2017
FORMULARIO COMPLETOCARE N’ CARE CHOICE PREMIUM (PPO) CARE N’ CARE CHOICE PLUS (PPO) CARE N’ CARE CHOICE (PPO)CARE N’ CARE CLASSIC (HMO)
(LISTA DE MEDICAMENTOS CUBIERTOS)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
ID de formulario 00017381, Versión 8. Este Formulario fue actualizado el 12/01/2016. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con el médico conserje de Care N’ Care Health Plan al 1-877-374-7993 (TTY 711) del 1 de octubre al 14 de febrero: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, los siete días de la semana. Del 15 de febrero al 30 de septiembre: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, de lunes a viernes. También puede enviar un correo electrónico a su médico conserje a [email protected] o visite www.cnchealthplan.com
Care N’ Care es una organización de Medicare Advantage que tiene un contrato con Medicare. La inscripción en Care N’ Care depende de la renovación del contrato.
Y0107_16_170_SPFinal01
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Nota para los miembros actuales: este Formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma.
Cuando esta Lista de medicamentos (Formulario) menciona “nosotros”, “nos” o “nuestro”, hace referencia a Care N’ Care Insurance Company, Inc. Cuando menciona “plan” o “nuestro plan,” hace referencia a Care N’ Care Health Plan (PPO) y Care N’ Care Health Plan (HMO).
Este documento incluye una lista de los medicamentos (Formulario) de nuestro plan, la cual está en vigencia desde el 12/01/2016. Para obtener un Formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.
Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los beneficios, el Formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el lunes, 1 de enero de 2018 y periódicamente durante el año.
Esta información está disponible de forma gratuita en otros idiomas. Llame a su médico conserje al 1-877-374-7993.
This information is available for free in other languages. Please call our Member Services at 1-877-374-7993 for additional information.
Esta información está disponible en distintos formatos, tamaño de letra grande, cintas de audio y en español o Vietnamita. Llame a su médico conserje al número que figura arriba si necesita información sobre el plan en otro formato o idioma.
¿En qué consiste el Formulario de Care N’ Care Health Plan?Un formulario es una lista de medicamentos cubiertos seleccionados por Care N’ Care Health Plan con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se considera que son parte necesaria de un programa de tratamiento de calidad. Normalmente, Care N’ Care Health Plan cubrirá los medicamentos incluidos en el formulario siempre que el medicamento sea necesario desde el punto de vista médico, el medicamento con receta se obtenga en una farmacia de la red de Care N’ Care Health Plan y se cumpla con otras normas del plan Para obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de cobertura.
¿Puede cambiar el Formulario (lista de medicamentos)?En general, si usted toma un medicamento de nuestro Formulario para 2017 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2017, excepto cuando esté disponible un nuevo medicamento genérico de menor costo o cuando se dé a conocer nueva información adversa acerca de la seguridad o eficacia del medicamento. Otros tipos de cambios en el Formulario, como por ejemplo, la eliminación de un medicamento de nuestro Formulario, no afectarán a los miembros que estén actualmente tomando el medicamento. Continuará disponible al mismo costo compartido para aquellos miembros que estén tomándolo por el resto del año de cobertura. Consideramos que es importante que tenga acceso continuo a los medicamentos del Formulario que estaban disponibles cuando eligió nuestro plan durante el resto del año de cobertura, salvo en los casos en los que usted podría ahorrar más dinero o que nosotros podríamos garantizarle su seguridad.
Si retiramos medicamentos de nuestro Formulario, o agregamos autorizaciones previas, límites de cantidad o restricciones de tratamientos escalonados en relación con un medicamento, o si pasamos un medicamento a un nivel superior de costo compartido, debemos notificar sobre el cambio a los miembros afectados por el cambio al menos 60 días antes de que entre en vigencia dicho cambio, o cuando el miembro solicite un resurtido del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 60 días. Si la Administración de Drogas y Alimentos considera que un medicamento de nuestro Formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro
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Formulario y notificaremos a los miembros que toman el medicamento en cuestión. El Formulario adjunto está vigente a partir del 12/01/2016. Para recibir información actualizada sobre los medicamentos cubiertos por Care N’ Care Health Plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. Si el plan realiza algún cambio negativo en el formulario que no sea de mantenimiento, los miembros afectados recibirán un aviso por escrito que explique el cambio y se actualizará el formulario que aparece en nuestro sitio web.
¿Cómo utilizo el Formulario?Hay dos formas para encontrar su medicamento dentro del Formulario:
Afección médica
El Formulario empieza en la página 1. Los medicamentos de este Formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran dentro de la categoría “Agentes Cardiovasculares”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Luego busque su medicamento debajo del nombre de la categoría.
Listado alfabético
Si no está seguro de qué categoría debe consultar, debe buscar su medicamento en el Índice que comienza en la página 90. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. En el Índice, están tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?Care N’ Care Health Plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de marca.
¿Hay alguna restricción en mi cobertura?Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir:
• Autorización previa: el plan exige que usted o su médico obtengan una autorización previa paradeterminados medicamentos. Esto significa que necesitará contar con la aprobación de Care N’ CareHealth Plan antes de obtener sus medicamentos con receta. Si no tienen la aprobación, es posible queno cubramos el medicamento.
• Límites de cantidad: para ciertos medicamentos, el plan limita la cantidad del medicamento que cubrirá.Por ejemplo, Care N’ Care Health Plan provee 30 comprimidos por receta de Januvia, comprimidos de100 mg. Esto puede ser complementario a un suministro estándar para un mes o tres meses.
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• Tratamiento escalonado: En algunos casos, Care N’ Care Health Plan requiere que usted primeropruebe ciertos medicamentos para tratar su enfermedad antes de que cubramos otro medicamento paraesa enfermedad. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, esposible que el plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A.Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B.
Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el Formulario que empieza en la página 1. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones de tratamientos escalonados. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.
Puede pedirle a Care N’ Care Health Plan que haga una excepción a estas restricciones o límites o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Para obtener información sobre cómo solicitar una excepción, consulte la sección titulada “¿Cómo puedo solicitar que se haga una excepción al formulario de Care N’ Care Health Plan?” en la página iii.
¿Qué pasa si mi medicamento no está en el Formulario?Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe ponerse en contacto con el Departamento de Servicios para los miembros y preguntar si su medicamento está cubierto.
Si resulta que Care N’ Care Health Plan no cubre el medicamento que toma, tiene dos alternativas:
• Puede pedir al Departamento de Servicios para los miembros una lista de medicamentos similaresque estén cubiertos por el plan. Cuando reciba la lista, muéstresela a su médico y pídale que le receteun medicamento similar que esté cubierto por Care N’ Care Health Plan.
• Puede solicitarnos que hagamos una excepción y cubramos el medicamento. Consulte más abajopara obtener información sobre cómo solicitar una excepción.
¿Cómo puedo solicitar que se haga una excepción al Formulario de Care N’ Care Health Plan?Puede solicitarle a Care N’ Care Health Plan que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos.
Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor.
• Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido menorsi este medicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, estoreduciría el monto que usted debe pagar por su medicamento.
• Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Porejemplo, para ciertos medicamentos, el plan limita la cantidad del medicamento que cubriremos.Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción allímite y cubramos una cantidad mayor.
Por lo general, Care N’ Care Health Plan solo aprobará su pedido de excepción si los demás medicamentos incluidos en el formulario del plan, el medicamento de menor costo compartido o las restricciones de uso adicionales no fueran tan efectivos para tratar su enfermedad o pudieran causarle efectos médicos adversos.
Debe ponerse en contacto con nosotros para solicitarnos una decisión inicial de cobertura respecto de una excepción al Formulario, al nivel o a la restricción de uso. Cuando solicita una excepción al Formulario, al nivel o a la restricción de uso, debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas.
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la solicitud de una excepción?Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el Formulario pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al Formulario para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado a seguir en su caso, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted sea miembro de nuestro plan.
Para cada uno de los medicamentos que no están incluidos en el Formulario o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta para menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días.
Si reside en un centro de atención a largo plazo, le permitiremos resurtir su receta hasta que le hayamos provisto un suministro de transición de 91 a 98 días, de manera consistente con incremento de provisión (a menos que tenga una receta para menos días). Cubriremos más de un resurtido de estos medicamentos durante los primeros 90 días en que usted sea miembro del plan. Si necesita un medicamento que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días (a menos que tenga una receta para menos días) mientras solicita la excepción al Formulario.
• Transición entre los años del plan: Debido a que la lista de medicamentos cubiertos que apareceen el formulario está sujeta a cambios de un año al otro, tenemos una política de transición para losmiembros actuales de Care N’ Care Health Plan que toman medicamentos que no estarán cubiertosen el nuevo año del plan o medicamentos que tendrán una tratamiento escalonado, autorización
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previa, o restricción en el límite de cantidad en el nuevo año del plan. Durante los primeros 90 días del nuevo año del plan, Care N’ Care Health Plan cubrirá un suministro temporario para 30 días (a menos que presente una receta para menos de 30 días, en cuyo caso permitiremos obtener múltiples surtidos hasta un total de 30 días) del medicamento con receta no incluido en el formulario (o medicamentos que tienen un tratamiento escalonado, requieren autorización previa o tienen restricción en el límite de cantidad) una vez que haya obtenido la receta de los medicamentos surtidos dentro los últimos 120 días desde la fecha en que intentó obtener un surtido. Además, los miembros a los que se les otorgó una excepción en el año del plan anterior y que continúan en el mismo plan para el nuevo año del plan se les permitirá un suministro temporario de 30 días (a menos que presente una receta para menos de 30 días, en cuyo caso permitiremos obtener múltiples surtidos hasta durante un total de 30 días).
• Transición de emergencia y cambios en el nivel de atención: Es posible que haya un cambio en elentorno de tratamiento a causa del nivel de atención que se necesita. Estas transiciones incluyen a:
Si recibe el alta del hospital o un centro de enfermería especializada y se trasladaa un ámbito domiciliario
Si ingresa a un hospital o centro de atención de enfermería especializada desdeun ámbito domiciliario
Si se traslada desde un centro de enfermería especializada a otro y este nuevocentro recibe los suministros de una farmacia diferente
Si finaliza su estadía de la Parte A de Medicare en un centro de atención deenfermería especializada (en donde los pagos incluyen todos los gastosde farmacia) y necesita utilizar ahora los beneficios de su plan de la Parte D
Si abandona el estado de hospicio y vuelven a la cobertura de la Parte A y Bde Medicare
Si se encuentra fuera del período de transición y experimenta un cambio en el nivel de atención, Care N’ Care Health Plan le permitirá obtener resurtido de los medicamentos del formulario durante 30/31 días (30 días en una farmacia minorista y 31 días en un entorno de atención a largo plazo [LTC]) y surtido de transición durante 30/31 días de emergencia (30 días en una farmacia minorista y 31 días en un entorno de LTC) para los medicamentos no incluidos en el formulario pero que requieren autorización previa o tratamiento escalonado). Esto ocurrirá según cada caso particular una vez que se haya presentado una excepción o apelación pero no se haya completado al finalizar el período de transición. Todos los surtidos de transición para los nuevos miembros, ya sean en farmacias minoristas o en entornos LTC, se tramitarán de manera automática. Si solicita un surtido fuera de los primeros 90 días con Care N’ Care Health Plan, usted o su farmacéutico deberá comunicarse con nosotros al 1-855-791-5302, los 7 días de la semana, 24 horas al día (los usuarios de TTY/TDD deben llamar al 711) así le implementamos nuestra política de transición. Si se inscribe en nuestro plan mientras vivía en su hogar y luego se convierte en residente de un centro LTC, comuníquese con nosotros al 1-855-791-5302, los 7 días de la semana, 24 horas al día (los usuarios de TTY/TDD deben llamar al 711) para informarnos que ahora es residente de un centro LTC. Podemos implementar una política de transición de LTC para usted. Esta política no aplica a licencias de corto plazo (es decir, feriados o vacaciones) de un LTC o un centro hospitalario.
Le enviaremos un aviso por escrito a través del correo de primera clase de E.E. U.U. dentro de los tres días hábiles a partir del momento en el que recibimos la transacción del surtido de transición de la farmacia. Esta incluirá una explicación del carácter temporal del surtido con receta, las instrucciones para identificar una alternativa terapéutica adecuada que se encuentre en nuestro formulario, una explicación de su derecho a solicitar una excepción al formulario y el procedimiento para solicitar la excepción al formulario.
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Para obtener más informaciónPara obtener información más detallada sobre la cobertura para medicamentos con receta de Care N’ Care Health Plan, consulte la Evidencia de cobertura y la demás documentación del plan.
Si tiene alguna pregunta sobre Care N’ Care Health Plan, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en las páginas de la portada y la portada posterior.
Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), durante las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O, visite http://www.medicare.gov.
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Formulario de Care N’ Care Health PlanEl formulario que se incluye más abajo brinda información sobre los medicamentos que cubre Care N’ Care Health Plan. Si tiene alguna dificultad para encontrar en la lista el medicamento que toma, consulte el Índice que comienza en la página 90.
La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (p. ej., JANUVIA), y los medicamentos genéricos están en letra minúscula y cursiva (p. ej., atorvastatin).
La información incluida en la columna de Requisitos/Límites indica si Care N’ Care Health Plan tiene algún requisito especial para la cobertura del medicamento. Todos los medicamentos de la Lista de medicamentos del plan se encuentran en uno de los cinco niveles de costo compartido. En la segunda columna de esta tabla, se indica el nivel de cada medicamento.
• Nivel 1: medicamentos genéricos preferidos: Menor costo, medicamentos genéricoso de marca comúnmente utilizados
• Nivel 2: medicamentos genéricos: Medicamentos genéricos o de marca que el plan ofrecea un costo mayor para usted que los medicamentos genéricos preferidos del nivel 1.
• Nivel 3: medicamentos de marca preferidos: Varios medicamentos de marca conocidosy algunos medicamentos genéricos de alto costo
• Nivel 4: medicamentos de marca no preferidos: Medicamentos genéricos no preferidosy medicamentos de marca no preferidos
• Nivel 5: medicamentos especializados: Medicamentos únicos o de alto costo
• Tier 4 – Non-Preferred Drugs $90 copay $180 copay• Tier 5 – Specialty Drugs 33% coinsurance 33% coinsurance
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Durante la Etapa de cobertura inicial, el plan paga la parte que le corresponde de los costos de susmedicamentos recetados cubiertos y usted paga la suya (el monto de su copago o coseguro). Su parte del costo variará según el medicamento y el lugar donde surta su receta. A continuación, encontrará un resumen delmonto de su copago según el nivel del medicamento.
Pedido por correo ominorista estándardentro de la red(hasta un suministropara 30 días)
Pedido por correo ominorista estándardentro de la red(hasta un suministro para 90días)
Care N’ Care Choice Premium (PPO) • Nivel 1 - Medicamentos genéricos
preferidos• Nivel 2 - Medicamentos genéricos• Nivel 3 - Medicamentos de marca
preferidos• Nivel 4 - Medicamentos de marca no• preferidos• Nivel 5 - Medicamentos de especialidad
Copago de $0
Copago de $10
Copago de $40
Copago de $85
Coseguro del 33%
Copago de $0
Copago de $20
Copago de $80
Copago de $170
Coseguro del 33%
Care N’ Care Choice Plus (PPO) • Nivel 1 - Medicamentos genéricos
preferidos• Nivel 2 - Medicamentos genéricos• Nivel 3 - Medicamentos de marca
preferidos• Nivel 4 - Medicamentos de marca no• preferidos• Nivel 5 - Medicamentos de especialidad
Copago de $0
Copago de $12
Copago de $45
Copago de $90
Coseguro del 33%
Copago de $0
Copago de $24
Copago de $90
Copago de $180
Coseguro del 33%
Care N’ Care Choice (PPO) • Nivel 1 - Medicamentos genéricos
preferidos• Nivel 2 - Medicamentos genéricos• Nivel 3 - Medicamentos de marca
preferidos• Nivel 4 - Medicamentos de marca no• preferidos• Nivel 5 - Medicamentos de especialidad
Copago de $4
Copago de $15
Copago de $45
Copago de $100
Coseguro del 33%
Copago de $8
Copago de $30
Copago de $90
Copago de $200
Coseguro del 33%
Care N' Care Classic (HMO) • Nivel 1 - Medicamentos genéricos
preferidos• Nivel 2 - Medicamentos genéricos• Nivel 3 - Medicamentos de marca
preferidos• Nivel 4 - Medicamentos de marca no• preferidos• Nivel 5 - Medicamentos de especialidad
Copago de $0
Copago de $8
Copago de $40
Copago de $90
Coseguro del 33%
Copago de $0
Copago de $16
Copago de $80
Copago de $180
Coseguro del 33%
Para conocer más detalles sobre el beneficio de medicamentos recetados, consulte su Evidencia de cobertura.
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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LEGEND
1: Tier 1 - Preferred Generics
2: Tier 2 - Generics
3: Tier 3 - Preferred Brands
4: Tier 4 - Non-Preferred Drugs
5: Tier 5 - Specialty
BD: Part B vs Part D determination. This prescription drug may be covered under Medicare Part B or D
depending upon the circumstances.
LA: Limited Access. This prescription drug is limited to certain pharmacies.
NMO: Not available through Mail Order.
PA: Prior Authorization. You (or your physician) are required to get prior authorization before you fill your
prescription for this drug. Without prior approval, we may not cover this drug.
QL: Quantity Limit. There is a limit on the amount of this drug that is covered per prescription, or within a
specific time frame.
ST: Step Therapy. In some cases, you may be required to first try certain drugs to treat your medical condition
before we will cover another drug for that condition.
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
ANALGESICS
OPIOID ANALGESICS, LONG-ACTING
EMBEDA ORAL CAPSULE EXTENDED RELEASE* 100-4
MG 5 NMO; QL (60 EA per 30 days)
EMBEDA ORAL CAPSULE EXTENDED RELEASE* 20-
0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG 4 NMO; QL (60 EA per 30 days)
FENTANYL TRANSDERMAL PATCH 72 HR 100
MCG/HR, 12 MCG/HR, 25 MCG/HR, 37.5 MCG/HR, 50
MCG/HR, 62.5 MCG/HR, 75 MCG/HR, 87.5 MCG/HR
3 NMO; QL (10 EA per 30 days)
hydromorphone hcl er oral 12 mg, 8 mg 4 NMO; QL (60 EA per 30 days)
hydromorphone hcl er oral 16 mg, 32 mg 5 NMO; QL (60 EA per 30 days)
HYSINGLA ER ORAL 100 MG, 120 MG 5 PA; NMO; QL (60 EA per 30
days)
HYSINGLA ER ORAL 20 MG, 30 MG, 40 MG, 60 MG, 80
MG 4
PA; NMO; QL (60 EA per 30
days)
LEVORPHANOL TARTRATE ORAL TABLET 2 MG 3 NMO; QL (240 EA per 30 days)
METHADONE HCL INJECTION SOLUTION 10 MG/ML 4 NMO; QL (360 ML per 30 days)
METHADONE HCL ORAL SOLUTION 10 MG/5ML 3 NMO; QL (1800 ML per 30 days)
METHADONE HCL ORAL SOLUTION 5 MG/5ML 3 NMO; QL (3600 ML per 30 days)
METHADONE HCL ORAL TABLET 10 MG, 5 MG 3 NMO; QL (240 EA per 30 days)
MORPHINE SULFATE ER BEADS ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 120 MG, 30 MG, 45 MG,
60 MG, 75 MG, 90 MG
3 NMO; QL (60 EA per 30 days)
MORPHINE SULFATE ER ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50
MG, 60 MG, 80 MG
3 NMO; QL (60 EA per 30 days)
MORPHINE SULFATE ER ORAL TABLET
EXTENDEDRELEASE* 100 MG, 200 MG 3 NMO; QL (90 EA per 30 days)
morphine sulfate er oral tablet extendedrelease* 15 mg, 30
mg, 60 mg 2 NMO; QL (90 EA per 30 days)
OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40 MG,
5 MG, 7.5 MG 3 NMO; QL (60 EA per 30 days)
OPANA ORAL TABLET 10 MG, 5 MG 3 NMO; QL (180 EA per 30 days)
OXYCODONE HCL ER ORAL 10 MG, 20 MG 3 NMO; QL (60 EA per 30 days)
OXYCODONE HCL ER ORAL 40 MG, 80 MG 4 NMO; QL (60 EA per 30 days)
OXYCONTIN ORAL 15 MG, 30 MG, 60 MG 4 NMO; QL (60 EA per 30 days)
Care N' Care Health Plan (List of Covered Drugs)
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
3
Drug Drug Tier Requirements/Limits
oxymorphone hcl er oral tablet extended release 12 hr* 10 mg,
15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg 4 NMO; QL (60 EA per 30 days)
SUBSYS SUBLINGUAL LIQUID† 100 MCG, 200 MCG,
400 MCG 5
PA; NMO; QL (120 EA per 30
days)
SUBSYS SUBLINGUAL LIQUID† 600 MCG, 800 MCG 5 PA; NMO; QL (240 EA per 30
days)
tramadol hcl er (biphasic) oral tablet extended release 24 hr*
300 mg 2 NMO; QL (30 EA per 30 days)
tramadol hcl er oral tablet extended release 24 hr* 100 mg,
200 mg 2 NMO; QL (30 EA per 30 days)
OPIOID ANALGESICS, SHORT-ACTING
ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100
MCG 4
PA; NMO; QL (120 EA per 30
days)
ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 200
MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG 5
PA; NMO; QL (120 EA per 30
days)
acetaminophen-codeine #2 oral tablet 300-15 mg 2 NMO; QL (180 EA per 30 days)
acetaminophen-codeine #3 oral tablet 300-30 mg 2 NMO; QL (180 EA per 30 days)
ACETAMINOPHEN-CODEINE #4 ORAL TABLET 300-60
MG 3 NMO; QL (180 EA per 30 days)
acetaminophen-codeine oral solution 120-12 mg/5ml 2 NMO; QL (5000 ML per 30 days)
ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG 3 PA; NMO; QL (180 EA per 30
days)
BUTALBITAL-APAP-CAFF-COD ORAL CAPSULE 50-
325-40-30 MG 3
PA; NMO; QL (180 EA per 30
days)
BUTALBITAL-APAP-CAFFEINE ORAL TABLET 50-325-
40 MG 3
PA; NMO; QL (180 EA per 30
days)
BUTALBITAL-ASA-CAFF-CODEINE ORAL CAPSULE
50-325-40-30 MG 3
PA; NMO; QL (180 EA per 30
days)
BUTALBITAL-ASPIRIN-CAFFEINE ORAL CAPSULE 50-
325-40 MG 3
PA; NMO; QL (180 EA per 30
days)
butorphanol tartrate injection solution 1 mg/ml 2 NMO; QL (960 ML per 30 days)
butorphanol tartrate injection solution 2 mg/ml 2 NMO; QL (480 ML per 30 days)
butorphanol tartrate nasal solution 10 mg/ml 2 NMO; QL (10 ML per 30 days)
capital/codeine oral suspension 120-12 mg/5ml 2 NMO; QL (5010 ML per 30 days)
codeine sulfate oral tablet 15 mg, 30 mg 2 NMO; QL (180 EA per 30 days)
CODEINE SULFATE ORAL TABLET 60 MG 3 NMO; QL (180 EA per 30 days)
duramorph injection solution 0.5 mg/ml 2 BD; NMO; QL (7200 ML per 30
days)
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
duramorph injection solution 1 mg/ml 2 BD; NMO; QL (3600 ML per 30
days)
fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 400 mcg,
600 mcg, 800 mcg 5
PA; NMO; QL (120 EA per 30
days)
fentanyl citrate buccal lollipop 200 mcg 4 PA; NMO; QL (120 EA per 30
days)
FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400
MCG, 600 MCG, 800 MCG 5
PA; NMO; QL (120 EA per 30
days)
hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml 2 NMO; QL (5500 ML per 30 days)
hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg 2 NMO; QL (360 EA per 30 days)
hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-200 mg 2 NMO; QL (150 EA per 30 days)
hydromorphone hcl oral liquid† 1 mg/ml 4 NMO; QL (1920 ML per 30 days)
hydromorphone hcl oral tablet 2 mg, 4 mg 2 NMO; QL (360 EA per 30 days)
HYDROMORPHONE HCL ORAL TABLET 8 MG 3 NMO; QL (240 EA per 30 days)
LAZANDA NASAL SOLUTION 100 MCG/ACT, 300
MCG/ACT, 400 MCG/ACT 5
PA; NMO; QL (30 EA per 30
days)
morphine sulfate (concentrate) oral solution 100 mg/5ml 2 NMO; QL (600 ML per 30 days)
morphine sulfate oral solution 10 mg/5ml 2 NMO; QL (3600 ML per 30 days)
morphine sulfate oral solution 20 mg/5ml 2 NMO; QL (2700 ML per 30 days)
morphine sulfate oral tablet 15 mg, 30 mg 2 NMO; QL (180 EA per 30 days)
oxycodone hcl oral concentrate 100 mg/5ml 2 NMO; QL (360 ML per 30 days)
oxycodone hcl oral tablet 10 mg, 15 mg, 5 mg 2 NMO; QL (180 EA per 30 days)
OXYCODONE HCL ORAL TABLET 20 MG, 30 MG 3 NMO; QL (180 EA per 30 days)
OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-
325 MG 3 NMO; QL (180 EA per 30 days)
oxycodone-acetaminophen oral tablet 5-325 mg 2 NMO; QL (360 EA per 30 days)
OXYCODONE-ACETAMINOPHEN ORAL TABLET 7.5-
325 MG 3 NMO; QL (240 EA per 30 days)
oxycodone-aspirin oral tablet 4.8355-325 mg 2 NMO; QL (360 EA per 30 days)
oxycodone-ibuprofen oral tablet 5-400 mg 2 NMO; QL (240 EA per 30 days)
OXYMORPHONE HCL ORAL TABLET 10 MG, 5 MG 3 NMO; QL (180 EA per 30 days)
SYNALGOS-DC ORAL CAPSULE 356.4-30-16 MG 4 NMO; QL (330 EA per 30 days)
tramadol hcl oral tablet 50 mg 1 NMO; QL (240 EA per 30 days)
tramadol-acetaminophen oral tablet 37.5-325 mg 1 NMO; QL (360 EA per 30 days)
ANESTHETICS
LOCAL ANESTHETICS
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
lidocaine hcl (pf) injection solution 0.5 % 1 NMO
lidocaine hcl injection solution 2 % 1 NMO
lidocaine-prilocaine external cream 2.5-2.5 % 2 NMO
ANTI-ADDICTION/SUBSTANCE ABUSE
TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium oral tablet delayed release 333 mg 2
disulfiram oral tablet 250 mg 2
disulfiram oral tablet 500 mg 1
naltrexone hcl oral tablet 50 mg 1 NMO
VIVITROL INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 380 MG 5 NMO
OPIOID ANTAGONISTS
BUPRENORPHINE HCL SUBLINGUAL TABLET
SUBLINGUAL 2 MG 3
PA; NMO; QL (90 EA per 30
days)
BUPRENORPHINE HCL SUBLINGUAL TABLET
SUBLINGUAL 8 MG 3
PA; NMO; QL (60 EA per 30
days)
BUPRENORPHINE HCL-NALOXONE HCL SUBLINGUAL
TABLET SUBLINGUAL 2-0.5 MG 3
PA; NMO; QL (360 EA per 30
days)
BUPRENORPHINE HCL-NALOXONE HCL SUBLINGUAL
TABLET SUBLINGUAL 8-2 MG 3
PA; NMO; QL (90 EA per 30
days)
naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml 1 NMO
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1
MG, 8-2 MG 4 PA; NMO
SMOKING CESSATION AGENTS
buproban oral tablet extended release 12 hr* 150 mg 2 NMO
bupropion hcl er (smoking det) oral tablet extended release 12
hr* 150 mg 1 NMO
bupropion hcl er (xl) oral tablet extended release 24 hr* 150
mg 2
CHANTIX CONTINUING MONTH PAK ORAL TABLET 1
MG 3 NMO
CHANTIX ORAL TABLET 0.5 MG, 1 MG 3 NMO
CHANTIX STARTING MONTH PAK ORAL TABLET 0.5
MG X 11 & 1 MG X 42 3 NMO
NICOTROL INHALATION INHALER 10 MG 4 NMO
ANTIBACTERIALS
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
AMINOGLYCOSIDES
AMIKACIN SULFATE INJECTION SOLUTION 500
MG/2ML 3 NMO
gentamicin in saline intravenous* solution 0.8-0.9 mg/ml-%,
1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%2 NMO
gentamicin sulfate injection solution 40 mg/ml 2 NMO
gentamicin sulfate intravenous* solution 10 mg/ml 2 NMO
neomycin sulfate oral tablet 500 mg 1 NMO
PAROMOMYCIN SULFATE ORAL CAPSULE 250 MG 3 NMO
STREPTOMYCIN SULFATE INTRAMUSCULAR*
SOLUTION RECONSTITUTED 1 GM 3 NMO
TOBI PODHALER INHALATION CAPSULE 28 MG 5 NMO
tobramycin inhalation nebulization solution 300 mg/5ml 2 BD; NMO
tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml 2 NMO
ANTIBACTERIALS, OTHER
chloramphenicol sod succinate intravenous* solution
reconstituted 1 gm 2 NMO
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 NMO
clindamycin palmitate hcl oral solution reconstituted 75
mg/5ml 2 NMO
CLINDAMYCIN PHOSPHATE IN D5W INTRAVENOUS*
SOLUTION 300 MG/50ML, 600 MG/50ML, 900 MG/50ML 3 NMO
CLINDAMYCIN PHOSPHATE INJECTION SOLUTION
300 MG/2ML, 600 MG/4ML, 900 MG/6ML 3 NMO
colistimethate sodium injection solution reconstituted 150 mg 4 BD; NMO
CUBICIN INTRAVENOUS* SOLUTION
RECONSTITUTED 500 MG 5 NMO
lincomycin hcl injection solution 300 mg/ml 2 BD; NMO
linezolid intravenous* solution 600 mg/300ml 5 NMO
linezolid oral suspension reconstituted 100 mg/5ml 4 NMO
linezolid oral tablet 600 mg 5 NMO; QL (60 EA per 30 days)
METHENAMINE HIPPURATE ORAL TABLET 1 GM 3 NMO
metronidazole in nacl intravenous* solution 500-0.79
mg/100ml-% 2 NMO
metronidazole oral capsule 375 mg 2 NMO
metronidazole oral tablet 250 mg, 500 mg 2 NMO
NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE
100 MG 3 PA; NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
nitrofurantoin macrocrystal oral capsule 25 mg, 50 mg 2 PA; NMO
nitrofurantoin monohyd macro oral capsule 100 mg 2 PA; NMO
nitrofurantoin oral suspension 25 mg/5ml 2 PA; NMO
polymyxin b sulfate injection solution reconstituted 500000
unit 2 NMO
SYNERCID INTRAVENOUS* SOLUTION
RECONSTITUTED 150-350 MG 5 BD; NMO
TINIDAZOLE ORAL TABLET 250 MG, 500 MG 3 NMO
trimethoprim oral tablet 100 mg 1 NMO
TYGACIL INTRAVENOUS* SOLUTION
RECONSTITUTED 50 MG 4 BD; NMO
VANCOMYCIN HCL INTRAVENOUS* SOLUTION
RECONSTITUTED 10 GM, 1000 MG, 500 MG 3 NMO
vancomycin hcl oral capsule 125 mg, 250 mg 4 NMO
XIFAXAN ORAL TABLET 200 MG 4 PA; NMO
XIFAXAN ORAL TABLET 550 MG 5 PA; NMO
BETA-LACTAM, CEPHALOSPORINS
CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12
HR* 500 MG 3 NMO
cefaclor oral capsule 250 mg, 500 mg 2 NMO
cefadroxil oral capsule 500 mg 1 NMO
cefadroxil oral suspension reconstituted 250 mg/5ml, 500
mg/5ml 2 NMO
cefadroxil oral tablet 1 gm 2 NMO
CEFAZOLIN SODIUM INJECTION SOLUTION
RECONSTITUTED 1 GM, 10 GM, 500 MG 3 NMO
cefdinir oral capsule 300 mg 2 NMO
cefdinir oral suspension reconstituted 125 mg/5ml, 250
mg/5ml 2 NMO
cefepime hcl injection solution reconstituted 1 gm, 2 gm 4 NMO
CEFIXIME ORAL SUSPENSION RECONSTITUTED 100
MG/5ML, 200 MG/5ML 3 NMO
cefotaxime sodium injection solution reconstituted 2 gm, 500
mg 2 NMO
cefotetan disodium injection solution reconstituted 1 gm, 2 gm 4 NMO
cefoxitin sodium injection solution reconstituted 10 gm 4 NMO
cefoxitin sodium intravenous* solution reconstituted 1 gm, 2
gm 4 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
cefpodoxime proxetil oral suspension reconstituted 100
mg/5ml, 50 mg/5ml 4 NMO
cefpodoxime proxetil oral tablet 100 mg, 200 mg 4 NMO
cefprozil oral suspension reconstituted 125 mg/5ml, 250
mg/5ml 2 NMO
cefprozil oral tablet 250 mg, 500 mg 2 NMO
CEFTAZIDIME INJECTION SOLUTION
RECONSTITUTED 1 GM, 2 GM, 6 GM 3 NMO
CEFTIN ORAL SUSPENSION RECONSTITUTED 125
MG/5ML, 250 MG/5ML 4 NMO
CEFTRIAXONE SODIUM INJECTION SOLUTION
RECONSTITUTED 250 MG, 500 MG 3 NMO
CEFTRIAXONE SODIUM INTRAVENOUS* SOLUTION
RECONSTITUTED 1 GM, 10 GM, 2 GM 3 NMO
cefuroxime axetil oral tablet 250 mg, 500 mg 2 NMO
CEFUROXIME SODIUM INJECTION SOLUTION
RECONSTITUTED 1.5 GM, 7.5 GM, 750 MG 3 NMO
cephalexin oral capsule 250 mg, 500 mg 1 NMO
cephalexin oral suspension reconstituted 125 mg/5ml, 250
mg/5ml 2 NMO
cephalexin oral tablet 250 mg 1 NMO
CLAFORAN INTRAVENOUS* SOLUTION
RECONSTITUTED 1 GM 4 NMO
FORTAZ INTRAVENOUS* SOLUTION
RECONSTITUTED 1 GM 4 NMO
SUPRAX ORAL CAPSULE 400 MG 3 NMO
SUPRAX ORAL SUSPENSION RECONSTITUTED 500
MG/5ML 3 NMO
SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 3 NMO
TAZICEF INJECTION SOLUTION RECONSTITUTED 2
GM 3 BD; NMO
TEFLARO INTRAVENOUS* SOLUTION
RECONSTITUTED 400 MG, 600 MG 4 NMO
ZERBAXA INTRAVENOUS* SOLUTION
RECONSTITUTED 1.5 (1-0.5) GM 4 NMO
BETA-LACTAM, OTHER
AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION
2 GM 4 NMO
aztreonam injection solution reconstituted 1 gm 4 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
CAYSTON INHALATION SOLUTION RECONSTITUTED
75 MG 5 PA; NMO
DORIBAX INTRAVENOUS* SOLUTION
RECONSTITUTED 500 MG 4 NMO
IMIPENEM-CILASTATIN INTRAVENOUS* SOLUTION
RECONSTITUTED 250 MG, 500 MG 3 NMO
INVANZ INJECTION SOLUTION RECONSTITUTED 1
GM 4 NMO
meropenem intravenous* solution reconstituted 500 mg 4 NMO
BETA-LACTAM, PENICILLINS
amoxicillin oral capsule 250 mg, 500 mg 1 NMO
amoxicillin oral suspension reconstituted 125 mg/5ml, 200
mg/5ml, 250 mg/5ml, 400 mg/5ml 1 NMO
amoxicillin oral tablet 500 mg, 875 mg 1 NMO
amoxicillin oral tablet chewable 125 mg, 250 mg 1 NMO
AMOXICILLIN-POT CLAVULANATE ER ORAL TABLET
EXTENDED RELEASE 12 HR* 1000-62.5 MG 3 NMO
amoxicillin-pot clavulanate oral suspension reconstituted 200-
28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9
mg/5ml
2 NMO
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125
mg, 875-125 mg 2 NMO
amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg,
400-57 mg 2 NMO
ampicillin oral capsule 250 mg 1 NMO
ampicillin oral capsule 500 mg 2 NMO
ampicillin oral suspension reconstituted 125 mg/5ml, 250
mg/5ml 2 NMO
ampicillin sodium injection solution reconstituted 1 gm, 125
mg 2 NMO
ampicillin sodium intravenous* solution reconstituted 10 gm 2 NMO
AMPICILLIN-SULBACTAM SODIUM INJECTION
SOLUTION RECONSTITUTED 3 (2-1) GM 3 NMO
AMPICILLIN-SULBACTAM SODIUM INTRAVENOUS*
SOLUTION RECONSTITUTED 1.5 (1-0.5) GM, 15 (10-5)
GM
3 NMO
BACTOCILL IN DEXTROSE INTRAVENOUS*
SOLUTION 1 GM/50ML, 2 GM/50ML 4 NMO
BICILLIN C-R 900/300 INTRAMUSCULAR*
SUSPENSION 900000-300000 UNIT/2ML 3 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
BICILLIN C-R INTRAMUSCULAR* SUSPENSION
1200000 UNIT/2ML 3 NMO
BICILLIN L-A INTRAMUSCULAR* SUSPENSION
1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML 3 NMO
dicloxacillin sodium oral capsule 250 mg 1 NMO
dicloxacillin sodium oral capsule 500 mg 2 NMO
NAFCILLIN SODIUM INJECTION SOLUTION
RECONSTITUTED 1 GM 4 NMO
nafcillin sodium injection solution reconstituted 10 gm 4 NMO
oxacillin sodium injection solution reconstituted 10 gm, 2 gm 4 NMO
PENICILLIN G POT IN DEXTROSE INTRAVENOUS*
SOLUTION 40000 UNIT/ML, 60000 UNIT/ML 3 NMO
PENICILLIN G POTASSIUM INJECTION SOLUTION
RECONSTITUTED 5000000 UNIT 3 NMO
PENICILLIN G PROCAINE INTRAMUSCULAR*
SUSPENSION 600000 UNIT/ML 4 NMO
PENICILLIN G SODIUM INJECTION SOLUTION
RECONSTITUTED 5000000 UNIT 3 NMO
penicillin v potassium oral solution reconstituted 125 mg/5ml,
250 mg/5ml 2 NMO
penicillin v potassium oral tablet 250 mg, 500 mg 1 NMO
piperacillin sod-tazobactam so intravenous* solution
reconstituted 3.375 (3-0.375) gm, 4.5 (4-0.5) gm 4 NMO
ZOSYN INTRAVENOUS* SOLUTION 2-0.25 GM/50ML, 3-
0.375 GM/50ML 4 NMO
MACROLIDES
azithromycin intravenous* solution reconstituted 500 mg 2 NMO
azithromycin oral packet 1 gm 2 NMO
azithromycin oral suspension reconstituted 100 mg/5ml, 200
mg/5ml 2 NMO
azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg 1 NMO
azithromycin oral tablet 600 mg 2 NMO
clarithromycin er oral tablet extended release 24 hr* 500 mg 2 NMO
clarithromycin oral suspension reconstituted 125 mg/5ml, 250
mg/5ml 2 NMO
clarithromycin oral tablet 250 mg, 500 mg 2 NMO
DIFICID ORAL TABLET 200 MG 5 NMO
E.E.S. GRANULES ORAL SUSPENSION
RECONSTITUTED 200 MG/5ML 3 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200
MG/5ML 3 NMO
ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400
MG/5ML 3 NMO
ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG,
333 MG, 500 MG 3 NMO
erythrocin lactobionate intravenous* solution reconstituted
500 mg 4 NMO
erythrocin stearate oral tablet 250 mg 2 NMO
erythromycin base oral capsule delayed release particles 250
mg 2 NMO
erythromycin base oral tablet 250 mg, 500 mg 2 NMO
erythromycin ethylsuccinate oral tablet 400 mg 2 NMO
PCE ORAL TABLET DELAYED RELEASE 333 MG, 500
MG 4 NMO
ZMAX ORAL SUSPENSION RECONSTITUTED 2 GM 4 NMO
QUINOLONES
AVELOX INTRAVENOUS* SOLUTION 400 MG/250ML 4 NMO
CIPRO IN D5W INTRAVENOUS* SOLUTION 400
MG/200ML 4 NMO
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 NMO
ciprofloxacin in d5w intravenous* solution 200 mg/100ml 2 NMO
ciprofloxacin intravenous* solution 400 mg/40ml 2 NMO
ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%),
500 mg/5ml (10%) 4 NMO
ciprofloxacin-ciproflox hcl er oral tablet extended release 24
hr* 1000 mg, 500 mg 2 NMO
levofloxacin in d5w intravenous* solution 500 mg/100ml 4 NMO
levofloxacin in d5w intravenous* solution 750 mg/150ml 2 NMO
levofloxacin intravenous* solution 25 mg/ml 4 NMO
LEVOFLOXACIN ORAL SOLUTION 25 MG/ML 3 NMO
levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 NMO
moxifloxacin hcl intravenous* solution 400 mg/250ml 2 NMO
MOXIFLOXACIN HCL ORAL TABLET 400 MG 3 NMO
SULFONAMIDES
sulfadiazine oral tablet 500 mg 2 NMO
sulfamethoxazole-trimethoprim intravenous* solution 400-80
mg/5ml 2 NMO
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
sulfamethoxazole-trimethoprim oral suspension 200-40
mg/5ml 2 NMO
sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-
160 mg 1 NMO
TETRACYCLINES
demeclocycline hcl oral tablet 150 mg, 300 mg 4 NMO
doxycycline hyclate intravenous* solution reconstituted 100
mg 4 NMO
doxycycline hyclate oral capsule 100 mg, 50 mg 2 NMO
doxycycline hyclate oral tablet 100 mg 2 NMO
DOXYCYCLINE HYCLATE ORAL TABLET 20 MG 3 NMO
doxycycline hyclate oral tablet delayed release 100 mg, 150
mg, 200 mg, 50 mg, 75 mg 4 NMO
doxycycline monohydrate oral capsule 100 mg, 50 mg 1 NMO
doxycycline monohydrate oral suspension reconstituted 25
mg/5ml 2 NMO
doxycycline monohydrate oral tablet 100 mg 2 NMO
DOXYCYCLINE MONOHYDRATE ORAL TABLET 150
MG, 50 MG, 75 MG 3 NMO
minocycline hcl er oral tablet extended release 24 hr* 135 mg,
45 mg, 90 mg 4 NMO
minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 2 NMO
MINOCYCLINE HCL ORAL TABLET 100 MG, 50 MG, 75
MG 3 NMO
VIBRAMYCIN ORAL SYRUP 50 MG/5ML 4 NMO
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
CEREBYX INJECTION SOLUTION 500 MG PE/10ML 4 NMO
fosphenytoin sodium injection solution 100 mg pe/2ml 2 NMO
LEVETIRACETAM ER ORAL TABLET EXTENDED
RELEASE 24 HR* 500 MG, 750 MG 3
LEVETIRACETAM IN NACL INTRAVENOUS*
SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500
MG/100ML
4 NMO
levetiracetam intravenous* solution 500 mg/5ml 1 NMO
levetiracetam oral solution 100 mg/ml 2
levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 1
roweepra oral tablet 500 mg 2
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
SPRITAM ORAL 1000 MG, 250 MG, 500 MG, 750 MG 4
BARBITURATES
phenobarbital oral elixir 20 mg/5ml 1 PA
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 60
mg 1 PA
phenobarbital oral tablet 32.4 mg, 64.8 mg, 97.2 mg 2 PA
BENZODIAZEPINES
clonazepam oral tablet 0.5 mg, 1 mg 2 QL (180 EA per 30 days)
clonazepam oral tablet 2 mg 2 QL (300 EA per 30 days)
clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg,
1 mg 2 QL (180 EA per 30 days)
clonazepam oral tablet dispersible 2 mg 2 QL (300 EA per 30 days)
DIAZEPAM GEL 10 MG, 2.5 MG, 20 MG 3 NMO
ONFI ORAL SUSPENSION 2.5 MG/ML 4
ONFI ORAL TABLET 10 MG, 20 MG 4 QL (60 EA per 30 days)
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN ORAL CAPSULE 300 MG 3
ethosuximide oral capsule 250 mg 1
ethosuximide oral solution 250 mg/5ml 1
LYRICA ORAL CAPSULE 150 MG, 200 MG, 225 MG, 25
MG, 50 MG, 75 MG 3 QL (120 EA per 30 days)
LYRICA ORAL CAPSULE 300 MG 3 QL (60 EA per 30 days)
LYRICA ORAL SOLUTION 20 MG/ML 3 QL (900 ML per 30 days)
zonisamide oral capsule 100 mg, 25 mg, 50 mg 2
GAMMA-AMINOBUTYRIC ACID (GABA)
AUGMENTING AGENTS
divalproex sodium er oral tablet extended release 24 hr* 250
mg, 500 mg 2
divalproex sodium oral tablet delayed release 125 mg, 250 mg,
500 mg 1
FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4
FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6
MG, 8 MG 4
gabapentin oral capsule 100 mg, 300 mg, 400 mg 1
gabapentin oral solution 250 mg/5ml 2
gabapentin oral tablet 600 mg, 800 mg 2
GABITRIL ORAL TABLET 12 MG, 16 MG 4
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50
MG 3
primidone oral tablet 250 mg, 50 mg 1
SABRIL ORAL PACKET 500 MG 5 NMO
SABRIL ORAL TABLET 500 MG 5 NMO
tiagabine hcl oral tablet 2 mg, 4 mg 2
valproate sodium intravenous* solution 500 mg/5ml 1 NMO
valproic acid oral capsule 250 mg 2
valproic acid oral syrup 250 mg/5ml 2
GLUTAMATE REDUCING AGENTS
felbamate oral suspension 600 mg/5ml 2
felbamate oral tablet 400 mg 2
felbamate oral tablet 600 mg 4
LAMICTAL STARTER ORAL KIT 25 (35) MG, 25 (42)-100
(7) MG, 25 (84)-100(14) MG 4 NMO
LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50
(7) MG, 50 & 100 & 200 MG 4 NMO
LAMOTRIGINE ER ORAL TABLET EXTENDED
RELEASE 24 HR* 100 MG, 200 MG, 25 MG, 250 MG, 300
MG, 50 MG
3
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1
lamotrigine oral tablet chewable 25 mg, 5 mg 1
LAMOTRIGINE ORAL TABLET DISPERSIBLE 100 MG,
200 MG, 25 MG, 50 MG 3
TOPIRAMATE ER ORAL 100 MG, 150 MG, 200 MG, 25
MG, 50 MG 3
topiramate oral capsule sprinkle 15 mg, 25 mg 2
topiramate oral tablet 100 mg, 25 mg, 50 mg 1
topiramate oral tablet 200 mg 2
TROKENDI XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 100 MG, 200 MG, 25 MG, 50 MG 4
SODIUM CHANNEL AGENTS
APTIOM ORAL TABLET 200 MG 4 QL (30 EA per 30 days)
APTIOM ORAL TABLET 400 MG 5 NMO; QL (30 EA per 30 days)
APTIOM ORAL TABLET 600 MG 5 NMO; QL (60 EA per 30 days)
APTIOM ORAL TABLET 800 MG 5 NMO; QL (45 EA per 30 days)
BANZEL ORAL SUSPENSION 40 MG/ML 4 QL (2400 ML per 30 days)
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
BANZEL ORAL TABLET 200 MG, 400 MG 4 QL (240 EA per 30 days)
BRIVIACT INTRAVENOUS* SOLUTION 50 MG/5ML 4 PA; NMO
BRIVIACT ORAL SOLUTION 10 MG/ML 5 PA; NMO
BRIVIACT ORAL TABLET 10 MG 4 PA
BRIVIACT ORAL TABLET 100 MG, 25 MG, 50 MG, 75
MG 5 PA; NMO
carbamazepine er oral capsule extended release 12 hour 100
mg, 200 mg, 300 mg 2
carbamazepine er oral tablet extended release 12 hr* 100 mg,
200 mg, 400 mg 2
carbamazepine oral suspension 100 mg/5ml 2
carbamazepine oral tablet 200 mg 2
DILANTIN ORAL CAPSULE 30 MG 3
epitol oral tablet 200 mg 2
oxcarbazepine oral suspension 300 mg/5ml 1
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1
OXTELLAR XR ORAL TABLET EXTENDED RELEASE
24 HR* 150 MG, 300 MG, 600 MG 4
PEGANONE ORAL TABLET 250 MG 3
phenytoin oral suspension 125 mg/5ml 1
phenytoin oral tablet chewable 50 mg 2
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300
mg 1
phenytoin sodium injection solution 50 mg/ml 1 NMO
TEGRETOL-XR ORAL TABLET EXTENDED RELEASE
12 HR* 100 MG 3
VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML 4 PA; NMO; QL (1200 ML per 30
days)
VIMPAT ORAL SOLUTION 10 MG/ML 4 PA; QL (1200 ML per 30 days)
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50
MG 4 PA; QL (60 EA per 30 days)
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates oral tablet 1 mg 2 PA
CHOLINESTERASE INHIBITORS
donepezil hcl oral tablet 10 mg, 5 mg 1
DONEPEZIL HCL ORAL TABLET 23 MG 3
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
donepezil hcl oral tablet dispersible 10 mg, 5 mg 2
galantamine hydrobromide er oral capsule extended release
24 hour 16 mg, 24 mg, 8 mg 2
galantamine hydrobromide oral solution 4 mg/ml 2
galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg 2
memantine hcl oral tablet 10 mg, 5 mg 2
MEMANTINE HCL ORAL TABLET 5 (28)-10 (21) MG 3 NMO
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 2
rivastigmine transdermal patch 24 hr 13.3 mg/24hr, 4.6
mg/24hr, 9.5 mg/24hr 2 QL (30 EA per 30 days)
N-METHYL-D-ASPARTATE (NMDA)
RECEPTOR ANTAGONIST
memantine hcl oral solution 2 mg/ml 2
NAMENDA XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 14 MG, 21 MG, 28 MG, 7 MG 3
NAMENDA XR TITRATION PACK ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG 3 NMO
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24
HOUR 14-10 MG, 28-10 MG 3
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl er (sr) oral tablet extended release 12 hr* 100
mg, 150 mg, 200 mg 1
bupropion hcl er (xl) oral tablet extended release 24 hr* 300
mg 1
bupropion hcl oral tablet 100 mg, 75 mg 1
FORFIVO XL ORAL TABLET EXTENDED RELEASE 24
HR* 450 MG 3 QL (30 EA per 30 days)
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 2
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1
mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 2
NEFAZODONE HCL ORAL TABLET 100 MG, 150 MG,
200 MG, 250 MG, 50 MG 3
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg 1
trazodone hcl oral tablet 300 mg 2
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 4
VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG 4 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
MONOAMINE OXIDASE INHIBITORS
EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6
MG/24HR, 9 MG/24HR 5 NMO; QL (30 EA per 30 days)
MARPLAN ORAL TABLET 10 MG 4
phenelzine sulfate oral tablet 15 mg 2
tranylcypromine sulfate oral tablet 10 mg 2
SEROTONIN/NOREPINEPHRINE REUPTAKE
INHIBITORS
BRISDELLE ORAL CAPSULE 7.5 MG 4
citalopram hydrobromide oral solution 10 mg/5ml 2
citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg 1
duloxetine hcl oral capsule delayed release particles 20 mg, 30
mg, 40 mg, 60 mg 2
escitalopram oxalate oral solution 5 mg/5ml 2
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1
FETZIMA ORAL CAPSULE EXTENDED RELEASE 24
HOUR 120 MG, 20 MG, 40 MG, 80 MG 4 QL (30 EA per 30 days)
FETZIMA TITRATION ORAL 20 & 40 MG 4 NMO
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1
FLUOXETINE HCL ORAL CAPSULE DELAYED
RELEASE 90 MG 3
fluoxetine hcl oral solution 20 mg/5ml 2
fluoxetine hcl oral tablet 10 mg, 20 mg 2
FLUOXETINE HCL ORAL TABLET 60 MG 3
FLUVOXAMINE MALEATE ER ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 100 MG, 150 MG 3
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1
paroxetine hcl er oral tablet extended release 24 hr* 12.5 mg,
25 mg, 37.5 mg 2
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1
PAXIL ORAL SUSPENSION 10 MG/5ML 4
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR*
100 MG, 25 MG, 50 MG 4
SARAFEM ORAL TABLET 10 MG, 20 MG 4
sertraline hcl oral concentrate 20 mg/ml 1
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1
TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 4 ST
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
venlafaxine hcl er oral capsule extended release 24 hour 150
mg, 37.5 mg, 75 mg 1
VENLAFAXINE HCL ER ORAL TABLET EXTENDED
RELEASE 24 HR* 150 MG, 37.5 MG, 75 MG 3
venlafaxine hcl er oral tablet extended release 24 hr* 225 mg 4
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75
mg 1
TRICYCLICS
amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50
mg, 75 mg 2 PA
amoxapine oral tablet 100 mg 1
amoxapine oral tablet 150 mg, 25 mg, 50 mg 2
CLOMIPRAMINE HCL ORAL CAPSULE 25 MG, 50 MG,
75 MG 3 PA
desipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1
desipramine hcl oral tablet 100 mg, 150 mg, 75 mg 2
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50
mg, 75 mg 2 PA
doxepin hcl oral concentrate 10 mg/ml 2 PA
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA
imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75
mg 4 PA
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1
nortriptyline hcl oral solution 10 mg/5ml 2
PROTRIPTYLINE HCL ORAL TABLET 10 MG, 5 MG 3
trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg 2 PA
ANTIEMETICS
ANTIEMETICS, OTHER
meclizine hcl oral tablet 12.5 mg, 25 mg 1 NMO
TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH
72 HR 1 MG/3DAYS 4 NMO
trimethobenzamide hcl oral capsule 300 mg 2 PA; NMO
EMETOGENIC THERAPY ADJUNCTS
AKYNZEO ORAL CAPSULE 300-0.5 MG 4 BD; NMO
ALOXI INTRAVENOUS* SOLUTION 0.25 MG/5ML 4 BD; NMO
CESAMET ORAL CAPSULE 1 MG 4 BD; NMO; QL (60 EA per 30
days)
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
dronabinol oral capsule 10 mg 5 PA; NMO; QL (60 EA per 30
days)
dronabinol oral capsule 2.5 mg 2 PA; NMO; QL (60 EA per 30
days)
dronabinol oral capsule 5 mg 4 PA; NMO; QL (60 EA per 30
days)
EMEND INTRAVENOUS* SOLUTION RECONSTITUTED
150 MG 4 BD; NMO
EMEND ORAL CAPSULE 80 & 125 MG 4 BD; NMO; QL (12 EA per 30
days)
EMEND ORAL SUSPENSION RECONSTITUTED 125 MG 4 BD; NMO
granisetron hcl intravenous* solution 0.1 mg/ml, 1 mg/ml 1 BD; NMO; QL (60 ML per 30
days)
granisetron hcl oral tablet 1 mg 1 BD; NMO; QL (60 EA per 30
days)
ondansetron hcl injection solution 4 mg/2ml, 4 mg/2ml (2ml
syringe) 1 BD; NMO
ondansetron hcl oral solution 4 mg/5ml 1 BD; NMO
ondansetron hcl oral tablet 24 mg 1 BD; NMO; QL (30 EA per 30
days)
ondansetron hcl oral tablet 4 mg, 8 mg 1 BD; NMO; QL (90 EA per 30
days)
ondansetron oral tablet dispersible 4 mg 1 BD; NMO; QL (90 EA per 30
days)
ondansetron oral tablet dispersible 8 mg 2 BD; NMO; QL (90 EA per 30
days)
SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR 3 NMO; QL (4 EA per 28 days)
ANTIFUNGALS
ANTIFUNGALS
ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML 4 BD; NMO
AMBISOME INTRAVENOUS* SUSPENSION
RECONSTITUTED 50 MG 4 BD; NMO
amphotericin b injection solution reconstituted 50 mg 4 BD; NMO
CANCIDAS INTRAVENOUS* SOLUTION
RECONSTITUTED 50 MG, 70 MG 5 BD; NMO
ERAXIS INTRAVENOUS* SOLUTION RECONSTITUTED
100 MG, 50 MG 4 NMO
fluconazole in sodium chloride intravenous* solution 200-0.9
mg/100ml-%, 400-0.9 mg/200ml-% 2 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml 2 NMO
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 2 NMO
flucytosine oral capsule 250 mg, 500 mg 5 NMO
griseofulvin microsize oral suspension 125 mg/5ml 4 NMO
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 4 NMO
ITRACONAZOLE ORAL CAPSULE 100 MG 3 PA; NMO
ketoconazole oral tablet 200 mg 1 NMO
LAMISIL ORAL PACKET 125 MG, 187.5 MG 4 NMO
MYCAMINE INTRAVENOUS* SOLUTION
RECONSTITUTED 100 MG 5 NMO
MYCAMINE INTRAVENOUS* SOLUTION
RECONSTITUTED 50 MG 4 NMO
NOXAFIL ORAL SUSPENSION 40 MG/ML 5 NMO
NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG 5 NMO
nystatin oral tablet 500000 unit 2 NMO
ORAVIG BUCCAL TABLET 50 MG 3 NMO
SPORANOX ORAL SOLUTION 10 MG/ML 5 PA; NMO
terbinafine hcl oral tablet 250 mg 1 NMO
voriconazole intravenous* solution reconstituted 200 mg 4 NMO
voriconazole oral suspension reconstituted 40 mg/ml 5 NMO; QL (300 ML per 30 days)
voriconazole oral tablet 200 mg, 50 mg 5 NMO; QL (120 EA per 30 days)
ANTIGOUT AGENTS
ANTIGOUT AGENTS
allopurinol oral tablet 100 mg, 300 mg 1
colchicine oral capsule 0.6 mg 2 NMO
colchicine oral tablet 0.6 mg 2 NMO
colchicine-probenecid oral tablet 0.5-500 mg 2
probenecid oral tablet 500 mg 2
ULORIC ORAL TABLET 40 MG, 80 MG 4
ANTI-INFLAMMATORY AGENTS
NONSTEROIDAL ANTI-INFLAMMATORY
DRUGS
CELECOXIB ORAL CAPSULE 100 MG, 200 MG, 400 MG 3
celecoxib oral capsule 50 mg 2
diclofenac potassium oral tablet 50 mg 2
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
diclofenac sodium er oral tablet extended release 24 hr* 100
mg 1
diclofenac sodium oral tablet delayed release 25 mg, 50 mg,
75 mg 1
DICLOFENAC-MISOPROSTOL ORAL TABLET
DELAYED RELEASE 50-0.2 MG, 75-0.2 MG 3
diflunisal oral tablet 500 mg 2
ETODOLAC ER ORAL TABLET EXTENDED RELEASE
24 HR* 400 MG, 500 MG, 600 MG 3
etodolac oral capsule 200 mg, 300 mg 2
etodolac oral tablet 400 mg, 500 mg 2
flurbiprofen oral tablet 100 mg, 50 mg 2
ibuprofen oral suspension 100 mg/5ml 1 NMO
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1
INDOCIN ORAL SUSPENSION 25 MG/5ML 3 PA
INDOMETHACIN ER ORAL CAPSULE EXTENDED
RELEASE* 75 MG 3 PA
indomethacin oral capsule 25 mg, 50 mg 1 PA
ketoprofen er oral capsule extended release 24 hour 200 mg 4
ketoprofen oral capsule 50 mg, 75 mg 2
ketorolac tromethamine intramuscular* solution 60 mg/2ml 2 PA; NMO
MEFENAMIC ACID ORAL CAPSULE 250 MG 3
meloxicam oral suspension 7.5 mg/5ml 1
meloxicam oral tablet 15 mg, 7.5 mg 1
nabumetone oral tablet 500 mg, 750 mg 1
naproxen dr oral tablet delayed release 375 mg, 500 mg 1
naproxen oral suspension 125 mg/5ml 1
naproxen oral tablet 250 mg, 375 mg, 500 mg 1
naproxen sodium oral tablet 275 mg 1
naproxen sodium oral tablet 550 mg 2
OXAPROZIN ORAL TABLET 600 MG 3
piroxicam oral capsule 10 mg, 20 mg 2
sulindac oral tablet 150 mg, 200 mg 1
tolmetin sodium oral capsule 400 mg 2
tolmetin sodium oral tablet 600 mg 2
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
dihydroergotamine mesylate injection solution 1 mg/ml 1 NMO; QL (24 ML per 28 days)
migergot suppository 2-100 mg 1 NMO; QL (20 EA per 28 days)
PROPHYLACTIC
divalproex sodium oral 125 mg 2
timolol maleate oral tablet 10 mg 1
SEROTONIN (5-HT) 1B/1D RECEPTOR
AGONISTS
almotriptan malate oral tablet 12.5 mg, 6.25 mg 2 NMO
dihydroergotamine mesylate nasal solution 4 mg/ml 1 NMO
frovatriptan succinate oral tablet 2.5 mg 2 NMO
IMITREX STATDOSE REFILL SUBCUTANEOUS* 4
MG/0.5ML 4 NMO
naratriptan hcl oral tablet 1 mg, 2.5 mg 2 NMO
RELPAX ORAL TABLET 20 MG, 40 MG 4 NMO
rizatriptan benzoate oral tablet 10 mg, 5 mg 2 NMO
rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 2 NMO
sumatriptan nasal solution 20 mg/act, 5 mg/act 2 NMO
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 NMO
sumatriptan succinate refill subcutaneous* 4 mg/0.5ml, 6
mg/0.5ml 2 NMO
sumatriptan succinate subcutaneous* 6 mg/0.5ml 4 NMO
sumatriptan succinate subcutaneous* solution 6 mg/0.5ml 2 NMO
TREXIMET ORAL TABLET 85-500 MG 4 NMO
zolmitriptan oral tablet 2.5 mg, 5 mg 2 NMO
zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 2 NMO
ZOMIG NASAL SOLUTION 5 MG 4 NMO
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine hcl oral tablet 125 mg 2 NMO
MESTINON ORAL SYRUP 60 MG/5ML 3 NMO
pyridostigmine bromide er oral tablet extendedrelease* 180
mg 2 NMO
pyridostigmine bromide oral tablet 60 mg 2 NMO
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone oral tablet 100 mg, 25 mg 2
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
pyrazinamide oral tablet 500 mg 2 NMO
RIFABUTIN ORAL CAPSULE 150 MG 3 NMO
ANTITUBERCULARS
CAPASTAT SULFATE INJECTION SOLUTION
RECONSTITUTED 1 GM 4 NMO
ETHAMBUTOL HCL ORAL TABLET 100 MG, 400 MG 3 NMO
isoniazid injection solution 100 mg/ml 1 NMO
isoniazid oral syrup 50 mg/5ml 1
isoniazid oral tablet 100 mg, 300 mg 1
PASER ORAL PACKET 4 GM 4 NMO
PRIFTIN ORAL TABLET 150 MG 4 NMO
RIFAMATE ORAL CAPSULE 150-300 MG 4 NMO
rifampin intravenous* solution reconstituted 600 mg 2 NMO
rifampin oral capsule 150 mg 1 NMO
rifampin oral capsule 300 mg 2 NMO
RIFATER ORAL TABLET 50-120-300 MG 4 NMO
SIRTURO ORAL TABLET 100 MG 5 NMO
TRECATOR ORAL TABLET 250 MG 4 NMO
ANTINEOPLASTICS
ALKYLATING AGENTS
BICNU INTRAVENOUS* SOLUTION RECONSTITUTED
100 MG 4 BD; NMO
BUSULFEX INTRAVENOUS* SOLUTION 6 MG/ML 5 BD; NMO
CARBOPLATIN INTRAVENOUS* SOLUTION 150
MG/15ML 3 BD; NMO
cisplatin intravenous* solution 100 mg/100ml 4 BD; NMO
cyclophosphamide oral capsule 25 mg, 50 mg 1 BD; NMO
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5
MG 4 NMO
HEXALEN ORAL CAPSULE 50 MG 5 NMO
IFOSFAMIDE INTRAVENOUS* SOLUTION
RECONSTITUTED 1 GM 3 BD; NMO
LEUKERAN ORAL TABLET 2 MG 3 NMO
melphalan hcl intravenous* solution reconstituted 50 mg 4 BD; NMO
MUSTARGEN INJECTION SOLUTION RECONSTITUTED
10 MG 5 BD; NMO
oxaliplatin intravenous* solution 100 mg/20ml 4 BD; NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
THIOTEPA INJECTION SOLUTION RECONSTITUTED 15
MG 5 BD; NMO
TREANDA INTRAVENOUS* SOLUTION
RECONSTITUTED 100 MG 5 BD; NMO
YONDELIS INTRAVENOUS* SOLUTION
RECONSTITUTED 1 MG 5 PA; NMO
ZANOSAR INTRAVENOUS* SOLUTION
RECONSTITUTED 1 GM 4 BD; NMO
ANTIANGIOGENIC AGENTS
AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML 5 BD; NMO
AVASTIN INTRAVENOUS* SOLUTION 400 MG/16ML 3 BD; NMO
CYRAMZA INTRAVENOUS* SOLUTION 100 MG/10ML,
500 MG/50ML 5 BD; NMO
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20
MG, 25 MG, 5 MG 5 PA; LA; NMO
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG,
50 MG 5 PA; NMO
ZALTRAP INTRAVENOUS* SOLUTION 100 MG/4ML 5 BD; NMO
ANTIMETABOLITES
ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML 3 BD; NMO
ALIMTA INTRAVENOUS* SOLUTION
RECONSTITUTED 500 MG 5 BD; NMO
ARRANON INTRAVENOUS* SOLUTION 5 MG/ML 4 BD; NMO
azacitidine injection suspension reconstituted 100 mg 5 BD; NMO
cladribine intravenous* solution 10 mg/10ml 5 BD; NMO
CLOLAR INTRAVENOUS* SOLUTION 1 MG/ML 4 BD; NMO
CYTARABINE (PF) INJECTION SOLUTION 100 MG/ML 3 BD; NMO
cytarabine injection solution 20 mg/ml 2 BD; NMO
decitabine intravenous* solution reconstituted 50 mg 2 BD; NMO
DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 4
fludarabine phosphate intravenous* solution reconstituted 50
mg 1 BD; NMO
FLUOROURACIL INTRAVENOUS* SOLUTION 2.5
GM/50ML 3 BD; NMO
GEMCITABINE HCL INTRAVENOUS* SOLUTION
RECONSTITUTED 1 GM 5 BD; NMO
mercaptopurine oral tablet 50 mg 2 NMO
methotrexate oral tablet 2.5 mg 2 BD; NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
methotrexate sodium (pf) injection solution 1 gm/40ml 1 BD; NMO
methotrexate sodium injection solution reconstituted 1 gm 1 BD; NMO
PURIXAN ORAL SUSPENSION 2000 MG/100ML 4 NMO
TABLOID ORAL TABLET 40 MG 3 NMO
TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 4 BD; NMO
ANTINEOPLASTICS
ABRAXANE INTRAVENOUS* SUSPENSION
RECONSTITUTED 100 MG 5 BD; NMO
ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000
UNIT/0.5ML 5 PA; LA; NMO
AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3
MG 5 NMO; QL (30 EA per 30 days)
AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MG 5 NMO; QL (60 EA per 30 days)
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 5 NMO; QL (30 EA per 30 days)
ALECENSA ORAL CAPSULE 150 MG 5 NMO
amifostine intravenous* solution reconstituted 500 mg 5 BD; NMO
BELEODAQ INTRAVENOUS* SOLUTION
RECONSTITUTED 500 MG 5 BD; NMO
bexarotene oral capsule 75 mg 5 NMO
bicalutamide oral tablet 50 mg 1 NMO; QL (30 EA per 30 days)
bleomycin sulfate injection solution reconstituted 30 unit 1 BD; NMO
BOSULIF ORAL TABLET 100 MG 5 PA; NMO; QL (120 EA per 30
days)
BOSULIF ORAL TABLET 500 MG 5 PA; NMO; QL (30 EA per 30
days)
CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG 5 NMO
CAPRELSA ORAL TABLET 100 MG 5 NMO; QL (60 EA per 30 days)
CAPRELSA ORAL TABLET 300 MG 5 NMO; QL (30 EA per 30 days)
COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 &
1 X 20 MG 5 NMO; QL (60 EA per 30 days)
COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 &
3 X 20 MG 5 NMO; QL (120 EA per 30 days)
COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG 5 NMO; QL (90 EA per 30 days)
COSMEGEN INTRAVENOUS* SOLUTION
RECONSTITUTED 0.5 MG 4 BD; NMO
COTELLIC ORAL TABLET 20 MG 5 LA; NMO
DACARBAZINE INTRAVENOUS* SOLUTION
RECONSTITUTED 200 MG 3 BD; NMO
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Drug Drug Tier Requirements/Limits
DARZALEX INTRAVENOUS* SOLUTION 100 MG/5ML 4 LA; NMO
daunorubicin hcl intravenous* injectable 5 mg/ml 2 BD; NMO
DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400
MG/ML 3 BD; NMO
dexrazoxane intravenous* solution reconstituted 250 mg 5 BD; NMO
DOCEFREZ INTRAVENOUS* SOLUTION
RECONSTITUTED 20 MG 5 BD; NMO
DOCETAXEL INTRAVENOUS* CONCENTRATE 80
MG/4ML 5 BD; NMO
DOCETAXEL INTRAVENOUS* SOLUTION 80 MG/8ML 5 BD; NMO
DOXIL INTRAVENOUS* INJECTABLE 2 MG/ML 5 BD; NMO
DOXORUBICIN HCL INTRAVENOUS* SOLUTION 2
MG/ML 3 BD; NMO
doxorubicin hcl liposomal intravenous* injectable 2 mg/ml 5 BD; NMO
ELIGARD SUBCUTANEOUS* KIT 22.5 MG, 30 MG, 45
MG, 7.5 MG 4 BD; NMO
ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED
1.5 MG 5 BD; NMO
ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED
7.5 MG 4 BD; NMO
EMCYT ORAL CAPSULE 140 MG 3 NMO
EMPLICITI INTRAVENOUS* SOLUTION
RECONSTITUTED 300 MG, 400 MG 5 PA; NMO
ERBITUX INTRAVENOUS* SOLUTION 100 MG/50ML 5 BD; NMO
ERIVEDGE ORAL CAPSULE 150 MG 5 NMO
ERWINAZE INJECTION SOLUTION RECONSTITUTED
10000 UNIT 3 PA; NMO
ETOPOPHOS INTRAVENOUS* SOLUTION
RECONSTITUTED 100 MG 4 BD; NMO
etoposide intravenous* solution 500 mg/25ml 1 BD; NMO
FARESTON ORAL TABLET 60 MG 3 QL (30 EA per 30 days)
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 5 PA; NMO
FASLODEX INTRAMUSCULAR* SOLUTION 250
MG/5ML 5 BD; NMO
FIRMAGON SUBCUTANEOUS* SOLUTION
RECONSTITUTED 120 MG, 80 MG 4 BD; NMO
flutamide oral capsule 125 mg 1 NMO
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 5 PA; NMO
GLEEVEC ORAL TABLET 100 MG 5 NMO; QL (180 EA per 30 days)
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Drug Drug Tier Requirements/Limits
GLEEVEC ORAL TABLET 400 MG 5 NMO; QL (60 EA per 30 days)
HALAVEN INTRAVENOUS* SOLUTION 1 MG/2ML 5 BD; NMO
HERCEPTIN INTRAVENOUS* SOLUTION
RECONSTITUTED 440 MG 5 BD; NMO
hydroxyprogesterone caproate intramuscular* solution 1.25
gm/5ml 5 PA; NMO
hydroxyurea oral capsule 500 mg 1 NMO
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 5 PA; NMO
ICLUSIG ORAL TABLET 15 MG 5 PA; NMO; QL (60 EA per 30
days)
ICLUSIG ORAL TABLET 45 MG 5 PA; NMO
idarubicin hcl intravenous* solution 10 mg/10ml 5 BD; NMO
imatinib mesylate oral tablet 100 mg 5 NMO; QL (180 EA per 30 days)
imatinib mesylate oral tablet 400 mg 5 NMO; QL (60 EA per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG 5 PA; NMO
INLYTA ORAL TABLET 1 MG 5 NMO; QL (180 EA per 30 days)
INLYTA ORAL TABLET 5 MG 5 NMO; QL (60 EA per 30 days)
INTRON A INJECTION SOLUTION 6000000 UNIT/ML 5 BD; NMO
INTRON A INJECTION SOLUTION RECONSTITUTED
10000000 UNIT 5 BD; NMO
INTRON A INJECTION SOLUTION RECONSTITUTED
18000000 UNIT, 50000000 UNIT 4 BD
IRESSA ORAL TABLET 250 MG 5 NMO
irinotecan hcl intravenous* solution 100 mg/5ml 4 BD; NMO
ISTODAX INTRAVENOUS* SOLUTION
RECONSTITUTED 10 MG 5 BD; NMO
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5
MG 5 NMO; QL (60 EA per 30 days)
KADCYLA INTRAVENOUS* SOLUTION
RECONSTITUTED 100 MG 5 NMO
KEPIVANCE INTRAVENOUS* SOLUTION
RECONSTITUTED 6.25 MG 4 BD; NMO
KEYTRUDA INTRAVENOUS* SOLUTION 100 MG/4ML 5 PA; NMO
KEYTRUDA INTRAVENOUS* SOLUTION
RECONSTITUTED 50 MG 5 PA; NMO
LENVIMA 10 MG DAILY DOSE ORAL 10 MG 5 NMO
LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG 5 NMO
LENVIMA 18 MG DAILY DOSE ORAL 10 & 4 (2) MG 5 NMO
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Drug Drug Tier Requirements/Limits
LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG 5 NMO
LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG 5 NMO
LENVIMA 8 MG DAILY DOSE ORAL 4 (2) MG 5 NMO
leucovorin calcium injection solution reconstituted 100 mg,
350 mg 1 BD; NMO
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 NMO
leuprolide acetate injection kit 1 mg/0.2ml 1 PA; NMO
LEVOLEUCOVORIN CALCIUM INTRAVENOUS*
SOLUTION 175 MG/17.5ML 3 BD; NMO
LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG 5 NMO
LUPRON DEPOT INTRAMUSCULAR* KIT 22.5 MG 5 PA; NMO; QL (1 EA per 90 days)
LUPRON DEPOT INTRAMUSCULAR* KIT 3.75 MG, 7.5
MG 5 PA; NMO; QL (1 EA per 30 days)
LUPRON DEPOT INTRAMUSCULAR* KIT 30 MG, 45 MG 5 PA; NMO; QL (1 EA per 112
days)
LYNPARZA ORAL CAPSULE 50 MG 5 PA; NMO
LYSODREN ORAL TABLET 500 MG 3 NMO
MATULANE ORAL CAPSULE 50 MG 5 NMO
megestrol acetate oral suspension 40 mg/ml 1 PA; NMO
megestrol acetate oral tablet 20 mg, 40 mg 1 PA; NMO
MEKINIST ORAL TABLET 0.5 MG, 2 MG 5 NMO
MESNA INTRAVENOUS* SOLUTION 100 MG/ML 3 BD; NMO
MESNEX ORAL TABLET 400 MG 5 NMO
MITOMYCIN INTRAVENOUS* SOLUTION
RECONSTITUTED 20 MG, 40 MG, 5 MG 3 BD; NMO
mitoxantrone hcl intravenous* concentrate 25 mg/12.5ml 1 BD; NMO
NEXAVAR ORAL TABLET 200 MG 5 LA; NMO; QL (120 EA per 30
days)
NILANDRON ORAL TABLET 150 MG 3 NMO; QL (60 EA per 30 days)
NILUTAMIDE ORAL TABLET 150 MG 3 NMO; QL (60 EA per 30 days)
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG 5 NMO
ODOMZO ORAL CAPSULE 200 MG 5 LA; NMO
OPDIVO INTRAVENOUS* SOLUTION 40 MG/4ML 5 PA; NMO
PACLITAXEL INTRAVENOUS* CONCENTRATE 300
MG/50ML 3 BD; NMO
PERJETA INTRAVENOUS* SOLUTION 420 MG/14ML 5 BD; NMO
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 5 LA; NMO
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Drug Drug Tier Requirements/Limits
PROLEUKIN INTRAVENOUS* SOLUTION
RECONSTITUTED 22000000 UNIT 5 BD; NMO
RITUXAN INTRAVENOUS* SOLUTION 500 MG/50ML 3 PA; NMO
SOLTAMOX ORAL SOLUTION 10 MG/5ML 4
SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG 5 NMO; QL (60 EA per 30 days)
SPRYCEL ORAL TABLET 140 MG 5 NMO; QL (30 EA per 30 days)
SPRYCEL ORAL TABLET 20 MG 5 NMO; QL (90 EA per 30 days)
STIVARGA ORAL TABLET 40 MG 5 PA; NMO
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50
MG 5 NMO
SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG,
600 MCG 5 NMO
SYNRIBO SUBCUTANEOUS* SOLUTION
RECONSTITUTED 3.5 MG 5 NMO
TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 NMO
TAGRISSO ORAL TABLET 40 MG, 80 MG 5 LA; NMO
tamoxifen citrate oral tablet 10 mg, 20 mg 1
TARCEVA ORAL TABLET 100 MG, 150 MG 5 NMO; QL (30 EA per 30 days)
TARCEVA ORAL TABLET 25 MG 5 NMO; QL (90 EA per 30 days)
TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 NMO; QL (120 EA per 30 days)
TECENTRIQ INTRAVENOUS* SOLUTION 1200
MG/20ML 4 BD; NMO
toposar intravenous* solution 1 gm/50ml 1 BD; NMO
TOPOTECAN HCL INTRAVENOUS* SOLUTION
RECONSTITUTED 4 MG 5 BD; NMO
TORISEL INTRAVENOUS* SOLUTION 25 MG/ML 5 BD; NMO
TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG 5 BD; NMO
tretinoin oral capsule 10 mg 5 NMO
TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML 3 BD; NMO
TYKERB ORAL TABLET 250 MG 5 NMO; QL (150 EA per 30 days)
UVADEX INJECTION SOLUTION 20 MCG/ML 4 BD; NMO
VECTIBIX INTRAVENOUS* SOLUTION 100 MG/5ML 4 BD; NMO
VELCADE INJECTION SOLUTION RECONSTITUTED 3.5
MG 5 BD; NMO
VENCLEXTA ORAL TABLET 10 MG, 50 MG 4 PA; LA; NMO
VENCLEXTA ORAL TABLET 100 MG 5 PA; LA; NMO
VENCLEXTA STARTING PACK ORAL 10 & 50 & 100 MG 4 PA; LA; NMO
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Drug Drug Tier Requirements/Limits
VINBLASTINE SULFATE INTRAVENOUS* SOLUTION 1
MG/ML 3 BD; NMO
VINCASAR PFS INTRAVENOUS* SOLUTION 1 MG/ML 3 BD; NMO
VINCRISTINE SULFATE INTRAVENOUS* SOLUTION 1
MG/ML 3 BD; NMO
VINORELBINE TARTRATE INTRAVENOUS* SOLUTION
50 MG/5ML 3 BD; NMO
VOTRIENT ORAL TABLET 200 MG 5 NMO; QL (120 EA per 30 days)
XALKORI ORAL CAPSULE 200 MG, 250 MG 5 NMO; QL (60 EA per 30 days)
XTANDI ORAL CAPSULE 40 MG 5 PA; ST; NMO; QL (120 EA per 30
days)
YERVOY INTRAVENOUS* SOLUTION 50 MG/10ML 5 BD; NMO
ZELBORAF ORAL TABLET 240 MG 5 NMO; QL (240 EA per 30 days)
ZOLINZA ORAL CAPSULE 100 MG 5 NMO; QL (120 EA per 30 days)
ZYDELIG ORAL TABLET 100 MG 5 NMO; QL (90 EA per 30 days)
ZYDELIG ORAL TABLET 150 MG 5 NMO; QL (60 EA per 30 days)
ZYKADIA ORAL CAPSULE 150 MG 3 NMO
ZYTIGA ORAL TABLET 250 MG 5 PA; NMO; QL (120 EA per 30
days)
AROMATASE INHIBITORS, 3RD
GENERATION
anastrozole oral tablet 1 mg 1
exemestane oral tablet 25 mg 2 QL (60 EA per 30 days)
letrozole oral tablet 2.5 mg 1
ANTIPARASITICS
ANTHELMINTICS
ALBENZA ORAL TABLET 200 MG 3 NMO
BILTRICIDE ORAL TABLET 600 MG 4 NMO
EMVERM ORAL TABLET CHEWABLE 100 MG 3 NMO
IVERMECTIN ORAL TABLET 3 MG 3 NMO
ANTIPROTOZOALS
ALINIA ORAL SUSPENSION RECONSTITUTED 100
MG/5ML 4 NMO; QL (180 ML per 30 days)
ALINIA ORAL TABLET 500 MG 4 NMO
atovaquone oral suspension 750 mg/5ml 5 NMO
ATOVAQUONE-PROGUANIL HCL ORAL TABLET 250-
100 MG, 62.5-25 MG 3 NMO
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Drug Drug Tier Requirements/Limits
chloroquine phosphate oral tablet 250 mg 1
chloroquine phosphate oral tablet 500 mg 2
COARTEM ORAL TABLET 20-120 MG 4 NMO
DARAPRIM ORAL TABLET 25 MG 3 NMO
hydroxychloroquine sulfate oral tablet 200 mg 2
mefloquine hcl oral tablet 250 mg 2
NEBUPENT INHALATION SOLUTION
RECONSTITUTED 300 MG 4 BD; NMO
PENTAM INJECTION SOLUTION RECONSTITUTED 300
MG 4 NMO
PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG 4 NMO
quinine sulfate oral capsule 324 mg 4 NMO
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate injection solution 1 mg/ml 1 NMO
benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 PA
trihexyphenidyl hcl oral elixir 0.4 mg/ml 1 PA
trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 PA
ANTIPARKINSON AGENTS, OTHER
amantadine hcl oral capsule 100 mg 2
amantadine hcl oral syrup 50 mg/5ml 2
amantadine hcl oral tablet 100 mg 2
entacapone oral tablet 200 mg 2
DOPAMINE AGONISTS
APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML 5 LA; NMO; QL (60 ML per 30
days)
bromocriptine mesylate oral capsule 5 mg 1
bromocriptine mesylate oral tablet 2.5 mg 2
NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2
MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8
MG/24HR
4
PRAMIPEXOLE DIHYDROCHLORIDE ER ORAL
TABLET EXTENDED RELEASE 24 HR* 0.375 MG, 0.75
MG, 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG
3
pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg,
0.5 mg, 0.75 mg, 1 mg, 1.5 mg 1
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Drug Drug Tier Requirements/Limits
ropinirole hcl er oral tablet extended release 24 hr* 12 mg, 2
mg, 4 mg, 6 mg, 8 mg 2
ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg, 5 mg 1
DOPAMINE PRECURSORS/ L-AMINO ACID
DECARBOXYLASE INHIBITORS
CARBIDOPA ORAL TABLET 25 MG 3
carbidopa-levodopa er oral tablet extendedrelease* 25-100
mg, 50-200 mg 2
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250
mg 1
carbidopa-levodopa oral tablet dispersible 10-100 mg 2
carbidopa-levodopa oral tablet dispersible 25-100 mg, 25-250
mg 1
carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg,
18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-
150-200 mg, 50-200-200 mg
2
MONOAMINE OXIDASE B (MAO-B)
INHIBITORS
AZILECT ORAL TABLET 0.5 MG, 1 MG 3 QL (30 EA per 30 days)
selegiline hcl oral capsule 5 mg 2
selegiline hcl oral tablet 5 mg 2
ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG 4
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
CHLORPROMAZINE HCL INJECTION SOLUTION 50
MG/2ML 3 BD; NMO
chlorpromazine hcl oral tablet 10 mg, 25 mg 2 BD
chlorpromazine hcl oral tablet 100 mg, 200 mg, 50 mg 2
compro suppository 25 mg 2 NMO
FLUPHENAZINE DECANOATE INJECTION SOLUTION
25 MG/ML 3 NMO
fluphenazine hcl injection solution 2.5 mg/ml 2 NMO
fluphenazine hcl oral concentrate 5 mg/ml 2
fluphenazine hcl oral elixir 2.5 mg/5ml 2
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1
haloperidol decanoate intramuscular* solution 100 mg/ml 2 NMO
haloperidol decanoate intramuscular* solution 50 mg/ml 1 NMO
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Drug Drug Tier Requirements/Limits
haloperidol lactate injection solution 5 mg/ml 2 NMO
haloperidol lactate oral concentrate 2 mg/ml 1
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5
mg 1
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 2
MOLINDONE HCL ORAL TABLET 10 MG, 25 MG, 5 MG 4
PERPHENAZINE ORAL TABLET 16 MG 3
perphenazine oral tablet 2 mg, 4 mg, 8 mg 2
PERPHENAZINE-AMITRIPTYLINE ORAL TABLET 2-10
MG, 2-25 MG, 4-10 MG, 4-25 MG, 4-50 MG 3 PA
pimozide oral tablet 1 mg, 2 mg 2
prochlorperazine edisylate injection solution 5 mg/ml 2 NMO
prochlorperazine maleate oral tablet 10 mg, 5 mg 1
prochlorperazine suppository 25 mg 2 NMO
thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 2 PA
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1
2ND GENERATION/ATYPICAL
ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 300 MG, 300 MG (1.5ML SYRINGE),
400 MG
4
ARIPIPRAZOLE ORAL TABLET 10 MG, 15 MG, 20 MG,
30 MG 3 QL (30 EA per 30 days)
ARIPIPRAZOLE ORAL TABLET 2 MG, 5 MG 3 QL (60 EA per 30 days)
ARIPIPRAZOLE ORAL TABLET DISPERSIBLE 10 MG, 15
MG 5 NMO; QL (60 EA per 30 days)
ARISTADA INTRAMUSCULAR* 441 MG/1.6ML 4 ST
ARISTADA INTRAMUSCULAR* 662 MG/2.4ML, 882
MG/3.2ML 5 ST; NMO
EQUETRO ORAL CAPSULE EXTENDED RELEASE 12
HOUR 100 MG, 200 MG, 300 MG 4
FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4
MG, 6 MG, 8 MG 4 NMO; QL (60 EA per 30 days)
FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 &
6 MG 4 NMO
GEODON INTRAMUSCULAR* SOLUTION
RECONSTITUTED 20 MG 4 NMO; QL (60 EA per 30 days)
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Drug Drug Tier Requirements/Limits
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION
117 MG/0.75ML 5 NMO; QL (0.75 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION
156 MG/ML 5 NMO; QL (1 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION
234 MG/1.5ML 5 NMO; QL (1.5 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION
39 MG/0.25ML 4 NMO; QL (0.25 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION
78 MG/0.5ML 4 NMO; QL (0.5 ML per 28 days)
INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 273
MG/0.875ML 5 NMO; QL (0.875 ML per 90 days)
INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 410
MG/1.315ML 5 NMO; QL (1.315 ML per 90 days)
INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 546
MG/1.75ML 5 NMO; QL (1.75 ML per 90 days)
INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 819
MG/2.625ML 5 NMO; QL (2.625 ML per 90 days)
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG 3 QL (30 EA per 30 days)
LATUDA ORAL TABLET 60 MG, 80 MG 3 QL (60 EA per 30 days)
NUPLAZID ORAL TABLET 17 MG 5 PA; NMO
olanzapine intramuscular* solution reconstituted 10 mg 4 NMO
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5
mg 1
OLANZAPINE ORAL TABLET DISPERSIBLE 10 MG, 15
MG, 20 MG, 5 MG 3 QL (30 EA per 30 days)
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-
25 mg, 6-25 mg, 6-50 mg 4
PALIPERIDONE ER ORAL TABLET EXTENDED
RELEASE 24 HR* 1.5 MG, 3 MG, 6 MG 3 QL (60 EA per 30 days)
PALIPERIDONE ER ORAL TABLET EXTENDED
RELEASE 24 HR* 9 MG 3 QL (30 EA per 30 days)
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300
mg, 400 mg, 50 mg 1
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG,
3 MG, 4 MG 5
PA; NMO; QL (30 EA per 30
days)
RISPERDAL CONSTA INTRAMUSCULAR*
SUSPENSION RECONSTITUTED 12.5 MG, 25 MG 4 NMO
RISPERDAL CONSTA INTRAMUSCULAR*
SUSPENSION RECONSTITUTED 37.5 MG, 50 MG 5 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
risperidone oral solution 1 mg/ml 2
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg 1
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg 2
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG,
2.5 MG, 5 MG 4 QL (60 EA per 30 days)
SEROQUEL XR ORAL TABLET EXTENDED RELEASE
24 HR* 150 MG, 200 MG, 300 MG, 400 MG, 50 MG 3
VRAYLAR ORAL 1.5 & 3 MG 4 ST; NMO
VRAYLAR ORAL CAPSULE 1.5 MG 5 ST; NMO; QL (120 EA per 30
days)
VRAYLAR ORAL CAPSULE 3 MG 5 ST; NMO; QL (60 EA per 30
days)
VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG 5 ST; NMO; QL (30 EA per 30
days)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 2
ZYPREXA RELPREVV INTRAMUSCULAR*
SUSPENSION RECONSTITUTED 210 MG 4 NMO
TREATMENT-RESISTANT
clozapine oral tablet 100 mg 2 NMO; QL (270 EA per 30 days)
clozapine oral tablet 200 mg, 25 mg 2 NMO; QL (120 EA per 30 days)
clozapine oral tablet 50 mg 2 NMO; QL (180 EA per 30 days)
CLOZAPINE ORAL TABLET DISPERSIBLE 100 MG, 25
MG 4 NMO; QL (270 EA per 30 days)
CLOZAPINE ORAL TABLET DISPERSIBLE 12.5 MG 4 NMO; QL (90 EA per 30 days)
clozapine oral tablet dispersible 150 mg 4 NMO; QL (270 EA per 30 days)
clozapine oral tablet dispersible 200 mg 5 NMO; QL (120 EA per 30 days)
VERSACLOZ ORAL SUSPENSION 50 MG/ML 4 NMO; QL (540 ML per 30 days)
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
cidofovir intravenous* solution 75 mg/ml 4 BD; NMO
GANCICLOVIR SODIUM INTRAVENOUS* SOLUTION
RECONSTITUTED 500 MG 3 BD; NMO
valganciclovir hcl oral tablet 450 mg 5 NMO
ANTIHEPATITIS AGENTS
adefovir dipivoxil oral tablet 10 mg 5 PA; NMO; QL (30 EA per 30
days)
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
BARACLUDE ORAL SOLUTION 0.05 MG/ML 5 NMO; QL (600 ML per 30 days)
DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG 5 PA; NMO
entecavir oral tablet 0.5 mg, 1 mg 5 NMO; QL (30 EA per 30 days)
HARVONI ORAL TABLET 90-400 MG 5 PA; NMO
PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION
135 MCG/0.5ML, 180 MCG/0.5ML 5 PA; NMO
PEGASYS SUBCUTANEOUS* SOLUTION 180
MCG/0.5ML, 180 MCG/ML 5 PA; NMO
PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120
MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80
MCG/0.5ML
5 PA; NMO
PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML,
150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML 5 PA; NMO
REBETOL ORAL SOLUTION 40 MG/ML 5 PA; NMO
RIBASPHERE ORAL TABLET 400 MG 4 PA; NMO
RIBASPHERE ORAL TABLET 600 MG 5 PA; NMO
ribasphere ribapak oral tablet 400 & 600 mg, 400 mg 5 PA; NMO
RIBASPHERE RIBAPAK ORAL TABLET 600 MG 5 PA; NMO
RIBAVIRIN ORAL CAPSULE 200 MG 3 PA; NMO; QL (180 EA per 30
days)
RIBAVIRIN ORAL TABLET 200 MG 3 PA; NMO; QL (180 EA per 30
days)
SOVALDI ORAL TABLET 400 MG 5 PA; NMO; QL (30 EA per 30
days)
TYZEKA ORAL TABLET 600 MG 5 PA; NMO; QL (30 EA per 30
days)
ZEPATIER ORAL TABLET 50-100 MG 5 PA; NMO
ANTIHERPETIC AGENTS
acyclovir oral capsule 200 mg 1 NMO
acyclovir oral suspension 200 mg/5ml 2 NMO
acyclovir oral tablet 400 mg, 800 mg 1 NMO
acyclovir sodium intravenous* solution 50 mg/ml 2 BD; NMO
valacyclovir hcl oral tablet 1 gm, 500 mg 2 NMO
ANTI-HIV AGENTS, NON-NUCLEOSIDE
REVERSE TRANSCRIPTASE INHIBITORS
EDURANT ORAL TABLET 25 MG 5 NMO; QL (30 EA per 30 days)
INTELENCE ORAL TABLET 100 MG 5 NMO; QL (120 EA per 30 days)
INTELENCE ORAL TABLET 200 MG 5 NMO; QL (60 EA per 30 days)
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Drug Drug Tier Requirements/Limits
INTELENCE ORAL TABLET 25 MG 4 QL (120 EA per 30 days)
NEVIRAPINE ER ORAL TABLET EXTENDED RELEASE
24 HR* 100 MG, 400 MG 3
NEVIRAPINE ORAL SUSPENSION 50 MG/5ML 3 QL (1200 ML per 30 days)
NEVIRAPINE ORAL TABLET 200 MG 3 QL (60 EA per 30 days)
RESCRIPTOR ORAL TABLET 100 MG 4 QL (360 EA per 30 days)
RESCRIPTOR ORAL TABLET 200 MG 4 QL (180 EA per 30 days)
SUSTIVA ORAL CAPSULE 200 MG 4 QL (120 EA per 30 days)
SUSTIVA ORAL CAPSULE 50 MG 4 QL (480 EA per 30 days)
SUSTIVA ORAL TABLET 600 MG 4 QL (30 EA per 30 days)
TYBOST ORAL TABLET 150 MG 4
ANTI-HIV AGENTS, NUCLEOSIDE AND
NUCLEOTIDE REVERSE TRANSCRIPTASE
INHIBITORS
abacavir sulfate oral tablet 300 mg 4 QL (60 EA per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg 5 NMO; QL (60 EA per 30 days)
DESCOVY ORAL TABLET 200-25 MG 5 NMO
DIDANOSINE ORAL CAPSULE DELAYED RELEASE 125
MG 3 QL (90 EA per 30 days)
DIDANOSINE ORAL CAPSULE DELAYED RELEASE 200
MG 3 QL (60 EA per 30 days)
DIDANOSINE ORAL CAPSULE DELAYED RELEASE 250
MG, 400 MG 3 QL (30 EA per 30 days)
EMTRIVA ORAL CAPSULE 200 MG 4 QL (30 EA per 30 days)
EMTRIVA ORAL SOLUTION 10 MG/ML 4 QL (680 ML per 28 days)
EPIVIR HBV ORAL SOLUTION 5 MG/ML 3
EPZICOM ORAL TABLET 600-300 MG 5 NMO; QL (30 EA per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 5 NMO; QL (30 EA per 30 days)
LAMIVUDINE ORAL SOLUTION 10 MG/ML 3 QL (960 ML per 30 days)
LAMIVUDINE ORAL TABLET 100 MG 3
LAMIVUDINE ORAL TABLET 150 MG 3 QL (60 EA per 30 days)
LAMIVUDINE ORAL TABLET 300 MG 3 QL (30 EA per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 4 QL (60 EA per 30 days)
PREZCOBIX ORAL TABLET 800-150 MG 5 NMO; QL (30 EA per 30 days)
RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML 4 NMO
STAVUDINE ORAL CAPSULE 15 MG, 20 MG 3 QL (120 EA per 30 days)
STAVUDINE ORAL CAPSULE 30 MG, 40 MG 3 QL (60 EA per 30 days)
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Drug Drug Tier Requirements/Limits
STAVUDINE ORAL SOLUTION RECONSTITUTED 1
MG/ML 3
TRUVADA ORAL TABLET 100-150 MG, 133-200 MG,
167-250 MG 5 NMO
TRUVADA ORAL TABLET 200-300 MG 5 NMO; QL (30 EA per 30 days)
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM 4 QL (1200 ML per 30 days)
VIREAD ORAL POWDER 40 MG/GM 5 NMO; QL (240 GM per 30 days)
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300
MG 5 NMO; QL (30 EA per 30 days)
ZIAGEN ORAL SOLUTION 20 MG/ML 4 QL (960 ML per 30 days)
ZIDOVUDINE ORAL CAPSULE 100 MG 3 QL (180 EA per 30 days)
ZIDOVUDINE ORAL SYRUP 50 MG/5ML 3 QL (1680 ML per 28 days)
ZIDOVUDINE ORAL TABLET 300 MG 3 QL (60 EA per 30 days)
ANTI-HIV AGENTS, OTHER
FUZEON SUBCUTANEOUS* SOLUTION
RECONSTITUTED 90 MG 5 NMO; QL (60 EA per 30 days)
ISENTRESS ORAL PACKET 100 MG 3
ISENTRESS ORAL TABLET 400 MG 5 NMO; QL (120 EA per 30 days)
ISENTRESS ORAL TABLET CHEWABLE 100 MG 4 QL (180 EA per 30 days)
ISENTRESS ORAL TABLET CHEWABLE 25 MG 3 QL (180 EA per 30 days)
SELZENTRY ORAL TABLET 150 MG 5 NMO; QL (240 EA per 30 days)
SELZENTRY ORAL TABLET 300 MG 5 NMO; QL (120 EA per 30 days)
TIVICAY ORAL TABLET 10 MG, 25 MG 4
TIVICAY ORAL TABLET 50 MG 5 NMO
VITEKTA ORAL TABLET 150 MG, 85 MG 5 NMO; QL (30 EA per 30 days)
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS ORAL CAPSULE 250 MG 5 NMO; QL (120 EA per 30 days)
APTIVUS ORAL SOLUTION 100 MG/ML 5 NMO; QL (285 ML per 28 days)
CRIXIVAN ORAL CAPSULE 200 MG 3 QL (450 EA per 30 days)
CRIXIVAN ORAL CAPSULE 400 MG 3 QL (270 EA per 30 days)
INVIRASE ORAL CAPSULE 200 MG 4 QL (300 EA per 30 days)
INVIRASE ORAL TABLET 500 MG 5 NMO; QL (120 EA per 30 days)
KALETRA ORAL SOLUTION 400-100 MG/5ML 5 NMO
KALETRA ORAL TABLET 100-25 MG 4 QL (300 EA per 30 days)
KALETRA ORAL TABLET 200-50 MG 5 NMO; QL (150 EA per 30 days)
LEXIVA ORAL SUSPENSION 50 MG/ML 3 QL (1575 ML per 28 days)
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LEXIVA ORAL TABLET 700 MG 5 NMO; QL (120 EA per 30 days)
NORVIR ORAL CAPSULE 100 MG 4 QL (360 EA per 30 days)
NORVIR ORAL SOLUTION 80 MG/ML 4 QL (480 ML per 30 days)
NORVIR ORAL TABLET 100 MG 4 QL (360 EA per 30 days)
PREZISTA ORAL SUSPENSION 100 MG/ML 4
PREZISTA ORAL TABLET 150 MG 4 QL (240 EA per 30 days)
PREZISTA ORAL TABLET 600 MG 5 NMO; QL (60 EA per 30 days)
PREZISTA ORAL TABLET 75 MG 4 QL (480 EA per 30 days)
PREZISTA ORAL TABLET 800 MG 5 NMO
REYATAZ ORAL CAPSULE 150 MG, 200 MG 5 NMO; QL (60 EA per 30 days)
REYATAZ ORAL CAPSULE 300 MG 5 NMO; QL (30 EA per 30 days)
REYATAZ ORAL PACKET 50 MG 5 NMO
TRIUMEQ ORAL TABLET 600-50-300 MG 5 NMO; QL (30 EA per 30 days)
VIRACEPT ORAL TABLET 250 MG 5 NMO; QL (300 EA per 30 days)
VIRACEPT ORAL TABLET 625 MG 5 NMO; QL (120 EA per 30 days)
ANTI-INFLUENZA AGENTS
RELENZA DISKHALER INHALATION AEROSOL
POWDER, BREATH ACTIVATED 5 MG/BLISTER 4 NMO
RIMANTADINE HCL ORAL TABLET 100 MG 3 NMO
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG 3 NMO
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6
MG/ML 3 NMO; QL (540 ML per 30 days)
VIRAZOLE INHALATION SOLUTION RECONSTITUTED
6 GM 5 BD; NMO
ANTIVIRALS, OTHER
ATRIPLA ORAL TABLET 600-200-300 MG 5 NMO; QL (30 EA per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 5 NMO; QL (30 EA per 30 days)
famciclovir oral tablet 125 mg, 250 mg, 500 mg 2 NMO
GENVOYA ORAL TABLET 150-150-200-10 MG 5 NMO; QL (60 EA per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 5 NMO
STRIBILD ORAL TABLET 150-150-200-300 MG 5 NMO; QL (30 EA per 30 days)
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 NMO
hydroxyzine hcl intramuscular* solution 25 mg/ml, 50 mg/ml 4 PA; NMO
hydroxyzine hcl oral syrup 10 mg/5ml 4 PA; NMO
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Drug Drug Tier Requirements/Limits
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA; NMO
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 2 PA; NMO
BENZODIAZEPINES
alprazolam er oral tablet extended release 24 hr* 0.5 mg 2 QL (90 EA per 30 days)
alprazolam er oral tablet extended release 24 hr* 1 mg, 3 mg 2 NMO; QL (90 EA per 30 days)
alprazolam intensol oral concentrate 1 mg/ml 2 NMO; QL (300 ML per 30 days)
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 2 NMO; QL (180 EA per 30 days)
ALPRAZOLAM ORAL TABLET DISPERSIBLE 0.25 MG,
0.5 MG, 1 MG 3 NMO; QL (360 EA per 30 days)
alprazolam xr oral tablet extended release 24 hr* 0.5 mg 2 NMO; QL (90 EA per 30 days)
chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 2 NMO; QL (120 EA per 30 days)
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 2 NMO; QL (180 EA per 30 days)
DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 3 NMO; QL (240 ML per 30 days)
DIAZEPAM ORAL SOLUTION 1 MG/ML 3 NMO; QL (1200 ML per 30 days)
diazepam oral tablet 10 mg 2 NMO; QL (120 EA per 30 days)
diazepam oral tablet 2 mg 2 NMO; QL (600 EA per 30 days)
diazepam oral tablet 5 mg 2 NMO; QL (240 EA per 30 days)
lorazepam intensol oral concentrate 2 mg/ml 2 NMO; QL (240 ML per 30 days)
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 2 NMO; QL (150 EA per 30 days)
OXAZEPAM ORAL CAPSULE 10 MG, 15 MG, 30 MG 3 NMO; QL (120 EA per 30 days)
BIPOLAR AGENTS
MOOD STABILIZERS
carbamazepine oral tablet chewable 100 mg 1
lithium carbonate er oral tablet extendedrelease* 300 mg, 450
mg 1
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1
lithium carbonate oral tablet 300 mg 1
lithium oral solution 8 meq/5ml 2
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose oral tablet 100 mg, 50 mg 2 QL (90 EA per 30 days)
acarbose oral tablet 25 mg 1 QL (90 EA per 30 days)
ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML 3 NMO
BYDUREON SUBCUTANEOUS* 2 MG 3
BYETTA 10 MCG PEN SUBCUTANEOUS* 10
MCG/0.04ML 3
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Drug Drug Tier Requirements/Limits
BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML 3
COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML 3 NMO
CVS GAUZE STERILE PAD 2"X2" 3 NMO
CYCLOSET ORAL TABLET 0.8 MG 4
EXEL COMFORT POINT PEN NEEDLE 29G X 12MM 3 NMO
EXEL PEN NEEDLES 1/2" 29G X 12MM 3
glimepiride oral tablet 1 mg, 2 mg, 4 mg 1
glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg,
5 mg 1
glipizide oral tablet 10 mg, 5 mg 1
glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-
500 mg 1 QL (120 EA per 30 days)
GLOBAL ALCOHOL PREP EASE PAD 70 % 3 NMO
INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG,
50-1000 MG, 50-500 MG 3
INVOKANA ORAL TABLET 100 MG, 300 MG 3
JANUMET ORAL TABLET 50-1000 MG, 50-500 MG 3 QL (60 EA per 30 days)
JANUMET XR ORAL TABLET EXTENDED RELEASE 24
HR* 100-1000 MG 3 QL (30 EA per 30 days)
JANUMET XR ORAL TABLET EXTENDED RELEASE 24
HR* 50-1000 MG, 50-500 MG 3 QL (60 EA per 30 days)
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG 3 QL (30 EA per 30 days)
JARDIANCE ORAL TABLET 10 MG, 25 MG 3 QL (30 EA per 30 days)
JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG,
2.5-850 MG 3 QL (60 EA per 30 days)
JENTADUETO XR ORAL TABLET EXTENDED
RELEASE 24 HR* 2.5-1000 MG 4 QL (60 EA per 30 days)
JENTADUETO XR ORAL TABLET EXTENDED
RELEASE 24 HR* 5-1000 MG 4 QL (30 EA per 30 days)
KORLYM ORAL TABLET 300 MG 5 PA; LA; NMO; QL (120 EA per
30 days)
metformin hcl er (osm) oral tablet extended release 24 hr*
1000 mg 2 QL (60 EA per 30 days)
metformin hcl er oral tablet extended release 24 hr* 500 mg 1 QL (120 EA per 30 days)
metformin hcl er oral tablet extended release 24 hr* 750 mg 1 QL (90 EA per 30 days)
metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1
miglitol oral tablet 100 mg, 25 mg, 50 mg 2
nateglinide oral tablet 120 mg, 60 mg 2
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pioglitazone hcl oral tablet 15 mg 1
pioglitazone hcl oral tablet 30 mg, 45 mg 2
pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 2 QL (30 EA per 30 days)
pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850
mg 2 QL (90 EA per 30 days)
PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML 3 NMO
RELI-ON INSULIN SYRINGE 29G 0.3 ML 3 NMO
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 2
repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg 2
RIOMET ORAL SOLUTION 500 MG/5ML 4
SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML 4 PA; QL (10.8 ML per 28 days)
symlinpen 60 subcutaneous* 1500 mcg/1.5ml 1 PA; QL (10.8 ML per 28 days)
SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG,
5-1000 MG, 5-500 MG3
tolazamide oral tablet 250 mg, 500 mg 1
tolbutamide oral tablet 500 mg 1
TRADJENTA ORAL TABLET 5 MG 3 QL (30 EA per 30 days)
VICTOZA SUBCUTANEOUS* 18 MG/3ML 3 QL (9 ML per 30 days)
GLYCEMIC AGENTS
GLUCAGEN HYPOKIT INJECTION SOLUTION
RECONSTITUTED 1 MG 3 NMO
GLUCAGON EMERGENCY INJECTION KIT 1 MG 3 NMO
PROGLYCEM ORAL SUSPENSION 50 MG/ML 3
INSULINS
LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML 3
LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3
LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100
UNIT/ML 3
LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3
NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION (70-
30) 100 UNIT/ML3
NOVOLIN N SUBCUTANEOUS* SUSPENSION 100
UNIT/ML 3
NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 3
NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML 3
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* (70-
30) 100 UNIT/ML3
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Drug Drug Tier Requirements/Limits
NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION
(70-30) 100 UNIT/ML 3
NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML 3
NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3
TOUJEO SOLOSTAR SUBCUTANEOUS* 300 UNIT/ML 3
BLOOD PRODUCTS/MODIFIERS/ VOLUME
EXPANDERS
ANTICOAGULANTS
argatroban intravenous* solution 250 mg/2.5ml 4 BD; NMO
ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3
enoxaparin sodium injection solution 300 mg/3ml 4 NMO
enoxaparin sodium subcutaneous* solution 100 mg/ml, 120
mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml,
80 mg/0.8ml
4 NMO
fondaparinux sodium subcutaneous* solution 10 mg/0.8ml, 5
mg/0.4ml, 7.5 mg/0.6ml 5 NMO
fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml 4 NMO
FRAGMIN SUBCUTANEOUS* SOLUTION 10000
UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000
UNT/0.72ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML
5 NMO
FRAGMIN SUBCUTANEOUS* SOLUTION 2500
UNIT/0.2ML, 5000 UNIT/0.2ML 4 NMO
heparin (porcine) in d5w intravenous* solution 40-5 unit/ml-
%, 50-5 unit/ml-% 1 BD; NMO
heparin sod (porcine) in d5w intravenous* solution 100
unit/ml 1 BD; NMO
heparin sodium (porcine) injection solution 1000 unit/ml,
10000 unit/ml, 20000 unit/ml, 5000 unit/ml 1 NMO
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 6 mg, 7.5 mg 1
PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 4
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg,
4 mg, 5 mg, 6 mg, 7.5 mg 1
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG 3
XARELTO STARTER PACK ORAL 15 & 20 MG 3 NMO
BLOOD FORMATION MODIFIERS
ARANESP (ALBUMIN FREE) INJECTION 100
MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 300
MCG/0.6ML, 500 MCG/ML
5 PA; NMO
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ARANESP (ALBUMIN FREE) INJECTION 25
MCG/0.42ML, 40 MCG/0.4ML, 60 MCG/0.3ML 3 PA; NMO
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100
MCG/ML, 200 MCG/ML, 300 MCG/ML 5 PA; NMO
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25
MCG/ML, 40 MCG/ML, 60 MCG/ML 3 PA; NMO
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000
UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000
UNIT/ML
4 PA; NMO
LEUKINE INTRAVENOUS* SOLUTION
RECONSTITUTED 250 MCG 5 PA; NMO
MIRCERA INJECTION 100 MCG/0.3ML, 50 MCG/0.3ML,
75 MCG/0.3ML 4 BD; NMO
MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML 5 PA; NMO; QL (9.6 ML per 30
days)
NEULASTA SUBCUTANEOUS* 6 MG/0.6ML 5 PA; NMO
NEUPOGEN INJECTION 300 MCG/0.5ML, 480
MCG/0.8ML 5 PA; NMO
NEUPOGEN INJECTION SOLUTION 300 MCG/ML 4 PA; NMO
NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML 5 PA; NMO
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000
UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML 3 PA; NMO
PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000
UNIT/ML 5 PA; NMO
PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75
MG 5
PA; NMO; QL (30 EA per 30
days)
tranexamic acid intravenous* solution 1000 mg/10ml 1 BD; NMO
tranexamic acid oral tablet 650 mg 2 NMO
ZARXIO INJECTION 300 MCG/0.5ML, 480 MCG/0.8ML 3 PA; NMO
PLATELET MODIFYING AGENTS
anagrelide hcl oral capsule 0.5 mg, 1 mg 1
aspirin-dipyridamole er oral capsule extended release 12 hour
25-200 mg 2
BRILINTA ORAL TABLET 60 MG, 90 MG 3
cilostazol oral tablet 100 mg, 50 mg 1
clopidogrel bisulfate oral tablet 300 mg 2 NMO
clopidogrel bisulfate oral tablet 75 mg 1
dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 PA
EFFIENT ORAL TABLET 10 MG 4
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CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1
clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2
mg/24hr, 0.3 mg/24hr 2
guanfacine hcl oral tablet 1 mg, 2 mg 1 PA
midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 2 NMO
ALPHA-ADRENERGIC BLOCKING AGENTS
DEMSER ORAL CAPSULE 250 MG 4 NMO
doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1
prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG 4
candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 2
eprosartan mesylate oral tablet 600 mg 2
irbesartan oral tablet 150 mg, 300 mg, 75 mg 1
losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1
telmisartan oral tablet 20 mg, 40 mg, 80 mg 1
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 2
ANGIOTENSIN-CONVERTING ENZYME
(ACE) INHIBITORS
benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 2
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5
mg 1
moexipril hcl oral tablet 15 mg, 7.5 mg 2
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1
trandolapril oral tablet 1 mg, 2 mg, 4 mg 1
ANTIARRHYTHMICS
amiodarone hcl intravenous* solution 150 mg/3ml 1 BD; NMO
amiodarone hcl oral tablet 200 mg 1
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Drug Drug Tier Requirements/Limits
amiodarone hcl oral tablet 400 mg 2
disopyramide phosphate oral capsule 100 mg, 150 mg 1 PA
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 2
flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1
mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 2
MULTAQ ORAL TABLET 400 MG 4
NORPACE CR ORAL CAPSULE EXTENDED RELEASE
12 HOUR 100 MG, 150 MG 4 PA
pacerone oral tablet 100 mg, 200 mg, 400 mg 1
PROPAFENONE HCL ER ORAL CAPSULE EXTENDED
RELEASE 12 HOUR 225 MG, 325 MG, 425 MG 3
propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 2
quinidine gluconate er oral tablet extendedrelease* 324 mg 1
quinidine sulfate oral tablet 200 mg, 300 mg 1
ANTIHYPERTENSIVE COMBINATIONS
ALDACTAZIDE ORAL TABLET 50-50 MG 4
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1
amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40
mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg 1
AMLODIPINE BESYLATE-VALSARTAN ORAL TABLET
10-160 MG, 10-320 MG, 5-160 MG, 5-320 MG 3
AMLODIPINE-VALSARTAN-HCTZ ORAL TABLET 10-
160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5
MG, 5-160-25 MG
3
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1
AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-
40 MG 4
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-
12.5 mg, 20-25 mg, 5-6.25 mg 2
BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG,
40-25 MG 4
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-
6.25 mg, 5-6.25 mg 1
candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg,
32-25 mg 2
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg,
50-15 mg, 50-25 mg 2
clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 mg 1
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enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1
fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-
12.5 mg 1
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg 1
losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg,
50-12.5 mg 1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-
25 mg 1 PA
metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50
mg, 50-25 mg 2
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg 1
spironolactone-hctz oral tablet 25-25 mg 1
TELMISARTAN-HCTZ ORAL TABLET 40-12.5 MG, 80-
12.5 MG, 80-25 MG 3
triamterene-hctz oral capsule 37.5-25 mg, 50-25 mg 1
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1
TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5
MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG 4
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25
mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg 1
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl oral capsule 200 mg, 400 mg 1
atenolol oral tablet 100 mg, 25 mg, 50 mg 1
bisoprolol fumarate oral tablet 10 mg, 5 mg 1
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1
COREG CR ORAL CAPSULE EXTENDED RELEASE 24
HOUR 10 MG, 20 MG, 40 MG, 80 MG 4
labetalol hcl intravenous* solution 5 mg/ml 2 NMO
labetalol hcl oral tablet 100 mg, 200 mg 1
labetalol hcl oral tablet 300 mg 2
metoprolol succinate er oral tablet extended release 24 hr*
100 mg, 25 mg, 50 mg 1
metoprolol succinate er oral tablet extended release 24 hr*
200 mg 2
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
metoprolol tartrate intravenous* solution 1 mg/ml, 5 mg/5ml 1 NMO
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1
nadolol oral tablet 20 mg, 40 mg, 80 mg 2
pindolol oral tablet 10 mg, 5 mg 2
propranolol hcl er oral capsule extended release 24 hour 120
mg, 160 mg, 60 mg, 80 mg 2
propranolol hcl intravenous* solution 1 mg/ml 1 NMO
propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80
mg 1
sotalol hcl (af) oral tablet 120 mg 1
sotalol hcl oral tablet 160 mg, 240 mg, 80 mg 1
timolol maleate oral tablet 20 mg, 5 mg 1
CALCIUM CHANNEL BLOCKING AGENTS
afeditab cr oral tablet extended release 24 hr* 30 mg, 60 mg 1
amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24
HR* 120 MG 4
cartia xt oral capsule extended release 24 hour 120 mg, 180
mg, 240 mg, 300 mg 1
diltiazem hcl er beads oral capsule extended release 24 hour
180 mg 1
diltiazem hcl er beads oral capsule extended release 24 hour
360 mg, 420 mg 2
diltiazem hcl er coated beads oral capsule extended release 24
hour 120 mg, 240 mg, 300 mg 1
diltiazem hcl er oral capsule extended release 12 hour 120 mg,
60 mg, 90 mg 2
diltiazem hcl intravenous* solution 50 mg/10ml 1 NMO
diltiazem hcl intravenous* solution reconstituted 100 mg 1 NMO
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1
dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg,
240 mg 1
felodipine er oral tablet extended release 24 hr* 10 mg, 2.5
mg, 5 mg 1
ISRADIPINE ORAL CAPSULE 2.5 MG, 5 MG 3
matzim la oral tablet extended release 24 hr* 180 mg, 240 mg,
300 mg, 360 mg, 420 mg 2
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
nicardipine hcl oral capsule 20 mg, 30 mg 1
nifedical xl oral tablet extended release 24 hr* 30 mg, 60 mg 1
nifedipine er osmotic release oral tablet extended release 24
hr* 30 mg, 60 mg 1
nifedipine er osmotic release oral tablet extended release 24
hr* 90 mg 2
nimodipine oral capsule 30 mg 4
NISOLDIPINE ER ORAL TABLET EXTENDED RELEASE
24 HR* 17 MG, 20 MG, 25.5 MG, 30 MG, 34 MG, 40 MG,
8.5 MG
3
taztia xt oral capsule extended release 24 hour 120 mg, 180
mg, 240 mg, 300 mg, 360 mg 1
verapamil hcl er oral capsule extended release 24 hour 100
mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg 2
VERAPAMIL HCL ER ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 360 MG 3
verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg,
240 mg 1
verapamil hcl intravenous* solution 2.5 mg/ml 1 NMO
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1
CARDIOVASCULAR AGENTS, OTHER
AMLODIPINE-ATORVASTATIN ORAL TABLET 10-10
MG, 10-20 MG, 10-40 MG, 10-80 MG, 2.5-10 MG, 2.5-20
MG, 2.5-40 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG
3
digitek oral tablet 125 mcg, 250 mcg 1
digoxin injection solution 0.25 mg/ml 1 NMO
digoxin oral solution 0.05 mg/ml 1
digoxin oral tablet 125 mcg, 250 mcg 1
pentoxifylline er oral tablet extendedrelease* 400 mg 1
RANEXA ORAL TABLET EXTENDED RELEASE 12 HR*
1000 MG, 500 MG 3
DIURETICS, CARBONIC ANHYDRASE
INHIBITORS
acetazolamide oral tablet 125 mg 1
acetazolamide oral tablet 250 mg 2
METHAZOLAMIDE ORAL TABLET 25 MG, 50 MG 4
DIURETICS, LOOP
bumetanide injection solution 0.25 mg/ml 1 NMO
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
EDECRIN ORAL TABLET 25 MG 4
furosemide injection solution 10 mg/ml, 10 mg/ml (4ml
syringe) 1 NMO
furosemide oral solution 10 mg/ml, 8 mg/ml 1
furosemide oral tablet 20 mg, 40 mg, 80 mg 1
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1
DIURETICS, POTASSIUM-SPARING
amiloride hcl oral tablet 5 mg 1
eplerenone oral tablet 25 mg, 50 mg 2
spironolactone oral tablet 100 mg, 25 mg, 50 mg 1
DIURETICS, THIAZIDE
chlorothiazide oral tablet 250 mg, 500 mg 2
CHLOROTHIAZIDE SODIUM INTRAVENOUS*
SOLUTION RECONSTITUTED 500 MG 3 NMO
chlorthalidone oral tablet 25 mg, 50 mg 1
DIURIL ORAL SUSPENSION 250 MG/5ML 4
hydrochlorothiazide oral capsule 12.5 mg 1
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1
indapamide oral tablet 1.25 mg, 2.5 mg 1
methyclothiazide oral tablet 5 mg 1
metolazone oral tablet 10 mg, 5 mg 2
metolazone oral tablet 2.5 mg 1
DYSLIPIDEMICS, FIBRIC ACID
DERIVATIVES
fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg,
43 mg, 67 mg 2
fenofibrate oral capsule 150 mg, 50 mg 2
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg 2
fenofibric acid oral capsule delayed release 135 mg, 45 mg 2
gemfibrozil oral tablet 600 mg 1
DYSLIPIDEMICS, HMG COA REDUCTASE
INHIBITORS
atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1
FLUVASTATIN SODIUM ER ORAL TABLET EXTENDED
RELEASE 24 HR* 80 MG 3
fluvastatin sodium oral capsule 20 mg, 40 mg 2
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 3
lovastatin oral tablet 10 mg, 20 mg, 40 mg 1
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1
rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg 2
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg 1
DYSLIPIDEMICS, OTHER
cholestyramine light oral packet 4 gm 2
cholestyramine light oral powder 4 gm/dose 2
colestipol hcl oral granules 5 gm 2
colestipol hcl oral tablet 1 gm 2
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40
MG, 5 MG, 60 MG 5
PA; NMO; QL (30 EA per 30
days)
KYNAMRO SUBCUTANEOUS* 200 MG/ML 4 PA
niacin er (antihyperlipidemic) oral tablet extendedrelease*
1000 mg, 500 mg, 750 mg 2
niacor oral tablet 500 mg 1 NMO
omega-3-acid ethyl esters oral capsule 1 gm 2
PRALUENT SUBCUTANEOUS* 150 MG/ML, 75 MG/ML 5 PA; NMO
REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS*
420 MG/3.5ML 5 PA; NMO
REPATHA SUBCUTANEOUS* 140 MG/ML 5 PA; NMO
REPATHA SURECLICK SUBCUTANEOUS* 140 MG/ML 5 PA; NMO
WELCHOL ORAL TABLET 625 MG 3
ZETIA ORAL TABLET 10 MG 4
VASODILATORS, DIRECT-ACTING
ARTERIAL/VENOUS
ISOSORBIDE DINITRATE ER ORAL TABLET
EXTENDEDRELEASE* 40 MG 3
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg 2
isosorbide mononitrate er oral tablet extended release 24 hr*
120 mg, 30 mg, 60 mg 1
isosorbide mononitrate oral tablet 10 mg, 20 mg 1
minitran transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr 1
NITRO-BID TRANSDERMAL OINTMENT 2 % 3
nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr 1
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
NITROGLYCERIN TRANSLINGUAL SOLUTION 0.4
MG/SPRAY 4
nitrostat sublingual tablet sublingual 0.3 mg, 0.4 mg 1
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.6
MG 3
VASODILATORS, DIRECT-ACTING
ARTERIAL
BIDIL ORAL TABLET 20-37.5 MG 4
hydralazine hcl injection solution 20 mg/ml 1 NMO
hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1
minoxidil oral tablet 10 mg, 2.5 mg 1
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY
DISORDER AGENTS, AMPHETAMINES
AMPHETAMINE-DEXTROAMPHET ER ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG,
25 MG, 30 MG, 5 MG
3 PA
amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg,
15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg 2
dextroamphetamine sulfate er oral capsule extended release
24 hour 10 mg, 15 mg, 5 mg 4 PA
DEXTROAMPHETAMINE SULFATE ORAL TABLET 10
MG, 5 MG 3 PA
VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40
MG, 50 MG, 60 MG, 70 MG 4 PA
zenzedi oral tablet 15 mg, 20 mg, 30 mg 4
ATTENTION DEFICIT HYPERACTIVITY
DISORDER AGENTS, NON-AMPHETAMINES
CLONIDINE HCL ER ORAL TABLET EXTENDED
RELEASE 12 HR* 0.1 MG 3 QL (120 EA per 30 days)
DAYTRANA TRANSDERMAL PATCH 15 MG/9HR 4 PA
guanfacine hcl er oral tablet extended release 24 hr* 1 mg, 2
mg, 3 mg, 4 mg 4 PA
METHYLPHENIDATE HCL ER (CD) ORAL CAPSULE
EXTENDED RELEASE* 10 MG, 30 MG, 50 MG, 60 MG 3 PA
METHYLPHENIDATE HCL ER (LA) ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 20 MG, 40 MG 3 PA
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
METHYLPHENIDATE HCL ER ORAL TABLET
EXTENDED RELEASE 24 HR* 18 MG, 27 MG, 36 MG, 54
MG
3 PA
METHYLPHENIDATE HCL ER ORAL TABLET
EXTENDEDRELEASE* 20 MG 3 PA
METHYLPHENIDATE HCL ORAL SOLUTION 10
MG/5ML, 5 MG/5ML 3 PA
methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 2 PA
STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40
MG, 60 MG, 80 MG 4 PA; QL (60 EA per 30 days)
STRATTERA ORAL CAPSULE 100 MG 4 PA; QL (30 EA per 30 days)
CENTRAL NERVOUS SYSTEM, OTHER
riluzole oral tablet 50 mg 4
tetrabenazine oral tablet 12.5 mg 5 PA; NMO; QL (90 EA per 30
days)
tetrabenazine oral tablet 25 mg 5 PA; NMO; QL (120 EA per 30
days)
FIBROMYALGIA AGENTS
LYRICA ORAL CAPSULE 100 MG 3 QL (120 EA per 30 days)
SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50
MG 3 QL (60 EA per 30 days)
SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 NMO
MULTIPLE SCLEROSIS AGENTS
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR*
10 MG 5
PA; NMO; QL (60 EA per 30
days)
AVONEX INTRAMUSCULAR* KIT 30 MCG 5 PA; NMO
AVONEX PEN INTRAMUSCULAR* 30 MCG/0.5ML 5 PA; NMO
AVONEX PREFILLED INTRAMUSCULAR* 30
MCG/0.5ML 5 PA; NMO
BETASERON SUBCUTANEOUS* KIT 0.3 MG 5 PA; NMO
COPAXONE SUBCUTANEOUS* 20 MG/ML, 40 MG/ML 5 PA; NMO
GILENYA ORAL CAPSULE 0.5 MG 5 PA; NMO
PLEGRIDY STARTER PACK SUBCUTANEOUS* 63 & 94
MCG/0.5ML 5 PA; NMO
PLEGRIDY SUBCUTANEOUS* 125 MCG/0.5ML 5 PA; NMO
TECFIDERA ORAL 120 & 240 MG 5 PA; NMO
TECFIDERA ORAL CAPSULE DELAYED RELEASE 120
MG, 240 MG 5
PA; NMO; QL (60 EA per 30
days)
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
TYSABRI INTRAVENOUS* CONCENTRATE 300
MG/15ML 5 PA; NMO
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
CEVIMELINE HCL ORAL CAPSULE 30 MG 3
chlorhexidine gluconate mouth/throat solution 0.12 % 1 NMO
clotrimazole mouth/throat troche 10 mg 1 NMO
lidocaine viscous mouth/throat solution 2 % 1 NMO
nystatin mouth/throat suspension 100000 unit/ml 1 NMO
pilocarpine hcl oral tablet 5 mg 2
PILOCARPINE HCL ORAL TABLET 7.5 MG 3
triamcinolone acetonide mouth/throat paste 0.1 % 2 NMO
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
8-MOP ORAL CAPSULE 10 MG 4 NMO
ACANYA EXTERNAL GEL 1.2-2.5 % 4 NMO
acitretin oral capsule 10 mg, 17.5 mg, 25 mg 5 PA; NMO
acyclovir external ointment 5 % 4 NMO
ADAPALENE EXTERNAL CREAM 0.1 % 3 NMO
ADAPALENE EXTERNAL GEL 0.1 %, 0.3 % 3 NMO
ALA SCALP EXTERNAL LOTION 2 % 4 NMO
alclometasone dipropionate external cream 0.05 % 1 NMO
alclometasone dipropionate external ointment 0.05 % 1 NMO
ALTABAX EXTERNAL OINTMENT 1 % 4 NMO
AMCINONIDE EXTERNAL CREAM 0.1 % 3 NMO
AMCINONIDE EXTERNAL LOTION 0.1 % 3 NMO
AMCINONIDE EXTERNAL OINTMENT 0.1 % 3 NMO
ammonium lactate external cream 12 % 1 NMO
ammonium lactate external lotion 12 % 1 NMO
AZELEX EXTERNAL CREAM 20 % 4 NMO
benzoyl peroxide-erythromycin external gel 5-3 % 2 NMO
betamethasone dipropionate aug external cream 0.05 % 1 NMO
betamethasone dipropionate aug external lotion 0.05 % 2 NMO
betamethasone dipropionate aug external ointment 0.05 % 2 NMO
betamethasone dipropionate external cream 0.05 % 2 NMO
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
betamethasone dipropionate external lotion 0.05 % 2 NMO
betamethasone dipropionate external ointment 0.05 % 2 NMO
betamethasone valerate external cream 0.1 % 2 NMO
betamethasone valerate external foam 0.12 % 2 NMO
betamethasone valerate external lotion 0.1 % 2 NMO
betamethasone valerate external ointment 0.1 % 2 NMO
calcipotriene external cream 0.005 % 4 NMO
calcipotriene external ointment 0.005 % 4 NMO
calcipotriene external solution 0.005 % 4 NMO
calcipotriene-betameth diprop external ointment 0.005-0.064
% 4 NMO
CALCITRIOL EXTERNAL OINTMENT 3 MCG/GM 4 NMO
CAPEX EXTERNAL SHAMPOO 0.01 % 4 NMO
ciclopirox external gel 0.77 % 2 NMO
ciclopirox external shampoo 1 % 2 NMO
ciclopirox olamine external cream 0.77 % 1 NMO
ciclopirox olamine external suspension 0.77 % 2 NMO
claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 4 NMO
clindamycin phos-benzoyl perox external gel 1-5 % 4 NMO
clindamycin phosphate external foam 1 % 2 NMO
clindamycin phosphate external gel 1 % 2 NMO
clindamycin phosphate external lotion 1 % 2 NMO
clindamycin phosphate external solution 1 % 2 NMO
clindamycin phosphate external swab 1 % 2 NMO
CLOBETASOL PROPIONATE E EXTERNAL CREAM 0.05
% 3 NMO
CLOBETASOL PROPIONATE EXTERNAL FOAM 0.05 % 3 NMO
CLOBETASOL PROPIONATE EXTERNAL GEL 0.05 % 3 NMO
CLOBETASOL PROPIONATE EXTERNAL LIQUID† 0.05
% 3 NMO
CLOBETASOL PROPIONATE EXTERNAL LOTION 0.05
% 3 NMO
CLOBETASOL PROPIONATE EXTERNAL OINTMENT
0.05 % 3 NMO
CLOBETASOL PROPIONATE EXTERNAL SHAMPOO
0.05 % 3 NMO
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
CLOBETASOL PROPIONATE EXTERNAL SOLUTION
0.05 % 3 NMO
CLODERM PUMP EXTERNAL CREAM 0.1 % 4 NMO
clotrimazole external cream 1 % 1 NMO
clotrimazole external solution 1 % 1 NMO
CONDYLOX EXTERNAL GEL 0.5 % 4 NMO
CORDRAN EXTERNAL TAPE 4 MCG/SQCM 4 NMO
CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5 4 NMO
CORTISPORIN EXTERNAL OINTMENT 1 % 4 NMO
COSENTYX SENSOREADY PEN SUBCUTANEOUS* 150
MG/ML 5 ST; NMO
COSENTYX SUBCUTANEOUS* 150 MG/ML 5 ST; NMO
DENAVIR EXTERNAL CREAM 1 % 4 NMO
DESONATE EXTERNAL GEL 0.05 % 4 NMO
DESONIDE EXTERNAL CREAM 0.05 % 3 NMO
DESONIDE EXTERNAL LOTION 0.05 % 3 NMO
DESONIDE EXTERNAL OINTMENT 0.05 % 3 NMO
DESOXIMETASONE EXTERNAL CREAM 0.05 %, 0.25 % 3 NMO
DESOXIMETASONE EXTERNAL GEL 0.05 % 3 NMO
DESOXIMETASONE EXTERNAL OINTMENT 0.25 % 3 NMO
diclofenac sodium transdermal gel 1 % 2 NMO
diclofenac sodium transdermal gel 3 % 5 PA; NMO; QL (100 GM per 30
days)
diclofenac sodium transdermal solution 1.5 % 4 NMO
DIFFERIN EXTERNAL LOTION 0.1 % 4 NMO
DIFLORASONE DIACETATE EXTERNAL CREAM 0.05 % 3 NMO
DIFLORASONE DIACETATE EXTERNAL OINTMENT
0.05 % 4 NMO
econazole nitrate external cream 1 % 2 NMO
ELIDEL EXTERNAL CREAM 1 % 4 PA; NMO
EPIDUO EXTERNAL GEL 0.1-2.5 % 4 NMO
EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % 4 NMO
ery external pad 2 % 1 NMO
erythromycin external gel 2 % 1 NMO
erythromycin external solution 2 % 1 NMO
EURAX EXTERNAL CREAM 10 % 4 NMO
EURAX EXTERNAL LOTION 10 % 4 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
EXELDERM EXTERNAL CREAM 1 % 4 NMO
EXELDERM EXTERNAL SOLUTION 1 % 4 NMO
FINACEA EXTERNAL GEL 15 % 4 NMO
FLUOCINOLONE ACETONIDE BODY EXTERNAL OIL
0.01 % 3 NMO
FLUOCINOLONE ACETONIDE EXTERNAL CREAM 0.01
%, 0.025 % 3 NMO
FLUOCINOLONE ACETONIDE EXTERNAL OINTMENT
0.025 % 3 NMO
FLUOCINOLONE ACETONIDE EXTERNAL SOLUTION
0.01 % 3 NMO
fluocinonide external cream 0.1 % 4 NMO
FLUOCINONIDE EXTERNAL GEL 0.05 % 3 NMO
FLUOCINONIDE EXTERNAL OINTMENT 0.05 % 3 NMO
FLUOCINONIDE EXTERNAL SOLUTION 0.05 % 3 NMO
FLUOCINONIDE-E EXTERNAL CREAM 0.05 % 3 NMO
FLUOROURACIL EXTERNAL CREAM 5 % 3 NMO
FLUOROURACIL EXTERNAL SOLUTION 2 %, 5 % 3 NMO
fluticasone propionate external cream 0.05 % 1 NMO
FLUTICASONE PROPIONATE EXTERNAL LOTION 0.05
% 3 NMO
fluticasone propionate external ointment 0.005 % 1 NMO
gentamicin sulfate external cream 0.1 % 1 NMO
gentamicin sulfate external ointment 0.1 % 2 NMO
HALOBETASOL PROPIONATE EXTERNAL CREAM 0.05
% 3 NMO
HALOBETASOL PROPIONATE EXTERNAL OINTMENT
0.05 % 3 NMO
HALOG EXTERNAL CREAM 0.1 % 4 NMO
HALOG EXTERNAL OINTMENT 0.1 % 4 NMO
HYDROCORTISONE BUTYRATE EXTERNAL
OINTMENT 0.1 % 3 NMO
HYDROCORTISONE BUTYRATE EXTERNAL
SOLUTION 0.1 % 3 NMO
HYDROCORTISONE ENEMA 100 MG/60ML 3 NMO
hydrocortisone external cream 1 %, 2.5 % 1 NMO
hydrocortisone external lotion 2.5 % 1 NMO
hydrocortisone external ointment 1 %, 2.5 % 1 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
HYDROCORTISONE VALERATE EXTERNAL CREAM
0.2 % 3 NMO
HYDROCORTISONE VALERATE EXTERNAL
OINTMENT 0.2 % 3 NMO
IMIQUIMOD EXTERNAL CREAM 5 % 3 NMO
ketoconazole external cream 2 % 2 NMO
ketoconazole external foam 2 % 2 NMO
ketoconazole external shampoo 2 % 1 NMO
LIDOCAINE EXTERNAL OINTMENT 5 % 3 NMO
LIDOCAINE EXTERNAL PATCH 5 % 3 PA; NMO; QL (90 EA per 30
days)
lidocaine hcl external gel 2 %, 2 % (10ml applicator) 1 NMO
lidocaine hcl external solution 4 % 1 NMO
MALATHION EXTERNAL LOTION 0.5 % 3 NMO
MENTAX EXTERNAL CREAM 1 % 4 NMO
methoxsalen rapid oral capsule 10 mg 2 PA; NMO
METRONIDAZOLE EXTERNAL CREAM 0.75 % 3 NMO
METRONIDAZOLE EXTERNAL GEL 0.75 %, 1 % 3 NMO
METRONIDAZOLE EXTERNAL LOTION 0.75 % 3 NMO
mometasone furoate external cream 0.1 % 1 NMO
mometasone furoate external ointment 0.1 % 1 NMO
mometasone furoate external solution 0.1 % 1 NMO
MUPIROCIN CALCIUM EXTERNAL CREAM 2 % 3 NMO
mupirocin external ointment 2 % 1 NMO
NAFTIFINE HCL EXTERNAL CREAM 1 %, 2 % 3 NMO
NAFTIN EXTERNAL CREAM 2 % 4 NMO
NAFTIN EXTERNAL GEL 1 % 4 NMO
nystatin external cream 100000 unit/gm 1 NMO
nystatin external ointment 100000 unit/gm 1 NMO
nystatin external powder 100000 unit/gm 1 NMO
oxiconazole nitrate external cream 1 % 4 NMO
OXISTAT EXTERNAL LOTION 1 % 4 NMO
PANDEL EXTERNAL CREAM 0.1 % 4 NMO
PANRETIN EXTERNAL GEL 0.1 % 5 NMO
PERMETHRIN EXTERNAL CREAM 5 % 3 NMO
PICATO EXTERNAL GEL 0.015 %, 0.05 % 5 NMO
You can find information on what the symbols and abbreviations on this table mean by going to page 1 of the
introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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Drug Drug Tier Requirements/Limits
podofilox external solution 0.5 % 2 NMO
PREDNICARBATE EXTERNAL CREAM 0.1 % 3 NMO
PREDNICARBATE EXTERNAL OINTMENT 0.1 % 3 NMO
procto-med hc cream 2.5 % 1 NMO
proctozone-hc cream 2.5 % 2 NMO
REGRANEX EXTERNAL GEL 0.01 % 5 PA; NMO
SANTYL EXTERNAL OINTMENT 250 UNIT/GM 3 NMO
selenium sulfide external lotion 2.5 % 1 NMO
silver sulfadiazine external cream 1 % 1 NMO
SKLICE EXTERNAL LOTION 0.5 % 4 NMO
SOOLANTRA EXTERNAL CREAM 1 % 4 NMO
STELARA SUBCUTANEOUS* 45 MG/0.5ML, 90 MG/ML 5 ST; NMO
SULFACETAMIDE SODIUM EXTERNAL SUSPENSION
10 % 3 NMO
SULFAMYLON EXTERNAL CREAM 85 MG/GM 4 NMO
TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 4 NMO
tacrolimus external ointment 0.03 %, 0.1 % 4 PA; NMO
TARGRETIN EXTERNAL GEL 1 % 5 NMO
TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % 4 NMO
TAZORAC EXTERNAL GEL 0.05 %, 0.1 % 4 NMO
TOLAK EXTERNAL CREAM 4 % 3 NMO
TOPICORT SPRAY EXTERNAL LIQUID† 0.25 % 4 NMO
TRETINOIN EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % 3 NMO
TRETINOIN EXTERNAL GEL 0.01 %, 0.025 % 3 NMO
tretinoin external gel 0.05 % 4 NMO
tretinoin microsphere external gel 0.04 %, 0.1 % 4 NMO
TRIAMCINOLONE ACETONIDE EXTERNAL AEROSOL,
SOLUTION 0.147 MG/GM 3 NMO
triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % 1 NMO
triamcinolone acetonide external lotion 0.025 % 1 NMO
triamcinolone acetonide external lotion 0.1 % 2 NMO
triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5
% 1 NMO
UCERIS FOAM 2 MG/ACT 4 ST; NMO
VALCHLOR EXTERNAL GEL 0.016 % 5 NMO
ZIANA EXTERNAL GEL 1.2-0.025 % 4 NMO
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Drug Drug Tier Requirements/Limits
ZONALON EXTERNAL CREAM 5 % 3 NMO
ZOVIRAX EXTERNAL CREAM 5 % 4 NMO
ENZYME REPLACEMENT/ MODIFIERS
ENZYME REPLACEMENT/ MODIFIERS
ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML 5 PA; LA; NMO
ALDURAZYME INTRAVENOUS* SOLUTION 2.9
MG/5ML 5 PA; LA; NMO
CEREZYME INTRAVENOUS* SOLUTION
RECONSTITUTED 400 UNIT 5 PA; LA; NMO
CYSTADANE ORAL POWDER 5 NMO
ELAPRASE INTRAVENOUS* SOLUTION 6 MG/3ML 5 PA; NMO
FABRAZYME INTRAVENOUS* SOLUTION
RECONSTITUTED 35 MG 5 PA; LA; NMO
KANUMA INTRAVENOUS* SOLUTION 20 MG/10ML 5 PA; NMO
KUVAN ORAL TABLET SOLUBLE 100 MG 5 PA; LA; NMO
levocarnitine oral solution 1 gm/10ml 1 BD
levocarnitine oral tablet 330 mg 1 BD
NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML 5 PA; NMO
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG 5 NMO
ORFADIN ORAL SUSPENSION 4 MG/ML 5 LA; NMO
RAVICTI ORAL LIQUID† 1.1 GM/ML 4
sodium phenylbutyrate oral powder 3 gm/tsp 2
ZAVESCA ORAL CAPSULE 100 MG 5 PA; NMO
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
atropine sulfate injection solution 0.05 mg/ml, 0.1 mg/ml 1 NMO
BENTYL INTRAMUSCULAR* SOLUTION 10 MG/ML 4 NMO
CUVPOSA ORAL SOLUTION 1 MG/5ML 4
dicyclomine hcl intramuscular* solution 10 mg/ml 1 NMO
dicyclomine hcl oral capsule 10 mg 1 NMO
dicyclomine hcl oral solution 10 mg/5ml 1 NMO
dicyclomine hcl oral tablet 20 mg 1 NMO
glycopyrrolate injection solution 4 mg/20ml 1 NMO
glycopyrrolate oral tablet 1 mg, 2 mg 2 NMO
methscopolamine bromide oral tablet 2.5 mg, 5 mg 2 NMO
ROBINUL INJECTION SOLUTION 0.4 MG/2ML 3 NMO
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Drug Drug Tier Requirements/Limits
ROBINUL-FORTE ORAL TABLET 2 MG 3 NMO
DIGESTIVE ENZYMES
CREON ORAL CAPSULE DELAYED RELEASE
PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT,
36000 UNIT, 6000 UNIT
4 ST
PANCREAZE ORAL CAPSULE DELAYED RELEASE
PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200
UNIT
3
PERTZYE ORAL CAPSULE DELAYED RELEASE
PARTICLES 16000 UNIT, 8000 UNIT 4 ST
VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT 4
ZENPEP ORAL CAPSULE DELAYED RELEASE
PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000
UNIT, 3000-10000 UNIT, 40000 UNIT, 5000 UNIT
3
GASTROINTESTINAL AGENTS, OTHER
AMOXICILL-CLARITHRO-LANSOPRAZ ORAL 3 NMO
cromolyn sodium oral concentrate 100 mg/5ml 1
diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml 1 NMO
diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 NMO
GATTEX SUBCUTANEOUS* KIT 5 MG 5 NMO
loperamide hcl oral capsule 2 mg 1 NMO
metoclopramide hcl injection solution 5 mg/ml 1 NMO
metoclopramide hcl oral solution 5 mg/5ml 1 NMO
metoclopramide hcl oral tablet 10 mg 1
metoclopramide hcl oral tablet 5 mg 1 NMO
METOCLOPRAMIDE HCL ORAL TABLET DISPERSIBLE
5 MG 3 NMO
MOVANTIK ORAL TABLET 12.5 MG, 25 MG 4 NMO
PYLERA ORAL CAPSULE 140-125-125 MG 4 NMO
RELISTOR ORAL TABLET 150 MG 3 PA; NMO
RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML,
12 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.4ML 4 PA; NMO
ursodiol oral capsule 300 mg 2
ursodiol oral tablet 250 mg, 500 mg 2
HISTAMINE2 (H2) RECEPTOR
ANTAGONISTS
cimetidine hcl oral solution 300 mg/5ml 2
cimetidine oral tablet 200 mg 2 NMO
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cimetidine oral tablet 300 mg, 400 mg, 800 mg 2
famotidine intravenous* solution 20 mg/2ml 2 NMO
famotidine oral suspension reconstituted 40 mg/5ml 2
famotidine oral tablet 20 mg, 40 mg 1
famotidine premixed intravenous* solution 20-0.9 mg/50ml-% 2 NMO
nizatidine oral capsule 150 mg, 300 mg 1
nizatidine oral solution 15 mg/ml 2
ranitidine hcl injection solution 150 mg/6ml 2 NMO
RANITIDINE HCL ORAL CAPSULE 150 MG, 300 MG 3
ranitidine hcl oral syrup 15 mg/ml 2
ranitidine hcl oral tablet 150 mg, 300 mg 1
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl oral tablet 0.5 mg, 1 mg 5 NMO
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3
LINZESS ORAL CAPSULE 145 MCG, 290 MCG 3
LAXATIVES
enulose oral solution 10 gm/15ml 1
gavilyte-c oral solution reconstituted 240 gm 1 NMO
generlac oral solution 10 gm/15ml 1
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1
GM 4 NMO
lactulose oral solution 10 gm/15ml 1
MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 4 NMO
OSMOPREP ORAL TABLET 1.102-0.398 GM 4 NMO
peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420
gm 1 NMO
peg-3350/electrolytes oral solution reconstituted 236 gm 1 NMO
polyethylene glycol 3350 oral powder 1 NMO
PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM 4 NMO
SUPREP BOWEL PREP ORAL SOLUTION 4 NMO
PROTECTANTS
CARAFATE ORAL SUSPENSION 1 GM/10ML 3
misoprostol oral tablet 100 mcg 1
misoprostol oral tablet 200 mcg 2
sucralfate oral tablet 1 gm 1
PROTON PUMP INHIBITORS
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DEXILANT ORAL CAPSULE DELAYED RELEASE 30
MG, 60 MG 3 ST; QL (30 EA per 30 days)
esomeprazole sodium intravenous* solution reconstituted 20
mg 2 NMO
lansoprazole oral capsule delayed release 15 mg, 30 mg 2
omeprazole oral capsule delayed release 10 mg, 40 mg 1
omeprazole oral capsule delayed release 20 mg 2
pantoprazole sodium oral tablet delayed release 20 mg, 40 mg 1
rabeprazole sodium oral tablet delayed release 20 mg 2
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg 1 NMO
bethanechol chloride oral tablet 50 mg 2 NMO
darifenacin hydrobromide er oral tablet extended release 24
hr* 15 mg, 7.5 mg 2
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24
HR* 25 MG, 50 MG 3 ST
oxybutynin chloride er oral tablet extended release 24 hr* 10
mg, 15 mg, 5 mg 2
oxybutynin chloride oral syrup 5 mg/5ml 1
oxybutynin chloride oral tablet 5 mg 1
tolterodine tartrate er oral capsule extended release 24 hour 2
mg, 4 mg 2
tolterodine tartrate oral tablet 1 mg, 2 mg 2
trospium chloride er oral capsule extended release 24 hour 60
mg 2
trospium chloride oral tablet 20 mg 2
VESICARE ORAL TABLET 10 MG, 5 MG 3
BENIGN PROSTATIC HYPERTROPHY
AGENTS
alfuzosin hcl er oral tablet extended release 24 hr* 10 mg 1
CARDURA XL ORAL TABLET EXTENDED RELEASE 24
HR* 4 MG, 8 MG 4
dutasteride oral capsule 0.5 mg 2
dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 2
finasteride oral tablet 5 mg 1
RAPAFLO ORAL CAPSULE 4 MG, 8 MG 4
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tamsulosin hcl oral capsule 0.4 mg 2
GENITOURINARY AGENTS, OTHER
CYSTAGON ORAL CAPSULE 150 MG, 50 MG 3
ELMIRON ORAL CAPSULE 100 MG 4 NMO
lithostat oral tablet 250 mg 2 NMO
neomycin-polymyxin b gu irrigation solution 40-200000 1 NMO
potassium citrate er oral tablet extendedrelease* 10 meq
(1080 mg), 15 meq (1620 mg), 5 meq (540 mg) 2 NMO
sodium chloride irrigation solution 0.9 % 1 NMO
PHOSPHATE BINDERS
calcium acetate (phos binder) oral capsule 667 mg 2
eliphos oral tablet 667 mg 1
RENVELA ORAL PACKET 0.8 GM, 2.4 GM 3
RENVELA ORAL TABLET 800 MG 3
VAGINAL PRODUCTS
CLEOCIN VAGINAL SUPPOSITORY 100 MG 3 NMO
clindamycin phosphate vaginal cream 2 % 2 NMO
ESTRACE VAGINAL CREAM 0.1 MG/GM 4
ESTRING VAGINAL RING 2 MG 4
FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 4
metronidazole vaginal gel 0.75 % 2 NMO
miconazole 3 vaginal suppository 200 mg 1 NMO
PREMARIN VAGINAL CREAM 0.625 MG/GM 3
terconazole vaginal cream 0.4 % 2 NMO
terconazole vaginal suppository 80 mg 2 NMO
VAGIFEM VAGINAL TABLET 10 MCG 4
zazole vaginal cream 0.8 % 1 NMO
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (ADRENAL)
GLUCOCORTICOIDS/MINERALOCORTICOI
DS
a-hydrocort injection solution reconstituted 100 mg 1 NMO
budesonide oral capsule delayed release particles 3 mg 4 NMO
cortisone acetate oral tablet 25 mg 2 NMO
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML 4 NMO
dexamethasone intensol oral concentrate 1 mg/ml 1 NMO
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dexamethasone oral elixir 0.5 mg/5ml 1 NMO
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2
mg, 4 mg, 6 mg 1 NMO
dexamethasone sodium phosphate injection solution 10 mg/ml,
120 mg/30ml 1 NMO
DEXPAK 13 DAY ORAL 1.5 MG (51) 4 NMO
fludrocortisone acetate oral tablet 0.1 mg 1
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 2 NMO
methylprednisolone acetate injection suspension 40 mg/ml, 80
mg/ml 1 NMO
methylprednisolone oral 4 mg 2 NMO
methylprednisolone oral tablet 16 mg, 32 mg, 8 mg 1 NMO
methylprednisolone oral tablet 4 mg 2 NMO
methylprednisolone sodium succ injection solution
reconstituted 125 mg, 40 mg 1 NMO
MILLIPRED ORAL SOLUTION 10 MG/5ML 4 NMO
MILLIPRED ORAL TABLET 5 MG 4 NMO
prednisolone sodium phosphate oral solution 15 mg/5ml, 25
mg/5ml, 6.7 (5 base) mg/5ml 2 NMO
PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET
DISPERSIBLE 10 MG 3 NMO
prednisolone sodium phosphate oral tablet dispersible 15 mg,
30 mg 4 NMO
prednisone intensol oral concentrate 5 mg/ml 1 NMO
prednisone oral 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48) 1 NMO
prednisone oral solution 5 mg/5ml 1 NMO
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50
mg 1 NMO
SOLU-CORTEF INJECTION SOLUTION
RECONSTITUTED 250 MG 3 NMO
SOLU-MEDROL INJECTION SOLUTION
RECONSTITUTED 2 GM, 500 MG 4 NMO
UCERIS ORAL TABLET EXTENDED RELEASE 24 HR* 9
MG 5 ST; NMO
VERIPRED 20 ORAL SOLUTION 20 MG/5ML 4 NMO
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
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ANABOLIC STEROIDS
ANADROL-50 ORAL TABLET 50 MG 4 NMO
OXANDROLONE ORAL TABLET 10 MG, 2.5 MG 3 PA; NMO
ANDROGENS
ANDRODERM TRANSDERMAL PATCH 24 HR 2
MG/24HR, 4 MG/24HR 3 PA
ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT
(1.62%) 4 PA
ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM
(1.62%), 40.5 MG/2.5GM (1.62%) 4 PA
AXIRON TRANSDERMAL SOLUTION 30 MG/ACT 4 PA
danazol oral capsule 100 mg, 200 mg, 50 mg 2 NMO
testosterone cypionate intramuscular* solution 100 mg/ml 1 NMO
testosterone cypionate intramuscular* solution 200 mg/ml 2 NMO
testosterone enanthate intramuscular* solution 200 mg/ml 2 NMO
TESTOSTERONE TRANSDERMAL GEL 10 MG/ACT
(2%), 25 MG/2.5GM (1%), 50 MG/5GM (1%) 3 PA
CONTRACEPTIVES
amethia oral tablet 0.15-0.03 &0.01 mg 1
amethyst oral tablet 90-20 mcg 1
apri oral tablet 0.15-30 mg-mcg 1 NMO
aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1
aviane oral tablet 0.1-20 mg-mcg 1
balziva oral tablet 0.4-35 mg-mcg 1
bekyree oral tablet 0.15-0.02/0.01 mg (21/5) 1
BEYAZ ORAL TABLET 3-0.02-0.451 MG 4
blisovi 24 fe oral tablet 1-20 mg-mcg(24) 1
blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1
blisovi fe 1/20 oral tablet 1-20 mg-mcg 1
briellyn oral tablet 0.4-35 mg-mcg 1
camila oral tablet 0.35 mg 1
caziant oral tablet 0.1/0.125/0.15 -0.025 mg 2
cryselle-28 oral tablet 0.3-30 mg-mcg 1 NMO
cyclafem 1/35 oral tablet 1-35 mg-mcg 1
cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS*
SUSPENSION 104 MG/0.65ML 4 NMO
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drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03
mg 1
emoquette oral tablet 0.15-30 mg-mcg 1
enpresse-28 oral tablet 1
errin oral tablet 0.35 mg 1 NMO
introvale oral tablet 0.15-0.03 mg 1
jolivette oral tablet 0.35 mg 1
juleber oral tablet 0.15-30 mg-mcg 1
junel 1.5/30 oral tablet 1.5-30 mg-mcg 1
junel 1/20 oral tablet 1-20 mg-mcg 1
junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1
junel fe 1/20 oral tablet 1-20 mg-mcg 1
kaitlib fe oral tablet chewable 0.8-25 mg-mcg 2
kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 NMO
kelnor 1/35 oral tablet 1-35 mg-mcg 1
kimidess oral tablet 0.15-0.02/0.01 mg (21/5) 1
larissia oral tablet 0.1-20 mg-mcg 1
lessina oral tablet 0.1-20 mg-mcg 1
levonorg-eth estrad triphasic oral tablet 1
levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10
MCG 4
loryna oral tablet 3-0.02 mg 2
LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG 4
lutera oral tablet 0.1-20 mg-mcg 1
lyza oral tablet 0.35 mg 2
marlissa oral tablet 0.15-30 mg-mcg 1
medroxyprogesterone acetate intramuscular* suspension 150
mg/ml 1 NMO
microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1
microgestin 1/20 oral tablet 1-20 mg-mcg 1
microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1
microgestin fe 1/20 oral tablet 1-20 mg-mcg 1
mononessa oral tablet 0.25-35 mg-mcg 1
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1
necon 1/35 (28) oral tablet 1-35 mg-mcg 1
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Drug Drug Tier Requirements/Limits
necon 10/11 (28) oral tablet 35 mcg 1
necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1
norethindrone oral tablet 0.35 mg 2
norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-
25 mcg 2
norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-
35 mcg 1
nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1
nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1
nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1
nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1
NUVARING VAGINAL RING 0.12-0.015 MG/24HR 3
ogestrel oral tablet 0.5-50 mg-mcg 1
orsythia oral tablet 0.1-20 mg-mcg 1
portia-28 oral tablet 0.15-30 mg-mcg 1
previfem oral tablet 0.25-35 mg-mcg 1
quasense oral tablet 0.15-0.03 mg 1
reclipsen oral tablet 0.15-30 mg-mcg 1
SAFYRAL ORAL TABLET 3-0.03-0.451 MG 4
setlakin oral tablet 0.15-0.03 mg 1
sprintec 28 oral tablet 0.25-35 mg-mcg 1
sronyx oral tablet 0.1-20 mg-mcg 1
tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 1
tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 2
tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 2
trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg 1
tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1
tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 NMO
trivora (28) oral tablet 1
velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1
vestura oral tablet 3-0.02 mg 2
vienva oral tablet 0.1-20 mg-mcg 2
vyfemla oral tablet 0.4-35 mg-mcg 1
xulane transdermal patch weekly 150-35 mcg/24hr 2
zovia 1/35e (28) oral tablet 1-35 mg-mcg 1
zovia 1/50e (28) oral tablet 1-50 mg-mcg 1
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ESTROGENS
CLIMARA PRO TRANSDERMAL PATCH WEEKLY
0.045-0.015 MG/DAY 4 PA
COMBIPATCH TRANSDERMAL PATCH BIWEEKLY
0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY 4 PA
DEPO-ESTRADIOL INTRAMUSCULAR* OIL 5 MG/ML 4 NMO
DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM 4 PA
DUAVEE ORAL TABLET 0.45-20 MG 4 PA
estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PA
estradiol transdermal patch biweekly 0.025 mg/24hr, 0.0375
mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr 2 PA
ESTRADIOL TRANSDERMAL PATCH WEEKLY 0.025
MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06
MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR
3 PA
estradiol valerate intramuscular* oil 20 mg/ml, 40 mg/ml 2 NMO
estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 2 PA
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1 PA
EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 4 PA
fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 PA
JINTELI ORAL TABLET 1-5 MG-MCG 3 PA
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5
MG 4 PA
MENOSTAR TRANSDERMAL PATCH WEEKLY 14
MCG/24HR 4 PA
norethindrone-eth estradiol oral tablet 1-5 mg-mcg 2 PA
PREFEST ORAL TABLET 1/1-0.09 MG (15/15) 4 PA
PREMARIN INJECTION SOLUTION RECONSTITUTED
25 MG 3 PA; NMO
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG 3 PA
PREMPHASE ORAL TABLET 0.625-5 MG 3 PA
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG,
0.625-2.5 MG, 0.625-5 MG 3 PA
PROGESTINS
MAKENA INTRAMUSCULAR* OIL 250 MG/ML 5 PA; NMO
medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg 1
MEGACE ES ORAL SUSPENSION 625 MG/5ML 4 PA
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MEGESTROL ACETATE ORAL SUSPENSION 625
MG/5ML 3 PA
NORETHINDRONE ACETATE ORAL TABLET 5 MG 3
progesterone micronized oral capsule 100 mg, 200 mg 2
SELECTIVE ESTROGEN RECEPTOR
MODIFYING AGENTS
raloxifene hcl oral tablet 60 mg 2
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/ MODIFYING
(PITUITARY)
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/ MODIFYING
(PITUITARY)
chorionic gonadotropin intramuscular* solution reconstituted
10000 unit 2 PA; NMO
DDAVP NASAL SOLUTION 0.01 % 4
desmopressin ace rhinal tube nasal solution 0.01 % 1
desmopressin ace spray refrig nasal solution 0.01 % 2
desmopressin acetate injection solution 4 mcg/ml 1 NMO
desmopressin acetate oral tablet 0.1 mg, 0.2 mg 2
INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML 5 PA; LA; NMO
NORDITROPIN FLEXPRO SUBCUTANEOUS*
SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5
MG/1.5ML
5 PA; NMO
NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS*
SOLUTION 10 MG/2ML 5 PA; NMO
NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS*
SOLUTION 20 MG/2ML 5 PA; NMO
SEROSTIM SUBCUTANEOUS* SOLUTION
RECONSTITUTED 4 MG, 5 MG, 6 MG 5 PA; NMO
STIMATE NASAL SOLUTION 1.5 MG/ML 4
ZORBTIVE SUBCUTANEOUS* SOLUTION
RECONSTITUTED 8.8 MG 5 PA; NMO
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/ MODIFYING
(THYROID)
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HORMONAL AGENTS,
STIMULANT/REPLACEMENT/ MODIFYING
(THYROID)
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50
mcg, 75 mcg, 88 mcg
1
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg 1
liothyronine sodium intravenous* solution 10 mcg/ml 2 NMO
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125
MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG,
300 MCG, 50 MCG, 75 MCG, 88 MCG
3
TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125
MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75
MCG, 88 MCG
3
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg,
175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg 1
HORMONAL AGENTS, SUPPRESSANT
(PARATHYROID)
HORMONAL AGENTS, SUPPRESSANT
(PARATHYROID)
SENSIPAR ORAL TABLET 30 MG 3 QL (120 EA per 30 days)
SENSIPAR ORAL TABLET 60 MG 5 NMO; QL (150 EA per 30 days)
SENSIPAR ORAL TABLET 90 MG 5 NMO; QL (120 EA per 30 days)
HORMONAL AGENTS, SUPPRESSANT
(PITUITARY)
HORMONAL AGENTS, SUPPRESSANT
(PITUITARY)
cabergoline oral tablet 0.5 mg 2 NMO
LUPRON DEPOT INTRAMUSCULAR* KIT 11.25 MG 5 PA; NMO; QL (1 EA per 28 days)
LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25
MG 5 PA; NMO; QL (1 EA per 90 days)
LUPRON DEPOT-PED INTRAMUSCULAR* KIT 15 MG 5 PA; NMO; QL (1 EA per 28 days)
octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml 1 PA
octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml 5 PA; NMO
octreotide acetate injection solution 50 mcg/ml 2 PA
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SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10
MG, 20 MG, 30 MG 5 PA; NMO
SIGNIFOR SUBCUTANEOUS* SOLUTION 0.3 MG/ML,
0.6 MG/ML, 0.9 MG/ML 4 QL (60 ML per 30 days)
SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION
120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML 5 PA; NMO
SOMAVERT SUBCUTANEOUS* SOLUTION
RECONSTITUTED 10 MG, 15 MG, 20 MG 5 PA; LA; NMO
SYNAREL NASAL SOLUTION 2 MG/ML 5 NMO
HORMONAL AGENTS, SUPPRESSANT
(THYROID)
ANTITHYROID AGENTS
methimazole oral tablet 10 mg, 5 mg 1
propylthiouracil oral tablet 50 mg 1
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE
24 HOUR 0.5 MG, 1 MG 4 BD
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE
24 HOUR 5 MG 5 BD; NMO
AZASAN ORAL TABLET 100 MG, 75 MG 3 BD
azathioprine oral tablet 50 mg 1 BD
AZATHIOPRINE SODIUM INJECTION SOLUTION
RECONSTITUTED 100 MG 4 BD; NMO
BENLYSTA INTRAVENOUS* SOLUTION
RECONSTITUTED 120 MG, 400 MG 5 BD; NMO
CELLCEPT INTRAVENOUS INTRAVENOUS*
SOLUTION RECONSTITUTED 500 MG 4 BD; NMO
CIMZIA PREFILLED SUBCUTANEOUS* KIT 2 X 200
MG/ML 5 PA; ST; NMO
CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG 5 PA; ST; NMO
cyclosporine intravenous* solution 50 mg/ml 2 BD; NMO
cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 2 BD
cyclosporine modified oral solution 100 mg/ml 2 BD
cyclosporine oral capsule 100 mg, 25 mg 2 BD
ENBREL SUBCUTANEOUS* 25 MG/0.5ML, 50 MG/ML 5 PA; NMO
ENBREL SUBCUTANEOUS* SOLUTION
RECONSTITUTED 25 MG 5 PA; NMO
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ENBREL SURECLICK SUBCUTANEOUS* 50 MG/ML 5 PA; NMO
ENVARSUS XR ORAL TABLET EXTENDED RELEASE
24 HR* 0.75 MG, 1 MG, 4 MG 4 BD
gengraf oral capsule 100 mg, 25 mg, 50 mg 2 BD
gengraf oral solution 100 mg/ml 2 BD
HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS* 40 MG/0.8ML, 40 MG/0.8ML (6
PACK)
5 PA; NMO
HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML 5 PA; NMO
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40
MG/0.8ML 5 PA; NMO
HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS*
40 MG/0.8ML 5 PA; NMO
HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20
MG/0.4ML, 40 MG/0.8ML 5 PA; NMO
KINERET SUBCUTANEOUS* 100 MG/0.67ML 5 PA; ST; NMO
mycophenolate mofetil oral capsule 250 mg 1 BD
MYCOPHENOLATE MOFETIL ORAL SUSPENSION
RECONSTITUTED 200 MG/ML 3 BD
mycophenolate mofetil oral tablet 500 mg 2 BD
mycophenolic acid oral tablet delayed release 180 mg, 360 mg 2 BD
NULOJIX INTRAVENOUS* SOLUTION
RECONSTITUTED 250 MG 5 BD; NMO
OTREXUP SUBCUTANEOUS* 10 MG/0.4ML, 12.5
MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 20 MG/0.4ML,
22.5 MG/0.4ML, 25 MG/0.4ML, 7.5 MG/0.4ML
4
PROGRAF INTRAVENOUS* SOLUTION 5 MG/ML 4 BD; NMO
RAPAMUNE ORAL SOLUTION 1 MG/ML 5 BD; NMO
RHEUMATREX ORAL TABLET 2.5 MG 3 BD
SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 3 BD
SANDIMMUNE ORAL SOLUTION 100 MG/ML 3 BD
SIMPONI ARIA INTRAVENOUS* SOLUTION 50 MG/4ML 5 ST; NMO
SIMPONI SUBCUTANEOUS* 100 MG/ML, 50 MG/0.5ML 5 ST; NMO
SIMULECT INTRAVENOUS* SOLUTION
RECONSTITUTED 20 MG 4 BD; NMO
sirolimus oral tablet 0.5 mg 2 BD
sirolimus oral tablet 1 mg 4 BD
sirolimus oral tablet 2 mg 5 BD; NMO
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tacrolimus oral capsule 0.5 mg, 1 mg 2 BD
tacrolimus oral capsule 5 mg 4 BD
ZORTRESS ORAL TABLET 0.25 MG 3 BD
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 5 BD; NMO
IMMUNIZING AGENTS, PASSIVE
ATGAM INTRAVENOUS* INJECTABLE 50 MG/ML 5 BD; NMO
BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML 5 BD; NMO
CARIMUNE NF INTRAVENOUS* SOLUTION
RECONSTITUTED 6 GM 5 PA; NMO
FLEBOGAMMA DIF INTRAVENOUS* SOLUTION 5
GM/50ML 3 BD; NMO
GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML 5 PA; NMO
GAMMAKED INJECTION SOLUTION 1 GM/10ML 3 BD; NMO
GAMMAPLEX INTRAVENOUS* SOLUTION 10
GM/200ML 5 PA; NMO
GAMUNEX-C INJECTION SOLUTION 1 GM/10ML 3 PA; NMO
HYPERRAB S/D INTRAMUSCULAR* INJECTABLE 150
UNIT/ML, 150 UNIT/ML (10ML) 4 NMO
SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML 5 NMO
THYMOGLOBULIN INTRAVENOUS* SOLUTION
RECONSTITUTED 25 MG 5 BD; NMO
VARIZIG INTRAMUSCULAR* SOLUTION 125
UNIT/1.2ML 4 NMO
IMMUNOMODULATORS
ACTEMRA INTRAVENOUS* SOLUTION 200 MG/10ML,
400 MG/20ML, 80 MG/4ML 5 ST; NMO
ACTEMRA SUBCUTANEOUS* 162 MG/0.9ML 5 ST; NMO
ARCALYST SUBCUTANEOUS* SOLUTION
RECONSTITUTED 220 MG 5 PA; NMO
ILARIS SUBCUTANEOUS* SOLUTION
RECONSTITUTED 180 MG 5 NMO
leflunomide oral tablet 10 mg, 20 mg 2
ORENCIA CLICKJECT SUBCUTANEOUS* 125 MG/ML 5 PA; ST; NMO
ORENCIA INTRAVENOUS* SOLUTION
RECONSTITUTED 250 MG 5 PA; ST; NMO
ORENCIA SUBCUTANEOUS* 125 MG/ML 5 PA; ST; NMO
XELJANZ ORAL TABLET 5 MG 5 ST; NMO
VACCINES
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ACTHIB INTRAMUSCULAR* SOLUTION
RECONSTITUTED 3 NMO
ADACEL INTRAMUSCULAR* SUSPENSION 5-2-15.5 LF-
MCG/0.5 3 NMO
BCG VACCINE INJECTION INJECTABLE 4 NMO
BEXSERO INTRAMUSCULAR* 3 NMO
BOOSTRIX INTRAMUSCULAR* SUSPENSION 5-2.5-18.5
, 5-2.5-18.5 (0.5ML SYRINGE) 3 NMO
CERVARIX INTRAMUSCULAR* SUSPENSION 3 NMO
DAPTACEL INTRAMUSCULAR* SUSPENSION 10-15-5 3 NMO
diphtheria-tetanus toxoids dt intramuscular* suspension 25-5
lfu/0.5ml 2 BD; NMO
ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML,
10 MCG/0.5ML (0.5ML SYRINGE), 20 MCG/ML 3 BD; NMO
GARDASIL 9 INTRAMUSCULAR* 4 NMO
GARDASIL 9 INTRAMUSCULAR* SUSPENSION 3 NMO
GARDASIL INTRAMUSCULAR* SUSPENSION 3 NMO
GARDASIL INTRAMUSCULAR* SUSPENSION (0.5ML
SYRINGE) 4 NMO
HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL
U/ML, 720 EL U/0.5ML 3 NMO
HIBERIX INJECTION SOLUTION RECONSTITUTED 10
MCG 4 NMO
IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5
UNIT/ML 4 BD; NMO
INFANRIX INTRAMUSCULAR* SUSPENSION 25-58-10 3 NMO
IPOL INJECTION INJECTABLE 3 NMO
IXIARO INTRAMUSCULAR* SUSPENSION 3 NMO
MENACTRA INTRAMUSCULAR* INJECTABLE 4 NMO
MENHIBRIX INTRAMUSCULAR* SOLUTION
RECONSTITUTED 5-5-2.5 MCG 3 NMO
MENOMUNE SUBCUTANEOUS* INJECTABLE 3 NMO
MENVEO INTRAMUSCULAR* SOLUTION
RECONSTITUTED 3 NMO
M-M-R II SUBCUTANEOUS* INJECTABLE 3 NMO
PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5
MCG/0.5ML 3 NMO
PROQUAD SUBCUTANEOUS* INJECTABLE 3 NMO
QUADRACEL INTRAMUSCULAR* SUSPENSION 3 NMO
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RABAVERT INTRAMUSCULAR* SUSPENSION
RECONSTITUTED 3 BD; NMO
RECOMBIVAX HB INJECTION SUSPENSION 10
MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5
MCG/0.5ML
3 BD; NMO
ROTARIX ORAL SUSPENSION RECONSTITUTED 3 NMO
ROTATEQ ORAL SOLUTION 3 NMO
TENIVAC INTRAMUSCULAR* INJECTABLE 5-2 LFU 3 BD; NMO
TETANUS-DIPHTHERIA TOXOIDS TD
INTRAMUSCULAR* SUSPENSION 2-2 LF/0.5ML 3 BD; NMO
TRUMENBA INTRAMUSCULAR* 4 NMO
TWINRIX INTRAMUSCULAR* SUSPENSION 720-20 3 BD; NMO
TYPHIM VI INTRAMUSCULAR* SOLUTION 25
MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE) 3 NMO
VAQTA INTRAMUSCULAR* SUSPENSION 25
UNIT/0.5ML, 50 UNIT/ML 3 NMO
VARIVAX SUBCUTANEOUS* INJECTABLE 1350
PFU/0.5ML 3 NMO
YF-VAX SUBCUTANEOUS* INJECTABLE 3 NMO
ZOSTAVAX SUBCUTANEOUS* SOLUTION
RECONSTITUTED 19400 UNT/0.65ML 3 NMO
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO ORAL CAPSULE EXTENDED RELEASE 24
HOUR 0.375 GM 3
ASACOL HD ORAL TABLET DELAYED RELEASE 800
MG 4 NMO
balsalazide disodium oral capsule 750 mg 2 NMO
DIPENTUM ORAL CAPSULE 250 MG 4
LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 3 NMO
MESALAMINE ORAL TABLET DELAYED RELEASE 800
MG 3 NMO
mesalamine-cleanser kit 4 gm 1 NMO
SFROWASA ENEMA 4 GM/60ML 4 NMO
SULFONAMIDES
sulfasalazine oral tablet 500 mg 1
sulfasalazine oral tablet delayed release 500 mg 1
METABOLIC BONE DISEASE AGENTS
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METABOLIC BONE DISEASE AGENTS
alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1
alendronate sodium oral tablet 40 mg 1 NMO
CALCITONIN (SALMON) NASAL SOLUTION 200
UNIT/ACT 3 BD
calcitriol intravenous* solution 1 mcg/ml 1 BD; NMO
calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 BD
calcitriol oral solution 1 mcg/ml 1 BD
doxercalciferol intravenous* solution 4 mcg/2ml 2 BD; NMO
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 2 BD
FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML 5 PA; NMO
IBANDRONATE SODIUM INTRAVENOUS* SOLUTION 3
MG/3ML 3 BD; NMO
IBANDRONATE SODIUM ORAL TABLET 150 MG 3
MIACALCIN INJECTION SOLUTION 200 UNIT/ML 4 BD; NMO
NATPARA SUBCUTANEOUS* 25 MCG 5 NMO
pamidronate disodium intravenous* solution 30 mg/10ml, 6
mg/ml, 90 mg/10ml 1 BD; NMO
paricalcitol intravenous* solution 2 mcg/ml 2 BD; NMO
PARICALCITOL INTRAVENOUS* SOLUTION 5
MCG/ML 3 BD; NMO
PARICALCITOL ORAL CAPSULE 1 MCG, 2 MCG, 4 MCG 3 BD
PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML 4 PA; NMO
RISEDRONATE SODIUM ORAL TABLET 150 MG, 35
MG, 35 MG (12 PACK), 35 MG (4 PACK), 5 MG 3
risedronate sodium oral tablet 30 mg 4 NMO
RISEDRONATE SODIUM ORAL TABLET DELAYED
RELEASE 35 MG 3
XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML 5 PA; NMO
zoledronic acid intravenous* concentrate 4 mg/5ml 2 BD; NMO
zoledronic acid intravenous* solution 5 mg/100ml 2 BD; NMO
MISCELLANEOUS
MISCELLANEOUS
ADRENACLICK INJECTION 0.15 MG/0.15ML, 0.3
MG/0.3ML 4 NMO
BOTOX INJECTION SOLUTION RECONSTITUTED 100
UNIT 4 PA; NMO
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CINRYZE INTRAVENOUS* SOLUTION
RECONSTITUTED 500 UNIT 5 NMO
epinephrine injection 0.3 mg/0.3ml 2 NMO
EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML 3 NMO
FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML 5 NMO
methylergonovine maleate oral tablet 0.2 mg 1 NMO
NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG 5 PA; NMO
NUEDEXTA ORAL CAPSULE 20-10 MG 3 PA
VPRIV INTRAVENOUS* SOLUTION RECONSTITUTED
400 UNIT 5 PA; NMO
OPHTHALMIC AGENTS
OPHTHALMIC PROSTAGLANDIN AND
PROSTAMIDE ANALOGS
bimatoprost ophthalmic solution 0.03 % 2
latanoprost ophthalmic solution 0.005 % 1
LUMIGAN OPHTHALMIC SOLUTION 0.01 % 3
TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % 3
travoprost ophthalmic solution 0.004 % 2
OPHTHALMIC AGENTS, OTHER
APRACLONIDINE HCL OPHTHALMIC SOLUTION 0.5 % 3 NMO
atropine sulfate ophthalmic solution 1 % 2
naphazoline hcl ophthalmic solution 0.1 % 1 NMO
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 2
proparacaine hcl ophthalmic solution 0.5 % 1 NMO
RESTASIS OPHTHALMIC EMULSION 0.05 % 3
OPHTHALMIC ANTI INFECTIVES
AZASITE OPHTHALMIC SOLUTION 1 % 3 NMO
bacitracin ophthalmic ointment 500 unit/gm 2 NMO
bacitracin-polymyxin b ophthalmic ointment 500-10000
unit/gm 1 NMO
ciprofloxacin hcl ophthalmic solution 0.3 % 1 NMO
erythromycin ophthalmic ointment 5 mg/gm 1 NMO
GATIFLOXACIN OPHTHALMIC SOLUTION 0.5 % 3 NMO
gentamicin sulfate ophthalmic ointment 0.3 % 1 NMO
gentamicin sulfate ophthalmic solution 0.3 % 1 NMO
levofloxacin ophthalmic solution 0.5 % 2 NMO
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MOXEZA OPHTHALMIC SOLUTION 0.5 % 3 NMO
neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-
10000 2 NMO
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-
10000-.025 2 NMO
ofloxacin ophthalmic solution 0.3 % 1 NMO
polymyxin b-trimethoprim ophthalmic solution 10000-0.1
unit/ml-% 1 NMO
sulfacetamide sodium ophthalmic solution 10 % 1 NMO
tobramycin ophthalmic solution 0.3 % 1 NMO
TOBREX OPHTHALMIC OINTMENT 0.3 % 3 NMO
trifluridine ophthalmic solution 1 % 4 NMO
VIGAMOX OPHTHALMIC SOLUTION 0.5 % 3 NMO
ZIRGAN OPHTHALMIC GEL 0.15 % 4 NMO
OPHTHALMIC ANTI-ALLERGY AGENTS
azelastine hcl ophthalmic solution 0.05 % 2 NMO
cromolyn sodium ophthalmic solution 4 % 1 NMO
epinastine hcl ophthalmic solution 0.05 % 2 NMO
OLOPATADINE HCL OPHTHALMIC SOLUTION 0.1 % 3 NMO
PATADAY OPHTHALMIC SOLUTION 0.2 % 3 NMO
PAZEO OPHTHALMIC SOLUTION 0.7 % 3 NMO
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 % 3
AZOPT OPHTHALMIC SUSPENSION 1 % 3
betaxolol hcl ophthalmic solution 0.5 % 2
brimonidine tartrate ophthalmic solution 0.15 % 2
brimonidine tartrate ophthalmic solution 0.2 % 1
carteolol hcl ophthalmic solution 1 % 1
COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 3
dorzolamide hcl ophthalmic solution 2 % 1
dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8
mg/ml 1
levobunolol hcl ophthalmic solution 0.5 % 1
metipranolol ophthalmic solution 0.3 % 2
PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION
RECONSTITUTED 0.125 % 4
SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 4
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timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % 2
timolol maleate ophthalmic solution 0.25 %, 0.5 % 1
OPHTHALMIC ANTI-INFLAMMATORIES
bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 2 NMO
BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 NMO
BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2
% 3 NMO
bromfenac sodium ophthalmic solution 0.09 % 2 NMO
CYSTARAN OPHTHALMIC SOLUTION 0.44 % 5 PA; NMO
dexamethasone sodium phosphate ophthalmic solution 0.1 % 1 NMO
diclofenac sodium ophthalmic solution 0.1 % 1 NMO
DUREZOL OPHTHALMIC EMULSION 0.05 % 3 NMO
FLAREX OPHTHALMIC SUSPENSION 0.1 % 4 NMO
fluorometholone ophthalmic suspension 0.1 % 2 NMO
flurbiprofen sodium ophthalmic solution 0.03 % 1 NMO
ILEVRO OPHTHALMIC SUSPENSION 0.3 % 4 NMO
ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % 1 NMO
LOTEMAX OPHTHALMIC GEL 0.5 % 3 NMO
LOTEMAX OPHTHALMIC OINTMENT 0.5 % 3 NMO
LOTEMAX OPHTHALMIC SUSPENSION 0.5 % 3 NMO
MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 4 NMO
neomycin-polymyxin-dexameth ophthalmic ointment 3.5-
10000-0.1 1 NMO
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-
10000-0.1 1 NMO
neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 2 NMO
prednisolone acetate ophthalmic suspension 1 % 2 NMO
prednisolone sodium phosphate ophthalmic solution 1 % 2 NMO
sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 NMO
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 3 NMO
TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 NMO
TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 3 NMO
tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 2 NMO
VEXOL OPHTHALMIC SUSPENSION 1 % 4 NMO
OTIC AGENTS
OTIC AGENTS
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acetic acid otic solution 2 % 1 NMO
CIPRO HC OTIC SUSPENSION 0.2-1 % 4 NMO
CIPRODEX OTIC SUSPENSION 0.3-0.1 % 4 NMO
fluocinolone acetonide otic oil 0.01 % 2 NMO
hydrocortisone-acetic acid otic solution 1-2 % 2 NMO
neomycin-polymyxin-hc otic solution 1 % 1 NMO
neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 NMO
ofloxacin otic solution 0.3 % 2 NMO
RESPIRATORY TRACT AGENTS
ANTIHISTAMINES
carbinoxamine maleate oral solution 4 mg/5ml 1 PA; NMO
carbinoxamine maleate oral tablet 4 mg 1 PA; NMO
cetirizine hcl oral syrup 1 mg/ml 1 NMO
clemastine fumarate oral tablet 2.68 mg 1 PA; NMO
cyproheptadine hcl oral syrup 2 mg/5ml 1 PA; NMO
cyproheptadine hcl oral tablet 4 mg 1 PA; NMO
diphenhydramine hcl injection solution 50 mg/ml 1 NMO
levocetirizine dihydrochloride oral solution 2.5 mg/5ml 1 NMO
levocetirizine dihydrochloride oral tablet 5 mg 1 NMO
promethazine hcl injection solution 25 mg/ml, 50 mg/ml 1 PA; NMO
promethazine hcl oral syrup 6.25 mg/5ml 1 PA; NMO
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 PA; NMO
promethazine hcl suppository 12.5 mg, 25 mg, 50 mg 4 PA; NMO
promethazine vc plain oral syrup 6.25-5 mg/5ml 2 PA; NMO
ANTI-INFLAMMATORIES, INHALED
CORTICOSTEROIDS
ARNUITY ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT 3
BUDESONIDE INHALATION SUSPENSION 0.25
MG/2ML, 0.5 MG/2ML 3 BD
budesonide inhalation suspension 1 mg/2ml 2 BD
FLOVENT DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST,
50 MCG/BLIST
3
FLOVENT HFA INHALATION AEROSOL† 110
MCG/ACT, 220 MCG/ACT, 44 MCG/ACT 3
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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PULMICORT FLEXHALER INHALATION AEROSOL
POWDER, BREATH ACTIVATED 180 MCG/ACT, 90
MCG/ACT
3
PULMICORT INHALATION SUSPENSION 0.25 MG/2ML,
0.5 MG/2ML, 1 MG/2ML 3 BD
ANTILEUKOTRIENES
montelukast sodium oral packet 4 mg 2
montelukast sodium oral tablet 10 mg 1
montelukast sodium oral tablet chewable 4 mg, 5 mg 2
zafirlukast oral tablet 10 mg, 20 mg 2
ZYFLO CR ORAL TABLET EXTENDED RELEASE 12
HR* 600 MG 4
ZYFLO ORAL TABLET 600 MG 4
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA INHALATION AEROSOL, SOLUTION
17 MCG/ACT 3
ipratropium bromide inhalation solution 0.02 % 1 BD
SPIRIVA HANDIHALER INHALATION CAPSULE 18
MCG 3
SPIRIVA RESPIMAT INHALATION AEROSOL,
SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT 3
BRONCHODILATORS,
PHOSPHODIESTERASE INHIBITORS
(XANTHINES)
aminophylline intravenous* solution 25 mg/ml 1 NMO
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML 3
theophylline er oral tablet extended release 12 hr* 100 mg,
200 mg, 300 mg, 450 mg 1
theophylline er oral tablet extended release 24 hr* 400 mg,
600 mg 1
BRONCHODILATORS, SYMPATHOMIMETIC
ADVAIR DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100-50 MCG/DOSE, 250-50
MCG/DOSE, 500-50 MCG/DOSE
3
ADVAIR HFA INHALATION AEROSOL† 115-21
MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT 3
albuterol sulfate er oral tablet extended release 12 hr* 4 mg, 8
mg 2
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albuterol sulfate inhalation nebulization solution (2.5 mg/3ml)
0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml 1 BD
albuterol sulfate oral syrup 2 mg/5ml 1
albuterol sulfate oral tablet 2 mg, 4 mg 2
BREO ELLIPTA INHALATION AEROSOL POWDER,
BREATH ACTIVATED 100-25 MCG/INH, 200-25
MCG/INH
3
COMBIVENT RESPIMAT INHALATION AEROSOL,
SOLUTION 20-100 MCG/ACT 4
ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 BD
levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml,
0.63 mg/3ml, 1.25 mg/0.5ml 2 BD
PROAIR HFA INHALATION AEROSOL, SOLUTION 108
(90 BASE) MCG/ACT 3
PROAIR RESPICLICK INHALATION AEROSOL
POWDER, BREATH ACTIVATED 108 (90 BASE)
MCG/ACT
3
PROVENTIL HFA INHALATION AEROSOL, SOLUTION
108 (90 BASE) MCG/ACT 3
SEREVENT DISKUS INHALATION AEROSOL POWDER,
BREATH ACTIVATED 50 MCG/DOSE 3
STIOLTO RESPIMAT INHALATION AEROSOL,
SOLUTION 2.5-2.5 MCG/ACT 3
SYMBICORT INHALATION AEROSOL† 160-4.5
MCG/ACT, 80-4.5 MCG/ACT 3
terbutaline sulfate injection solution 1 mg/ml 4 NMO
TERBUTALINE SULFATE ORAL TABLET 2.5 MG, 5 MG 3
VENTOLIN HFA INHALATION AEROSOL, SOLUTION
108 (90 BASE) MCG/ACT 3
MAST CELL STABILIZERS
cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 BD
NASAL AGENTS
azelastine hcl nasal solution 0.1 %, 0.15 % 2 NMO
BACTROBAN NASAL NASAL OINTMENT 2 % 4 NMO
BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 4 NMO
budesonide nasal suspension 32 mcg/act 2 NMO
DYMISTA NASAL SUSPENSION 137-50 MCG/ACT 4 NMO
flunisolide nasal solution 25 mcg/act (0.025%) 2 NMO
fluticasone propionate nasal suspension 50 mcg/act 1 NMO
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introduction. Formulary ID: 17381, Ver. 6 Last Updated 12/01/2016 Effective Date: 01/01/2017
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ipratropium bromide nasal solution 0.03 %, 0.06 % 1
mometasone furoate nasal suspension 50 mcg/act 2 NMO; QL (34 GM per 30 days)
OLOPATADINE HCL NASAL SOLUTION 0.6 % 3 NMO
OMNARIS NASAL SUSPENSION 50 MCG/ACT 4 NMO
VERAMYST NASAL SUSPENSION 27.5 MCG/SPRAY 4 NMO
ZETONNA NASAL AEROSOL, SOLUTION 37 MCG/ACT 4 NMO
PULMONARY ANTIHYPERTENSIVES
ADCIRCA ORAL TABLET 20 MG 5 PA; NMO; QL (60 EA per 30
days)
ADEMPAS ORAL TABLET 0.5 MG 5 NMO; QL (90 EA per 30 days)
ADEMPAS ORAL TABLET 1 MG, 1.5 MG, 2 MG, 2.5 MG 5 NMO
LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; NMO; QL (30 EA per 30
days)
OPSUMIT ORAL TABLET 10 MG 5 PA; NMO; QL (30 EA per 30
days)
REMODULIN INJECTION SOLUTION 1 MG/ML, 10
MG/ML, 2.5 MG/ML, 5 MG/ML 5 BD; NMO
sildenafil citrate oral tablet 20 mg 2 PA; QL (90 EA per 30 days)
TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 PA; LA; NMO; QL (60 EA per 30
days)
VENTAVIS INHALATION SOLUTION 20 MCG/ML 5 BD; NMO; QL (270 ML per 30
days)
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine inhalation solution 10 %, 20 % 1 BD; NMO
ARALAST NP INTRAVENOUS* SOLUTION
RECONSTITUTED 500 MG 5 PA; NMO
DALIRESP ORAL TABLET 500 MCG 4 QL (30 EA per 30 days)
ESBRIET ORAL CAPSULE 267 MG 5 PA; NMO
GLASSIA INTRAVENOUS* SOLUTION 1000 MG/50ML 5 PA; NMO
KALYDECO ORAL PACKET 50 MG, 75 MG 5 PA; NMO
KALYDECO ORAL TABLET 150 MG 5 PA; NMO
NUCALA SUBCUTANEOUS* SOLUTION
RECONSTITUTED 100 MG 5 PA; NMO
OFEV ORAL CAPSULE 100 MG 5 NMO
ORKAMBI ORAL TABLET 200-125 MG 5 PA; NMO
PROLASTIN-C INTRAVENOUS* SOLUTION
RECONSTITUTED 1000 MG 5 PA; NMO
PULMOZYME INHALATION SOLUTION 1 MG/ML 5 BD; NMO
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XOLAIR SUBCUTANEOUS* SOLUTION
RECONSTITUTED 150 MG 5 PA; LA; NMO
ZEMAIRA INTRAVENOUS* SOLUTION
RECONSTITUTED 1000 MG 5 PA; NMO
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
baclofen oral tablet 10 mg, 20 mg 1
chlorzoxazone oral tablet 500 mg 4 PA; NMO
cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg 4 PA; NMO
dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 4 NMO
metaxalone oral tablet 800 mg 4 PA; NMO
methocarbamol oral tablet 500 mg, 750 mg 4 PA; NMO
orphenadrine citrate er oral tablet extended release 12 hr*
100 mg 1 PA; NMO
TIZANIDINE HCL ORAL CAPSULE 2 MG, 4 MG, 6 MG 3
tizanidine hcl oral tablet 2 mg, 4 mg 1
SLEEP DISORDER AGENTS
BENZODIAZEPINES
ESTAZOLAM ORAL TABLET 1 MG 3 NMO; QL (60 EA per 30 days)
ESTAZOLAM ORAL TABLET 2 MG 3 NMO; QL (30 EA per 30 days)
FLURAZEPAM HCL ORAL CAPSULE 15 MG 3 NMO; QL (60 EA per 30 days)
FLURAZEPAM HCL ORAL CAPSULE 30 MG 3 NMO; QL (30 EA per 30 days)
TEMAZEPAM ORAL CAPSULE 15 MG, 22.5 MG, 30 MG 3 NMO; QL (30 EA per 30 days)
TEMAZEPAM ORAL CAPSULE 7.5 MG 3 NMO; QL (120 EA per 30 days)
TRIAZOLAM ORAL TABLET 0.125 MG 3 NMO; QL (30 EA per 30 days)
TRIAZOLAM ORAL TABLET 0.25 MG 3 NMO; QL (60 EA per 30 days)
GABA RECEPTOR MODULATORS
EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 MG,
5 MG 4
PA; NMO; QL (30 EA per 30
days)
ESZOPICLONE ORAL TABLET 1 MG 3 PA; NMO; QL (90 EA per 30
days)
ESZOPICLONE ORAL TABLET 2 MG, 3 MG 3 PA; NMO; QL (30 EA per 30
days)
zaleplon oral capsule 10 mg, 5 mg 4 PA; NMO
zolpidem tartrate er oral tablet extendedrelease* 12.5 mg,
6.25 mg 4
PA; NMO; QL (30 EA per 30
days)
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zolpidem tartrate oral tablet 10 mg, 5 mg 4 PA; NMO; QL (90 EA per 365
days)
SLEEP DISORDERS, OTHER
ARMODAFINIL ORAL TABLET 150 MG, 200 MG, 250
MG, 50 MG 3 PA
HETLIOZ ORAL CAPSULE 20 MG 5 NMO; QL (30 EA per 30 days)
MODAFINIL ORAL TABLET 100 MG, 200 MG 3 PA; QL (30 EA per 30 days)
NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50
MG 4 PA
ROZEREM ORAL TABLET 8 MG 4 QL (30 EA per 30 days)
SILENOR ORAL TABLET 3 MG, 6 MG 3
XYREM ORAL SOLUTION 500 MG/ML 5 PA; LA; NMO; QL (540 ML per
30 days)
THERAPEUTIC NUTRIENTS/ MINERALS/
ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
CHEMET ORAL CAPSULE 100 MG 4 NMO
DEPEN TITRATABS ORAL TABLET 250 MG 5 NMO
EXJADE ORAL TABLET SOLUBLE 125 MG 3 PA
EXJADE ORAL TABLET SOLUBLE 250 MG, 500 MG 5 PA; NMO
FERRIPROX ORAL SOLUTION 100 MG/ML 5 NMO
FERRIPROX ORAL TABLET 500 MG 4
kionex oral powder 1 NMO
SAMSCA ORAL TABLET 15 MG, 30 MG 5 PA; NMO
sodium polystyrene sulfonate oral suspension 15 gm/60ml 1 NMO
sps oral suspension 15 gm/60ml 1 NMO
SYPRINE ORAL CAPSULE 250 MG 3 NMO
ELECTROLYTE/MINERAL REPLACEMENT
ammonium chloride intravenous* solution 5 meq/ml 1 NMO
CARBAGLU ORAL TABLET 200 MG 5 NMO
dextrose in lactated ringers intravenous* solution 5 % 1 NMO
dextrose-nacl intravenous* solution 10-0.2 %, 10-0.45 %, 2.5-
0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %, 5-0.9 % 1 NMO
IONOSOL-B IN D5W INTRAVENOUS* SOLUTION 3 NMO
IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION 3 NMO
ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION 3 NMO
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Drug Drug Tier Requirements/Limits
ISOLYTE-S INTRAVENOUS* SOLUTION 3 NMO
kcl in dextrose-nacl intravenous* solution 10-5-0.45 meq/l-%-
%, 20-5-0.2 meq/l-%-%, 20-5-0.225 meq/l-%-%, 20-5-0.33
meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-
0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%
1 NMO
kcl-lactated ringers-d5w intravenous* solution 20 meq/l 1 NMO
klor-con 10 oral tablet extendedrelease* 10 meq 1
klor-con m15 oral tablet extendedrelease* 15 meq 2
KUVAN ORAL PACKET 100 MG, 500 MG 5 PA; LA; NMO
lactated ringers intravenous* solution 1 NMO
magnesium sulfate injection solution 50 %, 50 % (10ml
syringe) 1 NMO
normosol-m in d5w intravenous* solution 1 NMO
normosol-r in d5w intravenous* solution 1 NMO
NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION 3 NMO
PLASMA-LYTE 148 INTRAVENOUS* SOLUTION 3 NMO
PLASMA-LYTE A INTRAVENOUS* SOLUTION 3 NMO
PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION 3 NMO
potassium chloride crys er oral tablet extendedrelease* 10
meq, 20 meq 1
potassium chloride er oral capsule extended release* 10 meq,
8 meq 2
potassium chloride er oral tablet extendedrelease* 8 meq 1
potassium chloride in dextrose intravenous* solution 20-5
meq/l-%, 40-5 meq/l-% 1 NMO
potassium chloride in nacl intravenous* solution 20-0.45
meq/l-%, 20-0.9 meq/l-% 1 NMO
potassium chloride in nacl intravenous* solution 40-0.9 meq/l-
% 4 NMO
potassium chloride intravenous* solution 10 meq/100ml, 2
meq/ml, 20 meq/100ml, 40 meq/100ml 1 NMO
potassium chloride oral solution 20 meq/15ml (10%), 40
meq/15ml (20%) 2
ringers intravenous* solution 1 NMO
sodium chloride injection solution 2.5 meq/ml 1 NMO
sodium chloride intravenous* solution 0.45 %, 3 %, 5 % 1 NMO
sodium chloride intravenous* solution 0.9 % 2 NMO
tpn electrolytes intravenous* solution 1 BD; NMO
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NUTRIENTS
AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %,
8.5 % 3 BD; NMO
aminosyn ii/electrolytes intravenous* solution 8.5 % 1 BD; NMO
AMINOSYN/ELECTROLYTES INTRAVENOUS*
SOLUTION 7 % 4 BD; NMO
aminosyn/electrolytes intravenous* solution 8.5 % 1 BD; NMO
AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 % 3 BD; NMO
AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 % 3 BD; NMO
AMINOSYN-RF INTRAVENOUS* SOLUTION 5.2 % 4 BD; NMO
CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS*
SOLUTION 2.75 % 3 BD; NMO
CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS*
SOLUTION 2.75 % 3 BD; NMO
CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS*
SOLUTION 4.25 % 4 BD; NMO
CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS*
SOLUTION 4.25 % 3 BD; NMO
CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS*
SOLUTION 4.25 % 3 BD; NMO
CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS*
SOLUTION 5 % 3 BD; NMO
CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS*
SOLUTION 5 % 3 BD; NMO
CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS*
SOLUTION 5 % 3 BD; NMO
CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS*
SOLUTION 2.75 % 3 BD; NMO
CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS*
SOLUTION 4.25 % 3 BD; NMO
CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS*
SOLUTION 4.25 % 3 BD; NMO
CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS*
SOLUTION 4.25 % 3 BD; NMO
CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS*
SOLUTION 4.25 % 3 BD; NMO
CLINIMIX/DEXTROSE (5/15) INTRAVENOUS*
SOLUTION 5 % 3 BD; NMO
CLINIMIX/DEXTROSE (5/20) INTRAVENOUS*
SOLUTION 5 % 3 BD; NMO
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CLINIMIX/DEXTROSE (5/25) INTRAVENOUS*
SOLUTION 5 % 3 BD; NMO
clinisol sf intravenous* solution 15 % 1 BD; NMO
dextrose intravenous* solution 10 %, 5 % 1 BD; NMO
FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 % 4 BD; NMO
hepatamine intravenous* solution 8 % 1 BD; NMO
INTRALIPID INTRAVENOUS* EMULSION 30 % 4 BD; NMO
NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 % 3 BD; NMO
nutrilipid intravenous* emulsion 20 % 1 BD; NMO
plenamine intravenous* solution 15 % 2 BD; NMO
PREMASOL INTRAVENOUS* SOLUTION 10 % 3 BD; NMO
premasol intravenous* solution 6 % 1 BD; NMO
PROCALAMINE INTRAVENOUS* SOLUTION 3 % 3 BD; NMO
PROSOL INTRAVENOUS* SOLUTION 20 % 3 BD; NMO
TRAVASOL INTRAVENOUS* SOLUTION 10 % 3 BD; NMO
TROPHAMINE INTRAVENOUS* SOLUTION 10 % 3 BD; NMO
VITAMINS
prenatal oral tablet 27-1 mg 1 NMO
sodium fluoride oral tablet 2.2 (1 f) mg 1 NMO
90
8 8-MOP .................................... 54
A abacavir sulfate ....................... 37
abacavir-lamivudine-zidovudine
............................................ 37
ABELCET .............................. 19
ABILIFY MAINTENA .......... 33
ABRAXANE .......................... 25
ABSTRAL ................................ 3
acamprosate calcium ................ 5
ACANYA ............................... 54
acarbose .................................. 40
acebutolol hcl ......................... 47
acetaminophen-codeine ............ 3
acetaminophen-codeine #2 ....... 3
acetaminophen-codeine #3 ....... 3
ACETAMINOPHEN-
CODEINE #4 ....................... 3
acetazolamide ......................... 49
acetic acid ......................... 80, 81
acetylcysteine ......................... 84
acitretin ................................... 54
ACTEMRA ............................ 74
ACTHIB ........................... 74, 75
ACTIMMUNE ....................... 25
acyclovir ........................... 36, 54
acyclovir sodium .................... 36
ADACEL ................................ 75
ADAGEN ............................... 60
ADAPALENE ........................ 54
ADCIRCA .............................. 84
adefovir dipivoxil ................... 35
ADEMPAS ............................. 84
ADRENACLICK ................... 77
ADRUCIL .............................. 24
ADVAIR DISKUS ................. 82
ADVAIR HFA ....................... 82
afeditab cr ............................... 48
AFINITOR ............................. 25
AFINITOR DISPERZ ............ 25
a-hydrocort ............................. 64
AKYNZEO............................. 18
ALA SCALP .......................... 54
ALBENZA ............................. 30
albuterol sulfate ...................... 83
albuterol sulfate er .................. 82
alclometasone dipropionate .... 54
ALDACTAZIDE .................... 46
ALDURAZYME .................... 60
ALECENSA ........................... 25
alendronate sodium........... 76, 77
alfuzosin hcl er ....................... 63
ALIMTA ................................ 24
ALINIA .................................. 30
allopurinol .............................. 20
almotriptan malate .................. 22
alosetron hcl ........................... 62
ALOXI.................................... 18
ALPHAGAN P ....................... 79
alprazolam .............................. 40
ALPRAZOLAM ..................... 40
alprazolam er .......................... 40
alprazolam intensol................. 40
alprazolam xr .......................... 40
ALTABAX ............................. 54
amantadine hcl ........................ 31
AMBISOME .......................... 19
AMCINONIDE ...................... 54
amethia ................................... 66
amethyst.................................. 66
amifostine ............................... 25
AMIKACIN SULFATE ....... 5, 6
amiloride hcl ........................... 50
amiloride-hydrochlorothiazide46
aminophylline ......................... 82
AMINOSYN II ....................... 88
aminosyn ii/electrolytes .......... 88
aminosyn/electrolytes ............. 88
AMINOSYN/ELECTROLYTE
S .......................................... 88
AMINOSYN-HBC ................. 88
AMINOSYN-PF ..................... 88
AMINOSYN-RF .................... 88
amiodarone hcl ................. 45, 46
AMITIZA ............................... 62
amitriptyline hcl ..................... 18
amlodipine besy-benazepril hcl
............................................ 46
amlodipine besylate ................ 48
AMLODIPINE BESYLATE-
VALSARTAN .................... 46
AMLODIPINE-
ATORVASTATIN ............. 49
AMLODIPINE-VALSARTAN-
HCTZ .................................. 46
ammonium chloride ................ 86
ammonium lactate .................. 54
amoxapine............................... 18
AMOXICILL-CLARITHRO-
LANSOPRAZ..................... 61
amoxicillin ................................ 9
amoxicillin-pot clavulanate ...... 9
AMOXICILLIN-POT
CLAVULANATE ER .......... 9
AMPHETAMINE-
DEXTROAMPHET ER ..... 52
amphetamine-
dextroamphetamine ............ 52
amphotericin b ........................ 19
ampicillin .................................. 9
ampicillin sodium ..................... 9
AMPICILLIN-SULBACTAM
SODIUM .............................. 9
AMPYRA ............................... 53
ANADROL-50 ................. 65, 66
anagrelide hcl.......................... 44
anastrozole .............................. 30
ANDRODERM ...................... 66
ANDROGEL .......................... 66
ANDROGEL PUMP .............. 66
APOKYN ............................... 31
APRACLONIDINE HCL ....... 78
apri .......................................... 66
APRISO .................................. 76
APTIOM ................................. 14
APTIVUS ............................... 38
ARALAST NP........................ 84
aranelle ................................... 66
ARANESP (ALBUMIN FREE)
...................................... 43, 44
ARCALYST ........................... 74
argatroban ............................... 43
ARIPIPRAZOLE .................... 33
ARISTADA ............................ 33
ARMODAFINIL .................... 86
ARNUITY ELLIPTA ............. 81
ARRANON ............................ 24
ASACOL HD ......................... 76
ASCOMP-CODEINE ............... 3
aspirin-dipyridamole er .......... 44
Alphabetical Listing
91
ASSURE ID INSULIN
SAFETY SYR .................... 40
ASTAGRAF XL .................... 72
atenolol ................................... 47
atenolol-chlorthalidone........... 46
ATGAM ................................. 74
atorvastatin calcium................ 50
atovaquone ............................. 30
ATOVAQUONE-PROGUANIL
HCL .................................... 30
ATRIPLA ............................... 39
atropine sulfate ................. 60, 78
ATROVENT HFA ................. 82
AVASTIN .............................. 24
AVELOX ............................... 11
aviane ..................................... 66
AVONEX ............................... 53
AVONEX PEN ...................... 53
AVONEX PREFILLED ......... 53
AXIRON ................................ 66
azacitidine............................... 24
AZACTAM IN DEXTROSE ... 8
AZASAN ................................ 72
AZASITE ............................... 78
azathioprine ............................ 72
AZATHIOPRINE SODIUM .. 72
azelastine hcl .................... 79, 83
AZELEX ................................ 54
AZILECT ............................... 32
azithromycin ........................... 10
AZOPT ................................... 79
AZOR ..................................... 46
aztreonam ................................. 8
B bacitracin ................................ 78
bacitracin-polymyxin b .......... 78
bacitra-neomycin-polymyxin-hc
............................................ 80
baclofen .................................. 85
BACTOCILL IN DEXTROSE 9
BACTROBAN NASAL ......... 83
balsalazide disodium .............. 76
balziva .................................... 66
BANZEL .......................... 14, 15
BARACLUDE ....................... 36
BCG VACCINE ..................... 75
BECONASE AQ .................... 83
bekyree ................................... 66
BELEODAQ .......................... 25
benazepril hcl ......................... 45
benazepril-hydrochlorothiazide
............................................ 46
BENICAR .............................. 45
BENICAR HCT ..................... 46
BENLYSTA ........................... 72
BENTYL ................................ 60
benzoyl peroxide-erythromycin
............................................ 54
benztropine mesylate .............. 31
betamethasone dipropionate .. 54,
55
betamethasone dipropionate aug
............................................ 54
betamethasone valerate........... 55
BETASERON ........................ 53
betaxolol hcl ........................... 79
bethanechol chloride............... 63
bexarotene .............................. 25
BEXSERO .............................. 75
BEYAZ ................................... 66
bicalutamide ........................... 25
BICILLIN C-R ....................... 10
BICILLIN C-R 900/300 ........... 9
BICILLIN L-A ....................... 10
BICNU.................................... 23
BIDIL ..................................... 52
BILTRICIDE .......................... 30
bimatoprost ............................. 78
bisoprolol fumarate................. 47
bisoprolol-hydrochlorothiazide
............................................ 46
BIVIGAM .............................. 74
bleomycin sulfate ................... 25
BLEPHAMIDE ...................... 80
BLEPHAMIDE S.O.P. ........... 80
blisovi 24 fe ............................ 66
blisovi fe 1.5/30 ...................... 66
blisovi fe 1/20 ......................... 66
BOOSTRIX ............................ 75
BOSULIF ............................... 25
BOTOX .................................. 77
BREO ELLIPTA .................... 83
briellyn.................................... 66
BRILINTA ............................. 44
brimonidine tartrate ................ 79
BRISDELLE .......................... 17
BRIVIACT ............................. 15
bromfenac sodium .................. 80
bromocriptine mesylate .......... 31
budesonide .................. 64, 81, 83
BUDESONIDE....................... 81
bumetanide ............................. 49
BUPRENORPHINE HCL ........ 5
BUPRENORPHINE HCL-
NALOXONE HCL ............... 5
buproban ................................... 5
bupropion hcl .......................... 16
bupropion hcl er (smoking det) 5
bupropion hcl er (sr) ............... 16
bupropion hcl er (xl) ........... 5, 16
buspirone hcl .......................... 39
BUSULFEX ........................... 23
BUTALBITAL-APAP-CAFF-
COD ...................................... 3
BUTALBITAL-APAP-
CAFFEINE ........................... 3
BUTALBITAL-ASA-CAFF-
CODEINE............................. 3
BUTALBITAL-ASPIRIN-
CAFFEINE ........................... 3
butorphanol tartrate .................. 3
BYDUREON .......................... 40
BYETTA 10 MCG PEN ......... 40
BYETTA 5 MCG PEN ........... 41
BYSTOLIC............................. 47
C cabergoline ............................. 71
CABOMETYX ....................... 25
calcipotriene ........................... 55
calcipotriene-betameth diprop 55
CALCITONIN (SALMON) ... 77
calcitriol .................................. 77
CALCITRIOL ........................ 55
calcium acetate (phos binder) . 64
camila ..................................... 66
CANCIDAS ............................ 19
candesartan cilexetil ............... 45
candesartan cilexetil-hctz ....... 46
CAPASTAT SULFATE ......... 23
CAPEX ................................... 55
capital/codeine .......................... 3
CAPRELSA ............................ 25
captopril .................................. 45
captopril-hydrochlorothiazide 46
CARAFATE ........................... 62
CARBAGLU .......................... 86
carbamazepine .................. 15, 40
carbamazepine er .................... 15
CARBIDOPA ......................... 32
carbidopa-levodopa ................ 32
92
carbidopa-levodopa er ............ 32
carbidopa-levodopa-entacapone
............................................ 32
carbinoxamine maleate ........... 81
CARBOPLATIN .................... 23
CARDIZEM LA ..................... 48
CARDURA XL ...................... 63
CARIMUNE NF .................... 74
carteolol hcl ............................ 79
cartia xt ................................... 48
carvedilol ................................ 47
CAYSTON ............................... 9
caziant..................................... 66
cefaclor ..................................... 7
CEFACLOR ER ....................... 7
cefadroxil .................................. 7
CEFAZOLIN SODIUM ........... 7
cefdinir ..................................... 7
cefepime hcl ............................. 7
CEFIXIME ............................... 7
cefotaxime sodium ................... 7
cefotetan disodium ................... 7
cefoxitin sodium ....................... 7
cefpodoxime proxetil................ 8
cefprozil .................................... 8
CEFTAZIDIME ....................... 8
CEFTIN .................................... 8
CEFTRIAXONE SODIUM ..... 8
cefuroxime axetil ...................... 8
CEFUROXIME SODIUM ....... 8
celecoxib................................. 20
CELECOXIB ......................... 20
CELLCEPT INTRAVENOUS
............................................ 72
CELONTIN ............................ 13
cephalexin................................. 8
CEREBYX ............................. 12
CEREZYME .......................... 60
CERVARIX ........................... 75
CESAMET ............................. 18
cetirizine hcl ........................... 81
CEVIMELINE HCL .............. 54
CHANTIX ................................ 5
CHANTIX CONTINUING
MONTH PAK ...................... 5
CHANTIX STARTING
MONTH PAK ...................... 5
CHEMET ............................... 86
chloramphenicol sod succinate. 6
chlordiazepoxide hcl .............. 40
chlorhexidine gluconate ......... 54
chloroquine phosphate ............ 31
chlorothiazide ......................... 50
CHLOROTHIAZIDE SODIUM
............................................ 50
chlorpromazine hcl ................. 32
CHLORPROMAZINE HCL .. 32
chlorthalidone ......................... 50
chlorzoxazone ......................... 85
cholestyramine light ............... 51
chorionic gonadotropin........... 70
ciclopirox ................................ 55
ciclopirox olamine .................. 55
cidofovir ................................. 35
cilostazol ................................. 44
cimetidine ......................... 61, 62
cimetidine hcl ......................... 61
CIMZIA .................................. 72
CIMZIA PREFILLED ............ 72
CINRYZE ............................... 78
CIPRO HC .............................. 81
CIPRO IN D5W ..................... 11
CIPRODEX ............................ 81
ciprofloxacin ........................... 11
ciprofloxacin hcl ............... 11, 78
ciprofloxacin in d5w ............... 11
ciprofloxacin-ciproflox hcl er . 11
cisplatin .................................. 23
citalopram hydrobromide ....... 17
cladribine ................................ 24
CLAFORAN ............................ 8
claravis.................................... 55
clarithromycin ........................ 10
clarithromycin er .................... 10
clemastine fumarate ................ 81
CLEOCIN ............................... 64
CLIMARA PRO ..................... 69
clindamycin hcl ........................ 6
clindamycin palmitate hcl ........ 6
clindamycin phos-benzoyl perox
............................................ 55
clindamycin phosphate ..... 55, 64
CLINDAMYCIN PHOSPHATE
.............................................. 6
CLINDAMYCIN PHOSPHATE
IN D5W ................................ 6
CLINIMIX E/DEXTROSE
(2.75/10) ............................. 88
CLINIMIX E/DEXTROSE
(2.75/5) ............................... 88
CLINIMIX E/DEXTROSE
(4.25/10) ............................. 88
CLINIMIX E/DEXTROSE
(4.25/25) ............................. 88
CLINIMIX E/DEXTROSE
(4.25/5) ............................... 88
CLINIMIX E/DEXTROSE
(5/15) .................................. 88
CLINIMIX E/DEXTROSE
(5/20) .................................. 88
CLINIMIX E/DEXTROSE
(5/25) .................................. 88
CLINIMIX/DEXTROSE
(2.75/5) ............................... 88
CLINIMIX/DEXTROSE
(4.25/10) ............................. 88
CLINIMIX/DEXTROSE
(4.25/20) ............................. 88
CLINIMIX/DEXTROSE
(4.25/25) ............................. 88
CLINIMIX/DEXTROSE
(4.25/5) ............................... 88
CLINIMIX/DEXTROSE (5/15)
............................................ 88
CLINIMIX/DEXTROSE (5/20)
............................................ 88
CLINIMIX/DEXTROSE (5/25)
............................................ 89
clinisol sf ................................ 89
CLOBETASOL PROPIONATE
...................................... 55, 56
CLOBETASOL PROPIONATE
E .......................................... 55
CLODERM PUMP ................. 56
CLOLAR ................................ 24
CLOMIPRAMINE HCL ........ 18
clonazepam ............................. 13
clonidine hcl ........................... 45
CLONIDINE HCL ER ........... 52
clopidogrel bisulfate ............... 44
clorazepate dipotassium.......... 40
clorpres ................................... 46
clotrimazole ...................... 54, 56
clozapine ................................. 35
CLOZAPINE .......................... 35
COARTEM............................. 31
codeine sulfate .......................... 3
CODEINE SULFATE .............. 3
colchicine ................................ 20
colchicine-probenecid ............. 20
93
colestipol hcl .......................... 51
colistimethate sodium ............... 6
COMBIGAN .......................... 79
COMBIPATCH ...................... 69
COMBIVENT RESPIMAT ... 83
COMETRIQ (100 MG DAILY
DOSE) ................................ 25
COMETRIQ (140 MG DAILY
DOSE) ................................ 25
COMETRIQ (60 MG DAILY
DOSE) ................................ 25
COMFORT ASSIST INSULIN
SYRINGE........................... 41
COMPLERA .......................... 39
compro .................................... 32
CONDYLOX ......................... 56
COPAXONE .......................... 53
CORDRAN ............................ 56
COREG CR ............................ 47
cortisone acetate ..................... 64
CORTISPORIN ...................... 56
COSENTYX........................... 56
COSENTYX SENSOREADY
PEN .................................... 56
COSMEGEN .......................... 25
COTELLIC............................. 25
CREON .................................. 61
CRIXIVAN ............................ 38
cromolyn sodium ........ 61, 79, 83
cryselle-28 .............................. 66
CUBICIN ................................. 6
CUVPOSA ............................. 60
CVS GAUZE STERILE......... 41
cyclafem 1/35 ......................... 66
cyclafem 7/7/7 ........................ 66
cyclobenzaprine hcl ................ 85
cyclophosphamide .................. 23
CYCLOSET ........................... 41
cyclosporine ........................... 72
cyclosporine modified ............ 72
cyproheptadine hcl ................. 81
CYRAMZA ............................ 24
CYSTADANE ........................ 60
CYSTAGON .......................... 64
CYSTARAN .......................... 80
cytarabine ............................... 24
CYTARABINE (PF) .............. 24
D DACARBAZINE ................... 25
DAKLINZA ........................... 36
DALIRESP ............................. 84
danazol.................................... 66
dantrolene sodium .................. 85
dapsone ................................... 22
DAPTACEL ........................... 75
DARAPRIM ........................... 31
darifenacin hydrobromide er .. 63
DARZALEX .......................... 26
daunorubicin hcl ..................... 26
DAYTRANA.......................... 52
DDAVP .................................. 70
decitabine................................ 24
demeclocycline hcl ................. 12
DEMSER ................................ 45
DENAVIR .............................. 56
DEPEN TITRATABS ............ 86
DEPO-ESTRADIOL .............. 69
DEPO-MEDROL ................... 64
DEPO-PROVERA.................. 26
DEPO-SUBQ PROVERA 104
............................................ 66
DESCOVY ............................. 37
desipramine hcl....................... 18
desmopressin ace rhinal tube .. 70
desmopressin ace spray refrig 70
desmopressin acetate .............. 70
DESONATE ........................... 56
DESONIDE ............................ 56
DESOXIMETASONE............ 56
dexamethasone ....................... 65
dexamethasone intensol .......... 64
dexamethasone sodium
phosphate ...................... 65, 80
DEXILANT ...................... 62, 63
DEXPAK 13 DAY ................. 65
dexrazoxane ............................ 26
DEXTROAMPHETAMINE
SULFATE .......................... 52
dextroamphetamine sulfate er 52
dextrose .................................. 89
dextrose in lactated ringers ..... 86
dextrose-nacl .......................... 86
diazepam ................................. 40
DIAZEPAM ..................... 13, 40
DIAZEPAM INTENSOL ....... 40
diclofenac potassium .............. 20
diclofenac sodium....... 21, 56, 80
diclofenac sodium er .............. 21
DICLOFENAC-
MISOPROSTOL ................ 21
dicloxacillin sodium ............... 10
dicyclomine hcl ...................... 60
DIDANOSINE ....................... 37
DIFFERIN .............................. 56
DIFICID ................................. 10
DIFLORASONE DIACETATE
............................................ 56
diflunisal ................................. 21
digitek ..................................... 49
digoxin .................................... 49
dihydroergotamine mesylate . 21,
22
DILANTIN ............................. 15
diltiazem hcl ........................... 48
diltiazem hcl er ....................... 48
diltiazem hcl er beads ............. 48
diltiazem hcl er coated beads .. 48
dilt-xr ...................................... 48
DIPENTUM ........................... 76
diphenhydramine hcl .............. 81
diphenoxylate-atropine ........... 61
diphtheria-tetanus toxoids dt .. 75
dipyridamole ........................... 44
disopyramide phosphate ......... 46
disulfiram .................................. 5
DIURIL................................... 50
divalproex sodium ............ 13, 22
divalproex sodium er .............. 13
DIVIGEL ................................ 69
DOCEFREZ ........................... 26
DOCETAXEL ........................ 26
dofetilide ................................. 46
donepezil hcl ..................... 15, 16
DONEPEZIL HCL ................. 15
DORIBAX ................................ 9
dorzolamide hcl ...................... 79
dorzolamide hcl-timolol mal .. 79
doxazosin mesylate ................. 45
doxepin hcl ............................. 18
doxercalciferol ........................ 77
DOXIL .................................... 26
DOXORUBICIN HCL ........... 26
doxorubicin hcl liposomal ...... 26
doxycycline hyclate ................ 12
DOXYCYCLINE HYCLATE 12
doxycycline monohydrate ...... 12
DOXYCYCLINE
MONOHYDRATE ............. 12
dronabinol ............................... 19
drospirenone-ethinyl estradiol 67
94
DROXIA ................................ 24
DUAVEE ............................... 69
duloxetine hcl ......................... 17
duramorph ............................ 3, 4
DUREZOL ............................. 80
dutasteride .............................. 63
dutasteride-tamsulosin hcl ...... 63
DYMISTA .............................. 83
E E.E.S. GRANULES ............... 10
econazole nitrate ..................... 56
EDECRIN............................... 50
EDLUAR ................................ 85
EDURANT ............................. 36
EFFIENT ................................ 44
ELAPRASE ............................ 60
ELIDEL .................................. 56
ELIGARD .............................. 26
eliphos .................................... 64
ELIQUIS ................................ 43
ELITEK .................................. 26
ELIXOPHYLLIN ................... 82
ELMIRON .............................. 64
EMBEDA ................................. 2
EMCYT .................................. 26
EMEND .................................. 19
emoquette ............................... 67
EMPLICITI ............................ 26
EMSAM ................................. 17
EMTRIVA .............................. 37
EMVERM .............................. 30
enalapril maleate .................... 45
enalapril-hydrochlorothiazide 47
ENBREL ................................ 72
ENBREL SURECLICK ......... 73
ENGERIX-B .......................... 75
enoxaparin sodium ................. 43
enpresse-28 ............................. 67
entacapone .............................. 31
entecavir ................................. 36
enulose .................................... 62
ENVARSUS XR .................... 73
EPIDUO ................................. 56
EPIDUO FORTE.................... 56
epinastine hcl .......................... 79
epinephrine ............................. 78
EPIPEN 2-PAK ...................... 78
epitol ....................................... 15
EPIVIR HBV.......................... 37
eplerenone .............................. 50
EPOGEN ................................ 44
eprosartan mesylate ................ 45
EPZICOM .............................. 37
EQUETRO ............................. 33
ERAXIS.................................. 19
ERBITUX ............................... 26
ergoloid mesylates .................. 15
ERIVEDGE ............................ 26
errin ........................................ 67
ERWINAZE ........................... 26
ery ........................................... 56
ERYPED 200 ......................... 11
ERYPED 400 ......................... 11
ERY-TAB ............................... 11
erythrocin lactobionate ........... 11
erythrocin stearate .................. 11
erythromycin .................... 56, 78
erythromycin base .................. 11
erythromycin ethylsuccinate... 11
ESBRIET ................................ 84
escitalopram oxalate ............... 17
esomeprazole sodium ............. 63
ESTAZOLAM ........................ 85
ESTRACE .............................. 64
estradiol .................................. 69
ESTRADIOL .......................... 69
estradiol valerate..................... 69
estradiol-norethindrone acet ... 69
ESTRING ............................... 64
estropipate .............................. 69
ESZOPICLONE ..................... 85
ETHAMBUTOL HCL ........... 23
ethosuximide .......................... 13
etodolac .................................. 21
ETODOLAC ER .................... 21
ETOPOPHOS ......................... 26
etoposide ................................. 26
EURAX .................................. 56
EVAMIST .............................. 69
EVOTAZ ................................ 37
EXEL COMFORT POINT PEN
NEEDLE ............................ 41
EXEL PEN NEEDLES 1/2 .... 41
EXELDERM .......................... 57
exemestane ............................. 30
EXJADE ................................. 86
F FABRAZYME ....................... 60
famciclovir.............................. 39
famotidine ............................... 62
famotidine premixed ............... 62
FANAPT................................. 33
FANAPT TITRATION PACK
............................................ 33
FARESTON ........................... 26
FARYDAK ............................. 26
FASLODEX ........................... 26
felbamate ................................ 14
felodipine er ............................ 48
FEMRING .............................. 64
fenofibrate............................... 50
fenofibrate micronized ............ 50
fenofibric acid ......................... 50
FENTANYL ............................. 2
fentanyl citrate .......................... 4
FENTORA ................................ 4
FERRIPROX .......................... 86
FETZIMA ............................... 17
FETZIMA TITRATION ........ 17
FINACEA ............................... 57
finasteride ............................... 63
FIRAZYR ............................... 78
FIRMAGON ........................... 26
FLAREX................................. 80
FLEBOGAMMA DIF ............ 74
flecainide acetate .................... 46
FLOVENT DISKUS .............. 81
FLOVENT HFA ..................... 81
fluconazole ............................. 20
fluconazole in sodium chloride
............................................ 19
flucytosine .............................. 20
fludarabine phosphate ............. 24
fludrocortisone acetate ............ 65
flunisolide ............................... 83
fluocinolone acetonide............ 81
FLUOCINOLONE
ACETONIDE ..................... 57
FLUOCINOLONE
ACETONIDE BODY ......... 57
fluocinonide ............................ 57
FLUOCINONIDE .................. 57
FLUOCINONIDE-E............... 57
fluorometholone ..................... 80
FLUOROURACIL ........... 24, 57
fluoxetine hcl .......................... 17
FLUOXETINE HCL .............. 17
FLUPHENAZINE
DECANOATE .................... 32
fluphenazine hcl...................... 32
95
FLURAZEPAM HCL ............ 85
flurbiprofen............................. 21
flurbiprofen sodium ................ 80
flutamide................................. 26
fluticasone propionate ...... 57, 83
FLUTICASONE
PROPIONATE ................... 57
fluvastatin sodium .................. 50
FLUVASTATIN SODIUM ER
............................................ 50
fluvoxamine maleate .............. 17
FLUVOXAMINE MALEATE
ER ....................................... 17
fondaparinux sodium .............. 43
FORFIVO XL ........................ 16
FORTAZ .................................. 8
FORTEO ................................ 77
fosinopril sodium.................... 45
fosinopril sodium-hctz............ 47
fosphenytoin sodium .............. 12
FRAGMIN ............................. 43
FREAMINE HBC .................. 89
frovatriptan succinate ............. 22
furosemide .............................. 50
FUZEON ................................ 38
fyavolv .................................... 69
FYCOMPA ............................ 13
G gabapentin .............................. 13
GABITRIL ............................. 13
galantamine hydrobromide ..... 16
galantamine hydrobromide er. 16
GAMMAGARD ..................... 74
GAMMAKED ........................ 74
GAMMAPLEX ...................... 74
GAMUNEX-C ....................... 74
GANCICLOVIR SODIUM ... 35
GARDASIL ............................ 75
GARDASIL 9 ......................... 75
GATIFLOXACIN .................. 78
GATTEX ................................ 61
gavilyte-c ................................ 62
GEMCITABINE HCL ........... 24
gemfibrozil ............................. 50
generlac .................................. 62
gengraf .................................... 73
gentamicin in saline .................. 6
gentamicin sulfate ........ 6, 57, 78
GENVOYA ............................ 39
GEODON ............................... 33
GILENYA .............................. 53
GILOTRIF .............................. 26
GLASSIA ............................... 84
GLEEVEC ........................ 26, 27
GLEOSTINE .......................... 23
glimepiride.............................. 41
glipizide .................................. 41
glipizide er .............................. 41
glipizide-metformin hcl .......... 41
GLOBAL ALCOHOL PREP
EASE .................................. 41
GLUCAGEN HYPOKIT ....... 42
GLUCAGON EMERGENCY 42
glycopyrrolate ......................... 60
GOLYTELY ........................... 62
granisetron hcl ........................ 19
griseofulvin microsize ............ 20
griseofulvin ultramicrosize ..... 20
guanfacine hcl......................... 45
guanfacine hcl er .................... 52
guanidine hcl .......................... 22
H HALAVEN ............................. 27
HALOBETASOL
PROPIONATE ................... 57
HALOG .................................. 57
haloperidol .............................. 33
haloperidol decanoate ............. 32
haloperidol lactate .................. 33
HARVONI.............................. 36
HAVRIX ................................ 75
heparin (porcine) in d5w ........ 43
heparin sod (porcine) in d5w .. 43
heparin sodium (porcine)........ 43
hepatamine.............................. 89
HERCEPTIN .......................... 27
HETLIOZ ............................... 86
HEXALEN ............................. 23
HIBERIX ................................ 75
HUMIRA ................................ 73
HUMIRA PEDIATRIC
CROHNS START .............. 73
HUMIRA PEN ....................... 73
HUMIRA PEN-CROHNS
STARTER .......................... 73
HUMIRA PEN-PSORIASIS
STARTER .......................... 73
hydralazine hcl ....................... 52
hydrochlorothiazide ................ 50
hydrocodone-acetaminophen .... 4
hydrocodone-ibuprofen ............ 4
hydrocortisone .................. 57, 65
HYDROCORTISONE ........... 57
HYDROCORTISONE
BUTYRATE ....................... 57
HYDROCORTISONE
VALERATE ....................... 58
hydrocortisone-acetic acid ...... 81
hydromorphone hcl ................... 4
HYDROMORPHONE HCL .... 4
hydromorphone hcl er............... 2
hydroxychloroquine sulfate .... 31
hydroxyprogesterone caproate 27
hydroxyurea ............................ 27
hydroxyzine hcl ................ 39, 40
hydroxyzine pamoate.............. 40
HYPERRAB S/D.................... 74
HYSINGLA ER........................ 2
I IBANDRONATE SODIUM .. 77
IBRANCE............................... 27
ibuprofen................................. 21
ICLUSIG ................................ 27
idarubicin hcl .......................... 27
IFOSFAMIDE ........................ 23
ILARIS ................................... 74
ILEVRO ................................. 80
imatinib mesylate.................... 27
IMBRUVICA ......................... 27
IMIPENEM-CILASTATIN ..... 9
imipramine hcl ........................ 18
imipramine pamoate ............... 18
IMIQUIMOD ......................... 58
IMITREX STATDOSE REFILL
............................................ 22
IMOVAX RABIES ................ 75
INCRELEX ............................ 70
indapamide ............................. 50
INDOCIN ............................... 21
indomethacin .......................... 21
INDOMETHACIN ER ........... 21
INFANRIX ............................. 75
INLYTA ................................. 27
INTELENCE .................... 36, 37
INTRALIPID .......................... 89
INTRON A ............................. 27
introvale .................................. 67
INVANZ ................................... 9
INVEGA SUSTENNA ........... 34
INVEGA TRINZA ................. 34
96
INVIRASE ............................. 38
INVOKAMET ........................ 41
INVOKANA .......................... 41
IONOSOL-B IN D5W ........... 86
IONOSOL-MB IN D5W ........ 86
IPOL ....................................... 75
ipratropium bromide ......... 82, 84
ipratropium-albuterol ............. 83
irbesartan ................................ 45
irbesartan-hydrochlorothiazide
............................................ 47
IRESSA .................................. 27
irinotecan hcl .......................... 27
ISENTRESS ........................... 38
ISOLYTE-P IN D5W ............. 86
ISOLYTE-S ............................ 87
isoniazid ................................. 23
isosorbide dinitrate ................. 51
ISOSORBIDE DINITRATE ER
............................................ 51
isosorbide mononitrate ........... 51
isosorbide mononitrate er ....... 51
ISRADIPINE .......................... 48
ISTODAX .............................. 27
ITRACONAZOLE ................. 20
IVERMECTIN ....................... 30
IXIARO .................................. 75
J JAKAFI .................................. 27
jantoven .................................. 43
JANUMET ............................. 41
JANUMET XR ....................... 41
JANUVIA............................... 41
JARDIANCE .......................... 41
JENTADUETO ...................... 41
JENTADUETO XR................ 41
JINTELI ................................. 69
jolivette ................................... 67
juleber ..................................... 67
junel 1.5/30 ............................. 67
junel 1/20 ................................ 67
junel fe 1.5/30 ......................... 67
junel fe 1/20 ............................ 67
JUXTAPID ............................. 51
K KADCYLA ............................ 27
kaitlib fe.................................. 67
KALETRA ............................. 38
KALYDECO .......................... 84
KANUMA .............................. 60
kariva ...................................... 67
kcl in dextrose-nacl ................ 87
kcl-lactated ringers-d5w ......... 87
kelnor 1/35 .............................. 67
KEPIVANCE ......................... 27
ketoconazole ..................... 20, 58
ketoprofen ............................... 21
ketoprofen er........................... 21
ketorolac tromethamine .... 21, 80
KEYTRUDA .......................... 27
kimidess .................................. 67
KINERET ............................... 73
kionex ..................................... 86
klor-con 10 ............................. 87
klor-con m15 .......................... 87
KORLYM ............................... 41
KUVAN............................ 60, 87
KYNAMRO ........................... 51
L labetalol hcl ............................ 47
lactated ringers ....................... 87
lactulose .................................. 62
LAMICTAL STARTER......... 14
LAMICTAL XR ..................... 14
LAMISIL ................................ 20
LAMIVUDINE ...................... 37
lamivudine-zidovudine ........... 37
lamotrigine.............................. 14
LAMOTRIGINE .................... 14
LAMOTRIGINE ER .............. 14
lansoprazole ............................ 63
LANTUS ................................ 42
LANTUS SOLOSTAR........... 42
larissia ..................................... 67
latanoprost .............................. 78
LATUDA................................ 34
LAZANDA ............................... 4
leflunomide ............................. 74
LENVIMA 10 MG DAILY
DOSE.................................. 27
LENVIMA 14 MG DAILY
DOSE.................................. 27
LENVIMA 18 MG DAILY
DOSE.................................. 27
LENVIMA 20 MG DAILY
DOSE.................................. 28
LENVIMA 24 MG DAILY
DOSE.................................. 28
LENVIMA 8 MG DAILY
DOSE.................................. 28
lessina ..................................... 67
LETAIRIS .............................. 84
letrozole .................................. 30
leucovorin calcium ................. 28
LEUKERAN........................... 23
LEUKINE ............................... 44
leuprolide acetate .................... 28
levalbuterol hcl ....................... 83
LEVEMIR .............................. 42
LEVEMIR FLEXTOUCH...... 42
levetiracetam........................... 12
LEVETIRACETAM ER ........ 12
LEVETIRACETAM IN NACL
............................................ 12
levobunolol hcl ....................... 79
levocarnitine ........................... 60
levocetirizine dihydrochloride 81
levofloxacin ...................... 11, 78
LEVOFLOXACIN ................. 11
levofloxacin in d5w ................ 11
LEVOLEUCOVORIN
CALCIUM .......................... 28
levonorg-eth estrad triphasic .. 67
levora 0.15/30 (28) ................. 67
LEVORPHANOL TARTRATE
.............................................. 2
levothyroxine sodium ....... 70, 71
levoxyl .................................... 71
LEXIVA ........................... 38, 39
LIALDA ................................. 76
LIDOCAINE .......................... 58
lidocaine hcl........................ 5, 58
lidocaine hcl (pf)................... 4, 5
lidocaine viscous .................... 54
lidocaine-prilocaine .................. 5
lincomycin hcl .......................... 6
linezolid .................................... 6
LINZESS ................................ 62
liothyronine sodium ................ 71
lisinopril .................................. 45
lisinopril-hydrochlorothiazide 47
lithium..................................... 40
lithium carbonate .................... 40
lithium carbonate er ................ 40
lithostat ................................... 64
LIVALO ................................. 51
LO LOESTRIN FE ................. 67
LONSURF .............................. 28
loperamide hcl ........................ 61
lorazepam ............................... 40
97
lorazepam intensol.................. 40
loryna ...................................... 67
losartan potassium .................. 45
losartan potassium-hctz .......... 47
LOSEASONIQUE ................. 67
LOTEMAX ............................ 80
lovastatin ................................ 51
loxapine succinate .................. 33
LUMIGAN ............................. 78
LUPRON DEPOT ............ 28, 71
LUPRON DEPOT-PED ......... 71
lutera ....................................... 67
LYNPARZA........................... 28
LYRICA ........................... 13, 53
LYSODREN........................... 28
lyza ......................................... 67
M magnesium sulfate .................. 87
MAKENA .............................. 69
MALATHION ........................ 58
maprotiline hcl........................ 16
marlissa................................... 67
MARPLAN ............................ 17
MATULANE ......................... 28
matzim la ................................ 48
MAXIDEX ............................. 80
meclizine hcl .......................... 18
medroxyprogesterone acetate 67,
69
MEFENAMIC ACID ............. 21
mefloquine hcl ........................ 31
MEGACE ES ......................... 69
megestrol acetate .................... 28
MEGESTROL ACETATE ..... 70
MEKINIST ............................. 28
meloxicam .............................. 21
melphalan hcl ......................... 23
memantine hcl ........................ 16
MEMANTINE HCL .............. 16
MENACTRA ......................... 75
MENEST ................................ 69
MENHIBRIX ......................... 75
MENOMUNE ........................ 75
MENOSTAR .......................... 69
MENTAX ............................... 58
MENVEO ............................... 75
mercaptopurine ....................... 24
meropenem ............................... 9
MESALAMINE ..................... 76
mesalamine-cleanser .............. 76
MESNA .................................. 28
MESNEX................................ 28
MESTINON ........................... 22
metaxalone.............................. 85
metformin hcl ......................... 41
metformin hcl er ..................... 41
metformin hcl er (osm) ........... 41
METHADONE HCL ................ 2
METHAZOLAMIDE ............. 49
METHENAMINE HIPPURATE
.............................................. 6
methimazole ........................... 72
methocarbamol ....................... 85
methotrexate ........................... 24
methotrexate sodium .............. 25
methotrexate sodium (pf) ....... 25
methoxsalen rapid................... 58
methscopolamine bromide ..... 60
methyclothiazide .................... 50
methyldopa-hydrochlorothiazide
............................................ 47
methylergonovine maleate ..... 78
methylphenidate hcl ............... 53
METHYLPHENIDATE HCL 53
METHYLPHENIDATE HCL
ER ....................................... 53
METHYLPHENIDATE HCL
ER (CD) .............................. 52
METHYLPHENIDATE HCL
ER (LA) .............................. 52
methylprednisolone ................ 65
methylprednisolone acetate .... 65
methylprednisolone sodium succ
............................................ 65
metipranolol............................ 79
metoclopramide hcl ................ 61
METOCLOPRAMIDE HCL .. 61
metolazone.............................. 50
metoprolol succinate er .......... 47
metoprolol tartrate .................. 48
metoprolol-hydrochlorothiazide
............................................ 47
metronidazole ..................... 6, 64
METRONIDAZOLE .............. 58
metronidazole in nacl ............... 6
mexiletine hcl ......................... 46
MIACALCIN ......................... 77
miconazole 3........................... 64
microgestin 1.5/30 .................. 67
microgestin 1/20 ..................... 67
microgestin fe 1.5/30 .............. 67
microgestin fe 1/20 ................. 67
midodrine hcl .......................... 45
migergot .................................. 22
miglitol ................................... 41
MILLIPRED ........................... 65
minitran................................... 51
minocycline hcl ...................... 12
MINOCYCLINE HCL ........... 12
minocycline hcl er .................. 12
minoxidil................................. 52
MIRCERA .............................. 44
mirtazapine ............................. 16
misoprostol ............................. 62
MITOMYCIN......................... 28
mitoxantrone hcl ..................... 28
M-M-R II ................................ 75
MODAFINIL .......................... 86
moexipril hcl ........................... 45
MOLINDONE HCL ............... 33
mometasone furoate.......... 58, 84
mononessa .............................. 67
montelukast sodium ................ 82
morphine sulfate ....................... 4
morphine sulfate (concentrate) . 4
morphine sulfate er ................... 2
MORPHINE SULFATE ER..... 2
MORPHINE SULFATE ER
BEADS ................................. 2
MOVANTIK .......................... 61
MOVIPREP ............................ 62
MOXEZA ............................... 79
moxifloxacin hcl ..................... 11
MOXIFLOXACIN HCL ........ 11
MOZOBIL .............................. 44
MULTAQ ............................... 46
mupirocin ................................ 58
MUPIROCIN CALCIUM ...... 58
MUSTARGEN ....................... 23
MYCAMINE .......................... 20
mycophenolate mofetil ........... 73
MYCOPHENOLATE
MOFETIL ........................... 73
mycophenolic acid .................. 73
MYRBETRIQ......................... 63
N nabumetone............................. 21
nadolol .................................... 48
nafcillin sodium ...................... 10
NAFCILLIN SODIUM .......... 10
98
NAFTIFINE HCL .................. 58
NAFTIN ................................. 58
NAGLAZYME....................... 60
naloxone hcl ............................. 5
naltrexone hcl ........................... 5
NAMENDA XR ..................... 16
NAMENDA XR TITRATION
PACK ................................. 16
NAMZARIC........................... 16
naphazoline hcl ....................... 78
naproxen ................................. 21
naproxen dr ............................. 21
naproxen sodium .................... 21
naratriptan hcl ......................... 22
nateglinide .............................. 41
NATPARA ............................. 77
NEBUPENT ........................... 31
necon 0.5/35 (28).................... 67
necon 1/35 (28)....................... 67
necon 10/11 (28)..................... 68
necon 7/7/7 ............................. 68
NEFAZODONE HCL ............ 16
neomycin sulfate ...................... 6
neomycin-bacitracin zn-
polymyx .............................. 79
neomycin-polymyxin b gu ..... 64
neomycin-polymyxin-dexameth
............................................ 80
neomycin-polymyxin-
gramicidin........................... 79
neomycin-polymyxin-hc .. 80, 81
NEPHRAMINE ...................... 89
NEULASTA ........................... 44
NEUPOGEN .......................... 44
NEUPRO ................................ 31
NEVIRAPINE ........................ 37
NEVIRAPINE ER .................. 37
NEXAVAR ............................ 28
niacin er (antihyperlipidemic) 51
niacor ...................................... 51
nicardipine hcl ........................ 49
NICOTROL .............................. 5
nifedical xl .............................. 49
nifedipine er osmotic release .. 49
NILANDRON ........................ 28
NILUTAMIDE ....................... 28
nimodipine .............................. 49
NINLARO .............................. 28
NISOLDIPINE ER ................. 49
NITRO-BID ........................... 51
nitrofurantoin ............................ 7
nitrofurantoin macrocrystal ...... 7
NITROFURANTOIN
MACROCRYSTAL ............. 6
nitrofurantoin monohyd macro . 7
nitroglycerin ........................... 51
NITROGLYCERIN................ 52
nitrostat ................................... 52
NITROSTAT .......................... 52
nizatidine ................................ 62
NORDITROPIN FLEXPRO .. 70
norethindrone.......................... 68
NORETHINDRONE
ACETATE .......................... 70
norethindrone-eth estradiol..... 69
norgestim-eth estrad triphasic 68
normosol-m in d5w ................ 87
normosol-r in d5w .................. 87
NORMOSOL-R PH 7.4 ......... 87
NORPACE CR ....................... 46
NORTHERA .......................... 78
nortrel 0.5/35 (28)................... 68
nortrel 1/35 (21)...................... 68
nortrel 1/35 (28)...................... 68
nortrel 7/7/7 ............................ 68
nortriptyline hcl ...................... 18
NORVIR ................................. 39
NOVOLIN 70/30 .................... 42
NOVOLIN N .......................... 42
NOVOLIN R .......................... 42
NOVOLOG ............................ 43
NOVOLOG FLEXPEN .......... 42
NOVOLOG MIX 70/30 ......... 43
NOVOLOG MIX 70/30
FLEXPEN .......................... 42
NOVOLOG PENFILL ........... 43
NOXAFIL .............................. 20
NUCALA ............................... 84
NUEDEXTA .......................... 78
NULOJIX ............................... 73
NUPLAZID ............................ 34
nutrilipid ................................. 89
NUTROPIN AQ NUSPIN 10. 70
NUTROPIN AQ NUSPIN 20. 70
NUVARING ........................... 68
NUVIGIL ............................... 86
nystatin ....................... 20, 54, 58
O octreotide acetate .................... 71
ODEFSEY .............................. 39
ODOMZO............................... 28
OFEV ...................................... 84
ofloxacin ........................... 79, 81
ogestrel ................................... 68
olanzapine ............................... 34
OLANZAPINE ....................... 34
olanzapine-fluoxetine hcl ....... 34
OLOPATADINE HCL ..... 79, 84
omega-3-acid ethyl esters ....... 51
omeprazole ............................. 63
OMNARIS .............................. 84
ondansetron............................. 19
ondansetron hcl ....................... 19
ONFI ....................................... 13
OPANA .................................... 2
OPANA ER .............................. 2
OPDIVO ................................. 28
OPSUMIT............................... 84
ORAVIG................................. 20
ORENCIA .............................. 74
ORENCIA CLICKJECT ........ 74
ORFADIN .............................. 60
ORKAMBI ............................. 84
orphenadrine citrate er ............ 85
orsythia ................................... 68
OSMOPREP ........................... 62
OTREXUP .............................. 73
oxacillin sodium ..................... 10
oxaliplatin ............................... 23
OXANDROLONE ................. 66
OXAPROZIN ......................... 21
OXAZEPAM .......................... 40
oxcarbazepine ......................... 15
oxiconazole nitrate.................. 58
OXISTAT ............................... 58
OXTELLAR XR .................... 15
oxybutynin chloride ................ 63
oxybutynin chloride er ............ 63
oxycodone hcl ........................... 4
OXYCODONE HCL ................ 4
OXYCODONE HCL ER .......... 2
oxycodone-acetaminophen ....... 4
OXYCODONE-
ACETAMINOPHEN ............ 4
oxycodone-aspirin .................... 4
oxycodone-ibuprofen ................ 4
OXYCONTIN .......................... 2
OXYMORPHONE HCL .......... 4
oxymorphone hcl er .................. 3
99
P pacerone ................................. 46
PACLITAXEL ....................... 28
PALIPERIDONE ER ............. 34
pamidronate disodium ............ 77
PANCREAZE ........................ 61
PANDEL ................................ 58
PANRETIN ............................ 58
pantoprazole sodium .............. 63
paricalcitol .............................. 77
PARICALCITOL ................... 77
PAROMOMYCIN SULFATE . 6
paroxetine hcl ......................... 17
paroxetine hcl er ..................... 17
PASER ................................... 23
PATADAY ............................. 79
PAXIL .................................... 17
PAZEO ................................... 79
PCE......................................... 11
PEDVAX HIB ........................ 75
peg 3350-kcl-na bicarb-nacl ... 62
peg-3350/electrolytes ............. 62
PEGANONE .......................... 15
PEGASYS .............................. 36
PEGASYS PROCLICK ......... 36
PEGINTRON ......................... 36
PEG-INTRON REDIPEN ...... 36
PENICILLIN G POT IN
DEXTROSE ....................... 10
PENICILLIN G POTASSIUM
............................................ 10
PENICILLIN G PROCAINE . 10
PENICILLIN G SODIUM ..... 10
penicillin v potassium............. 10
PENTAM ............................... 31
pentoxifylline er ..................... 49
perindopril erbumine .............. 45
PERJETA ............................... 28
PERMETHRIN ...................... 58
perphenazine........................... 33
PERPHENAZINE .................. 33
PERPHENAZINE-
AMITRIPTYLINE ............. 33
PERTZYE .............................. 61
phenelzine sulfate ................... 17
phenobarbital .......................... 13
phenytoin ................................ 15
phenytoin sodium ................... 15
phenytoin sodium extended .... 15
PHOSPHOLINE IODIDE ...... 79
PICATO.................................. 58
pilocarpine hcl .................. 54, 78
PILOCARPINE HCL ............. 54
pimozide ................................. 33
pindolol ................................... 48
pioglitazone hcl ...................... 42
pioglitazone hcl-glimepiride... 42
pioglitazone hcl-metformin hcl
............................................ 42
piperacillin sod-tazobactam so10
piroxicam ................................ 21
PLASMA-LYTE 148 ............. 87
PLASMA-LYTE A ................ 87
PLASMA-LYTE-56 IN D5W 87
PLEGRIDY ............................ 53
PLEGRIDY STARTER PACK
............................................ 53
plenamine ............................... 89
podofilox ................................ 59
polyethylene glycol 3350 ....... 62
polymyxin b sulfate .................. 7
polymyxin b-trimethoprim ..... 79
POMALYST .......................... 28
portia-28 ................................. 68
potassium chloride .................. 87
potassium chloride crys er ...... 87
potassium chloride er.............. 87
potassium chloride in dextrose
............................................ 87
potassium chloride in nacl ...... 87
potassium citrate er ................. 64
POTIGA ................................. 14
PRADAXA ............................. 43
PRALUENT ........................... 51
pramipexole dihydrochloride . 31
PRAMIPEXOLE
DIHYDROCHLORIDE ER31
pravastatin sodium .................. 51
prazosin hcl............................. 45
PREDNICARBATE ............... 59
prednisolone acetate ............... 80
prednisolone sodium phosphate
...................................... 65, 80
PREDNISOLONE SODIUM
PHOSPHATE ..................... 65
prednisone .............................. 65
prednisone intensol ................. 65
PREFERRED PLUS INSULIN
SYRINGE ........................... 42
PREFEST ............................... 69
PREMARIN ..................... 64, 69
premasol ................................. 89
PREMASOL ........................... 89
PREMPHASE......................... 69
PREMPRO ............................. 69
prenatal ................................... 89
PREPOPIK ............................. 62
previfem .................................. 68
PREZCOBIX .......................... 37
PREZISTA ............................. 39
PRIFTIN ................................. 23
PRIMAQUINE PHOSPHATE
............................................ 31
primidone ................................ 14
PRISTIQ ................................. 17
PROAIR HFA ........................ 83
PROAIR RESPICLICK.......... 83
probenecid .............................. 20
PROCALAMINE ................... 89
prochlorperazine ..................... 33
prochlorperazine edisylate ...... 33
prochlorperazine maleate ........ 33
PROCRIT ............................... 44
procto-med hc ......................... 59
proctozone-hc ......................... 59
progesterone micronized ........ 70
PROGLYCEM ....................... 42
PROGRAF .............................. 73
PROLASTIN-C ...................... 84
PROLEUKIN ......................... 29
PROLIA .................................. 77
PROMACTA .......................... 44
promethazine hcl .................... 81
promethazine vc plain............. 81
propafenone hcl ...................... 46
PROPAFENONE HCL ER .... 46
proparacaine hcl...................... 78
propranolol hcl........................ 48
propranolol hcl er ................... 48
propylthiouracil ...................... 72
PROQUAD ............................. 75
PROSOL ................................. 89
PROTRIPTYLINE HCL ........ 18
PROVENTIL HFA ................. 83
PULMICORT ......................... 82
PULMICORT FLEXHALER . 82
PULMOZYME ....................... 84
PURIXAN .............................. 25
PYLERA................................. 61
pyrazinamide .......................... 23
100
pyridostigmine bromide ......... 22
pyridostigmine bromide er ..... 22
Q QUADRACEL ....................... 75
quasense ................................. 68
quetiapine fumarate ................ 34
quinapril hcl............................ 45
quinapril-hydrochlorothiazide 47
quinidine gluconate er ............ 46
quinidine sulfate ..................... 46
quinine sulfate ........................ 31
R RABAVERT .......................... 76
rabeprazole sodium ................ 63
raloxifene hcl .......................... 70
ramipril ................................... 45
RANEXA ............................... 49
ranitidine hcl ........................... 62
RANITIDINE HCL ................ 62
RAPAFLO .............................. 63
RAPAMUNE ......................... 73
RAVICTI ................................ 60
REBETOL .............................. 36
reclipsen ................................. 68
RECOMBIVAX HB .............. 76
REGRANEX .......................... 59
RELENZA DISKHALER ...... 39
RELI-ON INSULIN SYRINGE
............................................ 42
RELISTOR ............................. 61
RELPAX ................................ 22
REMODULIN ........................ 84
RENVELA ............................. 64
repaglinide .............................. 42
repaglinide-metformin hcl ...... 42
REPATHA ............................. 51
REPATHA PUSHTRONEX
SYSTEM ............................ 51
REPATHA SURECLICK ...... 51
RESCRIPTOR ........................ 37
RESTASIS ............................. 78
RETROVIR ............................ 37
REVLIMID ............................ 24
REXULTI ............................... 34
REYATAZ ............................. 39
RHEUMATREX .................... 73
RIBASPHERE ....................... 36
ribasphere ribapak .................. 36
RIBASPHERE RIBAPAK ..... 36
RIBAVIRIN ........................... 36
RIFABUTIN ........................... 23
RIFAMATE............................ 23
rifampin .................................. 23
RIFATER ............................... 23
riluzole .................................... 53
RIMANTADINE HCL ........... 39
ringers ..................................... 87
RIOMET ................................. 42
risedronate sodium ................. 77
RISEDRONATE SODIUM ... 77
RISPERDAL CONSTA ......... 34
risperidone .............................. 35
RITUXAN .............................. 29
rivastigmine ............................ 16
rivastigmine tartrate ................ 16
rizatriptan benzoate ................ 22
ROBINUL .............................. 60
ROBINUL-FORTE ................ 61
ropinirole hcl .......................... 32
ropinirole hcl er ...................... 32
rosuvastatin calcium ............... 51
ROTARIX .............................. 76
ROTATEQ ............................. 76
roweepra ................................. 12
ROZEREM ............................. 86
S SABRIL .................................. 14
SAFYRAL .............................. 68
SAMSCA................................ 86
SANCUSO ............................. 19
SANDIMMUNE .................... 73
SANDOSTATIN LAR DEPOT
............................................ 72
SANTYL ................................ 59
SAPHRIS................................ 35
SARAFEM ............................. 17
SAVELLA .............................. 53
SAVELLA TITRATION PACK
............................................ 53
selegiline hcl ........................... 32
selenium sulfide ...................... 59
SELZENTRY ......................... 38
SENSIPAR ............................. 71
SEREVENT DISKUS ............ 83
SEROQUEL XR..................... 35
SEROSTIM ............................ 70
sertraline hcl ........................... 17
setlakin.................................... 68
SFROWASA .......................... 76
SIGNIFOR.............................. 72
sildenafil citrate ...................... 84
SILENOR ............................... 86
silver sulfadiazine ................... 59
SIMBRINZA .......................... 79
SIMPONI ................................ 73
SIMPONI ARIA ..................... 73
SIMULECT ............................ 73
simvastatin .............................. 51
sirolimus ................................. 73
SIRTURO ............................... 23
SKLICE .................................. 59
sodium chloride ................ 64, 87
sodium fluoride ....................... 89
sodium phenylbutyrate ........... 60
sodium polystyrene sulfonate . 86
SOLTAMOX .......................... 29
SOLU-CORTEF ..................... 65
SOLU-MEDROL ................... 65
SOMATULINE DEPOT ........ 72
SOMAVERT .......................... 72
SOOLANTRA ........................ 59
sotalol hcl................................ 48
sotalol hcl (af) ......................... 48
SOVALDI............................... 36
SPIRIVA HANDIHALER ..... 82
SPIRIVA RESPIMAT ............ 82
spironolactone......................... 50
spironolactone-hctz................. 47
SPORANOX........................... 20
sprintec 28 .............................. 68
SPRITAM ............................... 13
SPRYCEL............................... 29
sps ........................................... 86
sronyx ..................................... 68
STAVUDINE ................... 37, 38
STELARA .............................. 59
STIMATE ............................... 70
STIOLTO RESPIMAT ........... 83
STIVARGA ............................ 29
STRATTERA ......................... 53
STREPTOMYCIN SULFATE . 6
STRIBILD .............................. 39
SUBOXONE ............................ 5
SUBSYS ................................... 3
sucralfate................................. 62
sulfacetamide sodium ............. 79
SULFACETAMIDE SODIUM
............................................ 59
sulfacetamide-prednisolone .... 80
sulfadiazine ............................. 11
101
sulfamethoxazole-trimethoprim
...................................... 11, 12
SULFAMYLON..................... 59
sulfasalazine ........................... 76
sulindac................................... 21
sumatriptan ............................. 22
sumatriptan succinate ............. 22
sumatriptan succinate refill .... 22
SUPRAX .................................. 8
SUPREP BOWEL PREP ....... 62
SUSTIVA ............................... 37
SUTENT................................. 29
SYLATRON........................... 29
SYMBICORT......................... 83
SYMLINPEN 120 .................. 42
symlinpen 60 .......................... 42
SYNAGIS............................... 74
SYNALGOS-DC ...................... 4
SYNAREL ............................. 72
SYNERCID .............................. 7
SYNJARDY ........................... 42
SYNRIBO .............................. 29
SYNTHROID ......................... 71
SYPRINE ............................... 86
T TABLOID .............................. 25
TACLONEX .......................... 59
tacrolimus ......................... 59, 74
TAFINLAR ............................ 29
TAGRISSO ............................ 29
TAMIFLU .............................. 39
tamoxifen citrate ..................... 29
tamsulosin hcl ......................... 64
TARCEVA ............................. 29
TARGRETIN ......................... 59
TASIGNA .............................. 29
TAZICEF ................................. 8
TAZORAC ............................. 59
taztia xt ................................... 49
TECENTRIQ .......................... 29
TECFIDERA .......................... 53
TEFLARO ................................ 8
TEGRETOL-XR .................... 15
telmisartan .............................. 45
TELMISARTAN-HCTZ ........ 47
TEMAZEPAM ....................... 85
TENIVAC .............................. 76
terazosin hcl............................ 45
terbinafine hcl ......................... 20
terbutaline sulfate ................... 83
TERBUTALINE SULFATE .. 83
terconazole.............................. 64
TESTOSTERONE.................. 66
testosterone cypionate ............ 66
testosterone enanthate............. 66
TETANUS-DIPHTHERIA
TOXOIDS TD .................... 76
tetrabenazine ........................... 53
THALOMID ........................... 24
theophylline er ........................ 82
thioridazine hcl ....................... 33
THIOTEPA ............................ 24
thiothixene .............................. 33
THYMOGLOBULIN ............. 74
tiagabine hcl ........................... 14
timolol maleate ........... 22, 48, 80
TINIDAZOLE .......................... 7
TIROSINT .............................. 71
TIVICAY................................ 38
tizanidine hcl .......................... 85
TIZANIDINE HCL ................ 85
TOBI PODHALER .................. 6
TOBRADEX .......................... 80
TOBRADEX ST..................... 80
tobramycin .......................... 6, 79
tobramycin sulfate .................... 6
tobramycin-dexamethasone .... 80
TOBREX ................................ 79
TOLAK .................................. 59
tolazamide .............................. 42
tolbutamide ............................. 42
tolmetin sodium ...................... 21
tolterodine tartrate .................. 63
tolterodine tartrate er .............. 63
TOPICORT SPRAY............... 59
topiramate ............................... 14
TOPIRAMATE ER ................ 14
toposar .................................... 29
TOPOTECAN HCL ............... 29
TORISEL................................ 29
torsemide ................................ 50
TOUJEO SOLOSTAR ........... 43
tpn electrolytes ....................... 87
TRACLEER ........................... 84
TRADJENTA ......................... 42
tramadol hcl .............................. 4
tramadol hcl er .......................... 3
tramadol hcl er (biphasic) ......... 3
tramadol-acetaminophen .......... 4
trandolapril ............................. 45
tranexamic acid ....................... 44
TRANSDERM-SCOP (1.5 MG)
............................................ 18
tranylcypromine sulfate .......... 17
TRAVASOL ........................... 89
TRAVATAN Z ....................... 78
travoprost ................................ 78
trazodone hcl .......................... 16
TREANDA ............................. 24
TRECATOR ........................... 23
TRELSTAR MIXJECT .......... 29
tretinoin............................. 29, 59
TRETINOIN ........................... 59
tretinoin microsphere .............. 59
TREXALL .............................. 25
TREXIMET ............................ 22
triamcinolone acetonide.... 54, 59
TRIAMCINOLONE
ACETONIDE ..................... 59
triamterene-hctz ...................... 47
TRIAZOLAM......................... 85
TRIBENZOR .......................... 47
trifluoperazine hcl ................... 33
trifluridine ............................... 79
trihexyphenidyl hcl ................. 31
tri-legest fe .............................. 68
tri-lo-estarylla ......................... 68
tri-lo-sprintec .......................... 68
trimethobenzamide hcl ........... 18
trimethoprim ............................. 7
trimipramine maleate .............. 18
trinessa (28) ............................ 68
TRINTELLIX ......................... 17
tri-previfem ............................. 68
TRISENOX ............................ 29
tri-sprintec............................... 68
TRIUMEQ .............................. 39
trivora (28) .............................. 68
TROKENDI XR ..................... 14
TROPHAMINE ...................... 89
trospium chloride .................... 63
trospium chloride er ................ 63
TRUMENBA .......................... 76
TRUVADA............................. 38
TWINRIX ............................... 76
TYBOST................................. 37
TYGACIL................................. 7
TYKERB ................................ 29
TYPHIM VI............................ 76
TYSABRI ............................... 54
102
TYZEKA ................................ 36
U UCERIS ............................ 59, 65
ULORIC ................................. 20
unithroid ................................. 71
ursodiol ................................... 61
UVADEX ............................... 29
V VAGIFEM .............................. 64
valacyclovir hcl ...................... 36
VALCHLOR .......................... 59
valganciclovir hcl ................... 35
valproate sodium .................... 14
valproic acid ........................... 14
valsartan ................................. 45
valsartan-hydrochlorothiazide 47
vancomycin hcl ........................ 7
VANCOMYCIN HCL ............. 7
VAQTA .................................. 76
VARIVAX ............................. 76
VARIZIG ............................... 74
VECTIBIX ............................. 29
VELCADE ............................. 29
velivet ..................................... 68
VENCLEXTA ........................ 29
VENCLEXTA STARTING
PACK ................................. 29
venlafaxine hcl ....................... 18
venlafaxine hcl er ................... 18
VENLAFAXINE HCL ER .... 18
VENTAVIS ............................ 84
VENTOLIN HFA ................... 83
VERAMYST .......................... 84
verapamil hcl .......................... 49
verapamil hcl er ...................... 49
VERAPAMIL HCL ER ......... 49
VERIPRED 20 ....................... 65
VERSACLOZ ........................ 35
VESICARE ............................ 63
vestura .................................... 68
VEXOL .................................. 80
VIBRAMYCIN ...................... 12
VICTOZA .............................. 42
VIDEX.................................... 38
vienva ..................................... 68
VIGAMOX ............................. 79
VIIBRYD ............................... 16
VIIBRYD STARTER PACK . 16
VIMPAT ................................. 15
VINBLASTINE SULFATE ... 30
VINCASAR PFS .................... 30
VINCRISTINE SULFATE .... 30
VINORELBINE TARTRATE30
VIOKACE .............................. 61
VIRACEPT ............................ 39
VIRAZOLE ............................ 39
VIREAD ................................. 38
VITEKTA ............................... 38
VIVITROL ............................... 5
voriconazole ........................... 20
VOTRIENT ............................ 30
VPRIV .................................... 78
VRAYLAR ............................. 35
vyfemla ................................... 68
VYVANSE ............................. 52
W warfarin sodium ...................... 43
WELCHOL ............................ 51
X XALKORI .............................. 30
XARELTO ............................. 43
XARELTO STARTER PACK
............................................ 43
XELJANZ .............................. 74
XGEVA .................................. 77
XIFAXAN ................................ 7
XOLAIR ................................. 85
XTANDI ................................. 30
xulane ..................................... 68
XYREM.................................. 86
Y YERVOY ............................... 30
YF-VAX ................................. 76
YONDELIS ............................ 24
Z zafirlukast ............................... 82
zaleplon................................... 85
ZALTRAP .............................. 24
ZANOSAR ............................. 24
ZARXIO ................................. 44
ZAVESCA .............................. 60
zazole ...................................... 64
ZELAPAR .............................. 32
ZELBORAF ........................... 30
ZEMAIRA .............................. 85
ZENPEP ................................. 61
zenzedi .................................... 52
ZEPATIER ............................. 36
ZERBAXA ............................... 8
ZETIA..................................... 51
ZETONNA ............................. 84
ZIAGEN ................................. 38
ZIANA .................................... 59
ZIDOVUDINE ....................... 38
ziprasidone hcl ........................ 35
ZIRGAN ................................. 79
ZMAX .................................... 11
zoledronic acid........................ 77
ZOLINZA ............................... 30
zolmitriptan............................. 22
zolpidem tartrate ..................... 86
zolpidem tartrate er ................. 85
ZOMIG ................................... 22
ZONALON ............................. 60
zonisamide .............................. 13
ZORBTIVE ............................ 70
ZORTRESS ............................ 74
ZOSTAVAX........................... 76
ZOSYN ................................... 10
zovia 1/35e (28) ...................... 68
zovia 1/50e (28) ...................... 68
ZOVIRAX .............................. 60
ZYDELIG ............................... 30
ZYFLO ................................... 82
ZYFLO CR ............................. 82
ZYKADIA .............................. 30
ZYPREXA RELPREVV ........ 35
ZYTIGA ................................. 30
ix
Este Formulario fue actualizado el 12/01/2016. El formulario puede cambiar en cualquier momento. A usted se le notificará al respecto cuando sea necesario. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con el médico conserje de Care N’ Care Health Plan al 1-877-374-7993 (TTY 711) del 1 de octubre al 14 de febrero: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, los siete días de la semana. Del 15 de febrero al 30 de septiembre: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, de lunes a viernes. También puede enviar un correo electrónico a su médico conserje a [email protected] o visitar www.cnchealthplan.com.
El formulario puede cambiar en cualquier momento. A usted se le notificará al respecto cuando sea necesario.
Care N’ Care cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.ATENCIÓN: Si habla español o vietnamita, hay servicios de asistencia de idiomas, sin cargo, disponibles para usted. Llame al 1-877-665-2622 (TTY: 711).
Care N’ Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-665-2622 (TTY: 711).
Care N’ Care tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-665-2622 (TTY: 711).
Esta información no es una descripción completa de los beneficios. Comuníquese con el plan para obtener más información. Pueden aplicarse ciertas limitaciones, copagos y restricciones. Los beneficios, la prima o los copagos/coseguros pueden cambiar el 1 de enero de cada año.
Care N’ Care es una organización de Medicare Advantage que tiene un contrato con Medicare. La inscripción en Care N’ Care depende de la renovación del contrato.
Este Formulario fue actualizado el 12/01/2016. El formulario puede cambiar en cualquier momento. A usted se le notificará al respecto cuando sea necesario. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con el médico conserje de Care N’ Care Health Plan al 1-877-374-7993 (TTY 711) del 1 de octubre al 14 de febrero: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, los siete días de la semana. Del 15 de febrero al 30 de septiembre: de 8:00 a.m. a 8:00 p.m., hora estándar del centro, de lunes a viernes. También puede enviar un correo electrónico a su médico conserje a [email protected] o visitar www.cnchealthplan.com.
P L A N D E S A L U D C A R E N ’ C A R E
I N F O R M A C I Ó N D E C O N T A C T O
DIRECCIÓN WEB:Visite Care N’ Care en www.cnchealthplan.com.
INFORMACIÓN DE VENTASLos posibles miembros futuros pueden llamar sin cargo al 1-877-665-2622 si tienen preguntas relacionadas con el programa Medicare Advantage los siete días de la semana, de 8:00 a.m. a 8:00 p.m., hora estándar del centro.
MÉDICO CONSERJELos miembros actuales pueden llamar sin cargo al 1-877-374-7993 si tienen preguntas relacionadas con el programa Medicare Advantage desde el 1 de octubre al 14 de febrero, los siete días de la semana, de 8:00 a.m. a 8:00 p.m., hora estándar del centro, o desde el 15 de febrero al 30 de septiembre, de lunes a viernes, de 8:00 a.m. a 8:00 p.m., hora estándar del centro.
USUARIOS DE TTYLos usuarios de TTY deben llamar sin cargo al 711. si tienen preguntas relacionadas con el programa Medicare Advantage.
BENEFICIO DE MEDICAMENTOS CON RECETALos miembros actuales pueden llamar sin cargo al 1-855-791-5302 si tienen preguntas relacionadas con el programa de medicamentos con receta de la Parte D de Medicare. Los usuarios de TTY deben llamar al 711.
INFORMACIÓN DE MEDICAREPara obtener más información sobre Medicare, comuníquese con Medicare al 1-800-Medicare (1-800-633-4227). Los usuarios de TTY deben llamar al 1-877-486-2048. Puede llamar las 24 horasdel día, los siete días de la semana.O, visite www.medicare.gov en la web.