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Comprehensive Medicare Formulary Complete List of Prescribed Drugs High and Low Option Medicare Supplement Plans With and Without Part D Plan Year 2012 (Updated for January 1, 2012) PLEASE READ: This document contains information about the drugs covered under this plan. Comprehensive Formulary E7848_G6000 HPMS ID 00012423 1-1-12.Final MDIS #2543 i What is the HealthChoice Medicare Formulary? The formulary is a list of drugs that are covered by HealthChoice. It includes both brand-name and generic drugs. Generic drugs are approved by the FDA as having the same active ingredient as brand-name drugs, but usually at a lower cost. This formulary list represents the prescription therapies believed to be a necessary part of a quality treatment program. Due to the Centers for Medicare and Medicaid Services (CMS) regulations, a few differences can be noted between the formulary for active and pre-Medicare members and the formulary for Medicare members. Note: This formulary has changed since last year. Please review this document to make sure the drugs you take are still listed. What is a tier? CMS requires each covered drug be placed in a tier. The HealthChoice tiers are: Tier 1 — Generics (all covered generics are Preferred) Tier 2 — Preferred brand-name Tier 3 — non-Preferred brand-name Tier 4 — Preferred, very high cost, and unique formulary drugs Tier 5 — Tobacco cessation drugs Can the formulary change? Yes. HealthChoice may add or remove drugs from its formulary during the year. When formulary changes occur, HealthChoice must notify members affected by the change: At least 60 days before the date the change becomes effective, or At the time you request a refill of the drug. If you are notified of a formulary change when refilling a prescription, you will be able to receive a 60-day supply of the drug. ii How do I use the HealthChoice Medicare Formulary? There are two ways to find your drugs within the formulary, by medical condition or by drug name. Brand-name drugs appear in all capital letters (e.g., PROTONIX) and generic drugs appear in lowercase italics (e.g., pantoprazole). Locating your drug by medical condition Drugs listed in this formulary are grouped by categories based on the medical condition they treat. For example, drugs used to treat a heart condition are listed under Cardiovascular Agents. If you know the condition your drug treats, you can look for it under that category name. Locating your drug by alphabetical listing If you are not sure what category your drug falls under, you can look for it in the Index located in the back of this formulary guide. The Index provides an alphabetical list of all the brand-name and generic drugs included in this document. Turn to the page listed in the Index to find your drug. Are there any restrictions on coverage? Some covered drugs have additional requirements or limits on coverage. Drugs that are subject to additional requirements or limits are indicated by a two letter code and can include: Quantity Limits (QL): For certain drugs, there are limits on the quantity covered. The limit is an exception to the Plans’ standard benefit of a 34- day supply or 100 units, whichever is greater. Step Therapy (ST): In some cases, HealthChoice requires you to try plan Preferred drugs to treat your medical condition before we will cover iii another drug that treats the same condition. If you try drug A to treat your medical condition and it does not work for you, the Plan may then cover another drug for your condition. Prior Authorization (PA): Certain drugs require prior authorization. In some cases, you must get prior authorization for drugs that are listed in the HealthChoice Medicare Formulary. Drugs that are not listed in the formulary also require prior authorization for coverage. If you don’t receive approval of your prior authorization request, HealthChoice will not cover your drug. Limited Availability (LA): Certain drugs may only be available at certain pharmacies. For more information, call Medco Member Services toll-free at 1-800-590-6828. TTY/TDD users call toll-free 1-800-716- 3231. Enhanced Drug (ED): These drugs are not normally covered by Medicare prescription drug plans but, HealthChoice may cover the drugs designated as ED drugs in this formulary. In some instances, a prior authorization review may be required. The amounts you pay do not count toward your total drug costs (i.e., the amounts you pay do not help you qualify for catastrophic coverage). If you receive extra help paying for your prescriptions, you will not receive help paying for an ED drug. Part B versus Part D Drug (B/D): These drugs may be covered under Medicare Part B or Medicare Part D depending on the circumstances. Prior authorization is required to determine how the drug must be billed. Your physician must provide information about the use and setting of the administration of the drug. iv What if my drug is not listed in the HealthChoice Medicare Formulary? If your drug is not listed in this formulary, you should first contact Medco Member Services and ask if your drug is covered. If you learn that HealthChoice does not cover your drug, you have two options: You can ask Medco for a list of similar drugs that are covered by HealthChoice. When you receive this list, you can show it to your doctor and ask him/her to prescribe a drug that is covered by HealthChoice. You can ask HealthChoice to make an exception and cover your drug. How do I request an exception to the HealthChoice Medicare Formulary? You can ask HealthChoice to make certain exceptions to its coverage rules. When you or your doctor ask for an exception, it is called asking for a prior authorization/exception. There are several types of exceptions you can ask us to make. Certain drugs listed in the HealthChoice Medicare Formulary require a Step Therapy prior authorization exception before they are covered. You must first try a designated drug to treat your medical condition. If the designated drug fails to treat your medical condition, you can request a Step Therapy prior authorization exception. Your doctor must contact Medco toll-free at 1-800-753-2851 and provide information to support your request. You can ask us to cover your drug even if it is non-Formulary and not listed in this guide. Please note, if we grant your request to cover a drug that is not in our formulary, it will be covered at the non-Preferred copay. To request a prior authorization/exception for a non-formulary v drug, your doctor must contact Medco toll-free at 1-800-753-2851 and provide information to support your request. Due to approved therapy guidelines, certain medications have set quantity limits. Quantity limits also apply if the drug form is other than a tablet or capsule. To request a prior authorization/exception to the quantity limitation rules, your doctor must contact Medco toll-free at 1- 800-753-2851 and provide information to support your request. Certain drugs listed in the HealthChoice Medicare Formulary require a general prior authorization/exception before they are covered. Generally, these drugs are very high cost, have specific prescribing guidelines, are usually used for cosmetic purposes, or might be covered under Medicare Part B. To request a prior authorization/exception for a covered drug, your doctor must contact Medco toll-free at 1-800-753- 2851 and provide information to support your request. If you choose a non-Preferred medication when a Preferred medication is available, you must pay the non-Preferred copay unless you request a prior authorization/exception to receive a lower copay (a tier exception). Be aware that medical guidelines must be met, and information supplied by your doctor must justify your request. To request a prior authorization/exception for a tier exception to receive a lower copay, your doctor must contact Medco and provide information to support your request. Your doctor can contact Medco toll-free at 1-800-841- 5409. When requesting an exception, your doctor must submit a statement supporting the request. Generally, we must make our decision within 72 hours of receiving your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we vi must give you a decision no later than 24 hours after we receive your prescriber’s or prescribing physician’s supporting statement. What do I do before I talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not listed in our formulary; or you may be taking a drug that is listed in our formulary, but your ability to get it is limited. For example, you may need a prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, HealthChoice may cover your drug in certain cases. For each of your drugs that is not listed in our formulary, or if your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a HealthChoice Network Pharmacy. After you receive your first 34-day supply, you will need to get a prior authorization/exception before HealthChoice will continue to cover this medication. If you are a resident of a long-term care (LTC) facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). If you need a drug that is not listed in our formulary or if your ability to get your drug is limited, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. We will cover up to two refills of these medications. HealthChoice covers a transition supply if you have a level of care change such as when you: Enter LTC facilities from hospitals or other settings; vii Leave LTC facilities and return to the community; Are discharged from a hospital to a home; End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under your Part D plan formulary; Revert from hospice status to standard Medicare Part A and B benefits; or Are discharged from a psychiatric hospital with medication regimens that are highly individualized. For more information For more detailed information about your prescription drug coverage, please review your HealthChoice Medicare Supplement Handbook and other plan materials or visit the HealthChoice website at www.healthchoiceok.com or www.sib.ok.gov. This Comprehensive Formulary is effective beginning January 1, 2012. If you have questions about the prescription drug program, visit the HealthChoice website or call Medco Member Services toll-free at 1-800-590-6828, 24 hours a day, 7 days a week. TTY/TDD users call toll-free 1-800-716-3231. If you have general questions about Medicare prescription drug coverage, please call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week or visit Medicare’s website at www.medicare.gov. TTY/TDD users can call toll-free 1-877-486-2048. This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, as authorized by 74 O.S. Section 1301, et seq; 34,000 copies have been printed at a cost of $.60 each. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries. This page intentionally blank. 1 Commonly Prescribed Therapeutic Drug Categories ANTI - INFECTIVES ANTIFUNGAL AGENTS Drug Name Drug Tier Require-ments/ Limits amphotericin b 1 B/D PA ANCOBON 2 clotrimazole troc 1 DIFLUCAN IN NACL 2 ERAXIS INJ 100MG 2 fluconazole in dextrose inj 0; 400mg/200ml 1 fluconazole susr 1 fluconazole tabs 1 GRIS-PEG 3 griseofulvin microsize 1 itraconazole 1 ketoconazole 1 NOXAFIL 2 nystatin susp 1 nystatin tabs 1 ORAVIG 2 SPORANOX ORAL SOLN 2 terbinafine tabs 1 VFEND IV 2 VFEND SUSR 2 voriconazole 1 ANTIVIRALS acyclovir caps 1 acyclovir inj 500mg 1 acyclovir susp 1 acyclovir tabs 1 amantadine 1 APTIVUS 4 ATRIPLA 4 BARACLUDE 2 COMBIVIR 4 CRIXIVAN 2 didanosine 1 EDURANT 4 EMTRIVA 2 Drug Name Drug Tier Require-ments/ Limits EPIVIR 2 EPIVIR HBV 2 EPZICOM 4 famciclovir 1 foscarnet sodium 1 B/D PA FUZEON 4 ganciclovir caps 1 HEPSERA 4 INTELENCE 4 INVIRASE CAPS 3 INVIRASE TABS 4 ISENTRESS 4 KALETRA ORAL SOLN 4 KALETRA TABS 200MG; 50MG 4 KALETRA TABS 100MG; 25MG 2 LEXIVA SUSP 2 LEXIVA TABS 4 NORVIR 2 PREZISTA TABS 150MG, 75MG 2 PREZISTA TABS 400MG, 600MG 4 REBETOL ORAL SOLN 2 RELENZA DISKHALER 2 QL(300 per 365 days) RESCRIPTOR 3 RETROVIR IV INFUSION 2 REYATAZ 2 ribapak 4 ribasphere caps 1 ribasphere tabs 200mg 1 ribasphere tabs 400mg, 600mg 4 ribavirin 1 rimantadine hcl 1 SELZENTRY 4 stavudine 1 SUSTIVA 2 TAMIFLU CAPS 45MG, 75MG 2 QL(60 per 365 days) TAMIFLU CAPS 30MG 2 QL(120 per 365 days) 2 Drug Name Drug Tier Require-ments/ Limits TAMIFLU SUSR 12MG/ML 2 TRIZIVIR 4 TRUVADA 4 TYZEKA 4 valacyclovir hcl 1 VALCYTE 4 VIDEX PEDIATRIC ORAL SOLN 2GM 2 VIRACEPT POWD 2 VIRACEPT TABS 4 VIRAMUNE 2 VIREAD 2 ZIAGEN 2 zidovudine 1 CEPHALOSPORINS cefaclor 1 cefadroxil 1 cefazolin inj 1gm, 1gm; 5%, 20gm, 500mg 1 cefdinir 1 cefepime inj 1gm, 2gm 1 cefotaxime sodium 1 cefoxitin sodium inj 10gm, 1gm, 2gm 1 cefpodoxime proxetil 1 ceftazidime inj 1gm, 2gm, 6gm 1 ceftriaxone sodium 1 cefuroxime axetil 1 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg 1 cephalexin 1 FORTAZ INJ 1GM/50ML; 5%, 2GM/50ML; 5%, 6GM 2 SUPRAX SUSR 3 TAZICEF INJ 1GM, 2GM, 6GM 2 TEFLARO 2 ZINACEF IN ISO-OSMOTIC DEXTROSE 2 ZINACEF IN ISO-OSMOTIC DILUENT 2 ZINACEF INJ 1.5GM, 750MG 2 ERYTHROMYCINS / OTHER MACROLIDES Drug Name Drug Tier Require-ments/ Limits azithromycin inj 500mg 1 azithromycin susr 1 azithromycin tabs 1 clarithromycin 1 clarithromycin er 1 e.e.s. 400 1 E.E.S. GRANULES 2 ERY-TAB TBEC 500MG 2 ery-tab tbec 250mg, 333mg 1 ERYTHROCIN LACTOBIONATE INJ 500MG 2 erythrocin stearate 1 ERYTHROMYCIN BASE 2 erythromycin ethylsuccinate 1 erythromycin/sulfisoxazole 1 ZMAX 2 MISCELLANEOUS ANTIINFECTIVES ALBENZA 2 ALINIA 2 amikacin sulfate inj 500mg/2ml, 50mg/ml 1 AZACTAM IN ISO-OSMOTIC DEXTROSE 2 AZACTAM INJ 2GM 2 aztreonam inj 1gm 1 BILTRICIDE 2 CAPASTAT SULFATE 3 CAYSTON 4 LA chloroquine 1 CLEOCIN GALAXY 2 CLEOCIN PEDIATRIC GRANULES 2 clindamycin hcl 1 clindamycin phosphate add-vantage 1 COARTEM 2 colistimethate sodium 1 CUBICIN 2 B/D PA DAPSONE 2 DARAPRIM 2 ethambutol 1 gentamicin sulfate inj 1 3 Drug Name Drug Tier Require-ments/ Limits gentamicin sulfate/0.9% sodium chloride 1 gentamicin sulfate/sodium chloride inj 1.2mg/ml; 0.9% 1 hydroxychloroquine 1 isonarif 1 ISONIAZID SYRP 2 isoniazid tabs 1 isotonic gentamicin inj 0.6mg/ml; 0.9%, 0.8mg/ml; 0.9% 1 KETEK 2 MALARONE 2 mebendazole 1 mefloquine hcl 1 MEPRON 4 meropenem inj 500mg 1 metronidazole 1 metronidazole in nacl 0.79% 1 MYCOBUTIN 2 NEBUPENT 2 B/D PA neomycin sulfate 1 paromomycin 1 PASER 2 PRIMAQUINE 2 PRIMAXIN I.M. 2 PRIMAXIN IV 2 pyrazinamide 1 QUALAQUIN 2 rifampin 1 SEROMYCIN 2 STREPTOMYCIN SULFATE 2 STROMECTOL 2 TOBI 4 B/D PA tobramycin inj 10mg/ml, 80mg/2ml 1 TOBRAMYCIN SULFATE / SODIUM CHLORIDE 2 TRECATOR 2 TYGACIL 2 XIFAXAN 2 ZYVOX 2 PENICILLINS Drug Name Drug Tier Require-ments/ Limits amoxicillin 1 amoxicillin/clavulanate potassium 1 amoxicillin/clavulanate potassium er 1 amoxicillin/potassium clavulanate tabs 1 ampicillin caps 1 ampicillin inj 10gm, 1gm 1 AMPICILLIN INJ 125MG 2 ampicillin susr 1 ampicillin-sulbactam inj 10gm; 5gm, 2gm; 1gm 1 BICILLIN C-R 2 BICILLIN L-A 2 dicloxacillin sodium 1 nafcillin sodium inj 10gm, 1gm 1 NALLPEN/DEXTROSE INJ 0; 1GM/50ML 2 PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE 2 penicillin g potassium inj 5mu 1 PENICILLIN G PROCAINE 2 PENICILLIN G SODIUM 2 penicillin v potassium 1 pfizerpen-g inj 20mu 1 piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm 1 ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML 2 QUINOLONES AVELOX 2 AVELOX ABC PACK 2 CIPRO I.V.-IN D5W INJ 200MG; 5% 2 ciprofloxacin inj 400mg/40ml 1 ciprofloxacin tabs 1 LEVAQUIN INJ 25MG/ML, 5%; 750MG/150ML 3 LEVAQUIN ORAL SOLN 3 LEVAQUIN TABS 3 NOROXIN 3 ofloxacin 1 SULFA'S / RELATED AGENTS 4 Drug Name Drug Tier Require-ments/ Limits sulfadiazine 1 sulfamethoxazole/trimethoprim 1 sulfamethoxazole/trimethoprim ds 1 TETRACYCLINES demeclocycline hcl 1 doxycycline hyclate caps 1 doxycycline hyclate inj 1 doxycycline hyclate tabs 1 doxycycline hyclate tbec 1 doxycycline monohydrate tabs 150mg, 50mg, 75mg 1 minocycline hcl 1 minocycline hcl er 1 tetracycline hcl 1 VIBRAMYCIN SYRP 2 URINARY TRACT AGENTS MACRODANTIN CAPS 25MG 2 methenamine hippurate 1 nitrofurantoin 1 nitrofurantoin macrocrystalline caps 50mg 1 nitrofurantoin monohydrate 1 PRIMSOL 3 trimethoprim 1 VANCOMYCIN VANCOCIN ORAL 2 vancomycin inj 1000mg, 10gm, 500mg 1 B/D PA VIBATIV INJ 250MG 2 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine 4 dexrazoxane inj 500mg 1 ELITEK INJ 1.5MG 4 leucovorin calcium inj 100mg, 350mg 1 leucovorin calcium tabs 25mg, 5mg 1 LEUCOVORIN CALCIUM TABS 10MG, 15MG 2 mesna 1 Drug Name Drug Tier Require-ments/ Limits MESNEX TABS 2 XGEVA 4 ZINECARD INJ 250MG 2 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 3 adriamycin inj 2mg/ml 1 AFINITOR TABS 10MG 4 PA QL(180 per 90 days) AFINITOR TABS 2.5MG, 5MG 4 PA QL(270 per 90 days) ALIMTA INJ 500MG 3 ALKERAN INJ 3 anastrozole 1 ARRANON 3 ARZERRA 2 AVASTIN INJ 100MG/4ML 3 azathioprine 1 B/D PA azathioprine sodium 1 B/D PA bicalutamide 1 BICNU 3 bleomycin sulfate inj 30unit 1 BUSULFEX 2 CAMPATH 3 carboplatin inj 150mg/15ml 1 CEENU 2 CELLCEPT INTRAVENOUS 2 CELLCEPT SUSR 2 B/D PA cisplatin inj 100mg/100ml 1 cladribine 1 CLOLAR 3 COSMEGEN 3 cyclophosphamide tabs 1 B/D PA cyclosporine caps 100mg, 25mg 1 B/D PA CYCLOSPORINE CAPS 50MG 2 B/D PA cyclosporine inj 1 B/D PA cyclosporine oral soln 1 B/D PA CYTARABINE AQUEOUS INJ 100MG/ML 2 cytarabine aqueous inj 20mg/ml 1 cytarabine inj 500mg 1 dacarbazine inj 200mg 1 5 Drug Name Drug Tier Require-ments/ Limits DACOGEN 2 daunorubicin hcl inj 20mg 1 DAUNOXOME 3 DOCETAXEL INJ 80MG/8ML 2 DOXIL 2 doxorubicin hcl 1 DROXIA 2 ELLENCE INJ 200MG/100ML 3 ELOXATIN INJ 100MG/20ML 3 ELSPAR 3 EMCYT 2 epirubicin hcl inj 50mg/25ml 1 ERBITUX INJ 100MG/50ML 3 ETOPOPHOS 3 etoposide inj 1 exemestane 1 FARESTON 3 FASLODEX 4 FIRMAGON INJ 120MG 4 FIRMAGON INJ 80MG 2 fludarabine phosphate inj 50mg 1 fluorouracil inj 500mg/10ml 1 flutamide 1 gemcitabine hcl inj 1gm 4 gengraf 1 B/D PA GLEEVEC 4 HALAVEN 4 HERCEPTIN 3 HEXALEN 4 hydroxyurea 1 idarubicin hcl inj 10mg/10ml 1 IFEX INJ 3GM 3 ifosfamide inj 1gm 1 ifosfamide/mesna 4 irinotecan inj 100mg/5ml 4 ISTODAX 2 IXEMPRA KIT INJ 45MG 4 JEVTANA 4 letrozole 1 LEUKERAN 2 leuprolide acetate 1 Drug Name Drug Tier Require-ments/ Limits LUPRON DEPOT INJ 3.75MG 2 LUPRON DEPOT INJ 11.25MG, 22.5MG, 30MG, 7.5MG 4 LUPRON DEPOT-PED INJ 11.25MG, 15MG 4 LYSODREN 2 MATULANE 4 MEGACE ES 2 megestrol acetate 1 melphalan hydrochloride 1 mercaptopurine 1 methotrexate 1 B/D PA methotrexate sodium inj 25mg/ml 1 METHOTREXATE SODIUM INJ 1GM 3 mitomycin inj 20mg 1 mitoxantrone hcl 1 MUSTARGEN 3 mycophenolate mofetil 1 B/D PA MYFORTIC 2 B/D PA NEORAL 2 B/D PA NEXAVAR 4 LA PA QL(360 per 90 days) NILANDRON 3 NIPENT 3 octreotide inj 100mcg/ml, 200mcg/ml, 50mcg/ml 1 octreotide inj 1000mcg/ml, 500mcg/ml 4 ONTAK 3 oxaliplatin inj 100mg/20ml 4 paclitaxel inj 300mg/50ml 1 pentostatin 1 PHOTOFRIN 3 PROGRAF INJ 2 B/D PA RAPAMUNE 2 B/D PA REVLIMID CAPS 15MG, 25MG 4 LA QL(21 per 28 days) REVLIMID CAPS 10MG, 5MG 4 LA QL(30 per 30 days) RHEUMATREX 3 B/D PA RITUXAN 2 PA SANDIMMUNE 2 B/D PA 6 Drug Name Drug Tier Require-ments/ Limits SANDOSTATIN LAR DEPOT 3 SIMULECT INJ 20MG 2 SOMATULINE DEPOT 4 SPRYCEL TABS 100MG, 140MG, 50MG, 70MG, 80MG 4 QL(90 per 90 days) SPRYCEL TABS 20MG 4 QL(180 per 90 days) SUTENT 4 PA QL(90 per 90 days) TABLOID 2 tacrolimus 1 B/D PA tamoxifen citrate 1 TARCEVA TABS 100MG, 150MG 4 PA QL(90 per 90 days) TARCEVA TABS 25MG 4 PA QL(180 per 90 days) TARGRETIN 2 TASIGNA CAPS 200MG 4 QL(336 per 84 days) TAXOTERE INJ 80MG/2ML, 80MG/4ML 4 THALOMID 4 PA thiotepa 1 toposar 1 topotecan hcl inj 4mg 1 TORISEL 4 PA TREANDA INJ 100MG 4 TRELSTAR DEPOT MIXJECT 3 TRELSTAR LA MIXJECT 3 TRELSTAR MIXJECT 3 tretinoin 1 TRISENOX 2 TYKERB 4 LA QL(540 per 90 days) VANDETANIB TABS 300MG 4 QL(90 per 90 days) VANDETANIB TABS 100MG 4 QL(180 per 90 days) VECTIBIX INJ 100MG/5ML 4 VELCADE 3 VIDAZA 4 QL(4200 per 90 days) vinblastine sulfate inj 10mg 1 vincasar pfs 1 Drug Name Drug Tier Require-ments/ Limits vincristine sulfate 1 vinorelbine tartrate inj 50mg/5ml 1 VOTRIENT 4 QL(360 per 90 days) ZANOSAR 3 ZOLINZA 4 QL(360 per 90 days) ZORTRESS TABS 0.5MG, 0.75MG 4 B/D PA ZORTRESS TABS 0.25MG 2 B/D PA ZYTIGA 4 PA QL(360 per 90 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL 2 carbamazepine 1 carbamazepine er tb12 1 CARBATROL 2 CELONTIN 2 clonazepam 1 ED DILANTIN CAPS 30MG 2 DILANTIN INFATABS 2 divalproex sodium cpsp 1 divalproex sodium er 1 divalproex sodium tbec 1 epitol 1 EQUETRO 2 ethosuximide 1 FELBATOL 2 gabapentin 1 GABITRIL 2 LAMICTAL ODT TBDP 2 LAMICTAL XR KIT 2 LAMICTAL XR TB24 100MG, 200MG, 25MG, 50MG 2 lamotrigine 1 levetiracetam 1 LYRICA 2 oxcarbazepine 1 PEGANONE 2 phenobarbital tabs 1 ED 7 Drug Name Drug Tier Require-ments/ Limits phenytoin 1 PHENYTOIN SODIUM 2 phenytoin sodium extended 1 primidone 1 SABRIL 2 TEGRETOL-XR TB12 100MG 2 topiramate 1 valproate sodium 1 valproic acid 1 VIMPAT 2 zonisamide 1 ANTIPARKINSONISM AGENTS APOKYN 2 LA AZILECT 2 benztropine mesylate 1 bromocriptine mesylate 1 carbidopa / levodopa 1 carbidopa/levodopa cr 1 carbidopa/levodopa odt 1 carbidopa/levodopa sr tbcr 50mg; 200mg 1 COMTAN 2 LODOSYN 2 MIRAPEX ER TB24 0.375MG, 0.75MG, 1.5MG, 3MG, 4.5MG 2 pramipexole dihydrochloride 1 REQUIP XL 2 ropinirole 1 selegiline 1 STALEVO 100 2 STALEVO 125 2 STALEVO 150 2 STALEVO 200 2 STALEVO 50 2 STALEVO 75 2 trihexyphenidyl 1 ZELAPAR 2 ANXIOLYTICS alprazolam 1 ED diazepam tabs 1 ED lorazepam tabs 1mg, 2mg 1 ED oxazepam 1 ED Drug Name Drug Tier Require-ments/ Limits HYPNOTIC AGENTS temazepam 1 ED MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine mesylate 1 ergotamine tartrate / caffeine 1 MAXALT 3 QL(36 per 90 days) MAXALT-MLT 3 QL(36 per 90 days) migergot 1 MIGRANAL 3 QL(24 per 90 days) naratriptan hcl tabs 2.5mg 1 QL(24 per 90 days) naratriptan hcl tabs 1mg 1 QL(36 per 90 days) RELPAX 3 QL(24 per 90 days) sumatriptan succinate inj 6mg/0.5ml 1 QL(12 per 90 days) sumatriptan succinate tabs 100mg 1 QL(27 per 90 days) sumatriptan succinate tabs 25mg, 50mg 1 QL(54 per 90 days) ZOMIG NASAL SOLN 3 QL(24 per 90 days) ZOMIG TABS 5MG 3 QL(24 per 90 days) ZOMIG TABS 2.5MG 3 QL(36 per 90 days) ZOMIG ZMT TBDP 5MG 3 QL(24 per 90 days) ZOMIG ZMT TBDP 2.5MG 3 QL(36 per 90 days) MISCELLANEOUS NEUROLOGICAL THERAPY ARICEPT ODT 2 ARICEPT TABS 23MG 2 COPAXONE 4 PA QL(90 per 90 days) donepezil hcl 1 EXELON ORAL SOLN 2 EXELON PT24 2 galantamine hydrobromide 1 8 Drug Name Drug Tier Require-ments/ Limits GILENYA 4 PA QL(28 per 28 days) MYTELASE 2 NAMENDA 2 NAMENDA TITRATION PAK 2 NUEDEXTA 2 rivastigmine tartrate 1 XENAZINE 4 LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen 1 cyclobenzaprine hcl 1 dantrolene sodium caps 1 MESTINON SYRP 2 MESTINON TIMESPAN 2 pyridostigmine bromide 1 regonol 1 tizanidine hcl 1 NARCOTIC ANALGESICS acetaminophen / codeine oral soln 1 acetaminophen / codeine tabs 300mg; 15mg 1 acetaminophen/codeine #3 1 acetaminophen/codeine #4 1 ascomp/codeine 1 BUPRENEX 2 buprenorphine hcl 1 codeine sulfate 1 DILAUDID INJ 2 DILAUDID-5 2 DILAUDID-HP INJ 10MG/ML 2 duramorph 1 EMBEDA 3 endocet 1 EXALGO 3 fentanyl citrate 1 fentanyl citrate oral transmucosal lpop 200mcg 1 fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 400mcg, 600mcg, 800mcg 4 Drug Name Drug Tier Require-ments/ Limits fentanyl patches 1 QL(45 per 90 days) hydrocodone bitartrate/acetaminophen tabs 1 hydrocodone/acetaminophen oral soln 500mg/15ml; 7.5mg/15ml 1 hydrocodone/acetaminophen tabs 1 hydrocodone/ibuprofen 1 hydromorphone hcl inj 10mg/ml 1 hydromorphone hcl tabs 1 INFUMORPH 200 2 INFUMORPH 500 2 KADIAN 2 levorphanol tartrate 1 margesic-h 1 methadone hcl conc 1 methadone hcl inj 1 methadone hcl oral soln 5mg/5ml 1 METHADONE HCL ORAL SOLN 10MG/5ML 2 methadone hcl tabs 1 methadose tabs 1 morphine sulfate er 1 morphine sulfate inj 0.5mg/ml, 1mg/ml 1 morphine sulfate oral soln 1 morphine sulfate tabs 1 ONSOLIS 2 OPANA ER 2 oxycodone / acetaminophen 1 oxycodone hcl caps 1 oxycodone hcl conc 1 oxycodone hcl tabs 15mg, 30mg, 5mg 1 oxycodone/aspirin 1 OXYCONTIN 3 ST oxymorphone hydrochloride 1 reprexain tabs 10mg; 200mg 1 ROXICET ORAL SOLN 2 roxicet tabs 325mg; 5mg 1 stagesic 1 zerlor 1 NON-NARCOTIC ANALGESICS 9 Drug Name Drug Tier Require-ments/ Limits ARTHROTEC 50 3 ARTHROTEC 75 3 butorphanol tartrate nasal soln 1 QL(30 per 90 days) CELEBREX 2 PA depade 1 diclofenac potassium 1 diclofenac sodium 1 diclofenac sodium ec 1 diclofenac sodium xr 1 diflunisal 1 etodolac 1 fenoprofen calcium 1 FLECTOR 3 flurbiprofen 1 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 800mg 1 indomethacin caps 1 indomethacin er 1 ketoprofen 1 ketoprofen er 1 meclofenamate sodium 1 mefenamic acid 1 meloxicam 1 nabumetone 1 naloxone 1 naltrexone 1 naproxen sodium tabs 275mg, 550mg 1 naproxen susp 1 naproxen tabs 250mg, 375mg 1 naproxen tbec 1 oxaprozin 1 PENNSAID 2 piroxicam 1 SUBOXONE 2 sulindac 1 tolmetin sodium 1 tramadol 1 tramadol hcl er 1 VIMOVO 2 Drug Name Drug Tier Require-ments/ Limits VOLTAREN GEL 2 PSYCHOTHERAPEUTIC DRUGS ABILIFY 2 ABILIFY DISCMELT 2 amitriptyline 1 amoxapine 1 budeprion sr 1 budeprion xl 1 bupropion hcl 1 bupropion hcl sr 1 buspirone hcl 1 chlordiazepoxide/amitriptyline 1 chlorpromazine 1 citalopram 1 clomipramine 1 clozapine tabs 100mg, 25mg, 50mg 1 CLOZAPINE TABS 200MG 2 CYMBALTA 2 desipramine 1 dextroamphetamine sulfate 1 PA dextroamphetamine sulfate er 1 PA doxepin 1 EMSAM 3 QL(90 per 90 days) FANAPT 3 FANAPT TITRATION PACK 3 FAZACLO 3 fluoxetine 1 fluoxetine dr 1 fluphenazine 1 fluphenazine decanoate inj 1 fluvoxamine 1 FOCALIN XR 2 PA GEODON 2 HALDOL 2 HALDOL DECANOATE 100 2 HALDOL DECANOATE 50 2 haloperidol 1 haloperidol decanoate inj 1 haloperidol lactate inj 1 imipramine 1 10 Drug Name Drug Tier Require-ments/ Limits imipramine pamoate 1 INVEGA 2 INVEGA SUSTENNA 2 LATUDA 2 lithium carbonate 1 lithium carbonate er 1 lithium citrate 1 loxapine 1 maprotiline 1 MARPLAN 2 METADATE CD CPCR 20MG, 30MG, 40MG, 50MG, 60MG 3 PA methylphenidate hcl 1 PA methylphenidate hydrochloride 1 PA mirtazapine 1 mirtazapine odt tbdp 30mg, 45mg 1 nefazodone 1 nortriptyline 1 ORAP 2 paroxetine 1 paroxetine er 1 PAXIL SUSP 2 perphenazine 1 phenelzine sulfate 1 PRISTIQ 2 protriptyline hcl 1 PROVIGIL 2 PA QL(90 per 90 days) RISPERDAL CONSTA 2 risperidone 1 risperidone odt 1 RITALIN LA 3 PA SAPHRIS 2 SEROQUEL 2 SEROQUEL XR 2 sertraline 1 SILENOR 3 STRATTERA 2 SURMONTIL 3 SYMBYAX 3 thioridazine 1 thiothixene 1 Drug Name Drug Tier Require-ments/ Limits tranylcypromine 1 trazodone 1 trifluoperazine 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 VIIBRYD 3 XYREM 4 zaleplon 1 QL(180 per 365 days) zolpidem 1 QL(180 per 365 days) zolpidem tartrate er tbcr 6.25mg 1 zolpidem tartrate er tbcr 12.5mg 1 QL(180 per 365 days) ZYPREXA 2 ZYPREXA ZYDIS 2 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mg/ml 1 amiodarone tabs 1 disopyramide phosphate 1 flecainide acetate 1 mexiletine 1 MULTAQ 2 NORPACE CR CP12 100MG 2 PACERONE TABS 100MG 2 pacerone tabs 200mg 1 procainamide 1 propafenone hcl 1 propafenone hcl er 1 quinidine gluconate er 1 quinidine sulfate 1 quinidine sulfate er 1 sorine 1 sotalol 1 TIKOSYN 3 ANTIHYPERTENSIVE THERAPY acebutolol 1 afeditab cr 1 amiloride 1 amiloride/hydrochlorothiazide 1 11 Drug Name Drug Tier Require-ments/ Limits amlodipine 1 amlodipine / benazepril 1 AMTURNIDE 2 atenolol 1 atenolol / chlorthalidone 1 benazepril 1 benazepril / hydrochlorothiazide 1 BENICAR 2 BENICAR HCT 2 betaxolol hcl 1 BIDIL 2 bisoprolol fumarate 1 bisoprolol fumarate / hydrochlorothiazide 1 bumetanide 1 BYSTOLIC 2 captopril 1 captopril/hydrochlorothiazide 1 cartia xt 1 carvedilol 1 chlorothiazide 1 chlorothiazide sodium 1 chlorthalidone tabs 25mg, 50mg 1 clonidine ptwk 1 clonidine tabs 1 COREG CR 2 DEMSER 2 DIBENZYLINE 3 dilt-cd cp24 120mg, 300mg 1 dilt-xr cp24 180mg, 240mg 1 diltiazem cd cp24 120mg, 240mg, 300mg 1 diltiazem hcl er cp12 1 diltiazem hcl er cp24 360mg, 420mg 1 diltiazem hcl inj 25mg/5ml 1 DILTIAZEM HCL INJ 100MG 2 diltiazem hcl tabs 1 diltzac cp24 120mg, 180mg, 240mg, 300mg 1 DIOVAN 2 DIOVAN HCT 2 Drug Name Drug Tier Require-ments/ Limits doxazosin 1 EDECRIN 2 enalapril 1 enalapril / hydrochlorothiazide 1 eplerenone 1 EXFORGE 2 EXFORGE HCT 2 felodipine er 1 fosinopril 1 fosinopril / hydrochlorothiazide 1 furosemide inj 1 furosemide oral soln 10mg/ml 1 FUROSEMIDE ORAL SOLN 8MG/ML 2 furosemide tabs 1 guanfacine hcl 1 hydralazine 1 hydrochlorothiazide 1 indapamide 1 isradipine 1 labetalol 1 lisinopril 1 lisinopril/hydrochlorothiazide 1 losartan potassium 1 losartan potassium/hydrochlorothiazide 1 matzim la 1 methyclothiazide 1 metolazone 1 metoprolol succinate er 1 metoprolol tartrate 1 metoprolol/hydrochlorothiazide 1 minoxidil tabs 1 moexipril 1 moexipril/hydrochlorothiazide 1 nadolol 1 nadolol/bendroflumethiazide 1 nicardipine caps 1 nifediac cc 1 nifedical xl 1 nifedipine 1 nifedipine er 1 12 Drug Name Drug Tier Require-ments/ Limits nimodipine 1 nisoldipine 1 nisoldipine er 1 perindopril erbumine 1 pindolol 1 prazosin 1 propranolol hcl 1 propranolol hcl er 1 propranolol/hydrochlorothiazide 1 quinapril 1 quinapril/hydrochlorothiazide 1 ramipril 1 REMODULIN 4 PA reserpine 1 SODIUM EDECRIN 2 spironolactone 1 spironolactone/hydrochlorothiazi de 1 taztia xt 1 TEKAMLO 2 TEKTURNA 2 TEKTURNA HCT 2 terazosin hcl 1 timolol maleate 1 torsemide tabs 1 trandolapril 1 triamterene/hydrochlorothiazide 1 TWYNSTA 2 VALTURNA 2 verapamil 1 verapamil er 1 CARDIAC GLYCOSIDES digoxin 1 LANOXIN 2 COAGULATION THERAPY AGGRENOX 2 ARIXTRA 2 cilostazol 1 CYKLOKAPRON 2 EFFIENT 2 Drug Name Drug Tier Require-ments/ Limits enoxaparin sodium inj 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml 1 enoxaparin sodium inj 100mg/ml, 120mg/0.8ml, 150mg/ml 4 FRAGMIN 2 HEPARIN SODIUM INJ 2000UNIT/ML 2 heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml 1 heparin sodium/d5w inj 5%; 40unit/ml 1 HEPARIN SODIUM/NACL 0.45% 2 heparin sodium/sodium chloride 0.9% premix 1 jantoven 1 LOVENOX INJ 300MG/3ML 2 pentopak 1 pentoxifylline er 1 PLAVIX 2 PRADAXA 2 PROMACTA 4 LA ticlopidine hcl 1 warfarin 1 LIPID/CHOLESTEROL LOWERING AGENTS CADUET 2 cholestyramine light pack 1 colestipol 1 fenofibrate 1 fenofibrate micronized 1 gemfibrozil 1 LIPITOR 2 lovastatin 1 LOVAZA 2 NIASPAN 2 pravastatin 1 prevalite powd 1 simvastatin 1 TRICOR 2 TRILIPIX 2 13 Drug Name Drug Tier Require-ments/ Limits WELCHOL 2 ZETIA 2 MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 2 NITRATES isosorbide dinitrate 1 isosorbide dinitrate er 1 isosorbide mononitrate 1 isosorbide mononitrate er 1 nitro-bid 1 NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR 2 nitroglycerin inj 1 B/D PA nitroglycerin pt24 1 nitroglycerin transdermal pt24 0.1mg/hr 1 NITROLINGUAL PUMPSPRAY 2 NITROSTAT 2 DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC calcipotriene 1 selenium sulfide lotn 2.5% 1 SORIATANE 2 BURN THERAPY silver sulfadiazine 1 ssd 1 thermazene 1 MISCELLANEOUS DERMATOLOGICALS 8-MOP 2 ammonium lactate 1 CARAC 2 CARMOL-HC 2 CONDYLOX GEL 2 ELIDEL 3 FLUOROPLEX 2 fluorouracil crea 1 fluorouracil external soln 1 imiquimod 1 laclotion 1 Drug Name Drug Tier Require-ments/ Limits OXSORALEN ULTRA 4 PANRETIN 2 podofilox 1 PROTOPIC 3 REGRANEX 2 SOLARAZE 2 UVADEX 3 VEREGEN 3 ZONALON 2 THERAPY FOR ACNE adapalene 1 amnesteem 1 avita crea 1 AZELEX 2 claravis caps 10mg, 20mg, 40mg 1 claravis caps 30mg 4 clindamycin phosphate external soln 1 clindamycin phosphate foam 1 clindamycin phosphate gel 1 clindamycin phosphate lotn 1 clindamycin phosphate swab 1 clindamycin/benzoyl peroxide 1 DIFFERIN LOTN 2 ery 1 erythromycin / benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 2 METROGEL 2 metronidazole 1 sotret 1 TAZORAC 2 tretinoin 1 TOPICAL ANESTHETICS lidocaine / prilocaine crea 1 lidocaine external soln 1 lidocaine gel 1 lidocaine inj 0.5%, 1% 1 lidocaine oint 1 lidocaine viscous 1 14 Drug Name Drug Tier Require-ments/ Limits LIDODERM 2 QL(270 per 90 days) TOPICAL ANTIBACTERIALS ALTABAX 2 BACTROBAN CREA 2 gentamicin sulfate crea 1 gentamicin sulfate oint 0.1% 1 mupirocin 1 PHISOHEX 2 sodium sulfacetamide 1 SULFAMYLON 2 TOPICAL ANTIFUNGALS ciclopirox 1 ciclopirox nail lacquer 1 ciclopirox olamine 1 clotrimazole / betamethasone 1 clotrimazole external crea 1 clotrimazole external soln 1 econazole nitrate 1 ketoconazole 1 NAFTIN 2 nyamyc 1 nystatin / triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 pedi-dri 1 TOPICAL ANTIVIRALS DENAVIR 2 ZOVIRAX CREA 3 ZOVIRAX OINT 3 TOPICAL CORTICOSTEROIDS ala cort 1 alclometasone dipropionate 1 amcinonide 1 augmented betamethasone dipropionate crea 1 augmented betamethasone dipropionate lotn 1 augmented betamethasone dipropionate oint 1 Drug Name Drug Tier Require-ments/ Limits betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 2 clobetasol propionate e 1 clobetasol propionate external soln 1 clobetasol propionate gel 1 clobetasol propionate oint 1 CLOBEX LOTN 2 CLOBEX SHAM 2 CORDRAN TAPE 2 DERMA-SMOOTHE / FS BODY OIL 2 desonide 1 desoximetasone 1 diflorasone diacetate 1 fluocinolone acetonide 1 fluocinonide emollient base 1 fluocinonide external soln 1 fluocinonide gel 1 fluocinonide oint 1 fluticasone propionate crea 1 fluticasone propionate oint 1 halobetasol propionate 1 hydrocortisone butyrate 1 hydrocortisone crea 1%, 2.5% 1 hydrocortisone lotn 2.5% 1 hydrocortisone oint 1%, 2.5% 1 hydrocortisone valerate 1 LOCOID LOTN 2 LUXIQ 2 mometasone furoate 1 PANDEL 2 prednicarbate 1 triamcinolone acetonide crea 1 triamcinolone acetonide lotn 1 triamcinolone acetonide oint 1 triderm 1 TOPICAL ENZYMES SANTYL 2 TOPICAL SCABICIDES / PEDICULICIDES acticin 1 15 Drug Name Drug Tier Require-ments/ Limits EURAX 2 LINDANE 2 malathion 1 permethrin crea 1 ULESFIA 3 DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS ACTONEL TABS 30MG 3 ADAGEN 4 LA alendronate sodium tabs 40mg 1 QL(90 per 90 days) anagrelide hydrochloride 1 ANTABUSE TABS 250MG 2 ARALAST NP INJ 400MG 4 LA BUPHENYL 2 CAMPRAL 2 CHEMET 2 CLINIMIX / DEXTROSE 2 DEXTROSE 10%/NACL 0.45% 2 dextrose 10% flex container 1 DEXTROSE 10%/NACL 0.2% 2 dextrose 2.5%/sodium chloride 0.45% 1 dextrose 5% 1 dextrose 5%/nacl 0.2% 1 dextrose 5%/nacl 0.225% 1 DEXTROSE 5%/NACL 0.33% 2 dextrose 5%/nacl 0.45% 1 dextrose 5%/nacl 0.9% 1 etidronate disodium 1 EVOXAC 3 EXJADE TBSO 125MG 2 LA EXJADE TBSO 250MG, 500MG 4 LA FOSRENOL 2 INCRELEX 4 LA kionex powd 1 levocarnitine oral soln 1 B/D PA levocarnitine tabs 1 B/D PA midodrine 1 ORFADIN 4 LA Drug Name Drug Tier Require-ments/ Limits pilocarpine hcl tabs 1 PROLASTIN INJ 500MG 4 LA PROLASTIN-C 4 LA RENAGEL 2 RENVELA 2 RILUTEK 4 SKELID 3 sodium chloride 0.9% 1 sodium chloride inj 0.9% 1 sodium polystyrene sulfonate 1 SYPRINE 2 SMOKING DETERRENTS BUPROBAN 5 QL(180 per 90 days) CHANTIX TABS 5 CHANTIX TABS 0.5MG, 1MG 5 QL(336 per 365 days) NICOTROL INHALER 5 QL(2688 per 365 days) NICOTROL NASAL 5 QL(7200 per 365 days) EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO 2 azelastine hcl 1 BACTROBAN NASAL 2 chlorhexidine gluconate oral rinse 1 ipratropium bromide nasal soln 1 periogard 1 triamcinolone in orabase 1 TYZINE 2 TYZINE PEDIATRIC NASAL DROPS 2 MISCELLANEOUS OTIC PREPARATIONS acetasol hc 1 acetic acid 1 DERMOTIC 2 hydrocortisone/acetic acid 1 16 Drug Name Drug Tier Require-ments/ Limits ofloxacin 1 OTIC STEROID / ANTIBIOTIC CIPRO HC 3 CIPRODEX 2 COLY-MYCIN S 2 CORTISPORIN-TC 2 cortomycin 1 neomycin/polymyxin/hc 1 neomycin/polymyxin/hydrocortiso ne otic susp 1 ENDOCRINE/DIABETES ADRENAL HORMONES a-hydrocort 1 a-methapred 1 B/D PA cortisone acetate 1 DEPO-MEDROL 2 B/D PA dexamethasone elix 1 dexamethasone inj 4mg/ml 1 DEXAMETHASONE INTENSOL 2 DEXAMETHASONE TABS 1MG, 2MG 2 dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg 1 fludrocortisone acetate 1 hydrocortisone tabs 1 methylprednisolone 1 B/D PA methylprednisolone acetate 1 B/D PA methylprednisolone sodiumsuccinate inj 125mg, 40mg 1 B/D PA METHYLPREDNISOLONE SODIUMSUCCINATE INJ 1000MG 2 B/D PA prednisolone sodium phosphate oral soln 1 B/D PA prednisone 1 B/D PA PREDNISONE INTENSOL 2 B/D PA SOLU-CORTEF INJ 100MG, 250MG 2 SOLU-MEDROL INJ 125MG, 2GM, 40MG, 500MG 2 B/D PA ANTITHYROID AGENTS methimazole 1 Drug Name Drug Tier Require-ments/ Limits propylthiouracil 1 DIABETES THERAPY acarbose 1 ACTOPLUS MET 2 ACTOS 2 ALCOHOL PREPS 2 APIDRA 2 QL(120 per 90 days) APIDRA SOLOSTAR 2 QL(120 per 90 days) AVANDAMET 2 AVANDARYL 2 AVANDIA 2 BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 2 QL(600 per 90 days) BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 2 QL(600 per 90 days) BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 2 QL(600 per 90 days) BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 2 QL(600 per 90 days) BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 2 QL(600 per 90 days) BYETTA 3 QL(7.2 per 90 days) DUETACT 2 GAUZE PADS 2"X2" 2 glimepiride 1 glipizide 1 glipizide / metformin 1 glipizide er 1 GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT 2 glyburide 1 glyburide / metformin 1 glyburide micronized 1 glycron tabs 1.5mg 1 GLYCRON TABS 4.5MG 2 HUMALOG 2 QL(120 per 90 days) 17 Drug Name Drug Tier Require-ments/ Limits HUMALOG KWIKPEN 2 QL(120 per 90 days) HUMALOG MIX 50/50 2 QL(120 per 90 days) HUMALOG MIX 50/50 KWIKPEN 2 QL(135 per 90 days) HUMALOG MIX 75/25 2 QL(120 per 90 days) HUMALOG MIX 75/25 KWIKPEN 2 QL(135 per 90 days) HUMULIN 70/30 2 QL(120 per 90 days) HUMULIN 70/30 PEN 2 QL(135 per 90 days) HUMULIN N 2 QL(120 per 90 days) HUMULIN N U-100 PEN 2 QL(135 per 90 days) HUMULIN R 2 QL(120 per 90 days) HUMULIN R U-500 (CONCENTRATED) 2 JANUMET 2 JANUVIA 2 KOMBIGLYZE XR 2 LANTUS 2 QL(120 per 90 days) LANTUS SOLOSTAR 2 QL(120 per 90 days) LEVEMIR 2 QL(120 per 90 days) LEVEMIR FLEXPEN 2 QL(135 per 90 days) metformin hcl 1 metformin hcl er 1 nateglinide 1 NOVOLIN 70/30 2 QL(120 per 90 days) NOVOLIN N 2 QL(120 per 90 days) NOVOLIN R 2 QL(120 per 90 days) NOVOLOG 2 QL(120 per 90 days) NOVOLOG FLEXPEN 2 QL(135 per 90 days) Drug Name Drug Tier Require-ments/ Limits NOVOLOG MIX 70/30 2 QL(120 per 90 days) NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2 QL(135 per 90 days) ONGLYZA 2 PRANDIN 2 PROGLYCEM 2 SYMLIN 3 QL(60 per 90 days) SYMLINPEN 120 3 QL(33 per 90 days) SYMLINPEN 60 3 QL(33 per 90 days) tolazamide 1 tolbutamide 1 MISCELLANEOUS HORMONES ALDURAZYME 4 B/D LA PA ANADROL-50 3 PA ANDRODERM 2 PA QL(180 per 90 days) ANDROGEL GEL 50MG/5GM 2 PA QL(900 per 90 days) ANDROGEL PUMP GEL 1.62% 2 PA ANDROID 2 PA androxy 1 PA cabergoline 1 calcitonin-salmon 1 QL(12 per 90 days) calcitriol 1 B/D PA CEREZYME INJ 200UNIT 4 B/D LA PA danazol 1 desmopressin acetate 1 FABRAZYME INJ 35MG 4 B/D LA PA fortical 1 QL(12 per 90 days) HECTOROL 2 KUVAN 4 LA NAGLAZYME 4 LA oxandrolone tabs 10mg 4 oxandrolone tabs 2.5mg 1 SAMSCA 4 SENSIPAR TABS 60MG, 90MG 4 SENSIPAR TABS 30MG 2 18 Drug Name Drug Tier Require-ments/ Limits SOMAVERT 2 PA QL(90 per 90 days) STIMATE 2 SYNAREL 3 testosterone cypionate inj 100mg/ml 1 PA testosterone enanthate 1 PA ZAVESCA 2 LA ZEMPLAR 2 B/D PA ZOMETA 4 THYROID HORMONES levothyroxine tabs 1 levoxyl 1 liothyronine sodium tabs 1 SYNTHROID 2 unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg 1 GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine sulfate inj 0.1mg/ml 1 ATROPINE SULFATE INJ 0.05MG/ML 2 dicyclomine hcl 1 glycopyrrolate 1 loperamide hcl caps 1 propantheline bromide 1 MISCELLANEOUS GASTROINTESTINAL AGENTS AMITIZA 2 ASACOL 2 ASACOL HD 2 balsalazide 1 CANASA 2 CIMZIA 4 PA QL(6 per 28 days) compro 1 constulose 1 CORTIFOAM 2 Drug Name Drug Tier Require-ments/ Limits CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT 2 CYSTADANE 2 DIPENTUM 3 dronabinol 1 B/D PA EMEND CAPS 40MG 2 B/D PA QL(3 per 90 days) EMEND CAPS 125MG 2 B/D PA QL(6 per 90 days) EMEND CAPS 2 B/D PA QL(18 per 90 days) EMEND CAPS 80MG 2 B/D PA QL(24 per 90 days) ENTOCORT EC 2 enulose 1 GASTROCROM 2 gavilyte-c 1 gavilyte-g 1 gavilyte-n/flavor pack 1 granisetron inj 0.1mg/ml, 1mg/ml 1 granisetron tabs 1 B/D PA hydrocortisone enem 1 lactulose 1 LOTRONEX 2 meclizine hcl 1 mesalamine enem 1 metoclopramide 1 ondansetron hcl inj 4mg/2ml 1 ondansetron hcl oral soln 1 B/D PA ondansetron hcl tabs 24mg 1 B/D PA QL(21 per 90 days) ondansetron hcl tabs 4mg, 8mg 1 B/D PA QL(135 per 90 days) ondansetron odt 1 B/D PA QL(135 per 90 days) 19 Drug Name Drug Tier Require-ments/ Limits PENTASA 2 polyethylene glycol 3350 powd 1 prochlorperazine 1 prochlorperazine edisylate 1 prochlorperazine maleate 1 procto-pak 1 proctosol hc 1 proctozone-hc 1 RELISTOR 2 REMICADE 4 PA SANCUSO 2 QL(6 per 90 days) sulfasalazine tabs 1 sulfazine ec 1 TRANSDERM-SCOP 3 trilyte 1 ursodiol 1 ZENPEP 2 ZUPLENZ 2 B/D PA QL(135 per 90 days) ULCER THERAPY CARAFATE SUSP 2 famotidine inj 1 famotidine premixed 1 famotidine susr 1 famotidine tabs 20mg, 40mg 1 lansoprazole 1 lansoprazole odt 1 misoprostol 1 NEXIUM I.V. 2 nizatidine 1 omeprazole cpdr 1 pantoprazole 1 PREVPAC 3 PYLERA 2 ranitidine hcl caps 1 ranitidine hcl syrp 1 ranitidine hcl tabs 1 sucralfate 1 ZANTAC INJ 50MG/50ML; 0.45% 2 Drug Name Drug Tier Require-ments/ Limits IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA ARANESP INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 25MCG/0.42ML, 25MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML 2 PA ARCALYST 4 LA AVONEX 4 PA QL(12 per 90 days) BETASERON 4 PA QL(45 per 90 days) EPOGEN 3 PA INTRON-A INJ 3MU/0.2ML, 6000000UNIT/ML 2 INTRON-A INJ 10MU/0.2ML, 5MU/0.2ML 4 INTRON-A WITH DILUENT INJ 10MU 4 LEUKINE 4 PA MOZOBIL 4 NEULASTA 3 PA NEUMEGA 4 PA NEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML 4 PA NORDITROPIN FLEXPRO 4 PA NORDITROPIN NORDIFLEX PEN 4 PA omnitrope inj 5mg/1.5ml 1 PA PEG-INTRON INJ 50MCG/0.5ML 4 PEG-INTRON REDIPEN 4 PEGASYS 4 PROCRIT 2 PA PROLEUKIN 4 REBIF 4 PA QL(18 per 90 days) REBIF TITRATION PACK 4 PA 20 Drug Name Drug Tier Require-ments/ Limits TEV-TROPIN 2 PA VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB 2 ADACEL 2 BOOSTRIX 2 CERVARIX 2 COMVAX 2 DAPTACEL 2 DECAVAC 2 DIPHTHERIA/TETANUS TOXOID PEDIATRIC 2 ENGERIX-B 2 B/D PA GARDASIL 2 HAVRIX 2 HIZENTRA INJ 1GM/5ML 4 PA IMOVAX RABIES (H.D.C.V.) 2 INFANRIX 2 IPOL INACTIVATED IPV 2 IXIARO 2 JE-VAX 2 M-M-R II W/DILUENT 10 DOSE 2 MENACTRA 2 MENOMUNE-A/C/Y/W-135 2 MENVEO 2 PEDVAX HIB 2 PRIVIGEN INJ 20GM/200ML 4 PA PROQUAD 2 RABAVERT 2 RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML 2 B/D PA ROTATEQ 2 TETANUS / DIPHTHERIA TOXOIDS-ADSORBED ADULT 2 TETANUS TOXOID ADSORBED 2 THYMOGLOBULIN 2 TRIPEDIA 2 TWINRIX 2 B/D PA TYPHIM VI 2 VAQTA 2 VARIVAX 2 Drug Name Drug Tier Require-ments/ Limits VIVAGLOBIN 4 PA YF-VAX 2 ZOSTAVAX 2 MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol 1 COLCRYS 2 probenecid 1 probenecid / colchicine 1 ULORIC 2 OSTEOPOROSIS THERAPY alendronate sodium tabs 35mg, 70mg 1 QL(12 per 90 days) alendronate sodium tabs 10mg, 5mg 1 QL(90 per 90 days) BONIVA INJ 2 BONIVA TABS 3 B/D PA QL(3 per 90 days) EVISTA 2 FORTEO 2 QL(7.2 per 90 days) OTHER RHEUMATOLOGICALS CUPRIMINE 2 DEPEN TITRATABS 2 ENBREL 4 PA QL(600 per 90 days) HUMIRA INJ 20MG/0.4ML 4 PA QL(2.4 per 90 days) HUMIRA INJ 40MG/0.8ML 4 PA QL(4.8 per 90 days) HUMIRA PEN-CROHNS DISEASE STARTER 4 PA leflunomide 1 QL(90 per 90 days) RIDAURA 3 SAVELLA 2 SAVELLA TITRATION PACK 2 SIMPONI 4 PA QL(1 per 30 days) OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS 21 Drug Name Drug Tier Require-ments/ Limits ALORA 2 QL(24 per 90 days) camila 1 CLIMARA PRO 2 QL(12 per 90 days) COMBIPATCH 2 QL(24 per 90 days) CRINONE 2 DEPO-PROVERA 2 DEPO-SUBQ PROVERA 104 3 DIVIGEL GEL 1MG/GM 2 QL(90 per 90 days) errin 1 ESTRADERM 2 QL(24 per 90 days) estradiol / norethindrone acetate tabs 1mg; 0.5mg 1 estradiol ptwk 1 QL(12 per 90 days) estradiol tabs 1 ESTRING 3 estropipate 1 jinteli 1 jolivette 1 medroxyprogesterone acetate 1 MENOSTAR 3 QL(12 per 90 days) nora-be 1 norethindrone tabs 5mg 1 ortho-est 1 PREFEST 3 PREMARIN TABS 2 PREMARIN W/APPLICATOR 2 PREMPHASE 2 PREMPRO 2 PROMETRIUM 2 VAGIFEM 2 VIVELLE-DOT 2 QL(24 per 90 days) MISCELLANEOUS OB/GYN CLEOCIN SUPP 2 clindamycin phosphate crea 1 GYNAZOLE-1 2 LYSTEDA 3 Drug Name Drug Tier Require-ments/ Limits metronidazole vaginal 1 miconazole 3 1 NUVARING 3 ORTHO EVRA 3 terconazole 1 vandazole 1 zazole crea 0.4% 1 ORAL CONTRACEPTIVES / RELATED AGENTS apri 1 aranelle 1 aviane 1 balziva 1 cesia 1 cryselle-28 1 cyclafem 1/35 1 cyclafem 7/7/7 1 ELLA 2 enpresse-28 1 gianvi 1 junel 1 junel fe 1.5/30 1 junel fe 1/20 1 kariva 1 kelnor 1/35 1 leena 1 lessina-28 1 levora 1 low-ogestrel 1 lutera 1 microgestin 1.5/30 1 microgestin 1/20 1 microgestin fe 1 microgestin fe 1.5/30 1 mononessa 1 necon 0.5/35-28 1 necon 1/35-28 1 necon 10/11-28 1 necon 7/7/7 1 next choice 1 nortrel 0.5/35 (28) 1 22 Drug Name Drug Tier Require-ments/ Limits nortrel 1/35 (21) 1 nortrel 1/35 (28) 1 nortrel 7/7/7 1 ocella 1 ogestrel 1 portia-28 1 previfem 1 quasense 1 reclipsen 1 solia 1 sprintec 28 1 sronyx 1 tri-legest fe 1 tri-previfem 1 tri-sprintec 1 trinessa 1 trivora-28 1 velivet 1 zeosa 1 zovia 1/35e 1 zovia 1/50e 1 OXYTOCICS METHERGINE TABS 2 OPHTHALMOLOGY ANTIBIOTICS ak-tob 1 AZASITE 2 bacitracin / polymyxin b 1 bacitracin ophthalmic oint 1 BESIVANCE 2 CILOXAN OINT 2 ciprofloxacin ophthalmic soln 1 erythromycin oint 1 gentak 1 gentamicin sulfate ophthalmic soln 1 gentasol 1 levofloxacin ophthalmic soln 1 MOXEZA 2 NATACYN 2 neomycin/bacitracin/polymyxin 1 Drug Name Drug Tier Require-ments/ Limits neomycin/polymyxin/gramicidin 1 ofloxacin 1 romycin 1 tobramycin ophthalmic soln 1 tobrasol 1 TOBREX OINT 2 trimethoprim sulfate/polymyxin b sulfate 1 VIGAMOX 2 ZYMAR 2 ZYMAXID 2 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl 1 BETOPTIC-S 2 carteolol hcl 1 ISTALOL 2 levobunolol hcl 1 metipranolol 1 timolol maleate 1 timolol maleate ophthalmic gel forming 1 TIMOPTIC OCUDOSE 2 CYCLOPLEGIC MYDRIATICS tropicamide 1 DIRECT ACTING MIOTICS PILOPINE HS 2 MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 azelastine hcl 1 BEPREVE 2 cromolyn sodium ophthalmic soln 1 epinastine hcl 1 LACRISERT 2 PATADAY 2 PATANOL 2 RESTASIS 2 QL(192 per 90 days) 23 Drug Name Drug Tier Require-ments/ Limits NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 2 BROMDAY 2 bromfenac 1 diclofenac sodium 1 flurbiprofen sodium 1 ketorolac tromethamine ophthalmic soln 1 NEVANAC 2 ORAL DRUGS FOR GLAUCOMA acetazolamide 1 acetazolamide sodium 1 methazolamide 1 OTHER GLAUCOMA DRUGS AZOPT 2 COMBIGAN 2 dorzolamide hcl 1 dorzolamide hcl/timolol maleate 1 latanoprost 1 LUMIGAN 2 TRAVATAN Z 2 STEROID-ANTIBIOTIC COMBINATIONS neomycin/polymyxin/bacitracin/h ydrocortisone 1 neomycin/polymyxin/dexamethaso ne 1 neomycin/polymyxin/hydrocortiso ne ophthalmic susp 1 poly-dex 1 TOBRADEX OINT 2 TOBRADEX ST 2 tobramycin/dexamethasone 1 ZYLET 2 STEROID-SULFONAMIDE COMBINATIONS sulfacetamide sodium / prednisolone sodium phospha 1 STEROIDS ALREX 2 dexamethasone ophthalmic soln 1 DUREZOL 2 Drug Name Drug Tier Require-ments/ Limits fluorometholone 1 FML 2 FML FORTE 2 LOTEMAX 2 prednisolone acetate 1 prednisolone sodium phosphate ophthalmic soln 1 SULFONAMIDES BLEPH-10 2 sodium sulfacetamide 1 SYMPATHOMIMETICS ALPHAGAN P 2 apraclonidine 1 brimonidine tartrate ophthalmic soln 0.2% 1 IOPIDINE OPHTHALMIC SOLN 1% 3 VASOCONSTRICTOR DECONGESTANTS ak-con 1 RENAL / GENITOURINARY IMPOTENCE AGENTS CAVERJECT 2 ED PA QL(6 per 30 days) CAVERJECT IMPULSE 2 ED PA QL(6 per 30 days) CIALIS 3 ED PA QL(6 per 30 days) LEVITRA 2 ED PA QL(6 per 30 days) MUSE 2 ED PA QL(6 per 30 days) VIAGRA 2 ED PA QL(6 per 30 days) RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS carbinoxamine maleate 1 cetirizine hcl syrp 1 24 Drug Name Drug Tier Require-ments/ Limits CLARINEX 3 CLARINEX REDITABS 3 CLARINEX-D 12 HOUR 3 CLARINEX-D 24 HOUR 3 clemastine fumarate syrp 1 clemastine fumarate tabs 2.68mg 1 epinephrine hcl inj 0.1mg/ml 1 EPIPEN 2 EPIPEN-JR 2 fexofenadine hcl 1 hydroxyzine hcl 1 levocetirizine dihydrochloride 1 palgic liqd 1 phenadoz 1 promethazine hcl 1 promethegan supp 25mg, 50mg 1 TWINJECT 2 PULMONARY AGENTS acetylcysteine 1 B/D PA ADVAIR DISKUS 2 ADVAIR HFA 2 albuterol sulfate er 1 albuterol sulfate nebu 1 B/D PA albuterol sulfate syrp 1 albuterol sulfate tabs 1 aminophylline 1 ASMANEX 120 METERED DOSES 2 ASMANEX 14 METERED DOSES 2 ASMANEX 30 METERED DOSES 2 ASMANEX 60 METERED DOSES 2 ATROVENT HFA 2 budesonide susp 1 B/D PA COMBIVENT 2 cromolyn sodium nebu 1 B/D PA DULERA 3 ELIXOPHYLLIN 3 FLOVENT DISKUS 2 FLOVENT HFA 2 Drug Name Drug Tier Require-ments/ Limits flunisolide nasal soln 0.025% 1 QL(200 per 90 days) fluticasone propionate susp 1 QL(48 per 90 days) FORADIL AEROLIZER 2 ipratropium bromide inhalation soln 1 B/D PA ipratropium bromide/albuterol sulfate 1 B/D PA LETAIRIS 4 LA metaproterenol sulfate 1 PERFOROMIST 2 B/D PA PROAIR HFA 2 PROVENTIL HFA 3 PULMICORT FLEXHALER 2 PULMICORT SUSP 1MG/2ML 2 B/D PA PULMOZYME 4 B/D PA QVAR 2 REVATIO 4 SEREVENT DISKUS 2 SINGULAIR 2 SPIRIVA HANDIHALER 2 SYMBICORT 2 terbutaline sulfate 1 THEO-24 3 theochron tb12 100mg, 300mg 1 theophylline er 1 TRACLEER 4 LA VENTOLIN HFA 2 XOLAIR 4 PA QL(7.2 per 30 days) zafirlukast 1 ZYFLO CR 3 UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS DETROL 2 DETROL LA 2 ENABLEX 2 flavoxate hcl 1 GELNIQUE 2 oxybutynin 1 25 Drug Name Drug Tier Require-ments/ Limits oxybutynin er 1 OXYTROL 2 QL(48 per 90 days) TOVIAZ 2 trospium chloride 1 VESICARE 2 BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY AVODART 2 finasteride 1 JALYN 2 RAPAFLO 2 tamsulosin hcl 1 UROXATRAL 2 CHOLINERGIC STIMULANTS bethanechol chloride 1 MISCELLANEOUS UROLOGICALS CYSTAGON 2 LA ELMIRON 2 potassium citrate extended-release 1 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate 1 eliphos 1 K-TABS 3 kcl 0.075%/d5w/nacl 0.45% 1 kcl 0.15%/d5w/lr 1 KCL 0.15%/D5W/NACL 0.2% 2 KCL 0.15%/D5W/NACL 0.225% 2 kcl 0.15%/d5w/nacl 0.9% 1 kcl 0.3%/d5w/lr iv lac ring 1 KCL 0.3%/D5W/NACL 0.2% 2 kcl 0.3%/d5w/nacl 0.45% 1 kcl 0.3%/d5w/nacl 0.9% 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 2 Drug Name Drug Tier Require-ments/ Limits MAGNESIUM SULFATE IN D5W INJ 5%; 10MG/ML 2 MAGNESIUM SULFATE INJ 2 NORMOSOL 2 POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225% 2 POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX 2 potassium chloride 0.15% d5w/nacl 0.33% 1 potassium chloride 0.15% d5w/nacl 0.45% viaflex 1 potassium chloride 0.15% nacl 0.9% 1 POTASSIUM CHLORIDE 0.15%/D5W 2 POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% 2 potassium chloride 0.224%/d5w 1 POTASSIUM CHLORIDE 0.3%/ NACL 0.9% 2 potassium chloride 0.3%/d5w 1 potassium chloride er cpcr 1 potassium chloride er tbcr 10meq, 20meq 1 potassium chloride inj 10meq/100ml, 10meq/50ml, 2meq/ml 1 POTASSIUM CHLORIDE INJ 0.4MEQ/ML, 30MEQ/100ML 2 ringers injection 1 sodium bicarbonate inj 7.5%, 8.4% 1 sodium chloride 0.45% viaflex 1 sodium chloride inj 2.5meq/ml, 3%, 5% 1 MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 2 AMINOSYN II 2 AMINOSYN II M 2 AMINOSYN-HBC 2 AMINOSYN-HF 2 AMINOSYN-PF 2 AMINOSYN-PF 7% 2 26 Drug Name Drug Tier Require-ments/ Limits CLINIMIX / DEXTROSE 2 CLINISOL SF 2 DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX 2 FREAMINE III 2 HEPATAMINE 2 HEPATASOL 2 INTRALIPID INJ 1.7%; 30% 2 intralipid inj 2.25%; 20% 1 IONOSOL 2 ISOLYTE 2 KCL 0.15%/D10W/NACL 0.2% 2 LIPOSYN III INJ 1.8%; 2.5%; 30% 2 NEPHRAMINE 2 NORMOSOL 2 PLASMA-LYTE 2 PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML 2 premasol inj 52meq/l; 1760mg/100ml; 880mg/100ml; 34meq/l; 1760mg/100ml; 372mg/100ml; 406mg/100ml; 526mg/100ml; 492mg/100ml; 492mg/100ml; 526mg/100ml; 356mg/100ml; 356mg/100ml; 390mg/100ml; 34mg/100ml; 152mg/100ml 1 TRAVASOL 2 TROPHAMINE 2 VITAMINS / HEMATINICS prenatal vitamins (generic) 1 sodium fluoride tabs 1 27 Index of Drugs 8 8-MOP................................................................. 13 A ABILIFY ............................................................... 9 ABILIFY DISCMELT .......................................... 9 ABRAXANE......................................................... 4 acarbose .............................................................. 16 acebutolol ............................................................ 10 acetaminophen / codeine....................................... 8 acetaminophen/codeine #3.................................... 8 acetaminophen/codeine #4.................................... 8 acetasol hc........................................................... 15 acetazolamide...................................................... 23 acetazolamide sodium ......................................... 23 acetic acid ........................................................... 15 acetylcysteine ...................................................... 24 ACTHIB .............................................................. 20 acticin.................................................................. 14 ACTIMMUNE .................................................... 19 ACTONEL .......................................................... 15 ACTOPLUS MET............................................... 16 ACTOS................................................................ 16 ACUVAIL........................................................... 23 acyclovir ................................................................ 1 ADACEL............................................................. 20 ADAGEN ............................................................ 15 adapalene ............................................................ 13 adriamycin............................................................. 4 ADVAIR DISKUS.............................................. 24 ADVAIR HFA .................................................... 24 afeditab cr ........................................................... 10 AFINITOR ............................................................ 4 AGGRENOX ...................................................... 12 a-hydrocort.......................................................... 16 ak-con.................................................................. 23 ak-tob................................................................... 22 ala cort ................................................................ 14 ALBENZA ........................................................... 2 albuterol sulfate................................................... 24 albuterol sulfate er .............................................. 24 alclometasone dipropionate ................................ 14 ALCOHOL PREPS..............................................16 ALDURAZYME..................................................17 alendronate sodium........................................15, 20 ALIMTA ................................................................4 ALINIA..................................................................2 ALKERAN ............................................................4 allopurinol............................................................20 ALOCRIL ............................................................22 ALORA................................................................21 ALPHAGAN P ....................................................23 alprazolam .............................................................7 ALREX ................................................................23 ALTABAX ..........................................................14 amantadine.............................................................1 amcinonide...........................................................14 a-methapred .........................................................16 amifostine...............................................................4 amikacin sulfate .....................................................2 amiloride..............................................................10 amiloride/hydrochlorothiazide ............................10 aminophylline.......................................................24 AMINOSYN ........................................................25 AMINOSYN II ....................................................25 AMINOSYN II M................................................25 AMINOSYN-HBC ..............................................25 AMINOSYN-HF..................................................25 AMINOSYN-PF ..................................................25 AMINOSYN-PF 7%............................................25 amiodarone ..........................................................10 AMITIZA.............................................................18 amitriptyline...........................................................9 amlodipine............................................................11 amlodipine / benazepril........................................11 ammonium lactate................................................13 amnesteem............................................................13 amoxapine..............................................................9 amoxicillin..............................................................3 amoxicillin/clavulanate potassium.........................3 amoxicillin/clavulanate potassium er ....................3 amoxicillin/potassium clavulanate.........................3 amphotericin b .......................................................1 ampicillin ...............................................................3 28 ampicillin-sulbactam............................................. 3 AMTURNIDE..................................................... 11 ANADROL-50 .................................................... 17 anagrelide hydrochloride.................................... 15 anastrozole ............................................................ 4 ANCOBON ........................................................... 1 ANDRODERM ................................................... 17 ANDROGEL....................................................... 17 ANDROGEL PUMP ........................................... 17 ANDROID .......................................................... 17 androxy................................................................ 17 ANTABUSE........................................................ 15 APIDRA .............................................................. 16 APIDRA SOLOSTAR ........................................ 16 APOKYN .............................................................. 7 apraclonidine ...................................................... 23 apri ...................................................................... 21 APTIVUS .............................................................. 1 ARALAST NP .................................................... 15 aranelle................................................................ 21 ARANESP........................................................... 19 ARCALYST........................................................ 19 ARICEPT .............................................................. 7 ARICEPT ODT ..................................................... 7 ARIXTRA ........................................................... 12 ARRANON ........................................................... 4 ARTHROTEC 50.................................................. 9 ARTHROTEC 75.................................................. 9 ARZERRA ............................................................ 4 ASACOL............................................................. 18 ASACOL HD ...................................................... 18 ascomp/codeine ..................................................... 8 ASMANEX 120 METERED DOSES ................ 24 ASMANEX 14 METERED DOSES................... 24 ASMANEX 30 METERED DOSES................... 24 ASMANEX 60 METERED DOSES................... 24 ASTEPRO ........................................................... 15 atenolol................................................................ 11 atenolol / chlorthalidone ..................................... 11 ATRIPLA .............................................................. 1 atropine sulfate.................................................... 18 ATROVENT HFA .............................................. 24 augmented betamethasone dipropionate............. 14 AVANDAMET....................................................16 AVANDARYL ....................................................16 AVANDIA...........................................................16 AVASTIN ..............................................................4 AVELOX ...............................................................3 AVELOX ABC PACK ..........................................3 aviane...................................................................21 avita......................................................................13 AVODART ..........................................................25 AVONEX.............................................................19 AZACTAM............................................................2 AZACTAM IN ISO-OSMOTIC DEXTROSE......2 AZASITE.............................................................22 azathioprine ...........................................................4 azathioprine sodium...............................................4 azelastine hcl..................................................15, 22 AZELEX ..............................................................13 AZILECT...............................................................7 azithromycin...........................................................2 AZOPT.................................................................23 aztreonam...............................................................2 B bacitracin .............................................................22 bacitracin / polymyxin b.......................................22 baclofen..................................................................8 BACTROBAN.....................................................14 BACTROBAN NASAL.......................................15 balsalazide ...........................................................18 balziva..................................................................21 BANZEL................................................................6 BARACLUDE .......................................................1 BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2 ...................16 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16 ...................16 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2 .....................16 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16...............................................................16 BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM ..........................................................................16 benazepril.............................................................11 29 benazepril / hydrochlorothiazide ........................ 11 BENICAR ........................................................... 11 BENICAR HCT .................................................. 11 benztropine mesylate ............................................. 7 BEPREVE ........................................................... 22 BESIVANCE ...................................................... 22 betamethasone dipropionate ............................... 14 betamethasone valerate....................................... 14 BETASERON .....................................................19 betaxolol hcl .................................................. 11, 22 bethanechol chloride........................................... 25 BETOPTIC-S ...................................................... 22 bicalutamide.......................................................... 4 BICILLIN C-R ...................................................... 3 BICILLIN L-A ...................................................... 3 BICNU .................................................................. 4 BIDIL .................................................................. 11 BILTRICIDE......................................................... 2 bisoprolol fumarate............................................. 11 bisoprolol fumarate / hydrochlorothiazide ......... 11 bleomycin sulfate................................................... 4 BLEPH-10........................................................... 23 BONIVA ............................................................. 20 BOOSTRIX......................................................... 20 brimonidine tartrate ............................................ 23 BROMDAY ........................................................ 23 bromfenac............................................................ 23 bromocriptine mesylate ......................................... 7 budeprion sr .......................................................... 9 budeprion xl........................................................... 9 budesonide........................................................... 24 bumetanide .......................................................... 11 BUPHENYL........................................................ 15 BUPRENEX.......................................................... 8 buprenorphine hcl ................................................. 8 BUPROBAN ....................................................... 15 bupropion hcl ........................................................ 9 bupropion hcl sr .................................................... 9 buspirone hcl ......................................................... 9 BUSULFEX .......................................................... 4 butorphanol tartrate.............................................. 9 BYETTA ............................................................. 16 BYSTOLIC ......................................................... 11 C cabergoline ..........................................................17 CADUET .............................................................12 calcipotriene ........................................................13 calcitonin-salmon.................................................17 calcitriol...............................................................17 calcium acetate ....................................................25 camila...................................................................21 CAMPATH............................................................4 CAMPRAL ..........................................................15 CANASA .............................................................18 CAPASTAT SULFATE ........................................2 CAPEX ................................................................14 captopril...............................................................11 captopril/hydrochlorothiazide .............................11 CARAC................................................................13 CARAFATE ........................................................19 carbamazepine .......................................................6 carbamazepine er...................................................6 CARBATROL .......................................................6 carbidopa / levodopa .............................................7 carbidopa/levodopa cr ...........................................7 carbidopa/levodopa odt .........................................7 carbidopa/levodopa sr ...........................................7 carbinoxamine maleate........................................23 carboplatin.............................................................4 CARMOL-HC......................................................13 carteolol hcl .........................................................22 cartia xt ................................................................11 carvedilol .............................................................11 CAVERJECT.......................................................23 CAVERJECT IMPULSE.....................................23 CAYSTON.............................................................2 CEENU ..................................................................4 cefaclor ..................................................................2 cefadroxil ...............................................................2 cefazolin .................................................................2 cefdinir ...................................................................2 cefepime .................................................................2 cefotaxime sodium..................................................2 cefoxitin sodium .....................................................2 cefpodoxime proxetil..............................................2 ceftazidime .............................................................2 30 ceftriaxone sodium ................................................ 2 cefuroxime axetil ................................................... 2 cefuroxime sodium................................................. 2 CELEBREX .......................................................... 9 CELLCEPT ........................................................... 4 CELLCEPT INTRAVENOUS.............................. 4 CELONTIN........................................................... 6 cephalexin.............................................................. 2 CEREZYME ....................................................... 17 CERVARIX ........................................................ 20 cesia..................................................................... 21 cetirizine hcl ........................................................ 23 CHANTIX........................................................... 15 CHEMET ............................................................ 15 chlordiazepoxide/amitriptyline.............................. 9 chlorhexidine gluconate oral rinse ..................... 15 chloroquine............................................................ 2 chlorothiazide...................................................... 11 chlorothiazide sodium ......................................... 11 chlorpromazine...................................................... 9 chlorthalidone ..................................................... 11 cholestyramine light ............................................ 12 CIALIS ................................................................ 23 ciclopirox............................................................. 14 ciclopirox nail lacquer ........................................ 14 ciclopirox olamine............................................... 14 cilostazol.............................................................. 12 CILOXAN........................................................... 22 CIMZIA............................................................... 18 CIPRO HC........................................................... 16 CIPRO I.V.-IN D5W............................................. 3 CIPRODEX......................................................... 16 ciprofloxacin.....................................................3, 22 cisplatin ................................................................. 4 citalopram ............................................................. 9 cladribine .............................................................. 4 claravis ................................................................ 13 CLARINEX......................................................... 24 CLARINEX REDITABS .................................... 24 CLARINEX-D 12 HOUR ................................... 24 CLARINEX-D 24 HOUR ................................... 24 clarithromycin ....................................................... 2 clarithromycin er................................................... 2 clemastine fumarate .............................................24 CLEOCIN ............................................................21 CLEOCIN GALAXY ............................................2 CLEOCIN PEDIATRIC GRANULES ..................2 CLIMARA PRO ..................................................21 clindamycin hcl ......................................................2 clindamycin phosphate...................................13, 21 clindamycin phosphate add-vantage......................2 clindamycin/benzoyl peroxide..............................13 CLINIMIX / DEXTROSE .............................15, 26 CLINISOL SF......................................................26 clobetasol propionate...........................................14 clobetasol propionate e........................................14 CLOBEX..............................................................14 CLOLAR................................................................4 clomipramine .........................................................9 clonazepam ............................................................6 clonidine...............................................................11 clotrimazole......................................................1, 14 clotrimazole / betamethasone ..............................14 clozapine ................................................................9 COARTEM............................................................2 codeine sulfate .......................................................8 COLCRYS ...........................................................20 colestipol ..............................................................12 colistimethate sodium.............................................2 COLY-MYCIN S.................................................16 COMBIGAN........................................................23 COMBIPATCH ...................................................21 COMBIVENT......................................................24 COMBIVIR............................................................1 compro .................................................................18 COMTAN ..............................................................7 COMVAX............................................................20 CONDYLOX .......................................................13 constulose.............................................................18 COPAXONE..........................................................7 CORDRAN TAPE...............................................14 COREG CR..........................................................11 CORTIFOAM ......................................................18 cortisone acetate ..................................................16 CORTISPORIN-TC.............................................16 cortomycin............................................................16 31 COSMEGEN......................................................... 4 CREON ............................................................... 18 CRINONE ........................................................... 21 CRIXIVAN ........................................................... 1 cromolyn sodium ........................................... 22, 24 cryselle-28 ........................................................... 21 CUBICIN .............................................................. 2 CUPRIMINE....................................................... 20 cyclafem 1/35....................................................... 21 cyclafem 7/7/7 ..................................................... 21 cyclobenzaprine hcl............................................... 8 cyclophosphamide ................................................. 4 cyclosporine .......................................................... 4 CYKLOKAPRON............................................... 12 CYMBALTA ........................................................ 9 CYSTADANE..................................................... 18 CYSTAGON ....................................................... 25 cytarabine.............................................................. 4 CYTARABINE AQUEOUS ................................. 4 D dacarbazine ........................................................... 4 DACOGEN ........................................................... 5 danazol ................................................................ 17 dantrolene sodium................................................. 8 DAPSONE ............................................................ 2 DAPTACEL........................................................ 20 DARAPRIM.......................................................... 2 daunorubicin hcl ................................................... 5 DAUNOXOME..................................................... 5 DECAVAC.......................................................... 20 demeclocycline hcl ................................................ 4 DEMSER............................................................. 11 DENAVIR........................................................... 14 depade ................................................................... 9 DEPEN TITRATABS ......................................... 20 DEPO-MEDROL ................................................ 16 DEPO-PROVERA .............................................. 21 DEPO-SUBQ PROVERA 104............................ 21 DERMA-SMOOTHE / FS BODY OIL .............. 14 DERMOTIC ........................................................ 15 desipramine ........................................................... 9 desmopressin acetate........................................... 17 desonide ...............................................................14 desoximetasone ....................................................14 DETROL..............................................................24 DETROL LA .......................................................24 dexamethasone...............................................16, 23 DEXAMETHASONE INTENSOL .....................16 dexrazoxane ...........................................................4 dextroamphetamine sulfate ....................................9 dextroamphetamine sulfate er................................9 DEXTROSE 10%/NACL 0.45% ........................15 DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX ........................................................26 dextrose 10% flex container.................................15 DEXTROSE 10%/NACL 0.2% ...........................15 dextrose 2.5%/sodium chloride 0.45% ................15 dextrose 5%..........................................................15 dextrose 5%/nacl 0.2% ........................................15 dextrose 5%/nacl 0.225%....................................15 DEXTROSE 5%/NACL 0.33%...........................15 dextrose 5%/nacl 0.45% ......................................15 dextrose 5%/nacl 0.9% ........................................15 diazepam ................................................................7 DIBENZYLINE...................................................11 diclofenac potassium..............................................9 diclofenac sodium ............................................9, 23 diclofenac sodium ec..............................................9 diclofenac sodium xr ..............................................9 dicloxacillin sodium...............................................3 dicyclomine hcl ....................................................18 didanosine..............................................................1 DIFFERIN............................................................13 diflorasone diacetate............................................14 DIFLUCAN IN NACL ..........................................1 diflunisal ................................................................9 digoxin..................................................................12 dihydroergotamine mesylate..................................7 DILANTIN ............................................................6 DILANTIN INFATABS........................................6 DILAUDID ............................................................8 DILAUDID-5.........................................................8 DILAUDID-HP......................................................8 dilt-cd ...................................................................11 diltiazem cd ..........................................................11 32 diltiazem hcl ........................................................ 11 diltiazem hcl er .................................................... 11 dilt-xr................................................................... 11 diltzac .................................................................. 11 DIOVAN ............................................................. 11 DIOVAN HCT .................................................... 11 DIPENTUM ........................................................ 18 DIPHTHERIA/TETANUS TOXOID PEDIATRIC ......................................................................... 20 disopyramide phosphate...................................... 10 divalproex sodium ................................................. 6 divalproex sodium er............................................. 6 DIVIGEL............................................................. 21 DOCETAXEL....................................................... 5 donepezil hcl.......................................................... 7 dorzolamide hcl ................................................... 23 dorzolamide hcl/timolol maleate......................... 23 doxazosin............................................................. 11 doxepin .................................................................. 9 DOXIL .................................................................. 5 doxorubicin hcl...................................................... 5 doxycycline hyclate ............................................... 4 doxycycline monohydrate...................................... 4 dronabinol ........................................................... 18 DROXIA ............................................................... 5 DUETACT .......................................................... 16 DULERA............................................................. 24 duramorph............................................................. 8 DUREZOL .......................................................... 23 E e.e.s. 400................................................................ 2 E.E.S. GRANULES .............................................. 2 econazole nitrate ................................................. 14 EDECRIN............................................................ 11 EDURANT............................................................ 1 EFFIENT............................................................. 12 ELIDEL............................................................... 13 eliphos ................................................................. 25 ELITEK................................................................. 4 ELIXOPHYLLIN................................................ 24 ELLA................................................................... 21 ELLENCE ............................................................. 5 ELMIRON ...........................................................25 ELOXATIN ...........................................................5 ELSPAR.................................................................5 EMBEDA...............................................................8 EMCYT..................................................................5 EMEND ...............................................................18 EMSAM.................................................................9 EMTRIVA .............................................................1 ENABLEX...........................................................24 enalapril...............................................................11 enalapril / hydrochlorothiazide ...........................11 ENBREL..............................................................20 endocet ...................................................................8 ENGERIX-B ........................................................20 enoxaparin sodium...............................................12 enpresse-28 ..........................................................21 ENTOCORT EC ..................................................18 enulose .................................................................18 epinastine hcl .......................................................22 epinephrine hcl.....................................................24 EPIPEN ................................................................24 EPIPEN-JR ..........................................................24 epirubicin hcl .........................................................5 epitol ......................................................................6 EPIVIR...................................................................1 EPIVIR HBV .........................................................1 eplerenone............................................................11 EPOGEN..............................................................19 EPZICOM ..............................................................1 EQUETRO.............................................................6 ERAXIS .................................................................1 ERBITUX ..............................................................5 ergotamine tartrate / caffeine ................................7 errin......................................................................21 ery ........................................................................13 ERY-TAB ..............................................................2 ERYTHROCIN LACTOBIONATE......................2 erythrocin stearate .................................................2 erythromycin ..................................................13, 22 erythromycin / benzoyl peroxide..........................13 ERYTHROMYCIN BASE ....................................2 erythromycin ethylsuccinate ..................................2 erythromycin/sulfisoxazole ....................................2 33 ESTRADERM...................................................... 21 estradiol................................................................ 21 estradiol / norethindrone acetate ......................... 21 ESTRING ............................................................. 21 estropipate............................................................ 21 ethambutol............................................................. 2 ethosuximide.......................................................... 6 etidronate disodium............................................. 15 etodolac ................................................................. 9 ETOPOPHOS........................................................ 5 etoposide................................................................ 5 EURAX ............................................................... 15 EVISTA............................................................... 20 EVOXAC ............................................................ 15 EXALGO .............................................................. 8 EXELON............................................................... 7 exemestane ............................................................ 5 EXFORGE ........................................................... 11 EXFORGE HCT .................................................. 11 EXJADE.............................................................. 15 F FABRAZYME .................................................... 17 famciclovir............................................................. 1 famotidine.............................................................19 famotidine premixed.............................................19 FANAPT ............................................................... 9 FANAPT TITRATION PACK ............................. 9 FARESTON .......................................................... 5 FASLODEX .......................................................... 5 FAZACLO ............................................................ 9 FELBATOL .......................................................... 6 felodipine er......................................................... 11 fenofibrate ........................................................... 12 fenofibrate micronized......................................... 12 fenoprofen calcium................................................ 9 fentanyl citrate....................................................... 8 fentanyl citrate oral transmucosal ........................ 8 fentanyl patches..................................................... 8 fexofenadine hcl................................................... 24 FINACEA............................................................ 13 finasteride............................................................ 25 FIRMAGON.......................................................... 5 flavoxate hcl .........................................................24 flecainide acetate .................................................10 FLECTOR..............................................................9 FLOVENT DISKUS............................................24 FLOVENT HFA ..................................................24 fluconazole .............................................................1 fluconazole in dextrose ..........................................1 fludarabine phosphate ...........................................5 fludrocortisone acetate ........................................16 flunisolide.............................................................24 fluocinolone acetonide.........................................14 fluocinonide..........................................................14 fluocinonide emollient base .................................14 fluorometholone ...................................................23 FLUOROPLEX....................................................13 fluorouracil ......................................................5, 13 fluoxetine................................................................9 fluoxetine dr ...........................................................9 fluphenazine ...........................................................9 fluphenazine decanoate inj ....................................9 flurbiprofen ............................................................9 flurbiprofen sodium..............................................23 flutamide ................................................................5 fluticasone propionate ...................................14, 24 fluvoxamine............................................................9 FML .....................................................................23 FML FORTE........................................................23 FOCALIN XR........................................................9 FORADIL AEROLIZER .....................................24 FORTAZ................................................................2 FORTEO ..............................................................20 fortical..................................................................17 foscarnet sodium....................................................1 fosinopril..............................................................11 fosinopril / hydrochlorothiazide ..........................11 FOSRENOL.........................................................15 FRAGMIN ...........................................................12 FREAMINE III ....................................................26 furosemide............................................................11 FUZEON................................................................1 G gabapentin..............................................................6 34 GABITRIL ............................................................ 6 galantamine hydrobromide ................................... 7 ganciclovir............................................................. 1 GARDASIL......................................................... 20 GASTROCROM ................................................. 18 GAUZE PADS 2 ................................................. 16 gavilyte-c ............................................................. 18 gavilyte-g............................................................. 18 gavilyte-n/flavor pack.......................................... 18 GELNIQUE......................................................... 24 gemcitabine hcl ..................................................... 5 gemfibrozil........................................................... 12 gengraf .................................................................. 5 gentak .................................................................. 22 gentamicin sulfate ......................................2, 14, 22 gentamicin sulfate/0.9% sodium chloride ............. 3 gentamicin sulfate/sodium chloride ...................... 3 gentasol ............................................................... 22 GEODON .............................................................. 9 gianvi................................................................... 21 GILENYA ............................................................. 8 GLEEVEC............................................................. 5 glimepiride .......................................................... 16 glipizide ............................................................... 16 glipizide / metformin............................................ 16 glipizide er........................................................... 16 GLUCAGEN HYPOKIT .................................... 16 GLUCAGON EMERGENCY KIT..................... 16 glyburide.............................................................. 16 glyburide / metformin.......................................... 16 glyburide micronized........................................... 16 glycopyrrolate ..................................................... 18 glycron................................................................. 16 granisetron .......................................................... 18 griseofulvin microsize ........................................... 1 GRIS-PEG............................................................. 1 guanfacine hcl ..................................................... 11 GYNAZOLE-1.................................................... 21 H HALAVEN............................................................ 5 HALDOL .............................................................. 9 HALDOL DECANOATE 100 .............................. 9 HALDOL DECANOATE 50.................................9 halobetasol propionate ........................................14 haloperidol.............................................................9 haloperidol decanoate inj ......................................9 haloperidol lactate inj............................................9 HAVRIX ..............................................................20 HECTOROL ........................................................17 HEPARIN SODIUM ...........................................12 heparin sodium/d5w.............................................12 HEPARIN SODIUM/NACL 0.45% ....................12 heparin sodium/sodium chloride 0.9% premix ....12 HEPATAMINE....................................................26 HEPATASOL ......................................................26 HEPSERA..............................................................1 HERCEPTIN..........................................................5 HEXALEN.............................................................5 HIZENTRA..........................................................20 HUMALOG .........................................................16 HUMALOG KWIKPEN......................................17 HUMALOG MIX 50/50 ......................................17 HUMALOG MIX 50/50 KWIKPEN...................17 HUMALOG MIX 75/25 ......................................17 HUMALOG MIX 75/25 KWIKPEN...................17 HUMIRA .............................................................20 HUMIRA PEN-CROHNS DISEASE STARTER ..........................................................................20 HUMULIN 70/30.................................................17 HUMULIN 70/30 PEN ........................................17 HUMULIN N.......................................................17 HUMULIN N U-100 PEN...................................17 HUMULIN R .......................................................17 HUMULIN R U-500 (CONCENTRATED)........17 hydralazine...........................................................11 hydrochlorothiazide .............................................11 hydrocodone bitartrate/acetaminophen.................8 hydrocodone/acetaminophen .................................8 hydrocodone/ibuprofen..........................................8 hydrocortisone .........................................14, 16, 18 hydrocortisone butyrate .......................................14 hydrocortisone valerate .......................................14 hydrocortisone/acetic acid...................................15 hydromorphone hcl ................................................8 hydroxychloroquine ...............................................3 35 hydroxyurea........................................................... 5 hydroxyzine hcl.................................................... 24 I ibuprofen ............................................................... 9 idarubicin hcl ........................................................ 5 IFEX ...................................................................... 5 ifosfamide .............................................................. 5 ifosfamide/mesna....................................................5 imipramine ............................................................ 9 imipramine pamoate............................................ 10 imiquimod............................................................ 13 IMOVAX RABIES (H.D.C.V.) .......................... 20 INCRELEX ......................................................... 15 indapamide.......................................................... 11 indomethacin ......................................................... 9 indomethacin er...................................................,, 9 INFANRIX.......................................................... 20 INFUMORPH 200 ................................................ 8 INFUMORPH 500 ................................................ 8 INTELENCE......................................................... 1 INTRALIPID ...................................................... 26 INTRON-A...........................................................19 INTRON-A WITH DILUENT.............................19 INVEGA.............................................................. 10 INVEGA SUSTENNA........................................ 10 INVIRASE ............................................................ 1 IONOSOL ........................................................... 26 IOPIDINE............................................................ 23 IPOL INACTIVATED IPV ................................ 20 ipratropium bromide ..................................... 15, 24 ipratropium bromide/albuterol sulfate................ 24 irinotecan .............................................................. 5 ISENTRESS .......................................................... 1 ISOLYTE ............................................................ 26 isonarif .................................................................. 3 ISONIAZID........................................................... 3 isosorbide dinitrate ............................................. 13 isosorbide dinitrate er ......................................... 13 isosorbide mononitrate........................................ 13 isosorbide mononitrate er ................................... 13 isotonic gentamicin ............................................... 3 isradipine............................................................. 11 ISTALOL.............................................................22 ISTODAX ..............................................................5 itraconazole............................................................1 IXEMPRA KIT......................................................5 IXIARO................................................................20 J JALYN.................................................................25 jantoven................................................................12 JANUMET...........................................................17 JANUVIA ............................................................17 JE-VAX................................................................20 JEVTANA..............................................................5 jinteli ....................................................................21 jolivette.................................................................21 junel......................................................................21 junel fe 1.5/30.......................................................21 junel fe 1/20..........................................................21 K KADIAN................................................................8 KALETRA.............................................................1 kariva ...................................................................21 kcl 0.075%/d5w/nacl 0.45% ................................25 KCL 0.15%/D10W/NACL 0.2% .........................26 kcl 0.15%/d5w/lr ..................................................25 KCL 0.15%/D5W/NACL 0.2% ...........................25 KCL 0.15%/D5W/NACL 0.225% .......................25 kcl 0.15%/d5w/nacl 0.9% ....................................25 kcl 0.3%/d5w/lr iv lac ring...................................25 KCL 0.3%/D5W/NACL 0.2% .............................25 kcl 0.3%/d5w/nacl 0.45% ....................................25 kcl 0.3%/d5w/nacl 0.9% ......................................25 kelnor 1/35 ...........................................................21 KETEK ..................................................................3 ketoconazole.....................................................1, 14 ketoprofen ..............................................................9 ketoprofen er ..........................................................9 ketorolac tromethamine .......................................23 kionex ...................................................................15 klor-con 10...........................................................25 klor-con 8.............................................................25 KLOR-CON M15 ................................................25 klor-con m20 ........................................................25 36 KOMBIGLYZE XR............................................ 17 K-TABS .............................................................. 25 KUVAN .............................................................. 17 L labetalol............................................................... 11 laclotion............................................................... 13 LACRISERT ....................................................... 22 LACTATED RINGERS...................................... 25 lactulose .............................................................. 18 LAMICTAL ODT ................................................. 6 LAMICTAL XR.................................................... 6 lamotrigine ............................................................ 6 LANOXIN........................................................... 12 lansoprazole .........................................................19 lansoprazole odt ...................................................19 LANTUS ............................................................. 17 LANTUS SOLOSTAR ....................................... 17 latanoprost .......................................................... 23 LATUDA ............................................................ 10 leena .................................................................... 21 leflunomide.......................................................... 20 lessina-28 ............................................................ 21 LETAIRIS ........................................................... 24 letrozole................................................................. 5 leucovorin calcium................................................ 4 LEUKERAN ......................................................... 5 LEUKINE.............................................................19 leuprolide acetate.................................................. 5 LEVAQUIN .......................................................... 3 LEVEMIR ........................................................... 17 LEVEMIR FLEXPEN......................................... 17 levetiracetam......................................................... 6 LEVITRA............................................................ 23 levobunolol hcl .................................................... 22 levocarnitine........................................................ 15 levocetirizine dihydrochloride............................. 24 levofloxacin ......................................................... 22 levora................................................................... 21 levorphanol tartrate ...............................................8 levothyroxine ....................................................... 18 levoxyl.................................................................. 18 LEXIVA ................................................................ 1 lidocaine...............................................................13 lidocaine / prilocaine ...........................................13 lidocaine viscous..................................................13 LIDODERM ........................................................14 LINDANE............................................................15 liothyronine sodium .............................................18 LIPITOR ..............................................................12 LIPOSYN III........................................................26 lisinopril...............................................................11 lisinopril/hydrochlorothiazide .............................11 lithium carbonate.................................................10 lithium carbonate er.............................................10 lithium citrate.......................................................10 LOCOID ..............................................................14 LODOSYN ............................................................7 loperamide hcl .....................................................18 lorazepam...............................................................7 losartan potassium...............................................11 losartan potassium/hydrochlorothiazide .............11 LOTEMAX ..........................................................23 LOTRONEX ........................................................18 lovastatin..............................................................12 LOVAZA .............................................................12 LOVENOX ..........................................................12 low-ogestrel..........................................................21 loxapine................................................................10 LUMIGAN...........................................................23 LUPRON DEPOT..................................................5 LUPRON DEPOT-PED.........................................5 lutera....................................................................21 LUXIQ .................................................................14 LYRICA.................................................................6 LYSODREN ..........................................................5 LYSTEDA ...........................................................21 M MACRODANTIN..................................................4 MAGNESIUM SULFATE ..................................25 MAGNESIUM SULFATE IN D5W ...................25 MALARONE.........................................................3 malathion .............................................................15 maprotiline...........................................................10 margesic-h..............................................................8 37 MARPLAN ......................................................... 10 MATULANE ........................................................ 5 matzim la ............................................................. 11 MAXALT.............................................................. 7 MAXALT-MLT .................................................... 7 mebendazole .......................................................... 3 meclizine hcl........................................................ 18 meclofenamate sodium.......................................... 9 medroxyprogesterone acetate ............................. 21 mefenamic acid...................................................... 9 mefloquine hcl ....................................................... 3 MEGACE ES ........................................................ 5 megestrol acetate................................................... 5 meloxicam.............................................................. 9 melphalan hydrochloride ...................................... 5 MENACTRA ...................................................... 20 MENOMUNE-A/C/Y/W-135 ............................. 20 MENOSTAR....................................................... 21 MENVEO............................................................ 20 MEPRON .............................................................. 3 mercaptopurine ..................................................... 5 meropenem............................................................ 3 mesalamine.......................................................... 18 mesna..................................................................... 4 MESNEX .............................................................. 4 MESTINON .......................................................... 8 MESTINON TIMESPAN ..................................... 8 METADATE CD ................................................ 10 metaproterenol sulfate......................................... 24 metformin hcl....................................................... 17 metformin hcl er .................................................. 17 methadone hcl ....................................................... 8 methadose.............................................................. 8 methazolamide..................................................... 23 methenamine hippurate ......................................... 4 METHERGINE................................................... 22 methimazole......................................................... 16 methotrexate .......................................................... 5 methotrexate sodium ............................................. 5 methyclothiazide.................................................. 11 methylphenidate hcl............................................. 10 methylphenidate hydrochloride........................... 10 methylprednisolone ............................................. 16 methylprednisolone acetate .................................16 methylprednisolone sodiumsuccinate ..................16 metipranolol.........................................................22 metoclopramide....................................................18 metolazone ...........................................................11 metoprolol succinate er........................................11 metoprolol tartrate...............................................11 metoprolol/hydrochlorothiazide ..........................11 METROGEL........................................................13 metronidazole...................................................3, 13 metronidazole in nacl 0.79% .................................3 metronidazole vaginal..........................................21 mexiletine .............................................................10 miconazole 3 ........................................................21 microgestin 1.5/30................................................21 microgestin 1/20...................................................21 microgestin fe.......................................................21 microgestin fe 1.5/30............................................21 midodrine .............................................................15 migergot .................................................................7 MIGRANAL..........................................................7 minocycline hcl ......................................................4 minocycline hcl er ..................................................4 minoxidil ..............................................................11 MIRAPEX ER .......................................................7 mirtazapine ..........................................................10 mirtazapine odt ....................................................10 misoprostol...........................................................19 mitomycin...............................................................5 mitoxantrone hcl ....................................................5 M-M-R II W/DILUENT 10 DOSE......................20 moexipril ..............................................................11 moexipril/hydrochlorothiazide.............................11 mometasone furoate .............................................14 mononessa............................................................21 morphine sulfate.....................................................8 morphine sulfate er ................................................8 MOXEZA ............................................................22 MOZOBIL ...........................................................19 MULTAQ ............................................................10 mupirocin .............................................................14 MUSE ..................................................................23 MUSTARGEN.......................................................5 38 MYCOBUTIN....................................................... 3 mycophenolate mofetil........................................... 5 MYFORTIC .......................................................... 5 MYTELASE.......................................................... 8 N nabumetone ........................................................... 9 nadolol................................................................. 11 nadolol/bendroflumethiazide............................... 11 nafcillin sodium..................................................... 3 NAFTIN .............................................................. 14 NAGLAZYME.................................................... 17 NALLPEN/DEXTROSE....................................... 3 naloxone ................................................................ 9 naltrexone.............................................................. 9 NAMENDA .......................................................... 8 NAMENDA TITRATION PAK ........................... 8 naproxen................................................................ 9 naproxen sodium ................................................... 9 naratriptan hcl....................................................... 7 NATACYN ......................................................... 22 nateglinide........................................................... 17 NEBUPENT .......................................................... 3 necon 0.5/35-28.................................................... 21 necon 1/35-28....................................................... 21 necon 10/11-28..................................................... 21 necon 7/7/7 ........................................................... 21 nefazodone........................................................... 10 neomycin sulfate.................................................... 3 neomycin/bacitracin/polymyxin .......................... 22 neomycin/polymyxin/bacitracin/hydrocortisone . 23 neomycin/polymyxin/dexamethasone .................. 23 neomycin/polymyxin/gramicidin ......................... 22 neomycin/polymyxin/hc ....................................... 16 neomycin/polymyxin/hydrocortisone............. 16, 23 NEORAL............................................................... 5 NEPHRAMINE................................................... 26 NEULASTA.........................................................19 NEUMEGA..........................................................19 NEUPOGEN ........................................................19 NEVANAC ......................................................... 23 NEXAVAR ........................................................... 5 NEXIUM I.V........................................................19 next choice ...........................................................21 NIASPAN ............................................................12 nicardipine ...........................................................11 NICOTROL INHALER.......................................15 NICOTROL NASAL...........................................15 nifediac cc ............................................................11 nifedical xl............................................................11 nifedipine..............................................................11 nifedipine er .........................................................11 NILANDRON........................................................5 nimodipine............................................................12 NIPENT .................................................................5 nisoldipine............................................................12 nisoldipine er .......................................................12 nitro-bid ...............................................................13 NITRO-DUR........................................................13 nitrofurantoin.........................................................4 nitrofurantoin macrocrystalline.............................4 nitrofurantoin monohydrate...................................4 nitroglycerin.........................................................13 nitroglycerin transdermal ....................................13 NITROLINGUAL PUMPSPRAY.......................13 NITROSTAT .......................................................13 nizatidine..............................................................19 nora-be.................................................................21 NORDITROPIN FLEXPRO................................19 NORDITROPIN NORDIFLEX PEN ..................19 norethindrone.......................................................21 NORMOSOL .................................................25, 26 NOROXIN .............................................................3 NORPACE CR.....................................................10 nortrel 0.5/35 (28)................................................21 nortrel 1/35 (21)...................................................22 nortrel 1/35 (28)...................................................22 nortrel 7/7/7 .........................................................22 nortriptyline .........................................................10 NORVIR ................................................................1 NOVOLIN 70/30 .................................................17 NOVOLIN N .......................................................17 NOVOLIN R........................................................17 NOVOLOG..........................................................17 NOVOLOG FLEXPEN .......................................17 NOVOLOG MIX 70/30.......................................17 39 NOVOLOG MIX 70/30 PREFILLED FLEXPEN ......................................................................... 17 NOXAFIL ............................................................. 1 NUEDEXTA ......................................................... 8 NUVARING........................................................ 21 nyamyc................................................................. 14 nystatin .............................................................1, 14 nystatin / triamcinolone....................................... 14 nystop .................................................................. 14 O ocella ................................................................... 22 octreotide............................................................... 5 ofloxacin.....................................................3, 16, 22 ogestrel ................................................................ 22 omeprazole ...........................................................19 omnitrope .............................................................19 ondansetron hcl ................................................... 18 ondansetron odt................................................... 18 ONGLYZA.......................................................... 17 ONSOLIS .............................................................. 8 ONTAK................................................................. 5 OPANA ER ........................................................... 8 ORAP .................................................................. 10 ORAVIG ............................................................... 1 ORFADIN ........................................................... 15 ORTHO EVRA ................................................... 21 ortho-est .............................................................. 21 oxaliplatin.............................................................. 5 oxandrolone......................................................... 17 oxaprozin............................................................... 9 oxazepam............................................................... 7 oxcarbazepine........................................................ 6 OXSORALEN ULTRA .......................
Object Description
Okla State Agency |
Employees Group Insurance Board, Oklahoma State and Education (OSEEGIB) |
Okla Agency Code |
'516' |
Title | HealthChoice Medicare formulary for high & low options : plan year... : for comprehensive guide use (complete formulary). |
Authors | Oklahoma State and Education Employees Group Insurance Board. |
Publisher | Oklahoma State and Education Employees Group Insurance Board |
Publication Date | 2009; 2010; 2011; 2012 |
Publication type | Manual |
Serial holdings | Electronic holdings: 2008-2011 |
Subject | Medicine--Oklahoma--Formulae, receipts, prescriptions. |
Purpose | The formulary is a list of drugs selected by HealthChoice. This list represents the prescription therapies believed to be a necessary part of a quality treatment program. |
Notes | issues through 2011 |
Historical Notes on State Agency | In 2011, the Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) was consolidated under the Office of State Finance, which in 2012 was renamed the Office of Management and Enterprise Services, and the Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) was renamed the Employee(s) Group Insurance Division under this agency. |
OkDocs Class# | E3610.5 M489f |
For all issues click | E3610.5 M489f |
Digital Format | PDF, Adobe Reader required |
ODL electronic copy | Downloaded from agency website: www.sib.state.ok.us/pdffiles/MedicareFormulary.pdf |
Rights and Permissions | This Oklahoma state government publication is provided for educational purposes under U.S. copyright law. Other usage requires permission of copyright holders. |
Language | English |
Month/year uploaded | November 2008 |
Date created | 2016-06-20 |
Date modified | 2016-06-20 |
OCLC number | 819810320 |
Description
Title | Medicare formulary 2012 |
Notes | #2543 |
OkDocs Class# | E3610.5 M489f 2012 |
Digital Format | PDF, Adobe Reader required |
ODL electronic copy | Downloaded from agency website: http://www.ok.gov/sib/documents/Final.print.version.%202012%20Medicare%20Formulary.pdf |
Rights and Permissions | This Oklahoma state government publication is provided for educational purposes under U.S. copyright law. Other usage requires permission of copyright holders. |
Language | English |
Full text | Comprehensive Medicare Formulary Complete List of Prescribed Drugs High and Low Option Medicare Supplement Plans With and Without Part D Plan Year 2012 (Updated for January 1, 2012) PLEASE READ: This document contains information about the drugs covered under this plan. Comprehensive Formulary E7848_G6000 HPMS ID 00012423 1-1-12.Final MDIS #2543 i What is the HealthChoice Medicare Formulary? The formulary is a list of drugs that are covered by HealthChoice. It includes both brand-name and generic drugs. Generic drugs are approved by the FDA as having the same active ingredient as brand-name drugs, but usually at a lower cost. This formulary list represents the prescription therapies believed to be a necessary part of a quality treatment program. Due to the Centers for Medicare and Medicaid Services (CMS) regulations, a few differences can be noted between the formulary for active and pre-Medicare members and the formulary for Medicare members. Note: This formulary has changed since last year. Please review this document to make sure the drugs you take are still listed. What is a tier? CMS requires each covered drug be placed in a tier. The HealthChoice tiers are: Tier 1 — Generics (all covered generics are Preferred) Tier 2 — Preferred brand-name Tier 3 — non-Preferred brand-name Tier 4 — Preferred, very high cost, and unique formulary drugs Tier 5 — Tobacco cessation drugs Can the formulary change? Yes. HealthChoice may add or remove drugs from its formulary during the year. When formulary changes occur, HealthChoice must notify members affected by the change: At least 60 days before the date the change becomes effective, or At the time you request a refill of the drug. If you are notified of a formulary change when refilling a prescription, you will be able to receive a 60-day supply of the drug. ii How do I use the HealthChoice Medicare Formulary? There are two ways to find your drugs within the formulary, by medical condition or by drug name. Brand-name drugs appear in all capital letters (e.g., PROTONIX) and generic drugs appear in lowercase italics (e.g., pantoprazole). Locating your drug by medical condition Drugs listed in this formulary are grouped by categories based on the medical condition they treat. For example, drugs used to treat a heart condition are listed under Cardiovascular Agents. If you know the condition your drug treats, you can look for it under that category name. Locating your drug by alphabetical listing If you are not sure what category your drug falls under, you can look for it in the Index located in the back of this formulary guide. The Index provides an alphabetical list of all the brand-name and generic drugs included in this document. Turn to the page listed in the Index to find your drug. Are there any restrictions on coverage? Some covered drugs have additional requirements or limits on coverage. Drugs that are subject to additional requirements or limits are indicated by a two letter code and can include: Quantity Limits (QL): For certain drugs, there are limits on the quantity covered. The limit is an exception to the Plans’ standard benefit of a 34- day supply or 100 units, whichever is greater. Step Therapy (ST): In some cases, HealthChoice requires you to try plan Preferred drugs to treat your medical condition before we will cover iii another drug that treats the same condition. If you try drug A to treat your medical condition and it does not work for you, the Plan may then cover another drug for your condition. Prior Authorization (PA): Certain drugs require prior authorization. In some cases, you must get prior authorization for drugs that are listed in the HealthChoice Medicare Formulary. Drugs that are not listed in the formulary also require prior authorization for coverage. If you don’t receive approval of your prior authorization request, HealthChoice will not cover your drug. Limited Availability (LA): Certain drugs may only be available at certain pharmacies. For more information, call Medco Member Services toll-free at 1-800-590-6828. TTY/TDD users call toll-free 1-800-716- 3231. Enhanced Drug (ED): These drugs are not normally covered by Medicare prescription drug plans but, HealthChoice may cover the drugs designated as ED drugs in this formulary. In some instances, a prior authorization review may be required. The amounts you pay do not count toward your total drug costs (i.e., the amounts you pay do not help you qualify for catastrophic coverage). If you receive extra help paying for your prescriptions, you will not receive help paying for an ED drug. Part B versus Part D Drug (B/D): These drugs may be covered under Medicare Part B or Medicare Part D depending on the circumstances. Prior authorization is required to determine how the drug must be billed. Your physician must provide information about the use and setting of the administration of the drug. iv What if my drug is not listed in the HealthChoice Medicare Formulary? If your drug is not listed in this formulary, you should first contact Medco Member Services and ask if your drug is covered. If you learn that HealthChoice does not cover your drug, you have two options: You can ask Medco for a list of similar drugs that are covered by HealthChoice. When you receive this list, you can show it to your doctor and ask him/her to prescribe a drug that is covered by HealthChoice. You can ask HealthChoice to make an exception and cover your drug. How do I request an exception to the HealthChoice Medicare Formulary? You can ask HealthChoice to make certain exceptions to its coverage rules. When you or your doctor ask for an exception, it is called asking for a prior authorization/exception. There are several types of exceptions you can ask us to make. Certain drugs listed in the HealthChoice Medicare Formulary require a Step Therapy prior authorization exception before they are covered. You must first try a designated drug to treat your medical condition. If the designated drug fails to treat your medical condition, you can request a Step Therapy prior authorization exception. Your doctor must contact Medco toll-free at 1-800-753-2851 and provide information to support your request. You can ask us to cover your drug even if it is non-Formulary and not listed in this guide. Please note, if we grant your request to cover a drug that is not in our formulary, it will be covered at the non-Preferred copay. To request a prior authorization/exception for a non-formulary v drug, your doctor must contact Medco toll-free at 1-800-753-2851 and provide information to support your request. Due to approved therapy guidelines, certain medications have set quantity limits. Quantity limits also apply if the drug form is other than a tablet or capsule. To request a prior authorization/exception to the quantity limitation rules, your doctor must contact Medco toll-free at 1- 800-753-2851 and provide information to support your request. Certain drugs listed in the HealthChoice Medicare Formulary require a general prior authorization/exception before they are covered. Generally, these drugs are very high cost, have specific prescribing guidelines, are usually used for cosmetic purposes, or might be covered under Medicare Part B. To request a prior authorization/exception for a covered drug, your doctor must contact Medco toll-free at 1-800-753- 2851 and provide information to support your request. If you choose a non-Preferred medication when a Preferred medication is available, you must pay the non-Preferred copay unless you request a prior authorization/exception to receive a lower copay (a tier exception). Be aware that medical guidelines must be met, and information supplied by your doctor must justify your request. To request a prior authorization/exception for a tier exception to receive a lower copay, your doctor must contact Medco and provide information to support your request. Your doctor can contact Medco toll-free at 1-800-841- 5409. When requesting an exception, your doctor must submit a statement supporting the request. Generally, we must make our decision within 72 hours of receiving your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we vi must give you a decision no later than 24 hours after we receive your prescriber’s or prescribing physician’s supporting statement. What do I do before I talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not listed in our formulary; or you may be taking a drug that is listed in our formulary, but your ability to get it is limited. For example, you may need a prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, HealthChoice may cover your drug in certain cases. For each of your drugs that is not listed in our formulary, or if your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a HealthChoice Network Pharmacy. After you receive your first 34-day supply, you will need to get a prior authorization/exception before HealthChoice will continue to cover this medication. If you are a resident of a long-term care (LTC) facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). If you need a drug that is not listed in our formulary or if your ability to get your drug is limited, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. We will cover up to two refills of these medications. HealthChoice covers a transition supply if you have a level of care change such as when you: Enter LTC facilities from hospitals or other settings; vii Leave LTC facilities and return to the community; Are discharged from a hospital to a home; End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under your Part D plan formulary; Revert from hospice status to standard Medicare Part A and B benefits; or Are discharged from a psychiatric hospital with medication regimens that are highly individualized. For more information For more detailed information about your prescription drug coverage, please review your HealthChoice Medicare Supplement Handbook and other plan materials or visit the HealthChoice website at www.healthchoiceok.com or www.sib.ok.gov. This Comprehensive Formulary is effective beginning January 1, 2012. If you have questions about the prescription drug program, visit the HealthChoice website or call Medco Member Services toll-free at 1-800-590-6828, 24 hours a day, 7 days a week. TTY/TDD users call toll-free 1-800-716-3231. If you have general questions about Medicare prescription drug coverage, please call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week or visit Medicare’s website at www.medicare.gov. TTY/TDD users can call toll-free 1-877-486-2048. This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance, as authorized by 74 O.S. Section 1301, et seq; 34,000 copies have been printed at a cost of $.60 each. Copies have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries. This page intentionally blank. 1 Commonly Prescribed Therapeutic Drug Categories ANTI - INFECTIVES ANTIFUNGAL AGENTS Drug Name Drug Tier Require-ments/ Limits amphotericin b 1 B/D PA ANCOBON 2 clotrimazole troc 1 DIFLUCAN IN NACL 2 ERAXIS INJ 100MG 2 fluconazole in dextrose inj 0; 400mg/200ml 1 fluconazole susr 1 fluconazole tabs 1 GRIS-PEG 3 griseofulvin microsize 1 itraconazole 1 ketoconazole 1 NOXAFIL 2 nystatin susp 1 nystatin tabs 1 ORAVIG 2 SPORANOX ORAL SOLN 2 terbinafine tabs 1 VFEND IV 2 VFEND SUSR 2 voriconazole 1 ANTIVIRALS acyclovir caps 1 acyclovir inj 500mg 1 acyclovir susp 1 acyclovir tabs 1 amantadine 1 APTIVUS 4 ATRIPLA 4 BARACLUDE 2 COMBIVIR 4 CRIXIVAN 2 didanosine 1 EDURANT 4 EMTRIVA 2 Drug Name Drug Tier Require-ments/ Limits EPIVIR 2 EPIVIR HBV 2 EPZICOM 4 famciclovir 1 foscarnet sodium 1 B/D PA FUZEON 4 ganciclovir caps 1 HEPSERA 4 INTELENCE 4 INVIRASE CAPS 3 INVIRASE TABS 4 ISENTRESS 4 KALETRA ORAL SOLN 4 KALETRA TABS 200MG; 50MG 4 KALETRA TABS 100MG; 25MG 2 LEXIVA SUSP 2 LEXIVA TABS 4 NORVIR 2 PREZISTA TABS 150MG, 75MG 2 PREZISTA TABS 400MG, 600MG 4 REBETOL ORAL SOLN 2 RELENZA DISKHALER 2 QL(300 per 365 days) RESCRIPTOR 3 RETROVIR IV INFUSION 2 REYATAZ 2 ribapak 4 ribasphere caps 1 ribasphere tabs 200mg 1 ribasphere tabs 400mg, 600mg 4 ribavirin 1 rimantadine hcl 1 SELZENTRY 4 stavudine 1 SUSTIVA 2 TAMIFLU CAPS 45MG, 75MG 2 QL(60 per 365 days) TAMIFLU CAPS 30MG 2 QL(120 per 365 days) 2 Drug Name Drug Tier Require-ments/ Limits TAMIFLU SUSR 12MG/ML 2 TRIZIVIR 4 TRUVADA 4 TYZEKA 4 valacyclovir hcl 1 VALCYTE 4 VIDEX PEDIATRIC ORAL SOLN 2GM 2 VIRACEPT POWD 2 VIRACEPT TABS 4 VIRAMUNE 2 VIREAD 2 ZIAGEN 2 zidovudine 1 CEPHALOSPORINS cefaclor 1 cefadroxil 1 cefazolin inj 1gm, 1gm; 5%, 20gm, 500mg 1 cefdinir 1 cefepime inj 1gm, 2gm 1 cefotaxime sodium 1 cefoxitin sodium inj 10gm, 1gm, 2gm 1 cefpodoxime proxetil 1 ceftazidime inj 1gm, 2gm, 6gm 1 ceftriaxone sodium 1 cefuroxime axetil 1 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg 1 cephalexin 1 FORTAZ INJ 1GM/50ML; 5%, 2GM/50ML; 5%, 6GM 2 SUPRAX SUSR 3 TAZICEF INJ 1GM, 2GM, 6GM 2 TEFLARO 2 ZINACEF IN ISO-OSMOTIC DEXTROSE 2 ZINACEF IN ISO-OSMOTIC DILUENT 2 ZINACEF INJ 1.5GM, 750MG 2 ERYTHROMYCINS / OTHER MACROLIDES Drug Name Drug Tier Require-ments/ Limits azithromycin inj 500mg 1 azithromycin susr 1 azithromycin tabs 1 clarithromycin 1 clarithromycin er 1 e.e.s. 400 1 E.E.S. GRANULES 2 ERY-TAB TBEC 500MG 2 ery-tab tbec 250mg, 333mg 1 ERYTHROCIN LACTOBIONATE INJ 500MG 2 erythrocin stearate 1 ERYTHROMYCIN BASE 2 erythromycin ethylsuccinate 1 erythromycin/sulfisoxazole 1 ZMAX 2 MISCELLANEOUS ANTIINFECTIVES ALBENZA 2 ALINIA 2 amikacin sulfate inj 500mg/2ml, 50mg/ml 1 AZACTAM IN ISO-OSMOTIC DEXTROSE 2 AZACTAM INJ 2GM 2 aztreonam inj 1gm 1 BILTRICIDE 2 CAPASTAT SULFATE 3 CAYSTON 4 LA chloroquine 1 CLEOCIN GALAXY 2 CLEOCIN PEDIATRIC GRANULES 2 clindamycin hcl 1 clindamycin phosphate add-vantage 1 COARTEM 2 colistimethate sodium 1 CUBICIN 2 B/D PA DAPSONE 2 DARAPRIM 2 ethambutol 1 gentamicin sulfate inj 1 3 Drug Name Drug Tier Require-ments/ Limits gentamicin sulfate/0.9% sodium chloride 1 gentamicin sulfate/sodium chloride inj 1.2mg/ml; 0.9% 1 hydroxychloroquine 1 isonarif 1 ISONIAZID SYRP 2 isoniazid tabs 1 isotonic gentamicin inj 0.6mg/ml; 0.9%, 0.8mg/ml; 0.9% 1 KETEK 2 MALARONE 2 mebendazole 1 mefloquine hcl 1 MEPRON 4 meropenem inj 500mg 1 metronidazole 1 metronidazole in nacl 0.79% 1 MYCOBUTIN 2 NEBUPENT 2 B/D PA neomycin sulfate 1 paromomycin 1 PASER 2 PRIMAQUINE 2 PRIMAXIN I.M. 2 PRIMAXIN IV 2 pyrazinamide 1 QUALAQUIN 2 rifampin 1 SEROMYCIN 2 STREPTOMYCIN SULFATE 2 STROMECTOL 2 TOBI 4 B/D PA tobramycin inj 10mg/ml, 80mg/2ml 1 TOBRAMYCIN SULFATE / SODIUM CHLORIDE 2 TRECATOR 2 TYGACIL 2 XIFAXAN 2 ZYVOX 2 PENICILLINS Drug Name Drug Tier Require-ments/ Limits amoxicillin 1 amoxicillin/clavulanate potassium 1 amoxicillin/clavulanate potassium er 1 amoxicillin/potassium clavulanate tabs 1 ampicillin caps 1 ampicillin inj 10gm, 1gm 1 AMPICILLIN INJ 125MG 2 ampicillin susr 1 ampicillin-sulbactam inj 10gm; 5gm, 2gm; 1gm 1 BICILLIN C-R 2 BICILLIN L-A 2 dicloxacillin sodium 1 nafcillin sodium inj 10gm, 1gm 1 NALLPEN/DEXTROSE INJ 0; 1GM/50ML 2 PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE 2 penicillin g potassium inj 5mu 1 PENICILLIN G PROCAINE 2 PENICILLIN G SODIUM 2 penicillin v potassium 1 pfizerpen-g inj 20mu 1 piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm 1 ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML 2 QUINOLONES AVELOX 2 AVELOX ABC PACK 2 CIPRO I.V.-IN D5W INJ 200MG; 5% 2 ciprofloxacin inj 400mg/40ml 1 ciprofloxacin tabs 1 LEVAQUIN INJ 25MG/ML, 5%; 750MG/150ML 3 LEVAQUIN ORAL SOLN 3 LEVAQUIN TABS 3 NOROXIN 3 ofloxacin 1 SULFA'S / RELATED AGENTS 4 Drug Name Drug Tier Require-ments/ Limits sulfadiazine 1 sulfamethoxazole/trimethoprim 1 sulfamethoxazole/trimethoprim ds 1 TETRACYCLINES demeclocycline hcl 1 doxycycline hyclate caps 1 doxycycline hyclate inj 1 doxycycline hyclate tabs 1 doxycycline hyclate tbec 1 doxycycline monohydrate tabs 150mg, 50mg, 75mg 1 minocycline hcl 1 minocycline hcl er 1 tetracycline hcl 1 VIBRAMYCIN SYRP 2 URINARY TRACT AGENTS MACRODANTIN CAPS 25MG 2 methenamine hippurate 1 nitrofurantoin 1 nitrofurantoin macrocrystalline caps 50mg 1 nitrofurantoin monohydrate 1 PRIMSOL 3 trimethoprim 1 VANCOMYCIN VANCOCIN ORAL 2 vancomycin inj 1000mg, 10gm, 500mg 1 B/D PA VIBATIV INJ 250MG 2 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine 4 dexrazoxane inj 500mg 1 ELITEK INJ 1.5MG 4 leucovorin calcium inj 100mg, 350mg 1 leucovorin calcium tabs 25mg, 5mg 1 LEUCOVORIN CALCIUM TABS 10MG, 15MG 2 mesna 1 Drug Name Drug Tier Require-ments/ Limits MESNEX TABS 2 XGEVA 4 ZINECARD INJ 250MG 2 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 3 adriamycin inj 2mg/ml 1 AFINITOR TABS 10MG 4 PA QL(180 per 90 days) AFINITOR TABS 2.5MG, 5MG 4 PA QL(270 per 90 days) ALIMTA INJ 500MG 3 ALKERAN INJ 3 anastrozole 1 ARRANON 3 ARZERRA 2 AVASTIN INJ 100MG/4ML 3 azathioprine 1 B/D PA azathioprine sodium 1 B/D PA bicalutamide 1 BICNU 3 bleomycin sulfate inj 30unit 1 BUSULFEX 2 CAMPATH 3 carboplatin inj 150mg/15ml 1 CEENU 2 CELLCEPT INTRAVENOUS 2 CELLCEPT SUSR 2 B/D PA cisplatin inj 100mg/100ml 1 cladribine 1 CLOLAR 3 COSMEGEN 3 cyclophosphamide tabs 1 B/D PA cyclosporine caps 100mg, 25mg 1 B/D PA CYCLOSPORINE CAPS 50MG 2 B/D PA cyclosporine inj 1 B/D PA cyclosporine oral soln 1 B/D PA CYTARABINE AQUEOUS INJ 100MG/ML 2 cytarabine aqueous inj 20mg/ml 1 cytarabine inj 500mg 1 dacarbazine inj 200mg 1 5 Drug Name Drug Tier Require-ments/ Limits DACOGEN 2 daunorubicin hcl inj 20mg 1 DAUNOXOME 3 DOCETAXEL INJ 80MG/8ML 2 DOXIL 2 doxorubicin hcl 1 DROXIA 2 ELLENCE INJ 200MG/100ML 3 ELOXATIN INJ 100MG/20ML 3 ELSPAR 3 EMCYT 2 epirubicin hcl inj 50mg/25ml 1 ERBITUX INJ 100MG/50ML 3 ETOPOPHOS 3 etoposide inj 1 exemestane 1 FARESTON 3 FASLODEX 4 FIRMAGON INJ 120MG 4 FIRMAGON INJ 80MG 2 fludarabine phosphate inj 50mg 1 fluorouracil inj 500mg/10ml 1 flutamide 1 gemcitabine hcl inj 1gm 4 gengraf 1 B/D PA GLEEVEC 4 HALAVEN 4 HERCEPTIN 3 HEXALEN 4 hydroxyurea 1 idarubicin hcl inj 10mg/10ml 1 IFEX INJ 3GM 3 ifosfamide inj 1gm 1 ifosfamide/mesna 4 irinotecan inj 100mg/5ml 4 ISTODAX 2 IXEMPRA KIT INJ 45MG 4 JEVTANA 4 letrozole 1 LEUKERAN 2 leuprolide acetate 1 Drug Name Drug Tier Require-ments/ Limits LUPRON DEPOT INJ 3.75MG 2 LUPRON DEPOT INJ 11.25MG, 22.5MG, 30MG, 7.5MG 4 LUPRON DEPOT-PED INJ 11.25MG, 15MG 4 LYSODREN 2 MATULANE 4 MEGACE ES 2 megestrol acetate 1 melphalan hydrochloride 1 mercaptopurine 1 methotrexate 1 B/D PA methotrexate sodium inj 25mg/ml 1 METHOTREXATE SODIUM INJ 1GM 3 mitomycin inj 20mg 1 mitoxantrone hcl 1 MUSTARGEN 3 mycophenolate mofetil 1 B/D PA MYFORTIC 2 B/D PA NEORAL 2 B/D PA NEXAVAR 4 LA PA QL(360 per 90 days) NILANDRON 3 NIPENT 3 octreotide inj 100mcg/ml, 200mcg/ml, 50mcg/ml 1 octreotide inj 1000mcg/ml, 500mcg/ml 4 ONTAK 3 oxaliplatin inj 100mg/20ml 4 paclitaxel inj 300mg/50ml 1 pentostatin 1 PHOTOFRIN 3 PROGRAF INJ 2 B/D PA RAPAMUNE 2 B/D PA REVLIMID CAPS 15MG, 25MG 4 LA QL(21 per 28 days) REVLIMID CAPS 10MG, 5MG 4 LA QL(30 per 30 days) RHEUMATREX 3 B/D PA RITUXAN 2 PA SANDIMMUNE 2 B/D PA 6 Drug Name Drug Tier Require-ments/ Limits SANDOSTATIN LAR DEPOT 3 SIMULECT INJ 20MG 2 SOMATULINE DEPOT 4 SPRYCEL TABS 100MG, 140MG, 50MG, 70MG, 80MG 4 QL(90 per 90 days) SPRYCEL TABS 20MG 4 QL(180 per 90 days) SUTENT 4 PA QL(90 per 90 days) TABLOID 2 tacrolimus 1 B/D PA tamoxifen citrate 1 TARCEVA TABS 100MG, 150MG 4 PA QL(90 per 90 days) TARCEVA TABS 25MG 4 PA QL(180 per 90 days) TARGRETIN 2 TASIGNA CAPS 200MG 4 QL(336 per 84 days) TAXOTERE INJ 80MG/2ML, 80MG/4ML 4 THALOMID 4 PA thiotepa 1 toposar 1 topotecan hcl inj 4mg 1 TORISEL 4 PA TREANDA INJ 100MG 4 TRELSTAR DEPOT MIXJECT 3 TRELSTAR LA MIXJECT 3 TRELSTAR MIXJECT 3 tretinoin 1 TRISENOX 2 TYKERB 4 LA QL(540 per 90 days) VANDETANIB TABS 300MG 4 QL(90 per 90 days) VANDETANIB TABS 100MG 4 QL(180 per 90 days) VECTIBIX INJ 100MG/5ML 4 VELCADE 3 VIDAZA 4 QL(4200 per 90 days) vinblastine sulfate inj 10mg 1 vincasar pfs 1 Drug Name Drug Tier Require-ments/ Limits vincristine sulfate 1 vinorelbine tartrate inj 50mg/5ml 1 VOTRIENT 4 QL(360 per 90 days) ZANOSAR 3 ZOLINZA 4 QL(360 per 90 days) ZORTRESS TABS 0.5MG, 0.75MG 4 B/D PA ZORTRESS TABS 0.25MG 2 B/D PA ZYTIGA 4 PA QL(360 per 90 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL 2 carbamazepine 1 carbamazepine er tb12 1 CARBATROL 2 CELONTIN 2 clonazepam 1 ED DILANTIN CAPS 30MG 2 DILANTIN INFATABS 2 divalproex sodium cpsp 1 divalproex sodium er 1 divalproex sodium tbec 1 epitol 1 EQUETRO 2 ethosuximide 1 FELBATOL 2 gabapentin 1 GABITRIL 2 LAMICTAL ODT TBDP 2 LAMICTAL XR KIT 2 LAMICTAL XR TB24 100MG, 200MG, 25MG, 50MG 2 lamotrigine 1 levetiracetam 1 LYRICA 2 oxcarbazepine 1 PEGANONE 2 phenobarbital tabs 1 ED 7 Drug Name Drug Tier Require-ments/ Limits phenytoin 1 PHENYTOIN SODIUM 2 phenytoin sodium extended 1 primidone 1 SABRIL 2 TEGRETOL-XR TB12 100MG 2 topiramate 1 valproate sodium 1 valproic acid 1 VIMPAT 2 zonisamide 1 ANTIPARKINSONISM AGENTS APOKYN 2 LA AZILECT 2 benztropine mesylate 1 bromocriptine mesylate 1 carbidopa / levodopa 1 carbidopa/levodopa cr 1 carbidopa/levodopa odt 1 carbidopa/levodopa sr tbcr 50mg; 200mg 1 COMTAN 2 LODOSYN 2 MIRAPEX ER TB24 0.375MG, 0.75MG, 1.5MG, 3MG, 4.5MG 2 pramipexole dihydrochloride 1 REQUIP XL 2 ropinirole 1 selegiline 1 STALEVO 100 2 STALEVO 125 2 STALEVO 150 2 STALEVO 200 2 STALEVO 50 2 STALEVO 75 2 trihexyphenidyl 1 ZELAPAR 2 ANXIOLYTICS alprazolam 1 ED diazepam tabs 1 ED lorazepam tabs 1mg, 2mg 1 ED oxazepam 1 ED Drug Name Drug Tier Require-ments/ Limits HYPNOTIC AGENTS temazepam 1 ED MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine mesylate 1 ergotamine tartrate / caffeine 1 MAXALT 3 QL(36 per 90 days) MAXALT-MLT 3 QL(36 per 90 days) migergot 1 MIGRANAL 3 QL(24 per 90 days) naratriptan hcl tabs 2.5mg 1 QL(24 per 90 days) naratriptan hcl tabs 1mg 1 QL(36 per 90 days) RELPAX 3 QL(24 per 90 days) sumatriptan succinate inj 6mg/0.5ml 1 QL(12 per 90 days) sumatriptan succinate tabs 100mg 1 QL(27 per 90 days) sumatriptan succinate tabs 25mg, 50mg 1 QL(54 per 90 days) ZOMIG NASAL SOLN 3 QL(24 per 90 days) ZOMIG TABS 5MG 3 QL(24 per 90 days) ZOMIG TABS 2.5MG 3 QL(36 per 90 days) ZOMIG ZMT TBDP 5MG 3 QL(24 per 90 days) ZOMIG ZMT TBDP 2.5MG 3 QL(36 per 90 days) MISCELLANEOUS NEUROLOGICAL THERAPY ARICEPT ODT 2 ARICEPT TABS 23MG 2 COPAXONE 4 PA QL(90 per 90 days) donepezil hcl 1 EXELON ORAL SOLN 2 EXELON PT24 2 galantamine hydrobromide 1 8 Drug Name Drug Tier Require-ments/ Limits GILENYA 4 PA QL(28 per 28 days) MYTELASE 2 NAMENDA 2 NAMENDA TITRATION PAK 2 NUEDEXTA 2 rivastigmine tartrate 1 XENAZINE 4 LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen 1 cyclobenzaprine hcl 1 dantrolene sodium caps 1 MESTINON SYRP 2 MESTINON TIMESPAN 2 pyridostigmine bromide 1 regonol 1 tizanidine hcl 1 NARCOTIC ANALGESICS acetaminophen / codeine oral soln 1 acetaminophen / codeine tabs 300mg; 15mg 1 acetaminophen/codeine #3 1 acetaminophen/codeine #4 1 ascomp/codeine 1 BUPRENEX 2 buprenorphine hcl 1 codeine sulfate 1 DILAUDID INJ 2 DILAUDID-5 2 DILAUDID-HP INJ 10MG/ML 2 duramorph 1 EMBEDA 3 endocet 1 EXALGO 3 fentanyl citrate 1 fentanyl citrate oral transmucosal lpop 200mcg 1 fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 400mcg, 600mcg, 800mcg 4 Drug Name Drug Tier Require-ments/ Limits fentanyl patches 1 QL(45 per 90 days) hydrocodone bitartrate/acetaminophen tabs 1 hydrocodone/acetaminophen oral soln 500mg/15ml; 7.5mg/15ml 1 hydrocodone/acetaminophen tabs 1 hydrocodone/ibuprofen 1 hydromorphone hcl inj 10mg/ml 1 hydromorphone hcl tabs 1 INFUMORPH 200 2 INFUMORPH 500 2 KADIAN 2 levorphanol tartrate 1 margesic-h 1 methadone hcl conc 1 methadone hcl inj 1 methadone hcl oral soln 5mg/5ml 1 METHADONE HCL ORAL SOLN 10MG/5ML 2 methadone hcl tabs 1 methadose tabs 1 morphine sulfate er 1 morphine sulfate inj 0.5mg/ml, 1mg/ml 1 morphine sulfate oral soln 1 morphine sulfate tabs 1 ONSOLIS 2 OPANA ER 2 oxycodone / acetaminophen 1 oxycodone hcl caps 1 oxycodone hcl conc 1 oxycodone hcl tabs 15mg, 30mg, 5mg 1 oxycodone/aspirin 1 OXYCONTIN 3 ST oxymorphone hydrochloride 1 reprexain tabs 10mg; 200mg 1 ROXICET ORAL SOLN 2 roxicet tabs 325mg; 5mg 1 stagesic 1 zerlor 1 NON-NARCOTIC ANALGESICS 9 Drug Name Drug Tier Require-ments/ Limits ARTHROTEC 50 3 ARTHROTEC 75 3 butorphanol tartrate nasal soln 1 QL(30 per 90 days) CELEBREX 2 PA depade 1 diclofenac potassium 1 diclofenac sodium 1 diclofenac sodium ec 1 diclofenac sodium xr 1 diflunisal 1 etodolac 1 fenoprofen calcium 1 FLECTOR 3 flurbiprofen 1 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 800mg 1 indomethacin caps 1 indomethacin er 1 ketoprofen 1 ketoprofen er 1 meclofenamate sodium 1 mefenamic acid 1 meloxicam 1 nabumetone 1 naloxone 1 naltrexone 1 naproxen sodium tabs 275mg, 550mg 1 naproxen susp 1 naproxen tabs 250mg, 375mg 1 naproxen tbec 1 oxaprozin 1 PENNSAID 2 piroxicam 1 SUBOXONE 2 sulindac 1 tolmetin sodium 1 tramadol 1 tramadol hcl er 1 VIMOVO 2 Drug Name Drug Tier Require-ments/ Limits VOLTAREN GEL 2 PSYCHOTHERAPEUTIC DRUGS ABILIFY 2 ABILIFY DISCMELT 2 amitriptyline 1 amoxapine 1 budeprion sr 1 budeprion xl 1 bupropion hcl 1 bupropion hcl sr 1 buspirone hcl 1 chlordiazepoxide/amitriptyline 1 chlorpromazine 1 citalopram 1 clomipramine 1 clozapine tabs 100mg, 25mg, 50mg 1 CLOZAPINE TABS 200MG 2 CYMBALTA 2 desipramine 1 dextroamphetamine sulfate 1 PA dextroamphetamine sulfate er 1 PA doxepin 1 EMSAM 3 QL(90 per 90 days) FANAPT 3 FANAPT TITRATION PACK 3 FAZACLO 3 fluoxetine 1 fluoxetine dr 1 fluphenazine 1 fluphenazine decanoate inj 1 fluvoxamine 1 FOCALIN XR 2 PA GEODON 2 HALDOL 2 HALDOL DECANOATE 100 2 HALDOL DECANOATE 50 2 haloperidol 1 haloperidol decanoate inj 1 haloperidol lactate inj 1 imipramine 1 10 Drug Name Drug Tier Require-ments/ Limits imipramine pamoate 1 INVEGA 2 INVEGA SUSTENNA 2 LATUDA 2 lithium carbonate 1 lithium carbonate er 1 lithium citrate 1 loxapine 1 maprotiline 1 MARPLAN 2 METADATE CD CPCR 20MG, 30MG, 40MG, 50MG, 60MG 3 PA methylphenidate hcl 1 PA methylphenidate hydrochloride 1 PA mirtazapine 1 mirtazapine odt tbdp 30mg, 45mg 1 nefazodone 1 nortriptyline 1 ORAP 2 paroxetine 1 paroxetine er 1 PAXIL SUSP 2 perphenazine 1 phenelzine sulfate 1 PRISTIQ 2 protriptyline hcl 1 PROVIGIL 2 PA QL(90 per 90 days) RISPERDAL CONSTA 2 risperidone 1 risperidone odt 1 RITALIN LA 3 PA SAPHRIS 2 SEROQUEL 2 SEROQUEL XR 2 sertraline 1 SILENOR 3 STRATTERA 2 SURMONTIL 3 SYMBYAX 3 thioridazine 1 thiothixene 1 Drug Name Drug Tier Require-ments/ Limits tranylcypromine 1 trazodone 1 trifluoperazine 1 venlafaxine hcl 1 venlafaxine hcl er cp24 1 VIIBRYD 3 XYREM 4 zaleplon 1 QL(180 per 365 days) zolpidem 1 QL(180 per 365 days) zolpidem tartrate er tbcr 6.25mg 1 zolpidem tartrate er tbcr 12.5mg 1 QL(180 per 365 days) ZYPREXA 2 ZYPREXA ZYDIS 2 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mg/ml 1 amiodarone tabs 1 disopyramide phosphate 1 flecainide acetate 1 mexiletine 1 MULTAQ 2 NORPACE CR CP12 100MG 2 PACERONE TABS 100MG 2 pacerone tabs 200mg 1 procainamide 1 propafenone hcl 1 propafenone hcl er 1 quinidine gluconate er 1 quinidine sulfate 1 quinidine sulfate er 1 sorine 1 sotalol 1 TIKOSYN 3 ANTIHYPERTENSIVE THERAPY acebutolol 1 afeditab cr 1 amiloride 1 amiloride/hydrochlorothiazide 1 11 Drug Name Drug Tier Require-ments/ Limits amlodipine 1 amlodipine / benazepril 1 AMTURNIDE 2 atenolol 1 atenolol / chlorthalidone 1 benazepril 1 benazepril / hydrochlorothiazide 1 BENICAR 2 BENICAR HCT 2 betaxolol hcl 1 BIDIL 2 bisoprolol fumarate 1 bisoprolol fumarate / hydrochlorothiazide 1 bumetanide 1 BYSTOLIC 2 captopril 1 captopril/hydrochlorothiazide 1 cartia xt 1 carvedilol 1 chlorothiazide 1 chlorothiazide sodium 1 chlorthalidone tabs 25mg, 50mg 1 clonidine ptwk 1 clonidine tabs 1 COREG CR 2 DEMSER 2 DIBENZYLINE 3 dilt-cd cp24 120mg, 300mg 1 dilt-xr cp24 180mg, 240mg 1 diltiazem cd cp24 120mg, 240mg, 300mg 1 diltiazem hcl er cp12 1 diltiazem hcl er cp24 360mg, 420mg 1 diltiazem hcl inj 25mg/5ml 1 DILTIAZEM HCL INJ 100MG 2 diltiazem hcl tabs 1 diltzac cp24 120mg, 180mg, 240mg, 300mg 1 DIOVAN 2 DIOVAN HCT 2 Drug Name Drug Tier Require-ments/ Limits doxazosin 1 EDECRIN 2 enalapril 1 enalapril / hydrochlorothiazide 1 eplerenone 1 EXFORGE 2 EXFORGE HCT 2 felodipine er 1 fosinopril 1 fosinopril / hydrochlorothiazide 1 furosemide inj 1 furosemide oral soln 10mg/ml 1 FUROSEMIDE ORAL SOLN 8MG/ML 2 furosemide tabs 1 guanfacine hcl 1 hydralazine 1 hydrochlorothiazide 1 indapamide 1 isradipine 1 labetalol 1 lisinopril 1 lisinopril/hydrochlorothiazide 1 losartan potassium 1 losartan potassium/hydrochlorothiazide 1 matzim la 1 methyclothiazide 1 metolazone 1 metoprolol succinate er 1 metoprolol tartrate 1 metoprolol/hydrochlorothiazide 1 minoxidil tabs 1 moexipril 1 moexipril/hydrochlorothiazide 1 nadolol 1 nadolol/bendroflumethiazide 1 nicardipine caps 1 nifediac cc 1 nifedical xl 1 nifedipine 1 nifedipine er 1 12 Drug Name Drug Tier Require-ments/ Limits nimodipine 1 nisoldipine 1 nisoldipine er 1 perindopril erbumine 1 pindolol 1 prazosin 1 propranolol hcl 1 propranolol hcl er 1 propranolol/hydrochlorothiazide 1 quinapril 1 quinapril/hydrochlorothiazide 1 ramipril 1 REMODULIN 4 PA reserpine 1 SODIUM EDECRIN 2 spironolactone 1 spironolactone/hydrochlorothiazi de 1 taztia xt 1 TEKAMLO 2 TEKTURNA 2 TEKTURNA HCT 2 terazosin hcl 1 timolol maleate 1 torsemide tabs 1 trandolapril 1 triamterene/hydrochlorothiazide 1 TWYNSTA 2 VALTURNA 2 verapamil 1 verapamil er 1 CARDIAC GLYCOSIDES digoxin 1 LANOXIN 2 COAGULATION THERAPY AGGRENOX 2 ARIXTRA 2 cilostazol 1 CYKLOKAPRON 2 EFFIENT 2 Drug Name Drug Tier Require-ments/ Limits enoxaparin sodium inj 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml 1 enoxaparin sodium inj 100mg/ml, 120mg/0.8ml, 150mg/ml 4 FRAGMIN 2 HEPARIN SODIUM INJ 2000UNIT/ML 2 heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml 1 heparin sodium/d5w inj 5%; 40unit/ml 1 HEPARIN SODIUM/NACL 0.45% 2 heparin sodium/sodium chloride 0.9% premix 1 jantoven 1 LOVENOX INJ 300MG/3ML 2 pentopak 1 pentoxifylline er 1 PLAVIX 2 PRADAXA 2 PROMACTA 4 LA ticlopidine hcl 1 warfarin 1 LIPID/CHOLESTEROL LOWERING AGENTS CADUET 2 cholestyramine light pack 1 colestipol 1 fenofibrate 1 fenofibrate micronized 1 gemfibrozil 1 LIPITOR 2 lovastatin 1 LOVAZA 2 NIASPAN 2 pravastatin 1 prevalite powd 1 simvastatin 1 TRICOR 2 TRILIPIX 2 13 Drug Name Drug Tier Require-ments/ Limits WELCHOL 2 ZETIA 2 MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 2 NITRATES isosorbide dinitrate 1 isosorbide dinitrate er 1 isosorbide mononitrate 1 isosorbide mononitrate er 1 nitro-bid 1 NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR 2 nitroglycerin inj 1 B/D PA nitroglycerin pt24 1 nitroglycerin transdermal pt24 0.1mg/hr 1 NITROLINGUAL PUMPSPRAY 2 NITROSTAT 2 DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC calcipotriene 1 selenium sulfide lotn 2.5% 1 SORIATANE 2 BURN THERAPY silver sulfadiazine 1 ssd 1 thermazene 1 MISCELLANEOUS DERMATOLOGICALS 8-MOP 2 ammonium lactate 1 CARAC 2 CARMOL-HC 2 CONDYLOX GEL 2 ELIDEL 3 FLUOROPLEX 2 fluorouracil crea 1 fluorouracil external soln 1 imiquimod 1 laclotion 1 Drug Name Drug Tier Require-ments/ Limits OXSORALEN ULTRA 4 PANRETIN 2 podofilox 1 PROTOPIC 3 REGRANEX 2 SOLARAZE 2 UVADEX 3 VEREGEN 3 ZONALON 2 THERAPY FOR ACNE adapalene 1 amnesteem 1 avita crea 1 AZELEX 2 claravis caps 10mg, 20mg, 40mg 1 claravis caps 30mg 4 clindamycin phosphate external soln 1 clindamycin phosphate foam 1 clindamycin phosphate gel 1 clindamycin phosphate lotn 1 clindamycin phosphate swab 1 clindamycin/benzoyl peroxide 1 DIFFERIN LOTN 2 ery 1 erythromycin / benzoyl peroxide 1 erythromycin external soln 1 erythromycin gel 1 FINACEA 2 METROGEL 2 metronidazole 1 sotret 1 TAZORAC 2 tretinoin 1 TOPICAL ANESTHETICS lidocaine / prilocaine crea 1 lidocaine external soln 1 lidocaine gel 1 lidocaine inj 0.5%, 1% 1 lidocaine oint 1 lidocaine viscous 1 14 Drug Name Drug Tier Require-ments/ Limits LIDODERM 2 QL(270 per 90 days) TOPICAL ANTIBACTERIALS ALTABAX 2 BACTROBAN CREA 2 gentamicin sulfate crea 1 gentamicin sulfate oint 0.1% 1 mupirocin 1 PHISOHEX 2 sodium sulfacetamide 1 SULFAMYLON 2 TOPICAL ANTIFUNGALS ciclopirox 1 ciclopirox nail lacquer 1 ciclopirox olamine 1 clotrimazole / betamethasone 1 clotrimazole external crea 1 clotrimazole external soln 1 econazole nitrate 1 ketoconazole 1 NAFTIN 2 nyamyc 1 nystatin / triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 pedi-dri 1 TOPICAL ANTIVIRALS DENAVIR 2 ZOVIRAX CREA 3 ZOVIRAX OINT 3 TOPICAL CORTICOSTEROIDS ala cort 1 alclometasone dipropionate 1 amcinonide 1 augmented betamethasone dipropionate crea 1 augmented betamethasone dipropionate lotn 1 augmented betamethasone dipropionate oint 1 Drug Name Drug Tier Require-ments/ Limits betamethasone dipropionate 1 betamethasone valerate 1 CAPEX 2 clobetasol propionate e 1 clobetasol propionate external soln 1 clobetasol propionate gel 1 clobetasol propionate oint 1 CLOBEX LOTN 2 CLOBEX SHAM 2 CORDRAN TAPE 2 DERMA-SMOOTHE / FS BODY OIL 2 desonide 1 desoximetasone 1 diflorasone diacetate 1 fluocinolone acetonide 1 fluocinonide emollient base 1 fluocinonide external soln 1 fluocinonide gel 1 fluocinonide oint 1 fluticasone propionate crea 1 fluticasone propionate oint 1 halobetasol propionate 1 hydrocortisone butyrate 1 hydrocortisone crea 1%, 2.5% 1 hydrocortisone lotn 2.5% 1 hydrocortisone oint 1%, 2.5% 1 hydrocortisone valerate 1 LOCOID LOTN 2 LUXIQ 2 mometasone furoate 1 PANDEL 2 prednicarbate 1 triamcinolone acetonide crea 1 triamcinolone acetonide lotn 1 triamcinolone acetonide oint 1 triderm 1 TOPICAL ENZYMES SANTYL 2 TOPICAL SCABICIDES / PEDICULICIDES acticin 1 15 Drug Name Drug Tier Require-ments/ Limits EURAX 2 LINDANE 2 malathion 1 permethrin crea 1 ULESFIA 3 DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS ACTONEL TABS 30MG 3 ADAGEN 4 LA alendronate sodium tabs 40mg 1 QL(90 per 90 days) anagrelide hydrochloride 1 ANTABUSE TABS 250MG 2 ARALAST NP INJ 400MG 4 LA BUPHENYL 2 CAMPRAL 2 CHEMET 2 CLINIMIX / DEXTROSE 2 DEXTROSE 10%/NACL 0.45% 2 dextrose 10% flex container 1 DEXTROSE 10%/NACL 0.2% 2 dextrose 2.5%/sodium chloride 0.45% 1 dextrose 5% 1 dextrose 5%/nacl 0.2% 1 dextrose 5%/nacl 0.225% 1 DEXTROSE 5%/NACL 0.33% 2 dextrose 5%/nacl 0.45% 1 dextrose 5%/nacl 0.9% 1 etidronate disodium 1 EVOXAC 3 EXJADE TBSO 125MG 2 LA EXJADE TBSO 250MG, 500MG 4 LA FOSRENOL 2 INCRELEX 4 LA kionex powd 1 levocarnitine oral soln 1 B/D PA levocarnitine tabs 1 B/D PA midodrine 1 ORFADIN 4 LA Drug Name Drug Tier Require-ments/ Limits pilocarpine hcl tabs 1 PROLASTIN INJ 500MG 4 LA PROLASTIN-C 4 LA RENAGEL 2 RENVELA 2 RILUTEK 4 SKELID 3 sodium chloride 0.9% 1 sodium chloride inj 0.9% 1 sodium polystyrene sulfonate 1 SYPRINE 2 SMOKING DETERRENTS BUPROBAN 5 QL(180 per 90 days) CHANTIX TABS 5 CHANTIX TABS 0.5MG, 1MG 5 QL(336 per 365 days) NICOTROL INHALER 5 QL(2688 per 365 days) NICOTROL NASAL 5 QL(7200 per 365 days) EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO 2 azelastine hcl 1 BACTROBAN NASAL 2 chlorhexidine gluconate oral rinse 1 ipratropium bromide nasal soln 1 periogard 1 triamcinolone in orabase 1 TYZINE 2 TYZINE PEDIATRIC NASAL DROPS 2 MISCELLANEOUS OTIC PREPARATIONS acetasol hc 1 acetic acid 1 DERMOTIC 2 hydrocortisone/acetic acid 1 16 Drug Name Drug Tier Require-ments/ Limits ofloxacin 1 OTIC STEROID / ANTIBIOTIC CIPRO HC 3 CIPRODEX 2 COLY-MYCIN S 2 CORTISPORIN-TC 2 cortomycin 1 neomycin/polymyxin/hc 1 neomycin/polymyxin/hydrocortiso ne otic susp 1 ENDOCRINE/DIABETES ADRENAL HORMONES a-hydrocort 1 a-methapred 1 B/D PA cortisone acetate 1 DEPO-MEDROL 2 B/D PA dexamethasone elix 1 dexamethasone inj 4mg/ml 1 DEXAMETHASONE INTENSOL 2 DEXAMETHASONE TABS 1MG, 2MG 2 dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg 1 fludrocortisone acetate 1 hydrocortisone tabs 1 methylprednisolone 1 B/D PA methylprednisolone acetate 1 B/D PA methylprednisolone sodiumsuccinate inj 125mg, 40mg 1 B/D PA METHYLPREDNISOLONE SODIUMSUCCINATE INJ 1000MG 2 B/D PA prednisolone sodium phosphate oral soln 1 B/D PA prednisone 1 B/D PA PREDNISONE INTENSOL 2 B/D PA SOLU-CORTEF INJ 100MG, 250MG 2 SOLU-MEDROL INJ 125MG, 2GM, 40MG, 500MG 2 B/D PA ANTITHYROID AGENTS methimazole 1 Drug Name Drug Tier Require-ments/ Limits propylthiouracil 1 DIABETES THERAPY acarbose 1 ACTOPLUS MET 2 ACTOS 2 ALCOHOL PREPS 2 APIDRA 2 QL(120 per 90 days) APIDRA SOLOSTAR 2 QL(120 per 90 days) AVANDAMET 2 AVANDARYL 2 AVANDIA 2 BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 2 QL(600 per 90 days) BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 2 QL(600 per 90 days) BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 2 QL(600 per 90 days) BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 2 QL(600 per 90 days) BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 2 QL(600 per 90 days) BYETTA 3 QL(7.2 per 90 days) DUETACT 2 GAUZE PADS 2"X2" 2 glimepiride 1 glipizide 1 glipizide / metformin 1 glipizide er 1 GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT 2 glyburide 1 glyburide / metformin 1 glyburide micronized 1 glycron tabs 1.5mg 1 GLYCRON TABS 4.5MG 2 HUMALOG 2 QL(120 per 90 days) 17 Drug Name Drug Tier Require-ments/ Limits HUMALOG KWIKPEN 2 QL(120 per 90 days) HUMALOG MIX 50/50 2 QL(120 per 90 days) HUMALOG MIX 50/50 KWIKPEN 2 QL(135 per 90 days) HUMALOG MIX 75/25 2 QL(120 per 90 days) HUMALOG MIX 75/25 KWIKPEN 2 QL(135 per 90 days) HUMULIN 70/30 2 QL(120 per 90 days) HUMULIN 70/30 PEN 2 QL(135 per 90 days) HUMULIN N 2 QL(120 per 90 days) HUMULIN N U-100 PEN 2 QL(135 per 90 days) HUMULIN R 2 QL(120 per 90 days) HUMULIN R U-500 (CONCENTRATED) 2 JANUMET 2 JANUVIA 2 KOMBIGLYZE XR 2 LANTUS 2 QL(120 per 90 days) LANTUS SOLOSTAR 2 QL(120 per 90 days) LEVEMIR 2 QL(120 per 90 days) LEVEMIR FLEXPEN 2 QL(135 per 90 days) metformin hcl 1 metformin hcl er 1 nateglinide 1 NOVOLIN 70/30 2 QL(120 per 90 days) NOVOLIN N 2 QL(120 per 90 days) NOVOLIN R 2 QL(120 per 90 days) NOVOLOG 2 QL(120 per 90 days) NOVOLOG FLEXPEN 2 QL(135 per 90 days) Drug Name Drug Tier Require-ments/ Limits NOVOLOG MIX 70/30 2 QL(120 per 90 days) NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2 QL(135 per 90 days) ONGLYZA 2 PRANDIN 2 PROGLYCEM 2 SYMLIN 3 QL(60 per 90 days) SYMLINPEN 120 3 QL(33 per 90 days) SYMLINPEN 60 3 QL(33 per 90 days) tolazamide 1 tolbutamide 1 MISCELLANEOUS HORMONES ALDURAZYME 4 B/D LA PA ANADROL-50 3 PA ANDRODERM 2 PA QL(180 per 90 days) ANDROGEL GEL 50MG/5GM 2 PA QL(900 per 90 days) ANDROGEL PUMP GEL 1.62% 2 PA ANDROID 2 PA androxy 1 PA cabergoline 1 calcitonin-salmon 1 QL(12 per 90 days) calcitriol 1 B/D PA CEREZYME INJ 200UNIT 4 B/D LA PA danazol 1 desmopressin acetate 1 FABRAZYME INJ 35MG 4 B/D LA PA fortical 1 QL(12 per 90 days) HECTOROL 2 KUVAN 4 LA NAGLAZYME 4 LA oxandrolone tabs 10mg 4 oxandrolone tabs 2.5mg 1 SAMSCA 4 SENSIPAR TABS 60MG, 90MG 4 SENSIPAR TABS 30MG 2 18 Drug Name Drug Tier Require-ments/ Limits SOMAVERT 2 PA QL(90 per 90 days) STIMATE 2 SYNAREL 3 testosterone cypionate inj 100mg/ml 1 PA testosterone enanthate 1 PA ZAVESCA 2 LA ZEMPLAR 2 B/D PA ZOMETA 4 THYROID HORMONES levothyroxine tabs 1 levoxyl 1 liothyronine sodium tabs 1 SYNTHROID 2 unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg 1 GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine sulfate inj 0.1mg/ml 1 ATROPINE SULFATE INJ 0.05MG/ML 2 dicyclomine hcl 1 glycopyrrolate 1 loperamide hcl caps 1 propantheline bromide 1 MISCELLANEOUS GASTROINTESTINAL AGENTS AMITIZA 2 ASACOL 2 ASACOL HD 2 balsalazide 1 CANASA 2 CIMZIA 4 PA QL(6 per 28 days) compro 1 constulose 1 CORTIFOAM 2 Drug Name Drug Tier Require-ments/ Limits CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT 2 CYSTADANE 2 DIPENTUM 3 dronabinol 1 B/D PA EMEND CAPS 40MG 2 B/D PA QL(3 per 90 days) EMEND CAPS 125MG 2 B/D PA QL(6 per 90 days) EMEND CAPS 2 B/D PA QL(18 per 90 days) EMEND CAPS 80MG 2 B/D PA QL(24 per 90 days) ENTOCORT EC 2 enulose 1 GASTROCROM 2 gavilyte-c 1 gavilyte-g 1 gavilyte-n/flavor pack 1 granisetron inj 0.1mg/ml, 1mg/ml 1 granisetron tabs 1 B/D PA hydrocortisone enem 1 lactulose 1 LOTRONEX 2 meclizine hcl 1 mesalamine enem 1 metoclopramide 1 ondansetron hcl inj 4mg/2ml 1 ondansetron hcl oral soln 1 B/D PA ondansetron hcl tabs 24mg 1 B/D PA QL(21 per 90 days) ondansetron hcl tabs 4mg, 8mg 1 B/D PA QL(135 per 90 days) ondansetron odt 1 B/D PA QL(135 per 90 days) 19 Drug Name Drug Tier Require-ments/ Limits PENTASA 2 polyethylene glycol 3350 powd 1 prochlorperazine 1 prochlorperazine edisylate 1 prochlorperazine maleate 1 procto-pak 1 proctosol hc 1 proctozone-hc 1 RELISTOR 2 REMICADE 4 PA SANCUSO 2 QL(6 per 90 days) sulfasalazine tabs 1 sulfazine ec 1 TRANSDERM-SCOP 3 trilyte 1 ursodiol 1 ZENPEP 2 ZUPLENZ 2 B/D PA QL(135 per 90 days) ULCER THERAPY CARAFATE SUSP 2 famotidine inj 1 famotidine premixed 1 famotidine susr 1 famotidine tabs 20mg, 40mg 1 lansoprazole 1 lansoprazole odt 1 misoprostol 1 NEXIUM I.V. 2 nizatidine 1 omeprazole cpdr 1 pantoprazole 1 PREVPAC 3 PYLERA 2 ranitidine hcl caps 1 ranitidine hcl syrp 1 ranitidine hcl tabs 1 sucralfate 1 ZANTAC INJ 50MG/50ML; 0.45% 2 Drug Name Drug Tier Require-ments/ Limits IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 LA ARANESP INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 25MCG/0.42ML, 25MCG/ML, 300MCG/0.6ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/0.3ML, 60MCG/ML 2 PA ARCALYST 4 LA AVONEX 4 PA QL(12 per 90 days) BETASERON 4 PA QL(45 per 90 days) EPOGEN 3 PA INTRON-A INJ 3MU/0.2ML, 6000000UNIT/ML 2 INTRON-A INJ 10MU/0.2ML, 5MU/0.2ML 4 INTRON-A WITH DILUENT INJ 10MU 4 LEUKINE 4 PA MOZOBIL 4 NEULASTA 3 PA NEUMEGA 4 PA NEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML 4 PA NORDITROPIN FLEXPRO 4 PA NORDITROPIN NORDIFLEX PEN 4 PA omnitrope inj 5mg/1.5ml 1 PA PEG-INTRON INJ 50MCG/0.5ML 4 PEG-INTRON REDIPEN 4 PEGASYS 4 PROCRIT 2 PA PROLEUKIN 4 REBIF 4 PA QL(18 per 90 days) REBIF TITRATION PACK 4 PA 20 Drug Name Drug Tier Require-ments/ Limits TEV-TROPIN 2 PA VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB 2 ADACEL 2 BOOSTRIX 2 CERVARIX 2 COMVAX 2 DAPTACEL 2 DECAVAC 2 DIPHTHERIA/TETANUS TOXOID PEDIATRIC 2 ENGERIX-B 2 B/D PA GARDASIL 2 HAVRIX 2 HIZENTRA INJ 1GM/5ML 4 PA IMOVAX RABIES (H.D.C.V.) 2 INFANRIX 2 IPOL INACTIVATED IPV 2 IXIARO 2 JE-VAX 2 M-M-R II W/DILUENT 10 DOSE 2 MENACTRA 2 MENOMUNE-A/C/Y/W-135 2 MENVEO 2 PEDVAX HIB 2 PRIVIGEN INJ 20GM/200ML 4 PA PROQUAD 2 RABAVERT 2 RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML 2 B/D PA ROTATEQ 2 TETANUS / DIPHTHERIA TOXOIDS-ADSORBED ADULT 2 TETANUS TOXOID ADSORBED 2 THYMOGLOBULIN 2 TRIPEDIA 2 TWINRIX 2 B/D PA TYPHIM VI 2 VAQTA 2 VARIVAX 2 Drug Name Drug Tier Require-ments/ Limits VIVAGLOBIN 4 PA YF-VAX 2 ZOSTAVAX 2 MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol 1 COLCRYS 2 probenecid 1 probenecid / colchicine 1 ULORIC 2 OSTEOPOROSIS THERAPY alendronate sodium tabs 35mg, 70mg 1 QL(12 per 90 days) alendronate sodium tabs 10mg, 5mg 1 QL(90 per 90 days) BONIVA INJ 2 BONIVA TABS 3 B/D PA QL(3 per 90 days) EVISTA 2 FORTEO 2 QL(7.2 per 90 days) OTHER RHEUMATOLOGICALS CUPRIMINE 2 DEPEN TITRATABS 2 ENBREL 4 PA QL(600 per 90 days) HUMIRA INJ 20MG/0.4ML 4 PA QL(2.4 per 90 days) HUMIRA INJ 40MG/0.8ML 4 PA QL(4.8 per 90 days) HUMIRA PEN-CROHNS DISEASE STARTER 4 PA leflunomide 1 QL(90 per 90 days) RIDAURA 3 SAVELLA 2 SAVELLA TITRATION PACK 2 SIMPONI 4 PA QL(1 per 30 days) OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS 21 Drug Name Drug Tier Require-ments/ Limits ALORA 2 QL(24 per 90 days) camila 1 CLIMARA PRO 2 QL(12 per 90 days) COMBIPATCH 2 QL(24 per 90 days) CRINONE 2 DEPO-PROVERA 2 DEPO-SUBQ PROVERA 104 3 DIVIGEL GEL 1MG/GM 2 QL(90 per 90 days) errin 1 ESTRADERM 2 QL(24 per 90 days) estradiol / norethindrone acetate tabs 1mg; 0.5mg 1 estradiol ptwk 1 QL(12 per 90 days) estradiol tabs 1 ESTRING 3 estropipate 1 jinteli 1 jolivette 1 medroxyprogesterone acetate 1 MENOSTAR 3 QL(12 per 90 days) nora-be 1 norethindrone tabs 5mg 1 ortho-est 1 PREFEST 3 PREMARIN TABS 2 PREMARIN W/APPLICATOR 2 PREMPHASE 2 PREMPRO 2 PROMETRIUM 2 VAGIFEM 2 VIVELLE-DOT 2 QL(24 per 90 days) MISCELLANEOUS OB/GYN CLEOCIN SUPP 2 clindamycin phosphate crea 1 GYNAZOLE-1 2 LYSTEDA 3 Drug Name Drug Tier Require-ments/ Limits metronidazole vaginal 1 miconazole 3 1 NUVARING 3 ORTHO EVRA 3 terconazole 1 vandazole 1 zazole crea 0.4% 1 ORAL CONTRACEPTIVES / RELATED AGENTS apri 1 aranelle 1 aviane 1 balziva 1 cesia 1 cryselle-28 1 cyclafem 1/35 1 cyclafem 7/7/7 1 ELLA 2 enpresse-28 1 gianvi 1 junel 1 junel fe 1.5/30 1 junel fe 1/20 1 kariva 1 kelnor 1/35 1 leena 1 lessina-28 1 levora 1 low-ogestrel 1 lutera 1 microgestin 1.5/30 1 microgestin 1/20 1 microgestin fe 1 microgestin fe 1.5/30 1 mononessa 1 necon 0.5/35-28 1 necon 1/35-28 1 necon 10/11-28 1 necon 7/7/7 1 next choice 1 nortrel 0.5/35 (28) 1 22 Drug Name Drug Tier Require-ments/ Limits nortrel 1/35 (21) 1 nortrel 1/35 (28) 1 nortrel 7/7/7 1 ocella 1 ogestrel 1 portia-28 1 previfem 1 quasense 1 reclipsen 1 solia 1 sprintec 28 1 sronyx 1 tri-legest fe 1 tri-previfem 1 tri-sprintec 1 trinessa 1 trivora-28 1 velivet 1 zeosa 1 zovia 1/35e 1 zovia 1/50e 1 OXYTOCICS METHERGINE TABS 2 OPHTHALMOLOGY ANTIBIOTICS ak-tob 1 AZASITE 2 bacitracin / polymyxin b 1 bacitracin ophthalmic oint 1 BESIVANCE 2 CILOXAN OINT 2 ciprofloxacin ophthalmic soln 1 erythromycin oint 1 gentak 1 gentamicin sulfate ophthalmic soln 1 gentasol 1 levofloxacin ophthalmic soln 1 MOXEZA 2 NATACYN 2 neomycin/bacitracin/polymyxin 1 Drug Name Drug Tier Require-ments/ Limits neomycin/polymyxin/gramicidin 1 ofloxacin 1 romycin 1 tobramycin ophthalmic soln 1 tobrasol 1 TOBREX OINT 2 trimethoprim sulfate/polymyxin b sulfate 1 VIGAMOX 2 ZYMAR 2 ZYMAXID 2 ANTIVIRALS trifluridine 1 ZIRGAN 3 BETA-BLOCKERS betaxolol hcl 1 BETOPTIC-S 2 carteolol hcl 1 ISTALOL 2 levobunolol hcl 1 metipranolol 1 timolol maleate 1 timolol maleate ophthalmic gel forming 1 TIMOPTIC OCUDOSE 2 CYCLOPLEGIC MYDRIATICS tropicamide 1 DIRECT ACTING MIOTICS PILOPINE HS 2 MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL 3 azelastine hcl 1 BEPREVE 2 cromolyn sodium ophthalmic soln 1 epinastine hcl 1 LACRISERT 2 PATADAY 2 PATANOL 2 RESTASIS 2 QL(192 per 90 days) 23 Drug Name Drug Tier Require-ments/ Limits NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL 2 BROMDAY 2 bromfenac 1 diclofenac sodium 1 flurbiprofen sodium 1 ketorolac tromethamine ophthalmic soln 1 NEVANAC 2 ORAL DRUGS FOR GLAUCOMA acetazolamide 1 acetazolamide sodium 1 methazolamide 1 OTHER GLAUCOMA DRUGS AZOPT 2 COMBIGAN 2 dorzolamide hcl 1 dorzolamide hcl/timolol maleate 1 latanoprost 1 LUMIGAN 2 TRAVATAN Z 2 STEROID-ANTIBIOTIC COMBINATIONS neomycin/polymyxin/bacitracin/h ydrocortisone 1 neomycin/polymyxin/dexamethaso ne 1 neomycin/polymyxin/hydrocortiso ne ophthalmic susp 1 poly-dex 1 TOBRADEX OINT 2 TOBRADEX ST 2 tobramycin/dexamethasone 1 ZYLET 2 STEROID-SULFONAMIDE COMBINATIONS sulfacetamide sodium / prednisolone sodium phospha 1 STEROIDS ALREX 2 dexamethasone ophthalmic soln 1 DUREZOL 2 Drug Name Drug Tier Require-ments/ Limits fluorometholone 1 FML 2 FML FORTE 2 LOTEMAX 2 prednisolone acetate 1 prednisolone sodium phosphate ophthalmic soln 1 SULFONAMIDES BLEPH-10 2 sodium sulfacetamide 1 SYMPATHOMIMETICS ALPHAGAN P 2 apraclonidine 1 brimonidine tartrate ophthalmic soln 0.2% 1 IOPIDINE OPHTHALMIC SOLN 1% 3 VASOCONSTRICTOR DECONGESTANTS ak-con 1 RENAL / GENITOURINARY IMPOTENCE AGENTS CAVERJECT 2 ED PA QL(6 per 30 days) CAVERJECT IMPULSE 2 ED PA QL(6 per 30 days) CIALIS 3 ED PA QL(6 per 30 days) LEVITRA 2 ED PA QL(6 per 30 days) MUSE 2 ED PA QL(6 per 30 days) VIAGRA 2 ED PA QL(6 per 30 days) RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS carbinoxamine maleate 1 cetirizine hcl syrp 1 24 Drug Name Drug Tier Require-ments/ Limits CLARINEX 3 CLARINEX REDITABS 3 CLARINEX-D 12 HOUR 3 CLARINEX-D 24 HOUR 3 clemastine fumarate syrp 1 clemastine fumarate tabs 2.68mg 1 epinephrine hcl inj 0.1mg/ml 1 EPIPEN 2 EPIPEN-JR 2 fexofenadine hcl 1 hydroxyzine hcl 1 levocetirizine dihydrochloride 1 palgic liqd 1 phenadoz 1 promethazine hcl 1 promethegan supp 25mg, 50mg 1 TWINJECT 2 PULMONARY AGENTS acetylcysteine 1 B/D PA ADVAIR DISKUS 2 ADVAIR HFA 2 albuterol sulfate er 1 albuterol sulfate nebu 1 B/D PA albuterol sulfate syrp 1 albuterol sulfate tabs 1 aminophylline 1 ASMANEX 120 METERED DOSES 2 ASMANEX 14 METERED DOSES 2 ASMANEX 30 METERED DOSES 2 ASMANEX 60 METERED DOSES 2 ATROVENT HFA 2 budesonide susp 1 B/D PA COMBIVENT 2 cromolyn sodium nebu 1 B/D PA DULERA 3 ELIXOPHYLLIN 3 FLOVENT DISKUS 2 FLOVENT HFA 2 Drug Name Drug Tier Require-ments/ Limits flunisolide nasal soln 0.025% 1 QL(200 per 90 days) fluticasone propionate susp 1 QL(48 per 90 days) FORADIL AEROLIZER 2 ipratropium bromide inhalation soln 1 B/D PA ipratropium bromide/albuterol sulfate 1 B/D PA LETAIRIS 4 LA metaproterenol sulfate 1 PERFOROMIST 2 B/D PA PROAIR HFA 2 PROVENTIL HFA 3 PULMICORT FLEXHALER 2 PULMICORT SUSP 1MG/2ML 2 B/D PA PULMOZYME 4 B/D PA QVAR 2 REVATIO 4 SEREVENT DISKUS 2 SINGULAIR 2 SPIRIVA HANDIHALER 2 SYMBICORT 2 terbutaline sulfate 1 THEO-24 3 theochron tb12 100mg, 300mg 1 theophylline er 1 TRACLEER 4 LA VENTOLIN HFA 2 XOLAIR 4 PA QL(7.2 per 30 days) zafirlukast 1 ZYFLO CR 3 UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS DETROL 2 DETROL LA 2 ENABLEX 2 flavoxate hcl 1 GELNIQUE 2 oxybutynin 1 25 Drug Name Drug Tier Require-ments/ Limits oxybutynin er 1 OXYTROL 2 QL(48 per 90 days) TOVIAZ 2 trospium chloride 1 VESICARE 2 BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY AVODART 2 finasteride 1 JALYN 2 RAPAFLO 2 tamsulosin hcl 1 UROXATRAL 2 CHOLINERGIC STIMULANTS bethanechol chloride 1 MISCELLANEOUS UROLOGICALS CYSTAGON 2 LA ELMIRON 2 potassium citrate extended-release 1 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate 1 eliphos 1 K-TABS 3 kcl 0.075%/d5w/nacl 0.45% 1 kcl 0.15%/d5w/lr 1 KCL 0.15%/D5W/NACL 0.2% 2 KCL 0.15%/D5W/NACL 0.225% 2 kcl 0.15%/d5w/nacl 0.9% 1 kcl 0.3%/d5w/lr iv lac ring 1 KCL 0.3%/D5W/NACL 0.2% 2 kcl 0.3%/d5w/nacl 0.45% 1 kcl 0.3%/d5w/nacl 0.9% 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 2 Drug Name Drug Tier Require-ments/ Limits MAGNESIUM SULFATE IN D5W INJ 5%; 10MG/ML 2 MAGNESIUM SULFATE INJ 2 NORMOSOL 2 POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225% 2 POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX 2 potassium chloride 0.15% d5w/nacl 0.33% 1 potassium chloride 0.15% d5w/nacl 0.45% viaflex 1 potassium chloride 0.15% nacl 0.9% 1 POTASSIUM CHLORIDE 0.15%/D5W 2 POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% 2 potassium chloride 0.224%/d5w 1 POTASSIUM CHLORIDE 0.3%/ NACL 0.9% 2 potassium chloride 0.3%/d5w 1 potassium chloride er cpcr 1 potassium chloride er tbcr 10meq, 20meq 1 potassium chloride inj 10meq/100ml, 10meq/50ml, 2meq/ml 1 POTASSIUM CHLORIDE INJ 0.4MEQ/ML, 30MEQ/100ML 2 ringers injection 1 sodium bicarbonate inj 7.5%, 8.4% 1 sodium chloride 0.45% viaflex 1 sodium chloride inj 2.5meq/ml, 3%, 5% 1 MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 2 AMINOSYN II 2 AMINOSYN II M 2 AMINOSYN-HBC 2 AMINOSYN-HF 2 AMINOSYN-PF 2 AMINOSYN-PF 7% 2 26 Drug Name Drug Tier Require-ments/ Limits CLINIMIX / DEXTROSE 2 CLINISOL SF 2 DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX 2 FREAMINE III 2 HEPATAMINE 2 HEPATASOL 2 INTRALIPID INJ 1.7%; 30% 2 intralipid inj 2.25%; 20% 1 IONOSOL 2 ISOLYTE 2 KCL 0.15%/D10W/NACL 0.2% 2 LIPOSYN III INJ 1.8%; 2.5%; 30% 2 NEPHRAMINE 2 NORMOSOL 2 PLASMA-LYTE 2 PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML; 300MG/100ML; 220MG/100ML; 290MG/100ML; 490MG/100ML; 840MG/100ML; 490MG/100ML; 200MG/100ML; 290MG/100ML; 410MG/100ML; 230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/100ML; 120MG/100ML; 140MG/100ML; 470MG/100ML 2 premasol inj 52meq/l; 1760mg/100ml; 880mg/100ml; 34meq/l; 1760mg/100ml; 372mg/100ml; 406mg/100ml; 526mg/100ml; 492mg/100ml; 492mg/100ml; 526mg/100ml; 356mg/100ml; 356mg/100ml; 390mg/100ml; 34mg/100ml; 152mg/100ml 1 TRAVASOL 2 TROPHAMINE 2 VITAMINS / HEMATINICS prenatal vitamins (generic) 1 sodium fluoride tabs 1 27 Index of Drugs 8 8-MOP................................................................. 13 A ABILIFY ............................................................... 9 ABILIFY DISCMELT .......................................... 9 ABRAXANE......................................................... 4 acarbose .............................................................. 16 acebutolol ............................................................ 10 acetaminophen / codeine....................................... 8 acetaminophen/codeine #3.................................... 8 acetaminophen/codeine #4.................................... 8 acetasol hc........................................................... 15 acetazolamide...................................................... 23 acetazolamide sodium ......................................... 23 acetic acid ........................................................... 15 acetylcysteine ...................................................... 24 ACTHIB .............................................................. 20 acticin.................................................................. 14 ACTIMMUNE .................................................... 19 ACTONEL .......................................................... 15 ACTOPLUS MET............................................... 16 ACTOS................................................................ 16 ACUVAIL........................................................... 23 acyclovir ................................................................ 1 ADACEL............................................................. 20 ADAGEN ............................................................ 15 adapalene ............................................................ 13 adriamycin............................................................. 4 ADVAIR DISKUS.............................................. 24 ADVAIR HFA .................................................... 24 afeditab cr ........................................................... 10 AFINITOR ............................................................ 4 AGGRENOX ...................................................... 12 a-hydrocort.......................................................... 16 ak-con.................................................................. 23 ak-tob................................................................... 22 ala cort ................................................................ 14 ALBENZA ........................................................... 2 albuterol sulfate................................................... 24 albuterol sulfate er .............................................. 24 alclometasone dipropionate ................................ 14 ALCOHOL PREPS..............................................16 ALDURAZYME..................................................17 alendronate sodium........................................15, 20 ALIMTA ................................................................4 ALINIA..................................................................2 ALKERAN ............................................................4 allopurinol............................................................20 ALOCRIL ............................................................22 ALORA................................................................21 ALPHAGAN P ....................................................23 alprazolam .............................................................7 ALREX ................................................................23 ALTABAX ..........................................................14 amantadine.............................................................1 amcinonide...........................................................14 a-methapred .........................................................16 amifostine...............................................................4 amikacin sulfate .....................................................2 amiloride..............................................................10 amiloride/hydrochlorothiazide ............................10 aminophylline.......................................................24 AMINOSYN ........................................................25 AMINOSYN II ....................................................25 AMINOSYN II M................................................25 AMINOSYN-HBC ..............................................25 AMINOSYN-HF..................................................25 AMINOSYN-PF ..................................................25 AMINOSYN-PF 7%............................................25 amiodarone ..........................................................10 AMITIZA.............................................................18 amitriptyline...........................................................9 amlodipine............................................................11 amlodipine / benazepril........................................11 ammonium lactate................................................13 amnesteem............................................................13 amoxapine..............................................................9 amoxicillin..............................................................3 amoxicillin/clavulanate potassium.........................3 amoxicillin/clavulanate potassium er ....................3 amoxicillin/potassium clavulanate.........................3 amphotericin b .......................................................1 ampicillin ...............................................................3 28 ampicillin-sulbactam............................................. 3 AMTURNIDE..................................................... 11 ANADROL-50 .................................................... 17 anagrelide hydrochloride.................................... 15 anastrozole ............................................................ 4 ANCOBON ........................................................... 1 ANDRODERM ................................................... 17 ANDROGEL....................................................... 17 ANDROGEL PUMP ........................................... 17 ANDROID .......................................................... 17 androxy................................................................ 17 ANTABUSE........................................................ 15 APIDRA .............................................................. 16 APIDRA SOLOSTAR ........................................ 16 APOKYN .............................................................. 7 apraclonidine ...................................................... 23 apri ...................................................................... 21 APTIVUS .............................................................. 1 ARALAST NP .................................................... 15 aranelle................................................................ 21 ARANESP........................................................... 19 ARCALYST........................................................ 19 ARICEPT .............................................................. 7 ARICEPT ODT ..................................................... 7 ARIXTRA ........................................................... 12 ARRANON ........................................................... 4 ARTHROTEC 50.................................................. 9 ARTHROTEC 75.................................................. 9 ARZERRA ............................................................ 4 ASACOL............................................................. 18 ASACOL HD ...................................................... 18 ascomp/codeine ..................................................... 8 ASMANEX 120 METERED DOSES ................ 24 ASMANEX 14 METERED DOSES................... 24 ASMANEX 30 METERED DOSES................... 24 ASMANEX 60 METERED DOSES................... 24 ASTEPRO ........................................................... 15 atenolol................................................................ 11 atenolol / chlorthalidone ..................................... 11 ATRIPLA .............................................................. 1 atropine sulfate.................................................... 18 ATROVENT HFA .............................................. 24 augmented betamethasone dipropionate............. 14 AVANDAMET....................................................16 AVANDARYL ....................................................16 AVANDIA...........................................................16 AVASTIN ..............................................................4 AVELOX ...............................................................3 AVELOX ABC PACK ..........................................3 aviane...................................................................21 avita......................................................................13 AVODART ..........................................................25 AVONEX.............................................................19 AZACTAM............................................................2 AZACTAM IN ISO-OSMOTIC DEXTROSE......2 AZASITE.............................................................22 azathioprine ...........................................................4 azathioprine sodium...............................................4 azelastine hcl..................................................15, 22 AZELEX ..............................................................13 AZILECT...............................................................7 azithromycin...........................................................2 AZOPT.................................................................23 aztreonam...............................................................2 B bacitracin .............................................................22 bacitracin / polymyxin b.......................................22 baclofen..................................................................8 BACTROBAN.....................................................14 BACTROBAN NASAL.......................................15 balsalazide ...........................................................18 balziva..................................................................21 BANZEL................................................................6 BARACLUDE .......................................................1 BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2 ...................16 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16 ...................16 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2 .....................16 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16...............................................................16 BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM ..........................................................................16 benazepril.............................................................11 29 benazepril / hydrochlorothiazide ........................ 11 BENICAR ........................................................... 11 BENICAR HCT .................................................. 11 benztropine mesylate ............................................. 7 BEPREVE ........................................................... 22 BESIVANCE ...................................................... 22 betamethasone dipropionate ............................... 14 betamethasone valerate....................................... 14 BETASERON .....................................................19 betaxolol hcl .................................................. 11, 22 bethanechol chloride........................................... 25 BETOPTIC-S ...................................................... 22 bicalutamide.......................................................... 4 BICILLIN C-R ...................................................... 3 BICILLIN L-A ...................................................... 3 BICNU .................................................................. 4 BIDIL .................................................................. 11 BILTRICIDE......................................................... 2 bisoprolol fumarate............................................. 11 bisoprolol fumarate / hydrochlorothiazide ......... 11 bleomycin sulfate................................................... 4 BLEPH-10........................................................... 23 BONIVA ............................................................. 20 BOOSTRIX......................................................... 20 brimonidine tartrate ............................................ 23 BROMDAY ........................................................ 23 bromfenac............................................................ 23 bromocriptine mesylate ......................................... 7 budeprion sr .......................................................... 9 budeprion xl........................................................... 9 budesonide........................................................... 24 bumetanide .......................................................... 11 BUPHENYL........................................................ 15 BUPRENEX.......................................................... 8 buprenorphine hcl ................................................. 8 BUPROBAN ....................................................... 15 bupropion hcl ........................................................ 9 bupropion hcl sr .................................................... 9 buspirone hcl ......................................................... 9 BUSULFEX .......................................................... 4 butorphanol tartrate.............................................. 9 BYETTA ............................................................. 16 BYSTOLIC ......................................................... 11 C cabergoline ..........................................................17 CADUET .............................................................12 calcipotriene ........................................................13 calcitonin-salmon.................................................17 calcitriol...............................................................17 calcium acetate ....................................................25 camila...................................................................21 CAMPATH............................................................4 CAMPRAL ..........................................................15 CANASA .............................................................18 CAPASTAT SULFATE ........................................2 CAPEX ................................................................14 captopril...............................................................11 captopril/hydrochlorothiazide .............................11 CARAC................................................................13 CARAFATE ........................................................19 carbamazepine .......................................................6 carbamazepine er...................................................6 CARBATROL .......................................................6 carbidopa / levodopa .............................................7 carbidopa/levodopa cr ...........................................7 carbidopa/levodopa odt .........................................7 carbidopa/levodopa sr ...........................................7 carbinoxamine maleate........................................23 carboplatin.............................................................4 CARMOL-HC......................................................13 carteolol hcl .........................................................22 cartia xt ................................................................11 carvedilol .............................................................11 CAVERJECT.......................................................23 CAVERJECT IMPULSE.....................................23 CAYSTON.............................................................2 CEENU ..................................................................4 cefaclor ..................................................................2 cefadroxil ...............................................................2 cefazolin .................................................................2 cefdinir ...................................................................2 cefepime .................................................................2 cefotaxime sodium..................................................2 cefoxitin sodium .....................................................2 cefpodoxime proxetil..............................................2 ceftazidime .............................................................2 30 ceftriaxone sodium ................................................ 2 cefuroxime axetil ................................................... 2 cefuroxime sodium................................................. 2 CELEBREX .......................................................... 9 CELLCEPT ........................................................... 4 CELLCEPT INTRAVENOUS.............................. 4 CELONTIN........................................................... 6 cephalexin.............................................................. 2 CEREZYME ....................................................... 17 CERVARIX ........................................................ 20 cesia..................................................................... 21 cetirizine hcl ........................................................ 23 CHANTIX........................................................... 15 CHEMET ............................................................ 15 chlordiazepoxide/amitriptyline.............................. 9 chlorhexidine gluconate oral rinse ..................... 15 chloroquine............................................................ 2 chlorothiazide...................................................... 11 chlorothiazide sodium ......................................... 11 chlorpromazine...................................................... 9 chlorthalidone ..................................................... 11 cholestyramine light ............................................ 12 CIALIS ................................................................ 23 ciclopirox............................................................. 14 ciclopirox nail lacquer ........................................ 14 ciclopirox olamine............................................... 14 cilostazol.............................................................. 12 CILOXAN........................................................... 22 CIMZIA............................................................... 18 CIPRO HC........................................................... 16 CIPRO I.V.-IN D5W............................................. 3 CIPRODEX......................................................... 16 ciprofloxacin.....................................................3, 22 cisplatin ................................................................. 4 citalopram ............................................................. 9 cladribine .............................................................. 4 claravis ................................................................ 13 CLARINEX......................................................... 24 CLARINEX REDITABS .................................... 24 CLARINEX-D 12 HOUR ................................... 24 CLARINEX-D 24 HOUR ................................... 24 clarithromycin ....................................................... 2 clarithromycin er................................................... 2 clemastine fumarate .............................................24 CLEOCIN ............................................................21 CLEOCIN GALAXY ............................................2 CLEOCIN PEDIATRIC GRANULES ..................2 CLIMARA PRO ..................................................21 clindamycin hcl ......................................................2 clindamycin phosphate...................................13, 21 clindamycin phosphate add-vantage......................2 clindamycin/benzoyl peroxide..............................13 CLINIMIX / DEXTROSE .............................15, 26 CLINISOL SF......................................................26 clobetasol propionate...........................................14 clobetasol propionate e........................................14 CLOBEX..............................................................14 CLOLAR................................................................4 clomipramine .........................................................9 clonazepam ............................................................6 clonidine...............................................................11 clotrimazole......................................................1, 14 clotrimazole / betamethasone ..............................14 clozapine ................................................................9 COARTEM............................................................2 codeine sulfate .......................................................8 COLCRYS ...........................................................20 colestipol ..............................................................12 colistimethate sodium.............................................2 COLY-MYCIN S.................................................16 COMBIGAN........................................................23 COMBIPATCH ...................................................21 COMBIVENT......................................................24 COMBIVIR............................................................1 compro .................................................................18 COMTAN ..............................................................7 COMVAX............................................................20 CONDYLOX .......................................................13 constulose.............................................................18 COPAXONE..........................................................7 CORDRAN TAPE...............................................14 COREG CR..........................................................11 CORTIFOAM ......................................................18 cortisone acetate ..................................................16 CORTISPORIN-TC.............................................16 cortomycin............................................................16 31 COSMEGEN......................................................... 4 CREON ............................................................... 18 CRINONE ........................................................... 21 CRIXIVAN ........................................................... 1 cromolyn sodium ........................................... 22, 24 cryselle-28 ........................................................... 21 CUBICIN .............................................................. 2 CUPRIMINE....................................................... 20 cyclafem 1/35....................................................... 21 cyclafem 7/7/7 ..................................................... 21 cyclobenzaprine hcl............................................... 8 cyclophosphamide ................................................. 4 cyclosporine .......................................................... 4 CYKLOKAPRON............................................... 12 CYMBALTA ........................................................ 9 CYSTADANE..................................................... 18 CYSTAGON ....................................................... 25 cytarabine.............................................................. 4 CYTARABINE AQUEOUS ................................. 4 D dacarbazine ........................................................... 4 DACOGEN ........................................................... 5 danazol ................................................................ 17 dantrolene sodium................................................. 8 DAPSONE ............................................................ 2 DAPTACEL........................................................ 20 DARAPRIM.......................................................... 2 daunorubicin hcl ................................................... 5 DAUNOXOME..................................................... 5 DECAVAC.......................................................... 20 demeclocycline hcl ................................................ 4 DEMSER............................................................. 11 DENAVIR........................................................... 14 depade ................................................................... 9 DEPEN TITRATABS ......................................... 20 DEPO-MEDROL ................................................ 16 DEPO-PROVERA .............................................. 21 DEPO-SUBQ PROVERA 104............................ 21 DERMA-SMOOTHE / FS BODY OIL .............. 14 DERMOTIC ........................................................ 15 desipramine ........................................................... 9 desmopressin acetate........................................... 17 desonide ...............................................................14 desoximetasone ....................................................14 DETROL..............................................................24 DETROL LA .......................................................24 dexamethasone...............................................16, 23 DEXAMETHASONE INTENSOL .....................16 dexrazoxane ...........................................................4 dextroamphetamine sulfate ....................................9 dextroamphetamine sulfate er................................9 DEXTROSE 10%/NACL 0.45% ........................15 DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX ........................................................26 dextrose 10% flex container.................................15 DEXTROSE 10%/NACL 0.2% ...........................15 dextrose 2.5%/sodium chloride 0.45% ................15 dextrose 5%..........................................................15 dextrose 5%/nacl 0.2% ........................................15 dextrose 5%/nacl 0.225%....................................15 DEXTROSE 5%/NACL 0.33%...........................15 dextrose 5%/nacl 0.45% ......................................15 dextrose 5%/nacl 0.9% ........................................15 diazepam ................................................................7 DIBENZYLINE...................................................11 diclofenac potassium..............................................9 diclofenac sodium ............................................9, 23 diclofenac sodium ec..............................................9 diclofenac sodium xr ..............................................9 dicloxacillin sodium...............................................3 dicyclomine hcl ....................................................18 didanosine..............................................................1 DIFFERIN............................................................13 diflorasone diacetate............................................14 DIFLUCAN IN NACL ..........................................1 diflunisal ................................................................9 digoxin..................................................................12 dihydroergotamine mesylate..................................7 DILANTIN ............................................................6 DILANTIN INFATABS........................................6 DILAUDID ............................................................8 DILAUDID-5.........................................................8 DILAUDID-HP......................................................8 dilt-cd ...................................................................11 diltiazem cd ..........................................................11 32 diltiazem hcl ........................................................ 11 diltiazem hcl er .................................................... 11 dilt-xr................................................................... 11 diltzac .................................................................. 11 DIOVAN ............................................................. 11 DIOVAN HCT .................................................... 11 DIPENTUM ........................................................ 18 DIPHTHERIA/TETANUS TOXOID PEDIATRIC ......................................................................... 20 disopyramide phosphate...................................... 10 divalproex sodium ................................................. 6 divalproex sodium er............................................. 6 DIVIGEL............................................................. 21 DOCETAXEL....................................................... 5 donepezil hcl.......................................................... 7 dorzolamide hcl ................................................... 23 dorzolamide hcl/timolol maleate......................... 23 doxazosin............................................................. 11 doxepin .................................................................. 9 DOXIL .................................................................. 5 doxorubicin hcl...................................................... 5 doxycycline hyclate ............................................... 4 doxycycline monohydrate...................................... 4 dronabinol ........................................................... 18 DROXIA ............................................................... 5 DUETACT .......................................................... 16 DULERA............................................................. 24 duramorph............................................................. 8 DUREZOL .......................................................... 23 E e.e.s. 400................................................................ 2 E.E.S. GRANULES .............................................. 2 econazole nitrate ................................................. 14 EDECRIN............................................................ 11 EDURANT............................................................ 1 EFFIENT............................................................. 12 ELIDEL............................................................... 13 eliphos ................................................................. 25 ELITEK................................................................. 4 ELIXOPHYLLIN................................................ 24 ELLA................................................................... 21 ELLENCE ............................................................. 5 ELMIRON ...........................................................25 ELOXATIN ...........................................................5 ELSPAR.................................................................5 EMBEDA...............................................................8 EMCYT..................................................................5 EMEND ...............................................................18 EMSAM.................................................................9 EMTRIVA .............................................................1 ENABLEX...........................................................24 enalapril...............................................................11 enalapril / hydrochlorothiazide ...........................11 ENBREL..............................................................20 endocet ...................................................................8 ENGERIX-B ........................................................20 enoxaparin sodium...............................................12 enpresse-28 ..........................................................21 ENTOCORT EC ..................................................18 enulose .................................................................18 epinastine hcl .......................................................22 epinephrine hcl.....................................................24 EPIPEN ................................................................24 EPIPEN-JR ..........................................................24 epirubicin hcl .........................................................5 epitol ......................................................................6 EPIVIR...................................................................1 EPIVIR HBV .........................................................1 eplerenone............................................................11 EPOGEN..............................................................19 EPZICOM ..............................................................1 EQUETRO.............................................................6 ERAXIS .................................................................1 ERBITUX ..............................................................5 ergotamine tartrate / caffeine ................................7 errin......................................................................21 ery ........................................................................13 ERY-TAB ..............................................................2 ERYTHROCIN LACTOBIONATE......................2 erythrocin stearate .................................................2 erythromycin ..................................................13, 22 erythromycin / benzoyl peroxide..........................13 ERYTHROMYCIN BASE ....................................2 erythromycin ethylsuccinate ..................................2 erythromycin/sulfisoxazole ....................................2 33 ESTRADERM...................................................... 21 estradiol................................................................ 21 estradiol / norethindrone acetate ......................... 21 ESTRING ............................................................. 21 estropipate............................................................ 21 ethambutol............................................................. 2 ethosuximide.......................................................... 6 etidronate disodium............................................. 15 etodolac ................................................................. 9 ETOPOPHOS........................................................ 5 etoposide................................................................ 5 EURAX ............................................................... 15 EVISTA............................................................... 20 EVOXAC ............................................................ 15 EXALGO .............................................................. 8 EXELON............................................................... 7 exemestane ............................................................ 5 EXFORGE ........................................................... 11 EXFORGE HCT .................................................. 11 EXJADE.............................................................. 15 F FABRAZYME .................................................... 17 famciclovir............................................................. 1 famotidine.............................................................19 famotidine premixed.............................................19 FANAPT ............................................................... 9 FANAPT TITRATION PACK ............................. 9 FARESTON .......................................................... 5 FASLODEX .......................................................... 5 FAZACLO ............................................................ 9 FELBATOL .......................................................... 6 felodipine er......................................................... 11 fenofibrate ........................................................... 12 fenofibrate micronized......................................... 12 fenoprofen calcium................................................ 9 fentanyl citrate....................................................... 8 fentanyl citrate oral transmucosal ........................ 8 fentanyl patches..................................................... 8 fexofenadine hcl................................................... 24 FINACEA............................................................ 13 finasteride............................................................ 25 FIRMAGON.......................................................... 5 flavoxate hcl .........................................................24 flecainide acetate .................................................10 FLECTOR..............................................................9 FLOVENT DISKUS............................................24 FLOVENT HFA ..................................................24 fluconazole .............................................................1 fluconazole in dextrose ..........................................1 fludarabine phosphate ...........................................5 fludrocortisone acetate ........................................16 flunisolide.............................................................24 fluocinolone acetonide.........................................14 fluocinonide..........................................................14 fluocinonide emollient base .................................14 fluorometholone ...................................................23 FLUOROPLEX....................................................13 fluorouracil ......................................................5, 13 fluoxetine................................................................9 fluoxetine dr ...........................................................9 fluphenazine ...........................................................9 fluphenazine decanoate inj ....................................9 flurbiprofen ............................................................9 flurbiprofen sodium..............................................23 flutamide ................................................................5 fluticasone propionate ...................................14, 24 fluvoxamine............................................................9 FML .....................................................................23 FML FORTE........................................................23 FOCALIN XR........................................................9 FORADIL AEROLIZER .....................................24 FORTAZ................................................................2 FORTEO ..............................................................20 fortical..................................................................17 foscarnet sodium....................................................1 fosinopril..............................................................11 fosinopril / hydrochlorothiazide ..........................11 FOSRENOL.........................................................15 FRAGMIN ...........................................................12 FREAMINE III ....................................................26 furosemide............................................................11 FUZEON................................................................1 G gabapentin..............................................................6 34 GABITRIL ............................................................ 6 galantamine hydrobromide ................................... 7 ganciclovir............................................................. 1 GARDASIL......................................................... 20 GASTROCROM ................................................. 18 GAUZE PADS 2 ................................................. 16 gavilyte-c ............................................................. 18 gavilyte-g............................................................. 18 gavilyte-n/flavor pack.......................................... 18 GELNIQUE......................................................... 24 gemcitabine hcl ..................................................... 5 gemfibrozil........................................................... 12 gengraf .................................................................. 5 gentak .................................................................. 22 gentamicin sulfate ......................................2, 14, 22 gentamicin sulfate/0.9% sodium chloride ............. 3 gentamicin sulfate/sodium chloride ...................... 3 gentasol ............................................................... 22 GEODON .............................................................. 9 gianvi................................................................... 21 GILENYA ............................................................. 8 GLEEVEC............................................................. 5 glimepiride .......................................................... 16 glipizide ............................................................... 16 glipizide / metformin............................................ 16 glipizide er........................................................... 16 GLUCAGEN HYPOKIT .................................... 16 GLUCAGON EMERGENCY KIT..................... 16 glyburide.............................................................. 16 glyburide / metformin.......................................... 16 glyburide micronized........................................... 16 glycopyrrolate ..................................................... 18 glycron................................................................. 16 granisetron .......................................................... 18 griseofulvin microsize ........................................... 1 GRIS-PEG............................................................. 1 guanfacine hcl ..................................................... 11 GYNAZOLE-1.................................................... 21 H HALAVEN............................................................ 5 HALDOL .............................................................. 9 HALDOL DECANOATE 100 .............................. 9 HALDOL DECANOATE 50.................................9 halobetasol propionate ........................................14 haloperidol.............................................................9 haloperidol decanoate inj ......................................9 haloperidol lactate inj............................................9 HAVRIX ..............................................................20 HECTOROL ........................................................17 HEPARIN SODIUM ...........................................12 heparin sodium/d5w.............................................12 HEPARIN SODIUM/NACL 0.45% ....................12 heparin sodium/sodium chloride 0.9% premix ....12 HEPATAMINE....................................................26 HEPATASOL ......................................................26 HEPSERA..............................................................1 HERCEPTIN..........................................................5 HEXALEN.............................................................5 HIZENTRA..........................................................20 HUMALOG .........................................................16 HUMALOG KWIKPEN......................................17 HUMALOG MIX 50/50 ......................................17 HUMALOG MIX 50/50 KWIKPEN...................17 HUMALOG MIX 75/25 ......................................17 HUMALOG MIX 75/25 KWIKPEN...................17 HUMIRA .............................................................20 HUMIRA PEN-CROHNS DISEASE STARTER ..........................................................................20 HUMULIN 70/30.................................................17 HUMULIN 70/30 PEN ........................................17 HUMULIN N.......................................................17 HUMULIN N U-100 PEN...................................17 HUMULIN R .......................................................17 HUMULIN R U-500 (CONCENTRATED)........17 hydralazine...........................................................11 hydrochlorothiazide .............................................11 hydrocodone bitartrate/acetaminophen.................8 hydrocodone/acetaminophen .................................8 hydrocodone/ibuprofen..........................................8 hydrocortisone .........................................14, 16, 18 hydrocortisone butyrate .......................................14 hydrocortisone valerate .......................................14 hydrocortisone/acetic acid...................................15 hydromorphone hcl ................................................8 hydroxychloroquine ...............................................3 35 hydroxyurea........................................................... 5 hydroxyzine hcl.................................................... 24 I ibuprofen ............................................................... 9 idarubicin hcl ........................................................ 5 IFEX ...................................................................... 5 ifosfamide .............................................................. 5 ifosfamide/mesna....................................................5 imipramine ............................................................ 9 imipramine pamoate............................................ 10 imiquimod............................................................ 13 IMOVAX RABIES (H.D.C.V.) .......................... 20 INCRELEX ......................................................... 15 indapamide.......................................................... 11 indomethacin ......................................................... 9 indomethacin er...................................................,, 9 INFANRIX.......................................................... 20 INFUMORPH 200 ................................................ 8 INFUMORPH 500 ................................................ 8 INTELENCE......................................................... 1 INTRALIPID ...................................................... 26 INTRON-A...........................................................19 INTRON-A WITH DILUENT.............................19 INVEGA.............................................................. 10 INVEGA SUSTENNA........................................ 10 INVIRASE ............................................................ 1 IONOSOL ........................................................... 26 IOPIDINE............................................................ 23 IPOL INACTIVATED IPV ................................ 20 ipratropium bromide ..................................... 15, 24 ipratropium bromide/albuterol sulfate................ 24 irinotecan .............................................................. 5 ISENTRESS .......................................................... 1 ISOLYTE ............................................................ 26 isonarif .................................................................. 3 ISONIAZID........................................................... 3 isosorbide dinitrate ............................................. 13 isosorbide dinitrate er ......................................... 13 isosorbide mononitrate........................................ 13 isosorbide mononitrate er ................................... 13 isotonic gentamicin ............................................... 3 isradipine............................................................. 11 ISTALOL.............................................................22 ISTODAX ..............................................................5 itraconazole............................................................1 IXEMPRA KIT......................................................5 IXIARO................................................................20 J JALYN.................................................................25 jantoven................................................................12 JANUMET...........................................................17 JANUVIA ............................................................17 JE-VAX................................................................20 JEVTANA..............................................................5 jinteli ....................................................................21 jolivette.................................................................21 junel......................................................................21 junel fe 1.5/30.......................................................21 junel fe 1/20..........................................................21 K KADIAN................................................................8 KALETRA.............................................................1 kariva ...................................................................21 kcl 0.075%/d5w/nacl 0.45% ................................25 KCL 0.15%/D10W/NACL 0.2% .........................26 kcl 0.15%/d5w/lr ..................................................25 KCL 0.15%/D5W/NACL 0.2% ...........................25 KCL 0.15%/D5W/NACL 0.225% .......................25 kcl 0.15%/d5w/nacl 0.9% ....................................25 kcl 0.3%/d5w/lr iv lac ring...................................25 KCL 0.3%/D5W/NACL 0.2% .............................25 kcl 0.3%/d5w/nacl 0.45% ....................................25 kcl 0.3%/d5w/nacl 0.9% ......................................25 kelnor 1/35 ...........................................................21 KETEK ..................................................................3 ketoconazole.....................................................1, 14 ketoprofen ..............................................................9 ketoprofen er ..........................................................9 ketorolac tromethamine .......................................23 kionex ...................................................................15 klor-con 10...........................................................25 klor-con 8.............................................................25 KLOR-CON M15 ................................................25 klor-con m20 ........................................................25 36 KOMBIGLYZE XR............................................ 17 K-TABS .............................................................. 25 KUVAN .............................................................. 17 L labetalol............................................................... 11 laclotion............................................................... 13 LACRISERT ....................................................... 22 LACTATED RINGERS...................................... 25 lactulose .............................................................. 18 LAMICTAL ODT ................................................. 6 LAMICTAL XR.................................................... 6 lamotrigine ............................................................ 6 LANOXIN........................................................... 12 lansoprazole .........................................................19 lansoprazole odt ...................................................19 LANTUS ............................................................. 17 LANTUS SOLOSTAR ....................................... 17 latanoprost .......................................................... 23 LATUDA ............................................................ 10 leena .................................................................... 21 leflunomide.......................................................... 20 lessina-28 ............................................................ 21 LETAIRIS ........................................................... 24 letrozole................................................................. 5 leucovorin calcium................................................ 4 LEUKERAN ......................................................... 5 LEUKINE.............................................................19 leuprolide acetate.................................................. 5 LEVAQUIN .......................................................... 3 LEVEMIR ........................................................... 17 LEVEMIR FLEXPEN......................................... 17 levetiracetam......................................................... 6 LEVITRA............................................................ 23 levobunolol hcl .................................................... 22 levocarnitine........................................................ 15 levocetirizine dihydrochloride............................. 24 levofloxacin ......................................................... 22 levora................................................................... 21 levorphanol tartrate ...............................................8 levothyroxine ....................................................... 18 levoxyl.................................................................. 18 LEXIVA ................................................................ 1 lidocaine...............................................................13 lidocaine / prilocaine ...........................................13 lidocaine viscous..................................................13 LIDODERM ........................................................14 LINDANE............................................................15 liothyronine sodium .............................................18 LIPITOR ..............................................................12 LIPOSYN III........................................................26 lisinopril...............................................................11 lisinopril/hydrochlorothiazide .............................11 lithium carbonate.................................................10 lithium carbonate er.............................................10 lithium citrate.......................................................10 LOCOID ..............................................................14 LODOSYN ............................................................7 loperamide hcl .....................................................18 lorazepam...............................................................7 losartan potassium...............................................11 losartan potassium/hydrochlorothiazide .............11 LOTEMAX ..........................................................23 LOTRONEX ........................................................18 lovastatin..............................................................12 LOVAZA .............................................................12 LOVENOX ..........................................................12 low-ogestrel..........................................................21 loxapine................................................................10 LUMIGAN...........................................................23 LUPRON DEPOT..................................................5 LUPRON DEPOT-PED.........................................5 lutera....................................................................21 LUXIQ .................................................................14 LYRICA.................................................................6 LYSODREN ..........................................................5 LYSTEDA ...........................................................21 M MACRODANTIN..................................................4 MAGNESIUM SULFATE ..................................25 MAGNESIUM SULFATE IN D5W ...................25 MALARONE.........................................................3 malathion .............................................................15 maprotiline...........................................................10 margesic-h..............................................................8 37 MARPLAN ......................................................... 10 MATULANE ........................................................ 5 matzim la ............................................................. 11 MAXALT.............................................................. 7 MAXALT-MLT .................................................... 7 mebendazole .......................................................... 3 meclizine hcl........................................................ 18 meclofenamate sodium.......................................... 9 medroxyprogesterone acetate ............................. 21 mefenamic acid...................................................... 9 mefloquine hcl ....................................................... 3 MEGACE ES ........................................................ 5 megestrol acetate................................................... 5 meloxicam.............................................................. 9 melphalan hydrochloride ...................................... 5 MENACTRA ...................................................... 20 MENOMUNE-A/C/Y/W-135 ............................. 20 MENOSTAR....................................................... 21 MENVEO............................................................ 20 MEPRON .............................................................. 3 mercaptopurine ..................................................... 5 meropenem............................................................ 3 mesalamine.......................................................... 18 mesna..................................................................... 4 MESNEX .............................................................. 4 MESTINON .......................................................... 8 MESTINON TIMESPAN ..................................... 8 METADATE CD ................................................ 10 metaproterenol sulfate......................................... 24 metformin hcl....................................................... 17 metformin hcl er .................................................. 17 methadone hcl ....................................................... 8 methadose.............................................................. 8 methazolamide..................................................... 23 methenamine hippurate ......................................... 4 METHERGINE................................................... 22 methimazole......................................................... 16 methotrexate .......................................................... 5 methotrexate sodium ............................................. 5 methyclothiazide.................................................. 11 methylphenidate hcl............................................. 10 methylphenidate hydrochloride........................... 10 methylprednisolone ............................................. 16 methylprednisolone acetate .................................16 methylprednisolone sodiumsuccinate ..................16 metipranolol.........................................................22 metoclopramide....................................................18 metolazone ...........................................................11 metoprolol succinate er........................................11 metoprolol tartrate...............................................11 metoprolol/hydrochlorothiazide ..........................11 METROGEL........................................................13 metronidazole...................................................3, 13 metronidazole in nacl 0.79% .................................3 metronidazole vaginal..........................................21 mexiletine .............................................................10 miconazole 3 ........................................................21 microgestin 1.5/30................................................21 microgestin 1/20...................................................21 microgestin fe.......................................................21 microgestin fe 1.5/30............................................21 midodrine .............................................................15 migergot .................................................................7 MIGRANAL..........................................................7 minocycline hcl ......................................................4 minocycline hcl er ..................................................4 minoxidil ..............................................................11 MIRAPEX ER .......................................................7 mirtazapine ..........................................................10 mirtazapine odt ....................................................10 misoprostol...........................................................19 mitomycin...............................................................5 mitoxantrone hcl ....................................................5 M-M-R II W/DILUENT 10 DOSE......................20 moexipril ..............................................................11 moexipril/hydrochlorothiazide.............................11 mometasone furoate .............................................14 mononessa............................................................21 morphine sulfate.....................................................8 morphine sulfate er ................................................8 MOXEZA ............................................................22 MOZOBIL ...........................................................19 MULTAQ ............................................................10 mupirocin .............................................................14 MUSE ..................................................................23 MUSTARGEN.......................................................5 38 MYCOBUTIN....................................................... 3 mycophenolate mofetil........................................... 5 MYFORTIC .......................................................... 5 MYTELASE.......................................................... 8 N nabumetone ........................................................... 9 nadolol................................................................. 11 nadolol/bendroflumethiazide............................... 11 nafcillin sodium..................................................... 3 NAFTIN .............................................................. 14 NAGLAZYME.................................................... 17 NALLPEN/DEXTROSE....................................... 3 naloxone ................................................................ 9 naltrexone.............................................................. 9 NAMENDA .......................................................... 8 NAMENDA TITRATION PAK ........................... 8 naproxen................................................................ 9 naproxen sodium ................................................... 9 naratriptan hcl....................................................... 7 NATACYN ......................................................... 22 nateglinide........................................................... 17 NEBUPENT .......................................................... 3 necon 0.5/35-28.................................................... 21 necon 1/35-28....................................................... 21 necon 10/11-28..................................................... 21 necon 7/7/7 ........................................................... 21 nefazodone........................................................... 10 neomycin sulfate.................................................... 3 neomycin/bacitracin/polymyxin .......................... 22 neomycin/polymyxin/bacitracin/hydrocortisone . 23 neomycin/polymyxin/dexamethasone .................. 23 neomycin/polymyxin/gramicidin ......................... 22 neomycin/polymyxin/hc ....................................... 16 neomycin/polymyxin/hydrocortisone............. 16, 23 NEORAL............................................................... 5 NEPHRAMINE................................................... 26 NEULASTA.........................................................19 NEUMEGA..........................................................19 NEUPOGEN ........................................................19 NEVANAC ......................................................... 23 NEXAVAR ........................................................... 5 NEXIUM I.V........................................................19 next choice ...........................................................21 NIASPAN ............................................................12 nicardipine ...........................................................11 NICOTROL INHALER.......................................15 NICOTROL NASAL...........................................15 nifediac cc ............................................................11 nifedical xl............................................................11 nifedipine..............................................................11 nifedipine er .........................................................11 NILANDRON........................................................5 nimodipine............................................................12 NIPENT .................................................................5 nisoldipine............................................................12 nisoldipine er .......................................................12 nitro-bid ...............................................................13 NITRO-DUR........................................................13 nitrofurantoin.........................................................4 nitrofurantoin macrocrystalline.............................4 nitrofurantoin monohydrate...................................4 nitroglycerin.........................................................13 nitroglycerin transdermal ....................................13 NITROLINGUAL PUMPSPRAY.......................13 NITROSTAT .......................................................13 nizatidine..............................................................19 nora-be.................................................................21 NORDITROPIN FLEXPRO................................19 NORDITROPIN NORDIFLEX PEN ..................19 norethindrone.......................................................21 NORMOSOL .................................................25, 26 NOROXIN .............................................................3 NORPACE CR.....................................................10 nortrel 0.5/35 (28)................................................21 nortrel 1/35 (21)...................................................22 nortrel 1/35 (28)...................................................22 nortrel 7/7/7 .........................................................22 nortriptyline .........................................................10 NORVIR ................................................................1 NOVOLIN 70/30 .................................................17 NOVOLIN N .......................................................17 NOVOLIN R........................................................17 NOVOLOG..........................................................17 NOVOLOG FLEXPEN .......................................17 NOVOLOG MIX 70/30.......................................17 39 NOVOLOG MIX 70/30 PREFILLED FLEXPEN ......................................................................... 17 NOXAFIL ............................................................. 1 NUEDEXTA ......................................................... 8 NUVARING........................................................ 21 nyamyc................................................................. 14 nystatin .............................................................1, 14 nystatin / triamcinolone....................................... 14 nystop .................................................................. 14 O ocella ................................................................... 22 octreotide............................................................... 5 ofloxacin.....................................................3, 16, 22 ogestrel ................................................................ 22 omeprazole ...........................................................19 omnitrope .............................................................19 ondansetron hcl ................................................... 18 ondansetron odt................................................... 18 ONGLYZA.......................................................... 17 ONSOLIS .............................................................. 8 ONTAK................................................................. 5 OPANA ER ........................................................... 8 ORAP .................................................................. 10 ORAVIG ............................................................... 1 ORFADIN ........................................................... 15 ORTHO EVRA ................................................... 21 ortho-est .............................................................. 21 oxaliplatin.............................................................. 5 oxandrolone......................................................... 17 oxaprozin............................................................... 9 oxazepam............................................................... 7 oxcarbazepine........................................................ 6 OXSORALEN ULTRA ....................... |
Date created | 2011-10-07 |
Date modified | 2012-02-14 |