ICS Community Care Plus FIDA-MMP

Transcripción

LISTA DE
MEDICAMENTOS
CUBIERTOS
Community Care Plus
FIDA-MMP 2016
1.877.ICS.2525
1.877.ICS.2525
www.icsny.org
www.icsny.org
H4465_ListofCoveredDrugsSpan_2016_92315_Approved
H4465_ListofCoveredDrugsSpan_2016_92315
ICS Community Care Plus FIDA-MMP | 2016
Lista de medicamentos cubiertos (Formulario)
Ésta es una lista de medicamentos que los participantes pueden obtener en ICS Community
Care Plus FIDA-MMP.
 ICS Community Care Plus FIDA-MMP es un plan de salud administrado que tiene un
contrato con Medicare y el Departamento de salud del estado de New York
(Medicaid) proporcionar los beneficios de los dos programas a los participantes a
través de un programa FIDA (Fully Integrated Duals Advantage o Organización
integral para personas elegibles para ambos programas).
 Los beneficios, la Lista de medicamentos cubiertos y las redes de proveedores
pueden cambiar durante el año y el 1º de enero de cada año.
 Usted siempre puede revisar la Lista de medicamentos cubiertos actualizada de ICS
Community Care Plus FIDA-MMP en internet en www.icsny.org/care-plus o llamar a
Servicios al participante de ICS Community Care Plus FIDA-MMP al
1.877.ICS.2525.
 Se pueden aplicar limitaciones y restricciones. Para obtener más información, llame
a Servicios al participante de ICS Community Care Plus FIDA-MMP o lea el Manual
del participante de ICS Community Care Plus FIDA-MMP.
 No hay copagos para los medicamentos cubiertos.
 Usted puede pedir esta información en otros formatos, como Braille o letra grande,
de manera gratuita. Llame al 1.877.ICS.2525. La llamada es gratuita.
 You can get this information for free in other languages. Call 1.877.ICS.2525 and
TTY: 711 during 8 a.m. to 8 p.m., Monday through Friday. The call is free.
 Usted puede obtener esta información en otros idiomas, de manera gratuita. Llame
al 1.877.ICS.2525 y TTY: 711 de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es
gratuita.
 Вы можете бесплатно получить всю эту информацию на других языках.
Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу 711 с понедельника по
пятницу с 8:00 до 20:00. Звонок бесплатный.
Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al
1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para
obtener más información, vaya a www.icsny.org/care-plus.
1
 您可免费获得所有这些信息的其他语言版本。请在周一至周五上午 8 点至晚上 8 点致
电 ICS，电话号码为 1.877.ICS.2525，听障专线 (TTY) 为 711。此为免费电话。
 Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan
1.877.ICS.2525 ak TTY 711, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis.
 이 모든 정보는 타 언어로 무료로 제공됩니다. 월요일~금요일, 오전 8시~오후 8시
사이에 1.877.ICS.2525 및 TTY(청각 장애인용 전화) 711로 ICS에 전화해 주십시오.
이 전화는 무료입니다.
 Le informazioni in questione sono disponibili gratuitamente anche in altre lingue.
Chiamare ICS ai numeri 1.877.ICS.2525 e TTY 711 tra le 8:00 e le 20.00 dal lunedì
al venerdì. La chiamata è gratuita.
 El estado de New York creó un Programa Ombudsman para los participantes para
proporcionarle a los Participantes asistencia gratuita, confidencial para los servicios
que ofrece ICS Community Care Plus FIDA-MMP. Para comunicarse con el
Ombudsman para el participante llame al 1.844.614.8800 o vaya a www.icannys.org.
Preguntas frecuentes (FAQ)
Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de
medicamentos cubiertos. Usted puede leer todas las Preguntas frecuentes para saber más o
buscar preguntas y respuestas.
1. ¿Qué medicamentos de receta se encuentran en la Lista de
medicamentos cubiertos? (Llamamos “Lista de medicamentos”
a la Lista de medicamentos cubiertos, para abrebiar.)
Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 15 son
los medicamentos cubiertos por ICS Community Care Plus FIDA-MMP. Los medicamentos
están disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si
tenemos un acuerdo con ellos, para trabajar con nosotros y proporcionarle servicios a usted.
Nos referimos a estas farmacias como “farmacias de la red”.
ICS Community Care Plus FIDA-MMP cubrirá todos los medicamentos de la Lista, si:
 Su médico u otro proveedor de la red dice que usted los necesita para mejorar o
para seguir sano,
2
 El medicamento es médicamente necesario para su enfermedad, y
 Usted surte la receta en una farmacia de la red de ICS Community Care Plus
FIDA-MMP.
 ICS Community Care Plus FIDA-MMP podría tener pasos adicionales para tener
acceso a ciertos tipos de medicamentos (lea en el pregunta #5 de abajo). En
algunos casos es probable que usted tenga que hacer algo antes de obtener un
medicamento, por ejemplo: primero probar otros medicamentos.
Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro
sitio web en www.icsny.org/care-plus o llame a Servicios al participante al 1.877.ICS.2525.
2. ¿La Lista de medicamentos cambia alguna vez?
Sí. ICS Community Care Plus FIDA-MMP podría agregar o quitar medicamentos de la Lista de
medicamentos durante el año. De manera general, la Lista de medicamentos sólo cambiará si:
 Aparece un nuevo medicamento, que funcione tan bien como algún medicamento
que se encuentre actualmente en la Lista de medicamentos o
 Nos enteramos que algún medicamento no es seguro.
También podemos cambiar nuestras reglas sobre sobre algunos medicamentos. Por ejemplo,
podríamos:
 Decidir si exigir o no aprobación previa para algún medicamento. (Aprobación
previa es el permiso de ICS Community Care Plus FIDA-MMP o su Equipo
interdisciplinario (IDT) antes que usted puede obtener un medicamento.)
 Aumentar o cambiar la cantidad de un medicamento que usted puede obtener
(llamado "límite de cantidad”).
 Agregar o cambiar restricciones de tratamiento progresivo de un medicamento.
(Terapia progresiva significa que usted podría tener que probar un medicamento
antes que cubramos otro medicamento.)
(Para obtener más información acerca de estas reglas para los medicamentos, lea la página 5.)
Le avisaremos cuando quitemos de la Lista de Medicamento algún medicamento que usted
esté tomando. También le diremos cuando cambiemos nuestras reglas para cubrir algún
medicamento. Las preguntas 3, 4 y 7 de abajo tienen más información sobre lo que sucederá
cuando cambie la Lista de medicamentos.
3
 Usted siempre puede leer la Lista de medicamentos actualizada de ICS
Community Care Plus FIDA-MMP en internet, en www.icsny.org/care-plus.
También puede llamar a Servicios al participante para revisar la Lista de
medicamentos actual, al 1.877.ICS.2525.
3. ¿Qué sucederá cuando aparezca un medicamento más barato
que funcione tan bien como algún medicamento que se
encuentre actualmente en la Lista de medicamentos?
Si aparece un medicamento más barato que funcione tan bien como algún medicamento que
se encuentre actualmente en la Lista de medicamentos:
 Es probable que su farmacéutico le dé un medicamento más barato la próxima
vez que surta su receta. Si usted y su proveedor deciden que el medicamento
más barato no es el correcto para usted, su proveedor puede indicarle al
farmacéutico que continúe surtiéndole el medicamento que toma ahora.
 Es probable que ICS Community Care Plus FIDA-MMP decida quitar el
medicamento más caro de la Lista de medicamentos. Si usted está tomando un
medicamento que quitamos de la Lista de medicamentos, porque aparece un
medicamento más barato que funcione tan bien, le avisaremos con 60 días de
anticipación antes de quitarlo de la Lista de medicamentos o cuando pida que
surtamos nuevamente el medicamento. En ese momento, usted podrá obtener un
suministro de 60 días del medicamento antes de que se haga el cambio en la
Lista de medicamentos.
 El plan Community Care Plus FIDA-MMP de ICS informará estos cambios a los
miembros por correo e incluirá información sobre cómo presentar una queja,
apelación o solicitud de excepción. El plan Community Care Plus FIDA-MMP de
ICS también publicará esta información en nuestro sitio web, el cual puede
encontrarse en www.icsny.org/care-plus y notificará a los miembros todos los años
sobre nuestro formulario actualizado. Esta información puede proporcionarse en
formatos alternativos.
4. ¿Qué sucederá cuándo averigüemos que algún medicamento no
es seguro?
4
Si la Administración de alimentos y medicamentos (FDA) dice que algún medicamento no es
seguro, lo quitaremos inmediatamente de la Lista de medicamentos. También le enviaremos
una carta y lo llamaremos para avistarle que el medicamento que no es seguro fue quitado de
la Lista de medicamentos. Se le indicará que se comunique con el médico que emite sus
recetas lo antes posible para recibir instrucciones a fin de reemplazar el medicamento
discontinuado. También puede ponerse en contacto con su gerente de atención para obtener
ayuda.
5. ¿La cobertura de medicamentos tiene alguna restricción o
límite? ¿O hay que hacer algo en particular para poder obtener
ciertos medicamentos?
Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted
puede obtener. En algunos casos, tendrá que hacer algo antes de poder obtener el
medicamento. Por ejemplo:
 Aprobación previa (o autorización previa): Para algunos medicamentos, usted
o su médico deben obtener una aprobación de ICS Community Care Plus FIDAMMP o su Equipo interdisciplinario (IDT) antes de surtir su receta. Y si usted no
consigue la aprobación, ICS Community Care Plus FIDA-MMP podría no cubrir el
medicamento.
 Límites de cantidad: A veces ICS Community Care Plus FIDA-MMP limita la
cantidad de un medicamento que usted puede obtener.
 Tratamiento progresivo: A veces ICS Community Care Plus FIDA-MMP exige
que usted siga un tratamiento progresivo. Esto significa que usted tendrá que
probar los medicamentos en un cierto orden para su enfermedad. Usted podría
tener que probar un medicamento antes de que cubramos otro medicamento. Si a
su médico le parece que el primer medicamento no funciona para usted, entonces
cubriremos el segundo.
Usted puede averiguar si su medicamento tiene algún requisito o límite adicional, leyendo los
cuadros de las página 15. Usted también puede obtener más información en nuestro sitio web
en www.icsny.org/care-plus. Hemos publicado documentos en línea que explican nuestra
autorización previa y las restricciones de la terapia escalonada. Usted puede pedirnos que le
enviemos una copia.
Usted también puede pedir una "excepción" a esos límites. Por favor lea en la pregunta 11 más
información sobre las excepciones.
5

Si usted está en un hogar para personas de la tercera edad u otra institución de
cuidados a largo plazo y necesita algún medicamento que no esté en la Lista de
medicamentos o si no puede obtener el medicamento que necesite fácilmente,
podemos ayudarle. Cubriremos un suministro de emergencia de 31 días del
medicamento que usted necesite (a menos que tenga una receta para menos
días), sin importar que usted sea o no un participante nuevo de ICS Community
Care Plus FIDA-MMP. Esto le dará tiempo para hablar con su médico u otro
proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro
medicamento similar en la Lista de medicamentos que usted pueda tomar en su
lugar o si tiene que pedir una excepción. Por favor lea en la pregunta 11 más
6. ¿Cómo sabrá si el medicamento que usted quiere tiene
limitaciones o si tiene que hacer algo para obtenerlo?
La Lista de medicamentos cubiertos de la página 15 tiene una columna llamada "Medidas
necesarias, restricciones o límites de uso".
7. ¿Qué sucederá si cambiamos nuestras reglas sobre cómo
cubrimos algunos medicamentos? Por ejemplo, si agregamos
requisitos de autorización (aprobación) previa, límites de
cantidad y/o restricciones de tratamiento progresivo a algún
medicamento.
Le avisaremos si agregamos requisitos de aprobación previa, límites de cantidad y/o
restricciones de tratamiento progresivo a un medicamento. Le avisaremos por lo menos 60 días
antes de agregar la restricción o cuando pida su siguiente resurtido. En ese momento, usted
podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en la
Lista de medicamentos. Esto le dará tiempo para hablar con su médico u otra persona que
prescribe sobre qué hacer después.
8. ¿Cómo puede encontrar un medicamento en la Lista de
medicamentos?
6
Hay dos maneras de encontrar un medicamento:
 Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del
medicamento), o
 Puede buscar por enfermedad.
Para buscar por orden alfabético, vaya a la sección alfabética de la lista en la página I-1.
Luego busque el nombre en la Lista de medicamentos.
Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por
enfermedad” de la página 15. Luego, busque su enfermedad. Por ejemplo, si usted tiene una
enfermedad del corazón, usted debe buscar en esa categoría. Ahí encontrará los
medicamentos que traten enfermedades del corazón.
9. ¿Qué pasará si el medicamento que usted quiere tomar no está
en la Lista de medicamentos?
Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicios al
participante al 1.877.ICS.2525 y pregunte por él. Si se entera que ICS Community Care Plus
FIDA-MMP no cubrirá el medicamento, usted puede hacer algo de lo siguiente:
 Pida a Servicios al participante una lista de medicamentos similar al que quiera
tomar. Luego, muestre la lista a su médico u otro proveedor médico. Éste podrá
recetarle un medicamento similar al de la Lista de medicamentos que usted quiere
tomar. O,
 Usted también puede pedir al plan o a su Equipo interdisciplinario (IDT) que haga
una excepción para cubrir su medicamento. Por favor lea en la pregunta 11 más
10. ¿Qué pasará si usted es un participante nuevo de ICS Community
Care Plus FIDA-MMP y no puede encontrar su medicamento en la
Lista o tiene problemas para obtener su medicamento?
Podemos ayudarle. Debemos cubrir un suministro temporario de hasta 90 días de su
medicamento, cuando sea necesario, durante los primeros 90 días que usted sea participante
de ICS Community Care Plus FIDA-MMP. Esto le dará tiempo para hablar con su médico u otro
proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la
Lista de medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción.
7
Cubriremos un suministro de hasta 90 días de su medicamento si:
 Usted está tomando algún medicamento que no esté en nuestra Lista de
medicamentos o
 Las reglas del plan de salud no le permiten obtener la cantidad recetada por su
proveedor médico o
 El medicamento requiere aprobación previa de ICS Community Care Plus FIDAMMP o de su Equipo interdisciplinario (IDT) o
 Usted toma algún medicamento que forme parte de una restricción de tratamiento
progresivo.
Si usted vive en un hogar para personas de la tercera edad u otra institución de cuidados a
largo plazo, usted puede resurtir su receta hasta por días por tanto tiempo como 98 días. Usted
podrá resurtir el medicamento varias veces durante los 98 días. Esto le dará tiempo a su
proveedor médico para cambiar su medicamento por alguno que esté en la Lista de
medicamentos o para pedir una excepción.
Si es un participante actual que experimenta un cambio en el nivel de atención de un
tratamiento por otro, es probable que reúna los requisitos para obtener el suministro para 90
días de un medicamento que no se encuentre en la Lista de medicamentos, a fin de darle
tiempo a su médico o a la persona que le emite las recetas para que localice un medicamento
en la lista o para que presente una excepción. Es probable que usted reúna los requisitos para
obtener el suministro de transición de nivel de atención si:






ingresa a un centro de atención a largo plazo (Long-Term Care, LTC) de un
hospital u otro establecimiento
abandona un centro de LTC y regresa a la comunidad
le dan de alta de un hospital y regresa a un hogar
finalizó su internación en un centro de enfermería especializada cubierto por la
Parte A de Medicare (incluidos los cargos de farmacia) y regresa a la cobertura
de la Parte D
vuelve del estado de cuidados paliativos a los beneficios estándar de la Parte A
y B de Medicare o
le dan de alta de un hospital psiquiátrico con regímenes de medicamentos que
son altamente individualizados.
11. ¿Puede pedir al plan que haga una excepción para cubrir su
medicamento?
8
Sí. Usted puede pedirle a ICS Community Care Plus FIDA-MMP o a su Equipo interdisciplinario
(IDT) que haga una excepción para cubrir su medicamento si éste no está en la Lista de
medicamentos.
Usted también puede pedirle a ICS Community Care Plus FIDA-MMP o a su IDT un cambio a
las reglas de su medicamento.
 Por ejemplo, ICS Community Care Plus FIDA-MMP podría limitar la cantidad que
cubriremos de un medicamento. Si su medicamento tiene un límite, usted puede
pedirnos a nosotros o a su IDT que cambiemos el límite y que cubramos más.
 Otros ejemplos: Usted puede pedirnos a nosotros o a su IDT que quitemos las
restricciones de tratamiento progresivo o los requisitos de aprobación previa.
12. ¿Cuánto tiempo toma obtener una excepción?
Primero, ICS Community Care Plus FIDA-MMP o su Equipo interdisciplinario (IDT) recibir
una declaración de su proveedor médico apoyando su pedido de una excepción. Después
de recibir la declaración, le daremos una decisión sobre su pedido de excepción a más
tardar en 72 horas.
Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar
72 horas para obtener una decisión, entonces usted puede pedir una excepción acelerada.
Ésta es una decisión más rápida. Si su proveedor médico apoya su pedido, le daremos una
decisión dentro de las 24 horas después de recibir la declaración de apoyo de su proveedor
médico.
13. ¿Cómo puede pedir una excepción?
Para pedir una excepción, llame a su Administrador de cuidados. Su Administrador de cuidados
trabajará con usted y su proveedor para ayudarle a pedir una excepción.
14. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos están hechos con los mismos ingredientes que los medicamentos
de marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas
tan conocidas. Los medicamentos genéricos son aprobados por la Administración de alimentos
y medicamentos (FDA).
9
ICS Community Care Plus FIDA-MMP cubre tanto medicamentos de marca como
medicamentos genéricos.
15. ¿Qué son los medicamentos de venta libre (OTC)?
OTC quiere decir "medicamentos que se venden sin receta". ICS Community Care Plus FIDAMMP cubre algunos medicamentos de venta libre cuando su proveedor escribe una receta para
ellos.
Usted puede leer la Lista de medicamentos de ICS Community Care Plus FIDA-MMP para ver
qué medicamentos de venta libre están cubiertos.
16. ¿ICS Community Care Plus FIDA-MMP cubre algún producto de
venta libre que no sea un medicamento?
ICS Community Care Plus FIDA-MMP cubre algunos productos de venta libre cuando su
proveedor escribe una receta para ellos. Entre los ejemplos se incluyen vendas de gasa,
algodones/almohadillas con alcohol, agujas y jeringas para la insulina, etc.
Usted puede leer la Lista de medicamentos de ICS Community Care Plus FIDA-MMP para ver
qué productos de venta libre, que no son medicamentos, están cubiertos.
17. ¿Cuánto es su copago?
A usted no le cobrarán un copago por los medicamentos de la Lista de medicamentos.
18. ¿Qué son los niveles de medicamentos? Los niveles son grupos
de medicamentos. Todo medicamento de la Lista de
medicamentos del plan se encuentra en uno de los 4 niveles.
Usted no tiene que pagar nada por los medicamentos de
cualquiera de los niveles.
 Nivel 1: Medicamentos genéricos cubiertos por Medicare
10
 Nivel 2: Medicamentos de marca y especialidad cubiertos por Medicare
 Nivel 3: Medicamentos genéricos y de marca no pertenecientes a la Parte D cubiertos
por Medicaid
 Nivel 4: Medicamentos de venta libre (over-the-counter, OTC) cubiertos por Medicaid
Lista de medicamentos cubiertos
La lista de medicamentos cubiertos que comienza en la página siguiente le da información
sobre los medicamentos cubiertos por ICS Community Care Plus FIDA-MMP. Si usted tiene
problemas para encontrar su medicamento en la lista, lea el Índice que comienza en la página
I-1.
La primera columna del cuadro contiene el nombre del medicamento. Los medicamentos de
marca están escritos en mayúsculas (p.ej.: AVONEX) y los medicamentos genéricos están
escritos en cursivas minúsculas (p.ej.: amoxicillin).
La información de la columna titulada "Medidas necesarias, restricciones o límites de uso", le
indica si ICS Community Care Plus FIDA-MMP tiene alguna regla para cubrir su medicamento.
Abreviaturas y símbolos
Dentro del cuerpo de este documento, encontrará las siguientes abreviaturas
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Restricción de administración de uso
PA
PA BvD
Restricción de la
autorización previa
Restricción de la
para determinar la
Usted (o su médico) debe recibir la
autorización previa de parte del plan
Community Care Plus FIDA-MMP de ICS
para surtir su receta a fin de obtener este
medicamento. Sin la autorización previa,
es probable que el plan Community Care
Plus FIDA-MMP de ICS no cubra este
medicamento.
Este medicamento puede ser elegible
para ser pagado por la Parte B o Parte D
de Medicare. Usted (o su médico) debe
11
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Parte B frente a la
Parte D
PA NSO
QL
ST
obtener la autorización previa de parte
del plan Community Care Plus FIDAMMP de ICS para determinar que este
medicamento está cubierto por la Parte
D de Medicare, a fin de surtir su receta
para obtener este medicamento. Sin la
autorización previa, es probable que
FIDA Care Complete no cubra este
medicamento.
Restricción de
solo para nuevos
miembros
Si es miembro nuevo o no ha tomado
antes este medicamento, usted (o su
médico) debe recibir la autorización
previa de parte del plan Community
Care Plus FIDA-MMP de ICS para
surtir su receta a fin de obtener este
medicamento. Sin la autorización
previa, es probable que FIDA Care
Complete no cubra este
medicamento.
Restricción de límite
de cantidad
El plan Community Care Plus FIDAMMP de ICS limita la cantidad de este
medicamento que está cubierto por la
receta o dentro de un período
específico.
Restricción de la
terapia escalonada
Antes de que el plan Community Care
Plus FIDA-MMP de ICS brinde
cobertura para este medicamento,
usted debe probar primero otros
medicamentos para tratar su afección
médica. Este medicamento solo
puede cubrirse si otro(s)
medicamento(s) no le funciona(n) a
usted.
Otras abreviaturas de la cobertura
12
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
LA
Medicamento con
acceso limitado
Es posible que este medicamento se
encuentre disponible solamente en
ciertas farmacias. Para obtener más
información, consulte su Directorio de
farmacias o llame al plan Community
Care Plus FIDA-MMP de ICS al
1.877.ICS.2525, de lunes a viernes, de 8
a. m. a 8 p. m o TTY al 711.
NM
Medicamentos
pedidos por correo:
Es posible que usted pueda recibir
suministro de más de un 1 mes de la
mayoría de los medicamentos en su
formulario a través de pedidos por correo
a una cuota de costo reducido. Los
medicamentos que no están disponibles
a través de su beneficio de pedidos por
correo se indican con " NM " en la
columna Requisitos / límites de su
formulario.
Medicamento que no
pertenece a la Parte
D
Este medicamento es un medicamento
que no pertenece a la Parte D cubierto
por Medicaid.
*
Nota: El símbolo (*) junto a un medicamento significa que el medicamento no es un
“medicamento Parte D”. Estos medicamentos tienen reglas diferentes para las apelaciones.
Una apelación es una manera formal de pedirnos que revisemos alguna decisión de cobertura
y que la cambiemos, si le parece que hemos cometido un error. Por ejemplo, ICS Community
Care Plus FIDA-MMP o su Equipo interdisciplinario (IDT) podría decidir que un medicamento
que usted quiere ya no está cubierto por Medicare o Medicaid. Si usted o su médico no están
de acuerdo con nuestra decisión, usted puede apelar. Para pedir instrucciones sobre cómo
apelar, llame a Servicios al participante, al 1.877.ICS.2525 o al Ombudsman para el
participante de FIDA al 1.877.ICS.2525. Usted también puede enterarse de cómo apelar una
decisión leyendo el Manual del participante.
13
Estos son los significados de los códigos usados en la columna “Pasos necesarios,
restricciones o límites de uso”:
(g) = Sólo se cubre la version genérica de este medicamento. La versión de marca no está
cubierta.
M = La versión de marca de este medicamento está en Nivel 3. La versión genérica está en
el Nivel 1.
PA = Autorización previa (aprobación): usted debe tener aprobación del plan o de su Equipo
interdisciplinario (IDT) antes de poder obtener este medicamento.
ST = Terapia progresiva: usted debe probar otro medicamento antes de poder obtener éste.
14
Tier level
What the
drug will
cost you
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
4
$0
(Acetaminophen)
(Acetaminophen
with Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Acetaminophen)
(Buprenorphine
HCl)
4
$0
1
$0
1
$0
1
$0
4
$0
1
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Analgesics
Analgesics, Miscellaneous
acephen * rectal suppository 120
mg
acephen * rectal suppository 325
mg, 650 mg
acetaminophen * oral
drops,suspension
tablet,disintegrating 80 mg
acetaminophen * rectal
acetaminophen-codeine oral
solution
acetaminophen-codeine oral tablet
300-15 mg, 300-30 mg
acetaminophen-codeine oral tablet
300-60 mg
arthritis pain relief (acetam) *
buprenorphine hcl injection
butalb-acetaminophen-caffeine oral
capsule 50-325-40 mg
QL (360 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
(Fioricet with
PA-HRM; QL (180 per
butalbital-acetaminop-caf-cod
1
$0
Codeine)
30 days)
PA-HRM; QL (180 per
butalbital-acetaminophen
(Tencon)
1
$0
30 days)
butalbital-acetaminophen-caff oral
PA-HRM; QL (180 per
(Esgic)
1
$0
capsule 50-325-40 mg
30 days)
butalbital-acetaminophen-caff oral
PA-HRM; QL (180 per
(Esgic)
1
$0
tablet 50-325-40 mg
30 days)
butalbital-aspirin-caffeine oral
PA-HRM; QL (180 per
(Fiorinal)
1
$0
capsule
30 days)
BUTRANS
2
$0
QL (4 per 28 days)
children's mapap *
(Acetaminophen)
4
$0
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
(Esgic)
1
$0
1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener
más información, vaya a www.icsny.org/care-plus.
15
Tier level
What the
drug will
cost you
4
4
4
4
$0
$0
$0
$0
4
$0
codeine sulfate oral tablet
codeine-butalbital-asa-caffein oral
capsule 30-50-325-40 mg
(Acetaminophen)
(Acetaminophen)
(Infants' Tylenol)
(Acetaminophen)
(Tylenol Sore
Throat)
(Codeine Sulfate)
(Fiorinal with
Codeine #3)
1
$0
1
$0
fentanyl
(Duragesic)
1
$0
fentanyl citrate
(Actiq)
1
$0
(Acetaminophen)
4
$0
(Hycet)
1
$0
Name of Drug
children's non-aspirin * oral
children's non-aspirin * oral
children's pain & fever relief * oral
children's pain reliever * oral
children's silapap *
feverall * rectal suppository 120
mg, 325 mg, 650 mg
hydrocodone-acetaminophen oral
solution
tablet 10-300 mg, 5-300 mg, 7.5-300 (Norco)
mg
tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
hydrocodone-ibuprofen
hydromorphone (pf) injection
solution 10 mg/ml
hydromorphone (pf) injection
solution 4 mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2
mg/ml
hydromorphone oral liquid
1
$0
(Norco)
1
$0
(Ibudone)
(Hydromorphone
HCl/PF)
1
$0
1
$0
(Dilaudid)
1
$0
1
$0
1
$0
1
$0
(Hydromorphone
HCl)
(Hydromorphone
HCl)
(Dilaudid)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days)
PA; QL (10 per 30
days)
PA; QL (120 per 30
days)
QL (30 per 30 days)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
16
Tier level
What the
drug will
cost you
(Dilaudid)
1
$0
(Dilaudid)
(Acetaminophen)
(Acetaminophen)
1
4
4
$0
$0
$0
2
$0
Name of Drug
hydromorphone oral tablet 2 mg, 4
mg
hydromorphone oral tablet 8 mg
jr. acetaminophen *
junior mapap *
LAZANDA
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (30 per 30
days)
mapap (acetaminophen) * oral
(Acetaminophen)
4
$0
capsule
(Acetaminophen)
4
$0
elixir
(Tylenol Sore
4
$0
liquid 500 mg/15 ml
Throat)
(Infants' Tylenol)
4
$0
suspension
(Tylenol)
4
$0
tablet
QL (30 per 30 days)
(Acetaminophen)
4
$0
tablet,chewable
mapap arthritis pain *
(Acetaminophen)
4
$0
mapap extra strength *
(Tylenol)
4
$0
methadone hcl oral tablet,soluble 40
QL (90 per 30 days)
(Diskets)
1
$0
mg
methadone injection
(Methadone HCl)
1
$0
methadone oral
(Methadone HCl)
1
$0
methadone oral
(Diskets)
1
$0
morphine concentrate oral solution (Morphine Sulfate)
1
$0
morphine concentrate oral syringe
(Morphine Sulfate)
1
$0
morphine in dextrose 5 % injection
(Morphine
pt controlled analgesia syring 50
1
$0
Sulfate/D5W)
mg/25 ml (2 mg/ml)
morphine injection solution 15
(Morphine Sulfate)
1
$0
mg/ml, 8 mg/ml
morphine injection syringe 10
(Morphine Sulfate)
1
$0
mg/ml
17
Tier level
What the
drug will
cost you
(Morphine Sulfate)
(Morphine Sulfate)
1
1
$0
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
2
$0
$0
$0
$0
(MS Contin)
1
$0
(MS Contin)
1
$0
(Morphine Sulfate)
(Acetaminophen)
(Tylenol Sore
Throat)
1
4
$0
$0
4
$0
(Tylenol)
4
$0
(Acetaminophen)
(Acetaminophen)
4
4
2
2
$0
$0
$0
$0
(Oxycodone
HCl/Acetaminophe
n)
1
$0
(Xolox)
1
$0
(Percodan)
(Oxycodone HCl)
(Oxycodone HCl)
(Roxicodone)
1
1
1
1
$0
$0
$0
$0
Name of Drug
morphine intramuscular
morphine intravenous
morphine intravenous solution 25
mg/ml, 50 mg/ml
morphine intravenous
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml
MORPHINE ORAL TABLET
morphine oral tablet extended
release 100 mg, 30 mg, 60 mg
morphine oral tablet extended
release 15 mg, 200 mg
morphine rectal
non-aspirin extra strength * oral
tablet
non-aspirin jr strength *
nortemp * oral
NUCYNTA
NUCYNTA ER
oxycodone hcl-acetaminophen oral
solution 5-325 mg/5 ml
oxycodone hcl-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
oxycodone hcl-aspirin
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
18
Tier level
What the
drug will
cost you
(Xolox)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
1
$0
2
$0
Name of Drug
oxycodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
tablet 10-650 mg
tablet 7.5-500 mg
oxycodone-aspirin
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15
MG, 20 MG, 30 MG, 40 MG, 60
MG
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet
oxymorphone oral tablet extended
release 12 hr 10 mg, 15 mg, 20 mg,
5 mg, 7.5 mg
oxymorphone oral tablet extended
release 12 hr 30 mg, 40 mg
pain relief adult *
pain relief * oral capsule
pain relief * oral tablet extended
release
pain reliever extra strength *
pain reliever jr strength *
pharbetol * oral tablet 325 mg
pharbetol * oral tablet 500 mg
q-pap extra strength *
q-pap * oral drops
q-pap * oral liquid
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
2
$0
(Opana)
1
$0
(Opana ER)
1
$0
(Opana ER)
1
$0
4
$0
4
$0
(Acetaminophen)
4
$0
(Tylenol)
(Acetaminophen)
(Tylenol)
(Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol Sore
Throat)
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
4
$0
(Tylenol Sore
Throat)
(Acetaminophen)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
19
Tier level
What the
drug will
cost you
(Tylenol)
(Acetaminophen)
(Tylenol)
(Tylenol)
(Ultram)
(Ultracet)
(Ibudone)
4
4
4
4
1
1
1
$0
$0
$0
$0
$0
$0
$0
(Motrin Ib)
(Ibuprofen)
(Ecotrin)
(Bayer Chewable
Aspirin)
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
1
$0
4
$0
1
$0
1
$0
1
$0
Name of Drug
q-pap * oral tablet
silapap *
tactinal *
tactinal extra strength *
tramadol oral tablet
tramadol-acetaminophen
xylon 10
Nonsteroidal AntiInflammatory Agents
advil * oral tablet
advil * oral tablet,chewable
aspirin * oral tablet
aspirin * oral tablet,chewable
aspirin * oral tablet,delayed release
(Ecotrin)
(dr/ec) 325 mg, 500 mg, 81 mg
aspirin * rectal
(Aspirin)
(Aspirin/Calcium
aspirin, buffered *
Carbonate/Mag)
aspir-low *
(Ecotrin)
(Aspirin/Calcium
bufferin * oral tablet 325 mg
Carbonate/Mag)
CALDOLOR INTRAVENOUS
RECON SOLN
celecoxib
(Celebrex)
(Children'S
children's advil *
Motrin)
(Choline Sal/Mag
choline,magnesium salicylate
Salicylate)
(Diclofenac
diclofenac potassium
Potassium)
diclofenac sodium oral tablet
(Voltaren-XR)
extended release 24 hr
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
20
Tier level
What the
drug will
cost you
1
$0
1
1
1
4
1
$0
$0
$0
$0
$0
1
$0
2
1
$0
$0
4
$0
4
4
$0
$0
(Ibuprofen)
1
$0
(Motrin Ib)
4
$0
(Ibuprofen)
1
$0
indomethacin oral capsule 25 mg
(Indomethacin)
1
$0
indomethacin oral capsule 50 mg
(Indomethacin)
1
$0
1
$0
1
$0
4
3
1
$0
$0
$0
1
$0
Name of Drug
diclofenac sodium oral
tablet,delayed release (dr/ec)
diclofenac sodium topical gel
diclofenac-misoprostol
diflunisal
e.c. prin *
etodolac
fenoprofen oral tablet
FLECTOR
flurbiprofen
ibuprofen * 100 mg/5 ml susp
children's (otc)
ibuprofen jr strength *
ibuprofen * oral
ibuprofen oral suspension 100 mg/5
ml
ibuprofen * oral tablet 100 mg, 200
mg
ibuprofen oral tablet 400 mg, 600
mg, 800 mg
(Diclofenac
Sodium)
(Solaraze)
(Arthrotec 50)
(Diflunisal)
(Ecotrin)
(Etodolac)
(Fenoprofen
Calcium)
(Flurbiprofen)
(Children'S
Motrin)
(Ibuprofen)
(Advil)
indomethacin oral capsule, extended
(Indomethacin)
release
(Indomethacin
indomethacin sodium
Sodium)
infant's ibuprofen *
(Infants' Motrin)
INFANT'S MOTRIN *
ketoprofen oral capsule
(Ketoprofen)
ketoprofen oral capsule,ext rel.
(Ketoprofen)
pellets 24 hr 200 mg
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per
30 days)
PA-HRM
21
Tier level
What the
drug will
cost you
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Ec-Naprosyn)
1
$0
(Anaprox)
1
$0
(Feldene)
(Salsalate)
(Bayer Chewable
Aspirin)
(Ecotrin)
(Sulindac)
(Tolmetin Sodium)
(Aspirin/Calcium
Carbonate/Mag)
1
1
$0
$0
4
$0
4
1
1
$0
$0
$0
4
$0
(Advil)
2
4
$0
$0
glydo
(Lidocaine HCl)
1
$0
lidocaine (pf) injection solution
(Xylocaine-MPF)
1
$0
lidocaine hcl injection solution
(Xylocaine)
1
$0
1
1
$0
$0
1
$0
Name of Drug
ketorolac oral
mefenamic acid
meloxicam
nabumetone
naproxen oral suspension
naproxen oral tablet
naproxen oral tablet,delayed release
(dr/ec)
naproxen sodium oral tablet 275
mg, 550 mg
piroxicam
salsalate
st joseph aspirin *
st. joseph aspirin *
sulindac oral
tolmetin
tri-buffered aspirin *
VOLTAREN TOPICAL
wal-profen * oral
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 30 days)
Anesthetics
Local Anesthetics
lidocaine hcl laryngotracheal
(Xylocaine)
lidocaine hcl mucous membrane gel (Lidocaine HCl)
lidocaine hcl mucous membrane
(Lidocaine HCl)
jelly in applicator
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
22
Tier level
What the
drug will
cost you
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Lidoderm)
1
$0
lidocaine topical ointment
(Lidocaine)
1
$0
lidocaine-prilocaine topical
(EMLA)
1
$0
lidocaine-prilocaine topical kit
RELADOR PAK
(Relador Pak)
1
1
$0
$0
Name of Drug
lidocaine hcl mucous membrane
solution
lidocaine hcl urethral
lidocaine topical adhesive
patch,medicated
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
Anti-Addiction/Substance
Abuse Treatment Agents
Anti-Addiction/Substance
Abuse Treatment Agents
acamprosate
(Acamprosate
Calcium)
1
$0
buprenorphine hcl sublingual
(Subutex)
1
$0
1
$0
1
2
$0
$0
2
$0
2
$0
2
$0
1
1
1
1
$0
$0
$0
$0
buprenorphine-naloxone
bupropion hcl sr 150 mg tablet f/c
CHANTIX
CHANTIX CONTINUING
MONTH BOX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
BOX
disulfiram
naloxone
naltrexone hcl
naltrexone
(Buprenorphine
HCl/Naloxone
HCl)
(Zyban)
(Antabuse)
(Naloxone HCl)
(Revia)
(Revia)
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
QL (56 per 28 days)
QL (56 per 28 days)
QL (53 per 28 days)
23
Name of Drug
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 14 MG/24 HR, 21 MG/24
HR
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 7 MG/24 HR
nicorelief * buccal gum
nicorette * buccal gum 2 mg
nicotine (polacrilex) *
nicotine * transdermal patch 24
hour 14 mg/24 hr, 7 mg/24 hr
nicotine * transdermal patch 24
hour 21 mg/24 hr, 22 mg/24 hr
NICOTROL
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
4
$0
4
$0
(Nicorette)
(Nicorette)
(Nicorette)
4
4
4
$0
$0
$0
(Nicoderm Cq)
4
$0
(Nicoderm Cq)
4
$0
2
$0
2
$0
ZUBSOLV
PA; QL (90 per 30
days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
(Xanax)
1
$0
(Chlordiazepoxide
chlordiazepoxide hcl
1
$0
HCl)
clonazepam oral tablet 0.5 mg, 1 mg (Klonopin)
1
$0
QL (90 per 30 days)
clonazepam oral tablet 2 mg
(Klonopin)
1
$0
clonazepam oral
QL (90 per 30 days)
tablet,disintegrating 0.125 mg, 0.25 (Clonazepam)
1
$0
mg, 0.5 mg, 1 mg
clonazepam oral
(Clonazepam)
1
$0
clorazepate dipotassium oral tablet
(Tranxene T-Tab)
1
$0
15 mg
clorazepate dipotassium oral tablet
QL (60 per 30 days)
(Tranxene T-Tab)
1
$0
3.75 mg, 7.5 mg
diazepam injection
(Diazepam)
1
$0
QL (10 per 28 days)
diazepam intensol
(Diazepam)
1
$0
24
Tier level
What the
drug will
cost you
(Diazepam)
1
$0
(Valium)
(Diastat)
(Ativan)
1
1
1
$0
$0
$0
ONFI ORAL SUSPENSION
2
$0
ONFI ORAL TABLET 10 MG, 20
MG
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet
diazepam rectal
lorazepam oral tablet
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
PA NSO; QL (480 per
30 days)
PA NSO; QL (60 per
30 days)
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl (iso-osm)
intravenous piggyback
gentamicin injection solution
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf) intravenous
solution
neomycin
streptomycin intramuscular
(Gentamicin In
Nacl, Iso-Osm)
(Gentamicin
Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
TOBI PODHALER INHALATION
tobramycin in 0.225 % nacl
(Tobi)
(Tobramycin/Sodiu
tobramycin in 0.9 % nacl
m Chloride)
(Tobramycin
tobramycin sulfate injection solution
Sulfate)
Antibacterials,
Miscellaneous
bacitracin intramuscular
(Bacitracin)
(Chloramphenicol
chloramphenicol sod succinate
Sod Succ)
PA BvD
PA BvD
25
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
1
1
$0
$0
$0
1
$0
1
$0
1
$0
(Macrodantin)
1
$0
(Macrodantin)
1
$0
Name of Drug
clindamycin hcl
clindamycin in 5 % dextrose
clindamycin palmitate hcl
clindamycin phosphate injection
clindamycin phosphate intravenous
solution
colistin (colistimethate na)
CUBICIN
linezolid
methenamine hippurate
methenamine mandelate
metronidazole in nacl (iso-os)
metronidazole oral
nitrofurantoin macrocrystal oral
capsule 100 mg, 25 mg
nitrofurantoin macrocrystal oral
capsule
(Cleocin HCl)
(Cleocin Phosphate
In D5w)
(Cleocin Palmitate)
(Cleocin
Phosphate)
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
(Metronidazole/So
dium Chloride)
(Flagyl)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (120 per
30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
26
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use of
nitrofurantoin drugs);
nitrofurantoin monohyd/m-cryst
(Macrobid)
1
$0
polymyxin b sulfate
(Polymyxin B
Sulfate)
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
1
$0
2
$0
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
SYNERCID
trimethoprim
vancomycin in d5w intravenous
piggyback
vancomycin intravenous recon soln
1,000 mg, 10 gram, 750 mg
vancomycin intravenous recon soln
500 mg
vancomycin oral
XIFAXAN ORAL TABLET 200
MG
XIFAXAN ORAL TABLET 550
MG
ZYVOX ORAL SUSPENSION
FOR RECONSTITUTION
Cephalosporins
cefaclor oral capsule
cefaclor oral suspension for
reconstitution 125 mg/5 ml, 250
mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500
mg/5 ml
cefadroxil oral tablet
(Trimethoprim)
(Vancomycin
HCl/D5W)
(Vancomycin HCl)
(Vancomycin
HCl/D5W)
(Vancocin HCl)
PA; QL (9 per 30 days)
PA; QL (60 per 30
days)
27
Name of Drug
CEFAZOLIN IN DEXTROSE
(ISO-OS) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML
(Cefazolin
cefazolin in dextrose (iso-os)
Sodium/Dextrose,
intravenous piggyback 2 gram/50 ml
Iso)
cefazolin injection recon soln 1
gram, 10 gram, 100 gram, 300 g,
(Cefazolin Sodium)
500 mg
cefdinir
(Cefdinir)
cefditoren pivoxil
(Spectracef)
cefepime
(Maxipime)
CEFEPIME IN DEXTROSE 5 %
CEFEPIME IN DEXTROSE,ISOOSM INTRAVENOUS
PIGGYBACK
cefotaxime
(Claforan)
cefoxitin
(Cefoxitin Sodium)
(Cefoxitin
cefoxitin in dextrose, iso-osm
Sodium/Dextrose,
intravenous piggyback 2 gram/50 ml
Iso)
(Cefpodoxime
cefpodoxime
Proxetil)
cefprozil
(Cefprozil)
ceftazidime injection recon soln 2
(Fortaz)
gram, 6 gram
ceftibuten
(Cedax)
ceftriaxone in dextrose,iso-os
(Ceftriaxone
intravenous piggyback 1 gram/50 ml Na/Dextrose, Iso)
CEFTRIAXONE IN
DEXTROSE,ISO-OS
INTRAVENOUS PIGGYBACK 2
GRAM/50 ML
ceftriaxone injection recon soln
(Rocephin)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
1
1
2
$0
$0
$0
$0
2
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
28
Tier level
What the
drug will
cost you
1
$0
1
$0
(Ceftin)
1
$0
(Zinacef)
1
$0
(Zinacef)
(Keflex)
1
1
$0
$0
(Cephalexin)
1
$0
(Cephalexin)
1
$0
2
$0
2
$0
2
$0
(Zithromax)
1
$0
(Biaxin)
1
$0
(Biaxin)
1
$0
(Clarithromycin)
1
$0
2
2
$0
$0
1
$0
2
$0
1
$0
Name of Drug
ceftriaxone intravenous recon soln 1
gram
CEFTRIAXONE INTRAVENOUS
RECON SOLN 2 GRAM
cefuroxime axetil oral tablet
cefuroxime sodium injection recon
soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
cephalexin oral capsule
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
MEFOXIN IN DEXTROSE (ISOOSM)
SUPRAX ORAL
TABLET,CHEWABLE
TEFLARO
Macrolides
azithromycin
clarithromycin oral suspension for
reconstitution
clarithromycin oral tablet
clarithromycin oral tablet extended
release 24 hr
DIFICID
ERYTHROCIN
erythromycin base oral
tablet,delayed release (dr/ec) 250
mg, 500 mg
ERYTHROMYCIN BASE ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythromycin ethylsuccinate oral
suspension for reconstitution 200
mg/5 ml
(Ceftriaxone
Na/Dextrose, Iso)
(Erythromycin
Base)
(Eryped 200)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 10 days)
29
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
2
1
2
1
$0
$0
$0
$0
1
$0
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
(Amoxicillin)
1
$0
(Augmentin)
1
$0
(Augmentin)
1
$0
(Augmentin XR)
1
$0
1
$0
1
$0
Name of Drug
erythromycin ethylsuccinate oral
tablet 400 mg
erythromycin oral capsule,delayed
release(dr/ec)
erythromycin oral tablet
erythromycin stearate oral tablet
250 mg
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1
gram
CAYSTON
imipenem-cilastatin
INVANZ
meropenem
meropenem-0.9% sodium chloride
Penicillins
amoxicillin oral capsule
amoxicillin oral suspension for
reconstitution
amoxicillin oral tablet
amoxicillin oral tablet,chewable 125
mg, 250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution
tablet
tablet extended release 12 hr
tablet,chewable
ampicillin
(Erythromycin
Ethylsuccinate)
(Erythromycin
Base)
(Erythromycin
Base)
(Erythromycin
Stearate)
(Azactam)
(Primaxin)
(Merrem)
(Meropenem-0.9%
Sodium Chloride)
(Amoxicillin/Potas
sium Clav)
(Ampicillin
Trihydrate)
Necessary Actions,
Restrictions, or
Limits on Use
LA
30
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
2
2
$0
$0
1
$0
1
1
$0
$0
1
$0
(Oxacillin Sodium)
1
$0
(Oxacillin Sodium)
(Pen G
Pot/DextroseWater)
(Penicillin G
Potassium)
(Penicillin G
Procaine)
(Penicillin V
Potassium)
(Zosyn)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
ampicillin sodium injection recon
soln
ampicillin sodium intravenous recon
soln
ampicillin-sulbactam injection
ampicillin-sulbactam intravenous
recon soln
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin injection
nafcillin intravenous recon soln
oxacillin in dextrose(iso-osm)
oxacillin injection recon soln 10
gram
oxacillin intravenous
penicillin g pot in dextrose
penicillin g potassium injection
recon soln 20 million unit
penicillin g procaine
penicillin v potassium
piperacillin-tazobactam
Quinolones
ciprofloxacin
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose
(Ampicillin
Sodium)
(Ampicillin
Sodium)
(Unasyn)
(Unasyn)
(Dicloxacillin
Sodium)
(Nafcillin Sodium)
(Nafcillin Sodium)
(Oxacillin
Sodium/Dextrose,
Iso)
Necessary Actions,
Restrictions, or
Limits on Use
(Cipro)
1
$0
(Cipro)
1
$0
(Cipro I.V.)
1
$0
(Ciprofloxacin
ciprofloxacin lactate
1
$0
Lactate)
31
Tier level
What the
drug will
cost you
(Levaquin)
1
$0
(Levofloxacin)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
1
1
$0
$0
$0
$0
(Sulfadiazine)
(Sulfamethoxazole/
Trimethoprim)
(Sulfamethoxazole/
Trimethoprim)
1
$0
1
$0
1
$0
(Bactrim)
1
$0
(Azulfidine)
(Sulfamethoxazole/
Trimethoprim)
(Azulfidine)
(Azulfidine)
1
$0
1
$0
1
1
$0
$0
(Morgidox)
1
$0
(Doryx)
(Doxycycline
Hyclate)
1
$0
1
$0
Name of Drug
levofloxacin in d5w intravenous
piggyback
levofloxacin intravenous
levofloxacin oral
moxifloxacin
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
sulfamethoxazole-trimethoprim oral
suspension
sulfamethoxazole-trimethoprim oral
tablet
sulfasalazine
sulfatrim
sulfazine
sulfazine ec
Tetracyclines
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate 100 mg tab f/c
doxycycline hyclate intravenous
Necessary Actions,
Restrictions, or
Limits on Use
doxycycline hyclate oral capsule
(Adoxa)
1
$0
100 mg
doxycycline hyclate oral capsule 50
(Morgidox)
1
$0
mg
doxycycline hyclate oral tablet 100
(Avidoxy)
1
$0
mg, 50 mg
doxycycline hyclate oral tablet 20
(Doryx)
1
$0
mg
doxycycline monohydrate oral
(Adoxa)
1
$0
capsule
32
Tier level
What the
drug will
cost you
(Vibramycin)
1
$0
(Avidoxy)
(Minocin)
(Minocycline HCl)
(Tetracycline HCl)
1
1
1
1
2
$0
$0
$0
$0
$0
Anticancer Agents
ABRAXANE
2
$0
ADCETRIS
2
$0
AFINITOR DISPERZ
2
$0
2
$0
2
$0
2
$0
1
2
1
2
$0
$0
$0
$0
Name of Drug
doxycycline monohydrate oral
suspension for reconstitution
doxycycline monohydrate oral tablet
minocycline oral capsule
minocycline oral tablet
tetracycline
TYGACIL
Necessary Actions,
Restrictions, or
Limits on Use
Anticancer Agents
AFINITOR ORAL TABLET 10
MG
AFINITOR ORAL TABLET 2.5
MG, 5 MG, 7.5 MG
ALIMTA INTRAVENOUS
RECON SOLN
anastrozole
AVASTIN
azacitidine
BELEODAQ
(Arimidex)
(Vidaza)
bexarotene
(Targretin)
1
$0
bicalutamide
(Casodex)
(Bleomycin
Sulfate)
1
$0
1
$0
BLINCYTO
2
$0
BOSULIF ORAL TABLET 100
MG
2
$0
bleomycin
PA NSO; QL (4 per 21
days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
PA NSO
PA NSO
PA NSO; QL (420 per
30 days)
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
33
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
COMETRIQ
2
$0
COTELLIC
2
$0
1
$0
2
$0
1
$0
Name of Drug
BOSULIF ORAL TABLET 500
MG
CAPRELSA ORAL TABLET 100
MG
CAPRELSA ORAL TABLET 300
MG
cyclophosphamide intravenous
recon soln
CYCLOPHOSPHAMIDE ORAL
CAPSULE
cyclophosphamide oral tablet
(Cyclophosphamid
e)
(Cyclophosphamid
e)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (63 per
28 days)
PA BvD
PA BvD; ST
PA BvD; ST
CYRAMZA
2
$0
PA NSO
dactinomycin
(Dactinomycin)
1
$0
DARZALEX
2
$0
PA NSO
decitabine
(Dacogen)
1
$0
doxorubicin hcl intravenous recon
PA BvD
(Doxorubicin HCl)
1
$0
soln 10 mg
doxorubicin hcl peg-liposomal
PA BvD
(Doxil)
1
$0
intravenous suspension 2 mg/ml
doxorubicin, peg-liposomal
(Doxil)
1
$0
PA BvD
DROXIA
2
$0
ELIGARD SUBCUTANEOUS
QL (1 per 84 days)
2
$0
SYRINGE 22.5 MG (3 MONTH)
QL (1 per 112 days)
2
$0
SYRINGE 30 MG (4 MONTH)
QL (1 per 168 days)
2
$0
SYRINGE 45 MG (6 MONTH)
2
$0
SYRINGE 7.5 MG (1 MONTH)
EMCYT
2
$0
34
Tier level
What the
drug will
cost you
EMPLICITI
2
$0
ERIVEDGE
2
$0
(Floxuridine)
2
1
1
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
(Fluorouracil)
1
$0
(Flutamide)
1
2
$0
$0
2
$0
2
$0
2
$0
2
2
1
$0
$0
$0
IBRANCE
2
$0
ICLUSIG ORAL TABLET 15 MG
2
$0
ICLUSIG ORAL TABLET 45 MG
2
$0
1
1
$0
$0
1
$0
Name of Drug
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
FARYDAK
FASLODEX
floxuridine
fluorouracil intravenous solution
2.5 gram/50 ml, 5 gram/100 ml, 500
mg/10 ml
flutamide
GAZYVA
(Etoposide)
(Aromasin)
GILOTRIF
GLEEVEC ORAL TABLET 100
MG
GLEEVEC ORAL TABLET 400
MG
HERCEPTIN
HEXALEN
hydroxyurea
ifosfamide intravenous recon soln
ifosfamide intravenous solution
ifosfamide-mesna
(Hydrea)
(Ifex)
(Ifex)
(Ifosfamide/Mesna
)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
PA BvD
PA BvD
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
35
Tier level
What the
drug will
cost you
IMBRUVICA
IMLYGIC INJECTION
SUSPENSION 10EXP6 (1
MILLION) PFU/ML
IMLYGIC INJECTION
SUSPENSION 10EXP8 (100
MILLION) PFU/ML
2
$0
2
$0
PA NSO
PA NSO; QL (4 per
365 days)
2
$0
days)
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
IRESSA
2
$0
IXEMPRA
2
$0
JAKAFI
2
$0
KEYTRUDA
2
$0
KYPROLIS
2
$0
LENVIMA
letrozole
LEUKERAN
2
1
2
$0
$0
$0
1
$0
1
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
Name of Drug
leuprolide subcutaneous kit
lomustine
LONSURF ORAL TABLET 156.14 MG
LONSURF ORAL TABLET 208.19 MG
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
(Femara)
(Leuprolide
Acetate)
(Gleostine)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
days)
PA NSO
PA NSO; QL (100 per
28 days)
PA NSO; QL (80 per
28 days)
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
PA NSO; QL (480 per
LYNPARZA
2
$0
30 days)
36
Tier level
What the
drug will
cost you
LYSODREN
MATULANE
megestrol oral suspension 625 mg/5 (Megestrol
ml
Acetate)
(Megestrol
megestrol oral tablet
Acetate)
MEKINIST ORAL TABLET 0.5
MG
2
2
$0
$0
1
$0
1
$0
2
$0
MEKINIST ORAL TABLET 2 MG
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
NEXAVAR
2
$0
NILANDRON
2
$0
NINLARO
2
$0
ODOMZO
ONCASPAR
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
2
2
$0
$0
2
$0
POMALYST
2
$0
Name of Drug
mercaptopurine
methotrexate sodium (pf) injection
recon soln
methotrexate sodium (pf) injection
solution
methotrexate sodium injection
methotrexate sodium oral
mitoxantrone
(Mercaptopurine)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitoxantrone
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
PA NSO; QL (120 per
30 days)
days)
PA NSO
PA NSO
PA NSO
PA NSO; QL (21 per
28 days)
PROLEUKIN
2
$0
PURIXAN
2
$0
REVLIMID
2
$0
PA NSO; LA
37
Tier level
What the
drug will
cost you
RITUXAN
SOLTAMOX
SPRYCEL ORAL TABLET 100
MG, 140 MG, 50 MG, 70 MG, 80
MG
2
2
$0
$0
2
$0
SPRYCEL ORAL TABLET 20 MG
2
$0
STIVARGA
2
$0
SUTENT
2
$0
SYLVANT
2
$0
SYNRIBO
2
$0
TABLOID
2
$0
TAFINLAR
2
$0
TAGRISSO
2
$0
1
$0
2
$0
2
$0
TARGRETIN ORAL
2
$0
TARGRETIN TOPICAL
2
$0
TASIGNA
2
$0
TEMODAR INTRAVENOUS
toposar intravenous
TREANDA
2
1
2
$0
$0
$0
Name of Drug
(Tamoxifen
Citrate)
tamoxifen
TARCEVA ORAL TABLET 100
MG, 25 MG
TARCEVA ORAL TABLET 150
MG
(Etoposide)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (28 per
28 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per
28 days)
PA NSO; QL (112 per
28 days)
PA NSO; (vial only)
38
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
1
2
2
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
VOTRIENT
2
$0
XALKORI
2
$0
XTANDI
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
SYRINGE 11.25 MG/2 ML
tretinoin (chemotherapy)
TREXALL
TYKERB
UNITUXIN
VALSTAR
VELCADE
vinorelbine intravenous solution
Necessary Actions,
Restrictions, or
Limits on Use
QL (1 per 168 days)
(Tretinoin)
(Navelbine)
YERVOY INTRAVENOUS
SOLUTION
YONDELIS
ZELBORAF
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA
ZYDELIG
QL (1 per 84 days)
QL (1 per 168 days)
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
QL (1 per 28 days)
PA NSO; QL (60 per
30 days)
39
Tier level
What the
drug will
cost you
ZYKADIA
2
$0
ZYTIGA
2
$0
1
$0
1
$0
1
$0
2
$0
QL (4 per 28 days)
$0
$0
$0
ST
ST
(Tegretol)
2
2
1
(Carbatrol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasm
odics
atropine injection solution 0.4
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05
(Atropine Sulfate)
mg/ml, 0.1 mg/ml
(Propantheline
propantheline
Bromide)
STIOLTO RESPIMAT
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension
carbamazepine oral tablet extended
release 12 hr
carbamazepine oral tablet,chewable
CELONTIN ORAL CAPSULE 300
MG
DILANTIN CAPSULE 30 MG
divalproex oral capsule, sprinkle
divalproex oral tablet extended
release 24 hr
divalproex oral tablet,delayed
release (dr/ec)
2
$0
(Depakote
Sprinkle)
1
$0
(Depakote ER)
1
$0
(Depakote)
1
$0
40
Tier level
What the
drug will
cost you
(Neurontin)
(Neurontin)
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
(Neurontin)
1
$0
2
$0
2
$0
(Lamictal)
1
$0
(Lamictal XR)
1
$0
(Lamictal)
1
$0
(Lamictal (Blue))
1
$0
(Keppra)
(Keppra)
(Keppra)
1
1
1
$0
$0
$0
(Keppra XR)
1
$0
(Phenobarbital)
2
2
1
2
2
1
$0
$0
$0
$0
$0
$0
(Phenobarbital)
1
$0
(Phenobarbital)
1
$0
Name of Drug
ethosuximide
felbamate
fosphenytoin
FYCOMPA ORAL TABLET
gabapentin oral capsule
gabapentin oral solution
gabapentin oral tablet 600 mg, 800
mg
GABITRIL ORAL TABLET 12
MG, 16 MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
lamotrigine oral tablet
lamotrigine oral tablet extended
release 24hr
lamotrigine oral tablet, chewable
dispersible
lamotrigine oral tablets,dose pack
25 mg (35)
levetiracetam intravenous
levetiracetam oral solution
levetiracetam oral tablet
levetiracetam oral tablet extended
release 24 hr
LYRICA ORAL CAPSULE
LYRICA ORAL SOLUTION
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital oral elixir
phenobarbital oral tablet 100 mg,
15 mg, 16.2 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
phenobarbital oral tablet 30 mg
(Zarontin)
(Felbatol)
(Cerebyx)
(Trileptal)
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (90 per 30 days)
ST
QL (90 per 30 days)
41
Tier level
What the
drug will
cost you
(Phenobarbital
Sodium)
1
$0
(Dilantin-125)
1
$0
(Dilantin)
(Phenytoin
Sodium)
(Dilantin)
1
$0
1
$0
1
$0
2
$0
(Gabitril)
(Topamax)
2
1
2
1
1
$0
$0
$0
$0
$0
(Qudexy XR)
1
$0
(Depacon)
(Depakene)
2
1
1
$0
$0
$0
(Depakene)
1
$0
$0
$0
$0
$0
QL (200 per 5 days)
QL (60 per 30 days)
(Zonegran)
2
2
2
1
(Aricept)
(Donepezil HCl)
1
1
1
$0
$0
$0
(Razadyne ER)
1
$0
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Galantamine Hbr)
1
$0
Name of Drug
phenobarbital sodium injection
solution
phenytoin oral suspension 125 mg/5
ml
phenytoin oral
phenytoin sodium
phenytoin sodium extended
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone
SABRIL
tiagabine
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er
24hr
TROKENDI XR
valproate sodium
valproic acid
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
VIMPAT INTRAVENOUS
VIMPAT ORAL SOLUTION
VIMPAT ORAL TABLET
zonisamide
(Mysoline)
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 30 days)
QL (90 per 30 days)
ST
Antidementia Agents
Antidementia Agents
donepezil oral tablet
donepezil oral tablet,disintegrating
EXELON TRANSDERMAL
galantamine oral capsule,ext rel.
pellets 24 hr
galantamine oral solution
42
Tier level
What the
drug will
cost you
1
1
1
1
$0
$0
$0
$0
2
$0
2
$0
2
1
$0
$0
1
$0
(Wellbutrin)
1
2
1
$0
$0
$0
(Wellbutrin SR)
1
$0
(Wellbutrin XL)
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Duloxetine)
1
$0
(Duloxetine)
1
$0
(Duloxetine)
1
$0
Name of Drug
galantamine oral tablet
memantine oral solution
memantine oral tablet
memantine oral tablets,dose pack
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
NAMZARIC
rivastigmine tartrate
(Razadyne)
(Namenda)
(Namenda)
(Namenda)
(Exelon)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
Antidepressants
Antidepressants
amitriptyline
amoxapine
BRINTELLIX
bupropion hcl oral tablet
bupropion hcl oral tablet extended
release , 150 mg
bupropion hcl oral tablet extended
release 24 hr
citalopram oral solution
citalopram oral tablet
clomipramine
desipramine oral
doxepin oral
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
release(dr/ec) 30 mg
release(dr/ec) 40 mg
(Amitriptyline
HCl)
(Amoxapine)
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
PA NSO-HRM
ST
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
(Cymbalta); QL (60
per 30 days)
(Cymbalta); QL (30
per 30 days)
(Irenka); QL (30 per 30
days)
43
Tier level
What the
drug will
cost you
(Prozac)
2
1
2
1
$0
$0
$0
$0
(Prozac Weekly)
1
$0
(Fluoxetine HCl)
(Fluoxetine HCl)
(Fluvoxamine
Maleate)
(Tofranil)
(Tofranil-Pm)
(Maprotiline HCl)
1
1
$0
$0
1
$0
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Nortriptyline HCl)
(Symbyax)
(Paxil)
1
1
1
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Paxil CR)
1
$0
2
$0
1
$0
1
$0
2
$0
ST; QL (30 per 30
days)
1
1
2
2
1
1
$0
$0
$0
$0
$0
$0
QL (30 per 30 days)
PA NSO-HRM
Name of Drug
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine oral capsule
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
fluvoxamine
imipramine hcl
imipramine pamoate
maprotiline
MARPLAN
mirtazapine
nefazodone
nortriptyline oral capsule
nortriptyline oral solution
olanzapine-fluoxetine
paroxetine hcl oral tablet
paroxetine hcl oral tablet extended
release 24 hr
PAXIL ORAL SUSPENSION
perphenazine-amitriptyline
phenelzine
(Lexapro)
(Perphenazine/Ami
triptyline HCl)
(Nardil)
PRISTIQ
protriptyline
sertraline
SILENOR
SURMONTIL
tranylcypromine
trazodone
(Protriptyline HCl)
(Zoloft)
(Parnate)
(Trazodone HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
ST
PA NSO-HRM
PA NSO-HRM
PA NSO-HRM
44
Tier level
What the
drug will
cost you
(Trimipramine
Maleate)
1
$0
(Effexor XR)
1
$0
(Venlafaxine HCl)
1
$0
(Venlafaxine HCl)
1
$0
2
$0
1
2
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Name of Drug
trimipramine
venlafaxine oral capsule,extended
release 24hr
venlafaxine oral tablet
venlafaxine oral tablet extended
release 24hr 150 mg, 37.5 mg, 75
mg
VIIBRYD
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose
CYCLOSET
(Precose)
GLYXAMBI
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 501,000 MG
INVOKAMET ORAL TABLET 50500 MG
INVOKANA ORAL TABLET 100
MG
INVOKANA ORAL TABLET 300
MG
JANUMET
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1001,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 50-1,000
MG
JANUVIA
QL (90 per 30 days)
ST; QL (30 per 30
days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
ST; QL (60 per 30
days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
JARDIANCE
2
$0
2
$0
2
$0
QL (30 per 30 days)
ST; QL (30 per 30
days)
45
Tier level
What the
drug will
cost you
JENTADUETO
2
$0
KORLYM
2
$0
(Glucophage)
(Glucophage)
(Glucophage)
1
1
1
$0
$0
$0
(Glucophage XR)
1
$0
(Glucophage XR)
1
$0
(Fortamet)
1
$0
(Starlix)
(Actos)
(Duetact)
(Actoplus Met)
1
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
SYMLINPEN 120
2
$0
SYMLINPEN 60
2
$0
SYNJARDY
2
$0
TRADJENTA
TRULICITY
VICTOZA
Insulins
HUMULIN R U-500
(CONCENTRATED)
LANTUS
LANTUS SOLOSTAR
NOVOLIN 70/30
NOVOLIN N
2
2
2
$0
$0
$0
2
$0
2
2
2
2
$0
$0
$0
$0
Name of Drug
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended
release 24 hr 500 mg
release 24 hr 750 mg
release 24hr
nateglinide
pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
PRANDIMET
repaglinide
repaglinide-metformin
(Prandin)
(Prandimet)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
PA; QL (10.8 per 28
days)
ST; QL (60 per 30
days)
QL (30 per 30 days)
ST; QL (4 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
46
Name of Drug
Tier level
What the
drug will
cost you
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG PENFILL
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended
release 24hr 10 mg
glipizide oral tablet extended
release 24hr 2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
glyburide micronized oral tablet 1.5
mg
glyburide micronized oral tablet 3
mg
glyburide micronized oral tablet 6
mg
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (30 per 28 days)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
1
1
1
1
$0
$0
$0
$0
(Glucotrol XL)
1
$0
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
1
$0
1
$0
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
(Glynase)
1
$0
glyburide oral tablet 1.25 mg
(Glyburide)
1
$0
glyburide oral tablet 2.5 mg
(Glyburide)
1
$0
glyburide oral tablet 5 mg
(Glyburide)
1
$0
glyburide-metformin oral tablet
1.25-250 mg
(Glucovance)
1
$0
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
47
Tier level
What the
drug will
cost you
(Glucovance)
1
$0
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
$0
$0
$0
(Miconazole
Nitrate)
4
$0
2
4
$0
$0
4
$0
2
1
4
4
4
4
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (120 per
30 days)
QL (60 per 30 days)
Antifungals
Antifungals
3 day vaginal *
ABELCET
af *
aloe vesta antifungal (micon) *
AMBISOME
amphotericin b
antifungal (tolnaftate) * topical
antifungal (tolnaftate) * topical
antifungal * topical solution
baza antifungal *
blis-to-sol (tolnaftate) *
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
(Tinactin)
(Miconazole
Nitrate)
(Amphotericin B)
(Tolnaftate)
(Tolnaftate)
(Undecylenic Acid)
(Nuzole)
(Tolnaftate)
PA BvD
PA BvD
PA BvD
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox
ciclopirox topical suspension
1
$0
Olamine)
ciclopirox-ure-camph-menth-euc
(Ciclodan)
1
$0
clotrimazole * 1% cream (otc)
(Lotrimin AF)
4
$0
clotrimazole * 1% solution (otc)
(Clotrimazole)
4
$0
clotrimazole 3 day *
(Gyne-Lotrimin)
4
$0
clotrimazole mucous membrane
(Clotrimazole)
1
$0
clotrimazole topical cream 1 %
(Clotrimazole)
1
$0
clotrimazole topical solution 1 %
(Lotrimin)
1
$0
48
Tier level
What the
drug will
cost you
(Gyne-Lotrimin)
(Clotrimazole)
(Gyne-Lotrimin)
4
4
4
$0
$0
$0
(Lotrisone)
1
$0
1
$0
4
$0
4
$0
1
4
1
$0
$0
$0
1
$0
1
$0
1
4
4
4
4
1
4
1
1
1
1
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
clotrimazole * vaginal cream
clotrimazole * vaginal tablet
clotrimazole-7 *
clotrimazole-betamethasone topical
cream
clotrimazole-betamethasone topical
lotion
critic-aid clear af *
dermafungal *
econazole topical
elon dual defense *
fluconazole
fluconazole in dextrose(iso-o)
fluconazole in nacl (iso-osm)
intravenous piggyback 400 mg/200
ml
flucytosine
foot odor control *
fungi cure *
FUNGI-NAIL * TOPICAL
fungoid-d *
griseofulvin microsize oral tablet
inzo antifungal *
itraconazole
ketoconazole oral
ketoconazole topical cream
ketoconazole topical shampoo
LAMISIL (AEROSOL) *
lamisil af * topical aerosol powder
lamisil af * topical powder
LAMISIL AT * TOPICAL
(Clotrimazole/Beta
methasone Dip)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Econazole Nitrate)
(Undecylenic Acid)
(Diflucan)
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Tinactin)
(Clotrimazole)
(Tinactin)
(Grifulvin V)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tinactin)
(Tolnaftate)
Necessary Actions,
Restrictions, or
Limits on Use
49
Name of Drug
micatin *
miconazole 7 * vaginal suppository
miconazole nitrate * topical cream
miconazole nitrate * vaginal
miconazole nitrate * vaginal
(Nuzole)
(Miconazole
Nitrate)
(Nuzole)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
miconazole nitrate * vaginal kit 200
(Monistat 3)
4
$0
mg- 2 % (9 gram)
miconazole nitrate vaginal
(Monistat 3)
1
$0
suppository 200 mg
MONISTAT 3 * VAGINAL COMB
4
$0
PACK,PREFILL APPL & CREAM
MONISTAT 3 * VAGINAL KIT
4
$0
(Miconazole
monistat 7 * vaginal
4
$0
Nitrate)
myco nail a *
(Undecylenic Acid)
4
$0
NOXAFIL ORAL
2
$0
NYSTATIN (BULK) POWDER 1
BILLION UNIT, 10 BILLION
1
$0
UNIT
nystatin oral
(Nystatin)
1
$0
nystatin oral
(Nystatin)
1
$0
nystatin topical
(Nystatin)
1
$0
nystatin topical powder 100,000
(Nystatin)
1
$0
unit/gram
(Nystatin/Triamcin
nystatin-triamcinolone
1
$0
)
remedy phytoplex antifungal *
(Miconazole
4
$0
topical ointment
Nitrate)
terbinafine hcl oral
(Lamisil)
1
$0
terbinafine hcl * topical
(Desenex)
4
$0
tolnaftate * topical
(Tinactin)
4
$0
tolnaftate * topical
(Tolnaftate)
4
$0
50
Name of Drug
triple paste af *
voriconazole intravenous
voriconazole oral
(Miconazole
Nitrate)
(Vfend IV)
(Vfend)
Tier level
What the
drug will
cost you
4
$0
1
1
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
Antihistamines
Antihistamines
alavert d-12 allergy-sinus *
allegra allergy *
aller-chlor * oral syrup
aller-chlor * oral tablet
allerclear d-12hr *
allerclear d-24hr *
allergy (chlorpheniramine) *
allergy (diphenhydramine) * oral
tablet
allergy relief (cetirizine) * oral
allergy relief (loratadine) * oral
allerhist-1 *
aller-tec d *
ambi 60pse-4cpm *
aprodine *
banophen allergy *
banophen * oral capsule 25 mg
banophen * oral
(Claritin-D 12
Hour)
(Fexofenadine
HCl)
(Chlorpheniramine
Maleate)
(Chlor-Trimeton)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Chlor-Trimeton)
(Diphenhydramine
HCl)
(Zyrtec)
(Claritin)
(Clemastine
Fumarate)
(Zyrtec-D)
(Pseudoephed/Chlo
rpheniramine)
(Pseudoephedrine/
Triprolidine)
(Zzzquil)
(Benadryl)
(Diphenhydramine
HCl)
51
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
(Zyrtec)
4
$0
(Zyrtec-D)
4
$0
(Zyrtec)
4
$0
(Dimetapp)
(Dimetapp)
(Fexofenadine
HCl)
(Children'S Zyrtec)
4
4
$0
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
4
4
$0
$0
$0
Name of Drug
benadryl allergy * oral tablet
cetirizine * oral solution
cetirizine * oral tablet 10 mg
cetirizine * oral tablet,chewable 5
mg
cetirizine-pseudoephedrine *
child allergy relf(cetirizine) * oral
tablet,chewable
child triaminic cold & allergy *
child wal-tap cold-allergy *
children's allegra allergy *
children's aller-tec *
CHILDREN'S CLARITIN *
children's wal-dryl allergy * oral
children's wal-zyr * oral
CHILDREN'S ZYRTEC
ALLERGY *
CLARITIN LIQUI-GEL *
CLARITIN * ORAL TABLET
CLARITIN REDITABS *
(Diphenhydramine
HCl)
(Children'S Zyrtec)
(Zyrtec)
(Zzzquil)
(Zyrtec)
Necessary Actions,
Restrictions, or
Limits on Use
(Clemastine
4
$0
Fumarate)
(Triaminic
cold & cough * oral liquid
Nighttime Cold4
$0
Cough)
(Pseudoephedrine/
cold-allergy-sinus *
4
$0
Triprolidine)
(Diphenhydramine
compoz *
4
$0
HCl)
(Cyproheptadine
cyproheptadine
1
$0
HCl)
(Clemastine
dailyhist-1 *
4
$0
Fumarate)
clemastine * oral tablet 1.34 mg
52
Name of Drug
(Clemastine
Fumarate)
dimaphen (pe) *
(Dimetapp)
(Triaminic
dimetapp cold-congestion *
Nighttime ColdCough)
diphenhist * oral capsule
(Benadryl)
diphenhist * oral
(Zzzquil)
(Diphenhydramine
diphenhist * oral tablet 25 mg
HCl)
diphenhydramine hcl injection
(Diphenhydramine
solution 50 mg/ml
HCl)
diphenhydramine hcl * oral capsule (Benadryl)
diphenhydramine hcl * oral tablet
(Diphenhydramine
50 mg
HCl)
(Chlorpheniramine
ed chlorped jr *
Maleate)
(Fexofenadine
fexofenadine * oral suspension
HCl)
fexofenadine * oral tablet 180 mg,
(Fexofenadine
60 mg
HCl)
levocetirizine
(Xyzal)
(Children'S
loratadine * oral
Claritin)
loratadine * oral
(Claritin)
loratadine-d * oral tablet extended (Claritin-D 12
release 12 hr
Hour)
loratadine-d * oral tablet extended (Claritin-D 24
release 24 hr
Hour)
(Diphenhydramine
nyt-time sleep *
HCl)
phenylephrine-chlorpheniramine * (Phenylephrine/Chl
oral tablet 4-10 mg
orpheniramine)
(Promethazine
promethazine oral syrup
HCl)
dayhist allergy *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
53
Name of Drug
q-dryl * oral liquid
siladryl sa *
simply sleep *
sinus & allergy (pseudoephed) *
sleep aid (diphenhydramine) * oral
sleep aid (doxylamine) *
sudogest sinus & allergy *
(Zzzquil)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
(Zzzquil)
(Doxylamine
Succinate)
(Pseudoephed/Chlo
rpheniramine)
TRIAMINIC COLD & COUGH NT
(PE) *
unisom sleepgels *
(Benadryl)
(Pseudoephedrine/
wal-act d cold & allergy *
Triprolidine)
wal-dryl allergy * oral
(Benadryl)
(Diphenhydramine
wal-dryl allergy * oral
HCl)
(Fexofenadine
wal-fex allergy *
HCl)
wal-finate *
(Chlor-Trimeton)
(Pseudoephed/Chlo
wal-finate-d *
rpheniramine)
(Claritin-D 24
wal-itin d *
Hour)
(Claritin-D 12
wal-itin d 12 hour *
Hour)
(Children'S
wal-itin * oral solution
Claritin)
wal-itin * oral tablet
(Claritin)
wal-itin * oral tablet,disintegrating (Claritin)
(Pseudoephed/Chlo
wal-phed * oral tablet 4-60 mg
rpheniramine)
Tier level
What the
drug will
cost you
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
54
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
(Benadryl)
4
$0
(Dimetapp)
(Children'S Zyrtec)
(Zyrtec)
(Zyrtec-D)
(Benadryl)
(Zzzquil)
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
1
1
2
$0
$0
$0
Name of Drug
wal-phed pe sinus & allergy *
wal-sleep z * oral capsule
wal-sleep z * oral liquid
wal-sleep z * oral
tablet,disintegrating
wal-som (diphenhydramine) * oral
capsule
wal-tap *
wal-zyr (cetirizine) * oral
wal-zyr (cetirizine) * oral
wal-zyr d *
z-sleep * oral capsule
z-sleep * oral liquid
ZYRTEC * ORAL CAPSULE
ZYRTEC * ORAL TABLET
ZYRTEC * ORAL
TABLET,DISINTEGRATING
(Phenylephrine/Chl
orpheniramine)
(Benadryl)
(Zzzquil)
(Unisom
Sleepmelts)
Necessary Actions,
Restrictions, or
Limits on Use
Anti-Infectives (Skin And
Mucous Membrane)
Anti-Infectives (Skin And
Mucous Membrane)
ABREVA *
AVC VAGINAL
clindamycin phosphate vaginal
metronidazole vaginal
terconazole vaginal cream
terconazole vaginal suppository
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
dihydroergotamine nasal
ERGOMAR
(D.H.E.45)
(Migranal)
QL (30 per 28 days)
QL (8 per 28 days)
QL (40 per 28 days)
55
Tier level
What the
drug will
cost you
(Amerge)
(Maxalt)
(Maxalt Mlt)
(Imitrex)
(Sumatriptan
Succinate)
(Imitrex)
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
(Imitrex)
1
$0
(Sumatriptan
Succinate)
1
$0
(Imitrex)
1
$0
(Imitrex)
1
$0
(Zomig)
1
$0
(Zomig Zmt)
1
$0
2
1
1
1
2
2
1
1
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
SIRTURO
2
$0
TRECATOR
2
$0
Name of Drug
naratriptan
rizatriptan oral tablet
rizatriptan oral tablet,disintegrating
sumatriptan nasal spray
sumatriptan 6 mg/0.5 ml inject 2
autoinjector,outer
sumatriptan oral tablet
sumatriptan succinate subcutaneous
cartridge
pen injector 4 mg/0.5 ml
pen injector 6 mg/0.5 ml
solution
zolmitriptan oral tablet
zolmitriptan oral
tablet,disintegrating
Necessary Actions,
Restrictions, or
Limits on Use
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (12 per 28 days)
QL (4 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin
rifampin
RIFATER
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
PA; QL (188 per 168
days)
56
Tier level
What the
drug will
cost you
2
1
4
4
1
2
2
$0
$0
$0
$0
$0
$0
$0
(Granisetron
HCl/PF)
1
$0
(Granisetron HCl)
1
$0
(Granisetron HCl)
1
$0
(Meclizine HCl)
4
$0
4
1
4
4
1
$0
$0
$0
$0
$0
1
$0
1
1
$0
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
2
$0
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Antinausea Agents
Antinausea Agents
AKYNZEO
dimenhydrinate injection solution
dramamine * oral tablet
driminate *
dronabinol
EMEND INTRAVENOUS
EMEND ORAL
granisetron (pf) intravenous
solution
granisetron hcl intravenous solution
1 mg/ml (1 ml)
granisetron hcl oral
meclizine * 12.5 mg caplet caplet
(otc)
meclizine * 25 mg tablet (otc)
meclizine oral tablet 12.5 mg, 25 mg
motion sickness *
motion sickness (meclizine) *
ondansetron
(Dimenhydrinate)
(Dimenhydrinate)
(Dimenhydrinate)
(Marinol)
(Meclizine HCl)
(Antivert)
(Dimenhydrinate)
(Meclizine HCl)
(Zofran Odt)
(Ondansetron
ondansetron hcl (pf)
HCl/PF)
ondansetron hcl oral
(Zofran)
prochlorperazine
(Compazine)
prochlorperazine edisylate injection (Prochlorperazine
solution
Edisylate)
prochlorperazine maleate
(Compazine)
prochlorperazine maleate oral
(Compazine)
promethazine hcl
(Phenergan)
(Promethazine
promethazine oral tablet
HCl)
promethazine rectal
(Phenergan)
TRANSDERM-SCOP
PA BvD
QL (2 per 28 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
57
Name of Drug
travel sickness (meclizine) *
wal-dram *
(Bonine)
(Dimenhydrinate)
Tier level
What the
drug will
cost you
4
4
$0
$0
2
2
1
1
$0
$0
$0
$0
1
$0
2
2
1
1
1
2
$0
$0
$0
$0
$0
$0
1
$0
2
2
1
$0
$0
$0
1
2
2
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
atovaquone-proguanil
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
NEBUPENT
paromomycin
PENTAM
PRIMAQUINE
quinine sulfate
(Mepron)
(Malarone)
(Chloroquine
Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin
Sulfate)
(Qualaquin)
PA BvD
QL (90 per 30 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine oral
bromocriptine
cabergoline
carbidopa
carbidopa-levodopa oral tablet
(Amantadine HCl)
(Benztropine
Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
QL (60 per 30 days)
PA-HRM
58
Tier level
What the
drug will
cost you
(Sinemet CR)
1
$0
(Stalevo 50)
(Comtan)
1
1
$0
$0
2
$0
(Mirapex)
(Requip)
1
1
$0
$0
(Requip XL)
1
$0
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
HCl)
1
1
$0
$0
1
$0
2
$0
2
$0
Name of Drug
carbidopa-levodopa oral tablet
extended release
carbidopa-levodopa-entacapone
entacapone
NEUPRO
pramipexole oral tablet
ropinirole oral tablet
ropinirole oral tablet extended
release 24 hr
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (30 per 30
days)
PA-HRM
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10
MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG
ABILIFY MAINTENA
INTRAMUSCULAR
RECON 400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SYRING
aripiprazole oral solution
aripiprazole oral tablet 10 mg, 15
mg, 20 mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
QL (90 per 30 days)
QL (1 per 28 days)
2
$0
QL (1 per 28 days)
2
$0
(Abilify)
1
$0
(Abilify)
1
$0
(Abilify)
1
$0
QL (30 per 30 days)
QL (60 per 30 days)
59
Tier level
What the
drug will
cost you
(Abilify Discmelt)
1
$0
(Abilify Discmelt)
1
$0
Name of Drug
aripiprazole oral
aripiprazole oral
ARISTADA INTRAMUSCULAR
SYRING 441 MG/1.6 ML
$0
2
$0
2
$0
1
$0
1
1
1
1
$0
$0
$0
$0
FANAPT ORAL TABLET
2
$0
FANAPT ORAL TABLETS,DOSE
PACK
2
$0
1
$0
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating
fluphenazine decanoate
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate
intramuscular solution 100 mg/ml
haloperidol decanoate
intramuscular solution 50 mg/ml
haloperidol lactate
QL (90 per 30 days)
QL (60 per 30 days)
QL (1.6 per 28 days)
2
chlorpromazine
Necessary Actions,
Restrictions, or
Limits on Use
(Chlorpromazine
HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
(Fluphenazine
Decanoate)
(Fluphenazine
HCl)
(Haloperidol)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
(Haloperidol
Lactate)
QL (90 per 30 days)
ST
ST; QL (60 per 30
days)
QL (6 per 28 days)
60
Name of Drug
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 1.5
MG, 3 MG, 9 MG
INVEGA ORAL TABLET
EXTENDED RELEASE 24HR 6
MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE
117 MG/0.75 ML
INVEGA SUSTENNA
156 MG/ML
INVEGA SUSTENNA
234 MG/1.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 39
MG/0.25 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 78
MG/0.5 ML
INVEGA TRINZA
273 MG/0.875 ML
INVEGA TRINZA
410 MG/1.315 ML
INVEGA TRINZA
546 MG/1.75 ML
INVEGA TRINZA
819 MG/2.625 ML
LATUDA ORAL TABLET 120
MG, 20 MG, 40 MG, 60 MG
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
$0
ST; QL (30 per 30
days)
2
$0
ST; QL (60 per 30
days)
2
$0
2
$0
QL (1 per 28 days)
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
ST; QL (30 per 30
days)
61
Name of Drug
Tier level
What the
drug will
cost you
LATUDA ORAL TABLET 80 MG
2
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Zyprexa Zydis)
1
$0
(Zyprexa Zydis)
1
$0
2
$0
(Invega)
1
$0
(Invega)
1
$0
(Perphenazine)
(Orap)
(Seroquel)
1
1
1
$0
$0
$0
2
$0
2
$0
2
$0
(Risperdal)
(Risperdal)
2
1
1
$0
$0
$0
(Risperdal M-Tab)
1
$0
(Risperdal M-Tab)
1
$0
loxapine succinate
molindone oral tablet 10 mg
olanzapine intramuscular
olanzapine oral tablet
olanzapine oral tablet,disintegrating
10 mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating
20 mg
ORAP
paliperidone oral tablet extended
release 24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended
release 24hr 6 mg
perphenazine
pimozide
quetiapine
REXULTI ORAL TABLET 0.25
MG
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG,
2 MG, 3 MG, 4 MG
RISPERDAL CONSTA
risperidone oral solution
risperidone oral tablet
risperidone oral
tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg
risperidone oral
tablet,disintegrating 3 mg, 4 mg
(Loxapine
Succinate)
(Moban)
(Moban)
(Moban)
(Zyprexa)
(Zyprexa)
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (31 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (4 per 28 days)
QL (60 per 30 days)
QL (60 per 30 days)
62
Name of Drug
SAPHRIS (BLACK CHERRY)
thioridazine
thiothixene
trifluoperazine
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine
HCl)
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 210 MG, 405
MG
(Geodon)
Tier level
What the
drug will
cost you
2
$0
1
1
$0
$0
1
$0
2
$0
1
$0
2
$0
1
1
2
2
2
$0
$0
$0
$0
$0
2
$0
1
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (60 per 30
days)
PA NSO-HRM
ST; QL (540 per 30
days)
QL (60 per 30 days)
Antivirals (Systemic)
Antiretrovirals
abacavir
abacavir-lamivudine-zidovudine
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
didanosine
EDURANT
EMTRIVA
EPIVIR HBV ORAL SOLUTION
EPZICOM
EVOTAZ
FUZEON SUBCUTANEOUS
GENVOYA
INTELENCE
INVIRASE
ISENTRESS
(Ziagen)
(Trizivir)
(Videx EC)
63
Tier level
What the
drug will
cost you
(Viramune)
(Viramune)
2
1
1
2
1
1
$0
$0
$0
$0
$0
$0
(Viramune XR)
1
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
2
1
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
2
2
1
$0
$0
$0
$0
Name of Drug
KALETRA
lamivudine
lamivudine-zidovudine
LEXIVA
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended
release 24 hr
NORVIR
PREZCOBIX
PREZISTA
RESCRIPTOR
RETROVIR INTRAVENOUS
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET
SELZENTRY
stavudine
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX 2 GRAM PEDIATRIC
VIRACEPT ORAL TABLET
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR 100
MG
VIREAD
VITEKTA
ZIAGEN ORAL SOLUTION
zidovudine oral capsule
(Epivir)
(Combivir)
(Zerit)
(Retrovir)
Necessary Actions,
Restrictions, or
Limits on Use
64
Tier level
What the
drug will
cost you
(Retrovir)
(Zidovudine)
1
1
$0
$0
(Foscavir)
1
2
1
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
DAKLINZA
2
$0
HARVONI
2
$0
OLYSIO
2
$0
SOVALDI
2
$0
TECHNIVIE
2
$0
Interferons
INTRON A INJECTION
PEGASYS
PEGASYS PROCLICK
PEGINTRON
2
2
2
2
$0
$0
$0
$0
SYLATRON
2
$0
Name of Drug
zidovudine oral syrup
zidovudine oral tablet
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
SYNAGIS
TAMIFLU ORAL CAPSULE 30
MG
MG
MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION
Hcv Antivirals
(Flumadine)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA; QL (28 per 28
days)
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (56 per 28
days)
PA NSO
PA
PA
PA
days)
Nucleosides And
Nucleotides
65
Tier level
What the
drug will
cost you
(Zovirax)
1
$0
(Zovirax)
1
$0
(Zovirax)
(Acyclovir
Sodium)
(Hepsera)
(Baraclude)
(Famvir)
(Cytovene)
(Rebetol)
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Copegus)
1
$0
(Valtrex)
(Valcyte)
2
1
1
2
$0
$0
$0
$0
(Lovenox)
2
2
1
$0
$0
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
Name of Drug
acyclovir oral capsule
acyclovir oral suspension 200 mg/5
ml
acyclovir oral tablet
acyclovir sodium intravenous
solution
adefovir
entecavir
famciclovir
ganciclovir sodium
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg, 400
mg, 600 mg
TYZEKA
valacyclovir
valganciclovir
VIRAZOLE
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
Blood
Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
ELIQUIS
enoxaparin subcutaneous solution
enoxaparin subcutaneous syringe
100 mg/ml
120 mg/0.8 ml, 80 mg/0.8 ml
150 mg/ml
enoxaparin subcutaneous syringe 30
mg/0.3 ml
mg/0.4 ml
QL (36 per 30 days)
QL (36 per 30 days)
QL (34 per 30 days)
QL (18 per 30 days)
66
Tier level
What the
drug will
cost you
(Lovenox)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Heparin
Sodium,Porcine/D5
W)
1
$0
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
(Heparin
Sodium,Porcine/Ns
/PF)
1
$0
(Heparin
Sodium,Porcine)
1
$0
1
$0
1
$0
Name of Drug
mg/0.6 ml
fondaparinux subcutaneous syringe
10 mg/0.8 ml
2.5 mg/0.5 ml
5 mg/0.4 ml
7.5 mg/0.6 ml
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml, 20,000 unit/500
ml (40 unit/ml), 25,000 unit/500 ml
(50 unit/ml)
heparin (porcine) in 5 % dex
25,000 unit/250 ml(100 unit/ml)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml
heparin (porcine) injection solution
1,000 unit/ml, 20,000 unit/ml, 5,000
unit/ml
heparin (porcine) injection solution
10,000 unit/ml
heparin sodium,porcine-pf
intravenous syringe 10 unit/ml
heparin, porcine (pf) injection
solution 5,000 unit/0.5 ml
heparin, porcine (pf) injection
heparin, porcine (pf) intravenous
syringe
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Heparin
Sodium,Porcine/PF
)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
Necessary Actions,
Restrictions, or
Limits on Use
QL (24 per 30 days)
QL (15 per 30 days)
QL (12 per 30 days)
QL (18 per 30 days)
PA BvD; (PA for
ESRD Only)
PA BvD
PA BvD
1
$0
1
$0
1
$0
PA BvD; (PA for
ESRD Only)
67
Name of Drug
Tier level
What the
drug will
cost you
heparin-0.45% nacl 25,000
units/250 ml (100 units/ml) bag
latex-free, inner
(Heparin Sod,Pork
In 0.45% NaCl)
1
$0
heparin-d5w 25,000 units/250 ml
(100 units/ml) bag excel container
(Heparin
Sodium,Porcine/D5
W)
1
$0
2
$0
1
$0
PRADAXA
2
$0
warfarin
(Coumadin)
XARELTO
Blood Formation Modifiers
CINRYZE
EPOGEN INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
GRANIX
LEUKINE INJECTION RECON
SOLN
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 50 MCG/0.3
ML, 75 MCG/0.3 ML
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT INJECTION
SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/2
ML, 20,000 UNIT/ML, 3,000
UNIT/ML, 4,000 UNIT/ML
1
2
$0
$0
2
$0
2
$0
2
$0
2
$0
IPRIVASK
jantoven
(Coumadin)
2
$0
2
2
2
2
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (24 per 28
days)
ST; QL (60 per 30
days)
PA
PA; QL (12 per 28
days)
PA; QL (0.6 per 28
days)
PA; QL (12 per 28
days)
2
$0
68
Tier level
What the
drug will
cost you
PROCRIT INJECTION
SOLUTION 40,000 UNIT/ML
2
$0
PROMACTA
2
$0
ZARXIO
Hematologic Agents,
Miscellaneous
2
$0
1
$0
1
$0
Name of Drug
anagrelide
(Aminocaproic
Acid)
(Agrylin)
protamine
(Protamine Sulfate)
1
$0
tranexamic acid intravenous
tranexamic acid oral
Platelet-Aggregation
Inhibitors
AGGRENOX
aspirin-dipyridamole
BRILINTA
cilostazol
clopidogrel
EFFIENT
pentoxifylline
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN, HUMAN 25 %
ALBUMIN, HUMAN 5 %
ALBUMINAR 25 %
ALBUMINAR 5 %
ALBURX (HUMAN) 5 %
ALBUTEIN 25 %
ALBUTEIN 5 %
BUMINATE 25 %
(Tranexamic Acid)
(Lysteda)
1
1
$0
$0
2
1
2
1
1
2
1
$0
$0
$0
$0
$0
$0
$0
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
aminocaproic acid oral
(Aggrenox)
(Pletal)
(Plavix)
(Pentoxifylline)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (30 per 30
days)
PA BvD; (PA for
ESRD Only)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
69
Name of Drug
BUMINATE 5 %
FLEXBUMIN 25 %
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
Tier level
What the
drug will
cost you
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
AMINOSYN 10 %
AMINOSYN 3.5 %
AMINOSYN 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
AMINOSYN 8.5 %
AMINOSYN 8.5 %ELECTROLYTES
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
AMINOSYN M 3.5 %
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 % (SULFITEFREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE
CLINIMIX 5%/D25W SULFITEFREE
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
70
Name of Drug
CLINIMIX 2.75%/D5W SULFIT
FREE
CLINIMIX 4.25%/D10W SULF
FREE
CLINIMIX 4.25%/D5W SULFIT
FREE
CLINIMIX 4.25%-D20W SULFFREE
CLINIMIX 4.25%-D25W SULFFREE
CLINIMIX 5%-D20W(SULFITEFREE)
CLINIMIX E 2.75%/D10W SUL
FREE
CLINIMIX E 2.75%/D5W SULF
FREE
FREE
FREE
CLINIMIX E 4.25%/D5W SULF
FREE
CLINIMIX E 5%/D15W SULFIT
FREE
FREE
FREE
CLINISOL SF 15 %
cysteine (l-cysteine) intravenous
solution
d10 %-0.9 % sodium chloride
dex4 glucose * oral tablet,chewable
(Cysteine HCl)
(Dextrose 10 %
and 0.9 % NaCl)
(Dextrose)
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
71
Name of Drug
dextrose 10 % in water (d10w)
dextrose 2.5 % in water(d2.5w)
dextrose 5 % in ringers
intravenous
(Dextrose 10 % in
Water)
(Dextrose 2.5 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5% In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
FREAMINE HBC 6.9 %
FREAMINE III 10 %
gluco burst *
glucose gel *
glucose * oral tablet,chewable
glutose 15 *
HEPATAMINE 8%
HEPATASOL 8 %
(Dextrose)
(Dextrose)
(Dextrose)
(Dextrose)
insta-glucose *
(Dextrose/Dextrin/
Maltose)
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN
LIPOSYN II
LIPOSYN III
NEPHRAMINE 5.4 %
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
2
4
4
4
4
2
2
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
2
$0
2
2
2
2
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
72
Tier level
What the
drug will
cost you
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Catapres)
(Clonidine
HCl/Chlorthalidon
e)
1
$0
1
$0
(Catapres-Tts 1)
1
$0
(Catapres-Tts 1)
1
$0
(Cardura)
(Tenex)
(Midodrine HCl)
1
1
1
$0
$0
$0
PA-HRM
2
$0
PA; QL (180 per 30
days)
(Vazculep)
(Minipress)
1
1
$0
$0
(Atacand)
(Atacand HCT)
2
2
1
1
$0
$0
$0
$0
2
$0
Name of Drug
NUTRILIPID
PERIKABIVEN
PREMASOL 10 %
PREMASOL 6 %
PROCALAMINE 3%
PROSOL 20 %
TRAVASOL 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet
clonidine hcl-chlorthalidone
clonidine transdermal patch weekly
0.1 mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly
0.3 mg/24 hr
doxazosin
guanfacine oral tablet
midodrine
NORTHERA
phenylephrine hcl injection
prazosin oral
Angiotensin Ii Receptor
Antagonists
BENICAR
BENICAR HCT
candesartan
candesartan-hydrochlorothiazid
ENTRESTO
QL (4 per 28 days)
QL (8 per 28 days)
ST
ST
PA; QL (60 per 30
days)
73
Name of Drug
irbesartan
irbesartan-hydrochlorothiazide
losartan
losartan-hydrochlorothiazide
telmisartan
telmisartan-hydrochlorothiazid
TRIBENZOR
valsartan
valsartan-hydrochlorothiazide
Angiotensin-Converting
Enzyme Inhibitors
benazepril
benazepril-hydrochlorothiazide
captopril
captopril-hydrochlorothiazide
enalapril maleate
enalaprilat intravenous solution
enalapril-hydrochlorothiazide
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
(Avapro)
(Avalide)
(Cozaar)
(Hyzaar)
(Micardis)
(Micardis HCT)
(Diovan)
(Diovan HCT)
(Lotensin)
(Lotensin HCT)
(Captopril)
(Captopril/Hydroch
lorothiazide)
(Vasotec)
(Enalaprilat
Dihydrate)
(Vaseretic)
(Fosinopril
Sodium)
(Fosinopril/Hydroc
hlorothiazide)
(Zestril)
(Zestoretic)
(Moexipril HCl)
(Moexipril/Hydroc
hlorothiazide)
(Aceon)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
Tier level
What the
drug will
cost you
1
1
1
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
74
Tier level
What the
drug will
cost you
(Cordarone)
1
$0
(Cordarone)
1
$0
(Norpace)
1
$0
(Tambocor)
(Lidocaine
HCl/PF)
1
$0
1
$0
1
$0
1
2
$0
$0
(Procainamide
HCl)
1
$0
(Rythmol SR)
1
$0
(Rythmol)
(Quinidine
Gluconate)
(Quinidine Sulfate)
1
$0
1
$0
1
2
$0
$0
(Sectral)
(Tenormin)
(Tenoretic 50)
(Kerlone)
(Zebeta)
(Ziac)
1
1
1
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg,
200 mg, 400 mg
amiodarone oral
disopyramide phosphate oral
capsule
flecainide
lidocaine (pf) intravenous syringe
50 mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8
mg/ml (0.8 %)
mexiletine
MULTAQ
procainamide injection
propafenone oral capsule,extended
release 12 hr
propafenone oral tablet
quinidine gluconate oral
quinidine sulfate
TIKOSYN
Beta-Adrenergic Blocking
Agents
acebutolol
atenolol
atenolol-chlorthalidone
betaxolol oral
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
BYSTOLIC
carvedilol
esmolol intravenous
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
(Coreg)
(Esmolol HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
75
Tier level
What the
drug will
cost you
(Labetalol HCl)
(Trandate)
(Toprol XL)
(Lopressor HCT)
(Lopressor)
(Lopressor)
(Corgard)
(Pindolol)
(Propranolol HCl)
1
1
1
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Inderal LA)
1
$0
(Propranolol HCl)
(Propranolol HCl)
(Propranolol/Hydro
chlorothiazid)
1
1
$0
$0
1
$0
(Betapace)
1
$0
(Betapace)
(Timolol Maleate)
1
1
$0
$0
(Cardizem CD)
(Cardizem CD)
1
1
$0
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem CD)
1
$0
(Cardizem LA)
1
$0
(Cardizem CD)
(Cardizem CD)
1
1
$0
$0
Name of Drug
labetalol intravenous solution
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous
metoprolol tartrate oral
nadolol
pindolol
propranolol intravenous
propranolol oral capsule,extended
release 24 hr
propranolol oral solution
propranolol oral tablet
propranolol-hydrochlorothiazid
sotalol hcl oral tablet 120 mg, 160
mg, 240 mg, 80 mg
sotalol oral
timolol maleate oral
Calcium-Channel Blocking
Agents
cartia xt
diltiazem hcl intravenous
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
release 12 hr
diltiazem hcl oral capsule,extended
release 24hr
diltiazem hcl oral tablet
diltiazem hcl oral tablet extended
release 24 hr
dilt-xr
matzim la
Necessary Actions,
Restrictions, or
Limits on Use
76
Tier level
What the
drug will
cost you
(Cardizem CD)
(Verapamil HCl)
1
1
$0
$0
(Verelan Pm)
1
$0
(Verelan)
1
$0
(Calan)
1
$0
(Calan SR)
1
$0
2
2
$0
$0
Name of Drug
taztia xt
verapamil intravenous syringe
verapamil oral capsule, 24 hr er
pellet ct
verapamil oral capsule,ext rel.
pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended
release
Cardiovascular Agents,
Miscellaneous
CORLANOR
DEMSER
digitek oral tablet 125 mcg
(Lanoxin)
1
$0
digitek oral tablet 250 mcg
(Lanoxin)
1
$0
digoxin injection
(Digoxin)
1
$0
2
$0
1
$0
1
$0
DIGOXIN ORAL SOLUTION
digoxin oral tablet
(Lanoxin)
dobutamine in d5w intravenous
parenteral solution 1,000 mg/250 ml
(Dobutamine
(4,000 mcg/ml), 250 mg/250 ml (1
HCl/D5W)
mg/ml), 500 mg/250 ml (2,000
mcg/ml)
Necessary Actions,
Restrictions, or
Limits on Use
ST
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
PA-HRM; QL (30 per
30 days)
PA-HRM
PA-HRM; QL (300 per
30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA BvD
77
Tier level
What the
drug will
cost you
(Dobutamine HCl)
(Dopamine
HCl/D5W)
(Dopamine HCl)
(Ephedrine Sulfate)
(Epinephrine
HCl/PF)
(Adrenaclick)
(Epinephrine)
1
$0
1
$0
1
1
$0
$0
1
$0
1
1
$0
$0
(Epinephrine)
1
$0
2
2
$0
$0
1
$0
2
1
$0
$0
Name of Drug
dobutamine intravenous solution
dopamine in 5 % dextrose
intravenous solution
dopamine intravenous solution
ephedrine sulfate injection solution
epinephrine hcl (pf) intravenous
epinephrine injection auto-injector
epinephrine injection solution
epinephrine injection syringe 0.1
mg/ml (1:10,000)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethamolin
FIRAZYR
hydralazine
(Ethanolamine
Oleate)
(Hydralazine HCl)
LANOXIN ORAL TABLET 187.5
MCG, 62.5 MCG
milrinone
milrinone in 5 % dextrose
intravenous piggyback 40 mg/200
ml (200 mcg/ml)
norepinephrine bitartrate
2
$0
(Milrinone Lactate)
1
$0
(Milrinone
Lactate/D5W)
1
$0
1
$0
(Levophed
Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
30 days)
PA BvD
PA BvD
PA BvD
papaverine injection solution
1
$0
PA
papaverine oral
1
$0
PA
RANEXA
2
$0
Dihydropyridines
amlodipine
(Norvasc)
1
$0
amlodipine-benazepril
(Lotrel)
1
$0
78
Tier level
What the
drug will
cost you
1
1
2
$0
$0
$0
2
$0
(Felodipine)
(Isradipine)
(Nicardipine HCl)
1
1
1
$0
$0
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
(Midamor)
(Amiloride/Hydroc
hlorothiazide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
1
$0
1
$0
1
1
1
$0
$0
$0
(Chlorthalidone)
1
$0
2
1
1
1
1
$0
$0
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
Name of Drug
amlodipine-valsartan
amlodipine-valsartan-hcthiazid
AZOR
CLEVIPREX INTRAVENOUS
EMULSION
felodipine
isradipine
nicardipine oral
nifedipine oral tablet extended
release 24hr 30 mg, 60 mg, 90 mg
nifedipine oral tablet extended
release 30 mg, 60 mg
Diuretics
amiloride oral
amiloride-hydrochlorothiazide
bumetanide
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25 mg, 50
mg
DYRENIUM
furosemide injection
furosemide oral solution
furosemide oral tablet
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
(Exforge)
(Exforge HCT)
(Furosemide)
(Furosemide)
(Lasix)
(Microzide)
(Hydrochlorothiazi
de)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
(Dyazide)
capsule
Necessary Actions,
Restrictions, or
Limits on Use
ST
79
Tier level
What the
drug will
cost you
(Maxzide)
1
$0
(Caduet)
(Lipitor)
(Questran)
(Cholestyramine/A
spartame)
1
1
1
$0
$0
$0
1
$0
(Questran)
1
$0
(Colestid)
1
2
$0
$0
(Slo-Niacin)
4
$0
(Lofibra)
(Tricor)
(Lofibra)
(Fibricor)
(Trilipix)
(Lopid)
(Mevacor)
1
1
1
1
1
1
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Niacin)
4
$0
(Slo-Niacin)
4
$0
(Niaspan)
1
$0
(Slo-Niacin)
4
$0
(Niacinamide)
(Lovaza)
4
1
2
2
$0
$0
$0
$0
Name of Drug
triamterene-hydrochlorothiazid oral
tablet
Dyslipidemics
amlodipine-atorvastatin
atorvastatin
cholestyramine (with sugar) oral
cholestyramine-aspartame oral
powder 4 gram
cholestyramine-aspartame oral
powder in packet 4 gram
colestipol
CRESTOR
endur-acin * oral tablet extended
release 500 mg
fenofibrate micronized
fenofibrate nanocrystallized
fenofibrate oral tablet
fenofibric acid
fenofibric acid (choline)
gemfibrozil oral
JUXTAPID
KYNAMRO
lovastatin
niacin * oral capsule, extended
release 500 mg
niacin * oral tablet 50 mg, 500 mg
niacin oral tablet extended release
24 hr
niacin * oral tablet extended release
500 mg
niacinamide * oral tablet 500 mg
omega-3 acid ethyl esters
PRALUENT PEN
PRALUENT SYRINGE
Necessary Actions,
Restrictions, or
Limits on Use
PA
80
Tier level
What the
drug will
cost you
1
2
2
1
2
2
$0
$0
$0
$0
$0
$0
(Inspra)
(Aldactone)
(Aldactazide)
1
1
1
$0
$0
$0
(Isochron)
(Isosorbide
Dinitrate)
(Isosorbide
Mononitrate)
1
$0
1
$0
1
$0
Name of Drug
pravastatin
REPATHA SURECLICK
REPATHA SYRINGE
simvastatin
VASCEPA
ZETIA
Renin-AngiotensinAldosterone System
Inhibitors
eplerenone
spironolactone
spironolacton-hydrochlorothiaz
Vasodilators
isosorbide dinitrate oral
isosorbide dinitrate sublingual
isosorbide mononitrate oral tablet
(Pravachol)
(Zocor)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
isosorbide mononitrate oral tablet
(Imdur)
1
$0
minitran transdermal patch 24 hour
QL (30 per 30 days)
(Nitro-Dur)
1
$0
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour
QL (60 per 30 days)
(Nitro-Dur)
1
$0
0.4 mg/hr
minoxidil oral
(Minoxidil)
1
$0
NITRO-BID
2
$0
nitroglycerin in 5 % dextrose
(Nitroglycerin/D5
1
$0
W)
nitroglycerin intravenous
(Nitroglycerin)
1
$0
nitroglycerin transdermal patch 24
QL (30 per 30 days)
hour 0.1 mg/hr, 0.2 mg/hr, 0.6
(Nitro-Dur)
1
$0
mg/hr
nitroglycerin transdermal patch 24
QL (60 per 30 days)
(Nitro-Dur)
1
$0
hour 0.4 mg/hr
NITROSTAT
2
$0
81
Tier level
What the
drug will
cost you
2
$0
1
$0
2
$0
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
1
1
$0
$0
1
$0
(Kapvay)
1
$0
(Focalin)
1
$0
(Dexedrine)
1
$0
(Dexedrine)
1
$0
(Adderall XR)
1
$0
(Adderall XR)
1
$0
(Romazicon)
1
$0
(Intuniv)
1
$0
1
$0
1
$0
(Lithobid)
1
$0
(Lithium Citrate)
1
$0
Name of Drug
PROGLYCEM
Necessary Actions,
Restrictions, or
Limits on Use
Central Nervous System
Agents
Central Nervous System
Agents
amphetamine salt combo
(Adderall)
AMPYRA
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
clonidine hcl oral tablet extended
release 12 hr
dexmethylphenidate oral tablet
dextroamphetamine oral capsule,
extended release
dextroamphetamine oral tablet
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
10 mg, 15 mg, 5 mg
dextroamphetamine-amphetamine
oral capsule,extended release 24hr
20 mg, 25 mg, 30 mg
flumazenil
guanfacine oral tablet extended
release 24 hr
lithium carbonate oral capsule
lithium carbonate oral tablet
lithium carbonate oral tablet
extended release
lithium citrate oral solution
QL (60 per 30 days)
PA; QL (60 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
(Lithium
Carbonate)
(Lithobid)
82
Tier level
What the
drug will
cost you
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Methylin)
(Ritalin)
(Methylphenidate
HCl)
1
1
$0
$0
1
$0
Name of Drug
methylphenidate oral capsule, er
biphasic 30-70 10 mg, 20 mg, 40
mg, 50 mg, 60 mg
methylphenidate oral capsule, er
biphasic 30-70 30 mg
methylphenidate oral capsule,er
biphasic 50-50 20 mg, 40 mg
methylphenidate oral capsule,er
biphasic 50-50 30 mg
methylphenidate oral solution
methylphenidate oral tablet
extended release
extended release 24hr 18 mg, 27
mg, 54 mg
extended release 24hr 36 mg
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
tetrabenazine
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
(Concerta)
1
$0
(Concerta)
1
$0
(Rilutek)
2
2
1
2
2
$0
$0
$0
$0
$0
1
$0
2
$0
3
1
1
1
1
$0
$0
$0
$0
$0
(Xenazine)
XENAZINE
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
AFTERA *
ashlyna
bekyree (28)
blisovi 24 fe
blisovi fe 1/20 (28)
(Seasonique)
(Mircette)
(Loestrin Fe)
(Loestrin Fe)
QL (6 per 365 days)
83
Tier level
What the
drug will
cost you
(Desogen)
(Nor-Q-D)
(Mircette)
1
1
1
$0
$0
$0
(Desogen)
1
$0
(Yaz)
(Aftera)
(Yaz)
(Demulen 1-50-21)
(Loestrin)
(Loestrin Fe)
(Loestrin Fe)
(Desogen)
(Loestrin Fe)
(Mircette)
(Seasonique)
(Loestrin Fe)
(Loestrin Fe)
(Aftera)
(Plan B One-Step)
(Plan B One-Step)
(Aftera)
1
4
2
1
1
1
1
1
1
1
1
1
1
1
4
1
1
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Amethyst)
1
$0
Name of Drug
cyred
deblitane
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol oral
tablet 0.1/.125/.15-25 mg-mcg, 0.150.03 mg
drospirenone-ethinyl estradiol
econtra ez *
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
gildess 1/20 (21)
gildess 24 fe
gildess fe 1/20 (28)
juleber
junel fe 24
kimidess (28)
l norgest/e.estradiol-e.estrad
larin 24 fe
larin fe 1/20 (28)
levonorgestrel * 1.5 mg tablet (otc)
levonorgestrel oral tablet 0.75 mg
levonorgestrel oral tablet 1.5 mg
levonorgestrel * oral tablet 1.5 mg
levonorgestrel-ethin estradiol oral
tablet 0.1-20 mg-mcg, 0.15-0.03 mg,
50-30 (6)/75-40 (5)/125-30(10)
levonorgestrel-ethin estradiol oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorgestrel-ethinyl estrad oral
tablet
tablet 0.15-0.03 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
(LevonorgestrelEthin Estradiol)
1
$0
(Amethyst)
1
$0
(Amethyst)
1
$0
QL (91 per 84 days)
84
Tier level
What the
drug will
cost you
(Amethyst)
1
$0
(Seasonique)
1
$0
(Plan B One-Step)
1
$0
(Ortho Evra)
(Nor-Q-D)
(Nor-Q-D)
1
1
1
$0
$0
$0
(Loestrin)
1
$0
(Loestrin Fe)
1
$0
(Modicon)
1
$0
(Norinyl 1+50)
(Ortho-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
1
1
$0
$0
1
$0
2
4
3
$0
$0
$0
1
$0
1
$0
4
4
$0
$0
Name of Drug
tablets,dose pack,3 month
l-norgest-eth estr/ethin estra
next choice one dose 1.5 mg tb (rx)
1.5 mg
norelgestromin/ethin.estradiol
norethindrone
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral
tablet 1-20 mg-mcg, 1.5-30 mg-mcg
norethindrone-e.estradiol-iron oral
tablet 1 mg-20 mcg (21)/75 mg (7),
1 mg-20 mcg (24)/75 mg (4), 120(5)/1-30(7) /1mg-35mcg (9), 1.5
mg-30 mcg (21)/75 mg (7)
norethindrone-ethinyl estrad oral
tablet 0.4-35 mg-mcg, 0.5-35 mgmcg, 0.5-35/1-35 mg-mcg/mg-mcg,
0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35
mg-mcg, 1-35 mg-mcg
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
opcicon one-step *
PLAN B ONE-STEP *
setlakin
tarina fe 1/20 (28)
(Aftera)
(LevonorgestrelEthin Estradiol)
(Loestrin Fe)
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (3 per 28 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
Cough And Cold Products
Cough And Cold Products
30pse-150gfn-15dm *
actinel pediatric *
(Trispec Pse)
(Trispec Pse)
85
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
adt robitussin peak cld dm max *
(G-Zyncof)
4
$0
(Pseudoephedrine
adult nasal decongestant *
4
$0
HCl)
(Dextromethorphan
adult robitussin lingering cld *
4
$0
Hbr)
adult robitussin peak cold dm *
(G-Zyncof)
4
$0
(Robitussin
adult wal-tussin *
Mucus-Chest
4
$0
Congest)
adult wal-tussin dm max *
(G-Zyncof)
4
$0
(Guaifenesin/Dextr
alka-seltzer plus mucus-conges *
4
$0
omethorphan)
(Dm/Phenyleph/Ch
ambi 10peh-4cpm-20dm *
4
$0
lorpheniramine)
ambi 20dm-4cpm *
(Coricidin Hbp)
4
$0
ambi 40pse-400gfn-20dm *
(Poly-Vent Dm)
4
$0
(D-Methorphan
ambi 60pse-4cpm-20dm *
Hb/P-Ephed
4
$0
HCl/Cp)
benzonatate *
(Zonatuss)
3
$0
(D-Methorphan
bio-dtuss dmx *
Hb/P-Epd
4
$0
HCl/Bpm)
bionel pediatric *
(Trispec Pse)
4
$0
biospec dmx *
(G-Zyncof)
4
$0
(D-Methorphan
bromphenex dm *
Hb/P-Epd
4
$0
HCl/Bpm)
(D-Methorphan
brompheniramine-pseudoeph-dm * Hb/P-Epd
4
$0
HCl/Bpm)
brompheniram-phenylephrine-dm * (Ala-Hist Dm)
3
$0
cheracol d *
(G-Zyncof)
4
$0
cheratussin dac *
(Tusnel C)
4
$0
chest congestion relief + dm *
(Allfen Dm)
4
$0
86
Name of Drug
chest congestion relief d *
chest congestion relief pe *
child cough & sore throat *
child mucinex chest congestion *
child plus cough & runny nose *
child triaminic cough-congest *
child wal-tussin cough relief *
children's chest congestion *
children's mucinex cough *
childrens plus multi-symp cold *
children's silfedrine *
children's sudafed *
children's sudafed pe cough *
chlophedianol-guaifenesin *
chlorpheniramine-phenyleph-dm *
codituss dm *
cold multi-symptom day/night *
(Poly-Vent Ir)
(Maxiphen)
(D-Methorphan
Hb/Acetaminophen
)
(Robitussin
Mucus-Chest
Congest)
(Dextromethorphn/
Acetaminoph/Cp)
(Cough Formula
Dm)
(Dextromethorphan
Hbr)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Childrens Tylenol
Plus Cold)
(Pseudoephedrine
HCl)
(Pseudoephedrine
HCl)
(Dextromethorphan
/Phenylephrine)
(Vanacof G)
(Dm/Phenyleph/Ch
lorpheniramine)
(Pyrilamine/Pe/De
xtromethorphan)
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
Tier level
What the
drug will
cost you
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
87
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
(Poly-Vent Dm)
4
$0
(Delsym)
4
$0
Name of Drug
cold relief m/s day/night *
cold-flu relief * oral liquid 12.5-301,000 mg/30 ml
cold-flu relief, day/night *
congestac *
coricidin hbp cold-multi sympt *
coricidin hbp * oral capsule
cough & cold * oral
cough & runny nose *
daytime cold & cough *
daytime cold-flu *
day-time cough *
daytime-nighttime *
daytime-nighttime cold-flu *
daytime-nighttime cough *
decongestant cough *
delsym cough+chest congest dm *
despec-dm (pseudoeph-dm-guaif) *
oral tablet 30-10-200 mg
dextromethorphan polistirex *
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(DMethorphan/Aceta
min/Doxylamn)
(Vicks DayquilNyquil)
(Poly-Vent Ir)
(DMethorphan/Aceta
min/Doxylamn)
(Guaifenesin/Dextr
omethorphan)
(Coricidin Hbp)
(Vicks Children'S
Nyquil)
(Triaminic)
(DMethorphan/Pe/Ac
etaminophen)
(Dextromethorphan
Hbr)
(Vicks DayquilNyquil)
(Dm/Pe/Acetamino
phen/Doxylamine)
(Dextromethorphan
Hb/Doxylamine)
(Trispec Pse)
(G-Zyncof)
Necessary Actions,
Restrictions, or
Limits on Use
88
Tier level
What the
drug will
cost you
(Robitussin
Mucus-Chest
Congest)
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Dm/Phenyleph/Ch
lorpheniramine)
(Despec)
(Trispec Pse)
(G-Zyncof)
(Dextromethorphan
/Pseudoephed)
(Robitussin
Mucus-Chest
Congest)
(Dm/Pe/Acetamino
ph/Diphenhydram)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Cough Formula
Dm)
(Tusnel C)
(Allfen)
4
$0
3
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
(Mucinex)
4
$0
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
4
$0
Name of Drug
diabetic siltussin das-na *
diabetic tussin dm * oral liquid 10100 mg/5 ml
diabetic tussin max st *
d-methorphan hb-p-epd hcl-bpm *
oral syrup 2-30-10 mg/5 ml
dm-phenyleph-chlorpheniramine *
oral drops 1-2-3 mg/ml
ed bron gp *
entre-cough *
expectorant dm * oral liquid
expectorant max strength *
expectorant * oral
flu formula daytime-nighttime *
flu severe cold-congestion *
geri-tussin dm *
guaifenesin dac *
guaifenesin * oral tablet 200 mg
guaifenesin * oral tablet extended
release 12hr
head congestion day-night *
Necessary Actions,
Restrictions, or
Limits on Use
89
Name of Drug
hydrocodone bit-homatrop me-br *
oral syrup 5-1.5 mg/5 ml
hydrocodone-chlorpheniramine *
hydrocodone-homatropine * oral
tablet
infants' non-aspirin cold *
liquibid d-r *
lortuss ex * oral syrup
mar-cof bp *
mar-cof cg *
maximum strength flu *
medi-brom *
mesehist dm *
mucus dm *
mucus dm max *
mucus relief cough *
mucus relief * oral tablet 400 mg
multi-symptom cold night time *
multi-symptom cold-cough *
nasal & sinus decongestant *
nasohist dm *
neo-tuss *
NEXAFED *
(Hydrocodone
Bit/Homatrop MeBr)
(Tussionex)
(Tussigon)
(Dm/Pseudoephed/
Acetaminophen)
(Maxiphen)
(Tusnel C)
(Bromphenira/Pseu
doephed/Codein)
(M-Clear Wc)
(Coricidin Hbp)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Mucinex Dm)
(Mucinex Dm)
(G-Zyncof)
(Allfen)
(Theraflu)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Sudafed 12-Hour)
(Dm/Phenyleph/Ch
lorpheniramine)
(G-Zyncof)
Tier level
What the
drug will
cost you
3
$0
3
$0
3
$0
4
$0
4
4
$0
$0
3
$0
3
4
$0
$0
4
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
90
Name of Drug
night time cold-flu * oral
night time cold-flu relief * oral
liquid
night time * oral capsule
nighttime cough *
(Dm/PEphed/Acetaminop
h/Doxylam)
h/Doxylam)
h/Doxylam)
(Dextromethorphan
Hb/Doxylamine)
NITE TIME COLD-FLU RELIEF *
ORAL CAPSULE
nite time-d cold-flu relief *
nohist-dm *
non-aspirin cold *
non-aspirin flu * oral tablet 30-15500 mg
pecgen dmx * oral liquid 15-125
mg/5 ml
pedia relief *
pedia relief cough-cold *
pedia relief infant *
pediacare multi-symptom cold *
h/Doxylam)
(Dm/Phenyleph/Ch
lorpheniramine)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Dm/Pseudoephed/
Acetaminophen)
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Pseudoephed)
(Dextromethorphan
/Phenylephrine)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
91
Name of Drug
phenylhistine dh *
poly-tussin *
promethazine-codeine *
promethazine-dm *
promethazine-phenyleph-codeine *
pseudoephedrine hcl * oral
pseudoephedrine hcl * oral
q-tapp dm *
q-tussin *
q-tussin dm *
refenesen * oral tablet 200 mg
refenesen pe *
relcof c *
REZIRA *
robafen *
robafen cough *
robafen dm *
robitussin cough-chest cong dm *
oral capsule
ROBITUSSIN LONG-ACTING *
(P-Ephed
HCl/Cod/Chlorphe
nir)
(Chlorcyclizine/Co
deine)
(Promethazine
HCl/Codeine)
(Promethazine/Dex
tromethorphan)
(Promethazine/Phe
nyleph/Codeine)
(Pseudoephedrine
HCl)
(Sudafed 12-Hour)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Robitussin
Mucus-Chest
Congest)
(Cough Formula
Dm)
(Allfen)
(Maxiphen)
(M-Clear Wc)
(Robitussin
Mucus-Chest
Congest)
(Robitussin)
(Cough Formula
Dm)
(Guaifenesin/Dextr
omethorphan)
Tier level
What the
drug will
cost you
4
$0
4
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
3
3
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
92
Name of Drug
robitussin pediatric *
rydex *
rynex dm *
safe tussin dm *
scot-tussin dm *
scot-tussin expectorant *
siltussin sa *
siltussin-dm *
sudogest *
suphedrin * oral
suphedrine pe day-night *
suphedrine severe cold max str *
(Dextromethorphan
Hbr)
(Bromphenira/Pseu
doephed/Codein)
(Brompheniram/Ph
enylephrine/Dm)
(G-Zyncof)
(Vicks Children'S
Nyquil)
(Robitussin
Mucus-Chest
Congest)
(Robitussin
Mucus-Chest
Congest)
(Cough Formula
Dm)
(Sudafed 12-Hour)
(Pseudoephedrine
HCl)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dm/Pseudoephed/
Acetaminophen)
THERAFLU DAYTIME COLDCOUGH *
THERAFLU MULTI-SYMPTOM
COLD *
triacting m-sym cold/cough *
triaminic cold & cough (pe) *
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Phenylephrine)
TRIAMINIC COUGH-SORE
THROAT *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
93
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
(Giltuss)
(Guaifenesin/Dm/P
seudoephedrine)
(Guaifenesin/Dm/P
seudoephedrine)
(Robitussin)
4
$0
4
$0
4
$0
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
tri-dex pe *
trymine cg *
tusnel diabetic *
TUSNEL NEW FORMULA *
ORAL SOLUTION
TUSNEL PEDIATRIC * ORAL
LIQUID
TUSSI PRES-B * ORAL LIQUID
4-10-30 MG/5 ML
tussin cf cough-cold *
tussin cf * oral
tussin cold-congestion *
tussin cough (dm only) * oral
tussin dm cough & chest * oral
liquid 10-200 mg/5 ml
tussin dm * oral
tussin maximum strength *
tussin pe * oral liquid
valu-tapp dm *
(Dm/Phenyleph/Ch
lorpheniramine)
(M-Clear Wc)
(G-Zyncof)
(Cough Formula
Dm)
(Dextromethorphan
Hbr)
(Despec)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
VANACOF *
vicks dayquil cold&flu relief * oral
capsule
vicks dayquil cough *
vicks nature fusion cough *
(DMethorphan/Pe/Ac
etaminophen)
(Dextromethorphan
Hbr)
(Dextromethorphan
Hbr)
Necessary Actions,
Restrictions, or
Limits on Use
94
Tier level
What the
drug will
cost you
4
$0
4
$0
4
4
$0
$0
4
$0
4
4
$0
$0
4
$0
4
$0
(G-Zyncof)
4
3
4
$0
$0
$0
(Evoxac)
1
$0
(Peridex)
1
$0
(Salagen)
1
3
$0
$0
(Sodium Fluoride)
3
$0
(Triamcinolone
Acetonide)
1
$0
2
1
$0
$0
Name of Drug
vicks nyquil severe cold-flu * oral
liquid
virdec dm *
virtussin ac *
wal-phed * oral tablet 30 mg
wal-phed pe day-night *
wal-tussin cough & cold cf *
wal-tussin cough * oral capsule
wal-tussin cough * oral liquid
wal-tussin dm *
zephrex-d *
ZONATUSS *
zyncof * oral liquid
(Dm/Pe/Acetamino
phen/Doxylamine)
(Dm/Phenyleph/Ch
lorpheniramine)
(M-Clear Wc)
(Sudafed 12-Hour)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Giltuss)
(Robitussin)
(Dextromethorphan
Hbr)
(Cough Formula
Dm)
(Sudafed 12-Hour)
Necessary Actions,
Restrictions, or
Limits on Use
Dental And Oral Agents
Dental And Oral Agents
cevimeline
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
pilocarpine hcl oral
PREVIDENT 5000 SENSITIVE *
sodium fluoride * oral
tablet,chewable 0.25 mg fluorid
(0.55 mg)
triamcinolone acetonide dental
Dermatological Agents
Dermatological Agents,
Other
8-MOP
acitretin
(Soriatane)
95
Tier level
What the
drug will
cost you
(Benzoyl Peroxide)
4
$0
(Benzoyl Peroxide)
4
$0
4
$0
4
1
1
1
$0
$0
$0
$0
4
$0
4
$0
4
$0
(Lac-Hydrin)
1
$0
(Lac-Hydrin)
1
$0
2
$0
(Benzoyl Peroxide)
4
$0
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Vectical)
4
1
1
1
1
$0
$0
$0
$0
$0
4
$0
2
2
2
2
2
$0
$0
$0
$0
$0
Name of Drug
acne medication * topical gel 10 %
acne medication * topical lotion 10
%
ACNE MEDICATION * TOPICAL
LOTION 5 %
acne-clear *
acyclovir topical
ALCOHOL PADS
ALCOHOL PREP PADS
amlactin * topical lotion
ammonium lactate * 12% cream
fragrance free (otc)
ammonium lactate * 12% lotion
(otc)
ammonium lactate topical cream 12
%
ammonium lactate topical lotion 12
%
ANACAINE
benzoyl peroxide * topical gel 10 %,
5%
BETADINE SPRAY *
calcipotriene scalp
calcipotriene topical cream
calcipotriene topical ointment
calcitriol topical
CASTELLANI PAINT MODIFIED
*
CONDYLOX TOPICAL GEL
COSENTYX (2 SYRINGES)
COSENTYX PEN
COSENTYX PEN (2 PENS)
FLUOROPLEX
(Benzoyl Peroxide)
(Zovirax)
(Ammonium
Lactate)
(Ammonium
Lactate)
(Ammonium
Lactate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA
PA
PA
96
Tier level
What the
drug will
cost you
(Carac)
(Fluorouracil)
(Ammonium
Lactate)
1
1
$0
$0
4
$0
(Aldara)
1
$0
(Isotretinoin)
1
$0
4
4
1
2
4
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
2
$0
4
$0
2
2
4
2
$0
$0
$0
$0
(Bacitracin)
4
$0
(Bacitracin)
4
$0
(Cleocin T)
1
$0
Name of Drug
fluorouracil topical cream
fluorouracil topical solution
geri-hydrolac * topical
imiquimod
isotretinoin oral capsule 10 mg, 20
mg, 30 mg, 40 mg
LACTINOL HX *
lobana bath *
methoxsalen rapid
PANRETIN
persa-gel *
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox
podophyllum resin
potassium hydroxide
(Mineral Oil)
(Oxsoralen-Ultra)
(Benzoyl Peroxide)
(Condylox)
(Podophyllum
Resin)
(Potassium
Hydroxide)
SANTYL
skin treatment *
TOLAK
VALCHLOR
zinc oxide * topical ointment
ZOVIRAX TOPICAL CREAM
Dermatological
Antibacterials
bacitracin * topical
bacitraycin plus * topical ointment
500 unit/gram
clindamycin phosphate topical gel
(Ammonium
Lactate)
(Boudreauxs)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (24 per
30 days)
QL (3 per 56 days)
QL (2 per 56 days)
QL (15 per 30 days)
97
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
clindamycin phosphate topical
(Cleocin T)
1
$0
lotion
clindamycin phosphate topical
(Cleocin T)
1
$0
solution
clindamycin phosphate topical swab (Cleocin T)
1
$0
(Erythromycin
erythromycin base-ethanol
1
$0
Base/Ethanol)
erythromycin with ethanol topical
(Emgel)
1
$0
gel
(Erythromycin
1
$0
solution
Base/Ethanol)
(Erythromycin
1
$0
swab
Base/Ethanol)
(Gentamicin
gentamicin topical
1
$0
Sulfate)
metronidazole topical
(Metrocream)
1
$0
(Rosadan)
1
$0
(Metrolotion)
1
$0
mupirocin
(Centany)
1
$0
mupirocin calcium
(Bactroban)
1
$0
(Neosporin G.U.
neomycin-polymyxin b gu
1
$0
Irrigant)
(Neomycin
neosporin (neo-bac-polym) * topical Su/Bacitrac
4
$0
Zn/Poly)
selenium sulfide
(Selenium Sulfide)
1
$0
(Silver Nitrate
silver nitrate applicators
1
$0
Applicator)
silver nitrate topical
(Silver Nitrate)
1
$0
silver sulfadiazine topical cream 1
(Silvadene)
1
$0
%
sulfacetamide sodium (acne)
(Klaron)
1
$0
(Neomycin
triple antibiotic * topical ointment
Su/Bacitrac
4
$0
Zn/Poly)
98
Tier level
What the
drug will
cost you
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Diprolene AF)
1
$0
(Betamethasone
Dipropionate)
1
$0
(Diprolene)
1
$0
(Diprolene)
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
1
1
$0
$0
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Dermatological AntiInflammatory Agents
alclometasone
aquanil hc *
beta-hc *
betamethasone dipropionate
betamethasone valerate topical
cream
foam
lotion
ointment
betamethasone, augmented topical
cream
gel
lotion
ointment
clobetasol propionate scalp solution
0.05 %
clobetasol scalp
clobetasol topical cream
clobetasol topical foam
clobetasol topical gel
clobetasol topical lotion
clobetasol topical ointment
clobetasol topical shampoo
(Alclometasone
Dipropionate)
(Cortizone-10)
(Cortizone-10)
(Betamethasone
Dipropionate)
(Betamethasone
Valerate)
(Luxiq)
(Betamethasone
Valerate)
(Betamethasone
Valerate)
(Clobetasol
Propionate)
(Clobetasol
Propionate)
(Temovate)
(Olux)
(Clobetasol
Propionate)
(Clobex)
(Temovate)
(Clobex)
99
Tier level
What the
drug will
cost you
1
1
4
$0
$0
$0
4
$0
4
4
1
1
1
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
4
$0
1
$0
4
$0
4
$0
1
$0
1
$0
Name of Drug
clobetasol-emollient topical
clocortolone pivalate
cortizone-10 * topical cream
CORTIZONE-10 * TOPICAL
LOTION
cortizone-10 * topical ointment
dermarest eczema (hydrocort) *
desonide topical cream
desonide topical ointment
desoximetasone
ELIDEL
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-emollient base
fluticasone topical cream
fluticasone topical ointment
halobetasol propionate
hydrocortisone * 1% cream
maximum strength (otc)
hydrocortisone * 1% ointment
carton (otc)
hydrocortisone acet-aloe vera
topical gel
hydrocortisone acetate * topical
cream 1 %
hydrocortisone acetate-aloe *
hydrocortisone acetate-urea
hydrocortisone butyrate topical
cream
(Temovate)
(Cloderm)
(Hydrocortisone)
(Hydrocortisone)
(Cortizone-10)
(Desowen)
(Desonide)
(Topicort)
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Acetate)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Acetate/Urea)
(Hydrocortisone
Butyrate)
Necessary Actions,
Restrictions, or
Limits on Use
100
Tier level
What the
drug will
cost you
(Locoid)
1
$0
(Locoid)
1
$0
1
$0
Name of Drug
ointment
solution
hydrocortisone butyr-emollient
(Hydrocortisone
Butyrate)
(Anusol-HC)
(Hydrocortisone)
Necessary Actions,
Restrictions, or
Limits on Use
hydrocortisone rectal cream 1 %
1
$0
hydrocortisone rectal cream 2.5 %
1
$0
hydrocortisone rectal enema 100
(Cortenema)
1
$0
mg/60 ml
hydrocortisone * topical cream 0.5
(Hydrocortisone)
4
$0
%
hydrocortisone topical cream 1 %,
(Anusol-HC)
1
$0
2.5 %
hydrocortisone * topical lotion 1 % (Cortizone-10)
3
$0
hydrocortisone topical lotion 2 %
(Scalacort)
1
$0
hydrocortisone * topical ointment
(Hydrocortisone)
4
$0
0.5 %
hydrocortisone topical ointment 1
(Hydrocortisone)
1
$0
%, 2.5 %
hydrocortisone valerate topical
(Hydrocortisone
1
$0
cream
Valerate)
hydrocortisone valerate topical
(Westcort)
1
$0
ointment
hydroskin * topical lotion
(Cortizone-10)
4
$0
mometasone
(Elocon)
1
$0
neosporin anti-itch *
(Hydrocortisone)
4
$0
prednicarbate
(Dermatop)
1
$0
preparation h hydrocortisone *
(Hydrocortisone)
4
$0
recort plus *
(Hydrocortisone)
4
$0
tacrolimus topical
(Protopic)
1
$0
triamcinolone acetonide topical
(Triamcinolone
1
$0
cream
Acetonide)
(Triamcinolone
1
$0
lotion
Acetonide)
101
Name of Drug
ointment 0.025 %, 0.1 %, 0.5 %
Dermatological Retinoids
adapalene topical cream
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM
tretinoin microspheres
tretinoin topical
Scabicides And
Pediculicides
lice cream rinse *
lice killing *
lice treatment (permethrin) *
lice treatment * topical liquid 1 %
malathion
permethrin topical cream
permethrin * topical liquid
(Triamcinolone
Acetonide)
(Differin)
(Differin)
(Retin-A Micro)
(Retin-A)
(Nix)
(Piperonyl
Butoxide/Pyrethrin
s)
(Nix)
(Nix)
(Ovide)
(Elimite)
(Nix)
Tier level
What the
drug will
cost you
1
$0
1
1
2
1
1
$0
$0
$0
$0
$0
4
$0
4
$0
4
4
1
1
4
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE
BD ECLIPSE LUER-LOK
SYRINGE 1 ML 27 X 1/2"
BD INSULIN PEN NEEDLE UF
SHORT
BD INSULIN SYRINGE ULTRAFINE SYRINGE 0.3 ML 31 X
5/16", 1 ML 31 X 5/16", 1/2 ML 31
X 5/16"
INSULIN SYRINGE-NEEDLE U100 SYRINGE 0.3 ML 29, 1 ML 29
X 1/2", 1/2 ML 28
102
Name of Drug
PEN NEEDLE, DIABETIC
NEEDLE 29 GAUGE X 1/2 "
VGO 40
Tier level
What the
drug will
cost you
1
$0
1
$0
4
$0
2
2
$0
$0
2
$0
2
2
$0
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
Disinfectants (For NonDermatologic Use)
Disinfectants (For NonDermatologic Use)
iodine *
(Iodine)
Enzyme
Replacement/Modifiers
Enzyme
Replacement/Modifiers
ADAGEN
ALDURAZYME
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CREON
ELAPRASE
ELITEK INTRAVENOUS RECON
SOLN
FABRAZYME INTRAVENOUS
RECON SOLN
KRYSTEXXA
KUVAN ORAL
TABLET,SOLUBLE
lipase-protease-amylase
(Lipase/Protease/A
mylase)
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
STRENSIQ
VIMIZIM
VPRIV
PA BvD
PA
PA
103
Name of Drug
Tier level
What the
drug will
cost you
ZAVESCA
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 82,000 UNIT, 20,000-68,000 109,000 UNIT, 25,000-85,000136,000 UNIT, 3,000-10,00016,000 UNIT, 40,000-136,000218,000 UNIT
2
$0
2
$0
2
1
4
1
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
1
$0
$0
(Isopto Atropine)
1
$0
(Little Remedies)
(Sodium Chloride)
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat
Agents, Miscellaneous
AKTEN (PF)
altacaine
altamist *
apraclonidine
artificial tears (petro/min) *
artificial tears (pf) * ophthalmic
dropperette 0.1-0.3 %
artificial tears (polyvin alc) *
artificial tears * ophthalmic drops
0.1-0.3 %
artificial tears(glycerin-peg) *
artificial tears(hypromellose) *
atropine ophthalmic drops
atropine ophthalmic ointment
atropine sulfate ophthalmic drops 1
%
ayr saline * nasal aerosol,spray
ayr saline * nasal drops
(Tetcaine)
(Little Remedies)
(Iopidine)
(Genteal Pm)
(Dextran
70/Hypromellose/P
F)
(Polyvinyl
Alcohol)
(Tears Naturale)
(Glycerin/Propylen
e Glycol)
(Genteal Mild To
Moderate)
(Isopto Atropine)
(Atropine Sulfate)
104
Tier level
What the
drug will
cost you
(Astepro)
1
$0
(Azelastine HCl)
(Dextran
70/Hypromellose/P
F)
(Carteolol HCl)
(Cromolyn
Sodium)
1
$0
4
$0
1
$0
1
$0
2
$0
1
2
4
$0
$0
$0
4
$0
1
$0
4
$0
4
$0
4
4
4
$0
$0
$0
(Isopto
Homatropine)
1
$0
(Atrovent)
1
$0
(Atrovent)
1
$0
(Genteal Mild To
Moderate)
4
$0
2
$0
Name of Drug
azelastine nasal aerosol,spray 137
mcg
azelastine ophthalmic
bion tears (pf) *
carteolol
cromolyn ophthalmic
CYCLOGYL OPHTHALMIC
DROPS 0.5 %
cyclopentolate
CYSTARAN
deep sea nasal *
dristan long lasting *
epinastine
eq gentle *
(Cyclogyl)
(Little Remedies)
(Oxymetazoline
HCl)
(Elestat)
(Genteal Mild To
Moderate)
GENTEAL MILD TO
MODERATE *
GENTEAL GEL *
GENTEAL MILD *
GENTEAL SEVERE *
homatropine hbr
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
isopto tears *
LACRISERT
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 25 days)
QL (30 per 28 days)
QL (15 per 10 days)
(Carboxymethylcel
4
$0
lulose Sodium)
lubricant dry eye relief *
105
Name of Drug
lubricant eye (cmc-glycer)(pf) *
lubricant eye (cmc-glycerin) *
lubricant eye (pg-peg 400) *
lubricant eye (polyv alcohol) *
lubricant eye (propyl glycol) *
lubricant eye drops * ophthalmic
dropperette
lubricant eye drops * ophthalmic
drops
lubricant gel *
lubricating drops *
lubrifresh pm *
muro 128 *
naphazoline
nasal decongestant (oxymetazl) *
natural balance *
natural tears (pf) *
nature's tears *
neo-synephrine 12 h spr (oxym) *
nighttime relief eye *
(Carboxymethylcel
l/Glycerin/PF)
(Refresh Optive)
(Systane)
(Polyvinyl
Alcohol)
(Propylene Glycol)
(Carboxymethylcel
lulose Sodium)
(Refresh Tears)
(Carboxymethylcel
l/Hypromellose)
(Refresh Optive)
(Genteal Pm)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
(Dextran
70/Hypromellose/P
F)
(Genteal Mild To
Moderate)
(Oxymetazoline
HCl)
(Petrolat,Wht/Min
Oil/Sod Chl)
(Little Remedies)
(Patanol)
(Mydfrin)
(Proparacaine HCl)
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
1
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
ocean nasal *
4
$0
olopatadine ophthalmic
1
$0
phenylephrine hcl ophthalmic
1
$0
proparacaine
1
$0
proparacaine hcl ophthalmic drops
(Proparacaine HCl)
1
$0
0.5 %
106
Name of Drug
proparacaine-fluorescein sod
pure & gentle eye *
(Proparacaine/Fluo
rescein Sod)
(Genteal Mild To
Moderate)
REFRESH CELLUVISC *
REFRESH CLASSIC (PF) *
REFRESH LACRI-LUBE *
REFRESH OPTIVE *
OPHTHALMIC DROPS
retaine cmc *
saline mist *
sea soft nasal mist *
sodium chloride * ophthalmic
SYSTANE *
SYSTANE GEL * OPHTHALMIC
DROPS,GEL
tears again * ophthalmic drops
tears again * ophthalmic ointment
tears naturale free (pf) *
tetracaine hcl (pf) ophthalmic
ultra fresh pm *
vicks qlearquil(oxymetazoline) *
(Carboxymethylcel
lulose Sodium)
(Little Remedies)
(Little Remedies)
(Sodium Chloride)
(Polyvinyl
Alcohol)
(Lanolin/Min
Oil/Petrolat, Wht)
(Dextran
70/Hypromellose/P
F)
(Tetracaine
HCl/PF)
(Lanolin/Min
Oil/Petrolat, Wht)
(Oxymetazoline
HCl)
(Afrin)
Tier level
What the
drug will
cost you
1
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
vicks sinex 12-hour *
4
$0
Anti-Infectives Agents
acetic acid otic
(Acetic Acid)
1
$0
bacitracin ophthalmic
(Bacitracin)
1
$0
107
Tier level
What the
drug will
cost you
1
$0
(Ilotycin)
(Zymaxid)
(Garamycin)
2
1
1
2
1
1
1
$0
$0
$0
$0
$0
$0
$0
(Garamycin)
1
$0
(Levofloxacin)
1
2
2
$0
$0
$0
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
Name of Drug
bacitracin-polymyxin b ophthalmic
CIPRODEX
ciprofloxacin hcl ophthalmic
ciprofloxacin hcl otic
COLY-MYCIN S
erythromycin ophthalmic
gatifloxacin
gentamicin ophthalmic
gentamicin sulfate ophthalmic
ointment 0.3 % (3 mg/gram)
levofloxacin ophthalmic
MOXEZA
NATACYN
neomy sulf-bacitrac zn-poly-hc
neomycin-bacitracin-poly-hc
neomycin-bacitracin-polymyxin
neomycin-polymyxin b-dexameth
neomycin-polymyxin-gramicidin
neomycin-polymyxin-hc ophthalmic
neomycin-polymyxin-hc otic
drops,suspension
neomycin-polymyxin-hc otic
solution
neo-polycin
ofloxacin ophthalmic
ofloxacin otic
(Bacitracin/Polymy
xin B Sulfate)
(Ciloxan)
(Cetraxal)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymy
xin)
(Maxitrol)
(Neosporin)
(Neomycin/Polymy
xin B Sulf/HC)
(Neomycin/Polymy
xin B Sulf/HC)
(Cortisporin)
(Neomycin
Su/Bacitra/Polymy
xin)
(Ocuflox)
(Ocuflox)
Necessary Actions,
Restrictions, or
Limits on Use
108
Name of Drug
polymyxin b sulf-trimethoprim
REFRESH OPTIVE ADVANCED
*
sulfacetamide sodium
sulfacetamide sodium ophthalmic
drops 10 %
sulfacetamide-prednisolone
TOBRADEX ST
tobramycin
trifluridine
VIGAMOX
ZIRGAN
ZYLET
Anti-Inflammatory Agents
ALREX
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
(Tobrex)
(Viroptic)
Tier level
What the
drug will
cost you
1
$0
4
$0
1
$0
1
$0
1
$0
2
1
1
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
bromfenac
(Bromfenac
Sodium)
1
$0
dexamethasone sodium phosphate
ophthalmic
(Dexasol)
1
$0
diclofenac sodium ophthalmic
(Diclofenac
Sodium)
1
$0
2
$0
(Flunisolide)
1
$0
(FML)
(Ocufen)
(Fluticasone
Propionate)
1
1
$0
$0
1
$0
2
1
2
$0
$0
$0
DUREZOL
flunisolide nasal spray,non-aerosol
25 mcg (0.025 %)
fluorometholone
flurbiprofen sodium
fluticasone nasal
ILEVRO
ketorolac ophthalmic
LOTEMAX
(Acular)
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (50 per 25 days)
QL (16 per 30 days)
109
Tier level
What the
drug will
cost you
2
1
$0
$0
1
$0
2
2
$0
$0
(Phazyme)
(Simethicone)
(Gas-X)
(Phazyme)
(Gas-X)
(Phazyme)
(Gas-X)
(Gas-X)
(Gas-X)
(Phazyme)
(Simethicone)
4
4
4
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Pepcid Ac)
(Tagamet Hb)
(Prevpac)
(Cimetidine HCl)
4
4
1
2
1
$0
$0
$0
$0
$0
(Cimetidine)
1
$0
Name of Drug
NEVANAC
prednisolone acetate
prednisolone sodium phosphate
ophthalmic
PROLENSA
RESTASIS
(Omnipred)
(Prednisolone Sod
Phosphate)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
anti-gas maximum strength *
bicarsim forte *
gas relief extra strength * oral
gas relief * oral capsule 125 mg
gas relief * oral
gas-x ultra-strength *
mi-acid gas relief *
mytab gas *
mytab gas maximum strength *
simethicone * oral capsule 180 mg
simethicone * oral
Antiulcer Agents And Acid
Suppressants
acid reducer (famotidine) *
acid relief (cimetidine) *
amoxicil-clarithromy-lansopraz
CARAFATE ORAL SUSPENSION
cimetidine hcl oral
cimetidine oral tablet 200 mg, 300
mg, 400 mg, 800 mg
cvs cimetidine * 200 mg tablet (otc)
esomeprazole sodium
famotidine (pf)
(Rx Product Only)
(Tagamet Hb)
4
$0
(Nexium I.V.)
1
$0
(Famotidine)
1
$0
(Famotidine In
famotidine (pf)-nacl (iso-os)
1
$0
Nacl,Iso-Osm/PF)
famotidine intravenous
(Famotidine)
1
$0
110
Tier level
What the
drug will
cost you
(Pepcid)
1
$0
(Prevacid 24hr)
4
$0
(Prevacid)
1
$0
(Cytotec)
(Omeprazole
Magnesium)
1
$0
4
$0
Name of Drug
famotidine oral tablet 20 mg, 40 mg
lansoprazole * dr 15 mg capsule
na/f (otc)
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol
omeprazole magnesium *
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
omeprazole oral capsule,delayed
(Prilosec)
1
$0
release(dr/ec)
omeprazole * oral tablet,delayed
(Omeprazole)
4
$0
release (dr/ec)
omeprazole-sodium bicarbonate
(Rx Product Only)
(Zegerid)
3
$0
oral capsule 20-1.1 mg-gram
pantoprazole oral
(Protonix)
1
$0
PRILOSEC OTC *
4
$0
pub famotidine * 20 mg tablet max
(Pepcid Ac)
4
$0
strength (otc)
ra omepraz-bicarb 20-1,100 cap
(Zegerid Otc)
4
$0
3x14 day course (otc)
ranitidine 150 mg tablet maximum
(Zantac)
4
$0
strength (otc)
ranitidine hcl injection
(Zantac)
1
$0
(Rx Product Only)
ranitidine hcl oral syrup
(Ranitidine HCl)
1
$0
(Rx Product Only)
ranitidine hcl oral tablet 150 mg,
(Rx Product Only)
(Zantac)
1
$0
300 mg
ranitidine hcl * oral tablet 75 mg
(Zantac)
4
$0
sucralfate oral suspension
(Sucralfate)
1
$0
sucralfate oral tablet
(Carafate)
1
$0
wal-zan 75 *
(Zantac)
4
$0
ZANTAC 75 *
4
$0
ZANTAC * ORAL TABLET 150
4
$0
MG
Gastrointestinal Agents,
Other
111
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Loperamide HCl)
4
$0
(Imodium A-D)
4
$0
(Pepto-Bismol)
4
$0
(Tums)
2
4
$0
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
$0
Name of Drug
acid gone antacid *
almacone * oral suspension
almacone-2 *
aluminum hydroxide gel * oral
suspension 320 mg/5 ml
AMITIZA
antacid anti-gas * oral suspension
200-200-20 mg/5 ml
antacid anti-gas * oral
antacid extra-strength * oral
tablet,chewable 300 mg (750 mg)
antacid plus extra strength *
anti-diarrheal *
anti-diarrheal (loperamide) * oral
capsule
anti-diarrheal (loperamide) * oral
bismatrol * oral suspension 262
mg/15 ml
BUPHENYL ORAL TABLET
calci-chew *
calcium antacid * oral
tablet,chewable 200 mg calcium
(500 mg)
calcium carbonate * oral
tablet,chewable 500 mg calcium
(1,250 mg)
(Gaviscon)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Aluminum
Hydroxide)
(Maalox Maximum
Strength)
(Calcium
Carbonate/Simethi
cone)
(Tums)
(Maalox Maximum
Strength)
(Pepto-Bismol)
(Calcium
calcium carbonate-vitamin d3 * oral
Carbonate/Vitamin
tablet,chewable 500-100 mg-unit
D3)
cal-gest antacid *
(Tums)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
112
Tier level
What the
drug will
cost you
2
4
$0
$0
4
$0
1
4
1
1
1
$0
$0
$0
$0
$0
1
$0
1
$0
4
$0
4
2
2
$0
$0
$0
(Maalox Maximum
Strength)
4
$0
(Almacone)
4
$0
(Robinul)
(Robinul)
(Loperamide HCl)
1
1
4
4
4
1
2
1
4
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
$0
Name of Drug
CARBAGLU
children's soothe *
comfort gel extra strength *
cromolyn oral
diamode *
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
flanax antacid *
foaming antacid *
GATTEX 30-VIAL
GATTEX ONE-VIAL
gelusil antacid & anti-gas * oral
suspension
gelusil antacid & anti-gas * oral
tablet,chewable
glycopyrrolate
glycopyrrolate
imodium a-d * oral liquid
IMODIUM A-D * ORAL TABLET
kaopectate (bismuth subsalicy) *
lactulose
LINZESS
loperamide oral
loperamide * oral
LOTRONEX
maalox advanced * oral suspension
(Tums)
(Maalox Maximum
Strength)
(Gastrocrom)
(Imodium A-D)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Maalox Maximum
Strength)
(Gaviscon)
(Pepto-Bismol)
(Lactulose)
(Loperamide HCl)
(Loperamide HCl)
(Maalox Maximum
Strength)
MAGNEBIND 300 *
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
QL (30 per 30 days)
113
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
2
2
$0
$0
$0
4
$0
4
$0
4
$0
2
$0
RELISTOR SUBCUTANEOUS
2
$0
RELISTOR SUBCUTANEOUS
2
$0
Name of Drug
magnesium oxide * oral capsule 500
(Uromag)
mg
magnesium oxide * oral tablet 250
(Magox 400)
mg, 400 mg, 500 mg
(Maalox Maximum
masanti double strength *
Strength)
(Methscopolamine
methscopolamine oral
Bromide)
(Metoclopramide
metoclopramide hcl injection
HCl)
(Metoclopramide
metoclopramide hcl oral
HCl)
metoclopramide hcl oral
(Reglan)
mgo *
(Magox 400)
(Maalox Maximum
mi-acid * oral suspension
Strength)
mi-acid * oral tablet,chewable
(Rolaids)
(Maalox Maximum
mintox *
Strength)
(Maalox Maximum
mintox maximum strength *
Strength)
mintox plus *
(Almacone)
MOVANTIK
NUTRESTORE
(Pepto-Bismol Topep-t-med *
Go)
phillips *
(Magox 400)
(Pepto-Bismol Topink bismuth * oral tablet,chewable
Go)
RAVICTI
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
114
Name of Drug
ri-gel ii *
ri-mox *
sodium bicarbonate * oral tablet
650 mg
sodium polystyrene sulfonate oral
powder
sodium polystyrene sulfonate oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal
enema 30 gram/120 ml
soothe (bismuth subsalicylate) *
oral
soothe regular strength *
stomach relief * oral
ultra strength antacid *
ursodiol oral capsule
ursodiol oral tablet
Laxatives
alophen *
bisac-evac *
bisacodyl * oral
bisacodyl * rectal
biscolax *
clearlax * oral
colace * oral capsule 100 mg
doc-q-lace *
docu *
docusate sodium * oral
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Sodium
Bicarbonate)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
(Bismuth
Subsalicylate)
(Pepto-Bismol)
(Bismuth
Subsalicylate)
(Tums)
(Actigall)
(Urso)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Gavilax)
(Sof-Lax)
(Sof-Lax)
(Docusate Sodium)
(Docusate Sodium)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
1
1
$0
$0
$0
4
4
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
115
Tier level
What the
drug will
cost you
(Docusate Sodium)
(Sof-Lax)
(Docusate Sodium)
(Sof-Lax)
(Enema)
4
4
4
4
4
$0
$0
$0
$0
$0
(Enema)
4
$0
(Docusate Sodium)
(Docusol Plus)
(Calcium
Polycarbophil)
(Fibercon)
(Citrucel)
(Psyllium Seed)
(Psyllium Seed
(With Sugar))
4
4
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
(Citrucel)
4
$0
(Citrucel)
(Fibercon)
4
4
4
4
3
4
4
$0
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
docusol *
dok * oral capsule
dok * oral tablet
dulcolax stool softener (dss) *
enema disposable *
enema * rectal enema * 19-7
gram/118 ml
enemeez *
enemeez plus *
equalactin *
fiber (calcium polycarbophil) *
fiber laxative (methylcellulo) *
fiber smooth *
fiber therapy (psyllium/sugar) *
fiber therapy * oral powder 2
gram/19 gram
fiber therapy * oral tablet
fiber-lax *
FLEET BISACODYL *
gentlelax *
glycolax * oral powder
healthylax *
hydrocil instant *
konsyl (sugar) * oral
konsyl fiber *
KONSYL SUGAR-FREE * ORAL
POWDER IN PACKET
laxative peg 3350 * oral powder
milk of magnesia *
mineral oil laxative *
(Gavilax)
(Gavilax)
(Miralax)
(Psyllium Seed)
(Psyllium Husk
(With Sugar))
(Fibercon)
(Gavilax)
(Milk Of
Magnesia)
(Mineral Oil)
Necessary Actions,
Restrictions, or
Limits on Use
116
Tier level
What the
drug will
cost you
2
$0
4
$0
4
$0
1
1
$0
$0
1
$0
4
$0
4
$0
4
$0
1
$0
(Miralax)
4
$0
(Docusate Sodium)
(Gavilax)
(Miralax)
(Psyllium Seed
(With Sugar))
(Sennosides)
(Senokot)
(Senokot)
(Senokot)
(Sennosides)
(Sennosides)
(Sennosides/Docus
ate Sodium)
(Sennosides/Docus
ate Sodium)
(Docusate Sodium)
4
4
4
$0
$0
$0
4
$0
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
Name of Drug
MOVIPREP
natural fiber laxative therapy *
oral saline laxative * oral
peg 3350-electrolytes
peg 3350-na sulf,bicarb,cl-kcl
peg-electrolyte soln
peri-colace *
phillips liqui-gels *
phosphate laxative * oral
polyethylene glycol 3350 oral
powder
polyethylene glycol 3350 * oral
powder in packet
promolaxin *
purelax * oral powder
purelax * oral powder in packet
reguloid * oral powder
senexon * oral syrup
senexon * oral tablet
senna lax *
senna laxative * oral tablet 8.6 mg
senna * oral capsule
senna * oral syrup 8.8 mg/5 ml
senna with docusate sodium *
senokot-s *
silace *
(Psyllium Seed
(With Sugar))
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
(Golytely)
(Nulytely with
Flavor Packs)
(Sennosides/Docus
ate Sodium)
(Sof-Lax)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene
Glycol 3350)
Necessary Actions,
Restrictions, or
Limits on Use
117
Tier level
What the
drug will
cost you
(Miralax)
(Nulytely with
Flavor Packs)
(Surfak)
(Dulcolax)
4
$0
1
$0
4
4
$0
$0
(Phoslo)
(Calcium Acetate)
(Calcium
Carbonate/Mag
Carb/Fa)
(Calcium Acetate)
1
1
$0
$0
1
$0
4
2
2
2
$0
$0
$0
$0
2
$0
(Oxybutynin
Chloride)
1
$0
(Ditropan XL)
1
$0
(Detrol LA)
1
$0
(Detrol)
1
2
$0
$0
(Trospium
Chloride)
1
$0
(Uroxatral)
(Flomax)
(Terazosin HCl)
1
1
1
$0
$0
$0
Name of Drug
smoothlax * oral
sodium chloride-nahco3-kcl-peg
oral recon soln 420 gram
stool softener * oral capsule 240 mg
the magic bullet *
Phosphate Binders
calcium acetate oral capsule
calcium acetate oral tablet 667 mg
calcium carbonate-mag carb-fa
calphron *
PHOSLYRA
RENAGEL
RENVELA
Necessary Actions,
Restrictions, or
Limits on Use
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ
oxybutynin chloride oral tablet
oxybutynin chloride oral tablet
extended release 24hr
tolterodine oral capsule,extended
release 24hr
tolterodine oral tablet
TOVIAZ
trospium
Genitourinary Agents,
Miscellaneous
alfuzosin
tamsulosin
terazosin
Heavy Metal Antagonists
118
Name of Drug
Heavy Metal Antagonists
deferoxamine injection recon soln
DEPEN TITRATABS
EXJADE
FERRIPROX
sodium thiosulfate intravenous
solution 1 gram/10 ml (100 mg/ml),
12.5 gram/50 ml (250 mg/ml)
SYPRINE
(Desferal)
(Sodium
Thiosulfate)
Tier level
What the
drug will
cost you
1
2
2
2
$0
$0
$0
$0
1
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
Hormonal Agents,
Stimulant/Replacement/Modif
ying
Androgens
ANDRODERM
ANDROGEL TRANSDERMAL
GEL IN METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL
GEL IN PACKET 1.62 % (20.25
MG/1.25 GRAM), 1.62 % (40.5
MG/2.5 GRAM)
danazol oral
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
testosterone transdermal gel in
packet 1 % (25 mg/2.5gram)
Estrogens And
Antiestrogens
2
$0
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(DepoTestosterone)
(Delatestryl)
1
1
1
$0
$0
$0
1
$0
1
$0
(Androgel)
1
$0
2
$0
COMBIPATCH
PA; QL (30 per 30
days)
PA; QL (150 per 30
days)
PA; QL (150 per 30
days)
PA
PA; QL (300 per 30
days)
PA-HRM; QL (8 per
28 days)
119
Name of Drug
Tier level
What the
drug will
cost you
$0
$0
$0
DUAVEE
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch
semiweekly
(Estrace)
2
2
1
(Vivelle-Dot)
1
$0
estradiol transdermal patch weekly
(Climara)
1
$0
1
1
1
1
2
2
2
2
2
2
2
1
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
estradiol valerate
(Delestrogen)
estradiol/norethindrone acet
(Activella)
estradiol-norethindrone acet
(Activella)
estropipate
(Ogen)
FEMRING
MENEST
PREMARIN INJECTION
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
raloxifene
(Evista)
VAGIFEM
Glucocorticoids/Mineralocorticoids
betamethasone acet,sod phos
(Celestone)
cortisone
(Cortisone Acetate)
dexamethasone oral
(Dexamethasone)
dexamethasone oral
(Dexamethasone)
dexamethasone sodium phosphate
(Dexamethasone
injection solution
Sod Phosphate)
(Fludrocortisone
fludrocortisone
Acetate)
hydrocortisone oral
(Cortef)
(Hydrocortisone
hydrocortisone sod succinate
Sod Succinate)
methylprednisolone
(Medrol)
methylprednisolone acetate
(Depo-Medrol)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM; QL (8 per
28 days)
PA-HRM; QL (4 per
28 days)
PA-HRM
PA-HRM
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (18 per 28 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
120
Tier level
What the
drug will
cost you
(A-Methapred)
1
$0
(A-Methapred)
1
$0
(Pediapred)
1
$0
(Prednisone)
1
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
2
2
2
2
$0
$0
$0
$0
$0
2
$0
2
2
$0
$0
1
$0
1
$0
1
$0
Name of Drug
methylprednisolone sodium succ
injection recon soln 125 mg, 40 mg
intravenous
prednisolone sodium phosphate oral
solution
prednisone
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
triamcinolone acetonide injection
(Triamcinolone
Acetonide)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
Pituitary
desmopressin injection
desmopressin nasal
desmopressin nasal
desmopressin oral
GENOTROPIN
GENOTROPIN MINIQUICK
INCRELEX
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3
MONTH) INTRAMUSCULAR
SYRINGE KIT
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
mcg/ml, 500 mcg/ml
octreotide acetate injection solution
50 mcg/ml
octreotide acetate injection syringe
SAIZEN
(Desmopressin
Acetate)
(DDAVP)
(Desmopressin
Acetate)
(DDAVP)
QL (15 per 30 days)
QL (15 per 30 days)
PA
PA
QL (1 per 84 days)
(Sandostatin)
(Octreotide
Acetate)
(Octreotide
Acetate)
PA
PA
2
$0
PA
121
Name of Drug
Tier level
What the
drug will
cost you
SAIZEN CLICK.EASY
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION
medroxyprogesterone intramuscular
medroxyprogesterone oral
MEGACE ES
megestrol oral suspension
norethindrone acetate
progesterone
progesterone micronized capsules
Thyroid And Antithyroid
Agents
2
$0
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
1
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
Immunological Agents
ARCALYST
ASTAGRAF XL
2
2
$0
$0
AUBAGIO
2
$0
1
$0
(Depo-Provera)
(Provera)
(Megace Es)
(Aygestin)
(Progesterone)
(Prometrium)
(Levothyroxine
Sodium)
levothyroxine oral
(Levoxyl)
liothyronine oral
(Cytomel)
methimazole oral tablet 10 mg, 5 mg (Tapazole)
propylthiouracil
(Propylthiouracil)
levothyroxine intravenous
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
QL (1 per 28 days)
QL (1 per 360 days)
QL (10 per 28 days)
QL (1 per 84 days)
Immunological Agents
azathioprine
(Imuran)
PA BvD
PA; QL (28 per 28
days)
PA BvD
122
Name of Drug
azathioprine sodium
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN
CELLCEPT INTRAVENOUS
CIMZIA
CIMZIA POWDER FOR
RECONST
cyclosporine intravenous
cyclosporine modified
cyclosporine oral capsule
cyclosporine, modified
ENBREL
ENBREL SURECLICK
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAPLEX
HUMIRA
HUMIRA PEN
HUMIRA PEN CROHN'S-UC-HS
START
HYPERRAB S/D (PF)
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
(Azathioprine
Sodium)
(Sandimmune)
(Neoral)
(Sandimmune)
(Neoral)
KINERET
leflunomide
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
(Arava)
(Cellcept)
(Myfortic)
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
2
$0
2
2
$0
$0
2
$0
1
1
1
1
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
2
2
2
$0
$0
$0
$0
PA BvD
PA
2
$0
PA; QL (18.76 per 28
days)
1
1
1
2
2
2
$0
$0
$0
$0
$0
$0
PA BvD
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA
123
Tier level
What the
drug will
cost you
2
2
2
2
2
1
1
$0
$0
$0
$0
$0
$0
$0
TYSABRI
2
$0
ZORTRESS
2
$0
2
$0
2
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
ENGERIX-B (PF)
2
$0
ENGERIX-B PEDIATRIC (PF)
2
$0
GARDASIL (PF)
GARDASIL 9 (PF)
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION
HAVRIX (PF)
IMOVAX RABIES VACCINE (PF)
2
2
$0
$0
2
$0
2
$0
2
$0
Name of Drug
ORENCIA (WITH MALTOSE)
PRIVIGEN
PROGRAF INTRAVENOUS
RAPAMUNE ORAL SOLUTION
RIDAURA
sirolimus
tacrolimus oral
(Rapamune)
(Hecoria)
Vaccines
ACTHIB (PF)
ADACEL(TDAP
ADOLESN/ADULT)(PF)
BCG VACCINE, LIVE (PF)
BEXSERO (PF)
BOOSTRIX TDAP
CERVARIX VACCINE (PF)
COMVAX (PF)
DAPTACEL (DTAP PEDIATRIC)
(PF)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
PA BvD
PA BvD; QL (3 per
365 days)
PA BvD; QL (3 per
365 days)
PA BvD
124
Name of Drug
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
IPOL INJECTION SUSPENSION
IXIARO (PF)
KINRIX (PF)
MENACTRA (PF)
INTRAMUSCULAR SOLUTION
MENHIBRIX (PF)
MENOMUNE - A/C/Y/W-135 (PF)
MENVEO A-C-Y-W-135-DIP (PF)
MENVEO MENA COMPONENT
(PF)
MENVEO MENCYW-135
COMPNT (PF)
M-M-R II (PF)
PEDIARIX (PF)
PEDVAX HIB (PF)
PENTACEL (PF)
PENTACEL ACTHIB
COMPONENT (PF)
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40
MCG/ML
RECOMBIVAX HB (PF)
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF)
INTRAMUSCULAR
Tier level
What the
drug will
cost you
2
$0
2
2
2
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
2
$0
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (2 per 365 days)
QL (2 per 365 days)
PA BvD
PA BvD; QL (3 per
365 days)
PA BvD; QL (3 per
365 days)
125
Name of Drug
TETANUS TOXOID,ADSORBED
(PF)
TETANUS,DIPHTHERIA TOX
PED(PF)
TETANUS-DIPHTHERIA
TOXOIDS-TD
TICE BCG
TRUMENBA
TWINRIX (PF)
TYPHIM VI
VAQTA (PF)
VARIVAX (PF)
YF-VAX (PF)
ZOSTAVAX (PF)
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
2
1
1
2
2
$0
$0
$0
$0
$0
$0
1
$0
2
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
QL (2 per 365 days)
QL (1 per 365 days)
Inflammatory Bowel Disease
Agents
Inflammatory Bowel
Disease Agents
APRISO
ASACOL HD
balsalazide
budesonide oral
DELZICOL
DIPENTUM
(Colazal)
(Entocort EC)
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
LACTATED RINGERS
IRRIGATION
ringers irrigation
sodium chloride irrigation
sorbitol irrigation
(Acetic Acid)
(Ringers Solution)
(Sodium Chloride
Irrig Solution)
(Sorbitol Solution)
126
Tier level
What the
drug will
cost you
1
$0
1
$0
(Alendronate
Sodium)
1
$0
(Fosamax)
1
$0
(Fosamax)
1
$0
(Miacalcin)
1
$0
Name of Drug
sorbitol-mannitol
water for irrigation, sterile
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Necessary Actions,
Restrictions, or
Limits on Use
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
alendronate oral solution
alendronate oral tablet 10 mg, 40
mg, 5 mg
alendronate oral tablet 35 mg, 70
mg
calcitonin (salmon)
calcitriol intravenous solution 1
mcg/ml
QL (4 per 28 days)
PA BvD; (PA for
(Calcitriol)
1
$0
ESRD Only)
PA BvD; (PA for
calcitriol oral
(Rocaltrol)
1
$0
ESRD Only)
PA BvD; (PA for
doxercalciferol intravenous
(Doxercalciferol)
1
$0
ESRD Only)
PA BvD; (PA for
doxercalciferol oral
(Hectorol)
1
$0
ESRD Only)
PA; QL (2.4 per 28
FORTEO
2
$0
days)
FORTICAL
2
$0
PA BvD; (PA for
(Ibandronate
ibandronate intravenous solution
1
$0
ESRD Only); QL (3
Sodium)
per 84 days)
PA BvD; QL (3 per 84
ibandronate intravenous syringe
(Boniva)
1
$0
days)
ibandronate oral
(Boniva)
1
$0
QL (1 per 28 days)
PA BvD; (PA for
MIACALCIN INJECTION
2
$0
ESRD Only)
NATPARA
2
$0
127
Tier level
What the
drug will
cost you
(Zemplar)
1
$0
(Actonel)
(Actonel)
2
1
1
$0
$0
$0
2
$0
(Zometa)
(Zoledronic
Acid/Mannitol and
Water)
1
$0
1
$0
(Reclast)
1
$0
2
$0
Name of Drug
paricalcitol oral
PROLIA
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
ZEMPLAR INTRAVENOUS
zoledronic acid intravenous
zoledronic acid-mannitol-water
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 28 days)
PA BvD; (PA for
ESRD Only)
PA BvD
Miscellaneous Therapeutic
Agents
Miscellaneous Therapeutic
Agents
ACTEMRA INTRAVENOUS
SOLUTION 200 MG/10 ML (20
MG/ML)
ACTEMRA SUBCUTANEOUS
ACTIMMUNE
allopurinol
(Zyloprim)
(Amifostine
amifostine crystalline
Crystalline)
(Citrate Phosphate
anticoag citrate phos dextrose
Dextros Soln)
AVONEX (WITH ALBUMIN)
AVONEX INTRAMUSCULAR
AVONEX INTRAMUSCULAR
BENLYSTA INTRAVENOUS
RECON SOLN
PA
2
$0
2
2
1
$0
$0
$0
1
$0
1
$0
2
2
2
$0
$0
$0
2
$0
PA
ST
ST
ST
PA
128
Tier level
What the
drug will
cost you
2
1
1
2
1
$0
$0
$0
$0
$0
1
$0
2
$0
(Acetic Acid)
(Droperidol)
(Avodart)
(Jalyn)
2
4
1
1
1
2
$0
$0
$0
$0
$0
$0
(Ergoloid
Mesylates)
1
$0
(Acetic Acid)
(Acetic Acid)
(Proscar)
(Fomepizole)
2
4
4
1
1
2
$0
$0
$0
$0
$0
$0
1
$0
GILENYA
2
$0
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
guanidine
hydroxyzine hcl intramuscular
hydroxyzine hcl oral solution 10
mg/5 ml
2
$0
2
$0
(Guanidine HCl)
(Hydroxyzine HCl)
1
1
$0
$0
(Hydroxyzine HCl)
1
$0
Name of Drug
BETASERON SUBCUTANEOUS
bethanechol chloride
buspirone
CERDELGA
colchicine oral tablet
colchicine-probenecid
COPAXONE SUBCUTANEOUS
SYRINGE
CYSTADANE
douche vinegar & water extra *
droperidol injection solution
dutasteride
dutasteride-tamsulosin
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS
extra cleansing douche *
feminine care douche *
finasteride oral tablet 5 mg
fomepizole
FUSILEV
GAUZE PAD TOPICAL
BANDAGE 2 X 2 "
(Urecholine)
(Buspirone HCl)
(Colcrys)
(Colchicine/Proben
ecid)
Necessary Actions,
Restrictions, or
Limits on Use
ST
PA
QL (30 per 30 days)
ST
PA; QL (28 per 28
days)
PA-HRM
PA-HRM
129
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
1
2
$0
$0
$0
KEVEYIS
2
$0
LEMTRADA
leucovorin calcium injection recon
soln 100 mg, 200 mg, 350 mg
2
$0
PA-HRM
PA-HRM
QL (30 per 30 days)
PA NSO; QL (120 per
30 days)
PA
1
$0
1
$0
1
$0
Name of Drug
hydroxyzine hcl oral tablet
hydroxyzine pamoate
JALYN
leucovorin calcium oral
levocarnitine (with sugar)
(Hydroxyzine HCl)
(Vistaril)
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
levocarnitine oral
(Carnitor)
1
$0
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
MESTINON TIMESPAN
MINERAL OIL *
mineral oil * topical
(Mesnex)
1
2
2
2
4
4
$0
$0
$0
$0
$0
$0
1
$0
OTEZLA
2
$0
OTEZLA STARTER
2
$0
OTREXUP (PF)
PLEGRIDY
probenecid
PROCYSBI
pyridostigmine bromide oral tablet
RASUVO (PF)
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
2
2
1
2
1
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
morrhuate sodium
(Mineral Oil)
(Sodium
Morrhuate)
(Probenecid)
(Mestinon)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
ST
130
Tier level
What the
drug will
cost you
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
1
$0
(Acetic Acid)
4
$0
(Acetic Acid)
4
2
$0
$0
2
$0
Name of Drug
REBIF TITRATION PACK
REMICADE
SENSIPAR
SIGNIFOR
SIMPONI
SIMPONI ARIA
STELARA SUBCUTANEOUS
SYRINGE
STERILE PADS TOPICAL
BANDAGE 2 X 2 "
summer's eve disposable douche *
vaginal solution
summers eve extra cleansing *
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)240 MG (46), 240 MG
2
$0
THALOMID
2
$0
TYBOST
2
$0
ULORIC
2
$0
XELJANZ
2
$0
(Diamox Sequels)
1
$0
(Acetazolamide)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (60 per 30 days)
PA
PA
PA
PA; QL (14 per 30
days)
PA; QL (60 per 30
days)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
ST; QL (30 per 30
days)
PA; QL (60 per 30
days)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule,
extended release
acetazolamide oral tablet
131
Tier level
What the
drug will
cost you
1
$0
2
$0
2
1
1
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
(Neptazane)
(Metipranolol)
1
1
2
$0
$0
$0
(Isopto Carpine)
1
$0
(Timoptic)
2
1
$0
$0
(Timoptic-Xe)
1
$0
Name of Drug
acetazolamide sodium
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT
betaxolol ophthalmic
bimatoprost
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
latanoprost
levobunolol
LUMIGAN OPHTHALMIC
DROPS 0.01 %
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1
%, 2 %, 4 %
SIMBRINZA
timolol maleate ophthalmic drops
timolol maleate ophthalmic gel
forming solution
TRAVATAN Z
travoprost (benzalkonium)
(Acetazolamide
Sodium)
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
2
$0
(Travoprost
(Benzalkonium))
1
$0
(Pyridostigmine
Bromide)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
(drops: 0.15%, 0.20%)
Parasympathomimetic
(Cholinergic Agents)
Parasympathomimetic
(Cholinergic Agents)
pyridostigmine bromide oral tablet
extended release
Replacement Preparations
132
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
(Caltrate 600 + D)
4
$0
(Caltrate 600 + D)
(Calcium
Carbonate)
(Calcium
Carbonate/Vitamin
D3)
(Caltrate 600 + D)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate)
(Calcium
Carbonate)
(Calcium
Carbonate/Vitamin
D2)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Calcium
Carbonate/Vitamin
D3)
4
$0
(Caltrate 600 + D)
4
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Replacement Preparations
ca-d3-mag ox-zinc-cop-mang-bor *
oral tablet,chewable
calcitrate *
calcium 500 + d (d3) *
calcium 500 + d * oral tablet 500
mg(1,250mg) -400 unit
calcium 500 with d *
calcium 600 *
calcium 600 + d(3) * oral capsule
calcium 600 + d(3) * oral tablet
calcium 600 with vitamin d3 * oral
calcium carbonate * oral
calcium carbonate * oral tablet 260
mg calcium (648 mg)
calcium carbonate-vitamin d2 *
capsule 600 mg(1,500mg) -100 unit,
600 mg(1,500mg) -400 unit, 600
mg(1,500mg) -500 unit
tablet 1,000 mg(2,500 mg)-800 unit,
500mg (1,250mg) -600 unit, 600
mg(1,500mg) -400 unit, 600
mg(1,500mg) -800 unit
(Ca/D3/Mag
Ox/Zinc/Cop/Mang
/Bor)
(Calcium Citrate)
(Caltrate 600 + D)
133
Tier level
What the
drug will
cost you
4
$0
(Calcium Chloride)
(Citracal-Vitamin
D)
(Calcium
Gluconate)
(Calcium
Gluconate)
1
$0
4
$0
1
$0
4
$0
(Calcium Lactate)
4
$0
(Caltrate 600 + D)
4
4
$0
$0
4
$0
4
$0
1
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
tablet,chewable 500 mg(1,250mg) 400 unit
calcium chloride intravenous
calcium citrate-vitamin d3 * oral
tablet 315-200 mg-unit
calcium gluconate intravenous
calcium gluconate * oral tablet 45
mg (500 mg)
calcium lactate * oral tablet 84 mg
(650 mg)
calcium+d * oral tablet
CALTRATE 600 + D *
CALTRATE WITH VITAMIN D3
*
(Calcium 600 + Vit
D)
(Citracal-Vitamin
D)
(Citric
citric acid-sodium citrate
Acid/Sodium
Citrate)
citrus calcium * oral tablet 315-250 (Citracal-Vitamin
mg-unit
D)
(Dextrose 10 %
d10 % & 0.45 % sodium chloride
and 0.45 % NaCl)
(Dextrose 2.5 %
d2.5 %-0.45 % sodium chloride
and 0.45 % NaCl)
(Dextrose 5 % and
d5 % and 0.9 % sodium chloride
0.9 % NaCl)
(Dextrose 5 %-0.45
% NaCl)
(Dextrose 10 %
dextrose 10 % and 0.2 % nacl
and 0.2 % NaCl)
(Dextrose 5%dextrose 5 %-lactated ringers
Lactated Ringers)
citracal + d maximum *
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
134
Name of Drug
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
electrolyte-48 in d5w
hi-cal plus vit d *
HYPERLYTE CR
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE M IN 5 % DEXTROSE
ISOLYTE-H IN 5 % DEXTROSE
ISOLYTE-P IN 5 % DEXTROSE
ISOLYTE-S
KELP (IODINE) *
(Dextrose 5 %-0.2
% NaCl)
(Dextrose 5 % and
0.3 % NaCl)
(Dextrose 5 %-0.2
% NaCl)
(Electrolyte-48
Solution/D5W)
(Caltrate 600 + D)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
4
2
2
2
2
2
2
2
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Potassium
1
$0
Chloride)
(Potassium
klor-con m10
1
$0
Chloride)
(Potassium
klor-con m15
1
$0
Chloride)
(Potassium
klor-con m20
1
$0
Chloride)
klor-con sprinkle
(Micro-K)
1
$0
(Calcium
liquid calcium with vitamin d *
Carbonate/Vitamin
4
$0
D3)
mag 64 *
(Slow-Mag)
4
$0
mag-delay *
(Slow-Mag)
4
$0
mag-g *
(Magonate)
4
$0
(Magnesium
magnesium (oxide/aa chelate) *
Oxide/Mag Aa
4
$0
Chelate)
klor-con 10
135
Name of Drug
magnesium chloride injection
magnesium gluconate * oral tablet
magnesium * oral tablet 250 mg
magnesium sulf in 0.45% nacl
magnesium sulfate in d5w
intravenous piggyback 1 gram/100
ml, 4 gram/100 ml
magnesium sulfate in water
magnesium sulfate injection
natural calcium *
NORMOSOL-M IN 5 %
DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
oysco 500/d * oral tablet
oysco d *
oysco-500 *
oyster shell calcium 500 *
oyster shell calcium with d *
(Magnesium
Chloride)
(Magonate)
(Magnesium)
(Magnesium Sulf
In 0.45% NaCl)
(Magnesium
Sulfate/D5W)
(Magnesium
Sulfate in Water)
(Magnesium
Sulfate)
(Calcium
Carbonate)
(Caltrate 600 + D)
(Caltrate 600 + D)
(Calcium
Carbonate)
(Calcium
Carbonate)
(Calcium
Carbonate/Vitamin
D2)
(Caltrate 600 + D)
(Caltrate 600 + D)
(Pedialyte)
(Pedialyte)
Tier level
What the
drug will
cost you
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
4
$0
2
$0
2
2
2
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
oyster shell calcium-vit d3 *
4
$0
oystercal-d *
4
$0
pediatric electrolyte * oral solution
4
$0
pediatric freezer pops *
4
$0
PHOS-NAK *
4
$0
phosphorus #1
(K-Phos Neutral)
1
$0
136
Tier level
What the
drug will
cost you
2
2
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(K-Tab ER)
1
$0
(K-Tab ER)
1
$0
(Potassium
Chloride)
1
$0
Name of Drug
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
potassium bicarb-citric acid
potassium bicarbonate-cit ac oral
tablet, effervescent 25 meq
potassium chlorid-d5-0.45%nacl
potassium chloride in 0.9%nacl
meq/l, 40 meq/l
potassium chloride in 5 % dex
meq/l, 30 meq/l, 40 meq/l
potassium chloride in lr-d5
potassium chloride intravenous
potassium chloride oral capsule,
extended release
potassium chloride oral liquid
potassium chloride oral packet
potassium chloride oral tablet
extended release
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
(Potassium
Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Klor-Con-Ef)
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
(Potassium
Chloride In D5w)
(Potassium
Chloride In Lr-D5)
(Potassium
Chloride)
(Micro-K)
(Potassium
Chloride)
(Klor-Con)
Necessary Actions,
Restrictions, or
Limits on Use
137
Name of Drug
(Potassium
Chloride-0.45%
NaCl)
(Potassium
potassium chloride-d5-0.2%nacl
Chloride/D50.2%NaCl)
(Potassium
Chloride/D5meq/l
0.3%NaCl)
(Potassium
Chloride/D50.9%NaCl)
potassium citrate
(Urocit-K)
potassium citrate-citric acid oral
(Potassium
packet
Citrate/Citric Acid)
(Potassium
potassium phosphate m-/d-basic
Phos,M-Basic-DBasic)
ringers intravenous
(Ringers Solution)
sodium acetate intravenous
(Sodium Acetate)
sodium bicarbonate intravenous
(Sodium
solution 1 meq/ml (8.4 %)
Bicarbonate)
sodium bicarbonate intravenous
(Sodium
syringe
Bicarbonate)
(Sodium Chloride
sodium chloride 0.45 % intravenous
0.45 %)
sodium chloride 0.9 % injection
(0.9 % Sodium
solution
Chloride)
(0.9 % Sodium
sodium chloride 0.9 % intravenous
Chloride)
(Sodium Chloride
sodium chloride 3 %
3 %)
(Sodium Chloride
sodium chloride 5 %
5 %)
sodium chloride intravenous
(Sodium Chloride)
potassium chloride-0.45 % nacl
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
138
Name of Drug
sodium citrate-citric acid
sodium lactate
sodium phosphate
sod-pot-k cit-sod cit-cit acid
(Citric
Acid/Sodium
Citrate)
(Sodium Lactate)
(Sodium Phos,MBasic-D-Basic)
(Sod/Pot/K Cit/Sod
Cit/Cit Acid)
TPN ELECTROLYTES
TPN ELECTROLYTES II
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
2
2
$0
$0
2
2
2
2
$0
$0
$0
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Respiratory Tract Agents
Anti-Inflammatories,
Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 100 MCG/ACTUATION,
50 MCG/ACTUATION
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 250 MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 110
MCG/ACTUATION
MCG/ACTUATION
MCG/ACTUATION
QVAR
Antileukotrienes
QL (60 per 30 days)
QL (12 per 28 days)
QL (60 per 30 days)
QL (13 per 28 days)
QL (60 per 30 days)
2
$0
QL (12 per 28 days)
2
$0
2
$0
2
$0
2
$0
QL (24 per 28 days)
139
Tier level
What the
drug will
cost you
(Singulair)
(Accolate)
1
1
$0
$0
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
(Albuterol Sulfate)
1
1
$0
$0
(Vospire ER)
1
$0
2
2
$0
$0
1
$0
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
1
$0
1
$0
(Theophylline
Anhydrous)
1
$0
(Theophylline/D5
W)
1
$0
Name of Drug
montelukast
zafirlukast
Bronchodilators
albuterol sulfate inhalation solution
for nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet
ATROVENT HFA
COMBIVENT RESPIMAT
metaproterenol oral
(Metaproterenol
Sulfate)
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA WITH HANDIHALER
STRIVERDI RESPIMAT
terbutaline oral
terbutaline subcutaneous
theophylline anhydrous oral tablet
extended release 12 hr 100 mg, 200
mg, 300 mg
theophylline in dextrose 5 %
mg/100 ml, 200 mg/50 ml, 400
mg/250 ml, 400 mg/500 ml, 800
mg/250 ml
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (8 per 30 days)
QL (17 per 25 days)
QL (2 per 30 days)
QL (60 per 30 days)
QL (4 per 30 days)
QL (30 per 30 days)
(Theophylline
1
$0
Anhydrous)
(Theophylline
theophylline oral
1
$0
Anhydrous)
theophylline oral
140
Tier level
What the
drug will
cost you
1
$0
2
$0
QL (1 per 28 days)
1
1
$0
$0
1
$0
PA BvD
PA BvD
PA BvD
4
2
$0
$0
ESBRIET
2
$0
KALYDECO
2
$0
NUCALA
OFEV
2
2
$0
$0
ORKAMBI
2
$0
PROLASTIN-C
sodium chloride * inhalation
solution for nebulization 0.9 %
XOLAIR
2
$0
3
$0
2
$0
Name of Drug
theophylline oral
TUDORZA PRESSAIR
Respiratory Tract Agents,
Other
acetylcysteine
acetylcysteine
cromolyn inhalation
cromolyn * nasal
DALIRESP
(Theophylline
Anhydrous)
(Acetadote)
(Acetadote)
(Cromolyn
Sodium)
(Nasalcrom)
(Pulmosal)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA
PA; QL (120 per 30
days)
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
1
$0
carisoprodol
(Soma)
1
$0
chlorzoxazone
(Parafon Forte
DSC)
1
$0
1
$0
1
1
$0
$0
cyclobenzaprine oral tablet 10 mg, 5
(Fexmid)
mg
dantrolene
(Dantrium)
dantrolene sodium
(Dantrium)
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
141
Name of Drug
metaxall
metaxalone
methocarbamol oral
tizanidine
(Skelaxin)
(Skelaxin)
(Robaxin)
(Zanaflex)
Tier level
What the
drug will
cost you
1
1
1
1
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
BELSOMRA
2
$0
HETLIOZ
NUVIGIL
ROZEREM
XYREM
2
2
2
2
$0
$0
$0
$0
1
$0
zaleplon
(Sonata)
(High Risk Med. QL
applies to all members;
PA required for 65
years and older with
over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (30
per 30 days)
PA
PA
LA
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
142
Name of Drug
Tier level
What the
drug will
cost you
zolpidem oral tablet
(Ambien)
1
$0
zolpidem oral tablet,ext release
multiphase
(Ambien CR)
1
$0
ADCIRCA
2
$0
ADEMPAS
2
$0
1
$0
LETAIRIS
2
$0
OPSUMIT
2
$0
ORENITRAM
REMODULIN
2
2
$0
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
PA-HRM; (High Risk
with over 90 days
cumulative use with
per 30 days)
Vasodilating Agents
Vasodilating Agents
epoprostenol (glycine)
sildenafil intravenous
(Flolan)
(Revatio)
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
PA BvD
PA; QL (37.5 per 1
day)
143
Tier level
What the
drug will
cost you
1
$0
TRACLEER
2
$0
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
2
2
2
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
Name of Drug
sildenafil oral
(Revatio)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (90 per 30
days)
PA; LA; QL (60 per 30
days)
PA BvD
PA BvD
PA BvD
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula *
a thru z high potency *
a thru z select 50+ formula *
a thru z select * oral tablet
(Multivitamin/Iron/
Folic Acid)
(Multivitamin WMinerals/Lutein)
(Biocel)
a thru z select * oral tablet 300-600(Biocel)
300 mcg, 500-300-250 mcg
(Multivits Wa thru z select women's *
Fe,Other Min/Lut)
abc plus *
(Biocel)
(One-A-Day
adult multivitamin gummies *
Vitacraves)
(One-A-Day
adult one daily gummies *
Vitacraves)
adults 50+ daily formula *
(Biocel)
(Multivitamin/Iron/
adults' daily formula *
Folic Acid)
(Vit A,C, and
airshield * oral tablet, effervescent
E/Dietary Supp
5,000-1000-30 unit-mg-unit
No.12)
animal chews *
(Multivitamin)
animal shape vitamins *
(Multivitamin)
144
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Dialyvite 800)
(Vitamin B
Complex)
(B-12)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
animal shapes plus iron *
antioxidant *
antioxidant vitamins * oral tablet
1,000 unit-200 mg-60 unit-2 mg
apatate forte *
ascorbic acid * oral tablet extended
release 1,500 mg
ascorbic acid * oral
b complete *
b complex 1 *
b complex-vitamin b12 *
b complex-vitamin c-folic acid *
b-100 complex * oral tablet
b-12 dots *
b-50 complex * oral tablet
bal b-100 *
bal b-50 *
balance b-100 *
balance b-50 *
balanced b-100 * oral
(Multivitamins
with Iron)
(Beta-Carotene(A)
W-C and E/Min)
(Vit A,C and
E/Lutein/Minerals)
(Multivitamin with
Minerals)
Necessary Actions,
Restrictions, or
Limits on Use
145
Name of Drug
(Vitamin B
Complex/Folic
Acid)
(Vit B Complex
balanced b-100 * oral tablet 100 mg 100 Cmb
#3/Herbs)
(Vitamin B
balanced b-150 *
Complex)
(Vitamin B
balanced b-50 complex *
Complex)
(Vitamin B
balanced b-50 * oral tablet
Complex)
(Vitamin B
b-complex * oral tablet
Complex)
b-complex with vitamin c * oral
(B Complex with
capsule
Vitamin C)
(Vita-Bee with C)
tablet
(Fa/Vit B Complex
tablet 400-500 mcg-mg
and C/Rice Bran)
(Multivitamin with
biosupp *
Minerals)
biotin * oral tablet 300 mcg
(Biotin)
(Multivitamin with
biovol *
Minerals)
c complex *
(Ascorbic Acid)
calcidol *
(Drisdol)
(Multivits Wcentamin *
Min/Ferrous Gluc)
central vite with lutein *
(Biocel)
(Multivitamin
central-vite for seniors *
W/Iron, Minerals)
central-vite * oral tablet 18-400 mg- (Multivitamin/Iron/
mcg
Folic Acid)
balanced b-100 * oral tablet 0.4 mg
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
146
Name of Drug
central-vite select * oral tablet
central-vite senior *
centram-care *
centravites 50 plus *
centrum complete *
centrum * oral liquid
centrum silver * oral tablet
century adults 50+ *
century mature * oral tablet
(Biocel)
(Multivits WMin/Ferrous Gluc)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Biocel)
century mature * oral tablet 0.4300-250 mg-mcg-mcg, 500-300-250 (Biocel)
mcg
(Multivitamin/Iron/
century * oral tablet 18-400 mg-mcg
Folic Acid)
century ultimate women's * oral
(Multivitamin/Iron/
tablet 18-400 mg-mcg
Folic Acid)
(Multivits Wcerovite *
Min/Ferrous Gluc)
(Multivitamin/Iron/
cerovite advanced formula *
Folic Acid)
certavite senior-antioxidant *
(Biocel)
certavite-antioxid (iron gluc) * oral (Multivits Wliquid 9 mg iron/15 ml
Min/Ferrous Gluc)
(Multivitamin/Iron/
certavite-antioxidant *
Folic Acid)
chewable multi vitamin *
(Multivitamin)
(Pedi Mv
child complete multivitamin *
No.58/Ferrous
Fumarate)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
147
Name of Drug
child vitamin with minerals *
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
children's chewable *
children's chewable complete * oral
(Multivitamin)
tablet,chewable
children's chewable vitamin *
(Multivitamin)
(Multivitamin
children's chewable w/minerals *
W/Iron, Minerals)
(Pedi Mv
children's complete vitamin *
No.67/Ferrous
Fumarate)
children's multivit w/extra c *
(Multivitamin)
childs chew vite *
(Multivitamin)
(Multivitamins
child's vitamin with iron *
with Iron)
child's vitamin with vitamin c *
(Multivitamin)
(Multivitamins
childs/iron *
with Iron)
cholecalciferol (vitamin d3) * oral
capsule 1,000 unit, 10,000 unit,
(D3-50)
5,000 unit
(Just D)
drops 5,000 unit/ml
(Cholecalciferol
liquid
(Vitamin D3))
(Vitamin D3)
tablet,chewable
complete 50+ *
(Biocel)
complete multi 50+ *
(Biocel)
(Multivits,Th Wcomplete multivitamin * oral tablet
Fe,Other Min)
complete multivitamin * oral tablet
(Biocel)
0.4-300-250 mg-mcg-mcg
complete multivitamin-mineral *
(Multivitamin/Iron/
oral tablet
Folic Acid)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
148
Tier level
What the
drug will
cost you
(Multivitamin
W/Iron, Minerals)
4
$0
(Biocel)
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
complete senior * oral tablet
complete senior * oral tablet 0.4300-250 mg-mcg-mcg
cyanocobalamin (vitamin b-12) *
injection
oral drops 1,000 mcg/ml
oral tablet 1,000 mcg, 100 mcg, 250
mcg, 500 mcg
daily gummies *
daily multiple * oral tablet
daily multiple * oral tablet 18-400
mg-mcg
daily multi-vitamin *
daily multivitamin with iron *
daily multi-vitamins/iron *
daily teen multi-vitamin *
daily value *
daily vitamin *
daily vitamin formula *
daily vitamin formula + iron *
daily vitamin formula-minerals *
daily vitamin with iron *
daily vites/iron *
daily-vite *
(Cyanocobalamin
(Vitamin B-12))
(Cyanocobalamin
(Vitamin B-12))
(B-12)
(One-A-Day
Vitacraves)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamins
with Iron)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamins
with Iron)
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
149
Tier level
What the
drug will
cost you
(Multivitamin)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
(B1,B2,B3,B6,B12
/Dexpan/Zn/Mang)
(Multivitamin with
Minerals)
(Drisdol)
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
3
$0
(Drisdol)
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
4
4
$0
$0
4
$0
Name of Drug
dino-life *
dino-life with extra c *
dino-life with iron-zinc *
eldertonic *
ellis tonic *
eql central-vite select * tablet
ergocalciferol (vitamin d2) *
ergocalciferol (vitamin d2) * oral
drops
essentia *
essential balance with lutein *
essential daily *
fe fumarate-doss-fa-bcomp and c *
fe fumarate-vit c-b12-if-fa * oral
capsule 110-0.5 mg
ferotrinsic *
ferretts *
ferrex 150 *
ferrex 150 plus *
(Multivitamin/Iron/
Folic Acid)
(Multivits WFe,Other Min/Lut)
(Tab A Vite)
(Fe
Fumarate/Doss/Fa/
Bcomp,C)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Ferrous Fumarate)
(Pic 200)
(Iron Aspgly and
Ps Cmplx/C/Sucac)
(Ferrous Fumarate)
Necessary Actions,
Restrictions, or
Limits on Use
ferrocite *
4
$0
ferrous fumarate * oral tablet 324
(Ferrous Fumarate)
4
$0
mg (106 mg iron)
ferrous gluconate * oral tablet
(Fergon)
4
$0
ferrous sulfate * oral
(Fer-In-Sol)
4
$0
(Ferrous Sulfate)
4
$0
150
Tier level
What the
drug will
cost you
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Multivitamin
W/Iron, Minerals)
4
$0
(Multivitamin)
4
$0
(Pedi Mv
No.79/Ferrous
Fumarate)
4
$0
(Multivitamin)
4
$0
(Folic Acid)
4
$0
4
$0
Name of Drug
ferrous sulfate * oral tablet 325 mg
(65 mg iron)
ferrous sulfate * oral tablet,delayed
release (dr/ec) 324 mg (65 mg iron)
flintstones complete (iron) * oral
tablet,chewable
flintstones multivitamin * oral
tablet,chewable
flintstones with iron *
flintstones/extra c * oral
tablet,chewable
folic acid * 1,000 mcg tablet p/f,s/f
(otc)
FOLIC ACID * ORAL CAPSULE
20 MG
folic acid * oral tablet 1 mg
folic acid * oral tablet 400 mcg
Necessary Actions,
Restrictions, or
Limits on Use
(Folic Acid)
3
$0
(Folic Acid)
4
$0
(Calcium/Multivita
fosfree *
4
$0
mins W-Iron)
geravim *
(Pediavit)
4
$0
geriaton *
(Pediavit)
4
$0
gummi bear multivitamin *
(Multivitamin)
4
$0
gummy swirls *
(Multivitamin)
4
$0
(Multivitamins
hair vitamins *
4
$0
with Iron)
(Multivitamin with
hair,skin & nails * oral tablet
4
$0
Minerals)
hair,skin & nails * oral tablet 1 mg (Mv,Ca,Min/Iron
4
$0
iron-66.7 mcg-1,000 mcg
Gluc/Fa/Biotin)
(Vit A,C and
healthy eyes *
4
$0
E/Lutein/Minerals)
hemocyte *
(Ferrous Fumarate)
4
$0
151
Name of Drug
(Vitamin B
Complex)
(Multivitamin Whigh potency multivit-multimin *
Minerals/Lutein)
honey bears *
(Multivitamin)
(Multivitamin
honey bears with iron-zinc *
W/Iron, Minerals)
(Multivitamin with
icaps plus *
Minerals)
iferex 150 *
(Pic 200)
iron high potency *
(Fergon)
kid's vitamins + extra c *
(Multivitamin)
(Ped Multivit
kids vitamins + iron *
#17/Iron Fumarate)
(Multivitamins
kid's vitamins + iron *
with Iron)
kid's vitamins * oral tablet,chewable (Multivitamin)
(Multivitamin
life-pack women's *
W/Iron, Minerals)
LIQUI-E *
little animals *
(Multivitamin)
little animals-iron * oral
(Multivitamins
tablet,chewable
with Iron)
lysiplex plus * oral liquid
(Pediavit)
MACUVITE *
MACUVITE EYE CARE *
maximum daily multivitamin *
(Tab A Vite)
(Multivitamin with
mega multiple/chelated mineral *
Minerals)
mega multivitamin with mineral *
(Multivitamin with
oral tablet
Minerals)
(One-A-Day
men's daily gummies *
Vitacraves)
men's multi-vitamin *
(Multivitamin)
hi-b complex *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
152
Name of Drug
men's one daily * oral tablet
(Multivitamin with
Minerals)
MEPHYTON *
milltrium senior *
multi complete with iron *
multi-day with iron *
multi-delyn with iron *
multiple vitamin-minerals *
multiple vitamins *
multiple vitamins with iron *
multivital platinum * oral tablet
multivital platinum * oral tablet
500-300-250 mcg
multivitamin 50 plus *
multi-vitamin hp/minerals *
multivitamin with iron *
multivitamin with minerals * oral
liquid
multivitamin with minerals * oral
tablet
multivitamins with min no.7-fa *
oral capsule 1 mg
multi-vite *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Ferr
ous Gluconate)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamins
with Iron)
(Biocel)
(Multivitamins,The
r W-Minerals)
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Multivitamins
with Min No.7/Fa)
(Multivitamin/Iron/
Folic Acid)
Tier level
What the
drug will
cost you
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
153
Tier level
What the
drug will
cost you
4
$0
1
$0
4
$0
4
$0
3
$0
4
$0
4
$0
(Niacinamide)
4
$0
(Pic 200)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamins,The
rapeutic)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Tab A Vite)
(Multivitamins
with Iron)
(Multivitamin)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
(Quintabs)
4
$0
(Multivitamin/Iron/
Folic Acid)
4
$0
Name of Drug
multi-vite 50 & over *
multivit-fluor 0.5 mg tab chew
chewable, d/f, s/f 0.5 mg
my favorite multiple *
my-vitalife *
(Pedi M.Vit No.17
with Fluoride)
(Multivitamin)
(Multivitamin with
Minerals)
NASCOBAL *
natural b-100 *
natural b-100 complex *
niacinamide * oral tablet extended
release
nu-iron *
ocutabs *
oncovite *
one daily 50 plus *
one daily complete * oral tablet
one daily energy * oral tablet
one daily essential * oral tablet
one daily maximum (with ca) *
one daily multi-vit w-mineral *
one daily multivitamin * oral tablet
one daily multivitamin * oral tablet
400 mcg
one daily multivit-iron(folic) *
(Vitamin B
Complex)
(Vit B Complex
100 Cmb
#2/Herbs)
Necessary Actions,
Restrictions, or
Limits on Use
154
Name of Drug
one daily * oral tablet
one daily plus iron * oral tablet
one daily plus iron * oral tablet 18400 mg-mcg
one daily plus minerals *
one daily with iron *
one-a-day essential *
one-a-day maximum formula *
one-a-day teen advantage * oral
tablet 18-400 mg-mcg
one-a-day teen advantage * oral
tablet 9 mg iron-400 mcg
opti-vitamins * oral tablet
opti-vitamins * oral tablet 1,000
unit-200 mg-60 unit-2 mg
pediatric multivitamin *
pharmacist favorite multi-vit *
phytonadione * oral tablet 100 mcg
poly-iron *
poly-vita *
poly-vita (iron) *
poly-vitamin *
poly-vitamin with iron *
(Multivitamin)
(Multivitamins
with Iron)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamin)
(Multivitamin with
Minerals)
(Multivitamin/Iron/
Folic Acid)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Beta-Carotene(A)
W-C and E/Min)
(Vit A,C and
E/Lutein/Minerals)
(Multivitamin)
(Multivitamin)
(Phytonadione)
(Pic 200)
(Pediatric Multivit
Comb No.20)
(Ped Multivit
#46/Iron Sulfate)
(Pediatric Multivit
Comb No.20)
(Ped Multivit
#46/Iron Sulfate)
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
poly-vitamins *
4
$0
prenatal formula * oral tablet 28 mg
(Classic Prenatal)
4
$0
iron- 800 mcg
155
Name of Drug
prenatal * oral tablet 28 mg iron800 mcg
prenatal tablet *
(Prenatal)
(Classic Prenatal)
(Prenatal
prenatal vit#96-ferrous fum-fa *
Vit#96/Ferrous
Fum/Fa)
prenatal vitamin with minerals *
(Classic Prenatal)
prenatal vitamins oral tablet 27 mg (Pnv with
iron- 1 mg
Ca,No.72/Iron/Fa)
prenatal vit-iron fumarate-fa *
(Classic Prenatal)
(A/C/E/Zinc/Sod
prosight *
Selenate/Copper)
pyridoxine * injection
(Pyridoxine HCl)
(Multivitamin
ra central-vite select * tab p/f
W/Iron, Minerals)
(Multivitamin
scooby-doo one a day *
W/Iron, Minerals)
senior tabs *
(Biocel)
(Multivitamin/Iron/
sentry * oral tablet 18-400 mg-mcg
Folic Acid)
sentry senior *
(Biocel)
sodium fluoride 1 mg (2.2 mg)
(Sodium Fluoride)
sodium fluoride oral tablet 1 mg
(Pedi M.Vit No.17
fluoride (2.2 mg)
with Fluoride)
spectravite adult 50+ * oral tablet
(Biocel)
spectravite advanced formula * oral (Multivitamin/Iron/
tablet
Folic Acid)
spectravite * oral liquid
(Pediavit)
(Multivitamins
spectravite * oral tablet,chewable
with Iron)
(Multivitamin
spectravite senior * oral tablet
W/Iron, Minerals)
spectravite senior * oral tablet 500(Biocel)
300-250 mcg
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
2
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
1
$0
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
156
Name of Drug
spectravite senior w-lycopene *
spectravite ultra women *
stress 500 plus zinc *
stress b with zinc *
stress b-biotin *
stress formula *
stress formula plus iron *
stress formula with iron *
stress formula with zinc *
sunvite *
super b complex-vitamin c *
super b maxi complex *
super b/c *
super b-50 complex *
super b-50 complex plus *
super multiple * oral tablet
super multivitamin *
(Multivitamin/Iron/
Folic Acid)
(Multivits,Stress
Formula/Zinc)
(Multivits,Stress
Formula/Zinc)
(Vitamin B
Complex)
(Multivits,Stress
Formula)
(Iron/Multivits,Stre
ss Formula)
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivits,Stress
Formula/Zinc)
(Mv-Min/Iron
Fum/Fa/K/Lyco/Lu
tn)
(Vita-Bee with C)
(Vitamin B
Complex/Folic
Acid)
(B Complex with
Vitamin C)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
157
Name of Drug
super quints *
super quints b-50 *
super thera vite m *
superior 35 *
superplex-t *
support *
support-500 *
tab-a-vite *
tab-a-vite/iron *
tab-a-vite-minerals *
thera m plus (ferrous fumarat) *
thera vitamin *
thera-d *
theradex m *
thera-m * oral tablet 27-0.4 mg
thera-m * oral tablet 9 mg iron-400
mcg
therapeutic liquid *
therapeutic m + beta-carotene *
(Vitamin B
Complex/Folic
Acid)
(Vitamin B
Complex)
(Multivitamins,The
r W-Minerals)
(Multivitamin
W/Iron, Minerals)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(B Complex with
Vitamin C)
(Multivitamin)
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Multivitamins,The
rapeutic)
(Vitamin D3)
(Multivit,Ther
Iron,Ca,Fa and
Min)
(Multivit,Ther
Iron,Ca,Fa and
Min)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Multivitamins,The
rapeutic)
(Tab A Vite)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
158
Name of Drug
therapeutic vitamin & mineral *
therapeutic vitamins/minerals *
therapeutic-m * oral tablet 9 mg
iron-400 mcg
therapeutic-m vitamin/minerals *
oral tablet 27-0.4 mg
thera-tabs *
theratrum complete 50 plus *
theratrum complete 50 plus/lut *
thiamine hcl * injection
thiamine hcl * oral tablet 500 mg
total b/c *
totalday multiple *
tri-vi-sol *
tri-vita *
tri-vitamin *
ultra b-100 complex * oral tablet
vision *
vision formula *
(Multivitamins,The
r W-Minerals)
(Multivitamins
with Min No.7/Fa)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Multivit,Ther
Iron,Ca,Fa and
Min)
(Multivitamins,The
rapeutic)
(Multivitamin
W/Iron, Minerals)
(Thiamine HCl)
(Thiamine HCl)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(Vit A
Palmitate/Vit C/Vit
D3)
(Pedi Multivits
A,C, and D3
No.21)
(Pedi Multivits
A,C, and D3
No.21)
(Vitamin B
Complex)
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
Tier level
What the
drug will
cost you
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
159
Name of Drug
(Vit A,C and
E/Lutein/Minerals)
(Multivitamin Wvision plus lutein *
Minerals/Lutein)
vit b cmplx 3-fa-vit c-biotin * oral
(Vit B Cmplx
tablet 1-60-300 mg-mg-mcg
3/Fa/Vit C/Biotin)
(Vit B Cmplx
vit b cmplx no3-fa-c-biot-zinc *
No3/Fa/C/Biot/Zin
c)
(Vitamin B
vit b complex-folic acid * oral tablet Complex/Folic
Acid)
(Multivitamins
vitalets * oral tablet,chewable
with Iron)
vitamin a * oral capsule 10,000
(Vitamin A)
unit, 25,000 unit
(Vitamin B
vitamin b complex *
Complex)
(Vitamin B
vitamin b-100 complex *
Complex)
(Cyanocobalamin/
vitamin b12-folic acid * oral
Folic Acid)
vitamin b-6 * oral tablet 250 mg, 50
(Pyridoxine HCl)
mg
vitamin c * oral syrup
(Ascorbic Acid)
vitamin c * oral tablet 1,000 mg,
(Ascorbic Acid)
250 mg
vitamin c * oral tablet extended
(Ascorbic Acid)
release
vitamin c * oral tablet,chewable 250
(Ascorbic Acid)
mg, 500 mg
vitamin d3 * oral capsule 1,000
(D3-50)
unit, 4,000 unit
vitamin d3 * oral tablet 1,000 unit,
(Vitamin D3)
400 unit
vision formula (with lutein) *
Tier level
What the
drug will
cost you
4
$0
4
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
160
Name of Drug
(Multivitamins,The
r W-Minerals)
(Vitamin B
vitamins b complex * oral tablet
Complex)
(Vit B
vitamins b complex * oral tablet 500
Comp/C/Fa/Iron/Vi
mg-400 mcg- 18 mg iron
t E)
(Vitamin B
vitamins b1,b2,b3,b5, and b6 * oral
Complex/Folic
tablet 0.4 mg
Acid)
vitamins for hair * oral tablet
(Multivitamin)
(Multivitamin Wvitrum senior * oral tablet
Minerals/Lutein)
vitrum senior * oral tablet 500-300(Biocel)
250 mcg
(One-A-Day
womens daily gummies *
Vitacraves)
women's daily multivitamin *
(Tab A Vite)
(Multivitamin/Iron/
yelets *
Folic Acid)
zoo chews *
(Multivitamin)
vitamins & minerals *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
161
INDEX
3
3 day vaginal .......................... 48
30pse-150gfn-15dm ............... 85
8
8-MOP.................................... 95
A
a thru z advanced formula .... 144
a thru z high potency ............ 144
a thru z select ....................... 144
a thru z select 50+ formula... 144
a thru z select women's ........ 144
abacavir .................................. 63
abacavir-lamivudine-zidovudine
............................................ 63
abc plus ................................ 144
ABELCET.............................. 48
ABILIFY DISCMELT ........... 59
ABILIFY MAINTENA ......... 59
ABRAXANE ......................... 33
ABREVA ............................... 55
acamprosate............................ 23
acarbose.................................. 45
acebutolol ............................... 75
acephen .................................. 15
acetaminophen ....................... 15
acetaminophen-codeine.......... 15
acetazolamide ....................... 131
acetazolamide sodium .......... 132
acetic acid..................... 107, 126
acetylcysteine ....................... 141
acid gone antacid.......... 111, 112
acid reducer (famotidine) ..... 110
acid relief (cimetidine) ......... 110
acitretin .................................. 95
acne medication ..................... 96
ACNE MEDICATION .......... 96
acne-clear ............................... 96
ACTEMRA .......................... 128
ACTHIB (PF) ....................... 124
ACTIMMUNE ..................... 128
actinel pediatric ...................... 85
acyclovir ..................... 65, 66, 96
acyclovir sodium .................... 66
ADACEL(TDAP
ADOLESN/ADULT)(PF) 124
ADAGEN ............................. 103
adapalene .............................. 102
ADCETRIS ............................ 33
ADCIRCA ............................ 143
adefovir .................................. 66
ADEMPAS........................... 143
adt robitussin peak cld dm max
............................................ 86
adult multivitamin gummies 144
adult nasal decongestant......... 86
adult one daily gummies ...... 144
adult robitussin lingering cld.. 86
adult robitussin peak cold dm 86
adult wal-tussin ...................... 86
adult wal-tussin dm max ........ 86
adults 50+ daily formula ...... 144
adults' daily formula ............. 144
ADVAIR DISKUS ............... 139
ADVAIR HFA ..................... 139
advil ........................................ 20
af 48
AFINITOR ............................. 33
AFINITOR DISPERZ ............ 33
AFTERA ................................ 83
AGGRENOX ......................... 69
airshield ................................ 144
AKTEN (PF) ........................ 104
AKYNZEO ............................ 57
alavert d-12 allergy-sinus ....... 51
I-1
Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de
ventaja doble completamente integrado (Fully Integrated Duals Advantage
Medicare-Medicaid Plan, FIDA MMP) de ICS
Identificación del formulario:16508.000, Versión: 9
ALBENZA ............................. 58
ALBUKED-25 ....................... 69
ALBUKED-5 ......................... 69
ALBUMIN, HUMAN 25 % ... 69
ALBUMIN, HUMAN 5 % ..... 69
ALBUMINAR 25 % .............. 69
ALBUMINAR 5 % ................ 69
ALBURX (HUMAN) 5 % ..... 69
ALBUTEIN 25 % .................. 69
ALBUTEIN 5 % .................... 69
albuterol sulfate .................... 140
alclometasone ......................... 99
ALCOHOL PADS ................. 96
ALCOHOL PREP PADS ....... 96
ALDURAZYME .................. 103
alendronate ........................... 127
alfuzosin ............................... 118
ALIMTA ................................ 33
ALINIA .................................. 58
alka-seltzer plus mucus-conges
............................................ 86
allegra allergy ......................... 51
aller-chlor ............................... 51
allerclear d-12hr ..................... 51
allerclear d-24hr ..................... 51
allergy (chlorpheniramine) ..... 51
allergy (diphenhydramine) ..... 51
allergy relief (cetirizine) ......... 51
allergy relief (loratadine)........ 51
allerhist-1................................ 51
aller-tec d ................................ 51
allopurinol ............................ 128
almacone .............................. 112
almacone-2 ........................... 112
aloe vesta antifungal (micon) . 48
alophen ................................. 115
ALPHAGAN P..................... 132
Fecha de entrada en vigencia:
01 de enero 2016
alprazolam .............................. 24
ALREX ................................ 109
altacaine ............................... 104
altamist ................................. 104
aluminum hydroxide gel ...... 112
amantadine hcl ....................... 58
ambi 10peh-4cpm-20dm ........ 86
ambi 20dm-4cpm ................... 86
ambi 40pse-400gfn-20dm ...... 86
ambi 60pse-4cpm ................... 51
ambi 60pse-4cpm-20dm......... 86
AMBISOME .......................... 48
amifostine crystalline ........... 128
amiloride ................................ 79
amiloride-hydrochlorothiazide79
AMINO ACIDS 15 % ............ 70
aminocaproic acid .................. 69
AMINOSYN 10 % ................. 70
AMINOSYN 3.5 % ................ 70
AMINOSYN 7 % ................... 70
AMINOSYN 7 % WITH
ELECTROLYTES ............. 70
AMINOSYN 8.5 % ................ 70
AMINOSYN 8.5 %ELECTROLYTES ............. 70
AMINOSYN II 10 % ............. 70
AMINOSYN II 15 % ............. 70
AMINOSYN II 7 % ............... 70
AMINOSYN II 8.5 % ............ 70
AMINOSYN II 8.5 %ELECTROLYTES ............. 70
AMINOSYN M 3.5 % ........... 70
AMINOSYN-HBC 7% .......... 70
AMINOSYN-PF 10 % ........... 70
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 70
AMINOSYN-RF 5.2 % ......... 70
amiodarone ............................. 75
amiodarone hcl ....................... 75
AMITIZA ............................. 112
amitriptyline ........................... 43
amlactin .................................. 96
amlodipine.............................. 78
amlodipine-atorvastatin .......... 80
amlodipine-benazepril ............ 78
amlodipine-valsartan .............. 79
amlodipine-valsartan-hcthiazid
............................................ 79
ammonium lactate .................. 96
amoxapine .............................. 43
amoxicil-clarithromy-lansopraz
.......................................... 110
amoxicillin ............................. 30
amoxicillin-pot clavulanate .... 30
amphetamine salt combo ........ 82
amphotericin b........................ 48
ampicillin ............................... 30
ampicillin sodium................... 31
ampicillin-sulbactam .............. 31
AMPYRA............................... 82
ANACAINE ........................... 96
anagrelide ............................... 69
anastrozole ............................. 33
ANDRODERM .................... 119
ANDROGEL ........................ 119
animal chews ........................ 144
animal shape vitamins .......... 144
animal shapes plus iron ........ 145
antacid anti-gas .................... 112
antacid extra-strength ........... 112
antacid plus extra strength.... 112
anticoag citrate phos dextrose
.......................................... 128
anti-diarrheal ........................ 112
anti-diarrheal (loperamide) .. 112
antifungal ............................... 48
antifungal (tolnaftate) ............. 48
anti-gas maximum strength .. 110
antioxidant............................ 145
antioxidant vitamins ............. 145
apatate forte .......................... 145
APOKYN ............................... 58
apraclonidine ........................ 104
APRISO ............................... 126
I-2
aprodine .................................. 51
APTIOM ................................ 40
APTIVUS ............................... 63
aquanil hc ............................... 99
ARCALYST ......................... 122
aripiprazole ....................... 59, 60
ARISTADA............................ 60
arthritis pain relief (acetam) ... 15
artificial tears ........................ 104
artificial tears (petro/min) .... 104
artificial tears (pf) ................. 104
artificial tears (polyvin alc) .. 104
artificial tears(glycerin-peg) . 104
artificial tears(hypromellose) 104
ASACOL HD ....................... 126
ascorbic acid ......................... 145
ashlyna.................................... 83
aspirin ..................................... 20
aspirin, buffered ..................... 20
aspirin-dipyridamole .............. 69
aspir-low ................................. 20
ASSURE ID INSULIN
SAFETY ........................... 102
ASTAGRAF XL .................. 122
atenolol ................................... 75
atenolol-chlorthalidone .......... 75
atorvastatin ............................. 80
atovaquone ............................. 58
atovaquone-proguanil ............. 58
ATRIPLA ............................... 63
atropine ........................... 40, 104
atropine sulfate ..................... 104
ATROVENT HFA ............... 140
AUBAGIO ........................... 122
AVASTIN .............................. 33
AVC VAGINAL .................... 55
AVONEX ............................. 128
AVONEX (WITH ALBUMIN)
.......................................... 128
ayr saline .............................. 104
azacitidine .............................. 33
azathioprine .......................... 122
01 de enero 2016
azathioprine sodium ............. 123
azelastine .............................. 105
AZILECT ............................... 58
azithromycin .......................... 29
AZOPT ................................. 132
AZOR ..................................... 79
aztreonam ............................... 30
B
b complete ............................ 145
b complex 1 .......................... 145
b complex-vitamin b12 ........ 145
b complex-vitamin c-folic acid
.......................................... 145
b-100 complex ..................... 145
b-12 dots............................... 145
b-50 complex ....................... 145
bacitracin .................. 25, 97, 107
bacitracin-polymyxin b ........ 108
bacitraycin plus ...................... 97
baclofen ................................ 141
bal b-100 .............................. 145
bal b-50 ................................ 145
balance b-100 ....................... 145
balance b-50 ......................... 145
balanced b-100 ............. 145, 146
balanced b-150 ..................... 146
balanced b-50 ....................... 146
balanced b-50 complex ........ 146
balsalazide ............................ 126
banophen ................................ 51
banophen allergy .................... 51
BANZEL ................................ 40
baza antifungal ....................... 48
BCG VACCINE, LIVE (PF) 124
b-complex ............................ 146
b-complex with vitamin c .... 146
BD ECLIPSE LUER-LOK .. 102
BD INSULIN PEN NEEDLE
UF SHORT ...................... 102
BD INSULIN SYRINGE
ULTRA-FINE .................. 102
bekyree (28) ........................... 83
BELEODAQ .......................... 33
BELSOMRA ........................ 142
benadryl allergy...................... 52
benazepril ............................... 74
benazepril-hydrochlorothiazide
............................................ 74
BENICAR .............................. 73
BENICAR HCT ..................... 73
BENLYSTA ......................... 128
benzonatate............................. 86
benzoyl peroxide .................... 96
benztropine ............................. 58
BETADINE SPRAY .............. 96
beta-hc .................................... 99
betamethasone acet,sod phos 120
betamethasone dipropionate ... 99
betamethasone valerate .......... 99
betamethasone, augmented .... 99
BETASERON ...................... 129
betaxolol ......................... 75, 132
bethanechol chloride ............ 129
BETHKIS ............................... 25
bexarotene .............................. 33
BEXSERO (PF) ................... 124
bicalutamide ........................... 33
bicarsim forte ....................... 110
BICILLIN C-R ....................... 31
BICILLIN L-A ....................... 31
bimatoprost........................... 132
bio-dtuss dmx ......................... 86
bion tears (pf) ....................... 105
bionel pediatric ....................... 86
biospec dmx ........................... 86
biosupp ................................. 146
biotin .................................... 146
biovol ................................... 146
bisac-evac ............................. 115
bisacodyl .............................. 115
biscolax ................................ 115
bismatrol............................... 112
bisoprolol fumarate ................ 75
I-3
bisoprolol-hydrochlorothiazide
............................................ 75
bleomycin ............................... 33
BLINCYTO............................ 33
blisovi 24 fe ............................ 83
blisovi fe 1/20 (28) ................. 83
blis-to-sol (tolnaftate) ............. 48
BOOSTRIX TDAP .............. 124
BOSULIF ......................... 33, 34
BREO ELLIPTA .................. 139
BRILINTA ............................. 69
brimonidine .......................... 132
BRINTELLIX ........................ 43
bromfenac ............................. 109
bromocriptine ......................... 58
bromphenex dm ...................... 86
brompheniramine-pseudoephdm ....................................... 86
brompheniram-phenylephrinedm ....................................... 86
budesonide............................ 126
bufferin ................................... 20
bumetanide ............................. 79
BUMINATE 25 % ................. 69
BUMINATE 5 % ................... 70
BUPHENYL ........................ 112
buprenorphine hcl............. 15, 23
buprenorphine-naloxone ........ 23
bupropion hcl ................... 23, 43
buspirone .............................. 129
butalb-acetaminophen-caffeine
............................................ 15
butalbital-acetaminop-caf-cod 15
butalbital-acetaminophen ....... 15
butalbital-acetaminophen-caff 15
butalbital-aspirin-caffeine ...... 15
BUTRANS ............................. 15
BYSTOLIC ............................ 75
C
c complex ............................. 146
cabergoline ............................. 58
01 de enero 2016
ca-d3-mag ox-zinc-cop-mangbor ............................ 132, 133
caffeine citrated ...................... 82
caffeine-sodium benzoate ...... 82
calci-chew ............................ 112
calcidol ................................. 146
calcipotriene ........................... 96
calcitonin (salmon)............... 127
calcitrate ............................... 133
calcitriol ......................... 96, 127
calcium 500 + d.................... 133
calcium 500 + d (d3) ............ 133
calcium 500 with d ............... 133
calcium 600 .......................... 133
calcium 600 + d(3) ............... 133
calcium 600 with vitamin d3 133
calcium acetate ..................... 118
calcium antacid .................... 112
calcium carbonate ........ 112, 133
calcium carbonate-mag carb-fa
.......................................... 118
calcium carbonate-vitamin d2
.......................................... 133
calcium carbonate-vitamin d3
.......................... 112, 133, 134
calcium chloride ................... 134
calcium citrate-vitamin d3 ... 134
calcium gluconate ................ 134
calcium lactate ..................... 134
calcium+d............................. 134
CALDOLOR .......................... 20
cal-gest antacid..................... 112
calphron................................ 118
CALTRATE 600 + D .......... 134
CALTRATE WITH VITAMIN
D3 ..................................... 134
CANCIDAS ........................... 48
candesartan ............................. 73
candesartan-hydrochlorothiazid
............................................ 73
CAPASTAT ........................... 56
CAPRELSA ........................... 34
captopril ................................. 74
captopril-hydrochlorothiazide 74
CARAFATE......................... 110
CARBAGLU ........................ 113
carbamazepine ........................ 40
carbidopa ................................ 58
carbidopa-levodopa .......... 58, 59
carbidopa-levodopa-entacapone
............................................ 59
CARIMUNE NF
NANOFILTERED ........... 123
carisoprodol .......................... 141
carteolol ................................ 105
cartia xt ................................... 76
carvedilol ................................ 75
CASTELLANI PAINT
MODIFIED ........................ 96
CAYSTON ............................. 30
cefaclor ................................... 27
cefadroxil ............................... 27
cefazolin ................................. 28
cefazolin in dextrose (iso-os) . 28
CEFAZOLIN IN DEXTROSE
(ISO-OS) ............................ 28
cefdinir ................................... 28
cefditoren pivoxil ................... 28
cefepime ................................. 28
CEFEPIME IN DEXTROSE 5
% ........................................ 28
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 28
cefotaxime .............................. 28
cefoxitin ................................. 28
cefoxitin in dextrose, iso-osm 28
cefpodoxime ........................... 28
cefprozil ................................. 28
ceftazidime ............................. 28
ceftibuten ................................ 28
ceftriaxone ........................ 28, 29
CEFTRIAXONE .................... 29
ceftriaxone in dextrose,iso-os 28
I-4
CEFTRIAXONE IN
DEXTROSE,ISO-OS ......... 28
cefuroxime axetil .................... 29
cefuroxime sodium ................. 29
celecoxib ................................ 20
CELLCEPT INTRAVENOUS
.......................................... 123
CELONTIN ............................ 40
centamin ............................... 146
central vite with lutein .......... 146
central-vite............................ 146
central-vite for seniors.......... 146
central-vite select . 147, 150, 156
central-vite senior ................. 147
centram-care ......................... 147
centravites 50 plus ................ 147
centrum ................................. 147
centrum complete ................. 147
centrum silver ....................... 147
century .................................. 147
century adults 50+ ................ 147
century mature ...................... 147
century ultimate women's..... 147
cephalexin .............................. 29
CEPROTIN (BLUE BAR) ..... 66
CERDELGA ........................ 129
CEREZYME ........................ 103
cerovite ................................. 147
cerovite advanced formula ... 147
certavite senior-antioxidant .. 147
certavite-antioxid (iron gluc) 147
certavite-antioxidant ............. 147
CERVARIX VACCINE (PF)
.......................................... 124
cetirizine ................................. 52
cetirizine-pseudoephedrine .... 52
cevimeline .............................. 95
CHANTIX .............................. 23
CHANTIX CONTINUING
MONTH BOX .................... 23
CHANTIX CONTINUING
MONTH PAK .................... 23
01 de enero 2016
CHANTIX STARTING
MONTH BOX ................... 23
cheracol d ............................... 86
cheratussin dac ....................... 86
chest congestion relief + dm .. 86
chest congestion relief d......... 87
chest congestion relief pe ....... 87
chewable multi vitamin ........ 147
child allergy relf(cetirizine) ... 52
child complete multivitamin 147
child cough & sore throat ....... 87
child mucinex chest congestion
............................................ 87
child plus cough & runny nose
............................................ 87
child triaminic cold & allergy 52
child triaminic cough-congest 87
child vitamin with minerals . 148
child wal-tap cold-allergy ...... 52
child wal-tussin cough relief .. 87
children's advil ....................... 20
children's allegra allergy ........ 52
children's aller-tec .................. 52
children's chest congestion..... 87
children's chewable .............. 148
children's chewable complete
.......................................... 148
children's chewable vitamin . 148
children's chewable w/minerals
.......................................... 148
CHILDREN'S CLARITIN ..... 52
children's complete vitamin . 148
children's mapap .................... 15
children's mucinex cough ....... 87
children's multivit w/extra c . 148
children's non-aspirin ............. 16
children's pain & fever relief . 16
children's pain reliever ........... 16
childrens plus multi-symp cold
............................................ 87
children's silapap .................... 16
children's silfedrine ................ 87
children's soothe ................... 113
children's sudafed ................... 87
children's sudafed pe cough ... 87
children's wal-dryl allergy...... 52
children's wal-zyr ................... 52
CHILDREN'S ZYRTEC
ALLERGY ......................... 52
childs chew vite .................... 148
child's vitamin with iron....... 148
child's vitamin with vitamin c
.......................................... 148
childs/iron............................. 148
chlophedianol-guaifenesin ..... 87
chloramphenicol sod succinate
............................................ 25
chlordiazepoxide hcl .............. 24
chlorhexidine gluconate ......... 95
chloroquine phosphate ........... 58
chlorothiazide ......................... 79
chlorothiazide sodium ............ 79
chlorpheniramine-phenyleph-dm
............................................ 87
chlorpromazine....................... 60
chlorthalidone......................... 79
chlorzoxazone ...................... 141
cholecalciferol (vitamin d3) . 148
cholestyramine (with sugar) ... 80
cholestyramine-aspartame ...... 80
choline,magnesium salicylate 20
ciclopirox ............................... 48
ciclopirox-ure-camph-menth-euc
............................................ 48
cilostazol ................................ 69
cimetidine ............................. 110
cimetidine hcl ....................... 110
CIMZIA ............................... 123
CIMZIA POWDER FOR
RECONST ....................... 123
CINRYZE .............................. 68
CIPRODEX .......................... 108
ciprofloxacin .......................... 31
ciprofloxacin hcl ............ 31, 108
I-5
ciprofloxacin in 5 % dextrose 31
ciprofloxacin lactate ............... 31
citalopram ............................... 43
citracal + d maximum........... 134
citric acid-sodium citrate ...... 134
citrus calcium ....................... 134
clarithromycin ........................ 29
CLARITIN ............................. 52
CLARITIN LIQUI-GEL ........ 52
CLARITIN REDITABS......... 52
clearlax ................................. 115
clemastine ............................... 52
CLEVIPREX .......................... 79
clindamycin hcl ...................... 26
clindamycin in 5 % dextrose .. 26
clindamycin palmitate hcl ...... 26
clindamycin phosphate .... 26, 55,
97, 98
CLINIMIX 5%/D15W
SULFITE FREE ................. 70
CLINIMIX 5%/D25W
SULFITE-FREE ................. 70
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 71
CLINIMIX 4.25%/D10W SULF
FREE .................................. 71
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 71
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 71
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 71
CLINIMIX 5%D20W(SULFITE-FREE) ... 71
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 71
SULF FREE ....................... 71
SUL FREE ......................... 71
SUL FREE ......................... 71
01 de enero 2016
SULF FREE ....................... 71
CLINIMIX E 5%/D15W
SULFIT FREE ................... 71
CLINIMIX E 5%/D20W
SULFIT FREE ................... 71
CLINIMIX E 5%/D25W
SULFIT FREE ................... 71
CLINISOL SF 15 %............... 71
clobetasol ............................... 99
clobetasol propionate ............. 99
clobetasol-emollient ............. 100
clocortolone pivalate ............ 100
clomipramine ......................... 43
clonazepam ............................ 24
clonidine ................................. 73
clonidine hcl ..................... 73, 82
clonidine hcl-chlorthalidone .. 73
clopidogrel ............................. 69
clorazepate dipotassium ......... 24
clotrimazole...................... 48, 49
clotrimazole 3 day .................. 48
clotrimazole-7 ........................ 49
clotrimazole-betamethasone .. 49
clozapine ................................ 60
COARTEM ............................ 58
codeine sulfate ....................... 16
codeine-butalbital-asa-caffein 16
codituss dm ............................ 87
colace ................................... 115
colchicine ............................. 129
colchicine-probenecid .......... 129
cold & cough .......................... 52
cold multi-symptom day/night87
cold relief m/s day/night ........ 88
cold-allergy-sinus ................... 52
cold-flu relief ......................... 88
cold-flu relief, day/night ........ 88
colestipol ................................ 80
colistin (colistimethate na) ..... 26
COLY-MYCIN S ................. 108
COMBIGAN ........................ 132
COMBIPATCH ................... 119
COMBIVENT RESPIMAT . 140
COMETRIQ ........................... 34
comfort gel extra strength .... 113
COMPLERA .......................... 63
complete 50+ ........................ 148
complete multi 50+ .............. 148
complete multivitamin ......... 148
complete multivitamin-mineral
.......................................... 148
complete senior .................... 149
compoz ................................... 52
COMVAX (PF) .................... 124
CONDYLOX ......................... 96
congestac ................................ 88
COPAXONE ........................ 129
coricidin hbp .......................... 88
coricidin hbp cold-multi sympt
............................................ 88
CORLANOR .......................... 77
cortisone ............................... 120
cortizone-10 ......................... 100
CORTIZONE-10 .................. 100
COSENTYX (2 SYRINGES) 96
COSENTYX PEN .................. 96
COSENTYX PEN (2 PENS) . 96
COTELLIC ............................ 34
cough & cold .......................... 88
cough & runny nose ............... 88
CREON ................................ 103
CRESTOR.............................. 80
critic-aid clear af .................... 49
CRIXIVAN ............................ 63
cromolyn .............. 105, 113, 141
CUBICIN ............................... 26
cyanocobalamin (vitamin b-12)
.......................................... 149
cyclobenzaprine ................... 141
CYCLOGYL ........................ 105
cyclopentolate ...................... 105
cyclophosphamide .................. 34
CYCLOPHOSPHAMIDE ...... 34
I-6
CYCLOSET ........................... 45
cyclosporine ......................... 123
cyclosporine modified .......... 123
cyclosporine, modified ......... 123
cyproheptadine ....................... 52
CYRAMZA ............................ 34
cyred ....................................... 84
CYSTADANE...................... 129
CYSTARAN ........................ 105
cysteine (l-cysteine) ............... 71
D
d10 % & 0.45 % sodium
chloride ............................. 134
d10 %-0.9 % sodium chloride 71
d2.5 %-0.45 % sodium chloride
.......................................... 134
d5 % and 0.9 % sodium chloride
.......................................... 134
.......................................... 134
dactinomycin .......................... 34
daily gummies ...................... 149
daily multiple ....................... 149
daily multi-vitamin ............... 149
daily multivitamin with iron. 149
daily multi-vitamins/iron ...... 149
daily teen multi-vitamin ....... 149
daily value ............................ 149
daily vitamin......................... 149
daily vitamin formula ........... 149
daily vitamin formula + iron 149
daily vitamin formula-minerals
.......................................... 149
daily vitamin with iron ......... 149
daily vites/iron ...................... 149
dailyhist-1 ............................... 52
daily-vite .............................. 149
DAKLINZA ........................... 65
DALIRESP ........................... 141
danazol ................................. 119
dantrolene ............................. 141
dantrolene sodium ................ 141
01 de enero 2016
dapsone .................................. 56
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 124
DARAPRIM .......................... 58
DARZALEX .......................... 34
dayhist allergy ........................ 53
daytime cold & cough ............ 88
daytime cold-flu ..................... 88
day-time cough....................... 88
daytime-nighttime .................. 88
daytime-nighttime cold-flu .... 88
daytime-nighttime cough ....... 88
deblitane ................................. 84
decitabine ............................... 34
decongestant cough ................ 88
deep sea nasal ....................... 105
deferoxamine................ 118, 119
delsym cough+chest congest dm
............................................ 88
DELZICOL .......................... 126
DEMSER ............................... 77
DEPEN TITRATABS .......... 119
DEPO-PROVERA ............... 122
dermafungal ........................... 49
dermarest eczema (hydrocort)
.......................................... 100
desipramine ............................ 43
desmopressin ........................ 121
desog-e.estradiol/e.estradiol ... 84
desogestrel-ethinyl estradiol .. 84
desonide ............................... 100
desoximetasone .................... 100
despec-dm (pseudoeph-dmguaif) .................................. 88
dex4 glucose........................... 71
dexamethasone ..................... 120
dexamethasone sodium
phosphate ................. 109, 120
dexmethylphenidate ............... 82
dextroamphetamine ................ 82
dextroamphetamineamphetamine ...................... 82
dextromethorphan polistirex .. 88
dextrose 10 % and 0.2 % nacl
.......................................... 134
............................................ 72
dextrose 2.5 % in water(d2.5w)
............................................ 72
............................................ 72
............................................ 72
............................................ 72
dextrose 5 % in ringers........... 72
dextrose 5 % in water (d5w) .. 72
dextrose 5 %-lactated ringers134
dextrose 5%-0.2 % sod chloride
.......................................... 135
dextrose 5%-0.3 % sod.chloride
.......................................... 135
............................................ 72
............................................ 72
dextrose with sodium chloride
.......................................... 135
diabetic siltussin das-na ......... 89
diabetic tussin dm................... 89
diabetic tussin max st ............. 89
diamode ................................ 113
diazepam .......................... 24, 25
diazepam intensol ................... 24
diclofenac potassium .............. 20
diclofenac sodium .... 20, 21, 109
diclofenac-misoprostol ........... 21
dicloxacillin............................ 31
dicyclomine .......................... 113
didanosine .............................. 63
DIFICID ................................. 29
diflunisal................................. 21
digitek..................................... 77
digoxin ................................... 77
I-7
DIGOXIN ............................... 77
dihydroergotamine ................. 55
DILANTIN CAPSULE 30 MG
............................................ 40
diltiazem hcl ........................... 76
dilt-xr ...................................... 76
dimaphen (pe)......................... 53
dimenhydrinate ....................... 57
dimetapp cold-congestion ...... 53
dino-life ................................ 150
dino-life with extra c ............ 150
dino-life with iron-zinc ........ 150
DIPENTUM ......................... 126
diphenhist ............................... 53
diphenhydramine hcl .............. 53
diphenoxylate-atropine ......... 113
disopyramide phosphate ......... 75
disulfiram ............................... 23
divalproex ............................... 40
d-methorphan hb-p-epd hcl-bpm
............................................ 89
dm-phenyleph-chlorpheniramine
............................................ 89
dobutamine ............................. 78
dobutamine in d5w ................. 77
doc-q-lace ............................. 115
docu ...................................... 115
docusate sodium ................... 115
docusol ................................. 116
dok ........................................ 116
donepezil ................................ 42
dopamine ................................ 78
dopamine in 5 % dextrose ...... 78
dorzolamide .......................... 132
dorzolamide-timolol ............. 132
douche vinegar & water extra
.......................................... 129
doxazosin................................ 73
doxepin ................................... 43
doxercalciferol...................... 127
doxorubicin hcl....................... 34
01 de enero 2016
doxorubicin hcl peg-liposomal
............................................ 34
doxorubicin, peg-liposomal ... 34
doxycycline hyclate ............... 32
doxycycline monohydrate 32, 33
dramamine.............................. 57
driminate ................................ 57
dristan long lasting ............... 105
dronabinol .............................. 57
droperidol ............................. 129
drospirenone-ethinyl estradiol 84
DROXIA ................................ 34
DUAVEE ............................. 120
dulcolax stool softener (dss) 116
DULERA ............................. 139
duloxetine............................... 43
DUREZOL ........................... 109
dutasteride ............................ 129
dutasteride-tamsulosin ......... 129
DYRENIUM .......................... 79
E
e.c. prin................................... 21
econazole................................ 49
econtra ez ............................... 84
ed bron gp .............................. 89
ed chlorped jr ......................... 53
EDURANT ............................ 63
EFFIENT................................ 69
ELAPRASE ......................... 103
eldertonic.............................. 150
electrolyte-48 in d5w ........... 135
ELIDEL................................ 100
ELIGARD .............................. 34
ELIQUIS ................................ 66
ELITEK................................ 103
ELLA ..................................... 84
ellis tonic .............................. 150
ELMIRON ........................... 129
elon dual defense.................... 49
EMCYT.................................. 34
EMEND ................................. 57
EMPLICITI ............................ 35
EMSAM ................................. 44
EMTRIVA ............................. 63
enalapril maleate .................... 74
enalaprilat ............................... 74
enalapril-hydrochlorothiazide 74
ENBREL .............................. 123
ENBREL SURECLICK ....... 123
endur-acin............................... 80
enema ................................... 116
enema disposable ................. 116
enemeez ................................ 116
enemeez plus ........................ 116
ENGERIX-B (PF) ................ 124
ENGERIX-B PEDIATRIC (PF)
.......................................... 124
enoxaparin ........................ 66, 67
entacapone .............................. 59
entecavir ................................. 66
entre-cough............................. 89
ENTRESTO ........................... 73
ephedrine sulfate .................... 78
epinastine ............................. 105
epinephrine ............................. 78
epinephrine hcl (pf) ................ 78
EPIPEN 2-PAK ...................... 78
EPIPEN JR 2-PAK................. 78
EPIVIR HBV ......................... 63
eplerenone .............................. 81
EPOGEN ................................ 68
epoprostenol (glycine).......... 143
EPZICOM .............................. 63
eq gentle ............................... 105
equalactin ............................. 116
ergocalciferol (vitamin d2)... 150
ergoloid ................................ 129
ERGOMAR ............................ 55
ERIVEDGE ............................ 35
ERYTHROCIN ...................... 29
erythromycin .................. 30, 108
erythromycin base .................. 29
ERYTHROMYCIN BASE .... 29
erythromycin base-ethanol ..... 98
I-8
erythromycin ethylsuccinate . 29,
30
erythromycin stearate ............. 30
erythromycin with ethanol ..... 98
ESBRIET.............................. 141
escitalopram oxalate ............... 44
esmolol ................................... 75
esomeprazole sodium ........... 110
essentia ................................. 150
essential balance with lutein. 150
essential daily ....................... 150
ESTRACE ............................ 120
estradiol ................................ 120
estradiol valerate .................. 120
estradiol/norethindrone acet . 120
estradiol-norethindrone acet . 120
estropipate ............................ 120
ethambutol .............................. 56
ethamolin ................................ 78
ethinyl estradiol/drospirenone 84
ethosuximide .......................... 41
ethynodiol d-ethinyl estradiol 84
etodolac .................................. 21
ETOPOPHOS ......................... 35
etoposide ................................ 35
EVOTAZ ................................ 63
EXELON ................................ 42
exemestane ............................. 35
EXJADE ............................... 119
expectorant ............................. 89
expectorant dm ....................... 89
expectorant max strength ....... 89
EXTAVIA ............................ 129
extra cleansing douche ......... 129
F
FABRAZYME ..................... 103
famciclovir ............................. 66
famotidine .................... 110, 111
famotidine (pf) ..................... 110
famotidine (pf)-nacl (iso-os) 110
FANAPT ................................ 60
FARESTON ........................... 35
01 de enero 2016
FARYDAK ............................ 35
FASLODEX ........................... 35
fe fumarate-doss-fa-bcomp and
c ........................................ 150
fe fumarate-vit c-b12-if-fa ... 150
felbamate ................................ 41
felodipine ............................... 79
feminine care douche ........... 129
FEMRING............................ 120
fenofibrate .............................. 80
fenofibrate micronized ........... 80
fenofibrate nanocrystallized ... 80
fenofibric acid ........................ 80
fenofibric acid (choline) ......... 80
fenoprofen .............................. 21
fentanyl .................................. 16
fentanyl citrate ....................... 16
ferotrinsic ............................. 150
ferretts .................................. 150
ferrex 150 ............................. 150
ferrex 150 plus ..................... 150
FERRIPROX........................ 119
ferrocite ................................ 150
ferrous fumarate ................... 150
ferrous gluconate .................. 150
ferrous sulfate............... 150, 151
FETZIMA .............................. 44
feverall ................................... 16
fexofenadine ........................... 53
fiber (calcium polycarbophil)
.......................................... 116
fiber laxative (methylcellulo)116
fiber smooth ......................... 116
fiber therapy ......................... 116
fiber therapy (psyllium/sugar)
.......................................... 116
fiber-lax ................................ 116
finasteride ............................. 129
FIRAZYR .............................. 78
flanax antacid ....................... 113
FLEBOGAMMA DIF .......... 123
flecainide ................................ 75
FLECTOR .............................. 21
FLEET BISACODYL .......... 116
FLEXBUMIN 25 % ............... 70
FLEXBUMIN 5 % ................. 70
flintstones complete (iron) ... 151
flintstones multivitamin ....... 151
flintstones with iron ............. 151
flintstones/extra c ................. 151
FLOVENT DISKUS ............ 139
FLOVENT HFA .................. 139
floxuridine .............................. 35
flu formula daytime-nighttime89
flu severe cold-congestion ..... 89
fluconazole ............................. 49
fluconazole in dextrose(iso-o) 49
fluconazole in nacl (iso-osm) . 49
flucytosine .............................. 49
fludrocortisone ..................... 120
flumazenil............................... 82
flunisolide............................. 109
fluocinonide ......................... 100
fluocinonide-emollient base . 100
fluorometholone ................... 109
FLUOROPLEX ...................... 96
fluorouracil ....................... 35, 97
fluoxetine ............................... 44
fluoxymesterone ................... 119
fluphenazine decanoate .......... 60
fluphenazine hcl ..................... 60
flurbiprofen ............................ 21
flurbiprofen sodium.............. 109
flutamide ................................ 35
fluticasone .................... 100, 109
fluvoxamine ........................... 44
foaming antacid .................... 113
folic acid ............................... 151
FOLIC ACID ....................... 151
fomepizole............................ 129
fondaparinux .......................... 67
foot odor control..................... 49
FORTEO .............................. 127
FORTICAL .......................... 127
I-9
foscarnet ................................. 65
fosfree ................................... 151
fosinopril ................................ 74
fosinopril-hydrochlorothiazide
............................................ 74
fosphenytoin ........................... 41
FREAMINE HBC 6.9 % ........ 72
FREAMINE III 10 % ............. 72
fungi cure ............................... 49
FUNGI-NAIL......................... 49
fungoid-d ................................ 49
furosemide .............................. 79
FUSILEV ............................. 129
FUZEON ................................ 63
FYCOMPA ............................ 41
G
gabapentin .............................. 41
GABITRIL ............................. 41
galantamine ...................... 42, 43
GAMASTAN S/D ................ 123
GAMMAGARD LIQUID .... 123
GAMMAPLEX .................... 123
ganciclovir sodium ................. 66
GARDASIL (PF) ................. 124
GARDASIL 9 (PF) .............. 124
gas relief ............................... 110
gas relief extra strength ........ 110
gas-x ultra-strength............... 110
gatifloxacin ........................... 108
GATTEX 30-VIAL .............. 113
GATTEX ONE-VIAL .......... 113
GAUZE PAD ....................... 129
GAZYVA ............................... 35
gelusil antacid & anti-gas ..... 113
gemfibrozil ............................. 80
GENOTROPIN .................... 121
GENOTROPIN MINIQUICK
.......................................... 121
gentamicin ................ 25, 98, 108
gentamicin in nacl (iso-osm) .. 25
gentamicin sulfate ................ 108
gentamicin sulfate (ped) (pf) .. 25
01 de enero 2016
gentamicin sulfate (pf) ........... 25
GENTEAL MILD TO
MODERATE ................... 105
GENTEAL GEL .................. 105
GENTEAL MILD ................ 105
GENTEAL SEVERE ........... 105
gentlelax ............................... 116
GENVOYA ............................ 63
GEODON ............................... 60
geravim ................................ 151
geriaton ................................ 151
geri-hydrolac .......................... 97
geri-tussin dm......................... 89
gildess 1/20 (21) ..................... 84
gildess 24 fe ........................... 84
gildess fe 1/20 (28)................. 84
GILENYA ............................ 129
GILOTRIF ............................. 35
GLEEVEC ............................. 35
glimepiride ............................. 47
glipizide.................................. 47
glipizide-metformin ............... 47
GLUCAGEN HYPOKIT ..... 129
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 129
gluco burst .............................. 72
glucose ................................... 72
glucose gel ............................. 72
glutose 15 ............................... 72
glyburide ................................ 47
glyburide micronized ............. 47
glyburide-metformin ........ 47, 48
glycolax ................................ 116
glycopyrrolate ...................... 113
glydo ...................................... 22
GLYXAMBI .......................... 45
granisetron (pf)....................... 57
granisetron hcl ........................ 57
GRANIX ................................ 68
griseofulvin microsize ............ 49
guaifenesin ............................. 89
guaifenesin dac....................... 89
guanfacine ........................ 73, 82
guanidine .............................. 129
gummi bear multivitamin ..... 151
gummy swirls ....................... 151
H
hair vitamins ......................... 151
hair,skin & nails ................... 151
halobetasol propionate ......... 100
haloperidol ............................. 60
haloperidol decanoate ............ 60
haloperidol lactate .................. 60
HARVONI ............................. 65
HAVRIX (PF) ...................... 124
head congestion day-night ..... 89
healthy eyes .......................... 151
healthylax ............................. 116
hemocyte .............................. 151
heparin (porcine) .................... 67
heparin (porcine) in 5 % dex . 67,
68
heparin (porcine) in nacl (pf) . 67
heparin sodium,porcine-pf ..... 67
heparin(porcine) in 0.45% nacl
............................................ 68
heparin, porcine (pf) ............... 67
HEPATAMINE 8% ............... 72
HEPATASOL 8 % ................. 72
HERCEPTIN .......................... 35
HETLIOZ ............................. 142
HEXALEN ............................. 35
hi-b complex ........................ 152
hi-cal plus vit d ..................... 135
high potency multivit-multimin
.......................................... 152
homatropine hbr ................... 105
honey bears .......................... 152
honey bears with iron-zinc ... 152
HUMIRA ............................. 123
HUMIRA PEN ..................... 123
HUMIRA PEN CROHN'S-UCHS START ....................... 123
I-10
HUMULIN R U-500
(CONCENTRATED) ......... 46
hydralazine ............................. 78
hydrochlorothiazide................ 79
hydrocil instant ..................... 116
hydrocodone bit-homatrop mebr ........................................ 90
hydrocodone-acetaminophen . 16
hydrocodone-chlorpheniramine
............................................ 90
hydrocodone-homatropine ..... 90
hydrocodone-ibuprofen .......... 16
hydrocortisone ...... 100, 101, 120
hydrocortisone acet-aloe vera
.......................................... 100
hydrocortisone acetate .......... 100
hydrocortisone acetate-aloe .. 100
hydrocortisone acetate-urea . 100
hydrocortisone butyrate 100, 101
hydrocortisone butyr-emollient
.......................................... 101
hydrocortisone sod succinate 120
hydrocortisone valerate ........ 101
hydromorphone ................ 16, 17
hydromorphone (pf) ............... 16
hydroskin .............................. 101
hydroxychloroquine ............... 58
hydroxyurea............................ 35
hydroxyzine hcl ............ 129, 130
hydroxyzine pamoate ........... 130
HYPERLYTE CR ................ 135
HYPERRAB S/D (PF) ......... 123
HYQVIA .............................. 123
I
ibandronate ........................... 127
IBRANCE .............................. 35
ibuprofen ................................ 21
ibuprofen jr strength ............... 21
icaps plus .............................. 152
ICLUSIG ................................ 35
iferex 150 ............................. 152
ifosfamide ............................... 35
01 de enero 2016
ifosfamide-mesna ................... 35
ILARIS (PF)......................... 123
ILEVRO ............................... 109
IMBRUVICA ......................... 36
imipenem-cilastatin ................ 30
imipramine hcl ....................... 44
imipramine pamoate............... 44
imiquimod .............................. 97
IMLYGIC .............................. 36
imodium a-d ......................... 113
IMODIUM A-D ................... 113
IMOGAM RABIES-HT (PF)
.......................................... 123
IMOVAX RABIES VACCINE
(PF) .................................. 124
INCRELEX .......................... 121
indapamide ............................. 79
indomethacin .......................... 21
indomethacin sodium ............. 21
INFANRIX (DTAP) (PF) .... 125
infant's ibuprofen ................... 21
INFANT'S MOTRIN ............. 21
infants' non-aspirin cold ......... 90
INLYTA ................................. 36
insta-glucose .......................... 72
INSULIN SYRINGE-NEEDLE
U-100 ............................... 102
INTELENCE.......................... 63
INTRALIPID ......................... 72
INTRON A............................. 65
INVANZ ................................ 30
INVEGA ................................ 61
INVEGA SUSTENNA .......... 61
INVEGA TRINZA................. 61
INVIRASE ............................. 63
INVOKAMET ....................... 45
INVOKANA .......................... 45
inzo antifungal ....................... 49
iodine.................................... 103
IONOSOL-B IN D5W ......... 135
IONOSOL-MB IN D5W...... 135
IPOL ..................................... 125
ipratropium bromide ............ 105
IPRIVASK ............................. 68
irbesartan ................................ 74
irbesartan-hydrochlorothiazide
............................................ 74
IRESSA .................................. 36
iron high potency ................. 152
ISENTRESS ........................... 63
ISOLYTE M IN 5 %
DEXTROSE ..................... 135
ISOLYTE-H IN 5 %
DEXTROSE ..................... 135
ISOLYTE-P IN 5 %
DEXTROSE ..................... 135
ISOLYTE-S ......................... 135
isoniazid ................................. 56
isopto tears ........................... 105
isosorbide dinitrate ................. 81
isosorbide mononitrate ........... 81
isotretinoin ............................. 97
isradipine ................................ 79
itraconazole ............................ 49
ivermectin............................... 58
IXEMPRA .............................. 36
IXIARO (PF)........................ 125
J
JAKAFI .................................. 36
JALYN ................................. 130
jantoven .................................. 68
JANUMET ............................. 45
JANUMET XR ...................... 45
JANUVIA .............................. 45
JARDIANCE ......................... 45
JENTADUETO ...................... 46
jr. acetaminophen ................... 17
juleber..................................... 84
junel fe 24............................... 84
junior mapap .......................... 17
JUXTAPID............................. 80
K
KABIVEN .............................. 72
KALETRA ............................. 64
I-11
KALYDECO ........................ 141
kaopectate (bismuth subsalicy)
.......................................... 113
KEDBUMIN .......................... 70
KELP (IODINE) .................. 135
ketoconazole ........................... 49
ketoprofen .............................. 21
ketorolac ......................... 22, 109
KEVEYIS ............................. 130
KEYTRUDA .......................... 36
kid's vitamins........................ 152
kid's vitamins + extra c......... 152
kids vitamins + iron.............. 152
kid's vitamins + iron ............. 152
kimidess (28) .......................... 84
KINERET ............................. 123
KINRIX (PF) ........................ 125
klor-con 10 ........................... 135
klor-con m10 ........................ 135
klor-con m15 ........................ 135
klor-con m20 ........................ 135
klor-con sprinkle .................. 135
konsyl (sugar) ....................... 116
konsyl fiber........................... 116
KONSYL SUGAR-FREE .... 116
KORLYM .............................. 46
KRYSTEXXA...................... 103
KUVAN ............................... 103
KYNAMRO ........................... 80
KYPROLIS ............................ 36
L
l norgest/e.estradiol-e.estrad... 84
labetalol .................................. 76
LACRISERT ........................ 105
LACTATED RINGERS....... 126
LACTINOL HX ..................... 97
lactulose................................ 113
LAMICTAL ........................... 41
LAMISIL (AEROSOL) ......... 49
lamisil af ................................. 49
LAMISIL AT ......................... 49
lamivudine .............................. 64
01 de enero 2016
lamivudine-zidovudine .......... 64
lamotrigine ............................. 41
LANOXIN ............................. 78
lansoprazole ......................... 111
LANTUS ................................ 46
LANTUS SOLOSTAR .......... 46
larin 24 fe ............................... 84
larin fe 1/20 (28) .................... 84
latanoprost ............................ 132
LATUDA ......................... 61, 62
laxative peg 3350 ................. 116
LAZANDA ............................ 17
leflunomide .......................... 123
LEMTRADA ....................... 130
LENVIMA ............................. 36
LETAIRIS ............................ 143
letrozole.................................. 36
leucovorin calcium ............... 130
LEUKERAN .......................... 36
LEUKINE .............................. 68
leuprolide ............................... 36
levetiracetam .......................... 41
levobunolol .......................... 132
levocarnitine ......................... 130
levocarnitine (with sugar) .... 130
levocetirizine .......................... 53
levofloxacin.................... 32, 108
levofloxacin in d5w................ 32
levonorgestrel ................... 84, 85
levonorgestrel-ethin estradiol. 84
levonorgestrel-ethinyl estrad . 84,
85
levothyroxine ....................... 122
LEXIVA ................................. 64
lice cream rinse .................... 102
lice killing ............................ 102
lice treatment ........................ 102
lice treatment (permethrin) .. 102
lidocaine ................................. 23
lidocaine (pf) .................... 22, 75
lidocaine hcl ..................... 22, 23
lidocaine in 5 % dextrose (pf) 75
lidocaine-prilocaine ................ 23
life-pack women's ................ 152
linezolid.................................. 26
LINZESS .............................. 113
liothyronine .......................... 122
lipase-protease-amylase ....... 103
LIPOSYN II ........................... 72
LIPOSYN III .......................... 72
liquibid d-r.............................. 90
liquid calcium with vitamin d
.......................................... 135
LIQUI-E ............................... 152
lisinopril ................................. 74
lisinopril-hydrochlorothiazide 74
lithium carbonate.................... 82
lithium citrate ......................... 82
little animals ......................... 152
little animals-iron ................. 152
l-norgest-eth estr/ethin estra ... 85
lobana bath ............................. 97
lomustine ................................ 36
LONSURF ............................. 36
loperamide ............................ 113
loratadine ................................ 53
loratadine-d ............................ 53
lorazepam oral solution .......... 25
lortuss ex ................................ 90
losartan ................................... 74
losartan-hydrochlorothiazide . 74
LOTEMAX .......................... 109
LOTRONEX ........................ 113
lovastatin ................................ 80
loxapine succinate .................. 62
lubricant dry eye relief ......... 105
lubricant eye (cmc-glycer)(pf)
.......................................... 106
lubricant eye (cmc-glycerin) 106
lubricant eye (pg-peg 400) ... 106
lubricant eye (polyv alcohol) 106
lubricant eye (propyl glycol) 106
lubricant eye drops ............... 106
lubricant gel.......................... 106
I-12
lubricating drops................... 106
lubrifresh pm ........................ 106
LUMIGAN ........................... 132
LUPRON DEPOT .................. 36
............................................ 36
............................................ 36
............................................ 36
LUPRON DEPOT-PED ....... 121
LUPRON DEPOT-PED (3
MONTH) .......................... 121
LYNPARZA .......................... 36
LYRICA ................................. 41
lysiplex plus ......................... 152
LYSODREN .......................... 37
M
maalox advanced .................. 113
MACUVITE ......................... 152
MACUVITE EYE CARE .... 152
mag 64 .................................. 135
mag-delay ............................. 135
mag-g.................................... 135
MAGNEBIND 300 .............. 113
magnesium ........................... 136
magnesium (oxide/aa chelate)
.......................................... 135
magnesium chloride ............. 136
magnesium gluconate ........... 136
magnesium oxide ................. 114
magnesium sulf in 0.45% nacl
.......................................... 136
magnesium sulfate ................ 136
magnesium sulfate in d5w .... 136
magnesium sulfate in water .. 136
malathion .............................. 102
mapap (acetaminophen) ......... 17
mapap arthritis pain ................ 17
mapap extra strength .............. 17
maprotiline ............................. 44
mar-cof bp .............................. 90
01 de enero 2016
mar-cof cg .............................. 90
MARPLAN ............................ 44
masanti double strength ....... 114
MATULANE ......................... 37
matzim la................................ 76
maximum daily multivitamin
.......................................... 152
maximum strength flu ............ 90
meclizine ................................ 57
medi-brom .............................. 90
medroxyprogesterone ........... 122
mefenamic acid ...................... 22
mefloquine ............................. 58
MEFOXIN IN DEXTROSE
(ISO-OSM) ........................ 29
mega multiple/chelated mineral
.......................................... 152
mega multivitamin with mineral
.......................................... 152
MEGACE ES ....................... 122
megestrol ........................ 37, 122
MEKINIST ............................ 37
meloxicam .............................. 22
memantine .............................. 43
MENACTRA (PF) ............... 125
MENEST.............................. 120
MENHIBRIX (PF) ............... 125
MENOMUNE - A/C/Y/W-135
(PF) .................................. 125
men's daily gummies ............ 152
men's multi-vitamin ............. 152
men's one daily..................... 153
MENVEO A-C-Y-W-135-DIP
(PF) .................................. 125
MENVEO MENA
COMPONENT (PF)......... 125
MENVEO MENCYW-135
COMPNT (PF) ................. 125
MEPHYTON ....................... 153
mercaptopurine ...................... 37
meropenem ............................. 30
meropenem-0.9% sodium
chloride............................... 30
mesehist dm............................ 90
mesna ................................... 130
MESNEX ............................. 130
MESTINON ......................... 130
MESTINON TIMESPAN .... 130
metaproterenol ..................... 140
metaxall ................................ 142
metaxalone ........................... 142
metformin ............................... 46
methadone .............................. 17
methadone hcl ........................ 17
methazolamide ..................... 132
methenamine hippurate .......... 26
methenamine mandelate ......... 26
methimazole ......................... 122
methocarbamol ..................... 142
methotrexate sodium .............. 37
methotrexate sodium (pf) ....... 37
methoxsalen rapid .................. 97
methscopolamine ................. 114
methyclothiazide .................... 79
methylphenidate ..................... 83
methylprednisolone .............. 120
methylprednisolone acetate .. 120
.......................................... 121
metipranolol ......................... 132
metoclopramide hcl .............. 114
metolazone ............................. 79
metoprolol succinate .............. 76
metoprolol ta-hydrochlorothiaz
............................................ 76
metoprolol tartrate .................. 76
metronidazole ............. 26, 55, 98
metronidazole in nacl (iso-os) 26
mexiletine ............................... 75
mgo....................................... 114
MIACALCIN ....................... 127
mi-acid ................................. 114
mi-acid gas relief .................. 110
I-13
micatin .................................... 50
miconazole 7 .......................... 50
miconazole nitrate .................. 50
midodrine ............................... 73
milk of magnesia .................. 116
milltrium senior .................... 153
milrinone ................................ 78
milrinone in 5 % dextrose ...... 78
mineral oil ............................ 130
MINERAL OIL .................... 130
mineral oil laxative ............... 116
minitran .................................. 81
minocycline ............................ 33
minoxidil ................................ 81
mintox .................................. 114
mintox maximum strength ... 114
mintox plus ........................... 114
MIRCERA.............................. 68
mirtazapine ............................. 44
misoprostol ........................... 111
mitoxantrone .......................... 37
M-M-R II (PF)...................... 125
moexipril ................................ 74
moexipril-hydrochlorothiazide
............................................ 74
molindone ............................... 62
mometasone.......................... 101
MONISTAT 3 ........................ 50
monistat 7 ............................... 50
montelukast .................. 139, 140
morphine .......................... 17, 18
MORPHINE ........................... 18
morphine concentrate ............. 17
morphine in dextrose 5 % ...... 17
morrhuate sodium................. 130
motion sickness ...................... 57
motion sickness (meclizine) ... 57
MOVANTIK ........................ 114
MOVIPREP.......................... 117
MOXEZA ............................. 108
moxifloxacin .......................... 32
MOZOBIL.............................. 68
01 de enero 2016
mucus dm ............................... 90
mucus dm max ....................... 90
mucus relief ............................ 90
mucus relief cough ................. 90
MULTAQ .............................. 75
multi complete with iron ...... 153
multi-day with iron .............. 153
multi-delyn with iron ........... 153
multiple vitamin-minerals .... 153
multiple vitamins ................. 153
multiple vitamins with iron .. 153
multi-symptom cold night time
............................................ 90
multi-symptom cold-cough .... 90
multivital platinum ............... 153
multivitamin 50 plus ............ 153
multi-vitamin hp/minerals .... 153
multivitamin with iron ......... 153
multivitamin with minerals .. 153
multivitamins with min no.7-fa
.......................................... 153
multi-vite .............................. 153
multi-vite 50 & over............. 154
mupirocin ............................... 98
mupirocin calcium ................. 98
muro 128 .............................. 106
my favorite multiple ............. 154
myco nail a ............................. 50
mycophenolate mofetil......... 123
mycophenolate sodium ........ 123
MYOZYME ......................... 103
MYRBETRIQ ...................... 118
mytab gas ............................. 110
mytab gas maximum strength
.......................................... 110
my-vitalife ............................ 154
N
nabumetone ............................ 22
nadolol.................................... 76
nafcillin .................................. 31
NAGLAZYME .................... 103
naloxone ................................. 23
naltrexone ............................... 23
naltrexone hcl ......................... 23
NAMENDA XR ..................... 43
NAMZARIC .......................... 43
naphazoline .......................... 106
naproxen ................................. 22
naproxen sodium .................... 22
naratriptan .............................. 56
nasal & sinus decongestant .... 90
nasal decongestant (oxymetazl)
.......................................... 106
NASCOBAL ........................ 154
nasohist dm ............................ 90
NATACYN .......................... 108
nateglinide .............................. 46
NATPARA ........................... 127
natural b-100 ........................ 154
natural b-100 complex ......... 154
natural balance ..................... 106
natural calcium ..................... 136
natural fiber laxative therapy 117
natural tears (pf) ................... 106
nature's tears ......................... 106
NEBUPENT ........................... 58
nefazodone ............................. 44
neomy sulf-bacitrac zn-poly-hc
.......................................... 108
neomycin ................................ 25
neomycin-bacitracin-poly-hc 108
neomycin-bacitracin-polymyxin
.......................................... 108
neomycin-polymyxin b gu ..... 98
neomycin-polymyxin bdexameth .......................... 108
neomycin-polymyxingramicidin ........................ 108
neomycin-polymyxin-hc ...... 108
neo-polycin........................... 108
neosporin (neo-bac-polym) .... 98
neosporin anti-itch................ 101
neo-synephrine 12 h spr (oxym)
.......................................... 106
I-14
neo-tuss .................................. 90
NEPHRAMINE 5.4 % ........... 72
NEULASTA ........................... 68
NEUMEGA ............................ 68
NEUPOGEN .......................... 68
NEUPRO ................................ 59
NEVANAC .......................... 110
nevirapine ............................... 64
NEXAFED ............................. 90
NEXAVAR ............................ 37
niacin ...................................... 80
niacinamide .................... 80, 154
nicardipine .............................. 79
NICODERM CQ .................... 24
nicorelief ................................ 24
nicorette .................................. 24
nicotine ................................... 24
nicotine (polacrilex) ............... 24
NICOTROL............................ 24
nifedipine................................ 79
night time ............................... 91
night time cold-flu .................. 91
night time cold-flu relief ........ 91
nighttime cough ...................... 91
nighttime relief eye .............. 106
NILANDRON ........................ 37
NINLARO .............................. 37
NITE TIME COLD-FLU
RELIEF .............................. 91
nite time-d cold-flu relief ....... 91
NITRO-BID ........................... 81
nitrofurantoin macrocrystal .... 26
nitrofurantoin monohyd/m-cryst
............................................ 27
nitroglycerin ........................... 81
nitroglycerin in 5 % dextrose . 81
NITROSTAT.......................... 81
nohist-dm................................ 91
non-aspirin cold ...................... 91
non-aspirin extra strength ....... 18
non-aspirin flu ........................ 91
non-aspirin jr strength ............ 18
01 de enero 2016
NORDITROPIN FLEXPRO 121
NORDITROPIN NORDIFLEX
.......................................... 121
norelgestromin/ethin.estradiol 85
norepinephrine bitartrate ........ 78
norethindrone ......................... 85
norethindrone (contraceptive) 85
norethindrone acetate ........... 122
norethindrone ac-eth estradiol 85
norethindrone-e.estradiol-iron 85
norethindrone-ethinyl estrad .. 85
norethindrone-mestranol ........ 85
norgestimate-ethinyl estradiol 85
norgestrel-ethinyl estradiol .... 85
NORMOSOL-M IN 5 %
DEXTROSE..................... 136
NORMOSOL-R PH 7.4 ....... 136
nortemp .................................. 18
NORTHERA .......................... 73
nortriptyline............................ 44
NORVIR ................................ 64
NOVOLIN 70/30 ................... 46
NOVOLIN N ......................... 46
NOVOLIN R .......................... 47
NOVOLOG ............................ 47
NOVOLOG FLEXPEN ......... 47
NOVOLOG MIX 70-30 ......... 47
NOVOLOG MIX 70-30
FLEXPEN .......................... 47
NOVOLOG PENFILL ........... 47
NOXAFIL .............................. 50
NUCALA ............................. 141
NUCYNTA ............................ 18
NUCYNTA ER ...................... 18
NUEDEXTA .......................... 83
nu-iron .................................. 154
NULOJIX ............................. 123
NUTRESTORE.................... 114
NUTRILIPID ......................... 73
NUTRILYTE ....................... 136
NUTRILYTE II ................... 136
NUVARING .......................... 85
NUVIGIL ............................. 142
nystatin ................................... 50
NYSTATIN (BULK) ............. 50
nystatin-triamcinolone ........... 50
nyt-time sleep ......................... 53
O
ocean nasal ........................... 106
OCTAGAM ......................... 123
octreotide acetate.................. 121
ocutabs ................................. 154
ODOMZO .............................. 37
OFEV ................................... 141
ofloxacin......................... 32, 108
olanzapine .............................. 62
olanzapine-fluoxetine ............. 44
olopatadine ........................... 106
OLYSIO ................................. 65
omega-3 acid ethyl esters ....... 80
omeprazole ........................... 111
omeprazole magnesium........ 111
omeprazole-sodium bicarbonate
.......................................... 111
ONCASPAR .......................... 37
oncovite ................................ 154
ondansetron ............................ 57
ondansetron hcl ...................... 57
ondansetron hcl (pf) ............... 57
one daily ............................... 155
one daily 50 plus .................. 154
one daily complete ............... 154
one daily energy ................... 154
one daily essential ................ 154
one daily maximum (with ca)
.......................................... 154
one daily multi-vit w-mineral
.......................................... 154
one daily multivitamin ......... 154
one daily multivit-iron(folic) 154
one daily plus iron ................ 155
one daily plus minerals ........ 155
one daily with iron ............... 155
one-a-day essential ............... 155
I-15
one-a-day maximum formula155
one-a-day teen advantage ..... 155
ONFI ...................................... 25
opcicon one-step..................... 85
OPDIVO ................................. 37
OPSUMIT ............................ 143
opti-vitamins ........................ 155
oral saline laxative................ 117
ORAP ..................................... 62
ORENCIA ............................ 123
ORENCIA (WITH MALTOSE)
.......................................... 124
ORENITRAM ...................... 143
ORFADIN ............................ 103
ORKAMBI ........................... 141
OTEZLA .............................. 130
OTEZLA STARTER ........... 130
OTREXUP (PF) ................... 130
oxacillin .................................. 31
oxacillin in dextrose(iso-osm) 31
oxandrolone .......................... 119
oxcarbazepine ......................... 41
OXTELLAR XR .................... 41
oxybutynin chloride ............. 118
oxycodone .............................. 18
oxycodone hcl-acetaminophen
............................................ 18
oxycodone hcl-aspirin ............ 18
oxycodone-acetaminophen ..... 19
oxycodone-aspirin .................. 19
OXYCONTIN ........................ 19
oxymorphone.......................... 19
oysco 500/d .......................... 136
oysco d ................................. 136
oysco-500 ............................. 136
oyster shell calcium 500 ....... 136
oyster shell calcium with d ... 136
oyster shell calcium-vit d3 ... 136
oystercal-d ............................ 136
P
pain relief ............................... 19
pain relief adult ...................... 19
01 de enero 2016
pain reliever extra strength..... 19
pain reliever jr strength .......... 19
paliperidone............................ 62
PANRETIN ............................ 97
pantoprazole ......................... 111
papaverine .............................. 78
paricalcitol............................ 128
paromomycin ......................... 58
paroxetine hcl ......................... 44
PASER ................................... 56
PAXIL .................................... 44
pecgen dmx ............................ 91
pedi m.vit no.17 with fluoride
.......................................... 154
pedia relief ............................. 91
pedia relief cough-cold .......... 91
pedia relief infant ................... 91
pediacare multi-symptom cold91
PEDIARIX (PF) ................... 125
pediatric electrolyte .............. 136
pediatric freezer pops ........... 136
pediatric multivitamin .......... 155
PEDVAX HIB (PF) ............. 125
peg 3350-electrolytes ........... 117
peg 3350-na sulf,bicarb,cl-kcl
.......................................... 117
PEGANONE .......................... 41
PEGASYS .............................. 65
PEGASYS PROCLICK ......... 65
peg-electrolyte soln .............. 117
PEGINTRON ......................... 65
PEN NEEDLE, DIABETIC . 103
penicillin g pot in dextrose ..... 31
penicillin g potassium ............ 31
penicillin g procaine ............... 31
penicillin v potassium ............ 31
PENTACEL (PF) ................. 125
PENTACEL ACTHIB
COMPONENT (PF)......... 125
PENTAM ............................... 58
pentoxifylline ......................... 69
pep-t-med ............................. 114
peri-colace ............................ 117
PERIKABIVEN ..................... 73
perindopril erbumine .............. 74
permethrin ............................ 102
perphenazine .......................... 62
perphenazine-amitriptyline .... 44
persa-gel ................................. 97
pharbetol................................. 19
pharmacist favorite multi-vit 155
phenelzine .............................. 44
phenobarbital .......................... 41
phenobarbital sodium ............. 42
phenylephrine hcl ........... 73, 106
phenylephrine-chlorpheniramine
............................................ 53
phenylhistine dh ..................... 92
phenytoin ................................ 42
phenytoin sodium ................... 42
phenytoin sodium extended ... 42
phillips.................................. 114
phillips liqui-gels.................. 117
PHOSLYRA......................... 118
PHOS-NAK ......................... 136
phosphate laxative ................ 117
PHOSPHOLINE IODIDE.... 132
phosphorus #1 ...................... 136
phytonadione ........................ 155
PICATO ................................. 97
pilocarpine hcl ................ 95, 132
pimozide ................................. 62
pindolol .................................. 76
pink bismuth......................... 114
pioglitazone ............................ 46
pioglitazone-glimepiride ........ 46
pioglitazone-metformin .......... 46
piperacillin-tazobactam .......... 31
piroxicam ............................... 22
PLAN B ONE-STEP .............. 85
PLASBUMIN 25 % ............... 70
PLASBUMIN 5 % ................. 70
PLASMA-LYTE 148 ........... 137
PLASMA-LYTE A .............. 137
I-16
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 137
PLEGRIDY .......................... 130
podofilox ................................ 97
podophyllum resin .................. 97
polyethylene glycol 3350 ..... 117
poly-iron ............................... 155
polymyxin b sulfate ................ 27
polymyxin b sulf-trimethoprim
.......................................... 109
poly-tussin .............................. 92
poly-vita ............................... 155
poly-vita (iron) ..................... 155
poly-vitamin ......................... 155
poly-vitamin with iron.......... 155
poly-vitamins........................ 155
POMALYST .......................... 37
potassium acetate ................. 137
potassium bicarb and chloride
.......................................... 137
potassium bicarb-citric acid . 137
potassium bicarbonate-cit ac 137
potassium chlorid-d5-0.45%nacl
.......................................... 137
potassium chloride ............... 137
potassium chloride in 0.9%nacl
.......................................... 137
potassium chloride in 5 % dex
.......................................... 137
potassium chloride in lr-d5... 137
potassium chloride-0.45 % nacl
.......................................... 138
.......................................... 138
.......................................... 138
.......................................... 138
potassium citrate................... 138
potassium citrate-citric acid . 138
potassium hydroxide .............. 97
01 de enero 2016
potassium phosphate m-/d-basic
.......................................... 138
POTIGA ................................. 42
PRADAXA ............................ 68
PRALUENT PEN .................. 80
PRALUENT SYRINGE ........ 80
pramipexole............................ 59
PRANDIMET ........................ 46
pravastatin .............................. 81
prazosin .................................. 73
prednicarbate ........................ 101
prednisolone acetate ............. 110
prednisolone sodium phosphate
.................................. 110, 121
prednisone ............................ 121
PREMARIN ......................... 120
PREMASOL 10 % ................. 73
PREMASOL 6 % ................... 73
PREMPHASE ...................... 120
PREMPRO ........................... 120
prenatal ................................. 156
prenatal formula ................... 155
prenatal tablet ....................... 156
prenatal vit#96-ferrous fum-fa
.......................................... 156
prenatal vitamin with minerals
.......................................... 156
prenatal vitamins .................. 156
prenatal vit-iron fumarate-fa 156
preparation h hydrocortisone 101
PREVIDENT 5000 SENSITIVE
............................................ 95
PREZCOBIX ......................... 64
PREZISTA ............................. 64
PRIFTIN ................................ 56
PRILOSEC OTC .................. 111
PRIMAQUINE ...................... 58
primidone ............................... 42
PRISTIQ ................................ 44
PRIVIGEN ........................... 124
PROAIR HFA ...................... 140
PROAIR RESPICLICK ....... 140
probenecid ............................ 130
procainamide .......................... 75
PROCALAMINE 3% ............ 73
prochlorperazine..................... 57
prochlorperazine edisylate ..... 57
prochlorperazine maleate ....... 57
PROCRIT ......................... 68, 69
PROCYSBI .......................... 130
progesterone ......................... 122
progesterone micronized
capsules ............................ 122
PROGLYCEM ....................... 82
PROGRAF ........................... 124
PROLASTIN-C .................... 141
PROLENSA ......................... 110
PROLEUKIN ......................... 37
PROLIA ............................... 128
PROMACTA ......................... 69
promethazine .................... 53, 57
promethazine hcl .................... 57
promethazine-codeine ............ 92
promethazine-dm ................... 92
promethazine-phenylephcodeine ............................... 92
promolaxin ........................... 117
propafenone ............................ 75
propantheline .......................... 40
proparacaine ......................... 106
proparacaine hcl ................... 106
proparacaine-fluorescein sod 107
propranolol ............................. 76
propranolol-hydrochlorothiazid
............................................ 76
propylthiouracil .................... 122
PROQUAD (PF) .................. 125
prosight................................. 156
PROSOL 20 % ....................... 73
protamine ............................... 69
protriptyline ............................ 44
pseudoephedrine hcl ............... 92
PULMOZYME .................... 103
pure & gentle eye ................. 107
I-17
purelax .................................. 117
PURIXAN .............................. 37
pyrazinamide .......................... 56
pyridostigmine bromide 130, 132
pyridoxine ............................ 156
Q
q-dryl ...................................... 54
q-pap ................................. 19, 20
q-pap extra strength ................ 19
q-tapp dm ............................... 92
q-tussin ................................... 92
q-tussin dm ............................. 92
QUADRACEL (PF) ............. 125
quetiapine ............................... 62
QUILLIVANT XR ................. 83
quinapril ................................. 74
quinapril-hydrochlorothiazide 74
quinidine gluconate ................ 75
quinidine sulfate ..................... 75
quinine sulfate ........................ 58
QVAR .................................. 139
R
RABAVERT (PF) ................ 125
raloxifene.............................. 120
ramipril ................................... 74
RANEXA ............................... 78
ranitidine hcl......................... 111
RAPAMUNE ....................... 124
RASUVO (PF) ..................... 130
RAVICTI.............................. 114
REBIF (WITH ALBUMIN) . 130
REBIF REBIDOSE .............. 130
REBIF TITRATION PACK 131
RECOMBIVAX HB (PF) .... 125
recort plus ............................. 101
refenesen ................................ 92
refenesen pe ............................ 92
REFRESH CELLUVISC ..... 107
REFRESH CLASSIC (PF) ... 107
REFRESH LACRI-LUBE ... 107
REFRESH OPTIVE ............. 107
01 de enero 2016
REFRESH OPTIVE
ADVANCED ................... 109
reguloid ................................ 117
RELADOR PAK .................... 23
relcof c ................................... 92
RELENZA DISKHALER ...... 65
RELISTOR .......................... 114
remedy phytoplex antifungal . 50
REMICADE ......................... 131
REMODULIN...................... 143
RENAGEL ........................... 118
RENVELA ........................... 118
repaglinide.............................. 46
repaglinide-metformin ........... 46
REPATHA SURECLICK ...... 81
REPATHA SYRINGE ........... 81
RESCRIPTOR ....................... 64
RESTASIS ........................... 110
retaine cmc ........................... 107
RETROVIR............................ 64
REVLIMID ............................ 37
REXULTI .............................. 62
REYATAZ ............................. 64
REZIRA ................................. 92
ribavirin .................................. 66
RIDAURA ........................... 124
rifabutin .................................. 56
rifampin .................................. 56
RIFATER ............................... 56
ri-gel ii .................................. 115
riluzole ................................... 83
rimantadine ............................ 65
ri-mox ................................... 115
ringers .......................... 126, 138
risedronate ............................ 128
RISPERDAL CONSTA ......... 62
risperidone.............................. 62
RITUXAN.............................. 38
rivastigmine tartrate ............... 43
rizatriptan ............................... 56
robafen ................................... 92
robafen cough......................... 92
robafen dm ............................. 92
robitussin cough-chest cong dm
............................................ 92
ROBITUSSIN LONG-ACTING
............................................ 92
robitussin pediatric ................. 93
ropinirole ................................ 59
ROTARIX ............................ 125
ROTATEQ VACCINE ........ 125
ROZEREM........................... 142
rydex....................................... 93
rynex dm ................................ 93
S
SABRIL ................................. 42
safe tussin dm ......................... 93
SAIZEN ............................... 121
SAIZEN CLICK.EASY ....... 122
saline mist ............................ 107
salsalate .................................. 22
SANDOSTATIN LAR DEPOT
.......................................... 122
SANTYL ................................ 97
SAPHRIS (BLACK CHERRY)
............................................ 63
SAVELLA ............................. 83
scooby-doo one a day........... 156
scot-tussin dm ........................ 93
scot-tussin expectorant ........... 93
sea soft nasal mist ................ 107
selegiline hcl .......................... 59
selenium sulfide ..................... 98
SELZENTRY ......................... 64
senexon................................. 117
senior tabs ............................ 156
senna..................................... 117
senna lax ............................... 117
senna laxative ....................... 117
senna with docusate sodium . 117
senokot-s .............................. 117
SENSIPAR ........................... 131
sentry .................................... 156
sentry senior ......................... 156
I-18
SEREVENT DISKUS .......... 140
SEROSTIM .......................... 122
sertraline ................................. 44
setlakin ................................... 85
SIGNIFOR ........................... 131
silace ..................................... 117
siladryl sa ............................... 54
silapap .................................... 20
sildenafil oral tablet 20 mg .. 143,
144
SILENOR ............................... 44
siltussin sa .............................. 93
siltussin-dm ............................ 93
silver nitrate ............................ 98
silver nitrate applicators ......... 98
silver sulfadiazine................... 98
SIMBRINZA ........................ 132
simethicone .......................... 110
simply sleep ............................ 54
SIMPONI ............................. 131
SIMPONI ARIA................... 131
simvastatin.............................. 81
sinus & allergy (pseudoephed)
............................................ 54
sirolimus ............................... 124
SIRTURO ............................... 56
skin treatment ......................... 97
sleep aid (diphenhydramine) .. 54
sleep aid (doxylamine) ........... 54
smoothlax ............................. 118
sodium acetate ...................... 138
sodium bicarbonate ...... 115, 138
sodium chloride ... 107, 126, 138,
141
sodium chloride 0.45 %........ 138
sodium chloride 0.9 %.......... 138
sodium chloride 3 %............. 138
sodium chloride 5 %............. 138
sodium chloride-nahco3-kcl-peg
.......................................... 118
sodium citrate-citric acid ...... 139
sodium fluoride .............. 95, 156
01 de enero 2016
sodium lactate ...................... 139
sodium phosphate................. 139
sodium polystyrene sulfonate
.......................................... 115
sodium thiosulfate ................ 119
sod-pot-k cit-sod cit-cit acid 139
SOLTAMOX ......................... 38
SOLU-CORTEF (PF) .......... 121
SOMATULINE DEPOT ...... 122
SOMAVERT........................ 122
soothe (bismuth subsalicylate)
.......................................... 115
soothe regular strength ......... 115
sorbitol ................................. 126
sorbitol-mannitol .................. 127
sotalol ..................................... 76
sotalol hcl ............................... 76
SOVALDI .............................. 65
spectravite ............................ 156
spectravite adult 50+ ............ 156
spectravite advanced formula
.......................................... 156
spectravite senior ................. 156
spectravite senior w-lycopene
.......................................... 157
spectravite ultra women ....... 157
SPIRIVA RESPIMAT ......... 140
SPIRIVA WITH
HANDIHALER ............... 140
spironolactone ........................ 81
spironolacton-hydrochlorothiaz
............................................ 81
SPRYCEL .............................. 38
st joseph aspirin...................... 22
st. joseph aspirin..................... 22
stavudine ................................ 64
STELARA............................ 131
STERILE PADS .................. 131
STIOLTO RESPIMAT .......... 40
STIVARGA ........................... 38
stomach relief ....................... 115
stool softener ........................ 118
STRATTERA......................... 83
STRENSIQ........................... 103
streptomycin ........................... 25
stress 500 plus zinc .............. 157
stress b with zinc .................. 157
stress b-biotin ....................... 157
stress formula ....................... 157
stress formula plus iron ........ 157
stress formula with iron........ 157
stress formula with zinc ....... 157
STRIBILD .............................. 64
STRIVERDI RESPIMAT .... 140
sucralfate .............................. 111
sudogest .................................. 93
sudogest sinus & allergy ........ 54
sulfacetamide sodium ........... 109
sulfacetamide sodium (acne) .. 98
sulfacetamide-prednisolone . 109
sulfadiazine ............................ 32
sulfamethoxazole-trimethoprim
............................................ 32
sulfasalazine ........................... 32
sulfatrim ................................. 32
sulfazine ................................. 32
sulfazine ec ............................. 32
sulindac .................................. 22
sumatriptan nasal spray .......... 56
sumatriptan succinate ............. 56
summer's eve disposable douche
.......................................... 131
summers eve extra cleansing 131
sunvite .................................. 157
super b complex-vitamin c ... 157
super b maxi complex .......... 157
super b/c ............................... 157
super b-50 complex .............. 157
super b-50 complex plus ...... 157
super multiple....................... 157
super multivitamin ............... 157
super quints .......................... 158
super quints b-50 .................. 158
super thera vite m ................. 158
I-19
superior 35 ............................ 158
superplex-t ............................ 158
suphedrin ................................ 93
suphedrine pe day-night ......... 93
suphedrine severe cold max str
............................................ 93
support .................................. 158
support-500 .......................... 158
SUPPRELIN LA .................. 122
SUPRAX ................................ 29
SURMONTIL ........................ 44
SUSTIVA ............................... 64
SUTENT ................................ 38
SYLATRON .......................... 65
SYLVANT ............................. 38
SYMLINPEN 120 .................. 46
SYMLINPEN 60 .................... 46
SYNAGIS .............................. 65
SYNAREL ........................... 131
SYNERCID ............................ 27
SYNJARDY ........................... 46
SYNRIBO .............................. 38
SYPRINE ............................. 119
SYSTANE ............................ 107
SYSTANE GEL ................... 107
T
tab-a-vite .............................. 158
tab-a-vite/iron ....................... 158
tab-a-vite-minerals ............... 158
TABLOID .............................. 38
tacrolimus ..................... 101, 124
tactinal .................................... 20
tactinal extra strength ............. 20
TAFINLAR ............................ 38
TAGRISSO ............................ 38
TAMIFLU .............................. 65
tamoxifen................................ 38
tamsulosin ............................ 118
TARCEVA ............................. 38
TARGRETIN ......................... 38
tarina fe 1/20 (28) ................... 85
TASIGNA .............................. 38
01 de enero 2016
TAZORAC ........................... 102
taztia xt ................................... 77
tears again ............................ 107
tears naturale free (pf) .......... 107
TECFIDERA........................ 131
TECHNIVIE .......................... 65
TEFLARO.............................. 29
telmisartan .............................. 74
telmisartan-hydrochlorothiazid
............................................ 74
TEMODAR ............................ 38
TENIVAC (PF) .................... 125
terazosin ............................... 118
terbinafine hcl ........................ 50
terbutaline ............................ 140
terconazole ............................. 55
testosterone .......................... 119
testosterone cypionate .......... 119
testosterone enanthate .......... 119
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 126
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 126
TETANUS-DIPHTHERIA
TOXOIDS-TD ................. 126
tetrabenazine .......................... 83
tetracaine hcl (pf) ................. 107
tetracycline ............................. 33
THALOMID ........................ 131
the magic bullet .................... 118
theophylline.................. 140, 141
theophylline anhydrous ........ 140
theophylline in dextrose 5 % 140
thera m plus (ferrous fumarat)
.......................................... 158
thera vitamin ........................ 158
thera-d .................................. 158
theradex m ............................ 158
THERAFLU DAYTIME
COLD-COUGH ................. 93
THERAFLU MULTISYMPTOM COLD ............ 93
thera-m ................................. 158
therapeutic liquid.................. 158
therapeutic m + beta-carotene
.......................................... 158
therapeutic vitamin & mineral
.......................................... 159
therapeutic vitamins/minerals
.......................................... 159
therapeutic-m ....................... 159
therapeutic-m vitamin/minerals
.......................................... 159
thera-tabs .............................. 159
theratrum complete 50 plus .. 159
theratrum complete 50 plus/lut
.......................................... 159
thiamine hcl .......................... 159
thioridazine............................. 63
thiothixene.............................. 63
tiagabine ................................. 42
TICE BCG............................ 126
TIKOSYN .............................. 75
timolol maleate ............... 76, 132
TIVICAY ............................... 64
tizanidine .............................. 142
TOBI PODHALER ................ 25
TOBRADEX ST .................. 109
tobramycin ........................... 109
tobramycin in 0.225 % nacl ... 25
tobramycin in 0.9 % nacl ....... 25
tobramycin sulfate .................. 25
TOLAK .................................. 97
tolazamide .............................. 48
tolbutamide............................. 48
tolmetin .................................. 22
tolnaftate................................. 50
tolterodine ............................ 118
topiramate............................... 42
toposar intravenous ................ 38
torsemide ................................ 79
total b/c................................. 159
I-20
totalday multiple................... 159
TOUJEO SOLOSTAR ........... 47
TOVIAZ ............................... 118
TPN ELECTROLYTES ....... 139
TPN ELECTROLYTES II ... 139
TRACLEER ......................... 144
TRADJENTA ......................... 46
tramadol.................................. 20
tramadol-acetaminophen ........ 20
trandolapril ............................. 74
tranexamic acid ...................... 69
TRANSDERM-SCOP ............ 57
tranylcypromine ..................... 44
TRAVASOL 10 % ................. 73
TRAVATAN Z .................... 132
travel sickness (meclizine) ..... 58
travoprost (benzalkonium) ... 132
trazodone ................................ 44
TREANDA ............................. 38
TRECATOR ........................... 56
TRELSTAR............................ 39
tretinoin ................................ 102
tretinoin (chemotherapy) ........ 39
tretinoin microspheres .......... 102
TREXALL.............................. 39
triacting m-sym cold/cough.... 93
triamcinolone acetonide 95, 101,
102, 121
triaminic cold & cough (pe) ... 93
TRIAMINIC COLD & COUGH
NT (PE) .............................. 54
TRIAMINIC COUGH-SORE
THROAT............................ 93
triamterene-hydrochlorothiazid
...................................... 79, 80
TRIBENZOR ......................... 74
tri-buffered aspirin ................. 22
tri-dex pe ................................ 94
trifluoperazine ........................ 63
trifluridine ............................ 109
trihexyphenidyl ...................... 59
trimethoprim ........................... 27
01 de enero 2016
trimipramine........................... 45
triple antibiotic ....................... 98
triple paste af .......................... 51
TRIUMEQ ............................. 64
tri-vi-sol................................ 159
tri-vita................................... 159
tri-vitamin ............................ 159
TROKENDI XR..................... 42
TROPHAMINE 10 % ............ 73
TROPHAMINE 6% ............... 73
trospium ............................... 118
TRULICITY .......................... 46
TRUMENBA ....................... 126
TRUVADA ............................ 64
trymine cg .............................. 94
TUDORZA PRESSAIR ....... 141
tusnel diabetic ........................ 94
TUSNEL NEW FORMULA.. 94
TUSNEL PEDIATRIC .......... 94
TUSSI PRES-B ...................... 94
tussin cf .................................. 94
tussin cf cough-cold ............... 94
tussin cold-congestion ............ 94
tussin cough (dm only)........... 94
tussin dm ................................ 94
tussin dm cough & chest ........ 94
tussin maximum strength ....... 94
tussin pe ................................. 94
TWINRIX (PF) .................... 126
TYBOST .............................. 131
TYGACIL .............................. 33
TYKERB................................ 39
TYPHIM VI ......................... 126
TYSABRI ............................ 124
TYVASO ............................. 144
TYVASO REFILL KIT ....... 144
TYVASO STARTER KIT ... 144
TYZEKA................................ 66
U
ULORIC ............................... 131
ultra b-100 complex ............. 159
ultra fresh pm ....................... 107
ultra strength antacid ............ 115
unisom sleepgels .................... 54
UNITUXIN ............................ 39
ursodiol................................. 115
V
VAGIFEM ........................... 120
valacyclovir ............................ 66
VALCHLOR .......................... 97
valganciclovir ......................... 66
valproate sodium .................... 42
valproic acid ........................... 42
valproic acid (as sodium salt). 42
valsartan ................................. 74
valsartan-hydrochlorothiazide 74
VALSTAR ............................. 39
valu-tapp dm .......................... 94
VANACOF ............................ 94
vancomycin ............................ 27
vancomycin in d5w ................ 27
VAQTA (PF)........................ 126
VARIVAX (PF) ................... 126
VASCEPA ............................. 81
VELCADE ............................. 39
venlafaxine ............................. 45
verapamil ................................ 77
VERSACLOZ ........................ 63
VGO 40 ................................ 103
vicks dayquil cold&flu relief . 94
vicks dayquil cough ............... 94
vicks nature fusion cough ...... 94
vicks nyquil severe cold-flu ... 95
vicks qlearquil(oxymetazoline)
.......................................... 107
vicks sinex 12-hour .............. 107
VICTOZA .............................. 46
............................................ 64
............................................ 64
VIGAMOX .......................... 109
VIIBRYD ............................... 45
VIMIZIM ............................. 103
I-21
VIMPAT ................................ 42
vinorelbine.............................. 39
VIRACEPT ............................ 64
VIRAMUNE XR .................... 64
VIRAZOLE ............................ 66
virdec dm ................................ 95
VIREAD ................................. 64
virtussin ac ............................. 95
vision .................................... 159
vision formula ...................... 159
vision formula (with lutein) . 160
vision plus lutein .................. 160
vit b cmplx 3-fa-vit c-biotin . 160
vit b cmplx no3-fa-c-biot-zinc
.......................................... 160
vit b complex-folic acid ....... 160
vitalets .................................. 160
vitamin a ............................... 160
vitamin b complex ................ 160
vitamin b-100 complex ........ 160
vitamin b12-folic acid .......... 160
vitamin b-6 ........................... 160
vitamin c ............................... 160
vitamin d3............................. 160
vitamins & minerals ............. 161
vitamins b complex .............. 161
vitamins b1,b2,b3,b5, and b6 161
vitamins for hair ................... 161
VITEKTA .............................. 64
vitrum senior ........................ 161
VOLTAREN .......................... 22
voriconazole ........................... 51
VOTRIENT ............................ 39
VPRIV .................................. 103
W
wal-act d cold & allergy ......... 54
wal-dram ................................ 58
wal-dryl allergy ...................... 54
wal-fex allergy ....................... 54
wal-finate................................ 54
wal-finate-d ............................ 54
wal-itin ................................... 54
01 de enero 2016
wal-itin d ................................ 54
wal-itin d 12 hour ................... 54
wal-phed ........................... 54, 95
wal-phed pe day-night............ 95
wal-phed pe sinus & allergy .. 55
wal-profen .............................. 22
wal-sleep z ............................. 55
wal-som (diphenhydramine) .. 55
wal-tap.................................... 55
wal-tussin cough .................... 95
wal-tussin cough & cold cf .... 95
wal-tussin dm ......................... 95
wal-zan 75 ............................ 111
wal-zyr (cetirizine) ................. 55
wal-zyr d ................................ 55
warfarin .................................. 68
water for irrigation, sterile ... 127
womens daily gummies........ 161
women's daily multivitamin . 161
X
XALKORI.............................. 39
XARELTO ............................. 68
XELJANZ ............................ 131
XENAZINE ........................... 83
XIFAXAN.............................. 27
XOLAIR............................... 141
XTANDI ................................ 39
xylon 10.................................. 20
XYREM ............................... 142
Y
yelets .................................... 161
YERVOY ............................... 39
YF-VAX (PF) ...................... 126
YONDELIS ............................ 39
Z
zafirlukast ............................. 140
zaleplon ................................ 142
ZANTAC ............................. 111
ZANTAC 75 ........................ 111
ZARXIO................................. 69
ZAVESCA ........................... 104
ZELBORAF ........................... 39
ZEMPLAR ........................... 128
ZENPEP ............................... 104
zephrex-d ................................ 95
ZETIA .................................... 81
ZIAGEN ................................. 64
zidovudine ........................ 64, 65
zinc oxide ............................... 97
ziprasidone hcl ....................... 63
ZIRGAN ............................... 109
ZOLADEX ............................. 39
zoledronic acid ..................... 128
.......................................... 128
ZOLINZA .............................. 39
zolmitriptan ............................ 56
zolpidem ............................... 143
ZOMETA ............................. 128
ZONATUSS ........................... 95
zonisamide.............................. 42
zoo chews ............................. 161
ZORTRESS .......................... 124
ZOSTAVAX (PF) ................ 126
ZOVIRAX .............................. 97
z-sleep .................................... 55
ZUBSOLV ............................. 24
ZYDELIG .............................. 39
ZYKADIA.............................. 40
ZYLET ................................. 109
zyncof ..................................... 95
ZYPREXA RELPREVV ........ 63
ZYRTEC ................................ 55
ZYTIGA ................................. 40
ZYVOX .................................. 27
Este formulario se actualizó el 12/31/2015. Si tiene preguntas, llame al plan Community Care Plus
FIDA-MMP de ICS al 1.877.ICS.2525, de lunes a viernes, de 8 a. m. a 8 p. m. La llamada es gratuita.
Para obtener más información, visite www.icsny.org/care-plus.
I-22
01 de enero 2016
1.877.ICS.2525
www.icsny.org
Oﬁcina Administrativa
Independence Care System
257 Park Ave. South
2nd Floor
New York, NY 10010
Centros de Atención al Paciente
400 East Fordham Road
10th floor
Bronx, New York 10458
25 Elm Place
5th Floor
Brooklyn, NY 11201

ICS Community Care Plus FIDA-MMP

Transcripción

Documentos relacionados

ICS Community Care Plus FIDA-MMP

14 Julio al 17 Agosto

conoce los regalos que mejor quedan en tu árbol de navidad

Ten Facts About Mental Illness - KINGS COUNTY behavioral health

VNSNY CHOICE FIDA Complete