................... 53
dermarest eczema (hydrocort)
.......................................... 108
desipramine ............................ 48
desmopressin ................ 129, 130
desog-e.estradiol/e.estradiol ... 89
desogestrel-ethinyl estradiol .. 89
desonide ............................... 108
desoximetasone .................... 108
despec-dm (pseudoeph-dmguaif) .................................. 96
dex4 glucose ........................... 75
dexamethasone ..................... 129
dexamethasone sodium
phosphate ................. 117, 129
dexmethylphenidate ............... 86
dextroamphetamine ................ 87
dextroamphetamineamphetamine ...................... 87
dextromethorphan polistirex .. 96
dextrose 10 % and 0.2 % nacl
.......................................... 144
............................................ 75
dextrose 2.5 % in water(d2.5w)
............................................ 76
............................................ 76
............................................ 76
............................................ 76
dextrose 5 % in ringers........... 76
dextrose 5 % in water (d5w) .. 76
dextrose 5 %-lactated ringers144
dextrose 5%-0.2 % sod chloride
.......................................... 144
dextrose 5%-0.3 % sod.chloride
.......................................... 144
............................................ 76
............................................ 76
dextrose with sodium chloride
.......................................... 144
diabetic siltussin das-na ......... 96
I-7
diabetic tussin dm ................... 96
diabetic tussin max st ............. 96
diamode ................................ 121
diazepam .......................... 28, 29
diazepam intensol ................... 28
diclofenac potassium .............. 24
diclofenac sodium .......... 24, 117
diclofenac-misoprostol ........... 24
dicloxacillin ............................ 35
dicyclomine .......................... 121
didanosine .............................. 67
DIFICID ................................. 33
diflunisal ................................. 24
digitek ..................................... 81
digox ....................................... 81
digoxin.................................... 81
DIGOXIN ............................... 81
dihydroergotamine ................. 60
DILANTIN ............................. 44
diltiazem hcl ........................... 80
dilt-xr ...................................... 80
dimaphen (pe)......................... 57
dimenhydrinate ....................... 61
dimetapp cold-congestion ...... 57
dino-life ................................ 159
dino-life with extra c ............ 159
dino-life with iron-zinc ........ 159
DIPENTUM ......................... 135
diphenhist ............................... 57
diphenhydramine hcl .............. 58
diphenoxylate-atropine ......... 121
disopyramide phosphate ......... 79
disulfiram ............................... 27
divalproex ......................... 44, 45
dobutamine ............................. 82
dobutamine in d5w ................. 82
doc-q-lace ............................. 124
docu ...................................... 124
docusate calcium .................. 124
docusate sodium ................... 124
docusol ................................. 124
dok ........................................ 124
01 de enero 2016
donepezil ................................ 47
dopamine ................................ 82
dopamine in 5 % dextrose ...... 82
dorzolamide.......................... 141
dorzolamide-timolol............. 141
douche vinegar & water extra
.......................................... 138
doxazosin ............................... 77
doxepin................................... 48
doxercalciferol ..................... 136
doxorubicin, peg-liposomal ... 39
doxy-100 ................................ 37
doxycycline hyclate ............... 37
doxycycline monohydrate ...... 37
dramamine.............................. 61
driminate ................................ 61
dristan long lasting ............... 113
dronabinol .............................. 61
droperidol ............................. 138
drospirenone-ethinyl estradiol 89
DROXIA ................................ 39
DUAVEE ............................. 128
dulcolax stool softener (dss) 124
DULERA ............................. 149
duloxetine............................... 48
DUREZOL ........................... 117
DYRENIUM .......................... 84
E
e.c. prin................................... 24
e.e.s. 400 ................................ 33
e.e.s. granules ......................... 33
econazole................................ 53
econtra ez ............................... 89
ed a-hist .................................. 58
ed a-hist dm ............................ 96
ed bron gp .............................. 96
ed chlorped jr ......................... 58
EDURANT ............................ 67
effer-k ................................... 144
EFFIENT................................ 73
ELAPRASE ......................... 111
eldertonic.............................. 159
electrolyte-48 in d5w ........... 144
ELIDEL ................................ 108
ELIGARD .............................. 39
elinest ..................................... 89
eliphos .................................. 126
ELIQUIS ................................ 70
ELITEK ................................ 111
ELLA ..................................... 89
ellis tonic .............................. 159
ELMIRON ........................... 138
elon dual defense .................... 53
EMCYT.................................. 39
EMEND ........................... 61, 62
emoquette ............................... 89
EMSAM ................................. 48
EMTRIVA ............................. 67
enalapril maleate .................... 78
enalaprilat ............................... 78
enalapril-hydrochlorothiazide 78
ENBREL .............................. 132
ENBREL SURECLICK ....... 132
endocet ................................... 19
endodan .................................. 19
endur-acin............................... 84
enema ................................... 124
enema disposable ................. 124
enemeez ................................ 124
enemeez plus ........................ 124
ENGERIX-B (PF) ................ 133
ENGERIX-B PEDIATRIC (PF)
.......................................... 133
enoxaparin .............................. 70
enpresse .................................. 89
enskyce ................................... 89
entacapone .............................. 63
entecavir ................................. 70
entre-cough............................. 96
enulose ................................. 121
ephedrine sulfate .................... 82
epinastine ............................. 113
epinephrine ............................. 82
EPIPEN 2-PAK ...................... 82
I-8
EPIPEN JR 2-PAK................. 82
epitol ....................................... 45
EPIVIR HBV ......................... 67
eplerenone .............................. 85
EPOGEN ................................ 72
epoprostenol (glycine) .......... 153
EPZICOM .............................. 67
eq gentle ............................... 113
equalactin ............................. 124
ergocalciferol (vitamin d2) ... 159
ergoloid ................................ 138
ERGOMAR ............................ 60
ERIVEDGE ............................ 39
errin ........................................ 89
ery pads ................................ 105
ery-tab .................................... 34
ERY-TAB .............................. 34
ERYTHROCIN ...................... 34
erythrocin (as stearate) ........... 34
erythromycin .................. 34, 116
erythromycin ethylsuccinate .. 34
erythromycin with ethanol .. 105,
106
ESBRIET.............................. 151
escitalopram oxalate ............... 48
esmolol ................................... 79
esomeprazole sodium ........... 118
essentia ................................. 159
essential balance with lutein. 159
essential daily ....................... 159
estarylla .................................. 89
ESTRACE ............................ 128
estradiol ................................ 128
estradiol valerate .................. 128
estradiol-norethindrone acet . 128
estropipate ............................ 128
ethambutol .............................. 61
ethamolin ................................ 82
ethosuximide .......................... 45
etodolac .................................. 24
ETOPOPHOS ......................... 39
etoposide ................................ 39
01 de enero 2016
EVOTAZ................................ 67
exemestane ............................. 39
EXJADE .............................. 127
expectorant ............................. 96
expectorant dm ....................... 96
expectorant max strength ....... 96
EXTAVIA ............................ 138
extra cleansing douche ......... 138
F
FABRAZYME ..................... 111
falmina (28) ............................ 89
famciclovir ............................. 70
famotidine ............................ 119
famotidine (pf) ..................... 118
famotidine (pf)-nacl (iso-os) 119
FANAPT ................................ 64
FARESTON ........................... 39
FARYDAK ............................ 39
FASLODEX ........................... 39
felbamate ................................ 45
felodipine ............................... 83
feminine care douche ........... 138
FEMRING............................ 128
fenofibrate .............................. 85
fenofibrate micronized ........... 84
fenofibrate nanocrystallized ... 84
fenofibric acid ........................ 85
fenofibric acid (choline) ......... 85
fenoprofen .............................. 24
fentanyl .................................. 19
fentanyl citrate ....................... 19
ferocon ................................. 159
ferotrinsic ............................. 159
ferretts .................................. 159
ferrex 150 ............................. 160
ferrex 150 plus ..................... 160
FERRIPROX........................ 127
ferrocite ................................ 160
ferrous fumarate ................... 160
ferrous gluconate .................. 160
ferrous sulfate....................... 160
FETZIMA .............................. 48
feverall ................................... 19
fexofenadine ........................... 58
fiber (calcium polycarbophil)
.......................................... 124
fiber laxative (methylcellulo)124
fiber smooth ......................... 124
fiber therapy ......................... 124
fiber therapy (psyllium/sugar)
.......................................... 124
fiber-lax ................................ 124
finasteride ............................. 138
FIRAZYR............................... 82
flanax antacid ....................... 121
FLEBOGAMMA DIF .......... 132
flecainide ................................ 79
FLECTOR .............................. 25
FLEET BISACODYL .......... 124
FLEXBUMIN 25 % ............... 73
FLEXBUMIN 5 % ................. 74
flintstones complete (iron) ... 160
flintstones multivitamin ....... 160
flintstones with iron ............. 160
flintstones/extra c ................. 160
FLOVENT DISKUS ............ 149
FLOVENT HFA .................. 149
floxuridine .............................. 39
flu formula daytime-nighttime96
flu severe cold-congestion ..... 97
flucaine ................................. 113
fluconazole ............................. 53
fluconazole in dextrose(iso-o) 53
fluconazole in nacl (iso-osm) . 54
flucytosine .............................. 54
fludrocortisone ..................... 129
flumazenil............................... 87
flunisolide............................. 117
fluocinonide ......................... 108
fluocinonide-e ...................... 108
fluorometholone ................... 117
FLUOROPLEX .................... 104
fluorouracil ..................... 39, 104
fluoxetine ............................... 48
I-9
fluphenazine decanoate .......... 64
fluphenazine hcl ..................... 65
flurbiprofen ............................ 25
flurbiprofen sodium .............. 117
flu-severe cold-cough daytime97
flutamide ................................ 39
fluticasone .................... 108, 117
fluvoxamine............................ 48
foaming antacid .................... 121
folic acid ............................... 160
FOLIC ACID ....................... 160
fomepizole ............................ 138
fondaparinux .......................... 71
FORTEO .............................. 136
FORTICAL .......................... 136
foscarnet ................................. 69
fosfree ................................... 160
fosinopril ................................ 78
fosinopril-hydrochlorothiazide
............................................ 78
fosphenytoin ........................... 45
FREAMINE HBC 6.9 % ........ 76
FREAMINE III 10 % ............. 76
fungi cure ............................... 54
FUNGI-NAIL......................... 54
fungoid-d ................................ 54
furosemide .............................. 84
FUSILEV ............................. 138
FUZEON ................................ 67
FYCOMPA ............................ 45
G
gabapentin .............................. 45
GABITRIL ............................. 45
galantamine ............................ 47
GAMASTAN S/D ................ 132
GAMMAGARD LIQUID .... 132
GAMMAPLEX .................... 132
ganciclovir sodium ................. 70
GARDASIL (PF) ................. 133
GARDASIL 9 (PF) .............. 133
gas relief ............................... 118
gas relief extra strength ........ 118
01 de enero 2016
gas-x ultra-strength .............. 118
gatifloxacin .......................... 116
GATTEX 30-VIAL .............. 121
GATTEX ONE-VIAL ......... 121
GAUZE PAD ....................... 138
gavilyte-c.............................. 124
gavilyte-g ............................. 125
gavilyte-n ............................. 125
GAZYVA ............................... 39
gelusil antacid & anti-gas..... 121
gemfibrozil ............................. 85
generlac ................................ 121
gengraf ................................. 132
GENOTROPIN .................... 130
GENOTROPIN MINIQUICK
.......................................... 130
gentak ................................... 116
gentamicin .............. 29, 106, 116
gentamicin in nacl (iso-osm) .. 29
gentamicin sulfate (ped) (pf) .. 29
gentamicin sulfate (pf) ........... 29
GENTEAL MILD TO
MODERATE ................... 113
GENTEAL GEL .................. 113
GENTEAL MILD ................ 113
GENTEAL SEVERE ........... 113
gentlelax ............................... 125
GEODON ............................... 65
geravim ................................ 161
geriaton ................................ 161
geri-hydrolac ........................ 104
gianvi (28) .............................. 89
gildagia ................................... 89
gildess .................................... 89
gildess 24 fe ........................... 89
gildess fe ................................ 89
GILENYA ............................ 138
GILOTRIF ............................. 39
GLEEVEC ....................... 39, 40
glimepiride ............................. 51
glipizide.................................. 51
glipizide-metformin ............... 51
GLUCAGEN HYPOKIT ..... 138
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 138
gluco burst .............................. 76
glucose ................................... 76
glucose gel.............................. 76
glutose 15 ............................... 76
glyburide ................................ 52
glyburide micronized ............. 52
glyburide-metformin .............. 52
glycolax ................................ 125
glycopyrrolate ...................... 121
glydo....................................... 26
GLYXAMBI .......................... 49
granisetron (pf) ....................... 62
granisetron hcl ........................ 62
GRANIX ................................ 72
griseofulvin microsize ............ 54
guaifenesin ............................. 97
guaifenesin dac ....................... 97
guanfacine ........................ 77, 87
guanidine .............................. 138
gummi bear multivitamin ..... 161
gummy swirls ....................... 161
H
hair vitamins ......................... 161
hair,skin & nails ................... 161
halobetasol propionate ......... 108
haloperidol ............................. 65
haloperidol decanoate ............ 65
haloperidol lactate .................. 65
HARVONI ............................. 69
HAVRIX (PF) ...................... 133
head congestion day-night ..... 97
healthy eyes .......................... 161
healthylax ............................. 125
heather .................................... 89
hemocyte .............................. 161
heparin (porcine) .................... 71
heparin (porcine) in 5 % dex . 71,
72
heparin (porcine) in nacl (pf) . 71
I-10
heparin lockflush(porcine)(pf) 71
heparin(porcine) in 0.45% nacl
............................................ 71
heparin, porcine (pf) ............... 71
HEPATAMINE 8% ............... 76
HEPATASOL 8 % ................. 76
HERCEPTIN .......................... 40
HETLIOZ ............................. 151
HEXALEN ............................. 40
hi-b complex......................... 161
hi-cal plus vit d ..................... 144
high potency multivit-multimin
.......................................... 161
homatropaire ........................ 113
homatropine hbr ................... 113
honey bears........................... 161
honey bears with iron-zinc ... 161
HUMIRA.............................. 132
HUMIRA CROHN'S DIS
START PCK .................... 132
HUMIRA PEN ..................... 132
HUMULIN R U-500 .............. 51
hydralazine ............................. 82
hydro skin ............................. 108
hydrochlorothiazide................ 84
hydrocil instant ..................... 125
hydrocodone-acetaminophen 19,
20
hydrocodone-chlorpheniramine
............................................ 97
hydrocodone-homatropine ..... 97
hydrocodone-ibuprofen .......... 20
hydrocortisone ...... 108, 109, 129
hydrocortisone acet-aloe vera
.......................................... 108
hydrocortisone acetate .......... 108
hydrocortisone butyrate ........ 108
hydrocortisone butyr-emollient
.......................................... 109
hydrocortisone valerate ........ 109
hydromet ................................ 97
hydromorphone ...................... 20
01 de enero 2016
hydromorphone (pf) ............... 20
hydroxychloroquine ............... 63
hydroxyurea ........................... 40
hydroxyzine hcl ............ 138, 139
hydroxyzine pamoate ........... 139
HYPERLYTE CR ................ 144
HYQVIA .............................. 132
I
ibandronate ........................... 136
IBRANCE .............................. 40
ibuprofen ................................ 25
ibuprofen jr strength ............... 25
icaps plus .............................. 161
ICLUSIG ................................ 40
iferex 150 ............................. 161
ifosfamide .............................. 40
ifosfamide-mesna ................... 40
ILARIS (PF)......................... 132
ILEVRO ............................... 117
IMBRUVICA ......................... 40
imipenem-cilastatin ................ 34
imipramine hcl ....................... 48
imipramine pamoate............... 48
imiquimod ............................ 104
imodium a-d ......................... 121
IMOGAM RABIES-HT (PF)
.......................................... 132
IMOVAX RABIES VACCINE
(PF) .................................. 133
INCRELEX .......................... 130
indapamide ............................. 84
indomethacin .......................... 25
indomethacin sodium ............. 25
INFANRIX (DTAP) (PF) .... 133
infant's ibuprofen ................... 25
INFANT'S MOTRIN ............. 25
infants' non-aspirin cold ......... 97
INLYTA ................................. 40
insta-glucose .......................... 76
INSULIN PEN NEEDLE .... 111
INSULIN SYRINGE-NEEDLE
U-100 ............................... 111
INTELENCE .......................... 67
INTRALIPID ......................... 76
INTRON A ............................. 69
introvale ................................. 89
INVANZ ................................ 34
INVEGA ................................ 65
INVEGA SUSTENNA .......... 65
INVEGA TRINZA ........... 65, 66
INVIRASE ............................. 67
INVOKAMET ....................... 49
INVOKANA .......................... 50
inzo antifungal........................ 54
iodine.................................... 111
IONOSOL-B IN D5W ......... 144
IONOSOL-MB IN D5W ...... 144
IPOL ..................................... 133
ipratropium bromide ............ 113
IPRIVASK ............................. 72
irbesartan ................................ 77
irbesartan-hydrochlorothiazide
............................................ 77
iron high potency ................. 161
ISENTRESS ........................... 68
ISOLYTE M IN 5 %
DEXTROSE ..................... 144
ISOLYTE-H IN 5 %
DEXTROSE ..................... 144
ISOLYTE-P IN 5 %
DEXTROSE ..................... 144
ISOLYTE-S ......................... 144
isoniazid ................................. 61
isopto tears ........................... 113
isosorbide dinitrate ................. 85
isosorbide mononitrate ..... 85, 86
isradipine ................................ 83
itraconazole ............................ 54
ivermectin............................... 63
IXEMPRA .............................. 40
IXIARO (PF)........................ 134
J
JAKAFI .................................. 40
JALYN ................................. 139
I-11
jantoven .................................. 72
JANUMET ............................. 50
JANUMET XR....................... 50
JANUVIA .............................. 50
JARDIANCE.......................... 50
jencycla .................................. 89
JENTADUETO ...................... 50
jolessa ..................................... 89
jolivette ................................... 90
junel 1.5/30 (21) ..................... 90
junel 1/20 (21) ........................ 90
junel fe 1.5/30 (28) ................. 90
junel fe 1/20 (28) .................... 90
junel fe 24 ............................... 90
junior mapap........................... 20
JUXTAPID ............................. 85
K
KABIVEN .............................. 76
KALETRA ............................. 68
KALYDECO ........................ 151
kaopectate (bismuth subsalicy)
.......................................... 121
kariva (28) .............................. 90
KEDBUMIN .......................... 74
k-effervescent ....................... 144
kelnor 1/35 (28) ...................... 90
KELP (IODINE) .................. 144
ketoconazole ........................... 54
ketoprofen .............................. 25
ketorolac ......................... 25, 117
KEYTRUDA .......................... 40
kid's vitamins........................ 161
kid's vitamins + extra c......... 161
kids vitamins + iron.............. 161
kid's vitamins + iron ............. 161
KINERET ............................. 132
KINRIX (PF) ........................ 134
kionex ................................... 122
klor-con 10 ........................... 144
klor-con m10 ........................ 145
klor-con m15 ........................ 145
klor-con m20 ........................ 145
01 de enero 2016
konsyl (sugar)....................... 125
konsyl fiber .......................... 125
KONSYL SUGAR-FREE.... 125
KORLYM .............................. 50
KRYSTEXXA ..................... 111
kurvelo ................................... 90
KUVAN ............................... 111
KYNAMRO ........................... 85
KYPROLIS ............................ 40
L
l norgest/e.estradiol-e.estrad .. 90
labetalol .................................. 79
LACRISERT ........................ 114
LACTATED RINGERS ...... 135
LACTINOL HX ................... 104
lactulose ............................... 122
LAMICTAL ........................... 45
LAMISIL (AEROSOL) ......... 54
lamisil af................................. 54
LAMISIL AT ......................... 54
lamivudine.............................. 68
lamivudine-zidovudine .......... 68
lamotrigine ............................. 45
LANOXIN ............................. 82
lansoprazole ......................... 119
LANTUS ................................ 51
LANTUS SOLOSTAR .......... 51
larin 1.5/30 (21) ..................... 90
larin 1/20 (21) ........................ 90
larin 24 fe ............................... 90
larin fe .................................... 90
latanoprost ............................ 141
LATUDA ............................... 66
laxative peg 3350 ................. 125
LAZANDA ............................ 20
leena 28 .................................. 90
leflunomide .......................... 132
LEMTRADA ....................... 139
LENVIMA ............................. 40
lessina..................................... 90
LETAIRIS ............................ 153
letrozole.................................. 40
leucovorin calcium ............... 139
LEUKERAN .......................... 40
LEUKINE .............................. 72
leuprolide ............................... 40
levetiracetam .......................... 45
levobunolol........................... 141
levocarnitine ......................... 139
levocarnitine (with sugar) .... 139
levocetirizine .......................... 58
levofloxacin .................... 36, 116
levofloxacin in d5w ................ 36
levonest (28) ........................... 90
levonorgestrel ......................... 90
levonorgestrel-ethinyl estrad .. 90
levora-28 ................................ 90
levothyroxine ....................... 131
LEXIVA ................................. 68
lice cream rinse .................... 110
lice killing ............................ 110
lice treatment ........................ 110
lidocaine ........................... 26, 27
lidocaine (pf) .................... 26, 79
lidocaine hcl ........................... 26
lidocaine in 5 % dextrose (pf) 79
lidocaine viscous .................... 27
lidocaine-prilocaine ................ 27
life-pack women's ................ 161
linezolid.................................. 30
LINZESS .............................. 122
liothyronine .......................... 131
lipodox ................................... 41
LIPOSYN II ........................... 76
LIPOSYN III .......................... 76
liquibid d-r.............................. 97
liquid calcium with vitamin d
.......................................... 145
LIQUI-E ............................... 162
lisinopril ................................. 78
lisinopril-hydrochlorothiazide 78
lithium carbonate.................... 87
lithium citrate ......................... 87
little animals ......................... 162
I-12
little animals-iron ................. 162
lobana bath ........................... 104
lohist-dm ................................ 97
lomedia 24 fe .......................... 90
lomustine ................................ 41
loperamide ............................ 122
loradamed ............................... 58
loratadine ................................ 58
loratadine-d ............................ 58
lorazepam ............................... 29
lorcet (hydrocodone) .............. 20
lorcet hd .................................. 20
lorcet plus ............................... 20
lortuss ex ................................ 97
loryna (28) .............................. 90
losartan ................................... 78
losartan-hydrochlorothiazide.. 78
LOTEMAX .......................... 117
LOTRONEX ........................ 122
lovastatin ................................ 85
low-ogestrel (28) .................... 90
loxapine succinate .................. 66
lubricant dry eye relief ......... 114
lubricant eye (cmc-glycer)(pf)
.......................................... 114
lubricant eye (cmc-glycerin) 114
lubricant eye (pg-peg 400) ... 114
lubricant eye (polyv alcohol) 114
lubricant eye (propyl glycol) 114
lubricant eye drops ............... 114
lubricant gel .......................... 114
lubricating drops................... 114
lubrifresh pm ........................ 114
LUMIGAN ........................... 141
LUPRON DEPOT .................. 41
............................................ 41
............................................ 41
............................................ 41
LUPRON DEPOT-PED ....... 130
01 de enero 2016
LUPRON DEPOT-PED (3
MONTH).......................... 130
lutera (28) ............................... 90
LYNPARZA .......................... 41
LYRICA ........................... 45, 46
lysiplex plus ......................... 162
LYSODREN .......................... 41
lyza ......................................... 91
M
maalox advanced .................. 122
MACUVITE ........................ 162
MACUVITE EYE CARE .... 162
mag 64 .................................. 145
mag-delay............................. 145
mag-g ................................... 145
MAGNEBIND 300 .............. 122
magnebind 400 ..................... 126
magnesium ........................... 145
magnesium (oxide/aa chelate)
.......................................... 145
magnesium chloride ............. 145
magnesium gluconate........... 145
magnesium oxide ................. 122
magnesium sulfate ............... 145
magnesium sulfate in d5w ... 145
magnesium sulfate in water . 145
malathion.............................. 110
mapap (acetaminophen) ......... 20
mapap arthritis pain................ 21
mapap extra strength .............. 21
maprotiline ............................. 48
mar-cof bp .............................. 97
mar-cof cg .............................. 97
margesic ................................. 21
marlissa .................................. 91
MARPLAN ............................ 48
masanti double strength ....... 122
MATULANE ......................... 41
matzim la................................ 80
maximum daily multivitamin
.......................................... 162
maximum strength flu ............ 97
meclizine ................................ 62
medi-brom .............................. 97
medroxyprogesterone ........... 131
mefenamic acid ...................... 25
mefloquine ............................. 63
MEFOXIN IN DEXTROSE
(ISO-OSM)......................... 33
mega multiple/chelated mineral
.......................................... 162
mega multivitamin with mineral
.......................................... 162
MEGACE ES ....................... 131
megestrol ........................ 41, 131
MEKINIST............................. 41
meloxicam .............................. 25
MENACTRA (PF) ............... 134
MENEST .............................. 128
MENHIBRIX (PF) ............... 134
MENOMUNE - A/C/Y/W-135
(PF)................................... 134
men's multi-vitamin ............. 162
men's one daily ..................... 162
MENVEO A-C-Y-W-135-DIP
(PF)................................... 134
MENVEO MENA
COMPONENT (PF) ......... 134
MENVEO MENCYW-135
COMPNT (PF) ................. 134
MEPHYTON ....................... 162
mercaptopurine....................... 41
meropenem ............................. 34
mesehist dm............................ 97
mesna ................................... 139
MESNEX ............................. 139
MESTINON ......................... 139
MESTINON TIMESPAN .... 139
metaproterenol ..................... 150
metaxalone ........................... 151
metformin ............................... 50
methadone .............................. 21
methadose............................... 21
methazolamide ..................... 141
I-13
methenamine hippurate .......... 30
methenamine mandelate ......... 30
methimazole ......................... 131
methocarbamol ..................... 151
methotrexate sodium .............. 41
methotrexate sodium (pf) ....... 41
methoxsalen rapid ................ 104
methscopolamine.................. 122
methyclothiazide .................... 84
methylphenidate ............... 87, 88
methylprednisolone .............. 129
methylprednisolone acetate .. 129
.......................................... 129
metipranolol ......................... 141
metoclopramide hcl .............. 122
metolazone ............................. 84
metoprolol succinate .............. 80
metoprolol ta-hydrochlorothiaz
............................................ 80
metoprolol tartrate .................. 80
metronidazole ........... 30, 60, 106
metronidazole in nacl (iso-os) 30
mexiletine ............................... 79
mgo ....................................... 122
MIACALCIN ....................... 136
mi-acid.................................. 122
mi-acid gas relief .................. 118
micatin .................................... 54
miconazole 7 .......................... 54
miconazole nitrate .................. 54
miconazole-3 .......................... 54
microgestin 1.5/30 (21) .......... 91
microgestin 1/20 (21) ............. 91
microgestin fe 1.5/30 (28) ...... 91
microgestin fe 1/20 (28) ......... 91
midodrine ............................... 77
milk of magnesia .................. 125
milltrium senior .................... 162
milrinone ................................ 83
milrinone in 5 % dextrose ...... 83
mimvey................................. 128
01 de enero 2016
mimvey lo ............................ 128
mineral oil ............................ 139
MINERAL OIL .................... 139
mineral oil laxative .............. 125
minitran .................................. 86
minocycline ............................ 37
minoxidil ................................ 86
mintox .................................. 122
mintox maximum strength ... 122
mintox plus........................... 122
MIRCERA ............................. 72
mirtazapine ............................. 48
misoprostol........................... 119
mitoxantrone .......................... 41
M-M-R II (PF) ..................... 134
moexipril ................................ 78
moexipril-hydrochlorothiazide
............................................ 78
mometasone ......................... 109
MONISTAT 3 ........................ 54
monistat 7 ............................... 55
mono-linyah ........................... 91
mononessa (28) ...................... 91
montelukast .......................... 149
morphine ................................ 21
MORPHINE ........................... 21
morphine concentrate ............. 21
morrhuate sodium ................ 139
MOVANTIK ........................ 123
MOVIPREP ......................... 125
MOXEZA ............................ 116
moxifloxacin .......................... 36
MOZOBIL ............................. 72
mucinex fast-max nite (doxyl) 97
mucinex fast-max sev cld-sinus
............................................ 98
mucus dm ............................... 98
mucus dm max ....................... 98
mucus relief ............................ 98
mucus relief cough ................. 98
MULTAQ .............................. 79
multi complete with iron ...... 162
multi-day with iron............... 162
multi-delyn with iron ........... 162
multiple vitamin-minerals .... 162
multiple vitamins.................. 162
multiple vitamins with iron .. 162
multi-symptom cold night time
............................................ 98
multi-symptom cold-cough .... 98
multivital platinum ............... 162
multivitamin 50 plus ............ 163
multi-vitamin hp/minerals .... 163
multivitamin with fluoride ... 163
multivitamin with iron ......... 163
multivitamin with minerals .. 163
multi-vite .............................. 163
multi-vite 50 & over ............. 163
mupirocin ............................. 106
mupirocin calcium................ 106
muro 128 .............................. 114
my favorite multiple ............. 163
my way ................................... 91
myco nail a ............................. 55
mycophenolate mofetil ......... 132
mycophenolate sodium ........ 132
MYOZYME ......................... 111
MYRBETRIQ .............. 126, 127
mytab gas ............................. 118
mytab gas maximum strength
.......................................... 118
my-vitalife ............................ 163
myzilra ................................... 91
N
nabumetone ............................ 25
nadolol .................................... 80
nafcillin .................................. 35
NAGLAZYME .................... 111
naloxone ................................. 27
naltrexone ............................... 27
NAMENDA XR ..................... 47
NAMZARIC .......................... 47
naphazoline .......................... 114
naproxen ........................... 25, 26
I-14
naproxen sodium .................... 26
naratriptan .............................. 60
nasal & sinus decongestant .... 98
nasal decongestant (oxymetazl)
.......................................... 114
NASCOBAL ........................ 163
NATACYN .......................... 116
nateglinide .............................. 50
NATPARA ........................... 136
natural b-100 ........................ 163
natural b-100 complex.......... 163
natural balance ..................... 114
natural calcium ..................... 145
natural fiber laxative therapy 125
natural tears (pf) ................... 114
nature's tears ......................... 114
NEBUPENT ........................... 63
necon 0.5/35 (28) ................... 91
necon 1/35 (28) ...................... 91
necon 1/50 (28) ...................... 91
necon 10/11 (28) .................... 91
necon 7/7/7 (28) ..................... 91
nefazodone ............................. 48
neomycin ................................ 29
neomycin-bacitracin-poly-hc 116
neomycin-bacitracin-polymyxin
.......................................... 116
neomycin-polymyxin b gu ... 106
neomycin-polymyxin bdexameth .......................... 116
neomycin-polymyxingramicidin ........................ 116
neomycin-polymyxin-hc ...... 116
neo-polycin ........................... 116
neo-polycin hc ...................... 116
neosporin (neo-bac-polym) .. 106
neosporin anti-itch ................ 109
neo-synephrine 12 h spr (oxym)
.......................................... 114
neo-tuss .................................. 98
nephplex rx ........................... 163
NEPHRAMINE 5.4 % ........... 76
01 de enero 2016
nephron fa ............................ 163
nephro-vite rx ....................... 163
NEULASTA .......................... 72
NEUMEGA............................ 72
NEUPOGEN .......................... 72
NEUPRO................................ 63
NEVANAC .......................... 118
nevirapine ............................... 68
NEXAFED ............................. 98
NEXAVAR ............................ 41
next choice one dose .............. 91
niacin ...................................... 85
niacinamide .................... 85, 164
niacor...................................... 85
nicardipine.............................. 83
NICODERM CQ .............. 27, 28
nicorelief ................................ 28
nicorette.................................. 28
nicotine................................... 28
nicotine (polacrilex) ............... 28
NICOTROL ........................... 28
nifedical xl ............................. 83
nifedipine ............................... 83
night time ............................... 98
night time cold-flu.................. 98
night time cold-flu relief ........ 98
nighttime cough ..................... 98
nighttime relief eye .............. 114
nikki (28)................................ 91
NILANDRON ........................ 41
NITE TIME COLD-FLU
RELIEF .............................. 98
nite time-d cold-flu relief ....... 98
NITRO-BID ........................... 86
nitrofurantoin macrocrystal .... 30
nitrofurantoin monohyd/m-cryst
............................................ 31
nitroglycerin ........................... 86
nitroglycerin in 5 % dextrose . 86
NITROSTAT ......................... 86
nohist-dm ............................... 98
non-aspirin cold ..................... 99
non-aspirin extra strength....... 21
non-aspirin flu ........................ 99
non-aspirin jr strength ............ 21
nora-be ................................... 91
NORDITROPIN FLEXPRO 130
NORDITROPIN NORDIFLEX
.......................................... 130
norepinephrine bitartrate ........ 83
norethindrone (contraceptive) 91
norethindrone acetate ........... 131
norethindrone ac-eth estradiol 91
norethindrone-e.estradiol-iron 91
norgestimate-ethinyl estradiol 91
norlyroc .................................. 91
NORMOSOL-M IN 5 %
DEXTROSE ..................... 145
NORMOSOL-R PH 7.4 ....... 146
nortemp .................................. 21
NORTHERA .......................... 77
nortrel 0.5/35 (28) .................. 91
nortrel 1/35 (21) ..................... 91
nortrel 1/35 (28) ..................... 91
nortrel 7/7/7 (28) .................... 91
nortriptyline ............................ 48
NORVIR ................................ 68
NOVOLIN 70/30 ................... 51
NOVOLIN N.......................... 51
NOVOLIN R .......................... 51
NOVOLOG ............................ 51
NOVOLOG FLEXPEN ......... 51
NOVOLOG MIX 70-30 ......... 51
NOVOLOG MIX 70-30
FLEXPEN .......................... 51
NOVOLOG PENFILL ........... 51
NOXAFIL .............................. 55
NUCYNTA ............................ 21
NUCYNTA ER ...................... 22
NUEDEXTA .......................... 88
nu-iron .................................. 164
NULOJIX ............................. 132
NUTRESTORE .................... 123
NUTRILIPID ......................... 77
I-15
NUTRILYTE ....................... 146
NUTRILYTE II .................... 146
NUVARING .......................... 91
NUVIGIL ............................. 151
nyamyc ................................... 55
nystatin ................................... 55
NYSTATIN (BULK) ............. 55
nystatin-triamcinolone............ 55
nystop ..................................... 55
O
ocean nasal ........................... 114
ocella ...................................... 91
OCTAGAM.......................... 132
octreotide acetate .................. 130
ocutabs.................................. 164
OFEV ................................... 151
ofloxacin ......................... 36, 117
ogestrel (28) ........................... 92
olanzapine .............................. 66
olanzapine-fluoxetine ............. 48
OLYSIO ................................. 69
omega-3 acid ethyl esters ....... 85
omeprazole ........................... 119
omeprazole magnesium ........ 119
omeprazole-sodium bicarbonate
.......................................... 119
ONCASPAR .......................... 41
oncovite ................................ 164
ondansetron ............................ 62
ondansetron hcl ...................... 62
ondansetron hcl (pf) ............... 62
one daily ............................... 164
one daily 50 plus .................. 164
one daily complete ............... 164
one daily energy ................... 164
one daily essential ................ 164
one daily maximum (with ca)
.......................................... 164
one daily multi-vit w-mineral
.......................................... 164
one daily multivitamin ......... 164
one daily multivitamin-iron.. 164
01 de enero 2016
one daily plus iron ................ 164
one daily plus minerals ........ 164
one daily with iron ............... 164
one-a-day essential ............... 164
one-a-day maximum formula164
one-a-day teen advantage ..... 165
ONFI .................................... 109
opcicon one-step .................... 92
OPDIVO ................................ 41
OPSUMIT ............................ 153
opti-vitamins ........................ 165
oral saline laxative ............... 125
oralone.................................. 103
ORAP ..................................... 66
ORENCIA ............................ 132
ORENCIA (WITH MALTOSE)
.......................................... 132
ORENITRAM ...................... 153
ORFADIN ............................ 111
orsythia ................................... 92
OTEZLA .............................. 139
OTEZLA STARTER ........... 139
OTREXUP (PF) ................... 139
oxacillin.................................. 35
oxacillin in dextrose(iso-osm) 35
oxandrolone.......................... 128
oxcarbazepine ........................ 46
OXTELLAR XR .................... 46
oxybutynin chloride ............. 127
oxycodone .............................. 22
oxycodone-acetaminophen .... 22
oxycodone-aspirin .................. 22
OXYCONTIN ........................ 22
oxymorphone ......................... 22
oysco 500/d .......................... 146
oysco d ................................. 146
oysco-500 ............................. 146
oyster shell calcium 500....... 146
oyster shell calcium with d .. 146
oyster shell calcium-vit d3 ... 146
oystercal-d ............................ 146
P
pacerone ................................. 79
pain relief ............................... 22
pain relief adult ...................... 22
pain reliever extra strength ..... 22
pain reliever jr strength .......... 22
pancrelipase 5000 ................. 111
PANRETIN .......................... 105
pantoprazole ......................... 119
papaverine .............................. 83
paricalcitol ............................ 136
paromomycin ......................... 63
paroxetine hcl ......................... 49
PASER ................................... 61
PAXIL .................................... 49
pecgen dmx ............................ 99
pedia relief.............................. 99
pedia relief cough-cold........... 99
pedia relief infant ................... 99
pediacare multi-symptom cold99
PEDIARIX (PF) ................... 134
pediatric electrolyte .............. 146
pediatric freezer pops ........... 146
pediatric multivitamin .......... 165
PEDVAX HIB (PF) ............. 134
peg 3350-electrolytes ........... 125
PEGANONE .......................... 46
PEGASYS .............................. 69
PEGASYS PROCLICK ......... 69
peg-electrolyte soln .............. 125
PEGINTRON ......................... 69
penicillin g pot in dextrose ..... 35
penicillin g potassium ............ 35
penicillin g procaine ............... 35
penicillin v potassium ............ 36
PENTACEL (PF) ................. 134
PENTACEL ACTHIB
COMPONENT (PF) ......... 134
PENTACEL DTAP-IPV
COMPNT (PF) ................. 134
PENTAM ............................... 63
pentoxifylline ......................... 73
I-16
pep-t-med ............................. 123
peri-colace ............................ 125
PERIKABIVEN ..................... 77
perindopril erbumine .............. 78
periogard .............................. 103
permethrin ............................ 110
perphenazine .......................... 66
perphenazine-amitriptyline .... 49
persa-gel ............................... 105
pfizerpen-g ............................. 36
pharbetol ........................... 22, 23
pharmacist favorite multi-vit 165
phenadoz ................................ 62
phenelzine .............................. 49
phenobarbital .......................... 46
phenobarbital sodium ............. 46
phenylephrine hcl ........... 77, 115
phenylhistine dh ..................... 99
phenytoin ................................ 46
phenytoin sodium ................... 46
phenytoin sodium extended.... 46
philith ..................................... 92
phillips .................................. 123
phillips liqui-gels .................. 125
PHOSLYRA ......................... 126
PHOS-NAK.......................... 146
phospha 250 neutral ............. 146
phosphate laxative ................ 125
PHOSPHOLINE IODIDE .... 141
PICATO ............................... 105
pilocarpine hcl .............. 103, 141
pimtrea (28) ............................ 92
pindolol .................................. 80
pink bismuth ......................... 123
pioglitazone ............................ 50
pioglitazone-glimepiride ........ 50
pioglitazone-metformin .......... 50
piperacillin-tazobactam .......... 36
pirmella .................................. 92
piroxicam................................ 26
PLAN B ONE-STEP .............. 92
PLASBUMIN 25 % ............... 74
01 de enero 2016
PLASBUMIN 5 % ................. 74
PLASMA-LYTE 148 ........... 146
PLASMA-LYTE A .............. 146
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 146
PLEGRIDY .......................... 139
podocon ................................ 105
podofilox .............................. 105
polyethylene glycol 3350 ..... 125
poly-iron ............................... 165
polymyxin b sulfate................ 31
polymyxin b sulf-trimethoprim
.......................................... 117
poly-tussin .............................. 99
poly-vita ............................... 165
poly-vita (iron) ..................... 165
poly-vitamin ......................... 165
poly-vitamin with iron ......... 165
poly-vitamins ....................... 165
POMALYST .......................... 42
portia ...................................... 92
potassium acetate ................. 146
potassium bicarb and chloride
.......................................... 146
potassium bicarb-citric acid . 146
potassium chlorid-d5-0.45%nacl
.......................................... 146
potassium chloride ............... 147
potassium chloride in 0.9%nacl
.......................................... 146
potassium chloride in 5 % dex
.......................................... 147
potassium chloride in lr-d5 .. 147
potassium chloride-0.45 % nacl
.......................................... 147
.......................................... 147
.......................................... 147
.......................................... 147
potassium citrate .................. 147
potassium citrate-citric acid . 147
potassium hydroxide ............ 105
potassium phosphate dibasic 148
POTIGA ................................. 46
PRADAXA ............................ 72
pramipexole ............................ 63
PRANDIMET ........................ 50
pravastatin .............................. 85
prazosin .................................. 77
prednicarbate ........................ 109
prednisolone acetate ............. 118
.................................. 118, 129
prednisone ............................ 129
PREMARIN ......................... 128
PREMASOL 10 % ................. 77
PREMASOL 6 % ................... 77
PREMPHASE ...................... 128
PREMPRO ........................... 129
prenatal ................................. 165
prenatal formula ................... 165
prenatal plus (calcium carb) . 165
prenatal vit#96-ferrous fum-fa
.......................................... 165
prenatal vitamin with minerals
.......................................... 165
prenatal vitamins low iron.... 165
prenatal vit-iron fumarate-fa 165
preparation h hydrocortisone 109
prevalite .................................. 85
PREVIDENT 5000 SENSITIVE
.......................................... 103
previfem ................................. 92
PREZCOBIX ......................... 68
PREZISTA ............................. 68
PRIFTIN................................. 61
PRILOSEC OTC .................. 119
PRIMAQUINE....................... 63
primidone ............................... 46
PRISTIQ................................. 49
PRIVIGEN ........................... 132
PROAIR HFA ...................... 150
I-17
PROAIR RESPICLICK ....... 150
probenecid ............................ 139
procainamide .......................... 79
PROCALAMINE 3%............. 77
prochlorperazine ..................... 62
prochlorperazine edisylate ..... 62
prochlorperazine maleate ....... 62
PROCRIT ......................... 72, 73
procto-pak ............................ 109
proctosol hc .......................... 109
proctozone-hc ....................... 109
PROCYSBI .......................... 139
progesterone in oil ................ 131
progesterone micronized ...... 131
PROGLYCEM ....................... 86
PROGRAF ........................... 132
PROLASTIN-C .................... 151
PROLENSA ......................... 118
PROLEUKIN ......................... 42
PROLIA ............................... 137
PROMACTA.......................... 73
promethazine .................... 58, 62
promethazine vc-codeine ....... 99
promethazine-codeine ............ 99
promethazine-dm.................... 99
promethegan ........................... 62
promolaxin ........................... 126
propafenone ............................ 79
propantheline .......................... 44
proparacaine ......................... 115
propranolol ............................. 80
propranolol-hydrochlorothiazid
............................................ 80
propylthiouracil .................... 131
PROQUAD (PF) .................. 134
prosight ................................. 165
PROSOL 20 % ....................... 77
protamine................................ 73
protriptyline ............................ 49
pseudoephedrine hcl ............... 99
PULMOZYME .................... 111
pure & gentle eye ................. 115
01 de enero 2016
purelax.................................. 126
PURIXAN .............................. 42
pyrazinamide .......................... 61
pyridostigmine bromide ....... 139
pyridoxine ............................ 166
Q
q-dryl ...................................... 58
q-pap ...................................... 23
q-pap extra strength................ 23
q-tapp dm ............................... 99
q-tussin ................................. 100
q-tussin dm ........................... 100
QUADRACEL (PF) ............. 134
quasense ................................. 92
quetiapine ............................... 66
QUILLIVANT XR................. 88
quinapril ................................. 78
quinapril-hydrochlorothiazide 78
quinidine gluconate ................ 79
quinidine sulfate ..................... 79
quinine sulfate ........................ 63
QVAR .................................. 149
R
RABAVERT (PF) ................ 134
raloxifene ............................. 129
ramipril ................................... 78
RANEXA ............................... 83
ranitidine hcl ........................ 119
RAPAMUNE ....................... 132
RASUVO (PF) ..................... 139
RAVICTI ............................. 123
REBIF (WITH ALBUMIN) 139
REBIF REBIDOSE .............. 140
REBIF TITRATION PACK 140
reclipsen (28) ......................... 92
RECOMBIVAX HB (PF) .... 134
recort plus............................. 109
refenesen .............................. 100
refenesen pe ......................... 100
REFRESH CELLUVISC ..... 115
REFRESH CLASSIC (PF) .. 115
REFRESH LACRI-LUBE ... 115
REFRESH OPTIVE ............. 115
REFRESH OPTIVE
ADVANCED ................... 117
reguloid ................................ 126
relcof c.................................. 100
RELENZA DISKHALER ...... 69
RELISTOR........................... 123
REMICADE ......................... 140
REMODULIN ...................... 153
RENAGEL ........................... 126
rena-vite rx ........................... 166
RENVELA ........................... 126
repaglinide .............................. 50
reprexain................................. 23
RESCRIPTOR ....................... 68
RESTASIS ........................... 118
retaine cmc ........................... 115
RETROVIR ............................ 68
REVLIMID ............................ 42
revonto ................................. 151
REYATAZ ............................. 68
REZIRA ............................... 100
ribasphere ............................... 70
RIDAURA ........................... 132
rifabutin .................................. 61
rifampin .................................. 61
RIFATER ............................... 61
ri-gel ii .................................. 123
riluzole ................................... 88
rimantadine............................. 69
ri-mox ................................... 123
ringers........................... 135, 148
risedronate ............................ 137
RISPERDAL CONSTA ......... 66
risperidone .............................. 66
RITUXAN .............................. 42
rivastigmine tartrate ............... 47
rizatriptan ............................... 60
robafen ................................. 100
robafen cough ....................... 100
robafen dm ........................... 100
I-18
robitussin cough-chest-cong dm
.......................................... 100
ROBITUSSIN LONG-ACTING
.......................................... 100
robitussin pediatric ............... 100
ropinirole .......................... 63, 64
rosadan ................................. 106
ROTARIX ............................ 134
ROTATEQ VACCINE ........ 134
roxicet ..................................... 23
ROZEREM ........................... 151
rydex ..................................... 100
rynex dm............................... 100
S
SABRIL.................................. 46
safe tussin dm ....................... 100
SAIZEN................................ 130
SAIZEN CLICK.EASY ....... 130
saline mist............................. 115
salsalate .................................. 26
SANDOSTATIN LAR DEPOT
.......................................... 130
SANTYL .............................. 105
SAPHRIS (BLACK CHERRY)
............................................ 67
SAVELLA.............................. 88
scooby-doo one a day ........... 166
scot-tussin dm....................... 100
scot-tussin expectorant ......... 100
sea soft nasal mist................. 115
selegiline hcl........................... 64
selenium sulfide ................... 106
SELZENTRY ......................... 68
senexon ................................. 126
senna ..................................... 126
senna lax ............................... 126
senna with docusate sodium . 126
senokot-s .............................. 126
SENSIPAR ........................... 140
sentry .................................... 166
sentry senior ......................... 166
SEREVENT DISKUS .......... 150
01 de enero 2016
SEROSTIM .......................... 130
sertraline ................................. 49
sharobel .................................. 92
SIGNIFOR ........................... 140
silace .................................... 126
siladryl sa ............................... 58
silapap .................................... 23
sildenafil ............................... 153
SILENOR ............................... 49
siltussin sa ............................ 100
siltussin-dm .......................... 101
silver nitrate ......................... 106
silver nitrate applicators ....... 106
silver sulfadiazine ................ 106
SIMBRINZA........................ 141
simethicone .......................... 118
simply sleep ........................... 58
SIMPONI ............................. 140
SIMPONI ARIA .................. 140
simvastatin ............................. 85
sinus & allergy (pseudoephed)
............................................ 58
sirolimus............................... 132
SIRTURO .............................. 61
skin treatment ....................... 105
sleep aid (diphenhydramine) .. 58
sleep aid (doxylamine) ........... 58
smoothlax ............................. 126
sodium acetate ...................... 148
sodium bicarbonate ...... 123, 148
sodium chloride ... 115, 135, 148,
151
sodium chloride 0.45 % ....... 148
sodium chloride 0.9 % ......... 148
sodium chloride 3 % ............ 148
sodium chloride 5 % ............ 148
sodium citrate-citric acid...... 148
sodium fluoride ............ 103, 166
sodium lactate ...................... 148
sodium phosphate................. 148
sodium polystyrene (sorb free)
.......................................... 123
sodium polystyrene sulfonate
.......................................... 123
sodium thiosulfate ................ 127
SOLTAMOX ......................... 42
SOLU-CORTEF (PF) .......... 129
SOMATULINE DEPOT ...... 130
SOMAVERT ........................ 130
soothe (bismuth subsalicylate)
.......................................... 123
soothe regular strength ......... 123
sorbitol ................................. 135
sorbitol-mannitol .................. 136
sorine ...................................... 80
sotalol ..................................... 80
sotalol af ................................. 80
SOVALDI .............................. 69
spectravite ............................ 166
spectravite adult 50+ ............ 166
spectravite advanced formula
.......................................... 166
spectravite senior.................. 166
spectravite senior w-lycopene
.......................................... 166
spectravite ultra women ....... 166
SPIRIVA RESPIMAT ......... 150
SPIRIVA WITH
HANDIHALER ............... 150
spironolactone ........................ 85
spironolacton-hydrochlorothiaz
............................................ 85
sprintec (28) ........................... 92
SPRYCEL .............................. 42
sps......................................... 123
sronyx ..................................... 92
ssd......................................... 106
st joseph aspirin ...................... 26
st. joseph aspirin ..................... 26
stavudine ................................ 68
STELARA ............................ 140
STERILE PADS .................. 140
STIVARGA ........................... 42
stomach relief ....................... 123
I-19
STRATTERA ......................... 88
streptomycin ........................... 29
stress 500 plus zinc............... 166
stress b with zinc .................. 166
stress b-biotin ....................... 166
stress formula ....................... 166
stress formula plus iron ........ 167
stress formula with iron ........ 167
stress formula with zinc ....... 167
STRIBILD .............................. 68
STRIVERDI RESPIMAT .... 150
sucralfate .............................. 119
sudogest ................................ 101
sudogest sinus & allergy ........ 59
sulfacetamide sodium ........... 117
sulfacetamide sodium (acne) 106
sulfacetamide-prednisolone.. 117
sulfadiazine ............................ 36
sulfamethoxazole-trimethoprim
............................................ 36
sulfasalazine ........................... 36
sulfatrim ................................. 36
sulfazine ................................. 36
sulfazine ec ............................. 36
sulindac .................................. 26
sumatriptan ............................. 60
sumatriptan succinate ....... 60, 61
summer's eve disposable douche
.......................................... 140
summers eve extra cleansing 140
sunvite .................................. 167
super b complex-vitamin c ... 167
super b/c ............................... 167
super b-50 complex .............. 167
super b-50 complex plus ...... 167
super multiple ....................... 167
super multivitamin ............... 167
super quints .......................... 167
super quints b-50 .................. 167
super thera vite m ................. 167
superior 35 ............................ 167
superplex-t ............................ 167
01 de enero 2016
suphedrin .............................. 101
suphedrine pe day-night ....... 101
suphedrine severe cold max str
.......................................... 101
support.................................. 167
support-500 .......................... 167
SUPPRELIN LA .................. 130
SUPRAX ................................ 33
SURMONTIL ........................ 49
SUSTIVA ............................... 68
SUTENT ................................ 42
syeda ...................................... 92
SYLATRON .......................... 69
SYLVANT ............................. 42
SYMLINPEN 120 .................. 51
SYMLINPEN 60 .................... 51
SYNAGIS .............................. 69
SYNAREL ........................... 140
SYNERCID............................ 31
SYNRIBO .............................. 42
SYPRINE ............................. 127
SYSTANE............................ 115
SYSTANE GEL ................... 115
T
tab-a-vite .............................. 168
tab-a-vite/iron ....................... 168
tab-a-vite-minerals ............... 168
TABLOID .............................. 42
tacrolimus ..................... 109, 133
tactinal .................................... 23
tactinal extra strength ............. 23
TAFINLAR ............................ 42
TAMIFLU .............................. 69
tamoxifen ............................... 42
tamsulosin ............................ 127
TARCEVA ............................. 42
TARGRETIN ......................... 42
tarina fe .................................. 92
TASIGNA .............................. 42
tazicef ..................................... 33
TAZORAC ........................... 110
taztia xt ................................... 80
tears again ............................ 115
tears naturale free (pf) .......... 115
TECFIDERA ........................ 140
TEFLARO .............................. 33
telmisartan .............................. 78
telmisartan-hydrochlorothiazid
............................................ 78
TEMODAR ............................ 43
tencon ..................................... 23
TENIVAC (PF) .................... 134
terazosin ............................... 127
terbinafine hcl ........................ 55
terbutaline............................. 150
terconazole ............................. 60
testosterone........................... 128
testosterone cypionate .......... 128
testosterone enanthate .......... 128
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 135
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 135
TETANUS-DIPHTHERIA
TOXOIDS-TD ................. 135
tetracaine hcl (pf) ................. 115
tetracycline ............................. 37
THALOMID ........................ 140
the magic bullet .................... 126
theochron .............................. 150
theophylline .......................... 150
theophylline in dextrose 5 % 150
thera m plus (ferrous fumarat)
.......................................... 168
thera vitamin ........................ 168
theradex m ............................ 168
THERAFLU DAYTIME
COLD-COUGH ............... 101
THERAFLU MULTISYMPTOM COLD .......... 101
thera-m ................................. 168
therapeutic liquid.................. 168
I-20
therapeutic m + beta-carotene
.......................................... 168
therapeutic vitamins/minerals
.......................................... 168
therapeutic-m........................ 168
therapeutic-m vitamin/minerals
.......................................... 168
thera-tabs .............................. 168
theratrum complete 50 plus .. 168
theratrum complete 50 plus/lut
.......................................... 168
thiamine hcl .................. 168, 169
thioridazine ............................. 67
thiothixene .............................. 67
tiagabine ................................. 46
TICE BCG ............................ 135
TIKOSYN .............................. 79
tilia fe ..................................... 92
timolol maleate ............... 80, 141
TIVICAY ............................... 68
tizanidine .............................. 151
TOBI PODHALER ................ 29
TOBRADEX ST .................. 117
tobramycin............................ 117
tobramycin in 0.225 % nacl ... 29
tobramycin in 0.9 % nacl ....... 29
tobramycin sulfate .................. 29
tolazamide .............................. 52
tolbutamide ............................. 52
tolmetin .................................. 26
tolnaftate ................................. 55
tolterodine ............................ 127
topiragen ................................. 46
topiramate ............................... 46
toposar .................................... 43
torsemide ................................ 84
total b/c ................................. 169
totalday multiple................... 169
TOUJEO SOLOSTAR ........... 51
TOVIAZ ............................... 127
TPN ELECTROLYTES ....... 148
TPN ELECTROLYTES II ... 148
01 de enero 2016
TRACLEER ......................... 153
TRADJENTA ........................ 51
tramadol ................................. 23
tramadol-acetaminophen ........ 23
trandolapril ............................. 78
tranexamic acid ...................... 73
TRANSDERM-SCOP............ 62
tranylcypromine ..................... 49
TRAVASOL 10 % ................. 77
TRAVATAN Z .................... 141
travel sickness (meclizine) ..... 62
travoprost (benzalkonium) ... 141
trazodone ................................ 49
TREANDA ............................ 43
TRECATOR .......................... 61
TRELSTAR ........................... 43
tretinoin ................................ 110
tretinoin (chemotherapy) ........ 43
tretinoin microspheres .......... 110
TREXALL ............................. 43
triacting m-sym cold/cough . 101
triamcinolone acetonide ...... 103,
109, 110, 129
triaminic cold & cough (pe) . 101
TRIAMINIC COLD & COUGH
NT (PE) .............................. 59
TRIAMINIC COUGH-SORE
THROAT ......................... 101
triamterene-hydrochlorothiazid
............................................ 84
trianex .................................. 110
TRIBENZOR ......................... 78
tri-buffered aspirin ................. 26
tricitrates .............................. 148
tri-dex pe .............................. 101
tri-estarylla ............................. 92
trifluoperazine ........................ 67
trifluridine ............................ 117
trihexyphenidyl ...................... 64
tri-legest fe ............................. 92
tri-linyah ................................. 92
trilyte with flavor packets .... 126
trimethoprim........................... 31
trinessa (28) ............................ 92
triple antibiotic ..................... 106
triple paste af .......................... 55
tri-previfem (28) ..................... 92
tri-sprintec (28) ...................... 92
TRIUMEQ ............................. 68
tri-vi-sol ................................ 169
tri-vita ................................... 169
tri-vitamin............................. 169
trivora (28) ............................. 92
TROKENDI XR ..................... 46
TROPHAMINE 10 % ............ 77
TROPHAMINE 6% ............... 77
trospium ............................... 127
TRULICITY........................... 51
TRUMENBA ....................... 135
TRUVADA ............................ 68
trymine cg ............................ 101
TUDORZA PRESSAIR ....... 150
tusnel diabetic ...................... 101
TUSNEL NEW FORMULA 101
TUSNEL PEDIATRIC ........ 101
TUSSI PRES-B .................... 101
tussin cf ................................ 101
tussin cf cough-cold ............. 101
tussin cold-congestion .......... 102
tussin cough (dm only) ......... 102
tussin dm .............................. 102
tussin dm cough & chest ...... 102
tussin maximum strength ..... 102
tussin pe................................ 102
TWINRIX (PF) .................... 135
TYBOST .............................. 140
TYGACIL .............................. 37
TYKERB ................................ 43
TYPHIM VI ......................... 135
TYSABRI............................. 133
TYVASO ............................. 153
TYVASO REFILL KIT ....... 153
TYVASO STARTER KIT ... 153
TYZEKA ................................ 70
I-21
U
u-cort .................................... 110
ULORIC ............................... 140
ultra b-100 complex ............. 169
ultra fresh pm ....................... 115
ultra strength antacid ............ 123
unisom sleepgels .................... 59
ursodiol ................................. 123
V
VAGIFEM............................ 129
valacyclovir ............................ 70
VALCHLOR ........................ 105
valganciclovir ......................... 70
valproate sodium .................... 46
valproic acid ........................... 46
valproic acid (as sodium salt) . 47
valsartan ................................. 78
valsartan-hydrochlorothiazide 78
VALSTAR ............................. 43
valu-tapp dm......................... 102
VANACOF .......................... 102
vancomycin ............................ 31
vancomycin in d5w ................ 31
VAQTA (PF) ........................ 135
VARIVAX (PF) ................... 135
VASCEPA.............................. 85
v-c forte ................................ 169
VELCADE ............................. 43
velivet triphasic regimen (28) 92
venlafaxine ............................. 49
verapamil ................................ 81
VERSACLOZ ........................ 67
vestura (28)............................. 92
VGO 40 ................................ 111
vic-forte ................................ 169
vicks dayquil cold&flu relief 102
vicks dayquil cough.............. 102
vicks nature fusion cough..... 102
vicks nyquil severe cold-flu . 102
vicks qlearquil(oxymetazoline)
.......................................... 115
vicks sinex 12-hour .............. 115
01 de enero 2016
vicodin.................................... 23
vicodin es ............................... 23
vicodin hp............................... 23
VICTOZA 3-PAK .................. 51
............................................ 68
............................................ 68
VIGAMOX .......................... 117
VIIBRYD ............................... 49
VIMIZIM ............................. 111
VIMPAT ................................ 47
vinorelbine ............................. 43
viorele (28) ............................. 92
VIRACEPT ............................ 68
VIRAMUNE XR ................... 68
VIRAZOLE............................ 70
virdec dm ............................. 102
VIREAD ................................ 68
virt-phos 250 neutral ............ 148
virtussin ac ........................... 102
vision .................................... 169
vision formula ...................... 169
vision formula (with lutein) . 169
vision plus lutein .................. 169
vit b complex-folic acid ....... 169
vitalets .................................. 169
vitamin a............................... 169
vitamin b complex................ 170
vitamin b-100 complex ........ 170
vitamin b-12 ......................... 170
vitamin b12-folic acid .......... 170
vitamin b-6 ........................... 170
vitamin c............................... 170
vitamin d2 ............................ 170
vitamin d3 ............................ 170
vitamin k .............................. 170
vitamins & minerals ............. 170
vitamins b complex .............. 170
vitamins for hair ................... 170
VITEKTA .............................. 68
vitrum senior ........................ 171
VOLTAREN .......................... 26
voriconazole ........................... 55
VOTRIENT ............................ 43
VPRIV .................................. 111
vyfemla (28) ........................... 92
W
wal-act d cold & allergy ......... 59
wal-dram ................................ 62
wal-dryl allergy ...................... 59
wal-fex allergy ....................... 59
wal-finate ............................... 59
wal-finate-d ............................ 59
wal-itin ................................... 59
wal-itin d ................................ 59
wal-itin d 12 hour ................... 59
wal-phed ......................... 59, 102
wal-phed pe day-night .......... 102
wal-phed pe sinus & allergy... 59
wal-profen .............................. 26
wal-sleep z.............................. 59
wal-som (diphenhydramine) .. 59
wal-tap .................................... 59
wal-tussin cough .................. 102
wal-tussin cough & cold cf .. 102
wal-tussin dm ....................... 102
wal-zan 75 ............................ 119
wal-zyr (cetirizine) ................. 60
wal-zyr d ................................ 60
warfarin .................................. 72
water for irrigation, sterile ... 136
wera (28) ................................ 92
womens daily gummies ........ 171
women's daily multivitamin . 171
X
XALKORI.............................. 43
XARELTO ............................. 72
XELJANZ ............................ 140
XENAZINE ........................... 88
XIFAXAN .............................. 31
XOLAIR............................... 151
XTANDI ................................ 43
xulane ..................................... 92
I-22
xylon 10 .................................. 23
XYREM ............................... 151
Y
yelets .................................... 171
YERVOY ............................... 43
YF-VAX (PF)....................... 135
Z
zafirlukast ............................. 149
zaleplon ................................ 152
ZANTAC.............................. 120
ZANTAC 75......................... 120
zarah ....................................... 92
ZAVESCA ........................... 111
zebutal .................................... 23
ZELBORAF ........................... 43
ZEMPLAR ........................... 137
zenatane ................................ 105
zenchent (28) .......................... 93
ZENPEP ............................... 112
zephrex-d .............................. 103
ZETIA .................................... 85
ZIAGEN ................................. 69
zidovudine .............................. 69
zinc oxide ............................. 105
ziprasidone hcl ....................... 67
ZIRGAN ............................... 117
ZOLADEX ............................. 43
zoledronic acid ..................... 137
.......................................... 137
ZOLINZA .............................. 44
zolmitriptan ............................ 61
zolpidem ............................... 152
ZOMETA ............................. 137
ZONATUSS ......................... 103
zonisamide.............................. 47
zoo chews ............................. 171
ZORTRESS .......................... 133
ZOSTAVAX (PF) ................ 135
zovia 1/35e (28)...................... 93
zovia 1/50e (28)...................... 93
ZOVIRAX ............................ 105
01 de enero 2016
z-sleep .................................... 60
ZUBSOLV ............................. 28
ZYDELIG .............................. 44
ZYKADIA ............................. 44
ZYLET ................................. 117
zyncof ................................... 103
ZYPREXA RELPREVV........ 67
ZYRTEC ................................ 60
ZYTIGA ................................. 44
ZYVOX .................................. 31
Este formulario se actualizó el 10/21/2015. Si tiene preguntas, llame al plan Community Care Plus
FIDA-MMP de ICS al 1.877.ICS.2525, de lunes a viernes, de 8 a. m. a 8 p. m. La llamada es gratuita.
Para obtener más información, visite www.icsny.org/care-plus.
I-23
01 de enero 2016
1.877.ICS.2525
www.icsny.org
Oﬁcina Administrativa
Independence Care System
257 Park Ave. South
2nd Floor
New York, NY 10010
Centros de Atención al Paciente
400 East Fordham Road
10th floor
Bronx, New York 10458
25 Elm Place
5th Floor
Brooklyn, NY 11201

ICS Community Care Plus FIDA-MMP

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